JACPT

Journal of Acute Care Physical Therapy

Fall 2010 Volume 1 Number 1

CASE REPORT RESEARCH REPORT

4 Chronic Inflammatory Demyelinating Polyradiculoneuropathy 21 The Effects of a Physical Therapy Triage System on the
from a Physical Therapists Perspective: A Case Report Outcomes of ICU Patients with Respiratory Failure

CLINICAL PRACTICE APTA 2010 Combined Sections Meeting

14 University of Rochester Acute Care Evaluation: Development of 30 Platform Presentation Abstracts
a New Functional Outcome Measure for the Acute Care Setting 34 Poster Abstracts

Acute Care Section - APTA, Inc.

JACPT EDITORIAL
Journal of Acute Care Physical Therapy Welcome to the Journal of Acute Care Physical Therapy! Arnold, Stephen Carp, Lee Ann Eagler, Barbara Ehrmann, Karen Holtgrefe, Diane Madras, Stephen
The first issue of JACPT has been in development since Morris, Barbara Smith, Beth Smith, Bonnie Swafford, and Patricia Ohtake have provided the kind of
Editorial Board our strategic planning retreat at this time last year. feedback necessary to elevate the scientific value of the manuscripts submitted thus far. This level of
Glenn Irion, PT, PhD, CWS - Editor in Chief At this retreat, we were challenged with ways of critique has been beneficial for the authors as well as preparing JACPT for consideration for indexing
Associate Professor of Physical Therapy in MEDLINE. Inclusion in MEDLINE is critical for the recognition of acute care physical therapy as a
University of South Alabama
supporting our Sections mission and vision. Among
307 N. University Blvd those aspects of the mission and vision, elevating the unique health care entity. We are required to submit an entire years worth of issues to be considered
HAHN 2011 practice of acute care physical therapy and making and our plan is to apply for inclusion as soon as we have this first year of issues completed.
Mobile, AL 36688 ourselves more visible to the health care community
phone 251 445-9243 were particularly instrumental in the decision to Finally, the efforts of Lieve Monnens and Judy Oiler of our management company, APTANJ, have been
fax 251 445-9238
create a journal dedicated specifically to the science critical in making this transformation into a full-fledged, standalone journal for acute care physical therapy.
girion@jaguar1.usouthal.edu Lieve and Judy have been responsible for the physical design as well as keeping us all connected and on
and practice of acute care physical therapy.
Beth A. Smith, PT, DPT, PhD - Deputy Editor track.
smitbeth@ohsu.edu A successful Journal is only one avenue for promoting
Scott LaRaus, PT, CWS - Associate Editor the mission and vision of the Acute Care Section. Getting this first issue to press--and trying to make it perfect--has been a huge undertaking and I hope
slaraus@aol.com The Board of Directors and Editorial Board of JACPT all reading this will both celebrate this accomplishment and seek ways to add to our journal. We
Kevin E. Brueilly, PT, PhD - Associate Editor will continue to work closely to achieve three basic are particularly in need of individuals who will find advertisers and promote our journal beyond the
brueilly.k@lynchburg.edu missions for JACPT 1. Demonstrating a unique body of members of the Section. Please send comments or questions to girion@jaguar1.usouthal.edu.
Jane L. Wetzel, PT, PhD - Associate Editor knowledge that distinguishes the acute care physical
wetzeljl@upmc.edu therapist from other physical therapists; 2. Defining
Acute Care Section Officers the role of the acute care physical therapist within Glenn L. Irion, PhD, PT, CWS
PRESIDENT health care; 3. Demonstrating a growing evidence- Editor in Chief, Journal of Acute Care Physical Therapy
James M. Smith, PT, DPT base to the practice of acute care physical therapy.
Assistant Professor of Physical Therapy
Utica College, 1600 Burrstone Road To distinguish ourselves, we need a repository for
Utica NY 13502-4857 the body of knowledge that defines our role in health
phone: (315) 792-3074 care. This body of knowledge should be sufficiently
jsmith@utica.edu
different from other physical therapy practices that Fall 2010 Volume 1 Number 1
VICE PRESIDENT we become recognized as the experts in practice of
Courtney Bryan, PT
14938 Plantation Oak Drive physical therapy for those with acute care needs. It
Houston, Tx 77068-3115 also needs to define our place in health care such that
phone (281) 440-6269 practitioners outside physical therapy seek out the CASE REPORT
courtney.bryan@tenethealth.com acute care physical therapist. A third aspect is the
SECRETARY continued growth of this area of practice. Thus, the Chronic Inflammatory Demyelinating Polyradiculoneuropathy 4
Sujoy Bose, PT emphasis of JACPT on the science and practice of acute from a Physical Therapists Perspective: A Case Report
27172 Lilly Drive care physical therapy.
Brownstown, MI 48183-2796 Doris Y. Chong, Leslie B. Glickman, Paz Susan Cabanero-Johnson
phone (734) 676-5054 I have been fortunate that the Editorial Advisory Board
bosetherapeutics@gmail.com
members for Acute Care Perspectives have taken on
TREASURER new roles as Associate Editors. Scott LaRaus, Kevin CLINICAL PRACTICE
Jan Lucas Nosse, PT
2345 N. 114th St. Brueilly, and Jane Wetzel have the important task of University of Rochester Acute Care Evaluation: Development of 14
Wauwatosa, WI 53226-1225 synthesizing the reports of peer reviewers with their
phone (414) 453-0135 own analysis of submitted manuscripts and reporting a New Functional Outcome Measure for the Acute Care Setting
jnosse@wi.rr.com to me with recommendations. They also review Julie DiCicco, Deborah Whalen
Acute Care Section Executive Office resubmissions/revisions of submitted manuscripts
Judy Oiler, CAE, Executive Director to ensure required revisions meet the standards
Lieve Monnens, Meetings & Events Coordinator of publication in JACPT. The development of JACPT RESEARCH REPORT
1100 U.S. Highway 130, Suite 3 has added several tasks beyond those of Acute Care The Effects of a Physical Therapy Triage System on the Outcomes 21
Robbinsville, NJ 08691-1108 Perspectives. I am happy to announce the appointment
phone (888) 762-2427 or (609) 208-0981
of Beth Smith as Deputy Editor. She adds another of ICU Patients with Respiratory Failure
fax (609) 208-1000
acute@acutept.org perspective in addition to another pair of hands and Joni Rapp, Jaime C. Paz, Christine McCallum, Jeanne Cole, Lynn Steffey
eyes to make JACPT the publication that I had hoped
it would be. Input from the Associate Editors and
www.acutept.org Deputy Editor have proved invaluable as we have put
this first issue of JACPT into a physical form. We have
APTA 2010 Combined Sections Meeting, San Diego, CA
by the Acute Care Section-APTA, Inc.
ISSN 1551-9147 been fortunate to have so many individuals volunteer Platform Presentation Abstracts 30
to become peer reviewers. The efforts of Scott
Poster Abstracts 34
1 Fall 2010 Volume I Number 1 JACPT JACPT Fall 2010 Volume I Number 1 2
INSTRUCTIONS FOR AUTHORS ADVERTISING
Journal of Acute Care Physical Therapy is the journal of the Acute Care Section-APTA. The goal of the JACPT accepts advertising that conforms
publication is to provide timely information to Section members in matters that relate to acute care to the standards of the APTA. We offer
physical therapy practice. We accept articles that offer a professional opinion, clinical approaches
and techniques, research, literature review, and continual quality improvement information. JACPT
is published four times a year and is mailed to Section members and paid subscribers. JACPT
advertising space inside the front and
back covers, on the back cover and
within other available space inside the

CASE REPORT
is copyrighted and registered with the Library of Congress. It is indexed in EBSCO and Gale.
Articles are submitted directly to the Editor-in-Chief. At least two reviewers and an Associate
Editor will review submitted articles. The Editor-in-Chief is ultimately responsible for all decisions.
journal. Sizes available include full-page,
half-page, quarter-page, and business card.
We prefer submissions in digital format.
Chronic Inflammatory
Articles submitted to JACPT are expected to be original work that has not been previously
published or under consideration by another publication. The Editor may consider republication
All advertising is subject to the approval
of the Journal of Acute Care Physical Demyelinating
of articles published elsewhere only with explicit permission of the other publication. Therapy Editor. The Editor reserves
Format the right to decline an advertisement
deemed inappropriate for publication.
Polyradiculoneuropathy
Articles must be submitted electronically as documents that can be read by Microsoft Word 2007
for Windows or Word 2008 for OS X (.doc or .docx). Use an easily readable 12-point font such as
Times New Roman or Arial. Type your article in double-spaced full-page format and we will convert
The acceptance of any advertisement
does not constitute endorsement by the from a Physical Therapists
APTA or the Section. Please contact the
it to the newsletter layout. Both pages and lines must be numbered. Microsoft Word has a line
numbering function to generate line numbers for you. Please minimize the use of text formatting.
We will set formatting for headings consistent with the style of the articles that appear in JACPT.
Acute Care Sections management office
at studio@aptanj.org or 888-762-2427 for
Perspective: A Case Report
rates and other information.
Because manuscripts undergo a masked review process, you must submit a masked version
with all author names, affiliations and any other potentially identifying information removed
from the article. An unmasked copy must also be submitted and will be kept with the
Doris Y. Chong, Leslie B. Glickman, Paz Susan Cabanero-
Editor-in-Chief only. Submit articles to the Editor-in-Chief at girion@jaguar1.usouthal.edu. Johnson
Each table and figure must be sent as a separate file. Although authors may be well-intentioned,
please refrain from creating an article with embedded tables and figures. During layout, we
must have the flexibility to place figures and tables where needed. If embedded, figures and
tables will need to be extracted, which is time-consuming and may lead to problems with size
ABSTRACT Doris Y. Chong, PT, MSc, DScPT, NCS
and clarity of the figure or table. Neurologic Clinical Specialist, inpatient
Purpose: Although the literature describes several medical
Cover Letter acute care at Stanford University
interventions for chronic inflammatory demyelinating Medical Center in California
A cover letter must be submitted as described in the full instructions on our website. Cover
letters with signatures from all authors may be mailed or faxed to the Editor at 251-445- polyradiculoneuropathy (CIDP), no evidenced-based approaches Adjunct Assistant Professor, Samuel
9238. to rehabilitation specific to CIDP can be found. This case report Merritt University
Abstract reviews key background information on CIDP, and describes an Assistant Clinical Professor, San
An abstract of the article suitable for electronic indexing services such as EBSCO is to be included. Francisco State University
It should be generally be less than 200 words and contain headings appropriate to the type of interdisciplinary approach to rehabilitation in an acute care setting.
dchon001@umaryland.edu
article. These headings generally include Purpose, Methods, Results, and Conclusions. Other It illustrates the use of medical knowledge, clinical reasoning, and
types should include a minimum of Purpose, Methods, and Conclusions.
evidence in selecting outcome measures, formulating a plan of care, Leslie B. Glickman, PT, PhD
Protection of Subjects
The name of the Institutional Review Board or Institutional Animal Care and Use Committee and guiding clinical decisions. Assistant Professor and Director of
that approved the research protocol must be included in the Methods section of the manuscript. Post-Professional Programs at the
Remove the name of the IRB or IACUC in the masked version. Methods: This case describes a 59-year-old man with multiple University of Maryland, School of
Biographical Sketch Medicine, Department of Physical
significant co-morbidities during a six-month period characterized Therapy and Rehabilitation Science in
Include a 2-3 sentence biographical sketch for each author in a separate file to aid in masking
the identity of authors during review. This information will not be distributed to reviewers or by significant pain, sensory changes, and progressive weakness. He Baltimore Maryland.
Associate Editors. Include the professional title, affiliation of each author, and an address (may deteriorated dramatically from independent ambulation to requiring LGlickman@som.umaryland.edu
be e-mail) where readers may contact an author for further information. All funding sources
supporting the work should be acknowledged following the biographical sketch at the end of a wheelchair. Symptom progression attributed to end-stage liver
the article. disease led to further diagnostic tests and eventually, a definitive Paz Susan Cabanero-Johnson, PT,
DScPT
References diagnosis of CIDP. Initial findings included significant major muscle Education Program Specialist,
Journal of Acute Care Physical Therapy follows the referencing style outlined in the Publication
Manual of the American Medical Association (AMA). Examples of the use of AMA Style can be
group weakness and a Functional Independence Measure (FIM) score Department of Veteran Affairs in
found in JACPT as well as a large number of medical and health-related journals. of 23 out of 126. Intervention was focused on therapeutic exercise, Maryland
Tables and Illustrations balance training, and functional training with progressive endurance Assistant Clinical Professor, University
Captions for Illustrations as well as tables must be submitted in a separate document, i.e., list activities. FIM score improved to 56, sufficient for discharge to an of Maryland at Baltimore
of tables and list of figures. Captions or titles may not be embedded in illustrations or tables. pcaba001@umaryland.edu
Placing labels within illustrations is discouraged. If text labels are included in a figure, they must acute rehabilitation facility.
be of sufficient size to be legible when the illustration is reduced to the width of one column of
the publication. Authors must obtain and submit written permission to publish photographs in
which patients are recognizable. Black and white photographs copy best. Electronic .jpg format Conclusion: For this patient with CIDP, effective collaborative
is preferred and must have a minimum resolution of 150 dpi. team communication and interdisciplinary management worked to
Reprints optimize clinical decision making and recovery.
We provide all authors with single copies of the issue in which their articles appear. If an article has
multiple authors, we prefer to send copies to the lead author to distribute. If this is geographically difficult,
please supply our Editor with mailing addresses for those individuals who will require separate mailings. Key words: Chronic inflammatory demyelinating polyneuropathy/
Complete instructions for authors may be obtained from the Acute Care Sections website polyradiculoneuropathy, demyelinating conditions, rehabilitation.
www.acutept.org

3 Fall 2010 Volume I Number 1 JACPT JACPT Fall 2010 Volume I Number 1
Chronic Inflammatory Demyelinating Polyradiculoneuropathy from a Physical Therapists Perspective
Chronic inflammatory
demyelinating polyneuropathy or
polyradiculoneuropathy (CIDP) is a
relatively uncommon autoimmune
disorder of peripheral nerves that
leads to progressive and significant
weakness, sensory loss, and areflexia.1
Due to its heterogeneous presentation,
distinguishing this condition from
other neurological diseases and
treating it in the early stages can
be difficult. Yet early medical and
rehabilitation intervention is crucial to
functional recovery in spite of the lack
of a definitive diagnosis and functional
progress.
Several medical interventions for
CIDP are described in the literature,
but no evidence-based approaches to
rehabilitation specific to CIDP can be
found. This case report reviews key
background information on CIDP
and describes an interdisciplinary
approach between medical and
physical therapy (PT) providers in an
acute care setting. It illustrates the
use of medical knowledge, clinical
reasoning, and evidence in selecting
outcome measures, formulating a
plan of care, and assisting with clinical
decisions.
The prevalence of CIDP ranges from
1.24 to 7.7 per 100,000 in many regions
of the world including Australia, Japan,
the United Kingdom, Norway, and
Italy.2-7 It affects people of all ages but
is most prevalent in those between 40
to 60 year old regardless of gender.8
In the US, incidence was reported to
be 1.6 per 100,000 per year to a high
of 8.9 per 100,000.9 As many as about
300,000 patients could have active
CIDP at a given time10 and CIDP
could represent 10-30% of previously
undiagnosed neuropathies.8
The pathogenesis of CIDP begins
with an autoimmune response to an
unknown trigger. The trigger leads
to lymphokine-induced damage to
myelin sheaths and axons of peripheral
nerves.11,12 Proposed triggers include
influenza vaccination, tetanus toxoid
immunization13,14 and hepatocellular
carcinoma.15,16 Viral infection is more
likely to trigger an autoimmune
5 Fall 2010 Volume I Number 1
response in individuals who have
immune-compromised conditions.
Clinical, laboratory, and
electrodiagnostic features are used
to diagnose CIDP. Based on these
criteria, the diagnosis of CIDP may be
categorized as possible, probable, or
definite categories (See Table 1).17,18
Laboratory and electrodiagnostic
criteria for a definitive diagnosis
vary between institutions in level
of sensitivity and specificity.19 A
successful treatment trial in the
absence of clinical, laboratory, and
electrodiagnostic features may also help
confirm a diagnosis of demyelinating
neuropathy.10,17,20
Since CIDP is an extremely
heterogeneous condition, the exact
clinical manifestations differ from
person to person. Diagnosis depends
on which structures are involved such
as cranial nerves or central nervous
system21-25 and its clinical presentation
such as distal versus proximal and
symmetrical versus asymmetrical.26,27
Differential diagnosis may include
polyneuropathy associated with
monoclonal gammopathy of
undetermined significance (MGUS),
polyn europathy-organomegaly-
endocrinopathy M protein and skin
changes (POEMS), and Charcot-
Marie-Tooth disease (CMT).
Yet, age of onset, clinical course,
electrophysiological presentation, and
response to medical therapy of these
diagnoses differ from CIDP.28-30
Patients with CIDP follow one of
three clinical courses: monophasic,
relapsing, or progressive. The
monophasic course consists of one
single episode of clinical deterioration
followed by sustained improvement.
The relapsing course involves at least
two separate deteriorations with
at least one improvement between
relapses. The progressive course
presents with unremitting gradual
deterioration. Factors determining
clinical course are unknown.
The clinical course of CIDP is
heterogeneous with variable prognosis.
Sixty-one per cent (61%) of patients
with a relapsing or monophasic course
experience minimal non-disabling
symptoms.31 In contrast, only 8% of
patients with a progressive course
have minor symptoms. Patients with
CIDP often present with decreased
functional balance, diminished quality
of life, and increased fatigue.32 In
general, patients with a sub-acute
onset, symmetrical symptoms, and
distal nerve abnormalities in nerve
conduction studies (NCS) have better
prognostic outcomes compared
with those with a chronic onset,
asymmetrical presentation, and
demyelination in the proximal nerve
segments.31,33
Initiating intervention as early as
possible until improvement reaches
a plateau is the norm.34 The most
common medical therapies include
prednisone, plasmapheresis, and
intravenous immunoglobulin (IVIg),
with similar short-term efficacy among
the three.35 First choice may depend
on medical history and concurrent
medical status, cost, side effects, and
administration factors.
Prednisone dosage varies and
treatment continues until strength
returns to normal or the condition
reaches a plateau over a three-
to-six-month-timeframe. 8,18,34,36,37
As early as two weeks after the
initiation of prednisone, patients
often show improved strength and
disability scores.38 Treatment with
IVIg has a high response rate and
long-term efficacy.39 Plasmapheresis
is less commonly used due to its
invasive nature, the need for special
equipment, and high cost.40 Physicians
consider alternative therapies when
patients do not respond readily to
basic intervention or when they
relapse.36,41
Very little evidence-based literature is
available to assist therapists with the
rehabilitation of patients with CIDP.
One study examined the effects
of a 12-week high-intensity bicycle
exercise program on physical fitness,
functional outcome, fatigue, and
quality of life in patients with CIDP
and Guillain-Barr Syndrome (GBS).42
JACPT
Chronic Inflammatory Demyelinating Polyradiculoneuropathy from a Physical Therapists Perspective
Table 1. Diagnostic Criteria for CIDP17-19
Clinical Presentation
yy >2 months progressive onset of
symptoms
yy Majority of motor dysfunction
yy Symmetrical and proximal + distal
weakness
yy Areflexia or hyporeflexia
Laboratory Features
yy CSF protein level of >45 mg/dL
yy Nerve biopsy = demyelination
Electrodiagnostic Features (NCS)
yy Reduction in CV in >2 motor
nerves
yy Abnormal CB/TD in >1 motor
nerves
yy Prolonged DL in >2 motor nerves
yy Absent FW or prolonged minimum
FW latencies in >2 motor nerves
Abbreviations: CSF, cerebrospinal fluid; NCS, nerve conduction study; CV, conduction velocity; CB/TD,
conduction block/temporal dispersion; DL, distal latency; FW, F-wave.
Patients improved significantly in
their cardiovascular fitness, muscle
strength, and quality of life. Despite
the high intensity training, patients
also reported a twenty per cent (20%)
reduction in fatigue severity and
impact of fatigue from pre- to post-
intervention. Although impairments,
activity limitations, and participation
restrictions resulting from CIDP fall
under the physical therapists scope
of practice and the Guide to Physical
Therapist Practice includes a practice
pattern on GBS or CIDP (Pattern 5G:
Impaired motor function and sensory
integrity associated with acute or
chronic polyneuropathies),43 evidence
supporting PT as an integral part of
the functional recovery of CIDP is
anecdotal.
JACPT
Definite Probable Possible
All clinical All clinical All clinical
presentation must be presentation must be presentation must be
present present present
All laboratory CSF result must be 1 positive result out
features must be positive or 2 positive of 3 (CSF, biopsy,
present results out of 3 (CSF, NCS)
biopsy, NCS)
All NCS features 2 positive results out 1 positive result out
must be present of 3 (CSF, biopsy, of 3 (CSF, biopsy,
NCS) NCS)
Based on available literature, the rehabilitation prognosis and plan
physical therapists roles include: of care. For example, the physical
1. Facilitating medical referral and therapist needs to communicate
need for further diagnostic tests with physicians if patients with
preliminary diagnoses of CIDP do
when suspecting an unconfirmed
not show functional improvement
case of CIDP. For example,
with traditional medical therapies.
patients with clinical presentations
Differential diagnoses or change
suggestive of CIDP but with an
in medical therapy may need to
unknown etiology or diagnosis may
be considered. Rehabilitation
trigger a referral to physicians and
prognosis and plan of care may
suggestions for a lumbar puncture
need to be revised if a differential
or an NCS.
diagnosis results.
2. Using knowledge of atypical
3. Applying knowledge of the side
symptoms, clinical variants,
effects of prednisone therapy to
differential diagnoses, and varying
the choice of exercise options.
responses related to medical
For example, in the presence of
therapies to assist in differentiating
osteoporosis where high-impact
the condition from others, and
exercise may increase the risk
formulating a more accurate
for falls and fractures, the physical
Fall 2010 Volume I Number 1 6
Chronic Inflammatory Demyelinating Polyradiculoneuropathy from a Physical Therapists Perspective
therapist needs to adjust activity
accordingly.
4. Observing the patient for possible
side effects by closely monitoring
vital signs and reporting these
effects. For example, hypotension
and cardiac arrhythmia may occur
during IVIg and plasmapheresis
therapies and mobility may be
contraindicated.
5. Communicating observations in
a timely and objective manner to
other health care providers to
facilitate better plan of care. For
example, alert them to important
signs and symptoms as well as key
patient responses to functional
activities and therapeutic
interventions.
CASE DESCRIPTION
History
The patient was a 59-year-old man
with a past medical history of non-
Hodgkins lymphoma, papillary
thyroid cancer, hepatitis C, and liver
cirrhosis. His surgical history included
thyroidectomy, nonmyeloablative
allogeneic stem cell transplant, and
transjugular intrahepatic portosystemic
shunt (TIPS) placement. His general
health was otherwise noncontributory.
The patient worked as a civil engineer
during the six months prior to his
hospital admission, is married and lives
with his wife in a single-story home.
Approximately six months prior to
this hospital admission, the patient
had worsening liver function and
underwent TIPS placement with
subsequent improvement. Two
months later, he again experienced
worsening of liver disease, developed
low back pain, and lower extremity
weakness. Symptoms progressed to
include headaches, fatigue, and bouts
of pneumonia. The patients functional
ability decreased over a four-month
period leading to wheelchair use for
mobility. Multiple acute care hospital
admissions followed and eventually
he was admitted to a skilled nursing
facility (SNF). Despite continued
rehabilitation, his functional status
continued to decline. This was initially
7 Fall 2010 Volume I Number 1
attributed to end-stage liver disease,
leading to discharge to home hospice
care. Eventually, during an acute care
admission for respiratory distress,
further diagnostic tests revealed
demyelinating features in the upper and
lower extremities, most prominent in
the distal regions, compatible with
CIDP. A definitive diagnosis of CIDP
was made one week after this hospital
admission.
Systems Review & Examination
At the initial PT examination, the patient
reported a 50-pound weight loss over the
last several months. Table 2 shows the
results of the cardiovascular/pulmonary,
integumentary, neuromuscular,
musculoskeletal, and internal organs
systems review. Both the patient and
his wifes goal was to obtain a definitive
diagnosis of his condition with the
ultimate hope that his condition was
treatable. The patient also wanted to
regain the ability to ambulate.
Physical examination included:
1. Pain: The patient reported 8-10/10
pain in the low back and bilateral
hips on the numeric pain rating
scale (NPRS), where zero = no
pain and 10 = worst possible pain.
NPRS is a responsive measure in
patients with low back pain.44 His
pain increased with touch or any
gentle lower limb movements, and
eased with rest and intravenous
(IV) morphine.
2. Passive range of motion (PROM):
Bilateral upper extremity PROM
was within functional limits (WFL).
Therapists were unable to test
PROM of the lower extremities
secondary to pain. From
observation during functional
mobility, he showed bilateral
passive hip and knee flexion to
90 in sitting, bilateral hips and
knees reached full extension in
supine, and ankle dorsiflexion to
a neutral position.
3. Coordination: He demonstrated
diminished finger-nose-finger
coordination and rapid alternating
movements (RAM) tests of his
upper extremities. The tests did
not reveal any gross dysmetria.
Coordination and RAM of his lower
extremities were not available due
to severe weakness and pain.
4. Sensory systems: Proprioception,
vibration, and pinprick sensation
were decreased on both lower
limbs and bilateral C3-4 dermatome
sensation.
5. Tone: Muscle tone in the upper
extremities was grade one (1)
on the Modified Ashworth Scale
but did not limit functional ROM.
Pain on both lower extremities
prevented the examination
of muscle tone. Deep tendon
reflexes (DTRs) were absent
at the Achilles tendons and
diminished (1+) at biceps, triceps,
and patellar tendons bilaterally.
6. Muscle strength: Weakness
was more severe in both lower
extremities than the upper
extremities and in distal versus
proximal regions (Table 3).
7. Functional abilities: Based on
the Functional Independence
Measure (FIM),45 bed mobility,
feeding, grooming, and orientation
required total assistance; problem
solving and attention to task
required moderate assistance
(Table 4).
While the Guide to Physical Therapist
Practice43 also suggested other tests
and measures, they were not included
at the initial examination due to the
patients low functional level, pain, and
activity tolerance.
Evaluation and Diagnosis
This patient was totally dependent
for all activities of daily living (ADLs)
and functional mobility with the
inability to continue his previous role
as an engineer. He presented with
significant pain, impaired sensation,
impaired DTR, significant weakness
in all extremities, impaired sphincter
control, and impaired social cognition.
His impairments, activity limitations,
and participation restrictions were
consistent with Practice Pattern 5G:
JACPT
Chronic Inflammatory Demyelinating Polyradiculoneuropathy from a Physical Therapists Perspective
Table 2. System Reviews
Systems
Cardiovascular/Pulmonary
Musculoskeletal
Neuromuscular
Integumentary
Internal Organ
Incontinent bowel and bladder
Impaired Motor Function and Sensory
Integrity Associated with Acute or
Chronic Polyneuropathies.43 The
physical, occupational, and speech
therapists recommended patient
discharge to an inpatient rehabilitation
setting after his acute care stay to
optimize functional recovery. In
addition, he would benefit from a social
work or psychology consultation for
emotional support during the process
of rehabilitation.
Prognosis
For CIDP, prognosis depends on clinical
course, clinical presentation, and initial
response to medical therapy.31,33 Long-
term poor outcomes, including severe
disability and inability to walk, occur in
thirteen per cent (13%) of patients with
CIDP even without comorbidities.32,34
Since this patients path to a confirmed
CIDP diagnosis was lengthy, with
severe existing co-morbidities, clinical
presentation and initial response to
medical therapy would determine his
prognosis. Strong indicators included
a somewhat symmetrical clinical
presentation, demyelination in the
distal nerve with abnormalities in NCS,
JACPT
Results
Temperature: 37.1C
Blood pressure: 115/73 mmHg in supine
Heart Rate: 95 beats per minute (bpm)
Respiration: 18 bpm
Oxygen saturation: 93% on two liters of oxygen
Symmetrical weakness, lower extremities weaker than upper extremities
Alert & Oriented x 2
Mild dysarthria
Limited bilateral upward gaze & impaired bilateral smooth pursuit
Diplopia on the far right gaze
Impaired proprioception/sensation
Abnormal tone and deep tendon reflexes (DTR)
Skin rash at buttock area
Negative liver and renal function tests
and a fair response to initial steroid ulcer development. Bed mobility
therapy. Due to a chronic onset of activities include rolling, scooting,
CIDP, expectations were for a slow bridging, and supine to and from
and incomplete functional recovery sitting.
with the patient requiring assistive
4. Increased bed to wheelchair
devices and perhaps orthothes for transfer from unable (limited by
future functional mobility. On a positive
pain) to dependent assistance of
note, this patient was very motivated two persons. This would increase
and had a supportive family.
sitting tolerance for pneumonia
Plan of Care and Interventions prevention.
Physical therapy short-term goals (one Physical therapy long-term goals (three
week) included:
weeks) included:
1. Decreased pain level at low back
1. Decreased pain level at low back
and bilateral hips from 8-10/10 and bilateral hips to 5/10 on NPRS
to 7/10 on NPRS to enable
to enable participation in transfer,
participation in bed mobility, seated ADLs, and wheelchair
transfer, and seated ADLs.
mobility.
2. Improved static sitting balance 2. Improved overall muscle strength
from dependent assistance to by one grade on MMT to facilitate
maximal assistance to enable use of extremities for functional
participation in seated ADLs and mobility.
prevent adverse effects from
prolonged bed rest. 3. Improved static sitting balance
with dependent assistance to
3. Improved bed mobility from
dynamic sitting balance with
dependent assistance of two
stand-by assistance to facilitate
persons to maximal assistance of
independence in seated ADLs
two persons to prevent pressure
using upper extremities.
Fall 2010 Volume I Number 1 8
Chronic Inflammatory Demyelinating Polyradiculoneuropathy from a Physical Therapists Perspective
Table 3. Manual Muscle Testing of Major Muscle Groups
Muscle Groups
(Bilateral, Symmetrical)
Shoulder flexion
Shoulder abduction
Elbow flexion
Elbow extension
Wrist flexion
Wrist extension
Finger flexion
Finger extension
Hip flexion
Hip extension
Hip internal/external rotation
Knee flexion
Knee extension
Ankle dorsiflexion
Ankle plantarflexion
4. Improved bed mobility from
dependent assistance of two
persons to moderate assistance
of one person to maintain skin
integrity. Bed mobility activities
include rolling, scooting, bridging,
and supine to and from sitting.
5. Improved bed to wheelchair
transfer from unable (limited by
pain) to maximal assistance of
one person squat pivot transfer
with a sliding board. This would
increase time out of bed for
seated ADLs and exercises.
6. Improved wheelchair mobility
from unable to able to propel
wheelchair 150 feet with
minimal assistance (required
assistance less than 25% of time)
to increase independence with
locomotion.
Initial goals did not include ambulation
secondary to significant lower
extremities weakness on MMT, pain,
limited activity tolerance, and risk of
overstretch weakness. The physical
therapist examined the patients
condition weekly and used examination
results to determine whether the patient
was ready to initiate gait training.
9 Fall 2010 Volume I Number 1
Initial Examination
3/5
2/5
3/5
3/5
3-/5
3-/5
2/5
2/5
1/5
1/5
1/5
0/5
0/5
0/5
0/5
Intervention sessions: Each session
consisted of approximately thirty
minutes of therapeutic exercise
and functional mobility training for
an average of five times per week.
The actual duration of each visit and
frequency of treatment depended
primarily on the patients activity
tolerance and fatigue level, as well
as the operational nature in the
acute care setting. The patient also
performed ADLs (grooming, personal
hygiene, and upper body dressing)
to tolerance and strengthening
exercises using exercise putty and
elastic bands outside of PT sessions.
In addition, nursing staff assisted
the patient to get out of bed into a
cardiac chair initially and a wheelchair
using a mechanical lift as the patient
progressed. Table 5 summarizes
the interventions by week. The
interventions were chosen based
on the patients interests, goals, and
priorities in this setting. This was
an attempt to minimize the adverse
effects of bed rest, balancing overuse
and fatigue with the patients pain
level, and perceived effort related to
activities, and motivation.
Discharge
4/5
4/5
5/5
5/5
4/5
4/5
3/5
3/5
2+/5
2-/5
2-/5
2/5
3/5
3-/5
3/5
Outcomes
About one week after the beginning of
prednisone therapy, the patient made
substantial progress in his strength
and functional mobility. He stayed in
the acute care hospital for one month
and progressed steadily in his body
function, strength, and functional
mobility (Tables 3, 4, 6). Upon
discharge from acute care, the patient
required minimal assistance for bed
mobility, supervision for wheelchair
mobility on level ground, and maximal
assistance of two persons for bed
to wheelchair transfer. He was able
to maintain good sitting balance
without support while performing
ADLs. Improvement in overall ADLs
performance, social cognition, and
continence bowel management
supported his admission to an acute
rehabilitation setting.
The positive relationship between
team members was a key to optimal
patient management in addition to a
fluid and dynamic approach to the plan
of care. While the literature reported
daily multidisciplinary rounds in
intensive care units were associated
with decreased mortality rate,46 no
published frequency guidelines for
JACPT
Chronic Inflammatory Demyelinating Polyradiculoneuropathy from a Physical Therapists Perspective
Table 4. Functional Independence Measure (FIM)44
FIM category Admission Discharge
Self-care
1. Eating 1 5
2. Grooming 1 5
3. Bathing 1 1
4. Dressing upper body 1 3
5. Dressing lower body 1 3
Sphincter control
6. Bladder management 1 1
7. Bowel management 1 1
Transfers
8. Bed, chair, wheelchair 0 1
9. Toilet 0 1
10. Tub, shower 0 1
Locomotion
11. Walk/wheelchair 0 5 (wheelchair)
12. Stairs 0 1
Communication
13. Comprehension 6 7
14. Expression 4 7
Social cognition
15. Social interaction 2 6
16. Problem solving 2 4
17. Memory 2 4
Total FIM Score 23 56
FIM Levels. 7 = Complete independence (timely, safe, no helper). 6 = Modified independence (device, no helper). 5 = Supervision (subject
= 100%). 4 = Minimal assist (subject = 75%+). 3 = Moderate assist (subject = 50%+). 2 = Maximal assist (subject = 25%+). 1 = Total assist
(subject = less than 25%). 0 = Unable to test.
medical unit rounds exists. In this condition, and providing input intolerance or adverse side-
case, the authors believed frequency during patient rounds. effects).
and quality of interactions and 3. Key areas: Alerts for medical The strength of communication
communications served this patient concerns, issues, challenges, included focus on patient-
well. These included: and obstacles that limit centered goals and support for
1. Frequency: Daily reciprocal rehabilitation progress, providers, patient, and family. A
communication exchanges patient frustration levels, weak area for this particular case
with occupational/speech and achievements towards was that communications were
therapists and nurses, and functional goals, exercise not always totally clear and timely.
as needed with physicians. tolerance, general motivation, Recommendations for future
Weekly patient-care rounds and well-being. improvement include greater
with all other disciplines such 4. Red flags: Communications sharing of test results, medication
as social workers and case for any neurologic changes, changes, and possible side effects
managers. significant decline in muscle of and expected results from
2. Type: Reading progress notes strength and/or functional medications and rehabilitation.
of other team members, abilities (signs and symptoms
discussing changes in patient may indicate medication
JACPT Fall 2010 Volume I Number 1 10
Chronic Inflammatory Demyelinating Polyradiculoneuropathy from a Physical Therapists Perspective Chronic Inflammatory Demyelinating Polyradiculoneuropathy from a Physical Therapists Perspective

Table 5. Summary of Weekly Physical Therapy Intervention Table 6. Summary of Weekly Physical Therapy Progress in Functional Mobility & Pain

Week 1 Week 2 Week 3 Week 4 Initial End of Week 1 End of Week 2 End of Week 3 Discharge
yy PROM and AAROM yy PROM and AAROM yy AAROM and AROM yy AAROM to lower Examination
to upper and lower to upper and lower to upper and lower extremities, 5-10 Pain yy 8-10/10 on yy 7-8/10 on yy 9/10 on yy 5/10 on yy 4/10 on
extremities, 5-10 extremities, 5-10 extremities, 5-10 repetitions each NPRS at low NPRS at low NPRS at low NPRS at low NPRS at low
repetitions each repetitions each repetitions each back and back and back and back back
yy Hand strengthening bilateral hips bilateral legs abdomen
yy Sitting balance and yy Sitting balance and yy Sitting balance and using exercise putty
functional activities at functional activities at functional activities Static Sitting yy Dependent yy Minimal yy Contact yy Supervised yy Supervised
edge of bed edge of bed yy Sitting balance and Balance assistance assistance guard
yy Standing Frame functional activities assistance
yy Transfer training yy Standing Frame or Dynamic Sitting yy Unable yy Maximal yy Minimal yy Contact yy Stand-by
between bed and Body Weight Support Balance assistance assistance guard assistance
wheelchair Therapy assistance
Bed Mobility yy Total yy Maximal yy Moderate yy Moderate yy Minimal
yy Transfer training
assistance of assistance of assistance of assistance of assistance of
between bed and
2 persons 2 persons 2 persons 1 person 1 person
wheelchair
Transfer yy Unable yy Unable yy Maximal yy Maximal yy Maximal
yy Wheelchair mobility assistance of assistance assistance of
Abbreviation: PROM, passive range of motion; AAROM, active-assisted range of motion; AROM, active range of motion. 2 persons to of 2 persons 1-2 persons
cardiac chair bed to bed to
wheelchair wheelchair
DISCUSSION of care. Medical interventions were key regardless of disease stages and Locomotion yy Unable yy Unable yy Unable yy Supervised yy Independent
The purpose of this case report was initially to reversing the inflammatory settings would have been beneficial. wheelchair wheelchair
to describe the collaborative medical process, which allowed the patient to The Fatigue Severity Score and Fatigue mobility on mobility on
and PT management of a patient with benefit from rehabilitation. Impact Scale are two examples of level ground level ground
CIDP who had multiple significant co- The patient in this case had slow potential outcome measures that 150 feet 500 feet
morbidities and many complications functional gains despite improvement could be used to indicate a change Abbreviation: NPRS, numeric pain rating scale.
over the course of his diagnostic in strength and endurance. in self-reported fatigue with exercise
and acute care period. The patients Complications related to his co- trainings.42 The development of
course of improvement relied on morbidities, which included an standardized outcome measures and
demyelinating polyneuropathy in New et al. Epidemiologic variability of influenza vaccine chronic inflammatory
coordination of care between the incidental finding of kidney stones, a specific practice guidelines for CIDP
South Wales, Australia. Ann Neurol. chronic inflammatory demyelinating demyelinating polyneuropathy. Age
medical and rehabilitation teams for urinary tract infection with methicillin- could lead to best practice care for 1999;46(6):910-913. polyneuropathy with different diagnostic Ageing. 2008;37:229-230.
optimal recovery. In the first two resistant staphylococcus aureus, and this condition.48 criteria: study of a UK population.
weeks of his acute care admission, 3. Lunn MP, Manju H, Choudhary PP, et 14. Pritchard J, Mukherjee R, Hughes
TIPS malfunctioning during his acute Muscle Nerve. 2009;39:432-438.
al. Chronic inflammatory demyelinating RA. Risk of relapse of Guillain-Barr
the patient showed little progress care stay, might have contributed to ACKNOWLEDGMENTS polyradiculoneuropathy: A prevalence 8. Kissel JT. The treatment of chronic syndrome or chronic inflammatory
in bodily function and mobility. His the slow improvement. The authors thank Jeffrey Teraoka, study in southeast England. J Neurol inflammatory demyelinating demyelinating polyradiculoneuropathy
initial pain level, low functional status, MD, Lisa Ikuma, MSPT, Debby Bolding, Neurosurg Psychiatry. 1999;66:677-680. polyradiculoneuropathy. Semin Neurol. following immunization. J Neurol
poor endurance, and anxiety about While the role of exercise prior to MS, OTR/L, and Diane Allen, PT, PhD 2003;23:169-179. Neurosurg Psychiatry. 2002;73:348-349.
the beginning of medical therapy is 4. Mygland A, Monstad P. Chronic
mobility greatly limited physical for their valuable comments during polyneuropathies in Vest-Agder, 9. Laughlin RS, Dyck PJ, Melton LJ, et al. 15. Arguedas MR, McGuire BM.
therapy interventions. The physical unclear, an appropriate level of training the preparation of the manuscript. Norway. Eur J Neurol. 2001;8:157-165. Incidence and prevalence of CIDP and Hepatocellular carcinoma presenting
therapists provision of supportive may minimize complications related
the association of diabetes mellitus. with chronic inflammatory
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19. Magda P, Latov N, Brannagan III TH,
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21. Alwan AA, Mejico LJ. Ophthalmoplegia,
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23. Kokubun N, Hirata K.
Neurophysiological evaluation
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25. Pineda AAM, Ogata K, Osoegawa
M, et al. A distinct subgroup of
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26. Katz JS, Saperstein S, Gronseth G,
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symmetrical neuropathy. Neurology.
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27. Lewis RA, Summer AJ, Brown MJ, et
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28. Notermans NC, Franssen H,
Eurelings M, et al. Diagnostic criteria
for demyelinating polyneuropathy
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29. Dispenzieri A. POEMS syndrome.
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30. Pareyson D. Differential diagnosis of
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31. Mygland A, Monstad P, Vedeler C. Onset
and course of chronic inflammatory
demyelinating polyneuropathy. Muscle
Nerve. 2005;31:589-593.
32. Kuwabara S, Misawa S, Mori M,
et al. Long term prognosis of
chronic inflammatory demyelinating
polyneuropathy: A five year follow up
of 38 cases. J Neurol Neurosurg Psychiatry.
2006;77:66-70.
33. Westblad ME, Forsberg A, Press
patients with chronic inflammatory
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Rehabil. 2008;24:1-6.
34. Toothaker TB, Brannagan TH.
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35. van Schaik IN, Winer JB, de Hann R,
et al. Intravenous immunoglobulin for
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polyradiculoneuropathy (Review).
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36. Gorson KC, Ropper AH. Chronic
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37. Said G. Chronic inflammatory
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Neuromuscul Disord. 2006;16:293-303.
38. Hughes R, Benas S, Willison H, et
al. Randomized controlled trial of
intravenous immunoglobulin versus oral
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demyelinating polyradiculoneuropathy.
Ann Neurol. 2001;50:195-201.
39. Hughes R. The role of IVIg in
autoimmune neuropathies: the latest
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40. Hahn AG, Bolton CF, Pillay N,
et al. Plasma-exchange therapy in
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polyneuropathy: a double-blind, sham-
controlled, cross-over study. Brain.
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41. Kuitwaard K, van Doorn PA.
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polyradiculoneuropathy. Drugs.
2009;69(8):987-1001.
42. Garssen MPJ, Bussman JBJ, Schmitz
PIM, et al. Physical training and fatigue,
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43. APTA. Guide to Physical Therapist
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Responsiveness of the numeric pain
rating scale in patients with low back
pain. Spine. 2005;30(11):1331-1334.
45. Ottenbacher KJ, Hsu Y, Granger CV,
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47. Boukhris S, Magy L, Gallouedec G,
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JACPT
CLINICAL

PRACTICE
University of Rochester Acute
Care Evaluation: Development
of a New Functional Outcome
Measure for the Acute Care
Setting
Julie DiCicco, Deborah Whalen
Julie DiCicco, MPT
ABSTRACT
Physical Therapist, University of
The Physical Therapy Department at the University of Rochester Rochester Medical Center
determined a need for a functional outcome measure to be used Julie_DiCicco@urmc.rochester.edu
in the acute care setting because current outcome measures in
Deborah Whalen, PT, DPT, MS
practice do not quantify the lower level function often found in this Senior Physical Therapist, University of
setting. After reviewing the literature, the Johns Hopkins Hospital Rochester Medical Center
Functional Acute Care Score (or JHH-FACS) was chosen to be Deborah_Whalen@urmc.rochester.
edu
trialed and did not adequately quantify the functional abilities of our
patient population. The tool was modified after a trial use period
and survey of staff members to create a new tool. We describe the
steps taken to create the outcome measure, called the University
of Rochester Acute Care Evaluation (or URACE), that objectively
assesses an individuals function while in the acute care setting.
Functional assessment is one of the acute care setting has been difficult. Due to the nature of the illnesses or
crucial elements of the initial evaluation The recent focus on improving efficiency injuries that cause individuals to be
for acute care physical therapy practice.1 admitted to acute care hospitals, declines
and reducing medical costs has led to
In the hospital setting, physical therapists a significant decrease in length of stay in strength are common, which can impair
employ interventions to address functional for acute care hospitalizations.2 This tasks such as bed mobility, transfers, and
impairments related to strength, range of focus demands the acute care physical ambulation. Significant functional decline
motion, flexibility, joint integrity, muscular therapist prepare for discharge early in has been observed within 48 hours of
endurance, and cardiopulmonary the rehabilitation process. Early discharge hospitalization.4 Although the average
dysfunction. Accordingly, an individualized planning is frequently complicated length of stay has decreased from 7.8
plan of care is formulated by acute care as many individuals develop new or days in 1970 to 4.8 days in 2005, the time
physical therapists to address functional worsening functional impairments during many individuals spend in the hospital can
skills such as gait, transfers, and bed hospitalization; therefore regaining still contribute to debility and decrease in
mobility.1 Functional outcome measures mobility may occur at a much slower function.5 The potential for long-term
are tools used to standardize assessment, rate than the resolution of the acute loss of function has led to an emphasis on
analyze outcomes and improve quality of illness.3 In addition, the aging population improving mobility as quickly as possible
care for individuals undergoing physical will continue to increase the demand for to enable the individual to be discharged
therapy treatment. However, finding either directly home or to a shorter term
overall medical care and in turn physical
research in outcome measures for the therapy referrals. facility.
JACPT Fall 2010 Volume I Number 1
Evaluation: Development of a New Functional Outcome Measure for the Acute Care Setting
In the acute care setting, the physical
therapists role includes clearly
and objectively documenting the
individuals functional status as a
means of developing a plan of care
and making an appropriate discharge
recommendation. The use of outcome
measures allows physical therapists
to standardize the assessment and
documentation of an individuals initial
functional status. Outcome measures
allow reassessment, so physical
therapists can objectively document
an individuals improved level of
function, determine the effectiveness
of treatment, and finalize discharge
planning. Discharge planning relies on
the physical therapist to determine an
individuals previous level of function
and then compare it to the current
level of function as documented by
the functional outcome measure.2
The individuals home environment,
equipment and any assistance at home
are also taken into consideration.6
Discharge planning is therefore highly
dependent on individuals functional
mobility supporting the need for
a standardized tool to ensure an
objective assessment.
Due to the short length of stay and
focus on early discharge planning the
acute care setting is often fast paced.
Individuals also may receive care
from many different services during
the course of only a few days, often
reducing the time available for the
physical therapist to effectively treat
patients in a manner that will make
substantial improvements in their
functional status. Many therapists
in acute care settings report feeling
inadequate time to work with
individuals due to the severity of
individuals illnesses, and interruptions
from other health care professionals
and visiting families.1 Consequently,
outcome measures for this setting
should be designed so they can be
completed in a timely manner due
to limited individual contact time and
potential interruptions.
One of many functional outcome
tools used by physical therapists is the
Functional Independence Measure (or
15
FIM). FIM is an appropriate outcome
tool for objectively assessing function
in acute rehabilitation because of its
validity in the general population
and its reliability, However, FIM has
not been shown to be effective in
the acute care population.7 A floor
effect can be seen in using the FIM for
acute care due to the small functional
improvement that is sometimes made
in such short hospital stays and the low
functional status of many individuals
referred to physical therapy. Notably,
the FIM does not account for the
effects of medical complications and
interruptions from other members
of the medical team that often occur
in the hospital setting. Complete FIM
scoring requires input from other
health care professionals as it is not
designed solely for assessing mobility.
Less known is the Alpha FIM
instrument, which was modified from
the FIM, for the purpose of measuring
an individuals functional status
during the first 72 hours of acute
care hospitalization.8 The Alpha FIM
was designed to triage individuals by
determining the next appropriate care
setting and pinpointing the earliest
opportunity for transfer, but presents
with the same interdisciplinary
limitations as the FIM.8 Due to
the limitations associated with the
FIM and Alpha FIM, a tool that
exclusively measures mobility that
can be completed independently by
a physical therapist is necessary for
efficient assessment in busy acute care
hospitals.
In 1996, the Johns Hopkins Hospital
research committee piloted a purpose of the functional outcome
modification to the motor FIM for
use in the acute care inpatient setting,
which they called the JHH-FACS. 9
The JHH-FACS was more specific
than the FIM due to the ability to
score each assistive device used as
well as breaking down the increments
of distance for locomotion. The
principal objective was to improve
the sensitivity of the motor portion of
the FIM while taking into account the
efficiency needed to be applicable to
the busy environment of the acute care
Fall 2010 Volume I Number 1
setting. A small pilot study provided
little detail regarding the methodology
used to perform testing of inter-rater
and intra-rater reliability. The findings
indicated fair reliability with transfer
ability and fair to good reliability with
locomotion. The reliability of stair
testing was incomplete due to lack of
sufficient data.9
Many other functional outcome tools
exist in the physical therapy literature
including but not limited to the Timed-
Up-and-Go Test (or TUG),10 the Berg
Balance Scale,11 the gait speed test12
and chair rise test.13 These outcome
tools were created to objectively
measure an individuals mobility.
However, many of the tasks involved
are too high functioning for a large
number of individuals in an acute care
setting and thus a floor effect might be
seen. Tools such as those mentioned
above may also fail to capture small
changes in the function of the activity
being measured. For example, a
person not able to stand without
assistance would receive a score of 0
on the TUG, gait speed and chair rise
tests because the tools only take into
account an individuals ability to stand
and walk, totally excluding any ability
to sit up from bed.
After reviewing the current
literature we were unable to find
any standardized outcome measures
relevant to patients in the acute
care setting that met our needs of
effectively analyzing the requisite
functional mobility skills related to
bed mobility, transfers, ambulation
and stair negotiation. Therefore, the
committee was to create an outcome
measure that would objectively assess
an individuals function while in acute
care.
METHODOLOGY
The Functional Outcome Committee
of the URMC Physical Therapy
Department trialed several different
outcome measures in an effort to
find a test that would be appropriate
at both evaluation and discharge for
our acute care hospital patients. The
physical therapy department started
JACPT
Evaluation: Development of a New Functional Outcome Measure for the Acute Care Setting
using the chair-rise and the gait and no further changes were deemed rail. The subset categories were also
speed tests as they were quick, easy necessary. able to identify measurable changes
and objective. Unfortunately, these RESULTS in functional mobility in patients who
outcome measures were not inclusive Based on the therapists survey were primarily bed bound.
enough for non-ambulatory individuals responses, the Functional Outcome As suggested by many of the acute
in the hospital setting. The next Committee made changes to the design care therapists, revisions were made
functional outcome measure trialed of the JHH-FACS in order to make it to improve sensitivity to ambulation
was the JHH-FACS. The committee more specific to the population in our distance as the previous JHH-FACS
introduced and in-serviced staff on the medical center. When changing the did not account for distances less than
JHH-FACS tool, and precise methods JHH-FACS, the first area addressed 5 feet.9 In the acute care setting, the
of scoring as shown in Appendix was the issue of bed mobility not being measurement of subtle changes in
1. Thirteen staff therapists, ranging scored independently of transfers and distances ambulated were necessary
from less than 1 year to more than therefore neglecting possible progress as hospitalized individuals are typically
20 years of acute care experience, being made by low functioning only seen for an average of 5 days
were trained in the use and scoring individuals. A considerable number per week. Therefore, small changes
of the instrument before using it on of individuals referred to physical in function need to be captured and
individuals in the hospital. The staff therapy at URMC have neurological measured as objectively as possible.
therapists had varying educational disorders, severe deconditioning and A further modification was also made
levels from bachelors to doctorate other severe conditions that limit or to the stair section. The category
degrees in physical therapy. All prevent transfers and ambulation. of stairs was broken into 4 subsets
thirteen staff members were asked The JHH-FACS was changed to allow to better quantify the number of
to utilize the tool to score all adult assessment of lower level mobility steps completed by an individual and
individuals at evaluation and discharge in bed bound individuals without to increase the overall sensitivity of
and record all scores on the data experiencing the floor effect present the tool. (See Appendix 3) The new
sheets. After a 3-month trial period, in the JHH-FACS. A subset system outcome tool was named the URACE.
the functional outcome committee was also created for the height of the All staff was trained in how to score
surveyed the physical therapists on head of the bed and the use of bed the tool before administering it to
their opinion of the JHH-FACS and rails due to the variety of conditions individuals in the hospital.
any suggested changes to the tool. and contraindications seen in the
The survey questions are included The scoring of the entire URACE
hospital setting. (See Appendix 3) tool was also uniformly changed to
in Appendix 2. The survey answers Higher scores were given for the
were used to make changes to the numeric values to allow for ease
ability to get out of bed with the in statistical analysis and for a total
tool to produce a more objective, head of the bed flat and no use of
sensitive outcome measure for the score to be calculated. The original
a bed rail as this is more difficult to JHH-FACS tool was scored with both
acute care physical therapists. (See perform. Subset categories helped
Table 1) The new tool was again numbers and letters and was found
to further standardize assessments to be confusing for the therapists
trialed for three months by all staff as an individuals ability to get out of
therapists. The survey was again given scoring the tool. The URACE
bed can vary greatly depending on the scoring form was also reformatted to
to the staff members for suggestions position of the bed and utilization of a
Table 1. Feedback from staff survey following trial of the JHH-FACS
Assesses patients abil-
Ease of use Ease of scoring Scoring specificity ity
No specific instructions
Confusing with numbers for bed positioning or bed Groups bed mobility and
Quick to administer and letters rail transfer abilities together
Ambulation distance does Able to assess ambulatory
Includes only functional Difficult to remember all not include distances less and non-ambulatory
activities scoring instructions than 5 feet individuals
Includes activities that Stair distances given only Able to assess with or
are already part of typical Still somewhat subjective 2 choices and not able to without use of assistive
evaluation in acute care scoring score for less than 6 steps devices for activities
JACPT Fall 2010 Volume I Number 1 16
Evaluation: Development of a New Functional Outcome Measure for the Acute Care Setting
provide the therapist with a scoring
key on the same document to avoid
having to refer back separate scoring
instructions for every individual seen.
(See Appendix 3) Prior to using the
URACE, all therapists were trained
in the proper testing and scoring of
the new tool. (See Appendix 4) The
procedure of testing also needed to
be consistent so that patients were
assessed in the same way regardless
of the clinician in an effort to improve
interrater reliability. Therefore, the
committee members decided, that
the first time an individual performed
a supine to sit maneuver with a
physical therapist a URACE outcome
measure was scored despite whether
this occurred during the initial visit or
on a subsequent visit. This ensured
that all individuals being scored were
off of bed rest and able to tolerate
sitting upright.
DISCUSSION
The goal of the functional outcome
committee was to create an outcome
measure that would objectively
assess an individuals function in
the acute care setting as the trend
in health care is on greater use of
tools to objectify current evaluation
techniques and assess outcomes to
help determine treatment efficacy.14
With a focus on cost-saving measures
and improved efficiency in health
care today, physical therapists
productivity has come under great
scrutiny in the hospital setting. This
requires an outcome measure that
is both quick to administer and easy
to score.2 Many physical therapists
often choose to not administer an
outcome measure on patients due
to time constraints or the lack of
availability of an appropriate measure.
Many changes were made to the JHH-
FACS to create more sensitivity for
lower functioning individuals that
are often seen in the acute care
setting. The URACE is clearly able to
assess a persons function from bed
mobility through stair negotiation.
Accommodations were also made for
different bed positions and equipment
used during mobility in order to
17
ensure re-test scores were accurately
measuring progress and helping to
increase inter-rater reliability.
The URACE was designed with
efficiency in mind. It is comprised of
activities already included in a typical,
general physical therapy evaluation
so that no extra time is needed to
administer the tool. The scoring of
the tool can also be accomplished in an
efficient manner simply by circling the
correct score for each of the assessed
activities. If a particular activity cannot
be completed not tested is circled
and the tester provides a brief written
explanation. (See Appendix 3)
Similar to the FIM, the limitations to
the URACE include not being able to
account for individuals who are not yet
stable enough for mobilization. The
URACE tool allows physical therapists
to assess the ability to go from supine
to sitting at the edge of the bed, but
does not account for lower level bed
bound activities such as rolling or
scooting up in bed. Another limitation,
like the FIM, is that the scoring of
the assistance level provided to the
patient is still somewhat subjective.
The amount of assistance is scored
based on the percentage of the task
completed by the patient and could
be perceived differently by separate
therapists. While this method of
grading was found to be reliable in the
FIM7, it is still a somewhat subjective
grading system. The URACE has not
thus far been tested for reliability and
validity. Further study would need
to be done to determine whether it
has acceptable validity. Additionally,
the URACE has no total score so
therefore at this time it cannot be
statistically correlated to the FIM or
any other functional outcome tool.
Further testing may also be useful to
determine if the URACE can play a
role in predicting appropriate setting
for discharge.
Overall, the URACE outcome measure
is appropriate to use in the acute care
setting of a level I trauma center for a
multitude of individuals. Clinicians in
acute care or perhaps skilled nursing
facilities could use this tool as it would
Fall 2010 Volume I Number 1
closely encompass their populations
functional abilities.
REFERENCES
1. Curtis KA, Martin T. Perceptions
of acute care physical therapy
practice: Issues for physical therapist
preparation. Phys Ther. 1993;
73(9):581-594.
2. Jette DU, Brown R, Collette N, Friant
W, Graves L. Physical therapists
management of patients in the acute
care setting: An observational study.
Phys Ther. 2009; 89(11):1158-1181.
3. Hirsch CH, Sommers L, Olsen A,
Mullen L, Winograd CH. The natural
history of functional morbidity in
hospitalized older patients. J Am
Geriatr Soc. 1990; 38(12):1296-1303.
4. Cornette P, Swine C, Malhomme B,
Gillet JB, Meert P, DHoore W. Early
evaluation of the risk of functional
decline following hospitalization of
older patients: Development of a
predictive tool. Eur J Public Health.
2006; 16(2):203-208.
5. DeFrances CJ, Hall MJ. 2005 national
hospital discharge survey. Adv Data.
2007; (385):1-19.
6. Lopopolo RB, Keehn M. The effect of
hospital restructuring on the role of
physical therapists in acute care. Phys
Ther. 1997; 77(9):918-936.
7. van der Putten JJ, Hobart JC, Freeman
JA, Thompson AJ. Measuring change in
disability after inpatient rehabilitation:
Comparison of the responsiveness of
the barthel index and the functional
independence measure. Journal
of Neurology, Neurosurgery &
Psychiatry. 1999; 66(4):480-484.
8. Anonymous. Measurement and
Outcomes in the Acute Hospital.
Proceedings of the Measurement and
Outcomes in the Acute Hospital,
February 2007.
9. The John Hopkins Hospital.
JHH Function Acute Care Score
<http://www.acutept.org/resources.
html>.1996.
10. Yeung TS, Wessel J, Stratford PW,
MacDermid JC. The timed up and
go test for use on an inpatient
orthopaedic rehabilitation ward.
Journal of Orthopaedic & Sports
Physical Therapy. 2008; 38(7):410-
417.
JACPT
Evaluation: Development of a New Functional Outcome Measure for the Acute Care Setting
11. Shumway-Cook A, Baldwin M, the clinical setting. J Am Geriatr Soc. 14. Kigin C. A systems view of physical
Polissar NL, Gruber W. Predicting 2003; 51(3):314-322. therapy care: Shifting to a new
the probability for falls in community- paradigm for the profession. Physical
13. Ferrucci L, Guralnik JM, Bandeen-
dwelling older adults. Phys Ther. 1997; Therapy. 2009; 89(11):1117-1119.
Roche KJ, Lafferty ME, Pahor M,
77(8):812-819.
Fried LP. <http://www.grc.nia.nih.gov/
12. Studenski S, Perera S, Wallace D, et branches/ledb/whasbook/tablcont.
al. Physical performance measures in htm>.
Appendix 1 Appendix 2
Appendix 1 {{144 The John Hopkins Hospital 1996; }}
144 The John Hopkins Hospital 1996 Questionnaire
on the JHH-FACS
In your opinion is the JHH-FACS
easy to administer?
Yes No
If no, please explain why.
In your opinion is the JHH-FACS
easy to score?
Yes No
If no, please explain why.
Instr: Circle appropriate item in each column.
* Please indicate below nature of interrupted score.
Was the scoring specific
*__________________________________________
enough?
__________________________________________
Yes No
Patient name: __________________________
Therapist scoring I.E.: ___________________Date of I.E.: ______________________ If no, please explain why.
Therapist scoring D.C.: _________________Date of D.C.: _______________________
Total #Rxs at D.C.: __________________
Do you feel this tool adequately
enables you to score a patients
ability?
Yes No
If no, please explain why.
What other changes would
you recommend?
Instr: Circle appropriate item in each column.
* Please indicate below nature of interrupted score.
*__________________________________________
___________________________________________
Patcom #: __________________________
HX #: ______________________________
Date of I.E.: ___________________________
DCd to (please circle one )Home Home PT Rehab NH Sub Acute Rehab
OP Hospice
JACPT Fall 2010 Volume I Number 1 18
Evaluation: Development of a New Functional Outcome Measure for the Acute Care Setting Evaluation: Development of a New Functional Outcome Measure for the Acute Care Setting

1
Appendix 3 Appendix 4
URACE Testing and Scoring Instructions
Activities are scored taking into account the amount of assistance required by the patient and the percentage
Appendix 3 of patient effort put forth into the activity. The level of assistance is scored 1 to 7, again using the level of the patient effort along with the amount of
assistance required. A score of N/T or not tested is given if the activity was not able to be completed for any reason including interruptions or safety
reasons. Please identify reason for not tested for any activity not able to be scored.
Assistance Scoring:
1 = total assistance or <25% patient effort
2 = maximal assistance or 25-49% patient effort
3 = moderate assistance or 50-74% patient effort
4 = minimal assistance or >74% patient effort
5 = supervision or setup only
6 = modified independence by use of assistive device only
7 = independent

For all activities and all measures if a patient seems to be between two scores the lower of the two scores is given.
Scores are also identified for any assistive devices used or distances traveled.
For supine to sitting activity a bed score is given to objectively identify the position of the head of the bed as this can greatly effect a patients ability to
complete the tested activity.
1 = > 45
2 = < 45
3 = head of bed is flat
For the supine to sitting activity a bedrail score is also given to objectively identify the use of a bedrail or not as this can also greatly effect a patients ability
to complete the tested activity.
1 = use of bed rail
2 = no use of bed rail
For transfer scoring the amount of assistance is scored based on the above assistance scoring scale. Then the type of transfer is identified as outlined
below:
1 = sit-pivot transfer
2 = sit-stand transfer
3 = stand pivot transfer
For transfer scoring a device must also be identified for the patient scored as below:
1 = walker
2 = crutches
3 = cane
4 = none/other
For locomotion scoring an activity must first be chosen and circled on the score sheet: ambulation or wheelchair mobility. The assistance level and device
scoring is completed as above. Distance must be scored as below:
1 = 1-24ft.
2 = 25-49ft.
3 = 50-149ft.
4 = 150+ft.
For stairs scoring the assistance level is completed as outlined above. A score will then be given for device used on the stairs as below:
1 = handrail
2 = crutches
3 = cane
4 = none/other
Then a score must be given for distance as follows:
1 = 1-3 steps
2 = 4-6 steps
3 = 7-9 steps
4 = 10 steps
In order to reflect a patients true ability it is important to allow and encourage a patient to give his/her best effort with all portions of the test.

19 Fall 2010 Volume I Number 1 JACPT JACPT Fall 2010 Volume I Number 1 20

RESEARCH
REPORT
Joni Rapp, PT, DPT
Physical Therapist, Summa Hospital
System
jrapp05@windstream.net
Jaime C. Paz PT, DPT, MS
Clinical Associate Professor, Walsh
University
jpaz@walsh.edu
Christine McCallum, PT, PhD, GCS
Director of Clinical Education, Walsh
University
cmccallum@walsh.edu
Jeanne Cole, PT, CCCE, CCI
Physical Therapist, Summa
System
coleje@summa-health.org
Lynn Steffey, PT
Physical Therapist, Summa Health
System
steffeyl@summa-health.org
The Effects of a Physical Therapy Triage System on the Outcomes of ICU Patients with Respiratory Failure
The rising costs of health care,
particularly in the intensive care
unit (ICU)1 as well as the resultant
The Effects of a Physical reduction in reimbursement made
by government and private insurance
Therapy Triage System on the providers, has driven an increased
need to decrease length of stay in acute
care hospitals.2 Research has firmly
Outcomes of ICU Patients with established the increased benefits of
earlier mobility after common medical
Respiratory Failure events such as myocardial infarction
(MI) and orthopedic surgeries, which
include increased functional abilities,
Joni Rapp, Jaime C. Paz, Christine McCallum, Jeanne Cole, shorter length of stay (LOS), and
Lynn Steffey decreased total cost of stay.3,4 In
the past, critically ill (CI) patients
were considered medically unstable
and, therefore, placed on bed rest.
ABSTRACT
However, recent research has begun
Background: In September 2003, the Summa Health System to show how the early mobilization
implemented an activity protocol and a triage system to prioritize of patients in the ICU can produce
the delivery of physical therapy services in the intensive care unit similar beneficial results.3,5-9
(ICU). The triage system first identified patients who required Despite continued concern among
skilled physical therapy (PT) interventions to reach the expected health care providers that the CI
continuum of care level (COC) at discharge and then allocated PT patient may not be appropriate
for early mobilization, a thorough
services accordingly.
medical and objective screening
Purpose: The purpose of this study is to answer the clinical question, has been shown to provide safe
Does the triage system decrease length of stay (LOS), decrease the mobilization without any major
medical complications.10-12 A decision-
number of PT visits, and improve physical function while achieving
the predicted COC level for patients with respiratory failure who making framework was described
by Stiller et al,12 which included
were admitted to the ICU? a thorough medical background
Health
Methods: A retrospective chart review utilized a sample of 117 review and monitoring of currently
patients, 60 patients from January to May of 2002 (Group 1) and cardiovascular and respiratory status.
57 patients from January to March of 2007 (Group 2). Group 2 In this study, patient functioning was
improved without any significant
was further divided into 41 Level I patients (Group 2a), 12 Level II changes in medical condition. Overall,
patients (Group 2b), and 4 Level III patients (Group 2c), based on the extensive benefits can be achieved as
Triage system criteria. Non-parametric tests and central tendency a result of early mobilization of the
comparisons were used to compare the hospital LOS, ICU LOS, CI patient if therapists are trained in
number of PT visits, patient function at evaluation and discharge, proper screening and monitoring of
these patients.10-12
discharge plan at evaluation, and continuum of care level for Group
As increased patient function has been
1 and 2.
linked to decreased length of stay, the
Results: Hospital LOS and ICU LOS were both decreased by two Center for Medicare Services has
days and the number of PT visits per patient decreased by two encouraged hospitals to improve
sessions when comparing Groups 1 and 2. Significant changes in patient function through documented
quality of care.13 Quality of care or
function from initial evaluation to discharge were shown in Group 1,
change in level of functioning can
Group 2a and Group 2b. Patients achieved the predicted COC level
be quantitatively measured through
72% of the time in Group 2. outcome tools such as the Functional
Conclusion: A physical therapy triage system can decrease patient Independence Measure and the Timed
hospital and ICU LOS, decrease the number of PT visits and achieve Get up and Go, which are commonly
used in skilled nursing facilities, but are
the predicted continuum of care level.
Fall 2010 Volume I Number 1 JACPT JACPT
not feasible for the acute care setting.
As a result, the Kansas University
Hospital Physical Therapy Acute
Care Functional Outcomes Tool was
developed. This tool helps to quantify
improved function and mobility
of ICU patients and was used at
interdisciplinary quality improvement
team meetings. The scale outlines
change in function of several functional
tasks including bed mobility, transfers,
gait, and walking distances. The scale
also considers the patients prior level
of functioning and discharge status.
Swafford et al13 found that in general
those patients who returned home
had higher score changes than those
patients who made no improvement
in function and were discharged to
another level of patient care.13
In order to more easily determine
the level of care needed at discharge,
Scott and Petrosino14 developed the
Physical Therapy Continuum of Care,
a decision-making framework (Fig. 1).
The framework outlines levels of the
continuum of care from a physical
therapy perspective and denotes the
recommended treatment duration
based on patient acuity in inpatient,
outpatient and homebound practice
settings. When determining the
continuum of care level needed upon
discharge from an inpatient acute care
setting, the therapist should consider
the patients current and premorbid
functional abilities, the ability to
participate in therapy sessions, the
patients needs, and the prior living
environment.
Patients with increasingly complex
impairments are spending less time
in intensive care units and acute care
hospitals. The role of the physical
therapist has begun to include
prioritizing patients based upon their
predicted response to interventions,
length of stay, and expected level of
health care required upon hospital
discharge.16-18 Therefore Akron City
Hospital, part of the Summa Health
System (SHS) created a physical therapy
triage system to help maintain quality
of care by providing the appropriate
number of PT visits needed to improve
Fall 2010 Volume I Number 1
patient function while still achieving
the predicted continuum of care level
at discharge. The triage system at SHS
was developed in 2003 based upon
the evidence that early mobilization
helps to decrease LOS and after
internal review of PT practices within
the hospital. It was aimed at assisting
therapists in prioritizing and expediting
patient care while decreasing the
number of physical therapy visits,
based upon patient need. The
internally developed triage system
involves 3 components: 1) identifying
patients who do or do not require
skilled physical therapy interventions,
2) determining the frequency of visits
necessary to reach the expected level
of functioning and 3) determining the
continuum of care level at discharge
without compromising quality of care
(Fig 2).19 The physical therapist uses
the triage system for each CI patient
evaluation in the ICU. During the
plan of care development, the PT
determines the continuum of care
level expected upon discharge from
the acute hospital based upon factors
including living environment, prior
level of functioning, and medical
reimbursement available.
The triage system consists of 3 levels,
each of which determines frequency
of PT visits. A patient at Level 1 is able
to follow commands and requires
intensive skilled PT services to achieve
the expected continuum of care level
upon discharge. This patient receives
5 - 7 PT sessions per week. A patient
at Level II is also appropriate for
skilled PT services but is close to
prior level of functioning and only
requires 1 4 PT sessions per week
to reduce deconditioning. A patient at
Level III is not appropriate for skilled
PT services and care is turned over
to nursing. These patients are usually
at their prior level of function and
often include patients with long-term
chronic conditions.
Prior to full implementation and
acceptance of the triage system, a
year-long quality assurance (QA)
monitoring process was completed in
2004. This process involved evaluation
22
The Effects of a Physical Therapy Triage System on the Outcomes of ICU Patients with Respiratory Failure
Figure 1. Physical Therapy Continuum of Care
of each ICU patient chart by a senior
therapist to determine uniformity of
the documentation of triage levels by
the staff PTs. The result of the QA
process determined few errors in the
assignment of a triage level and follow
up interventions by hospital PTs.
The purposes of this study were to
evaluate the effectiveness of the triage
system and to answer the clinical
question: Does the triage system
decrease length of stay (LOS) (both
hospital and ICU), improve physical
function, and decrease the number of
PT visits while achieving the predicted
continuum of care level for patients
with respiratory failure who were
admitted to the ICU?
METHODS
This is a non-experimental, descriptive
23
study in which a retrospective chart
review of patients admitted to the
ICU at SHS between January and
March of 2002 and between January
and March of 2007 was used for data
collection.
Sample
An initial sample was collected by
Summa Health Systems Quality
Resource Management that included
patients given a primary diagnosis
of respiratory failure resulting in
mechanical ventilation. Patients were
excluded from the sample if they
had expired while in the hospital,
were discharged to hospice, were
initially seen for cardiac or orthopedic
procedures, or were found to have
other life-limiting co-morbidities.
The final sample included 2 Groups of
patients. Group 1 consisted of sixty
Fall 2010 Volume I Number 1
patients who received PT services
prior to initiation of the triage system.
Group 2 consisted of 57 patients who
received PT services after the triage
system was put in place. Group 2 was
further divided into three subgroups
based on the triage system criteria
(Fig. 2). Group 2a consisted of 41
patients triaged as Level I; Group 2b
consisted of,12 patients triaged as
Level II;, and Group 2c of 4 patients
at Level III.
Data level of functioning at discharge or
The administrative data provided
by Summa Health Systems Quality
Resource Management included age,
sex, hospital length of stay, ICU length
of stay, the number of co-morbidities,
and discharge status from the hospital.
A retrospective chart review was then
completed by 3 physical therapists on
JACPT
The Effects of a Physical Therapy Triage System on the Outcomes of ICU Patients with Respiratory Failure
Figure 2.
the final sample of 117 patients to
collect the following data: diagnosis,
number of PT visits, number of days
from admission to PT examination,
level of functioning at PT examination,
at the last documented PT visit, the
continuum of care level predicted at
initial PT examination, and triage level
designated by the evaluating physical
therapist.
The chart review identified the level
of function documented at initial PT
JACPT
examination and at the last physical
therapy treatment note prior to
discharge from the hospital. For
purposes of comparison, these data
were collapsed and stratified into six
levels of function (Table 1) similar to
the classifications used in the Kansas
University Hospital Physical Therapy
Acute Care Functional Outcomes
Tool.13 Several patients were seen
only once by physical therapy and
therefore, their data were eliminated
from the comparisons of change in
level of functioning.
Fall 2010 Volume I Number 1
The continuum of care (COC) level
predicted by the evaluating therapist at
the initial evaluation was divided into
six categories based upon the following
labels: long term acute care, skilled
nursing facilities (SNF), rehabilitation,
home with or without assistance,
SNF versus home or uncertain. The
category of uncertain was typically
given when the patient was sedated
or unconscious and a true prognosis
could not yet be determined. The
category of SNF versus Home was
considered a correct prognosis if the
patient had gone home or to a skilled
nursing facility.
Analysis
Data analysis was completed using
SPSS 17.0 and Microsoft Excel 2007
software. Non-parametric tests were
used and included the Mann-Whitney
U and the Wilcoxon signed-ranks
test. The Mann-Whitney U test was
performed to compare Groups 1 and
2 regarding level of function, length
of stay, and group characteristics.
The Wilcoxon signed-ranks test was
performed to compare change in
function or change in COC level for
an individual group over time. The
level of significance was set at 0.05 for
these analyses. Central tendencies,
or averages, were used in addition
to statistical significance to identify
changes in the number of physical
therapy visits and number of days of
hospital and ICU length of stay for
Groups 1 and 2.
RESULTS
Demographics
The characteristics for Groups 1
& 2 are outlined in Table 2. The
characteristics of Group 2, which
was further divided into Groups 2a,
2b and 2c, are outlined in Table 3.
For the number of co-morbidities,
which was calculated by counting the
number of diagnostic codes, Group
1 was significantly higher (p < .001)
than Group 2 (including subgroups)
for reasons unknown to the authors.
However, this may be attributed to
changes in medical management over
24
The Effects of a Physical Therapy Triage System on the Outcomes of ICU Patients with Respiratory Failure
Table 1. Data Collection Categories for Level of Function
Level of Function at initial examination and discharge
1. Sedated, not tested, dependent for all transfers
2. Bed mobility or bed exercises
3. Pivot transfer or sit to stand transfer
4. Ambulate 0-10 ft
5. Ambulate 11-50 ft
6. Ambulate 51-149 ft
7. Ambulate 150 ft or more
a five-year span. The average number
of physical therapy visits decreased by
2.5 visits in Group 2 compared with
Group 1 (p=.001). The mean hospital
length of stay and ICU length of stay
decreased by approximately two days
in Group 2 compared with Group 1,
although statistical tests performed
did not indicate a high probability
of true differences between groups
(Mann-Whitney U test for hospital
LOS: p=.283, and ICU LOS: p=.876)
(Fig 3).
Level of Function
The level of function at initial evaluation
for Groups 1 and 2 appeared to be
different based on the Mann-Whitney
U test (p=.015). This suggests an initial
difference between the groups, which
prevented us from exploring any
further between group comparisons
regarding change in function from
initial evaluation to discharge from
hospital. Patients from both Group
1 and Group 2 who received only
one PT visit were eliminated, as no
comparison data was available at
discharge. Additionally, all Group 2c
patients were eliminated since these
patients would not receive more than
one PT visit.
For these reasons, a within group
analysis was performed using the
Wilcoxon signed ranks test to compare
level of function from evaluation to
discharge within Groups 1, 2a and
2b (Fig 4). The results indicated
improvement from evaluation to
discharge for Group 1 (p < .001),
Group 2a (p < .001) and Group
2b (p=.009). When evaluating the
25
change in level of function within each
group, Group 2a showed the greatest
improvement with 85% of patients
(27/32) advancing by at least one
or more functional levels. Similarly,
in Group 2b, 82% of patients (9/11)
showed an improvement in physical
functioning from initial evaluation to
the last documented PT treatment.
Group 1 also demonstrated an
improvement with 77% of patients
(42/55) improving in function.
Continuum of Care
Analysis of the continuum of care
level predictions and outcomes was
also completed only for Group 2
because achieving the predicted COC
level was a goal of the triage system.
Prior to the triage system, achieving
the predicted COC was also a goal,
Table 2. Characteristics of Groups 1 & 2
Group 1
(pre-
Triage)
Number of patients 60
Age 63
Ratio of Male to Female 27:33
Number of co-morbidities 20.75
LOS 18.4
ICU LOS 11.13
Number of PT visits 6.1
Days from admission
to PT evaluation 4.68
Fall 2010 Volume I Number 1
but it was not consistently monitored
or documented and therefore could
not be analyzed in this study. When
considering the patients in Group
2, the evaluating physical therapist
was able to correctly identify the
COC level deemed necessary by the
attending physician upon hospital
discharge in 72% of the cases (Fig
5). Based on the Wilcoxon signed-
ranks test (p=.064) the predicted
COC level at evaluation was the same
COC level achieved upon discharge.
In other words the therapists COC
prediction at the initial evaluation was
correct.
DISCUSSION
The purpose of this study was to
determine the effectiveness of the
physical therapy triage system in
decreasing the number of physical
therapy visits, decreasing the length
of stay (hospital and ICU), increasing
patient function, and achieving the
predicted continuum of care level for
patients with respiratory failure who
were admitted to the ICU. The goal
of the triage system was to improve
patient function in order for the patient
to advance from the ICU to the next
level of care as quickly as possible
while utilizing fewer PT visits. The
intent was to provide physical therapy
services with a higher frequency to
P value
(Mann-
Whitney
U test)
Group 2 2002 vs
(Triage) 2007
57
64 .764
26:31 .947
6.74 .000
16.1 .283
9.9 .876
3.6 .001
5.03 .834
JACPT
The Effects of a Physical Therapy Triage System on the Outcomes of ICU Patients with Respiratory Failure
Table 3. Characteristics of Group 2 Categorized by Triage Level
Group 2a Group 2b Groups 2c
(Triage level I) (Triage level II) (Triage level III)
Number of patients 41 12 4
Number of co-morbidities 6.4 7.5 7.75
LOS 15.3 19.4 14
ICU LOS 9.02 13.58 8
Number of PT visits 3.42 5.08 1.25
Days from admission
to PT evaluation 5.3 4.83 3.5
those patients who had the potential at this facility. could not safely conclude that the
to improve more quickly or who triage system led to greater increase
Level of Function
required more intense therapy while We hypothesized that the triage system in physical function compared with
decreasing the frequency of visits would increase physical function physical therapy management prior to
to patients with chronic conditions for the 2007 (Group 2) patients initiating the triage system. We were
without compromising quality of compared with the 2002 (Group 1) able to determine whether the patient
care. As frequency of therapy visits patients upon hospital discharge or at categorization component of the
increase, the patient should improve the last documented PT visit. Because triage system was effective. Group
in function, which would allow for a Groups 1 and 2 were different at initial 2 was divided into Groups 2a (Triage
more rapid transfer out of the ICU. evaluation, statistical comparisons Level I) and 2b (Triage Level II), and
Quality of care at Summa Health could not be made. Therefore, we compared separately to identify
Systems indicates that the appropriate
number of PT visits necessary to
improve patient function and achieve Figure 3.
the predicted continuum of care level
at discharge has been provided.
Length of Stay
A decrease in the number of physical
therapy visits, the average hospital
LOS, and the average intensive care
unit LOS occurred from 2002 (Group
1) to 2007 (Group 2) (Fig 3). The
decrease in the length of stay, for both
hospital and ICU, may be in part due to
changes in patient management in that
5-year time span as costs for acute
care have risen and reimbursement
has been reduced. However, the
U.S. Department of Health and
Human Services Healthcare Cost
and Utilization Project20 indicated
no change in average hospital LOS
from 2002 to 2007. In comparison,
the Summa Health System was able
to decrease the hospital LOS in
2007, which may have been partially
attributed to addition of the triage
system. Further analysis of all the
contributing variables to hospital LOS
is necessary to fully determine the
reasons for decrease in hospital LOS
JACPT Fall 2010 Volume I Number 1 26
The Effects of a Physical Therapy Triage System on the Outcomes of ICU Patients with Respiratory Failure
Figure 4. Change in Level of Function
change in function from evaluation to
discharge in each of those respective
groups. Change in function within
Group 1 was also analyzed to provide
comparison to the triage subgroups.
Improvement in function from initial
evaluation to discharge within each
group (Groups 1, 2a and 2b) was
found to be statistically significant
(Fig 4). Although the initial difference
between Groups 1 and 2, did not allow
us to test the full effectiveness of the
triage system statistically, our results
suggest that the triage system helps
physical therapists in clinical decision
making and their ability to allocate PT
services appropriately to CI patients
while still achieving improvement in
functional levels. These results are
consistent with previous literature
documenting the ability of physical
therapists to manage CI patients
successfully in the ICU.1,8,9,12,13
Continuum of Care Level
The Summa Health System triage
classification includes a physical therapy
evaluation of the patient, which identifies
the expected discharge continuum of
27
on the continuum of care by discharge
from the ICU and acute care hospital
including living environment, prior level
of functioning, and available medical
reimbursement. Upon the initial
examination, physical therapists at
Summa were correctly identifying the
continuum of care level at discharge
over 70% of the time (Fig 5). This
may be a result of the ability of acute
care therapists to predict and achieve
goals since the COC level is strongly
linked to physical level of functioning,
or it may also be a result of the physical
therapists role in discharge planning.15,21
At Summa Health System, the COC
level prognosis is a vital communication
tool between the evaluating physical
therapist and other physical therapists,
other health care providers, and
social workers for discharge planning.
Recent literature also documents a
higher readmission rate for patients
when a physical therapists discharge
recommendations are not followed.21
Therefore, the results of this study
help to substantiate the critical role
care level. Each therapist considers that physical therapists have in patient
many factors to determine the potential care and discharge planning in the acute
for each patient to reach a certain level care setting.
Figure 5. Continuum of Care Level at Discharge
Fall 2010 Volume I Number 1 JACPT
The Effects of a Physical Therapy Triage System on the Outcomes of ICU Patients with Respiratory Failure
Limitations
The limitations of this study include a
relatively small sample size compared
with a similar study9 and the possible
role of changes in medical management
over a five-year span. The samples
analyzed for the study covered a small
period and included patients with
many different medical diagnoses,
patients with a large age range, and
patients with various medical histories
including drug abuse and chronic
non-life threatening conditions.
Complexity in patient population
may have further limited statistical
significance; however, this variety of
sampled patients may have increased
the likelihood of outcome application
to other mechanically ventilated
patients. Additionally, the long time
span between groups may have also
affected the results. Over several
years, length of stay and COC level
may have been altered by not only the
physical therapy protocols but also
by changes in the health care system
such as reimbursement restrictions
and newer, more effective medical
treatments.
Another possible limitation to this
study was the data gathering points.
For the data, the initial level of
functioning was compared with the
function documented at the last PT
visit. However, the data collectors
often noticed that higher levels of
functional activity were achieved by
patients during their stay than was
recorded at the last PT visit. This was
due partly to the common practice (at
this facility) of allowing the patient to
complete only bed exercises on the
day of expected transfer to another
facility to allow energy conservation.
This practice may have negatively
skewed the data and decreased
significance; therefore a larger
statistical significance may have been
seen if the comparison had been made
between level of functioning at initial
evaluation and the highest level of
activity achieved.
Further limitations of this study are
due to the nature of a retrospective
study and include a lack of standard
JACPT
documentation and differing methods
of patient care. This may have occurred
as a result of staff with less triage
protocol training, such as short-term
contract employees and students. As
described by Jette et al,15 clinicians
with less acute care experience tend
to be more conservative with their
continuum of care level recommended
upon discharge. This may also be
true regarding the level of activity the
therapist encourages their patients to
achieve. Future research in this area
will need to address these limitations
to better understand the exact
implications of this triage system
or similar systems utilized at other
facilities.
CONCLUSION
Triage systems similar to the one
created by Summa Health System
have been described in professional
literature, however no current
research studies have been identified
to determine the efficacy of such
a system.16,17 This research study
demonstrates the effectiveness of a
triage system in decreasing LOS (both
hospital and ICU), and allocating the
appropriate number of PT visits to CI
patients. The data also demonstrate
how physical therapy is able to increase
the functional ability of the patient
in the acute care setting regardless
of a triage protocol. Lastly, physical
therapists using the triage system
were able to correctly identify the
level of care required upon discharge.
Results of this study confirm the vital
role physical therapists play in the
medical management of the acute
care patient.
REFERENCES
1. Hopkins RO, Spuhler VJ, Thomsen
GE. Transforming ICU culture to
facilitate early mobility. Crit Care Clin.
2007;23:81-96.
2. Reis E. Filling an acute need: PTs and
team collaboration in the hospital. PT
Magazine. 2002;10(9):34-38,41,83.
3. Reis E. Filling an acute need: PTs and
team collaboration in the hospital. PT
Magazine. 2002;10(9):34-38,41,83.
4. Allen C, Glasziou, Del Mar C. Bed
Fall 2010 Volume I Number 1
rest: a potentially harmful treatment
needing more careful evaluation. The
Lancet. 1999;354(9186):1229-1233.
5. Chiang LL, Wang LY, Wu CP, Wu HD,
Wu YT. Effects of physical training
on functional status in patients with
prolonged mechanical ventilation.
Physical Therapy. 2006;86(9):1271-
1281.
6. Wong, WP. Physical Therapy for a
patient in acute respiratory failure.
Physical Therapy. 2000;80(7):662-
670.
7. Mundy LM, Leet TL, Darst K,
Schnitzler MA, Dunagan WC.
Early mobilization of patients with
community-acquired pneumonia.
Chest. 2003; 124(3):883-889.
8. Morris PE, Herridge MS. Early
intensive care unit mobility: future
directions. Crit Care Clin. 2007;23:97-
110.
9. Morris PE, Goad A, Thompson C,
Taylor K, Harry B, Passmore L, Ross
A, Anderson L, Baker S, Sanchez
M, Penley L, Howard A, Dixon L,
Leach S, Small R, Hite RD, Haponik
E. Early intensive care unit mobility
therapy in the treatment of acute
respiratory failure. Crit Care Med.
2008; 36(8):2444-5.
10. Dean E. Mobilizing patients in the
ICU: evidence and principles of
practice. Acute Care Perspectives.
2008;17(1):1,3-9.
11. Perme C, Chandrashekar RK.
Managing the patient on mechanical
ventilation in ICU: Early mobility
and walking program. Acute Care
Perspectives. 2008;17(1):10-15.
12. Stiller K, Phillips AC, Lambert P. The
safety of mobilisation and its effect
on haemodynamic and respiratory
status of intensive care patients.
Physiotherapy Theory and Practice.
2004;20:175-185.
13. Swafford, BB. Validity of Kansas
university hospital physical therapy
acute care functional outcomes tool.
Acute Care Perspectives. 2008;Fall:14-
18.
14. Scott R, Petrosino C. Physical therapy
management. St. Louis, Missouri:
Mosby Elsevier;2008:74-84.
15. Jette DU, Griver L, Keck C. A
qualitative study of clinical decision
making in recommending discharge
28
The Effects of a Physical Therapy Triage System on the Outcomes of ICU Patients with Respiratory Failure
placement from the acute care setting.
Physical Therapy. 2003;83(3):224-236.
16. Reis E. Filling an acute need: PTs and
team collaboration in the hospital. PT
Magazine. 2002;10(9):34-38,41,83.
17. Anonymous. Challenges. PT Magazine.
2000;8(1):43.
18. Beattie PF, Nelson RM. Evaluating
research studies that address
prognosis for patients receiving
physical therapy care: a clinical update.
Physical Therapy. 2007;87(11);1527-
1535.
19. Summa Health System hospitals.
Inpatient physical therapy triaging
process [memorandum]. Sept. 2003
20. U.S. Department of Health and
Human Services. Healthcare Cost and
Utilization Project National Inpatient
Sample. Available at: hppt://hcupnet.
ahrq.gov. Accessed July 5, 2009.
21. Smith BA, Fields CJ, Fernandez
N. Physical Therapists make
accurate and appropriate discharge
recommendations for patients who
are acutely ill. Phys Ther. 2010;90
(5)693-703.
THE CRITICAL EDGE
www.acutept.org
29
Fall 2010 Volume I Number 1
Platform Presentation Abstracts
Low Frequency Ultrasound
Delivered at 35KHZ Decreases
Methicillin Resistance in a Clinical
Wound Isolate of MRSA.
Conner-Kerr, Teresa 1
; the tested cultures that demonstrated
Alston, Geleana ; Kute, Tim.3
2 conversion to a methicillin-susceptible
1. Physical Therapy, Winston-
Salem State University, Winston-
Salem , NC, United States.
2. Microbiology, NC A&T University,
Greensboro, NC, United States.
3. Pathology , Wake Forest University
School of Medicine, Winston Salem,
NC, United States.
Purpose/Hypothesis : The purpose
of this study was to determine if low
frequency ultrasound (LFU) delivered at
35 KHz reverses methicillin resistance
in a clinical wound isolate of MRSA.
Number of Subjects : A known
clinical isolate of MRSA from a lower
extremity wound with an established
resistance to oxacillin and erythromycin
was exposed to LFU treatment.
Materials/Methods : The MRSA
isolate was subcultured, plated and
grown on sheep blood agar (SBA)
using standard microbiological
techniques. Serial dilutions of the
organisms were prepared using sterile
saline. Cultures received either no
treatment or treatment with LFU for
30, 60 and 180 seconds. Inocula from
each of the test groups were placed
on SBA. Subsequently, an oxcillin test
disk was placed on the SBA plates
in the initial zone or first quadrant
used for organism innoculation. The
organisms were incubated at 37
degrees C and grown overnight. The
zone of inhibition was determined
JACPT JACPT
for each test group according to
manufacturers guidelines. Three
separate experiments were performed
with 3 replications each. Inocula of
organism were then plates and grown
over night to determine persistence of
methicillin susceptibility. This process
was continued for 72 hours post-
ultrasound treatment. Samples of
MRSA from the control, nontreatment
group and LFU treated groups
were also examined using scanning
electron microscopy to determine if
ultrastructural changes had occurred
as the result of treatment. Samples
were also taken for flow cytometry.
Results : Zones of inhibition
congruent with oxicillin (oral form
of methicillin) susceptibility were
detected for the clinical isolate of
MRSA at all tested treatment times.
A dose-dependent increase in the
zone of inhibition was detected with
35 KHz LFU treatment times as low
as 30 seonds. The zone of inhibition
increased by 14% with a treatment
time of 60 seconds and by 30% with a
treatment time of 180 seconds. These
zones of inhibition were maintained
for as long as 48 hours after LFU
treatment. LFU was also effective in
changing other colonial characteristics
of MRSA as well as producing
significant reduction in colony counts
and changing membrane permeability.
Conclusions : This is the first
demonstration of the reversal of
methicillin resistance with a biophysical
energy. The data suggest that LFU
reduces or reverses methicillin
Fall 2010 Volume I Number 1
APTA 2010
Combined Sections Meeting
San Diego, CA
resistance in a clinical isolate of MRSA
for up to 48 hours after initial treatment.
Clinical Relevance : Delivery of
LFU at 35 KHz may be an effective
treatment for wounds heavily
colonized or infected with MRSA.
KEYWORDS: MRSA, Low
Frequency Ultrasound, Wounds
Survey on the Use of Aides to
Support Physical Therapists
Services
Smith, Jim M.; Crist, Molly H.;
Probst, Suzanne. Utica College,
Utica, NY, United States.
Purpose/Hypothesis : Use of staff
to support the physical therapist (PT)
is a strategy that may increase the
PTs efficiency. The profession has
defined PTs and PT assistants (PTAs)
as the only providers of interventions,
and the aide as: any support
personnel who perform designated
tasks related to the operation of the
physical therapy service. Tasks are
those activities that do not require
the clinical decision making of the
PT or the clinical problem solving of
the PTA (APTA HOD P06-00-17-
28). The last investigation of the role
of aides (1993) reported the use of
aides for providing treatment was a
common practice. The purpose of this
investigation was to (1) determine the
extent aides provide physical therapy
services under the supervision of a
PT; (2) identify PTs opinions about
the utilization of aides; and (3) identify
the resources PTs use to inform
their decisions for aide utilization.
30
APTA 2010 Combined Section Meeting: Platform Presentation Abstracts
Number of Subjects : Subjects
were PTs in Connecticut. 500 were
randomly selected and mailed a
survey. 120 surveys were returned for
a response rate of 24% and 118 of the
surveys were determined to be usable.
Materials/Methods : A survey was
designed to collect information from
PTs on the tasks performed by aides.
The survey also gathered demographic
data and information on PTs
opinions regarding support staff. The
frequency distribution of responses
was analyzed and Spearmans
rho analysis was performed to
determine correlation between the
responses and the demographic data.
Results : The tasks identified as
those most frequently performed
by aides were thermotherapy
(36%), aerobic/endurance activities
(32%), active/resistive exercise with
equipment (29%), whirlpool (16%)
and data collection for height and
weight (16%). Opinions on the use of
aides included: 54.3% reported that
the utilization of aides had presented
them with an ethical dilemma during
their career; 47.5% reported that
they were comfortable with aide
involvement in their practice; and
83.9% reported that they were
legally responsible for actions of an
aide. Resources that informed PTs
decision on utilization of aides were
familiarity with APTAs position
on the use of support staff (59%);
instruction received during education
(52%); familiarity with state statutes
(52%); and recommendations from
an administrator or manager (38%).
Conclusions : A minority of PTs
relied on aides to support them in
the clinic. There was little, if any,
correlation between aide utilization
and demographic data. For some
respondents the services provided
by an aide did not appear to be
consistent with positions of the
APTA. The use of aides to perform
services caused an ethical dilemma or
discomfort for a sizable number of PTs.
Clinical Relevance : PTs use of
31
aides to support clinical practice
varied widely. PTs may benefit from
education on the use or role of the aide
in their practice, including information
on statutory requirements and the
positions of the APTA.
KEYWORDS: Aide, Direction and
supervision
Total Femur Replacement: The
Role of the Acute Care Phyiscal
Therapist in Recovery and
Outcomes
Lieberman, Allison1; Beecher,
Gina1; Metoxen, Jason.2 I. PT/OT,
New York University- Hospital for
Joint Diseases, New York, NY, United
States. 2. The Hospital for Special
Surgery, NY, NY.
Purpose : The purpose of this
presentation is to educate acute care
physical therapists regarding existing
indications, surgical techniques,
post-operative management, and
functional outcomes following a total
femur replacement. This lecture
will emphasize current literature,
physician protocols, and physical
therapy treatment options.
Description : This presentation
will examine the history and surgical
indications for the total femur
replacement, describe the surgical
techniques and prosthetic components
available, and discuss post-operative
patient complications and management.
There will be a review of acute care
protocols following the procedure,
in addition to physical therapy and
rehabilitation outcomes. A case
study of a patient status-post total
femur replacement will highlight the
physical therapists role in treatment.
Summary of Use : Physical
therapists in the acute care
environment will gain insight into
the total femur replacement surgery,
understand the restrictions following
the procedure, be educated on
physical therapy protocols, understand
appropriate short and long-term
physical therapy goals, and be capable
Fall 2010 Volume I Number 1
of educating patients and caregivers
regarding rehabilitation outcomes.
Importance to Members: As
total femur replacement becomes
increasingly common in the acute care
setting, it is imperative that physical
therapists in this environment have
knowledge of current indications,
surgical techniques, and post-surgical
rehabilitation. This presentation will
provide acute care physical therapists
with current information about the
total femur replacement and provide
them with the tools to better educate
their patients, colleagues, and other
healthcare staff.
KEYWORDS: total femur
replacement, tumor resection
Comparison of Targeted Lower
Extremity Resistance Exercise
with Usual Care Progressive
Ambulation Post-Liver
Transplantation
Mandel, David W.; Roach,
Kathryn E. Physical Therapy,
University of Miami Miller School of
Medicine, Coral Gables, FL, United
States.
Purpose/Hypothesis : Individuals
with chronic liver disease develop
significant muscle wasting (protein-
energy malnutrition) resulting
in impaired strength and activity
limitations. Liver transplantation
promotes survival and improves
quality of life; however, muscular
rehabilitation is not addressed by
current post-operative care. Previous
research using aerobic walking
exercise post-liver transplantation
demonstrated muscle strength
remained impaired. Muscle requires
progressive resistance to increase
mass and strength. The purpose of
this study was to compare the effect
of a 12 week home exercise program
(HEP) of targeted lower extremity
resistance exercise on muscle strength
to the usual care of progressive
ambulation post-liver transplantation.
JACPT
Number of Subjects : Twenty-two
subjects s/p liver transplant [14 men,
8 women, mean age 53.9 years, mean
time post-surgery 8.3 weeks ] (12
controls and 10 experimental) were
recruited from a liver transplant clinic.
Materials/Methods : A randomized
study was conducted with a
control group performing usual
care ambulation and a treatment
group performing a progressive
HEP targeting the gastrocsoleus,
quadricep, and gluteal muscle
groups. The intervention progressed
from gravity eliminated exercise to
movement against gravity and elastic
bands of increasing resistance. A
physical therapist performed the initial
exercise instruction and then provided
telephone and clinic follow-up. Baseline,
8, and 12 week measurements were
taken on strength measures: Heel-rise
and Bridging; and activity limitation
measures: 30 Second Chair Stand
(CS), 6 Minute Walk Test (6MWT).
Results : Repeated Measures ANOVA
demonstrated significant differences
in the change from baseline to follow
up for Bridging (treatment increased
from 23.5 to 56.5, control increased
from 24.7 to 32.2 [p<.01]) and for CS
(treatment increased from 9 to 14,
control increased from 9 to 10 [p=.05]).
Heel-rise approached significance
(treatment increased from 10.4 to
21.4, control increased from 12 to
16.9 [p=.12]). Although the treatment
group improved more than controls
for 6MWT (treatment increased
from 1294 to 1608, control increased
from 1137 to 1371) the difference
failed to reach statistical significance
(p=.32). There were no adverse
effects on liver enzymes or surgical
incision dehiscence in either group.
Conclusions : Both treatment
and control groups improved from
baseline; however, the treatment
group that performed progressive
resistance exercise improved more
in strength and function compared
to the control group that only
performed aerobic walking activity.
JACPT
APTA 2010 Combined Section Meeting: Platform Presentation Abstracts
Clinical Relevance : Post-transplant
both treatment and control groups
were expected to improve due to
reversal of liver disease related protein-
energy malnutrition. However, our
findings demonstrated progressive
resistance training increased muscle
strength and function beyond that of
usual post-operative care. A physical
therapist directed HEP is ideal for this
patient population due to the severity
of their muscle wasting and the
acuity of their post-operative medical
status.
KEYWORDS: Liver Transplantation,
Muscle Strength, Resistance Exercise
PT Staff Training Model for
Optimizing Outcomes in Patients
Status Post Ventricular Assist
Device Placement
Fields, Christina J.; McKenney,
Kate M. Division of Physical Therapy,
University of Michigan, Ann Arbor,
MI, United States.
Purpose/Hypothesis : The purpose
of this platform presentation is to
propose a model for PT staff training
and aggressive physical therapy
following ventricular assist device
(VAD) placement. The average length
of stay at the University of Michigan
Healthy System (UMHS) is 21 days
following VAD placement, while
nationwide average is 30 days. We
believe this shorter length of stay is
partially due to an aggressive model
of physical therapy management
and coordination with VAD team.
Our physical therapy model includes
extensive staff training of safe,
yet aggressive physical therapy
involvement beginning post-operative
day 1, well defined discharge goals
and ongoing physical therapy
throughout the acute hospital stay.
Number of Subjects : Not Applicable
Materials/Methods : We compared
average inpatient length of stay
data using information collected at
UMHS and information published
in the Journal of the American
Fall 2010 Volume I Number 1
Medical Association. Staff training
for independent management of
VAD patients includes: VAD specific
perfusion training classes, hands-on
practice with demo VAD, extensive
VAD research notebook, mentoring
by senior staff before and during
direct patient care, and competency
testing. Physical therapy goals for
hospitalization and discharge include
a standing order for physical therapy
which is received post-operative day 0,
standing activity orders which include
up to chair three times per day and
ambulation four times per day and
physician expectations. Discharge goals
include independence with mobility,
independence with VAD alarms
to allow for independent mobility,
independence with strengthening
program and independence with
precautions to allow for safe mobility.
Results : As noted above average
inpatient length of stay following
placement of a VAD is 21 days at
UMHS. The most recently published
data obtained from a November
2008 JAMA submission, indicates
average length of stay is 30 days
nationwide. We are also currently
obtaining more up to date information
from the national database.
Conclusions : While there are
multiple factors that affect length of
stay, we feel that extensive PT staff
training and aggressive physical therapy
in the post-VAD placement patient
contributes to our shorter length of
stay and better patient outcomes.
Clinical Relevance : As the number
of facilities placing VADs increases,
we hope to share a model of PT staff
training and aggressive post-operative
management designed to increase
patient independence, shorten length
of stay and avoid detrimental effects
of bed rest such as loss of strength
and function as well as medical
complications including pneumonia,
deep vein thrombosis, pulmonary
embolism and pressure ulcers.
KEYWORDS: Ventricular Assist
32
APTA 2010 Combined Section Meeting: Platform Presentation Abstracts
Device, Length of stay, Staff training.
The Challenges of Morbid
Obesity and Multi-Organ Failure:
A Case Study of Early Mobility in
the Intensive Care Unit
Korupolu, Radha1; Zanni, Jennifer2;
Butler, Martha2; Needham,
Dale. 1. Pulmonary & Critical Care
1
Medicine, Johns Hopkins University,
Baltimore, MD, United States.
2. Physical Medicine & Rehabiliation,
Johns Hopkins Hospital, Baltimore,
MD, United States.
Background & Purpose : The
prevalence of obesity has risen
dramatically over recent decades,
causing hospitals and rehabilitation
facilities to develop new approaches
to manage patients who are obese.
Approximately 25% of patients in
intensive care units (ICU) are obese
and 7% are morbidly obese with these
rates projected to increase. Critical
illness in patients with morbid obesity
presents unique challenges, including
prolonged mechanical ventilation,
thromboembolic disease, pressure
ulcers, and markedly impaired physical
function. For these patients, early
physical therapy (PT) and mobilization
may reduce complications, decrease
length of stay and improve patient
outcomes; however, interdisciplinary
team work is key for success.
Case Description : A 44-year
old female with morbid obesity
(BMI=69, 425 lbs, 5 6) presented
from home in septic shock with
acute renal failure and hypoxemic
respiratory failure. Her past medical
history included hypoventilation
syndrome requiring ventilatory
support at night via tracheostomy,
diabetes, hypertension and chronic
venothromboembolic disease. Prior
to admission, the patient could
ambulate approximately 10 feet with a
walker, but reported generally using a
wheelchair for mobility. In the medical
ICU (MICU), the patient received
controlled mechanical ventilation via
tracheostomy. Vasopressor support
33
and hemodialysis were required for
the first 2 - 3 days. On MICU Day 2,
PT was consulted and the patient sat
at the edge of bed with assistance.
Via the interdisciplinary efforts of
PT, respiratory therapy and nursing
to safely manage 2 central lines,
mechanical ventilation and life support
equipment, the patient received twice-
daily graduated PT activities, including
therapeutic exercise, sitting on the
edge of bed, sit to stand, sitting in a
chair, and ambulation. On MICU Day
7, the patient ambulated a total of 120
feet, with 3 rest breaks, using a walker.
Outcomes : Rather than facing
functional decline while in the MICU
with septic shock and multi-organ
failure, the patient left the MICU
walking a much greater distance than
her baseline as a result of intensive
early PT and strong interdisciplinary
teamwork. On Day 9, the patient
was discharged from the MICU
directly home (without a stay on the
ward or in a rehabilitation facility)
with continued PT via homecare.
Discussion : Despite morbid
obesity, markedly impaired baseline
function, and septic shock with
multi-organ failure, early mobility in
the ICU was feasible and markedly
improved physical function beyond
baseline with discharge home directly
from the MICU. In patients who
are morbidly obese and critically
ill, early and intensive PT with
interdisciplinary teamwork may help
prevent common hospital-acquired
complications, improve functional
status, and minimize length of stay.
KEYWORDS: obesity, early
mobility, critical illness
Teal
Fall 2010 Volume I Number 1
Poster Abstracts
Gait and Balance Deficits in a
Patient Hospitalized with Bipolar
Schizoaffective Disorder: a Case
Report.
Kranenburg, Megan; Cleary,
Kimberly K. Eastern Washington
University, Spokane, WA, United
States.
Background & Purpose : In
schizoaffective disorder, symptoms of
schizophrenia and a mood disorder
with psychotic features overlap. Up to
one-third of patients diagnosed with
schizophrenia may have schizoaffective
disorder. Evidence indicates that
affective disorders affect a persons
psychomotor skills and gait. Patients
with schizophrenia show decreased
ability to regulate stride length, and
those with bipolar disorder exhibit
significantly increased variability in
swing time. Existing research is clear
that the mental illness itself is likely the
primary cause of altered gait patterns.
Case Description : The patient
described in this report was a 56-year-
old female admitted to an inpatient
psychiatric hospital. In addition to her
psychiatric illness, she had multiple
systemic and musculoskeletal co-
morbidities, including osteoarthritis,
Type II diabetes, and asthma. In
addition, an anoxic brain injury
experienced during infancy left her
with diminished cognitive function.
Gait analysis revealed an unpredictable
gait pattern. She dragged her right
foot and used a step-to pattern that
varied with speed, and she exhibited
a Trendelenburg lurch bilaterally. Use
of a front wheeled walker may have
exacerbated poor gait habits. Her initial
score on the Berg Balance measure
JACPT JACPT
was 45/56, indicating falls risk of 80%.
Her prognosis was fair to return to
her goal of ambulating independently
without an assistive device.
Outcomes : The plan of care for this
patient included strengthening and
gait retraining. Specific interventions
included aquatic therapy (walking, side-
stepping, bicycles, and wall squats),
lower extremity ergometry, and
wedge sitting. The patients difficulty
maintaining focus during physical
therapy sessions was the primary
challenge to treatment. The patient
was treated in the pool 3 times and
in the clinic 7 times over her two and
a half week episode of care. At re-
examination prior to discharge, the
patients Berg Balance score increased
to 48/56, which reduced her falls risk
to approximately 60%. Subjectively,
the quality of her performance of these
functional tasks also improved. No
measurable, consistent improvement
in gait was noted, but the patient did
begin exercising independently by the
end of the episode of care. The patient
was discharged from the inpatient
research demonstrates muscle wasting
psychiatric hospital to a group home
setting.
Discussion : The slight improvement in
this patients balance may be attributed
to aquatic therapy, which has been
shown to decrease lateral postural
sway in older women with lower
extremity osteoarthritis. The ongoing
gait deficits are most likely the result
of her mental illness, however, future
research should examine the effects of
specific physical therapy interventions
on gait dysfunction in patients with
psychiatric illness. Information about
these disease-specific dysfunctions
Fall 2010 Volume I Number 1
APTA 2010
Combined Sections Meeting
San Diego, CA
should also be formally incorporated
into entry-level physical therapist
education in order to fully prepare
the acute care physical therapist for
appropriate intervention planning in
this patient population.
KEYWORDS: Gait, Schizoaffective,
Balance
Efficacy of a 12 Week Progressive
Resistance Training Protocol
in a Patient Following Liver
Transplantation
Mandel, David W.; Concepcion,
Nicholas; Jiunta, Justin; Martis,
Elissa; Ramos, Daniel. Physical
Therapy, University of Miami Miller
School of Medicine, Coral Gables, FL,
United States.
Background & Purpose : Chronic
liver disease affects more than 5 million
Americans and results in severe loss
of muscle mass, strength, and activity
limitation. Liver transplantation serves
as a modality to prolong survival and
improve quality of life (QOL). However,
continues, strength and QOL remains
impaired, and many individuals do not
return to employment. Current post-
liver transplant care does not include
rehabilitation of lost muscle strength.
The purpose of this study was to assess
the efficacy of a 12 week progressive
resistance training (PRT) home
exercise protocol, closely monitored
by a physical therapist (PT), consisting
of 14 exercises predominantly
focusing on the lower extremities
(LE). Research indicates that short-
term PRT programs are effective at
increasing strength and lean body mass
34
APTA 2010 Combined Section Meeting: Poster Abstracts
in adults with HIV and ESRD, both of
which demonstrate similar degrees of
muscle wasting.
Case Description : Patient was
a 56 year old male diagnosed with
Laennecs Cirrhosis 3 years prior to
transplantation. The patients past
medical history reveals a 28 pack year
smoking history, alcohol consumption,
and family history of liver disease. The
patient was evaluated 12 weeks post-
transplantation for baseline measures
of LE strength, function, and QOL. LE
strength was assessed via Heel-Rise,
Bridging, 30 Second Chair Stand, and
the 6 Minute Walk Test (6MWT).
QOL measures were recorded using a
self-reported SF-36 and Chronic Liver
Disease Questionnaire (CLDQ). The
intervention, performed every other
day, consisted of 14 LE exercises,
targeting key muscle groups (gastroc-
soleous, quadriceps, and gluteal),
progressing from anti-gravity to
resistance with elastic bands. The PT
demonstrated proper performance of
the intervention and reevaluated with
weekly telephone monitoring. Post-
intervention testing was conducted on
weeks 8 and 12.
Outcomes : Exercise compliance was
high. Post-intervention, the patients
LE strength significantly improved from
baseline: Heel-Rise increased by 23,
Bridging increased by 47, Chair Stands
increased by 4, and 6MWT improved
by 676 feet. Our patient reported
an increase in strength, energy level,
and ability to lift heavy objects on
the CLDQ. Improvements across all
domains of the SF-36 were observed,
with the most significant occurring in
physical function, role physical, role
emotional, and bodily pain.
Discussion : Current protocol post-
transplantation consists of gradual
return to normal activities without
addressing musculoskeletal impairments
associated with liver disease. This case
report suggests that an emphasis on
rehabilitation of LE muscle strength
using targeted resistance exercise is
effective in improving outcomes in this
population. A PRT protocol should be
considered as an adjunct to the current
35
usual care post-liver transplantation.
A home based execise program was
ideal for this patient population due
to the acuity of thier post-operative
medical status limiting frequent travel
to outpatient clinics and potentially
minimized healthcare costs.
KEYWORDS: liver transplantation,
muscle strength, resistance exercise.
The importance of adverse drug
event (ADE) identification by
the physical therapist (PT) in the
acute rehabilitation setting: a
case example.
Howard, Jennifer1; Nordon-
Craft, Amy 1; Page, Robert
2
; Struessel, Tami.1 1. Physical
Therapy, University of Colorado-
Denver, Aurora, CO, United States.
2. School of Pharmacy, University
of Colorado-Denver, Denver, CO,
United States.
Background & Purpose : Patients
admitted to acute rehabilitation are
expected to be medically stable and to
participate in three hours of therapy
per day. Earlier discharge from the
acute inpatient setting has led to an
increase in acuity and complexity of
patients in this setting. Due to frequent
patient contact and continuous
assessment of function, a PT may be
the first to identify subtle physiological
changes and subsequent functional
decline associated with medications.
As PT education has evolved, there
has been an increased focus on PTs
knowledge of pharmacotherapy. Even
with this enhanced knowledge, PTs
may not address ADEs with members
of the medical team due to lack of
confidence, uncertainty of their role
in pharmacological management,
or failure to identify a link between
rehabilitation decline and medication
change. The purpose of this case report
is to describe an example in which
failure to identify an ADE contributed
to a less than optimal patient outcome
in the acute rehabilitation setting.
Case Description : LM is a 67 year
old male who sustained an incomplete
C6 ASIA B spinal cord injury following
Fall 2010 Volume I Number 1
a motor vehicle accident (MVA).
Sixteen days post-MVA, LM was
transferred to acute rehabilitation
with multiple co-morbidities including
type II diabetes mellitus, obesity, and
hypertension, and poly-pharmacy.
Due to acute respiratory and renal
failure, he was transferred to acute
care and required extensive medical
management, including discontinuation
of his ACE-inhibitor medication. Upon
re-admission to the rehabilitation
setting, LM remained in renal failure
(creatinine level=3.9 mg/dL, BUN
levels=84 mg/dL) but was tolerating
progressive amounts of rehabilitation
including sitting upright for one hour
without orthostatic symptoms. Within
24 hours of reintroduction of the
ACE-inhibitor, LM became severely
orthostatic (52/36 at 45 of upright)
despite use of an abdominal binder and
lower extremity bandaging.
Outcomes : After the reintroduction
of the ACE-inhibitor, LM was unable
to fully participate in rehabilitation or
progress in his functional goals. Lack of
progress led to transfer to a long term
acute care facility. His lack of progress
was most likely primarily due to the
ADE.
Discussion : ADEs occur across all
health settings. Upon retrospective
review the effect of the ACE-inhibitor
on the patients physiological and
functional status was identified. Risk
factors for ACE-inhibitor intolerance
include: serum sodium levels < 130
mEq/L, the addition of high dose loop
diuretics, and baseline systolic BPs < 90
mmHg. Our patient met two of these
criteria and ultimately demonstrated
symptomatic orthostatic hypotension.
PTs must be aware of the effects
of medications on function and
communicate observed changes in
patient status to the rehabilitation team.
Attention to the patients response to
medications may help the PT develop
an appropriate plan of care, explain
changes in treatment effectiveness, and
optimize rehabilitation outcomes in a
medically complex patient.
KEYWORDS: adverse drug event,
spinal cord injury, acute rehabilitation.
JACPT
Identifying Components of Acute
Care Physical Therapy Practice
Through Analysis of Presentations
at Combined Sections Meeting
Smith, Jim M. Utica College, Utica,
NY, United States.
Purpose : Presentations at the
Combined Sections Meetings (CSM)
of the APTA reflect the topics being
addressed by physical therapy clinicians
and researchers. The identification of
the topics being addressed in acute
care will provide information about
practices in acute care physical therapy.
That information may be of interest
to the Acute Care Section, as it is in
the process of practice analysis as a
component of developing specialist
certification with the American
Board of Physical Therapy Specialties.
Description : There were 84 platform
and poster presentations sponsored
by the Acute Care Section at the
CSM 2004 - 2009. The abstracts for
the platform and poster presentations
were reviewed. Presentations prior
to 2004 were excluded to ensure
analysis of current practice activities.
Summary of Use : Eight categories
evolved and the themes are identified
in order of most frequent to least
frequent:
1. Patient/client management for
multiple physical systems issues
(26%)
2. Patient/client management for
integumentary issues (19%)
3. Patient/client management for
cardiopulmonary issues (17%)
4. Administration and practice
environment issues (15%
5. Education and professional
development issues (8%)
6. Patient/client management for
neuromuscular issues (5%)
7. Patient/client management for
musculoskeletal issues (5%)
8. Other/no specific category (5%)
Importance to Members: These
JACPT
APTA 2010 Combined Section Meeting: Poster Abstracts
themes represent the topics and issues
of scholarly interest to acute care PTs
and PTAs. The common theme across
the majority of the presentations
was the management of complex or
medically urgent patient/client issues.
The most frequently encountered
topics were issues and strategies for
the physical therapists management of
multiple-system pathology, followed by
integumentary pathology. The domain
of administration and practice
issues revealed topics unique to the
advancement of physical therapy
practice in acute care environments.
The relevance is that these categories
identify the types and frequency of
the topics of scholarly interest to
acute care physical therapy that were
addressed at CSM over the last 6 years.
This should inform the current analysis
of acute care physical therapy practice
and it may inform the priorities for
future research activity in acute care
physical therapy.
KEYWORDS: practice analysis,
practice area.
Medial sternotomies: A
systematic review and evidence-
based guidelines for postoperative
sternal precautions
Tuttle, Karen; Mincer, Andi B.;
Thompson, Anne W. Physical
Therapy, Armstrong Atlantic State
University, Savannah, GA, United
States.
Purpose/Hypothesis : Current
postoperative guidelines for patients
who have had a medial sternotomy
vary widely in activities allowed and
timeframes for recovery. This study
combined a systematic review of
peer-reviewed literature, popular
web sources for patient information,
and biomechanical analysis of
activities of daily living (ADL)
that are commonly limited during
recovery from a medial sternotomy.
Number of Subjects : Three
subjects were used for simple
biomechanical analysis of sit to
stand, push/pull, and lifting tasks.
Fall 2010 Volume I Number 1
Materials/Methods : Medline,
PubMed, E-pub, and Galileo database
searches were performed for peer-
reviewed research articles, using
sternal precautions and sternal
dehiscence as keywords. Nursing and
physical therapy texts and the American
Association of Cardiovascular and
Pulmonary Rehabilitation guidelines
were reviewed. Additionally,
dynamometry was used to establish
the forces generated during
various push, pull, and lift tasks.
Results : While the type of
surgical closure influences sternal
stability,sternal dehiscence occurs
in less than 3% of sternotomies.
Biomechanical forces from typical
ADLs should not have enough force
to distract the typical closure more
than 2 mm,which is the threshold
for potential dehiscence. Coughing
presented the greatest risk. Risk
factors include obesity, postoperative
infection (i.e. pneumonia and urinary
tract infections), diabetes mellitus,
re-operations, harvesting of bilateral
internal mammary arteries, and
age greater than 60 years old.
Conclusions : Following medial
sternotomy, all patients should be
encouraged to (1) stabilize the chest
by crossing their arms or hugging a
pillow while coughing; (2) use lower
extremities more than uppers when
transferring from sit to stand; (3)
use gentle, controlled motions when
pushing, pulling, or lifting; (4) avoid
resistance training and sports for three
months with sternal stability testing prior
to reengaging in these activities; and (5)
immediately report any increased pain
or feelings of instability in the sternum.
Clinical Relevance : Postoperative
guidelines should allow patients the
maximum freedom to resume normal
mobility, yet appropriately restrict
activities which may be harmful.
This report incorporates evidence
from peer-reviewed literature and
biomechanical analysis to provide
comprehensive sternal precautions
following medial sternotomy.
36
APTA 2010 Combined Section Meeting: Poster Abstracts
KEYWORDS: sternal precautions,
sternotomy.
Impressions of Physical Therapy
Students Towards Hospital Based
Physical Therapy Care
Sanders, Babette1; Surufka,
Megan ; Tito, Nicole1; Smith, Jim
1
M.2 1. Physical Therapy and Human
Movement Sciences, Northwestern
University, Chicago, IL, United States.
2. Department of Physical Therapy,
Utica College, Utica, NY, United
States.
Purpose/Hypothesis : Hospital-
based physical therapy (HBPT) or
acute care is one environment in which
physical therapists (PTs) practice.
PTs have many contributions during
the course of a patients stay in the
hospital and must possess a wide array
of skills in order to provide competent
services to the patient. However,
despite the importance of HBPT, its
popularity seems to be diminished
in both the PT and student PT
populations. There seems to be many
negative connotations towards HBPT
which are deterring the interest of a
large amount of PTs or potential PTs.
The purpose of this study was to gain
information on student PTs reasons
for the apparent decreasing interest
in hospital based practice as a PT.
Number of Subjects : 48
Materials/Methods : Materials/
Methods : PT students from
Northwestern University and Utica
College completed a demographic
sheet. After reviewing their responses,
they were categorized into groups
depending on the amount exposure
or experience in the acute care
setting for physical therapy. Exposure/
Experience was determined based on
the amount of hours completed in
observation, volunteering, internship
and employment in HBPT. The
categories consisted of those with less
than 20 hours exposure, those with
more than 20 hours exposure, and
those who had completed a formal
full time clinical education experience.
Small groups were formed with
subjects from the same categories and
37
focus group discussions were held.
During these discussions a series of 13
questions created by the researchers
were asked and the group discussions
lasted approximately 30 minutes. All
focus group discussions were audio
taped and the sessions transcribed
and coded for common themes by the
same researchers.
Results : Students with a formal
clinical education experience expressed
more specific insights regarding their
impressions of HBPT. In general, their
responses were more positive, with
greater understanding of the inpatient
setting as a whole and the value of
physical therapy in the patients care;
the responses from students with the
least exposure to HBPT were more
negative about HBPT.
Conclusions : Regardless of how much
time was spent in HBPT for observation,
volunteering, or even employment,
students with specific full time clinical
education experiences working in the
clinician role demonstrated greater
understanding and expressed more
positive impressions of that setting.
They suggested that acute care facilities
do more to advertise the pace and
complexity of HBPT as a positive work
environment.
Clinical Relevance : Academic and
clinical institutions should partner to
provide more opportunities to expose
students to HBPT so that they become
more aware of the positive attributes
this practice setting offers. This could
potentially lead to more physical
therapist students being attracted to
HBPT as a career choice.
KEYWORDS: acute care, clinical
education, career choices.
Patient readmission rates
are lower when acute care
physical therapists discharge
recommendations are followed.
Fields, Christina J.1; Fernandez,
Natalia M.1; Smith, Beth A.2
1. Division of Physical Therapy,
University of Michigan Hospital,
Ann Arbor, MI, United States.
Fall 2010 Volume I Number 1
2. School of Kinesiology, University
of Michigan, Ann Arbor, MI, United
States.
Purpose/Hypothesis : The purpose
of our study was to determine the
frequency with which the acute care PTs
recommendation of patient discharge
location matched the patients actual
discharge location, as well as the impact
of mismatches. In addition, we explored
factors associated with a mismatch.
Number of Subjects : Our
retrospective study included the
discharge recommendations of 40
acute care PTs for 762 patients in
a large academic medical center.
Materials/Methods : We calculated
the frequency of mismatch between
physical therapist recommendation
and patient discharge location. We
assessed the relationship between
mismatches and patient readmission
rate. We also explored factors
contributing to a mismatch: therapists
acute care experience and treatment
by one or multiple therapists
from evaluation to discharge.
Results : Overall, therapists discharge
recommendations were followed
84% of the time. Patients were more
likely to be readmitted when the PT
recommendation was not followed.
Conclusions : Our study supports the
role of physical therapists in discharge
planning in the acute care setting.
Clinical Relevance : PTs
demonstrated the ability to
make appropriate discharge
recommendations for complex, acutely
ill patients with fluctuating functional
and medical status.
KEYWORDS: discharge
recommendations, readmission rate,
acute care.
A Case Study of the Effect of
Body-Weight Support Treadmill
Training on the Function of an
Individual with a Transtibial
Amputation and Comorbidities
JACPT
Sartor-Glittenberg, Cecelia;
Wong, Rebecca. Arizona School of
Health Sciences, A.T. Still University,
Mesa, AZ, United States.
Purpose/Hypothesis : Purpose:
Determine if body-weight support
treadmill training (BWSTT) improved
the function of an individual with a
chronic transtibial (TT) amputation
and comorbidities, and who
had already completed standard
rehabilitation. Hypothesis: BWSTT
would improve endurance, chosen
gait velocity, self-reported locomotor
ability and decrease fear of falling in an
individual with a TT amputation and
comorbidities.
Number of Subjects : Subject: A
41-year-old female with a left TT
amputation due to musculoskeletal
instability two and one half years prior
to the study. She had comorbidities
of obesity, weight 336 lbs or BMI
of 54, and a recent right total knee
replacement (TKR). Prior to the TKR
she had a fear of falling, a history of falls
and gait impairments.
Materials/Methods : Impairment
measures included a measure of fear
of falling using the Activities-Specific
Balance Confidence Scale (ABC).
Activity measures include distance
walked during a 6-minute wat velocity
using the 10-meter Walk Test, and a
self-report of locomotor ability using
the Locomotor Capabilities Index 5
(LCI5). Study protocol: 2 weeks of
pre-testing (4 sessions total), 4 weeks
of intervention, and 1 post-test 2
weeks after the intervention. The
proposed intervention of BWSTT was
to be carried out 3 times per week for
4 weeks. The outcome measures were
to be collected during the pre-testing
sessions and once per week prior to
the third intervention session that
week.
Results : Although the study was
designed for 21 total sessions, only
8 sessions were completed: 4 testing
sessions, 3 before intervention and
1 after 1 week of intervention, and 4
training sessions. The subject reported
that she could not complete the study
because she had to move to another
JACPT
APTA 2010 Combined Section Meeting: Poster Abstracts
city. Of the testing sessions completed,
the subject increased her chosen gait
speed from 0.5 m/sec to 0.6 m/sec
by the fourth testing session. Total
distance walked during the 6-minute
walk test increased by 88 feet. ABC
scores changed from the fir to second
testing session, from 51.9% to 60.6%.
There was no significant change in
the total LCI5 score through the four
testing sessions; the scores ranged
from 35 to 37 out of a possible 42.
Conclusions : Even though the
subject did not complete the training
sessions with the BWSTT, there
were observable improvements in
gait velocity and in total distance
walked in 6 minutes. Based on the
results of this study, BWSTT may
be beneficial for individuals with TT
amputations who ambulate with a
prosthesis and have comorbidities,
which may make traditional
locomotor training impractical.
Clinical Relevance : Although
independent ambulation may be
achieved following a lower extremity
amputation, recent studies have shown
that many individuals with amputation
do not use their prosthesis at all, and
if ambulation ichieved, approximately
two-thirds of individuals remain
ambulatory after two years. Although
BWSTT is used in practice by
prosthetists and physical therapists,
there are not many research studies
done on individuals with amputations.
KEYWORDS: prosthetics, body
weight support treadmill training,
amputee.
Developing and Implementing
a Program using Functional
Outcome Measures in Acute Care
at Parkland Health & Hospital
System (PHHS)
Belk, Beth; Cao, Keri. Parkland
Health & Hospital System, Dallas, TX,
United States.
Purpose : To display the development
and implementation process of using
functional outcome measures in acute
care at PHHS. The steps described
include functional outcome measure
Fall 2010 Volume I Number 1
selection, literature review, notebook
compilation, PT staff education, and
follow up with staff.
Description : The program
development included outcome
measure selection based on patient and
diagnosis appropriateness, feasibility,
high validity and reliability, and clinical
relevance. A literature review for each
outcome measure was performed to
determine patient appropriateness
and psychometric properties. 2
notebooks were compiled: notebook
1 included tables, instruction, and
scoring interpretation, and notebook 2
included reference articles. An inservice
was given to PT staff to explain the
purpose of the program and instruction
on the various outcome measures.
The implementation process involved
encourageing PT staff to use functional
outcome measures during their acute
care rotation. To ensure accountability,
PT Staff was asked to record outcome
measure usage on log forms. They
were also asked to fill out a survey at
the end of their acute care rotation
describing benefits and limitations of
using functional outcome measures in
acute care. The authors collected the
log forms and surveys to determine
the need for change in the program.
Summary of Use : This program
provides physical therapists the tools
for using functional outcome meausures
in acute care. It specifically describes
the development and implementation
process of using functional
outcome measures in acute care at
Parkland Health & Hospital System.
Importance to Members: The use
of functional outcome measures in all
areas of physical therapy is widespread.
Most importantly outcome measures
help determine effective and efficient
treatment intervention, establish
patient specific and functional
goals, document change, and aid in
reimbursement and benchmarking
purposes. This program is an example
of how to develop and implement the
use of functional outcome measures in
an acute care setting.
38
APTA 2010 Combined Section Meeting: Poster Abstracts
KEYWORDS: Functional Outcome
Measures, Acute Care.
Self-Reported Measurements of
Vital Signs by Physical Therapists
Harris, Katherine S.; Smith,
Megan; Agnese, Kristen. Quinnipiac
University, Hamden, CT, United
States.
Purpose/Hypothesis : Vital signs are
listed as part of a systems review that
should be performed with all patients
or clients at the start of physical therapy
care. The purpose of this study was to
survey physical therapists (PTs) who
were members of the Connecticut
Physical Therapy Association (CPTA)
to determine the role in assessing
vital signs and to determine if the
assessment of vital signs has increased
since past studies. The hypothesis
stated that there would be an increase
in the number of PTs who assess vital
signs as compared to previous studies.
It was also hypothesized that home
health and acute care PTs would assess
vital signs more frequently than PTs in
other settings.
Number of Subjects : Members
of the CPTA (Connecticut Physical
Therapy Association),767, were invited
to participate in an online survey.
Materials/Methods : The
questionnaire consisted of demographic
information and a 17-item survey
about opinions regarding vital signs and
assessment of vital signs. Data analysis
included descriptive statistics consisting
of frequency, return rate and response
characteristics, measurement and use
of vital signs, reasons given for not
measuring vital signs and relationship
between practice settings and the
assessment of vital signs.
Results : One-hundred-four
participants responded to the survey,
for a response rate of fourteen percent.
However, thirty-one surveys could
not be used because the surveys were
incomplete, therefore our sample size
was 73. Usable survey questionnaires
were received from 73 respondents
(14% and of those 50.7% reported
working in an outpatient facility. The
39
majority of respondents strongly agreed
or agreed (71.2%) that measurement
of HR, BP and RR should be included in
physical therapy screening and 67.1%
(strongly agree or agree) indicated that
assessing vital signs on a routine basis
in clinical practice was essential. The
majority of respondents never assessed
BP, HR or RR (37%, 31.5%, and 43.8%,
respectively) as part of the examination
of a new patient. Clinicians in home
health, followed by acute care and
nursing home (respectively), assessed
vital signs the most while clinicians in
the school system assessed vital signs
the least.
Conclusions : Our data indicated that
vital signs were infrequently measured
in new patients and existing patients.
However, the majority of participants
generally agreed that vital signs should
be assessed on a routine basis in clinical
practice. Our data indicates that our
hypotheses were correct and that more
PTs are assessing vital signs than in
previous studies and PTs in acute care,
home health and nursing home settings
are assessing vital signs the most.
Clinical Relevance : Vital signs
are a critical component to physical
therapy evaluation and progression
of treatment interventions. This small
study indicated that vital signs are
considered important though rarely
obtained. Further research across care
settings and geographic regions should
be undertalen to assess barriers to
vital sign monitoring.
KEYWORDS: vital signs.
Ascertaining the Effectiveness and
Safety of Contact Low-Frequency
Ultrasound (LFU) in an Acute,
Post-Surgical Wound with Exposed
Hardware
Hakim, Daniel2; Cooke, L. Ruth2;
Myers, Barbara2; Horowitz,
Jeffrey ; Hakim, Ellen W.1 1. Physical
2
Therapy and Rehabilitation Science,
University of Maryland School of
Medicine, Baltimore, MD, United States.
2. Integrated Wound Healing Center,
Franklin Square Hospital Center, MedStar
Health, Baltimore, MD, United States.
Fall 2010 Volume I Number 1
Background & Purpose : It
has been suggested that hardware
exposure within a wound bed heralds
a contaminated state and presents
a deterrent to stable granulation
tissue. With few existent guidelines
predicting primary closure success
atop exposed hardware, the safety and
efficacy of second-generation healing
technologies, namely LFU, under such
circumstances have not been studied.
This case report served to determine
if LFU is a useful adjunct to negative
pressure wound therapy (NPWT)
in healing a wound with exposed
hardware.
Case Description : The subject was
a 54 year-old male referred to physical
therapy (PT) status-post dehiscence of
right tibiotalar calcaneal arthrodesis
site. The patients past medical history
included CAD, HTN, NIDDM and
venous insufficiency. While best
practice algorithms suggested favorable
soft tissue reconstruction only upon
hardware removal, maintenance of the
implants was vital for bony fusion and
joint stability. Consequently, irrigation
and surgical debridement occurred to
promote visualization of the wound
bed, facilitate removal of necrosis and
enable aggressive cleansing prior to use
of NPWT. PT sessions included LFU
and NPWT application 3 times per
week. Operating parameters aligned
with industry standards. Healing
progress was ascertained via analysis
of wound measurements, wound
bed characteristics, wound drainage,
and integrity of the periwound
environment. Given wound location,
need for compression, and use of a
stabilizing orthosis, a new NPWT
dressing component (for bridging) was
initially attempted; however, difficulties
with seal maintenance warranted
resumption of traditional NPWT
dressing approaches.
Outcomes : Within one week of
post-operative debridement, the
hardware was fully concealed by
granulation tissue and wound depth
decreased 19%. Emerging granulation
tissue appeared stable and within four
weeks wound depth decreased 53%.
JACPT
Wound margin maceration during the
first three weeks of care resulted in a
15% increase in width and only a 2.6%
decrease in length. Upon return to
the traditional NPWT dressing, a 25%
decrease in width and a 6% decrease in
length occurred over the subsequent
two weeks. Drainage decreased as
customary with the NPWT usage.
Necrotic and devitalized tissues
were minimized via serial use of LFU.
Negative wound cultures and the
absence of local or systemic signs of
infection negated the need for antibiotic
management. Application of a skin
graft or bioengineered skin substitute
is currently being considered.
Discussion : While long-term
outcomes are yet unknown, it did
appear the wound derived benefit from
the debriding and bacteriocidal effects
offered via LFU. Further, no adverse
effects to the orthopedic hardware or
the operating ultrasound sound head
were noted. Progress may have been
slowed by initial difficulties with the
alternate dressing component of the
NPWT system. Analysis indicated the
patient benefitted from concomitant
use of LFU and NPWT to granulate
over exposed hardware and prepare
the wound for closure.
KEYWORDS: low frequency
ultrasound, hardware exposure,
wound healing.
A Comprehensive Physical
Therapy Approach for a
Premature Infant in the Neonatal
Intensive Care Unit (NICU):
Aligning with the Evidence
Tarr, Kelly M.2; Hakim, Ellen W.1
1. Physical Therapy and Rehabilitation
Science, University of Maryland School of
Medicine, Baltimore, MD, United States.
2. Physical Medicine and Rehabilitation,
University of Maryland Medical Center,
Baltimore, MD, United States.
Background & Purpose : Clinical
research established that neurologic
maturation of a neonate can be
positively influenced by proper
positioning, integration of massage
techniques, implementation of calming
JACPT
APTA 2010 Combined Section Meeting: Poster Abstracts
strategies and use of specific handling
techniques. (Beachy, 2003; Ferrari
et al., 2007; Hernandez-Reif, Diego,
& Field, 2007; Hill, Engle, Jorgensen,
Kralik, & Whitman, 2005; Short,
Brooke-Brunn, Reeves, Yeager, &
Thorpe, 1996; Campos, 1989). It is
also reported that early intervention
of the neonate improves long-term
outcomes and quality of life. (Mahoney
& Cohen, 2005). This case report
assessed the impact of changes to
infant development and organization
in a neonatal intensive care unit
(NICU) with implementation of select
interventions by physical therapists,
and reinforced by a multidisciplinary
team.
Case Description : The subject of
this report was an extremely low birth
weight (1 pound, 2 ounces) infant born
at 24 weeks gestational age. Significant
medical complications included
bronchopulmonary dysplasia, patent
ductus arteriosus, hyperbilirubinemia,
respiratory instability, and confinement
to an incubator given inadequate
thermoregulatory ability. Upon physical
therapy examination at 31 weeks post-
conceptional age, the infant presented
with decreased maintenance of a flexed
posture, hypotonia in the absence
of purposeful movement, inability
to self-calm, a right cervical rotation
preference, and vital sign instability
with position changes. Comprehensive,
evidence-based interventions were
implemented consisting of positioning
techniques (swaddling and nesting),
calming techniques (facilitated tuck and
non-nutritive sucking) and massage.
Determination of subject response to
interventions, as well as neuromotor
development and organization,
occurred via the Morgan Neonatal
Neurobehavioral Exam and vital sign
monitoring.
Outcomes : Utilization of multimodal
interventions revealed increased flexion
and tone as evidenced by improved
scores on the posture section of the
Morgan Neonatal Neurobehavioral
scale, improved ability to self-calm
with facilitation, increased tolerance
to changes in position as evidenced
Fall 2010 Volume I Number 1
by increased vital sign stability, slightly
greater arousal, decreased touch
aversion with handling as evidenced
by decreased irritability, and reduced
supplemental oxygen requirements.
The subjects right cervical rotation
preference and limited respiratory
endurance did not respond as
anticipated despite intervention.
Discussion : Current findings
demonstrate the benefits of early
physical therapy intervention on a
medically fragile infant in the NICU.
Ongoing monitoring of the infant needs
to occur to fully appreciate the degree
to which developmental delay, as well
as cognitive and behavioral disorders,
were minimized or averted based
upon the therapy offered. Additional
investigation to identify more specific
temporal guidelines for physical therapy
involvement in the NICU would be of
benefit.
KEYWORDS: premature infant and
developmental disabilities, neuromotor
development and physical therapy,
Morgan Neonatal Neurobehavioral
Examination.
Is a General Orthopedic Class
Taught by Physical Therapists In
A Community Hospital Effective
in Providing Sustained Knowledge
to Nurses?
Warner, Elizabeth M.; Montague,
Diane C.; Zinko, Michael W.
Physical Medicine, Bristol Hospital,
Bristol, CT, United States.
Purpose/Hypothesis : The purpose
of this project was to determine if
the recently implemented class on
general orthopedics given by physical
therapists to graduate nurses new to
our institution was effective. Feedback
from new nurses revealed that the
didactic portion of their training
included less than 1 hour of lecture
on the care of the patient with an
orthopedic diagnosis. Our hypothesis
was that an on-site training class specific
to orthopedic care at our community
hospital would result in improved
nursing knowledge immediately after
the class as well as one month later.
40
APTA 2010 Combined Section Meeting: Poster Abstracts
Number of Subjects : All graduate
nurses from 3/08 to 3/09 were included
in this study. This was a total of 22 people.
Materials/Methods : A written 10
question test (6 multiple choice and
4 true/false) was devised to be given
pre- and then immediately post-
class as well as again 1 month later.
Students in the class were aware of
the schedule for testing. Grades were
recorded in an Excel Spreadsheet and
statistics were compiled from this.
Results : Scores show improvements
in pre- to post-test scores as well as
pre- to one month follow up scores.
Pre-test mean was 57.7% with a range
of 30%-90% and a standard deviation of
13.43. Immediate post-test mean was
87.7% with a range of 80-100% and a
standard deviation of 6.85. One month
follow up mean was 83.6% with a range
of 70-100% and a standard deviation of
8.39. Individual students averaged a
postitive gain from pre- to post-test
score of 28.6% and pre- to one month
post-test scores of 25.9%. T test reveals
statistical significance at the <0.05 level.
Conclusions : A knowledge deficit
has been reported by graduate nurses
entering our facility regarding the care of
the patient with an orthopedic diagnosis.
Data collected shows improvements
in test scores both immediately after
and one month after the orthopedic
class. These scores show knowledge
gained is retained at least one month
post-class. We recommend further
study to assure that this knowledge
will be retained for greater than a one
month period as well as to determine
if carryover to patient care is achieved.
Clinical Relevance : True multi-
disciplinary care is a model strived for by
many practitioners. In order to achieve
this, caregivers from across disciplines
need to have an understanding of and
respect for contributions made by all
members of the healthcare team. By
enhancing knowledge, teamwork and
multidisciplinary care planning can be
facilitated so that the goal of maximizing
patient outcomes can be achieved.
41
KEYWORDS: orthopedics, post
test, physical therapy.
Use of mobility protocol decreases
the length of stay in the intensive
care unit.
Berg, Beth ; McMahon, Peg ;
2 2
Ronnebaum, Julie.1 1. Des Moines
University, Des Moines, IA, United States.
2. Mercy Medical Center, Des Moines ,
IA, United States.
Purpose/Hypothesis : Background:
Research has shown that immobilization
for a critically ill patient leads to
further complications and that physical
therapy aids by improving function
and may decrease the patients length
of stay in the intensive care unit.
Purpose: The purpose of this study is to
assess the effectiveness of a prescribed
mobility protocol for patients with
respiratory failure in the intensive care
unit. Additionally, we will assess the the
implementation of the mobility protocol
across different medical diagnosis.
Hypothesis: We hypothesize
that the mobility protocol will
substantially decrease the length
of stay in the intensive care unit as
compared to those who received
standard physical therapy treatments
without the mobility protocol.
Number of Subjects : Number
of subjects: The study includes a
stratified sampling of 100 patients
that were admitted to the intensive
care unit over the past year for the
group with the implementation of
the mobility protocol and the year
prior to the implementation of the
mobility protocol. The patients are
divided into groups based on whether
they received the mobility protocol
or received standard physical therapy
treatments without the mobility
protocol. The groups include equal
number of males and females.
Materials/Methods : Materials/
Methods: Patients admitted to the
intensive care unit with respiratory
distress were evaluated for specific
criteria to be included in the mobiltiy
protocol program. The mobility
Fall 2010 Volume I Number 1
protocol was administered by an acute
care physical therapist. The mobility
protocol includes transfer training, gait
training abd therapeutic exercise along
with specail settings on the ventilator.
the physical therapy portion of the
mobility protocol is administered 1 time
per day after medical clearance. Some of
the variables that are assessed include:
the length of stay in the intensive care
unit, time spent on the ventilator, lab
reports, and vitals. Our study utilizes
a single factor design for repeated
measures, involving two groups of
patients: those receiving the mobility
protocol and those who did not.
Results : Results: Preliminary results
of the data, are indicative of improved
gas exchange, decreased time on the
ventialtor, and improved functional
mobility. In addition, the length of stay
appears to be minimized by 30% after the
implementation of the mobiltiy protocol.
Conclusions : Conclusion: There
appears to be a positive correlation
between the implementation of the
mobility protocol and the reduced
length of stay in the intensive care
unit. This is an ongoing study to be
completed by the end of the year and
all of the results will be presented
at the combined Sections Meeting.
Clinical Relevance : Clinical
Relevance: The use of the mobility
protocol is beneficail in decreaseing
the length of stay in the intensive
care unit as well as decreasing further
complications from immobility.
KEYWORDS: mobility protocol,
intensive care, early mobility.
JACPT
Registration & information
for these Acute Care courses
at APTAs Learning Center can be found at
http://learningcenter.apta.org
ONLINEA CSM10: Mobilizing Patients With Femoral Catheters in ICU: Clinical Considerations
Christiane Perme, PT
$45 Nonmember/$27 Member 0.15 CEUs (1.5 contact hours)
CSM10: Evidence-Based Medicine: Multiple Sclerosis Drugs and Exercise
Implications
Steven Kantor, DPT; Mary Jane Myslinski, EdD
$98 Nonmember/$59 Member 0.325 CEUs (3.25 contact hours)
CSM10: Multidisciplinary Perspectives in the Management of Venous
Thromboembolism
Raegan Muller, MPT; Robyn Teply, PharmD, MBA
$83 Nonmember/$50 Member 0.275 CEUs (2.75 contact hours)
PRINTA Geriatrics Section: Clinical Management of Physical and Chemical Restraints
Allison Lieberman, PT, MSPT, GCS; Hospital for Joint Diseases at NYU Langone Med Ctr, NY, NY
$125 Nonmember/$75 Member/$67.50 Geriatric Section Member 0.5 CEUs (5.0 contact hours)
Progressive Multifocal Leukoencephalopathy in a Patient with AIDS
Meredith E Drench, PT, PhD
$49 Nonmember/$29 Member 0.2 CEUs (2 contact hours)
Promoting Early Mobility and Rehabilitation in the Intensive Care Unit - I
Jennifer M. Zanni PT, MSPT, Department of Physical Medicine and Rehabilitation, Johns Hopkins
Hospital, Baltimore, MD; Dale M. Needham MD, PhD, Department of Physical Medicine and
Rehabilitation, Johns Hopkins Hospital, Baltimore, MD & Division of Pulmonary and Critical Care
Medicine, Johns Hopkins University, Baltimore, MD
$49 Nonmember/$29 Member 0.2 CEUs (2.0 contact hours)
Recognizing and Reporting Signs of Child Abuse
Cynthia N Potter, PT, DPT, PCS
$49 Nonmember/$29 Member 0.2 CEUs (2 contact hours)
Progressive Multifocal Leukoencephalopathy in a Patient with AIDS
Meredith E Drench, PT, PhD
$49 Nonmember/$29 Member 0.2 CEUs (2 contact hours)
Sciatica or Intermittent Vascular Claudication?
John C Gray, PT, OCS, FAAOMPT
$49 Nonmember/$29 Member 0.2 CEUs (2 contact hours)
The Integumentary System - Repair and Management: An Overview
Joseph McCulloch, PT, PhD, FAPTA
$49 Nonmember/$29 Member 0.2 CEUs (2 contact hours)
JACPT Fall 2010 Volume I Number 1 42
JACPT
Journal of Acute Care Physical Therapy
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