JACPT Abstracts & Archive
Abstracts from JACPT issues are available to view for free. To access full-text articles:
Members: Past issues of JACPT are available online for members. Just click the link next to the issue you would like to access, login, and you can download a pdf of the issue.
Your Acute Care Section membership includes a subscription to JACPT. If you are looking for an issues/articles, you may request a reprint for $10 from our Executive Office. Use the Reprint Request Form.
Non-Members: If you are looking for an issue/article from 1993 to present, you may request a reprint for $10 from our Executive Office. Use the Reprint Request Form.
If you would like to subscribe to JACPT, please complete our JACPT Subscription Form. Or better yet, join the Acute Care Section! Membership includes a subscription to JACPT and members-only access to past issues of JACPT.
JACPT is listed in EBSCO, an online database of research journals, and is indexed in Gale. If you have access to these databases, you can retrieve past editions and articles this way as well.
This page has the most current JACPT abstracts. To review older JACPT abstracts (2010-2011), please visit here.
JACPT 2013, Volume 4, Number 1 (archived issue posted after mailing to subscribers completed)
Measuring Functional Status in the Acute Treatment Phase Following Trauma
Melanie M. Parker, Roya Ghazinouri, Yvonne Michaud, Sihui Li, Selwyn O. Rogers
Background: Increasing emphasis is being placed on reporting outcomes beyond mortality following traumatic injury. We examined the functional status of patients in the acute phase after multiple trauma using a standardized scale, the Acute Care Index of Function (ACIF). Methods: We analyzed ACIF scores obtained during initial and discharge physical therapy evaluations of patients admitted to the trauma service. Over a two-year period, this included 526 patients. Demographic data, injury characteristics, and discharge destination were extracted from the institutional
trauma registry for study. Results: Patients over 65 years of age constituted 37% of this group, while 29% were between 41-65, and 34% were less than 40 years of age (mean 54 ± 24 years). The most common mechanism of injury was falling (42%), followed by motor vehicle crash (41.8%). The proportion of patients with an ISS (Injury Severity Score) greater than 15 was 50.8%. The median initial ACIF score was 42.5 and the median discharge ACIF score was 71.8. Mean discharge ACIF scores for patients with ISS >15 were lower than scores for patients with ISS ≤ 15 (74.7 vs. 62.6, p < 0.0001). Discharge ACIF scores were also significantly different based on age. Mean values of discharge ACIF scores were calculated for six groups of discharge dispositions. Analysis of variance was used to compare the differences in these means for the three largest groups: home (93.7 ± 15.1), home with services (86.2 ± 16.4), and extended care facility (45.5 ± 20.1). Conclusion: The ACIF showed improvement over time in the acute phase after trauma. A relationship of discharge ACIF scores to discharge disposition was also found. Reporting functional outcomes in the acute care setting is feasible and offers additional opportunity for setting benchmarks in trauma care and for improvements in resource allocation.
Gait Speed Improves During Physical Therapy in General Acute Care, Skilled Nursing, and Inpatient Rehabilitation - A Pilot Study
Heather J. Braden, Mansoo Ko, Maddie Bohmfalk, Katie Hortick, Scott Hasson
Objective: To describe gait speed and gait speed changes that occurred in patients who received physical therapy in general health care settings of acute care, skilled nursing, and inpatient rehabilitation settings. Design: Pre-post observational cross-sectional study of changes in gait speed.
Setting: Acute care, skilled nursing, and inpatient rehabilitation facilities of a regional medical center in the United States. Participants: Individuals (n=110) admitted with physical therapy referrals with full weight bearing status who could ambulate 20 feet and consented to
participate. Main Outcome Measure: Change in gait speed from initial visit to therapy discharge. Results: Two-way mixed ANOVA determined that mean gait speed improved significantly between initial and discharge time points (p<.001). An interaction effect between gait speed and health care settings ( p<.001), indicated varying levels of speed achieved across different health care settings. Post hoc tests using Bonferroni adjustments showed acute care discharge gait speed was not significantly different from skilled nursing (p=0.352), but inpatient rehabilitation was significantly different from both acute care (p<.001) and skilled nursing (p=0.02) units. Paired t-tests of the individual health care settings revealed that gait speed was significantly improved in acute care [initial vs. discharge; 0.31(0.22) vs. 0.38 (0.21) m/s], skilled nursing [0.36 (0.19) vs. 0.61(0.39) m/s],
and inpatient rehabilitation [0.60( 0.70) vs. 0.98 (0.72) m/s]. Minimal detectable change for gait speed was 0.16m/s in acute care, 0.14m/s in skilled nursing, and 0.51m/s inpatient rehabilitation. Conclusions: Self-selected gait speed is an informative measure. Gait speed improved from physical therapy initial evaluation to discharge in 3 different health care settings. In acute care, gait speeds improved over a short course of therapy, but these speeds would still be considered to be slow relative to community requirements. In skilled nursing and inpatient rehabilitation, patients achieve gait speeds required for limited community level ambulation.
The Effect of Monophasic Vs. Biphasic Current on Healing Rate and Blood Flow in People With Pressure and Neuropathic Ulcers
Daryl Lawson, Jerrold Petrofsky
Background: Endothelial dysfunction due to diabetes may be one reason why at least 15% of people with diabetes will eventually develop a lower extremity ulcer with delayed healing and risk of amputation. Recent evidence shows that skin blood flow may be increased with electrical stimulation if treatment is done in a warm room. However, optimal stimulation waveform is unknown. Optimizing the stimulation waveform may increase healing even more. The purpose of this investigation was to compare two electrical waveforms to determine which increased blood flow blood flow and wound healing more in chronic stage III or IV pressure ulcers and in Wagner stage II neuropathic ulcers when using a warm room. Materials and Methods: Forty subjects with chronic pressure or neuropathic ulcers were treated at an outpatient wound center. Twenty were people with neuropathic ulcers and twenty with pressure ulcers. Treatment consisted of biphasic or monophasic electrical stimulation up to 20 mA for 30 minutes, 3x/ week for 4 weeks in a 32ºC room. Skin blood flow was measured by a Laser Doppler imager. Results: Subjects with neuropathic ulcers receiving biphasic current had significantly higher healing rate (70.0% ± 32.3%) than those receiving. monophasic current (42% ± 22.3%; p<0.01). Significantly greater increases in blood flow were seen with biphasic current vs. monophasic current in people with pressure ulcers during stimulation at the outside of the wound (p<0.001) and also in subjects with neuropathic ulcers (p<0.05). Biphasic current also demonstrated a significant “carryover effect” or elevated blood flow from the initial test to test 2 and/or 4 for people with pressure ulcers (p<0.049) and neuropathic ulcers (p<0.042). Conclusion: Both patients with neuropathic and pressure ulcers receiving biphasic current demonstrated greater blood flow and healing rates compared with patients receiving monophasic current when treated in a 32ºC room.
Effects of Upper Extremity Movements on Sternal Skin Stress
Glenn L. Irion, Julie Gamble, Cassie Harmon, Enoch Jones, Ashley Vaccarella
Purpose: Sternal precautions given to patients following median sternotomy are based on expert opinion. Although specific limits are often stated within different versions of sternal precautions, no evidence exists to support any specific cut-off values. The purpose is to determine whether evidence exists for lifting restrictions and transfer methods given as sternal precautions. Methods: 22 healthy subjects (18 female, 4 male), ages 40-69 (mean 53) were instrumented with a Doppler blood flow probe to measure acceleration of skin overlying the sternum. Participants performed 3 trials each of 4 lifting tasks (arm only, 12-ounce can, 1-liter bottle and gallon jug from countertop to shelf). Sit-to-stand and supine-to-sit were each performed two different ways. Sternal skin stress was recorded while subjects performed transfer techniques taught by therapists to minimize upper extremity use and when using transfers that allow pushing up on the hands. Doppler shift caused by skin acceleration was recorded during each procedure. Results: Sternal skin stress during each lifting task was significantly different from all others (p < 0.001, repeated measures ANOVA, Tukey post-hoc tests). Sternal skin stress during transfers as taught by therapists was significantly less than that recorded during typical patient-selected transfer technique (paired t-tests, p = .007 for sit-to-stand and p = 0.015 for supine-to-sit). Conclusions: Lifting heavier objects causes more sternal skin stress than lighter objects. Transfer techniques taught as sternal precautions cause less sternal skin stress than commonly used transfer techniques. Although sternal precautions may be based on real differences in sternal skin stress within subjects during movements involving the upper extremities, the large variation among subjects in sternal skin stress suggests that no clear cut off for activities can be supported.
JACPT 2012, Volume 3, Number 3
Physical Therapist Consultation in the Emergency Department: A Multiple Case Report Describing Three Arizona Programs
Lauren Kesteloot, Michael T Lebec
Purpose: Physical Therapist (PT) consultation in the Emergency Department (ED) is an emerging but poorly understood service. This project describes the framework, practice models, and challenges associated with three ED PT programs. Methods: Descriptive data from three ED PT programs in Arizona were collected via survey and interview responses from PTs providing care in these settings. Based on these individuals’ perceptions, researchers compiled aggregate data to form a descriptive profile of each program. Results: PTs in these Arizona EDs provide care between eight to twelve hours per day with the majority of consultations involving patients with musculoskeletal conditions. Non-orthopedic referrals were commonly initiated to assess patient safety. Subjects reported they most frequently provided care focused on patient education, exercise prescription, pain management and discharge planning. ED PT services were perceived to decrease hospital admissions, increase patient satisfaction, and enhance patient education. Commonly reported challenges included inconsistent reimbursement, productivity tracking, and space/equipment limitations. Conclusions: These findings describing operations, demographics, benefits, and challenges in ED PT programs may be used to guide future efforts in developing this area of practice.
Rehabilitation Considerations and Medical Management in an Adult Patient with Toxic Epidermal Necrolysis
Rosann Toma, Suzanne Brown
Purpose: This case report highlights the etiology, clinical presentation, current medical treatment and acute rehabilitation intervention of an adult patient diagnosed with Toxic Epidermal Necrolysis (TEN). Stevens Johnson Syndrome/Toxic Epidermal Necrolysis (SJS/TEN) is a rare, painful, and potentially fatal, epidermolysis with involvement of skin and mucus membranes.1 The diagnostic classification is based on skin detachment of the patient’s total body surface area (TBSA). While some guidelines for medical management are available for SJS/TENS, limited published literature is available concerning rehabilitation considerations for interventions of patients with this condition. Methods: This case report discusses the diagnosis and medical management, while focusing on the physical therapy contribution to the treatment team. Outcomes were assessed using the Numeric Pain Rating Scale (NPRS), pulse oximetry, blood pressure, heart rate, six-minute walk test, gait distances, strength measures, and functional ability. The patient’s physical therapy treatment included interventions for pulmonary care, strength, endurance, activity tolerance, and pain. Outcomes: The patient was discharged home 29 days post onset, with improvement in pathology, impairments, and functional limitations. This case report adds to current understanding of this syndrome, medical interventions and functional rehabilitation considerations.
One Program’s Journey to Joint Commission Certification for Wound Services
Purpose: Acute care hospitals are increasingly seeking disease-specific certification of programs within their facilities and Physical Therapists (PTs) are well positioned to lead as well as participate in the certification process. Process: Disease Specific Program Certification by The Joint Commission is a voluntary process that demonstrates commitment to excellence in providing disease-specific services in comprehensive manner. Certification standards evaluate the scope of a specific disease, condition or service and a program’s effectiveness in using clinical guidelines and performance measurement to improve clinical care. The path to certification is an intense, structured process and requires an interdisciplinary approach to meet each element of performance contained within five overarching standards. Summary: This article is an overview of the path to The Joint CommissionDisease-Specific Certification in Wound Care at Cape Regional Medical Center in Cape May Court House New Jersey.
CSM 2013 Platform Presentations Abstracts & Poster Abstracts
Please see the issue for the full listing of all abstracts for Acute Care Section sponsored platforms and posters.
JACPT 2012, Volume 3, Number 2
Normal Pressure Hydrocephalus
Barbara Billek-Sawhney, Nicholas A Jackson
Idiopathic normal pressure hydrocephalus (NPH) is a neurological disorder described as wet, wild, and wobbly. This syndrome presents in older adults and is characterized by urinary incontinence (wet), dementia (wild), and gait dysfunction (wobbly). Although physical therapists (PTs) may encounter NPH in most practice arenas, PTs in acute care hospitals may be responsible for performing objective measures on individuals suspected of having NPH. Results of objective tests help determine whether patients are candidates for shunting. This paper will present background information on NPH and discuss implications for acute care PTs with an emphasis on gait assessment.
Normal Pressure Hydrocephalus Physical Therapy Assessment Before and After Cerebrospinal Fluid Drainage
Nicholas A Jackson, Barbara Billek-Sawhney
The concepts related to objective testing by physical therapists on patients suspected of having idiopathic normal pressure hydrocephalus (NPH) are presented. The protocol for NPH At Mount Carmel East Hospital, Columbus, OH was applied to a 73-year-old male patient. The patient was admitted for a 3-day drain protocol to determine whether he would be a candidate for shunt placement.
Improving the Care of Patients who have Difficulty Weaning from the Ventilator in the Acute Care Setting
Julianne Palmieri, Marianne R Orest
Purpose: Our physical therapists aspired to provide effective, evidence-based examination and interventions for patients who have difficulty weaning from ventilation in order to maximize function.
Process: Acute physical therapy staff identified areas where improvements were needed, the challenges encountered when treatments are being provided for this patient population, and the goals for this project as well as potential solutions. Physical therapy staff was surveyed to discern their comfort level with progression of mobility with patients using ventilators. A survey of other healthcare team members was completed to ascertain their perception of physical therapy’s role when treating this patient population. Hospitals similar to ours were contacted to determine what standards of care these facilities utilized, and a literature search was completed. Post-implementation surveys were completed by the physical therapy staff and other healthcare team members. Outcomes: An algorithm and a standard of care were developed to provide guidance to therapists for examination and interventions. An informational handout on ventilator settings and terminology was completed. Summary: We describe a quality improvement project for patients who have difficulty weaning from the ventilator in the acute care setting. We are hopeful that our experience and process may be helpful to other facilities undertaking a similar project.
Earlier Mobilization Decreases the Length of Stay in the Intensive Care Unit
Julie A Ronnebaum, Joseph P Weir, Tracy A Hilsabeck
Background: Earlier mobilization of patients in the intensive care unit (ICU) improves outcomes and decreases the length of stay in the hospital. Not all facilities are adhering to this approach due to concern regarding patient safety and/or medical clearance. The purpose of this study was to compare the effectiveness of two protocols (Mobility Protocol (MP), and Standard Physical Therapy (SPT)) for patients with respiratory failure in the ICU. Methods: This study was a retrospective review of 28 charts of patients admitted to the intensive care unit with a diagnosis of respiratory distress. Patients qualifying for the MP group were compared with patients in the SPT on total days in the ICU, time spent on the ventilator, and days before physical therapy was ordered. The MP is an interdisciplinary approach to care for patients in the intensive care unit. Results: The patients on the MP protocol spent a mean (± SD) of 13.3 ± 6.3 days in the ICU compared with patients on the SPT protocol who spent 24.9 ± 13.7 days (p=.007, d=1.11). Time spent on the ventilator for the MP group was 14.5 ± 8.7 days compared with 30.9 ± 20.0 days for the SPT group (p=.007, d=1.09). Physical Therapy was ordered on average 1.9 days earlier for those patients in the MP group relative to those in the SPT group. Discussion: Early mobilization in the ICU with an interdisciplinary approach improved outcomes in the ICU for patients with respiratory distress. This approach led to decreased days spent the ICU and decreased days spent on the ventilator, equating to a savings of $22,000 per patient in the ICU.
Evidence for the Validity of the Medline Pressure Ulcer Prevention Program (mPUPP)
Daniel L Young, Debashish Chakravarthy, Kiarash Mirkia
Introduction: Pressure ulcers (PrU) develop on 1 million people every year and the costs for treating this problem approach $11 billion. While not all PrUs can be prevented, most can be and Medicare has begun to deny payment for PrUs that develop in hospitals. A pressure ulcer prevention program has been developed and the researchers sought to evaluate the impact of the program. Methods: The program was based on previously published evidence that clinician involvement, patient, family, and caregiver education, and good skin care are important components of a successful prevention program. All facilities participating in the program, for which pre and post program PrU incidence data were available, were included in the study. Pre-program PrU incidence data were collected from 99 facilities and compared to post-program PrU incidence data. Results: The mean pre-program PrU incidence was 6.18 (range 38 to 0) and the mean post program incidence was 2.82 (range 24 to 0), yielding an average improvement for the entire sample of 3.36 (range -8 to 34), a 54% improvement. This difference was statistically significant, t (98) = 6.349, p<.001. No statistical differences between PrU rates or changes in facilities of different types or sizes were observed. Conclusions: The program demonstrated validity by reducing PrU incidence in facilities of different types. Whether this improvement is different from other pressure ulcer reduction programs is not known.
JACPT 2012, Volume 3, Number 1
Applying Principles of Exercise Testing and Prescription to a Patient with Type 2 Diabetes
Diabetes mellitus affects 8.3% of the population and is the seventh leading cause of death in United States. In acute care physical therapy, patients with Type 2 Diabetes Mellitus (T2D) are commonly seen for a multitude of reasons. Through this applied case study, the epidemiology of T2D is presented. A brief review of the benefits of exercise, precautions, and contraindications associated with physical therapy and T2D are presented. This article employs a case study of an examination of a 62-year old woman referred to physical therapy 4 days following admission with a primary diagnosis of diabetic ketoacidosis. Special tests are employed to validate the patient’s status and her rehabilitation potential. The 30-second sit to stand test, 6-minute walk test, and gait speed are presented and interpreted in reference to the patient case.
Case Report: Deciding Activity Level for an Acute Post-surgical Patient with an Elevated Risk of Bleeding
Carol S. Einhorn
Background and Purpose: The international normalized ratio (INR) is a mathematical calculation involving prothrombin time (PT) and the international sensitivity index of the thromboplastin reagent used in the PT test. INR was developed to correct for variability in PT testing caused by variable sensitivities of reagents and is used to monitor the effectiveness of anticoagulation treatment. Guidelines for interpretation of laboratory values state that activity modification may need to be considered when INR is >3.5 and bedrest may need to be considered if INR is >5.0. The purpose of this report is to illustrate factors to be considered in addition to the INR value in clinical decision making regarding the safety of mobilizing an acute post-surgical patient with an elevated risk of bleeding. In a more general sense this case can also serve as an example of the importance of knowledge-based clinical decision making to determine physical therapy interventions. Case Description: An 82-year-old woman receiving warfarin following heart surgery, who presented with postoperative respiratory insufficiency and an INR of 5.9. After discussion among the patient’s physical therapist, nurse, and physician assistant, the decision to get the patient out of bed, despite the high INR, was made to promote improved respiratory function. Outcome: The patient was transferred from bed to chair and no adverse events occurred. Discussion: INR values provide a guideline for activity level but other factors may need to be considered when making decisions regarding physical therapy intervention. Areas for further research include the effect of activity level on bleeding risk in the setting of an elevated INR, and the effect of activity level and positioning on pulmonary function.
Acute Care Outcomes Status Post Total Knee Arthroplasty with Continuous Femoral Nerve Block: Case Report
Background and Purpose: Total knee arthroscopy (TKA) is a common orthopedic surgery procedure of the aging adult. Management of postoperative pain is imperative to the speed of functional recovery. Continuous femoral nerve block (CFNB) has been introduced to control pain and decrease common side effects of this procedure. Quadriceps weakness has been a concern with the use of the CFNB. This case report will describe the acute care outcomes of a patient who had a TKA with CFNB.
Case Description: The patient was an 88-year-old man diagnosed with osteoarthritis of the left knee. This patient underwent a left TKA and received a CFNB with Ropivacaine. The patient received physical therapy via the standard joint camp protocol, starting on postoperative day 1.
Outcomes: Functional abilities, left knee range of motion, pain, return of muscle function, and length of hospital stay were assessed. Left knee range of motion at discharge was 6 to 90 degrees. Active quadriceps motor control was present with 2/5 strength as demonstrated by the inability to perform a straight leg raise with full knee extension (lag of 6 degrees). Discussion: For this patient, the pain ratings decreased after the catheter for the CFNB was taken out. Quadriceps weakness persisted throughout the hospital stay and the patient was discharged home with a knee immobilizer for safety at night on postoperative day 3.
Acute Physical Therapy and Length of Hospital Stay Following Lumbar Discectomy and Lumbar Fusion: A Retrospective Analysis
Neena K Sharma, Paul M. Arnold, Joan K McMahon, Lindsay Loyd, Carla H. Sabus, Brendan R. O'Connor
Purpose: Lumbar fusion and discectomy are commonly performed spinal surgical procedures. Factors associated with post-surgical length of hospital stay (LOS) have not been investigated. The purpose of this study was to evaluate factors, including utilization of acute physical therapy intervention (APTI), that were associated with LOS following lumbar discectomy or fusion. Method: A retrospective medical record review was conducted for 100 patients who underwent lumbar discectomy or fusion between December 1, 2007 and December 1, 2009. We tested for correlations of APTI, patient and surgery characteristics with LOS. Results: Age, number of surgical levels, functional dependency and number of acute physical therapy visits all yielded significant bivariate correlation to LOS. The dichotomous variables, type of surgery, sex, and discharge placement level were related to significant differences in LOS. These variables were included in a linear regression model to test for unique contributions of variance of these factors to LOS. Follow-up analysis tested the unique contributions of APTI and functional dependency to variability in LOS. Conclusion: Increased LOS is associated with greater age, greater number of pathological levels, fusion, greater functional dependency, discharge status to a care facility, male sex, and more physical therapy visits. While this study design cannot distinguish the impact of APTI on LOS, it suggests factors that may guide identification of patients likely to have a longer LOS.