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RESEARCH PODIUM
PRESENTATIONS
Presented by SarahWeir, E.J. Gann, BryanColeman-Selgado,Cristina Gallo, and HelenChan
OCTOBER 9-10, 2021
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Movement Analysis Language
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Sarah Weir, PT, DPT
Effectiveness of Plyometric Exercise on Increasing Gait Speed, Strength, and Power
in Children with Cerebral Palsy: A Systematic Review
and Meta-Analysis
Cerebral Palsy (CP)
Permanent, non-progressive motor and postural impairments caused by damage to the developing brain (Bax et al., 2005)
Common impairments include spasticity, weakness, reduced power generation, gait deviations, and postural control (Graham et al., 2016)
Classified by severity according to the Gross Motor Function Classification System (GMFCS) I-V (Palisano et al. 2016)
Significance of CP
LEADING CAUSE OF PHYSICAL DISABILITY IN CHILDREN WORLDWIDE
(Ryan, 2017)
1.5 and 3.8 per 1000 births
Medical Costs:• 10x higher for children with CP
• Estimated lifetime cost to care for an individual with CP nearly $1 million (Durkin et al., 2016)
(CDC, 2019)
Spastic CP ≈ 80% of all cases (CDC, 2019)
IF DECREASED, IS OFTEN ASSOCIATED WITH:
CAN BE INDICATIVE OF:Functional capacity General health status Fall risk
IS PREDICTIVE FORResponse to rehabilitation Functional dependence Mobility disability
Gait Speed(6th vital sign)
1.
2.
3.
1.
2.
3.
Decreased strength Decreased power Decreased participation
(Fritz, 2009; WHO, 2020)
⇩lower extremity strength and power are
associated with⇩ gait speed
(Riad, 2008)
PT aims to improve strength,
power, and gait speed in
children with CP
There is no standard best
treatment protocol for addressing impairments
and limitations in this
population
CLINICAL PROBLEM
GAIT
(Williams, 2019; Van Der Krogt, 2012; Riad, 2008)
• Speed changes kinematicsVelocity Dependent
• Strength, balance, coordinationComplex
• Ankle plantar flexors• Hip extensors
Requires Power
Generation
Requires Dynamic Control
• Concentric/eccentric contractions in different phases
GAIT IN CP
https://www.physio-pedia.com/File:Classification_of_CP_gait_.jpg
PLYOMETRIC TRAINING:
Requires power + eccentric and
concentric control
DYNAMIC
Minimal equipment
required
COST EFFECTIVE
Speed component mimics demands of functional activity
VELOCITY DEPENDENT
Jumping, bounding, lunging, skipping
EXAMPLES
(Gannotti et al., 2016; Davies et al., 2015; LaChance, 1995)
Eccentric contraction followed by rapid concentric contraction
of the same muscle
PLYOMETRIC TRAININGImproves bone mineral density for mild to moderately impaired children with CP (Gannotti et al., 2016)
Improves sprint speed in elite young football players (Bianchi et al., 2018)
Improves maximum strength and power in healthy young athletes (Peitz et al., 2018)
Increases power generation and change of direction ability in athletes (Asadi et al., 2016)
Increases LE strength, speed, and power and preadolescent soccer athletes (Drouzas et al., 2020)
Improves motor performance in prepubertal children (McKay et al., 2012)
THEORETICAL CONSTRUCTIF gait speed is a velocity dependent activity that requires task-specific muscle adaptations,
AND plyometric training can increase power and force production in muscle groups necessary for gait,
THEN plyometric training can feasibly impact gait speed in children with CP.
Novak et al., 2020
Gap in the Literature
• Circuit training intervention including plyometric, aerobic, and gait training• 13 school-aged children with CP• Improvements in walking speed
Gorter et al., 2009
• Task-oriented intervention including plyometrics• Case report of 15-year-old girl with CP• Improvements in endurance, power, agility, stairs, gross motor skills, walking speed
Fisher-Pipher et al., 2017
• Combined plyometric intervention• 3 school-aged boys with CP• Improvements in gross motor ability, agility, and upper extremity power• Inconsistent findings for LE power and speed
Johnson et al., 2014
Gap in the Literature
Traditional strength training ≠ improvements in power or gait
speed
Plyometric training has promising
preliminary results for
increases in strength, power generation, and
gait speed
No systematic review or
meta-analysis exists comparing
the effects of plyometric
training on gait speed, strength,
or power gains in children with CP
Databases and Search terms
DATABASES:
SEARCH TERMS: ● cerebral palsy
● plyometric OR power OR power training OR high velocity OR lower extremity functional training OR jump*
● gait speed OR gait velocity OR walking speed OR walking velocity
FILTER: <18 years old
Inclusion & Exclusion Criteria
INCLUSION:
(1) Full-text, English
(2) <18 years with CP diagnosis
(3) GMFCS I-II, ambulatory no AD
(4) Plyometric training, speed based lower
extremity strength training
(5) Gait speed was reported as an outcome
measure
EXCLUSION:
(1) Below level 2c evidence
(2) The intervention included
treadmill or other gait
specific training,
water-based interventions,
electronic stimulation,
whole-body vibration, or
use of exoskeleton.
GMFCS I-II, ambulatory no AD treadmill or other gait
specific training,
Study SelectionSecondary reviewer confirmed studies
met inclusion criteria
Level of evidence
PEDro STROBE Study design
n= Age GMFCS level
CP Diagnosis
Elnaggar et al., 2019
1b 7/10 RCT 39 8-12 I Unilateral spastic
Kara et al., 2019 1b 6/10 RCT 43 7-16 I Unilateral
spastic
Van Vulpen et al., 2017 2b 19/22
Double-baseline cohort
22 4-10 I-IIUnilateral
or bilateral spastic
Surana et al., 2019
1b 7/10 RCT 24 2-13 I-II Unilateral spastic
Intervention Dosage Outcomes Results
Elnaggar et al., 2019
Control: Flexibility, balance, postural correction, progressive strength training, coordinationExperimental: Plyometric jumping, hopping, squatting variations
2x/wk x 8 wks 60min
traditional PT + 30min PLYO
Gait speed, stride length, step time,
strength of quadriceps and
hamstrings
Improved gait speed, stride length, step
time, and LE strength in
experimental group
Kara et al., 2019
Control: Locomotor training, weight-bearing symmetry, stretchingExperimental: Plyometric jumping variations; functional strength and balance training
3x/wk x 12 wks 60-90min/
session
Gait speed, isometric LE
strength, power, GMFM E, TUG
Improved gait speed, LE strength, muscle power, GMFM E, and
TUG scores in experimental group
Van Vulpen et al., 2017
Usual Care Period: Individualized standard PT careTraining Period: Resisted power exercises
3x/wk x 14 wks 60min/session
Gait speed, sprinting power,
isometric LE strength, GMFM
Improved gait speed and sprinting power
during training period
Surana et al., 2019
Control: UE bimanual trainingExperimental: Plyometric kicking, jumping, hopping, skipping variations; functional strength and balance training
5d/wk x 9 wks (2h/d for total
of 90 hrs)
Gait speed, gait endurance,
sprinting power, sit to stand
strength, single leg stance
Improved gait speed, sit to stand strength, single leg balance in experimental group
RESULTS
Variable Study Outcome Measure
Gait Speed
Elnaggar et al., 2019Kara et al., 2019Van Vulpen et al., 2017Surana et al., 2019
10-meter walking path 5x (m/s)1MWT (m)1MWT (m)1MWT (m)
LE Strength
Elnaggar et al., 2019Kara et al., 2019Van Vulpen et al., 2017Surana et al., 2019
Isometric knee extension (Nm)Isometric knee extension (N/kg)Isometric knee extension (Nm)30-second chair rise test (#STS)
LE Power Kara et al., 2019Van Vulpen et al., 2017
Muscle Power Sprint Test (W)Muscle Power Sprint Test (W)
OUTCOME MEASURES EXTRACTED FOR META-ANALYSIS
0.87 (lg)
0.63 (mod)
0.74 (mod)
0.93 (lg)
1.0 (lg)
Within-Group Grand Effect Sizes
Statistically significant
Between-Group Grand Effect Sizes
Walking Speed1-Minute Walk Test (1MWT)
Clinical Significance1MWT CLINICAL SIGNIFICANCE:
Clinical Units
Within: 7.83mBetween: 6.91m
MCID 5.1m (GMFCS I); 5.6m (GMFCS II)
Lower Extremity StrengthIsometric knee extension strength
Lower Extremity PowerMuscle Power Sprint Test (MPST) MPST CLINICAL SIGNIFICANCE:
Clinical Units 29.11W
MDC 25W (GMFCS I-II)
Isometric Knee Extension:
Clinical Units Within: 6.58NmBetween: 8.13Nm
MCID/MDC Not available
Clinically Significant
Clinically Significant
MCID = minimal clinically important difference
MDC = minimal detectable change
SUMMARY OF OUTCOMES
4 studies included with high levels of evidence
RESULTSOUTCOME
SIGNIFICANCE
STATISTICAL CLINICAL
GAIT SPEEDWithin-group
GAIT SPEEDBetween-group
LE STRENGTHWithin-group NA
LE STRENGTHBetween-group NA
LE POWERWithin-group
Pooled findings met statistical and clinical significance
DISCUSSION: Specificity
Power generation is required for both plyometrics and gait, and is not traditionally included in progressive
resisted strength training (Moreau et al., 2013)
Plyometric training mimics phases of the walking cycle by requiring both concentric and eccentric
muscle contractions (Davies et al., 2015)
Motor skills are specific and only superficially resemble other similar skills or variations of the same
skill (Shea and Kohl, 1990)
DISCUSSION: Muscle adaptations
These specific muscle adaptations result in greater gait speed, strength, and power generation (Moreau, 2013; Armand, 2016)
Plyometric training leads to increased fascicle length and maximum contraction velocity of the muscle (Moreau et al., 2016)
Plyometric training improves strength; strength gains are associated with improvements in walking capacity
(Salem, 2009; Moreau, 2016)
Significant positive correlation between muscle thickness and functional level (Choe et al., 2018)
IMPLICATIONS FOR CLINICAL PRACTICE
Plyometric training can be a great addition to physical therapy interventions for improving gait speed
Task-specific approach to strength and power training allows for carry-over to gait function (Moreau et al., 2013)
Quadricep strength gains can contribute to increased stride length and faster walking speed (Elnaggar et al., 2019)
Feasible in clinic and for HEP implementation
DIRECTIONS FOR FUTURE RESEARCHAnkle PF and hip extensor strength (Riad et al., 2008)
Dorsiflexion strength (Moreau et al., 2013)
Plyometrics in isolation
Larger sample sizes and consistent study protocols
Specific dosing parameters
Children with GMFCS III
Plyometrics and spasticity
Specific changes throughout gait cycle
IN CONCLUSION
Functional strength training at higher movement velocities resulted in greater improvements in walking speed, muscle strength, and power generation compared to traditional PT.
Plyometric training is an effective intervention for children with CP and should be incorporated into PT treatments
Foundational research for future studies to expand upon.
REFERENCES:● Armand S, Decoulon G, Bonnefoy-Mazure A. Gait analysis in children with cerebral palsy. EFORT Open Rev. 2016;1(12):448-460. Published 2016 Dec 22.
doi:10.1302/2058-5241.1.000052● Bax M, Goldstein M, Rosenbaum P, et al. Proposed definition and classification of cerebral palsy, April 2005. Dev Med Child Neurol. 2005;47(8):571-576.
doi:10.1017/s001216220500112x● Booth ATC, Buizer AI, Meyns P, Oude Lansink ILB, Steenbrink F, van der Krogt MM. The efficacy of functional gait training in children and young adults with
cerebral palsy: a systematic review and meta-analysis. Dev Med Child Neurol. 2018;60(9):866-883. doi:10.1111/dmcn.13708● Brændvik SM, Goihl T, Braaten RS, Vereijken B. The Effect of Increased Gait Speed on Asymmetry and Variability in Children With Cerebral Palsy. Front Neurol.
2020;10:1399. Published 2020 Jan 30. doi:10.3389/fneur.2019.01399● Chakraborty S, Nandy A, Kesar TM. Gait deficits and dynamic stability in children and adolescents with cerebral palsy: A systematic review and meta-analysis. Clin
Biomech (Bristol, Avon). 2020;71:11-23. doi:10.1016/j.clinbiomech.2019.09.005● Choe YR, Kim JS, Kim KH, Yi TI. Relationship Between Functional Level and Muscle Thickness in Young Children With Cerebral Palsy. Ann Rehabil Med.
2018;42(2):286-295. doi:10.5535/arm.2018.42.2.286● Davies G, Riemann BL, Manske R. Current concepts of plyometric exercise. Int J Sports PhysTher. 2015;10(6):760-786.● Elnaggar RK, Elbanna MF, Mahmoud WS, Alqahtani BA. Plyometric exercises: Subsequent changes of weightbearing symmetry, muscle strength and walking
performance inchildren with unilateral cerebral palsy. J Musculoskelet Neuronal Interact. 2019;19(4).● Fisher-Pipher S Pt Dpt, Kenyon LK Pt Dpt PhD Pcs, Westman M Pt Dpt. Improving balance, mobility, and dual-task performance in an adolescent with cerebral palsy:
A casereport. Physiother Theory Pract. 2017;33(7):586-595. doi:10.1080/09593985.2017.1323359● Fritz S, Lusardi M. White paper: “walking speed: The sixth vital sign.” J Geriatr Phys Ther.2009;32(2):2-5. doi: 10.1519/00139143-200932020-00002● Gallinger, T. L. (2019). Muscle length adaptations to high-velocity training in young adults with Cerebral Palsy (Unpublished master's thesis). University of Calgary,
Calgary, AB.http://hdl.handle.net/1880/110613● Gannotti ME, Breive EL, Miller K, Mobyed R, Cameron RA. Exercise programs designed and dosed to improve bone mineral density in children with cerebral palsy.
Crit Rev PhysRehabil Med. 2016;28(4):283-304. doi:10.1615/critrevphysrehabilmed.V28.I4.50
● Goldberg EJ, Requejo PS, Fowler EG. Joint moment contributions to swing knee extension acceleration during gait in children with spastic hemiplegic cerebral palsy. J Biomech.2010;43(5):893-899. doi:10.1016/j.jbiomech.2009.11.008
● Gorter H, Holty L, Rameckers EEA, Elvers HJWH, Oostendorp RAB. Changes in endurance and walking ability through functional physical training in children with cerebral palsy.Pediatr Phys Ther. 2009;21(1):31-37. doi:10.1097/PEP.0b013e318196f563
REFERENCES (cont.):● Graham, H. K., Rosenbaum, P., Paneth, N., Dan, B., Lin, J.-P., Damiano, D. L., Lieber, R. L. (2016). Cerebral palsy. Nature Rev Dis Prim, 15082.
doi:10.1038/nrdp.2015.82 ● Hassani S, Krzak JJ, Johnson B, et al. One-Minute Walk and modified Timed Up and Go tests in children with cerebral palsy: performance and minimum clinically
important differences. Dev Med Child Neurol. 2014;56(5):482-489. doi:10.1111/dmcn.12325● Jewell DV. Guide to Evidence-Based Physical Therapy Practice. Sudbury, MA: Jones andBartlett; 2008● Johnson BA, Salzberg CL, Stevenson DA. A systematic review: plyometric training programs for young children. J Strength Cond Res. 2011 Sep;25(9):2623-33. Doi:
10.1519/JSC.0b013e318204caa0.● Kara OK, Livanelioglu A, Yardimci BN, Soylu AR. The Effects of Functional Progressive Strength and Power Training in Children With Unilateral Cerebral Palsy.
Pediatr Phys Ther. 2019;31(3):286-295. doi:10.1097/PEP.0000000000000628● LaChance P. Plyometric exercise l. Strength Cond J. 1995;17(4): 16-23.● Lee JH, Sung IY, Yoo JY. Therapeutic effects of strengthening exercise on gait function of cerebral palsy. Disabil Rehabil. 2008;30(19):1439-44.
doi:10.1080/09638280701618943.● Maher CG, Sherrington C, Herbert RD, et al. Reliability of the PEDro scale for rating quality of randomized controlled trials. Phys Ther. 2003;83:713–721● Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern
Med. 2009;151:264–269, W64 doi: 10.7326/0003-4819-151-4-200908180-00135● Moreau NG, Falvo MJ, Damiano DL. Rapid force generation is impaired in cerebral palsy and is related to decreased muscle size and functional mobility. Gait Post.
2012;35(1):154-158. doi:10.1016/j.gaitpost.2011.08.027● Moreau NG, Bodkin AW, Bjornson K, Hobbs A, Soileau M, Lahasky K. Effectiveness of Rehabilitation Interventions to Improve Gait Speed in Children With Cerebral
Palsy:Systematic Review and Meta-analysis. Phys Ther. 2016;96(12):1938-1954.doi:10.2522/ptj.20150401● Oudenhoven LM, van Vulpen LF, Dallmeijer AJ, de Groot S, Buizer AI, van der Krogt MM. Effects of functional power training on gait kinematics in children with
cerebral palsy. Gait Posture. 2019;73:168-172. doi:10.1016/j.gaitpost.2019.06.023● Riad J, Haglund-Akerlind Y, Miller F. Power generation in children with spastic hemiplegic cerebral palsy. Gait Post. 2008 May;27(4):641-647. doi:
10.1016/j.gaitpost.2007.08.010.● Ryan JM, Cassidy EE, Noorduyn SG, O’Connell NE. Exercise interventions for cerebral palsy. Cochrane Database Syst Rev. 2017;2017(6).
doi:10.1002/14651858.CD011660.pub2● Palisano, R. J., Orlin, M., & Schreiber, J. (2016). Campbell’s physical therapy for children expert consult (5th ed.). Philadelphia, PA: Saunders.
REFERENCES (cont.):● Pirpiris M, Gates PE, McCarthy JJ, et al. Function and well-being in ambulatory children with cerebral palsy. J Pediatr Orthop. 2006;26(1):119-124.
doi:10.1097/01.bpo.0000191553.26574.27● Salem Y, Godwin EM. Effects of task-oriented training on mobility function in children with cerebral palsy. NeuroRehabilitation. 2009;24(4):307-313.
doi:10.3233/NRE-2009-0483● Schenker R., W Coster W., Parush S. (2005) Participation and activity performance of students with cerebral palsy within the school environment, Disability and
Rehabilitation, 27:10,539-552, doi: 10.1080/09638280400018437● Surana BK, Ferre CL, Dew AP, Brandao M, Gordon AM, Moreau NG. Effectiveness of Lower-Extremity Functional Training (LIFT) in Young Children with
Unilateral Spastic Cerebral Palsy: A Randomized Controlled Trial. Neurorehabil Neural Repair. 2019;33(10):862-872. doi:10.1177/1545968319868719● van der Krogt MM, Delp SL, Schwartz MH. How robust is human gait to muscle weakness?. Gait Post. 2012;36(1):113-119. doi:10.1016/j.gaitpost.2012.01.017● Van Vulpen LF, De Groot S, Rameckers E, Becher JG, Dallmeijer AJ. Improved Walking Capacity and Muscle Strength after Functional Power-Training in Young
Children with Cerebral Palsy. Neurorehabil Neural Repair. 2017;31(9):827-841. doi:10.1177/1545968317723750● Verschuren O, Ketelaar M, Takken T, Van Brussel M, Helders PJ, Gorter JW. Reliability of hand-held dynamometry and functional strength tests for the lower
extremity in children with cerebral palsy. Disabil Rehabil. 2008;30:1358-1366. doi: 10.1080/09638280701639873● Verschuren O, Takken T, Ketelaar M, Gorter JW, Helders PJM. Reliability for running tests for measuring agility and anaerobic muscle power in children and
adolescents with cerebral palsy. Pediatr Phys Ther. 2007;19(2):108-115. doi: 10.1097/pep.0b013e318036bfce● von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP, et al. Strengthening the reporting of observational studies in epidemiology (STROBE)
statement: Guidelines for reporting observational studies. BMJ. 2007;335:806–8.● Whitney D, Kamdar N, Hirth RA, Hurvitz EA, Peterson MD. Economic burden of paediatric-onset disabilities among young and middle-aged adults in the USA: a
cohort study of privately insured beneficiaries. BMJ Open. 2019;9(9):e030490. Published 2019 Sep 3. doi:10.1136/bmjopen-2019-030490● Williams G, Kahn M, Randall A. Strength training for walking in neurologic rehabilitation is not task specific: a focused review. Am J Phys Med Rehabil.
2014;93(6):511-522.doi:10.1097/PHM.0000000000000058● Williams G, Hassett L, Clark R, et al. Improving Walking Ability in People with Neurologic Conditions: A Theoretical Framework for Biomechanics-Driven Exercise
Prescription. Arch Phys Med Rehabil. 2019;100(6):1184-1190.doi:10.1016/j.apmr.2019.01.003● World Health Organization. International Classification of Functioning, Disability, and Health:Children & Youth Version: ICF-CY. World Health Organization, 2007.
THANK YOU!
Questions?Special thank you to:
Lisa Johanson, PT, MS, DPTCasey Nesbit, PT, DPT, DSc, PCSAshley Rawlins, PT, DPTVincent Leddy, PT, DPTTim Jannisse, PT, DPTHalie Gordon, PT, DPTAnna Schroeder, PT, DPTJamie Flanagan, PT, DPTKoshi, PhDoggoCooper, PhDoggo
Extra Resources
Intervention Dosage Outcomes Results
Elnaggar et al., 2019
Control: Flexibility, balance, postural correction, progressive strength training, coordinationExperimental: Plyometric jumping, hopping, squatting variations
2x/wk x 8 wks 60min
traditional PT + 30min PLYO
Gait speed, stride length, step time,
strength of quadriceps and
hamstrings
Improved gait speed, stride length, step
time, and LE strength in
experimental group
Kara et al., 2019
Control: Locomotor training, weight-bearing symmetry, stretchingExperimental: Plyometric jumping variations; functional strength and balance training
3x/wk x 12 wks 60-90min/
session
Gait speed, isometric LE
strength, power, GMFM E, TUG
Improved gait speed, LE strength, muscle power, GMFM E, and
TUG scores in experimental group
Van Vulpen et al., 2017
Usual Care Period: Individualized standard PT careTraining Period: Resisted power exercises
3x/wk x 14 wks 60min/session
Gait speed, sprinting power,
isometric LE strength, GMFM
Improved gait speed and sprinting power
during training period
Surana et al., 2019
Control: UE bimanual trainingExperimental: Plyometric kicking, jumping, hopping, skipping variations; functional strength and balance training
5d/wk x 9 wks (2h/d for total
of 90 hrs)
Gait speed, gait endurance,
sprinting power, sit to stand
strength, single leg stance
Improved gait speed, sit to stand strength, single leg balance in experimental group
Variable Study Outcome Measure
Gait Speed
Elnaggar et al., 2019Kara et al., 2019Van Vulpen et al., 2017Surana et al., 2019
10-meter walking path 5x (m/s)1MWT (m)1MWT (m)1MWT (m)
LE Strength
Elnaggar et al., 2019Kara et al., 2019Van Vulpen et al., 2017Surana et al., 2019
Isometric knee extension (Nm)Isometric knee extension (N/kg)Isometric knee extension (Nm)30-second chair rise test (#STS)
LE Power Kara et al., 2019Van Vulpen et al., 2017
Muscle Power Sprint Test (W)Muscle Power Sprint Test (W)
OUTCOME MEASURES EXTRACTED FOR META-ANALYSIS
DIRECTIONS FOR FUTURE RESEARCHAnkle PF and hip extensor strength (Riad et al., 2008)
Dorsiflexion strength (Moreau et al., 2013)
Plyometrics in isolation
Larger sample sizes and consistent study protocols
Specific dosing parameters
Children with GMFCS III
Plyometrics and spasticity
Specific changes throughout gait cycle
10/4/2021
1
A Novel Functional Electrical Stimulation Device and Telerehabilitation to Improve Walking Function in a Person with Multiple Sclerosis: A Case
Report.EJ Gann, DPT, NCS; Valerie Block, DPTSc; Diane Allen, PT, PhD
Background• Foot drop is a common impairment in MS (Dapul, 2015)
• Functional electrical stimulation (FES) can improve foot drop (Miller, 2017)
• Industry standard devices (i.e. Bioness) are cost-prohibitive• Multiple clinic visits required to optimize device settings are burdensome for patients• EvoWalk is an economic alternative that may improve access to FES intervention when combined
with telerehabilitation
Aims• Assess the effectiveness of a novel FES device • Demonstrate feasibility of using telerehabilitation as the primary mode of delivering FES
intervention
Case Description
• 35 year old female with relapsing remitting Multiple sclerosis (RRMS)
• EDSS = 5.0• Presented with unilateral right foot drop• Currently ambulates with prefab AFO, SPC• History of frequent falls (~1/week) at home & work due to
catching foot on objects
1
2
10/4/2021
2
ActiGraph (validation without FES)
EvoWalk
FES OFF (step count only) FES ON + weekly step
count
ActiGraph (validation with FES)
T25FW, TUG, 2MWT MSWS-12, MSIS,
Telerehab Satisfaction Survey
Week 0 Weeks 2-6 Week 8In-clinic baseline assessment Telehealth visits In-clinic final assessment
Methods
Results: Clinical measures
-60.00 -50.00 -40.00 -30.00 -20.00 -10.00 0.00 10.00 20.00
ns_T25FW
ns_TUG
ns_2MWT
EVO_T25FW
EVO_TUG
EVO_2MWT
MSWS-12
MSIS
MFIS
Percentage Change Pre-Vs. Post-EVO Walk Use
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3
0
1000
2000
3000
4000
5000
6000
1 2 3 4 5 6 7 8 9
Dai
ly S
tep
co
un
t
Number of days
Daily STEPS Pre- and Post EvoWalk
daily_av_pre
daily_av_post
Results: Daily step count
Results: Feasibility
• 100% (3/3) scheduled telerehabilitation sessions completed• No adverse events
Percentage of telerehabilitation visits completed
• 10-item survey rating satisfaction related to telerehabilitation visit• Rated on 5-point Likert scale (1: Not at all satisfied; 5: very satisfied)• Average participant satisfaction score = 5.0
Telerehabilitation Satisfaction Survey (Miller et al. 2021)
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Conclusions
Gait parameters, activity level and
QOL improved during the
intervention period
Telerehabilitation was a safe &
feasible method of monitoring and progressing FES
Use of telerehabilitation
with FES may improve access to this intervention while reducing cost/burden for
patients
References
Dapul GP, Bethoux F. Functional electrical stimulation for foot drop in multiple sclerosis. US Neurol.2015;11(1):10-18. doi:10.17925/usn.2015.11.01.10
Gervasoni E, Parelli R, Uszynski M, et al. Effects of Functional Electrical Stimulation on Reducing Falls and Improving Gait Parameters in Multiple Sclerosis and Stroke. 2017;9:339-347. doi:10.1016/j.pmrj.2016.10.019
Khan F, Amatya B, Kesselring J, Galea M. Telerehabilitation for persons with multiple sclerosis (Review ).201 doi:10.1002/14651858.CD010508.pub2.www.cochranelibrary.com
Khurana SR, Beranger AG, Felix ER. Perceived Exertion Is Lower When Using a Functional Electrical Stimulation Neuroprosthesis Compared with an Ankle-Foot Orthosis in Persons with Multiple Sclerosis: A Preliminary Study. Am J Phys Med Rehabil. 2017;96(3):133-139. doi:10.1097/PHM. 0000000000000626
Miller L, McFadyen A, Lord AC, et al. Functional Electrical Stimulation for Foot Drop in Multiple Sclerosis: A Systematic Review and Meta-Analysis of the Effect on Gait Speed. Arch Phys Med Rehabil. 2017;98(7):1435-1452. doi:10.1016/j.apmr.2016.12.007
Miller MJ, Pak SS, Keller DR, Barnes DE. Evaluation of Pragmatic Telehealth Physical Therapy Implementation During the COVID-19 Pandemic. Phys Ther. 2021 Jan 4;101(1):pzaa193. doi: 10.1093/ptj/pzaa193. PMID: 33284318; PMCID: PMC7665714
Tella S Di, Pagliari C, Blasi V, Mendozzi L, Rovaris M, Baglio F. Integrated telerehabilitation approach in multiple sclerosis : A systematic review and meta analysis. 2019. doi:10.1177/1357633X19850381
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Additional Resources & Contact Info
EvoWalk device: https://www.evolutiondevices.com/
Email: [email protected]
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CPTA 2021 Annual Conference Presentation 10/10/2021
October 10, 2021 1
Exploring Holistic Admissions following a year of Racial Awakening: Does Implicit Bias affect Interview Scoring of DPT Program applicants? A
Case Study
Virtual Annual Conference
October 10, 2021
©Bryan Coleman‐Salgado, PT, DPT, CWSAssociate Professor, Department of Physical Therapy
California State University, Sacramento
All Applicants
Screened for GPA, GRE &
Hours minimums
Ranked based on GPA, Ltrs of Rec, SES, Language
Scores tallied; Final RankingInterviewed
Holistic Admissions at the CSUS DPT program
Barriers to URM applicants?
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CPTA 2021 Annual Conference Presentation 10/10/2021
October 10, 2021 2
CSUS Weighting of Admissions Ranking Variables
55%GPA & Adv.
Courses
15%SBC
30%Interviews & Ltrs of Recmd
Academic Metrics
Holistic Variables:
Individual Attributes
Skills & Background Characteristics
25
18.816.4
20.6
27 26.6 26.5
0
5
10
15
20
25
30
Amer.Ind Afr‐Amer, Black Asian Amer,PacIs
Latinx Mixed White Alone Unknown
Qualified Applicants Acceptance Rates, D06‐09 [N=858](%)
P = .004
P = .037
Related Previous Research Findings
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CPTA 2021 Annual Conference Presentation 10/10/2021
October 10, 2021 3
Interviews in DPT admissions
• The use of interviews is not universal; about half (8/15) of PT programs in California utilize interviews; nationally 2/3 of the DPT program require interviews
• When used, interviews serve to gather information, assist decision making, verify information on the application and for recruitment
• Interview scoring has the potential to reflect the unconscious biases of the interviewers when making judgments about the interviewees
Implicit Bias• Implicit biases involve associations outside conscious awareness that lead to positive or negative associations about certain groups of people (150 categorized so far)
• Changing the unconscious into conscious thinking enables us to show greater awareness in avoiding acting on these biases
• Trainings for individuals to bring awareness of unaware biases are available free and anonymously as Implicit Association Tests at implicit.harvard.edu/implicit;
• Trainings for organizations are available, such as the “Unconscious Bias to Conscious Inclusion” seminars.
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CPTA 2021 Annual Conference Presentation 10/10/2021
October 10, 2021 4
Bringing Awareness of Implicit Bias to the Interview Process
• Review of an Implicit Bias Reduction Cheat Sheet reviewed immediately before interviews has proved helpful in increasing diversity in medical school admissions (Capers 2020).
• Not just for admissions: Implicit bias plays a role in disparities in healthcare! (FitzGerald & Hurst 2017)
Image: bctpartners.com
N = 2580
All Applicants 2017‐2021
N = 1258
Did not Qualify
N = 1322
Qualified Applicants
N = 707
Not Ranked for Interview
N = 615Invited to Interview
N = 202
Declined Interview
N = 413
Interviewed
N = 337
Interviewed 2017‐2020
N = 76
Interviewed 2021
Subjects: 5 years of applicant interviews
Prior to the 2021 interviews, all panelists received a brief implicit bias reduction training
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CPTA 2021 Annual Conference Presentation 10/10/2021
October 10, 2021 5
Live Interview Panels
• 8‐10 panels per year• 3 physical therapist members/panel; one applicant interviewee at a time
• Applicants were randomly assigned to panels• Any panelist able to recuse the panel from interviewing an applicant that they know or know of.
• Structured interview• Panelists’ scores of applicant are based on a rubric, and the total score of the panel is recorded (90 points possible).
• No strict time limit was placed on the interview
Methods: Observational Study Variables
• Mean interview scores within each cohort were recorded and also converted to Z‐scores in order to standardize scores across panels
• A preliminary analysis to rule‐out statistically significant z‐scores between the panels for each within‐year panel scores showed No significant differences in any of the 5 years’ panel scorings
• Applicant’s self‐selected racial, ethnic and gender were extracted from their PTCAS application
• Further disaggregation of Asian American identities was also tested
• Independent Samples t‐tests were analyzed
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CPTA 2021 Annual Conference Presentation 10/10/2021
October 10, 2021 6
Descriptive Statistics: Number of Panels and Interviewees by Year
YearNumber of Panels
Number Interviewed in person
Alt Date Virtual
Interview
Total Number
Interviewed
2017 9 81 3 84
2018 11 90 2 92
2019 9 70 3 73
2020 10 84 4 88
2021 9 74* 2 76
5‐year Ave 9.6 79.8 2.8 82.6
* All interviews were done virtually in 2021
Results: Mean Interview score analysis between select subgroups, pre‐ and post‐ bias reduction training
Dichotomous
Comparison
Groups
2017‐20
Mean Interview
Score (n=337)
2017‐20
Between Group
Z‐Scores P value
2021
Mean Interview
Score (n=76)
2021
Between group Z‐
scores P value
White Racial
identity
White alone 71.0
(n=174).001
66.6
(n=31).165
Not White alone65.3
(n=163)
70.1
(n=45)
Asian American &
Pacific Islander
AAPI any64.6
(n= 97).009
69.2
(n=27).801
Not any AAPI 69.7
(n=240)
68.4
(n=49)
Latino Ethnic
Identity
Latino 64.0
(n=48).043
71.6
(n=14).252
Not Latino 68.9
(n=289)
68.0
(n=62)
Gender identityFemale
71.0
(n=194).000
70.7
(n=41).066
Male64.4
(N=143)
66.2
(N=36)
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Results: Disaggregating Asian American Identities
Dicotomous
Comparison Groups
on t‐test
2017‐2020
Mean
Interview
Score
(68.2)
2017‐2020
Between
cohort Z‐
Scores P
value
2021
Mean
Interview
Score
(68.6)
2021
Between
cohort Z‐
Scores P
value
East Asian‐American*
East AA any 66.5
(n=55).188
69.9
(n=15).573
All others (not any
AAPI identity)
69.7
(n=240)
68.4
(n=49)
Southeast Asian‐
American/Pacific
Islander†
SEAAPI any62.2
(n= 42).003
68.3
(n=12).979
All others (not any
SEAAPI identity)
69.7
(n=240)
68.4
(n=49)Bold are statistically significant at the α = .05 level. The effect size in this case (Cohen’s d) is medium
*East Asian‐American refers to persons with any Chinese, Japanese, Taiwanese, Korean, Malaysian, Pakistani or Indian
heritage (not SE Asia heritage).
†Southeast Asian‐American/Pacific Islander refers to persons with Southeast Asian or Pacific Islander heritage, including
but not limited to Native Hawaiian, Filipino, Vietnamese, Hmong, Indonesian, Thai, Nepali, Cham, and “Other Asian”.
Conclusions: Summary of Key Findings1. White alone applicants’ interview scores were statistically
significantly higher than not White alone applicants; Female applicants’ interview scores were statistically significantly higher than male applicants
2. Asian American and Latino applicants’ interview scores were statistically significantly lower than non‐Asian American and non‐Latino applicants, respectively
3. The 2021 interviews that were conducted after a brief implicit bias mitigation intervention, showed no statistically significant differences in scores among any racial or gender groups.
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October 10, 2021 8
Discussion• Big question: Were the score differentials seen in the past 5 years favoring White alone and Female applicants & disfavoring Asian American and Latino applicants due to implicit bias on the part of panelists, or on better performance by those applicant groups?
• Were the positive changes in 2021 attributable to the brief implicit bias mitigation effort OR to a general raised awareness of bias during the previous year, OR from some combination of these factors? Or neither?
• Did the 2021 online interviews (vs. in‐person interviews) confound the comparisons? If so, how?
• Future research: Implement implicit bias mitigation training for all faculty and interview panelists; a case‐control study?
Questions
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CPTA 2021 Annual Conference Presentation 10/10/2021
October 10, 2021 9
Thank You
Please contact me if you want to collaborate on similar research of, and/or revisions to, your DPT program’s admissions practices!
Dicotomous
Comparison
Groups on t‐
test
2017
Mean
Interview
Score
(68.2;
n=84)
2017
Between
group P
value
2018
Mean
Interview
Score
(66.3;
n=92)
2018
Between
group P
value
2019
Mean
Interview
Score
(68.5;
n=73)
2019
Between
group P
value
2020
Mean
Interview
Score
(68.3;
n=88)
2020
Between
group P
value
2021
Mean
Interview
Score
(68.6;
n=76)
2021
Between
group P
value
White
Racial
identity
White alone 71.5
(n=47).045
67.8
(n=45).435
70.7
(n=38).150
73.7
(n=44).021
66.6
(n=31).165
Not White
alone
63.9
(n=37)
64.9
(n=47)
66.0
(n=35)
66.4
(n=44)
70.1
(n=45)
Asian
American
& Pacific
Islander
AAPI any63.3
(n= 22).128
64.1
(n= 28).428
67.3
(n= 20).625
64.3
(n= 227).016
69.2
(n=27).801
Not AAPI
any
69.9
(n=62)
67.3
(n=64)
68.9
(n=53)
72.6
(n=61)
68.4
(n=49)
Latino
Ethnic
Identity
Latino 66.1
(n=10).691
58.2
(n=10).131
58.7
(n=11).011
69.7
(n=17).904
71.6
(n=14).252
Not Latino 68.5
(n=74)
67.3
(n=82)
70.2
(n=62)
70.1
(n=71)
68.0
(n=62)
Gender
identity
Female68.5
(n=44).845
69.8
(n=56).029
71.2
(n=42).050
74.4
(n=52).002
70.7
(n=41).066
Male67.8
(N=40)
60.9
(N=36)
64.7
(N=31)
63.8
(N=36)
66.2
(n=35)
Results: Mean Interview Scores by Select Subgroups by Cohort
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10/4/2021
1
The Reliability and Level of Agreement of Shoulder Range of Motion Measurements Through Telehealth with Kinovea vs. Hudl
Cristina Gallo, SPTFaculty advisor: Deborah Lowe, PT, MS, MA, PhD
Background
Use of telehealth sessions in physical therapy practice have increased due to the current COVID-19 pandemic.
The goniometer is commonly used by healthcare professionals to assess joint range of motion.
Many online and cell phone movement analysis applications currently exist, but there is limited research on best practices for measuring joint range of motion through telehealth.
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BackgroundPast studies have determined the goniometer tool to have good to excellent reliability (Norkin et al., 2016).
Multiple past studies have found Kinovea to have good to excellent intra-rater and inter-rater reliability (Cabrera-Martos et al., 2019, Fernandez-Gonzalez et al., 2020, Moral-Munoz et al., 2015).
One study found Hudl to be an effective tool when assessing gait deviations (Weber, 2020), while another found Hudl to be an invalid tool when assessing lower extremity active range of motion when running (Neal et al., 2020).
Goniometry and Kinovea were determined to have excellent intra-rater reliability (Santana et al., 2020).
Purpose Statement
The purpose of this study was to compare the reliability of two virtual assessments of shoulder flexion and abduction active range of motion (AROM) using Hudl and Kinovea, and to determine the level of agreement of these two software apps for assessing joint motion.
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Methods
Participants: Third-year Doctorate of Physical Therapy students from Mount Saint Mary’s University (N =13), ages 21-45
Exclusion criteria: shoulder surgery or shoulder injury in the past six months, or current shoulder pain.
Participants performed maximal right shoulder flexion and abduction AROM, while being recorded over Zoom through a laptop.
Zoom recordings were uploaded to Kinovea, a 2D motion capture system, and Hudl, a 2D performance analysis application, for assessment of right shoulder joint angles.
Participant Demographics
Characteristics Mean (SD)
Age (yrs) 28.53 ± 4.135
Sex (% Male/Female) 53.8%/ 46.2%
Dominant UE (% Right/Left)
84.6%/15.4%
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Equipment/ Environment Set-up
● Laptop placed 5 ft away from participant
● Laptop screen set at 110-degree angle on a high-low table
● The high-low table was adjusted to the height of the participant’s greater trochanter of their right femur
ApplicationsUsed
Kinovea
Hudl
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Statistical findings IBM SPSS Statistics for Windows, Version 20.0 Intra-rater reliability
coefficientsInter-rater reliability
coefficients
ICC (95% CI) ICC (95% CI)
Shoulder FLX AROMKinoveaHudl
0.970.98
0.990.97
Shoulder ABD AROMKinoveaHudl
0.970.98
0.970.98
Statistical findingsIBM SPSS Statistics for Windows, Version 20.0
Level of Agreement between Kinovea and Hudl
Mean Difference Between Methods
ICC (95% CI)
Shoulder FLX AROM 2.9231 ± 2.63 0.969 (1.3345, 4.5116)
Shoulder ABD AROM 1.8462 ± 1.28 0.972 (1.0720, 2.6203)
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Conclusions
High level of agreement and excellent intra-rater and inter-rater reliability for Hudl and Kinovea for measurements of shoulder flexion and abduction AROM. Therefore, physical therapists can use either app to reliably and accurately obtain shoulder joint ROM during telerehabilitation.Limitations include: small sample size, using visual estimates for location of bony landmarks over video, and inability to manually reduce compensatory movements. Future research including other apps, with larger sample size, would help to determine the best software to obtain accurate objective measurements.
Thank you.
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References Aspinall, S., Sparks, T., King, A., Price, M.J., & Godsiff, S. A Mobile App to Replace the Goniometer? A Pilot Study
Focusing on the Measurement of Knee Range of Movement. Journal of Sports Science. 2019;7(3).
Cabrera-Martos I, Ortiz-Rubio A, Torres-Sánchez I, López-López L, Rodríguez-Torres J, Valenza C. Agreement Between
Face‐to‐Face and Tele‐assessment of Upper Limb Functioning in Patients with Parkinson Disease. PM&R.
2019;11(6):590-596.
Fernández-González P, Koutsou A, Cuesta-Gómez A, Carratalá-Tejada M, Miangolarra-Page JC, Molina-Rueda F.
Reliability of Kinovea® Software and Agreement with a Three-Dimensional Motion System for Gait Analysis
in Healthy Subjects. Sensors (Basel). 2020;20(11):3154. Published 2020 Jun 2.
Garving C, Jakob S, Bauer I, Nadjar R, Brunner UH. Impingement Syndrome of the Shoulder. Dtsch Arztebl Int. 2017
Nov 10;114(45):765-776.
Moral-Muñoz, J. A., Esteban-Moreno, B., Arroyo-Morales, M., Cobo, M. J., & Herrera-Viedma, E. (2015). Agreement
Between Face-to-Face and Free Software Video Analysis for Assessing Hamstring Flexibility in Adolescents.
Journal of Strength and Conditioning Research, 29(9), 2661-2665.
References Neal BS, Lack SD, Barton CJ, Birn-Jeffery A, Miller S, Morrissey D. Is markerless, smart phone recorded
two-dimensional video a clinically useful measure of relevant lower limb kinematics in runners with
patellofemoral pain? A validity and reliability study. Phys Ther Sport. 2020;43:36-42.
Norkin, C. C., White, D. J., Torres, J., Molleur, J. G., Littlefield, L. G., & Malone, T. W. (2016). Measurement of joint
motion: A guide to goniometry. Philadelphia: F.A. Davis Company.
Puig-Diví A, Escalona-Marfil C, Padullés-Riu JM, Busquets A, Padullés-Chando X, Marcos-Ruiz D. Validity and
reliability of the Kinovea program in obtaining angles and distances using coordinates in 4 perspectives.
PLoS One. 2019;14(6):e0216448. Published 2019 Jun 5.
Santana J, Gallo C, Gertler A., The Reliability and Concurrent Validity of Shoulder Range of Motion Measurements
Through Telehealth with Kinovea. Los Angeles; 2020.
Weber CF, McClinton S. VALIDITY AND RELIABILITY OF VIDEO-BASED ANALYSIS OF UPPER TRUNK ROTATION
DURING RUNNING. Int J Sports Phys Ther. 2020;15(6):910-919.
Wosik J, Fudim M, Cameron B, et al. Telehealth transformation: COVID-19 and the rise of virtual care. J Am Med
Inform Assoc. 2020;27(6):957-962.
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1
The Optimal Time to Re‐assess Patients
with Benign Paroxysmal Positional
Vertigo (BPPV) to Decrease Risk for Canal
Conversion: An Evidence Review
Helen Chan, PT, DPTBoard Certified Clinical Specialist in Neurologic Physical Therapy
Research
Presentation
October 10, 2021
Clinical Question
Case #1• 70 yo female: L posterior canal converted to a L horizontal
cupulolithiasis• Took 6 sessions before complete resolution
Case #2• 44 yo male: R posterior cupulolithiasis converted to R
horizontal cupulolithiasis• During re-assessment, very robust horizontal nystagmus• “worst day of my entire life”• 4 sessions before complete resolution
2Slide Footer
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What could I havedone better?
3
Getty Images
Canal Conversion
• Otoconia from one canal moves into another canal
• Occurs in about 6-7% of those treated with canalithrepositioning maneuvers (CRM)*
• Most common conversion is from posterior canal to horizontal canal*
4
*Bhattachartta et al, 2017
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Clinical Practice Guidelines: BPPV
• Most commonly encountered complications with treating BPPV: nausea, vomiting, fainting, and conversion to lateral canal BPPV during the course of treatment*
• Theory: rapid reassessment after CRM can lead to canal conversion*
• Research needs: Determine the optimal number of CRMs and the time interval between performance of CRMs for patients with posterior canal BPPV*
5*Bhattacharyya, 2017
PURPOSE
To perform literature search to determine the optimal time to re-assess patients with BPPV to decrease risk of canal
conversion
6
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Methods
• PubMed, PEDro, Cochrane
• Keywords: benign paroxysmal positional vertigo, canal switch, canal conversion
• Inclusion criteria: subjects >18 yo, subjects assessed with Dix Hallpike and/or Roll Test, subjects treated with some type of maneuver, documentation that subjects underwent canal conversion, a specific time for re-assessment was documented within the session
• Level of evidence was determined for each study based on the APTA’s Clinical Practice Guidelines Process Manual
7
Results
Search yielded 52 results and only 4 articles were included after all inclusion criteria were applied
8
Author Level of Evidence Time documented
Lin et al, 2012 4 1-2 min
Babic et al, 2012 4 1 min
Foster et al, 2012 4 15 min
Dispenza et al, 2015 4 5 min10 min15 min
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Lin et al
• Case report• 37yo female (+) R Dix Hallpike: R posterior canalithiasis• CRM for R posterior canal• R Dix Hallpike repeated (1-2 min after CRM): robust R beating
nystagmus which transformed into left beating nysatgmus of lesser intensity when rolled to her left side horizontal canalithiasis
• BBQ Roll was performed, but was unsuccessful• HEP for BBQ at home, symptoms resolved in a few days
Authors cite:• - not having head maintaining 30 deg of ext during CRM• - performing re-assessment too sooncould be factors that promote canal conversion
9
Babic et al
• Retrospective case review• 189 patients with (+) Dix Hallpike or Roll Test• Treated with CRM, BBQ Roll, Deep Head Hang Maneuver• Success was confirmed by performing a positional test 1 min
after maneuver was completed
• 41 patients (22%) underwent some type of conversion• Most common pathway of conversion was posterior
canalithiasis to horizontal canalithiasis ~60%• Waiting <1 min between maneuver and re-assessment
increases probability of conversion• Recommends waiting more after maneuver to allow otoconia to
settle in the utricle, but does not specify how long
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Foster et al
• Prospective case series• 44 patients (+) Dix Hallpike for posterior canal BPPV• Treated with CRM with a break of <2 min between each
maneuver until no observed nystagmus or reported vertigo.• 15 min follow up Dix Hallpike to determine complete resolution
• 15% developed conversion or re-entry; all occurred immediately during a Dix Hallpike after a successful maneuver
11
Foster et al
• Newly liberated particles are immediately above entrances to the horizontal canal and common crus
• If head is placed in a favorable position (ie: Dix Hallpike, Semont), canal conversion can occur
• Recommendations: Risk of canal conversion can be decreased by allowing an upright rest interval of 15 min between maneuvers
12
Foster et al 2012
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Dispenza, et al
• Prospective case series• 127 patients (+) Dix Hallpike or Roll Test• Treated with Semont or Gans maneuver for PC BPPV; Gufoni
manuever for HC BPPV• Randomly divided patients into 3 groups as to when they were
re-assessed: 5 min, 10 min, 15 min
• 5 min group: ~30% of patients experienced canal re-entry (p<0.001)*
• 10 min group: 5%• 15 min group: 2%
• Minimum time to wait before re-assessment: 10 min to reduce risk of canal re-entry or canal conversion
13*statistically significant
Conclusion
No definitive time to re-assess patients with BPPV based on the literature due to:• Paucity of studies on canal conversion and time to re-assess• Low levels of evidence• Heterogeneity of studies
HOWEVER...• Based on the evidence out there, it appears that a minimum of
10 min between CRM and re-assessment may reduce the risk of canal conversion
• Reducing length of symptoms, treatment, and recovery period
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References
Babic B, Jesic SD, Milovanovic JD, Arsovic NA. Unintentional conversion of benign paroxysmal positional
vertigo caused by repositioning procedures for canalithiasis: transional BPPV. Eu Arch Otorhinolaryngol.
2014; 271:967-973.
Bhattacharyya N et al. Clinical Practice Guideline” Benign Paroxysmal Positional Vertigo (Update).
Otolaryngology-Head and Neck Surgery. 2017;156(3S):S1-S47
Dispenza F, DeStephano A, Constatino C, Rando D, Giglione M, Stagno R, Bennici E. Canal switch and re-
entry phenomenon in benign paroxysmal positional vertigo: difference between immediate an delayed
occurrence. ACTA Otorhinolaryngologica Italica. 2015;35:116-120.
Foster CA, Zaccaro K, Strong D. Canal Conversion and Reentry: A Risk of Dix Hallpike During Canalith
Repositioning Procedures. Otology & Neurology. 2012;33:199-203
Lin GC, Basura, GJ, Wong HT, Heidenreich KD. Canal Switch After Canalith Repositioning Procedure for
Benign Paroxysmal Positional Vertigo. The Laryngoscope. 2012:122: 2076-2078
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• Review of documentation of patient services or charting;
• Review of billing practices;
• Review of staffing and supervision practices;
• Assisting with compliance with federal programs, e.g. Medicare;
• Review of payer contracts;
• Review of charging methodologies and fee schedules and
• A clinic/facility on-site assessment of how effectively the practice engages in practice excellence, practice metrics, legal compliance and current business protocols.
California Physical Therapy Association | 1990 Del Paso Road | Sacramento, CA 95834 | (916) 929-2782 | www.ccapta.org
CPTA PROFESSIONAL CONSULTING SERVICES
Providing You with the Tools You Need for an Effective PracticePractice and payment issues are often time consuming and difficult to resolve. The California Physical Therapy Association (CPTA) Professional Consulting Services (PCS) can help!
The CPTA PCS Program provides members with flexibly designed, cost-effective services for those who experience practice and payment issues daily. We also collaborate with CPTA members to ensure their clinic/facility effectively engages in practice excellence, legal compliance and current business protocols.
THE FEES
The PCS fee includes:
• Initial two-hour phone/email expert consultation$300 (2 or more hours, additional $100 per hour)
• On-site Quality Assurance Consultation services$750 for up to 4 hours, excludes travel expenses
• On-site Quality Assurance Consultation services$1500 for 5-8 hours, excludes travel expenses
• Web-based Education – $250 per hour
THE PROCESS
Place a call to CPTA to assess your needs. If it’s determined you will require more than one hour of time, CPTA’s PCS Program is the resource for you.
After signing a non-disclosure and liability agreement, you will:
• Pay consultation fee(s)• Be referred to a content expert/schedule on-
site assessment consultation• Have the option to retain extended services at
the fee level described above
Note: PCS services are offered to CPTA members only and do not include legal consultations.
CPTA Resource Manual
California Physical Therapy Association | 1990 Del Paso Road | Sacramento, CA 95834 | (916) 929-2782 | www.ccapta.org
The CPTA Resource Manual offers comprehensive resources designed to meet the needs of all physical therapists in every practice setting. The manual subscription includes a variety of practice resources, updated annually.
BENEFITS OVERVIEW
Provider Payment ResourcesEthics and Professionalism ResourcesAdministrative/Operation ResourcesStandards for Practice ExcellenceCalifornia Physical Therapy Practice Act
HIPAA ResourcesFunctional Outcome Resources
Sample Policy and Procedure Manual
CPTA’s Resource Manual was designed to guide in the process of starting a private practice while enhancing and promoting quality physical therapy practice.
By establishing a set of quality practice indicators embedded within the manual, physical therapy clinics are provided standards of excellence for measuring performance. In addition, the manual provides clinics with the necessary resources to become quality providers of physical therapy services.
EXCELLENCE STARTS HERE
THREE SIMPLE WAYS TO PURCHASE
Call CPTA at (800) 743-2782, or
Fax the completed form below to (916) 646-5960, or
Mail completed form to California Physical Therapy Association (CPTA), 1990 Del Paso Road, Sacramento, CA 95834
CPTA Resource Manual
Name (Required) Member Number (If Applicable)
Address
City/State Zip Code
Phone ( ) Fax ( )
Email (Required)
PURCHASE FEE
This fee includes one: ALL FOR ONE LOW PRICE!¡ Hard Copy Manual .. . . . . . . . . . . . . . . . . . $299 for CPTA Members (Includes Tax/S&H)¡ USB Only . . . . . . . . . . . . . . . . . . . . . . . . . . . $149 for CPTA Members (Includes Tax/S&H)
¡ Both of the Above Items . . . . . . . . . . . . . $325 for CPTA Members (Includes Tax/S&H)
¡ *Renewal* Hard Copy Manual . . . . . . . . . . . . $100 for Subscription Renewal (Includes Tax/S&H)
¡ *Renewal* USB Only . . . . . . . . . . . . . . . . . . . $60 for Subscription Renewal (Includes Tax/S&H)
¡ Both of the Above Items . . . . . . . . . . . . . $130 for Subscription Renewal (Includes Tax/S&H)
¡ Student Manual - USB Only . . . . $100 for CPTA Student Members (Includes Tax/S&H)
No refunds provided
¡ Check (payable to California Physical Therapy Association)
¡ VISA ¡ MasterCard ¡ American Express ¡ Discover
Cardholder’s name (print)
Card Number / / /
Exp. Date CVV#
Signature
FOR CPTA USE
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Paid $ Due $
Ck#/CC Auth
Confirm Sent
BE SURE TO INCLUDE ALL INFORMATION REQUESTED BELOW:
Please type or print legibly all information below.Download the form at: www.ccapta.org
EXCELLENCE STARTS HERE
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101Physical Therapy Malpractice
WHAT IS MALPRACTICE?Malpractice is a type of negligence that pertains to professionals. It is the failure to provide the degree of care required of a professional under the scope of license resulting in injury, death or damage.
HOW COURTS DEFINE MALPRACTICE VS. HOW PATIENTS DEFINE MALPRACTICE
Courts
Four elements must exist for an incident to be considered malpractice:
• Duty: a physical therapist-client/patient relationship must exist
• Breach: standard of care was not met
• Cause: injury was caused by the PT’s error or omission
• Harm: injury resulted in damages
Patients
To patients, it is the perception of wrongdoing:
• Even excellent PTs can fail to connect with all of their patients.
• If a patient perceives he or she has been injured as a result of the care you provided, or failed to provide, that patient could sue.
Alleged Injury Top 5 by Distribution*
*HPSO and CNA. Physical Therapy Professional Liability Exposure Claim Report: 4th Edition. 2021. www.hpso.com/ptclaimreport.
Distribution of Malpractice Claims by Alleged Errors*
Common Physical Therapy Malpractice Allegations:*
- Improper management of surgical patient
- Failure to follow practitioner orders
- Injury during manual therapy- Improper technique - Failure to complete proper
patient assessment
- Failure to monitor patient during treatment
- Injury during passive range of motion
- Failure to cease treatment with excessive/unexpected pain
- Injury during electrotherapy, heat therapy, or using hot packs
28.4% Fractures19.0% Increase or exacerbation
of injury/symptoms16.4% Burns5.1% Muscle/ligament damage3.8% Herniated disc
27.6% Improper management over the course of treatment
16.1% Improper performance using a biophysical agent
13.4% Improper performance using therapeutic exercise
7.0% Improper performance of manual therapy
10.2% Other (see report for additional details)
25.7% Failure to supervise or monitor
27.6% Improper management over the course of treatment
25.7% Failure to supervise or monitor
16.1% Improper performance using a biophysical agent
13.4% Improper performance using therapeutic exercise
7.0% Improper performance of manual therapy
10.2% Other (see report for additional details)
10.2%
16.1%
13.4%
27.6%
25.7% 7.0%
Types of recoverable damages:
| Medical expenses | Lost income |
| Funeral expenses |
| Mental anguish | Pain and suffering |
| Loss of consortium |
Malpractice lawsuits serve two goals
COMPENSATE PATIENTS WHO ASSERT DAMAGE DUE TO PROFESSIONAL NEGLIGENCE1one
ENCOURAGE SAFE AND RESPONSIBLE PHYSICAL THERAPY PRACTICE
two2
Healthcare Providers Service Organization is a registered trade name of Affinity Insurance Services, Inc. (TX 13695); (AR 100106022); in CA & MN, AIS Affinity Insurance Agency, Inc. (CA 0795465); in OK, AIS Affinity Insurance Services Inc.; in CA, Aon Affinity Insurance Services, Inc. (CA 0G94493); Aon Direct Insurance Administrators and Berkely Insurance Agency and in NY, AIS Affinity Insurance Agency.© 2021 Affinity Insurance Services, Inc. I-13892-0521
| Professional liability insurance is coverage purchased by physical therapists to safeguard against malpractice allegations by |
Providing personal protection Paying indemnity for economic and non-economic damages
Professional Liability INSURANCE
Covering costs associated with hiring legal representation
*HPSO and CNA. Physical Therapy Professional Liability Exposure Claim Report: 4th Edition. 2021. www.hpso.com/ptclaimreport.
Severe burn, requiring surgery$280,688
Traumatic brain injury$254,608
Fracture$155,403
Increase of exacerbation of injury/symptoms$145,767
Loss of use of limb$137,046
Fall resulting in abrasion/irritation/laceration$97,745
Death$236,713
Muscle/ligament damage$169,740
REQUEST A FREE QUOTE
| HPSO.com | 800.982.9491 |
What to do if you have been named in a malpractice lawsuit?
If you become aware of a filed or potential professional liability claim against you, receive a subpoena to testify in a deposition or trial, or have any reason to believe that there may be a potential threat to your license to practice, you should immediately contact your personal insurance carrier.
Report claims or potential claims to your insurance carrier, even if your employer advises you that it will provide you with an attorney and/or cover you for a professional liability settlement
or verdict amount.
Never testify in a deposition without first consulting your insurance carrier or, if you do not carry individual liability insurance, the organization’s risk manager or legal counsel.
Refrain from discussing the matter with anyone other than your defense attorney or the claim professionals managing your claim.
Copy and retain all legal documents for your records, including summons and complaints, subpoenas, and attorney letters.
Selected Average Total Incurred by Alleged Injury*
Reports shouldn’t take up half your day!Our auto-report generator saves your clinic time and money!Customize and print your report in less than 15 minutes!
Carlsbad, California | 800.333.3539 | [email protected]
Return from Family and Medical Leave Healthy Worker AuditFunconal ReviewReturn-to-WorkPrior-to-Hire
FCA/FCE/Pre-Hire/HWA/FMLA
Funconal Capacity Assessments
Your all-in-one, cloud-based outpatient EHR and billing therapy solution.Net Health Therapy for Private Practice gives you everything you need—practice management, scheduling, documentation, billing, productivity tools, MIPS reporting and more—in one software solution to keep your outpatient clinic running smoothly so you can focus on your patients.
All the functionality you need in one modern, cloud-based system.
Scheduling
Documentation
Quickly access billing, productivity and operations reports
View schedule by day, week or month
Practice Management
Billing
Monitor all required authorizations
Easily track Plan of Care (POC) signatures
Analyze trends with patient attendance metrics and visit management reports
Access and analyze corporate and multi-clinic performance data at-a-glance using dashboards
Create filters to view schedule by therapist, clinical team, discipline, or visit type
Easily identify visit specifics with customizable color-coding
Keep on top of changes with easy drag-and-drop capability
Visualize provider availability based on therapists’ scheduling templates
Reduce no shows and cancellations with automated appointment reminder calls, texts or emails (optional)
Efficiently document treatment from all therapy disciplines – physical therapy (PT), occupational therapy (OT) and speech-language pathology (SLP)
Stay compliant through alerts (i.e. Medicare Therapy Threshold Estimates, Progress Reports and more)
Take advantage of industry leading functional assessments
Meet documentation needs for both adult and pediatric populations
Start documenting immediately with built-in templates and organize by body part or skill area
Customize workflow, questions and forms to meet your practice’s specific needs
Adapt easily with an intuitive, familiar SOAP note format designed with therapists’ input
NET HEALTH THERAPY FOR PRIVATE PRACTICE
Interact with patients in real-time using secure Videoconferencing for Telehealth
Maximize patient engagement with the Patient Portal
Prevent eligibility denials with embedded electronic insurance verification
Streamline your billing process with coding, billing and patient demographics all in one system
Improve claims accuracy and reduce denials with validation prior to electronic submission to the clearinghouse
Easily post payments with Auto-Import ERAs
Process Patient Statements through our clearinghouse service or print in-house with our customizable statement options
Keep on top of Accounts Receivable with comprehensive financial reports
Not sure exactly what your practice needs for success?Don’t worry, we have several plans for you to choose from to fit your needs, your size and your budget. For more information contact us at [email protected], 800.411.6281, or visit nethealth.com.
Consider these optional integrations to enhance your practice:
Appointment RemindersReduce no shows and cancellations with automated appointment reminder calls, texts or emails.
E-faxing SolutionEliminate paper and save time with built-in e-faxing.
Home Exercise Program (HEP)Improve patient engagement with easy online personalized home exercise plans.
Eligibility VerificationSave time verifying patients’ eligibility for services from within the system.
Single Sign-On (SSO)Improve security and streamline user management by accessing Net Health Therapy using your facility’s existing authentication policies and login procedures.
Reputation Management
Generate more timely, positive patient reviews with the click of a button to improve your online ratings and boost clinic growth.
FOTO Patient OutcomesBoost patient satisfaction and promote outcomes to referral sources with access to benchmarks, analysis, compliance and reporting tools.
Merit-based Incentive Payment System (MIPS) / Qualified Clinical Data Registry (QCDR)Streamline collection and reporting with MIPS / QCDR integration.
Digital Marketing Services (DMS)Grow your practice with improved online presence and reputation.
Patient Statement ServicesSave money by eliminating supplies and labor costs for manually printing and mailing patient statements.
Videoconferencing for TelehealthIncrease access to care for patients with travel limitations - interact with patients in real-time over a secure audio/video connection.
Ensure your success and fully utilize Net Health Therapy for Private Practice through access to training and support from implementation through on-boarding any new staff:
• Dedicated project manager during implementation
• US-based phone and email support
• 24/7 access to online training at Net Health University, including role-based training, functionality reviews of new releases and best practices for compliant documentation.
West Coast University’s
committed to delivering transformational education within a culture of integrity and personal accountability.
MISSION BASED ON A KEEN VISION To remain at the forefront of healthcare education.
STUDENT CENTRIC EDUCATIONAL ENVIRONMENT By challenging ourselves to be the best we can be, we help our students become the best they can be— equipped with the knowledge and skills required for a successful and rewarding career.
WE ARE SEEKING CANDIDATES THAT ARE • Passionate about teaching and service
• Enthusiastic about a creative environment
• Excited about sharing scholarly endeavors
• Interested in lifelong learning
For more information on open positions, please visit:
westcoastuniversity.edu/about/jobs
For questions about employment, please contact:
Advance your career in Sunny Southern California
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