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W3138199274 abstract "Let me start by acknowledging what an honor it is to have been selected to present the third Carole B Lewis Distinguished Lecture Award, particularly as Dr Lewis, for whom it is named, is someone I have known and respected for many years. As I am called on from time to time to give lectures on various topics, I take solace in the fact that far greater individuals than I have questioned their worthiness to speak. The Biblical book of Exodus (4:10) records Moses as saying to the Lord “I am not eloquent, either in the past or since you have spoken to your servant, but I am slow of speech and tongue.” He asked that his brother do the talking instead. I thought of asking my wife—a far better storyteller than I. In the Biblical record of his second letter to the Corinthians (10:10) the apostle Paul lamented being described as one whose “letters are weighty and strong, but his bodily presence is weak, and his speech of no account.” Perhaps that's true of me—you can decide. I admit I'd sometimes rather write than talk. In contemplating what to share with you, I have defaulted to that with which I am most comfortable—the integration of research and practice. You may have had your fill of admonitions to engage in evidence-based or evidence-informed practice. You may be a clinician who has decried the clinical irrelevance of research or a researcher known to bemoan the baselessness of clinical practice. There is an alternative. Research and practice can be embraced as mutually beneficial or symbiotic along with teaching. I will share hereafter examples of this symbiosis, perhaps more than you would like to hear. Before sharing examples of research in practice, let me comment on the title and outline the objectives as they differ slightly from those originally proposed. I have substituted the word “research” for “scholarship” in the title—largely because of an expanding inclusiveness of the latter term. I have eliminated research focused on pelvifemoral rhythm, as it was conducted outside a clinical setting. Furthermore, I have consolidated balance and gait under the topic of mobility based on the International Classification of Functioning, Disability and Health (ICF), Disability and Health's definition of mobility as “maintaining and changing position.”1 So the objectives now are to: explain the relationship between research and practice, summarize the findings of several case studies and systematic reviews, and discuss the evolution of original research focused on range of motion/stretching, muscle strength, and mobility. A statement made about “academics” by Steve Rose almost 40 years ago merits pondering.2 He wrote “I am not suggesting that everyone teaching physical therapists be split into three equal parts, one for practice, one for research, and one for teaching. I am suggesting that each and every one of us who teaches must combine all three elements to some degree.” I would extend Steve Rose's admonition to include practitioners as well. That is, their practice should be combined to some degree with research and teaching. Indeed, clinical performance (according to Sackett et al3) presupposes that clinicians possess and apply appropriate knowledge and skills. Herein, I emphasize knowledge. Appropriate knowledge may be acquired from the research literature or engagement with research-informed clinicians, but it may also be generated through personal observation and research. Of course, the clinician must be motivated to conduct research and expect to encounter barriers. In my experience such barriers are usually human. People in some settings are antagonistic to research. Long, long ago I had a physician question the appropriateness of therapists being engaged in research. He did not see it as our role. It seemed he did not see it as his role either. Feinstein,4 whose writings I was introduced by Steve Rose, emphasized the importance of clinical observation in the beginning of his book Clinical Judgment. Therein he posited that every patient encounter is an n = 1 experiment. He further suggested that “improved methods will have to include evidence obtained in the often unplanned ‘experiments' of ordinary clinical practice.”5 The following quote from Feinstein is worth contemplating: “In caring for patients, clinicians constantly perform experiments. During a single week of active practice, a busy clinician conducts more experiments than most of his laboratory colleagues do in a year. Although clinicians do not usually regard ordinary patient care as a type of experiment, every aspect of clinical management can be designed, executed, and appraised with intellectual procedures identical to those used in any experimental situation.” The incorporation of research with practice, by the way, fits nicely with the components of the Guide to Physical Therapist Practice as research can inform examination (much of mine has), evaluation, diagnosis, prognosis, and interventions (including the instructional).6 The research to which I am referring can involve case studies, case series, case control/cohort studies, experiments, or reviews—though it might be argued that reviews are not research. Expert opinion is definitely not research—even if published in a book or presented in a course. Therefore, it should be considered skeptically—even if it's my own opinion or yours. I've already provided some broad objectives. Hereafter I'll provide some examples of integrating research and practice. You'll see that each research example is preceded by published research and clinical observation. The first example I'd like to share relates to the use of hydrotherapy in wound care. I don't claim to be an expert on the topic of wound care or suggest that what I describe is best practice in 2021. The example, however, does illustrate a point. Back in the day, when first working in a hospital, I used to see a lot of patients with open wounds. The Guide to Physical Therapist Practice lists hydrotherapy as an intervention for integumentary repair.6 Knowing that high bacterial loads can slow healing,7 I sought how I might best reduce such loads. Niederhuber et al8 found greater bacterial load reduction from feet that were rinsed after agitation, factors I did not observe to be optimized in practice. I observed patients with ulcers positioned in a manner not subject to direct agitation and not rinsed after immersion. Using directed agitation, followed by rinsing, I found increased bacterial loads in whirlpool water used to treat a patient with a venous stasis ulcer.9 It makes sense. We use running water when we wash our hands and shower rather than just soak in a sink or tub if our intent is to get clean. We don't presume to wash out a jar with a lid on it. When working in a rehabilitation setting, I noticed that a lot of patients had reduced shoulder range of motion, particularly after stroke. This shouldn't have been too surprising as Brocklehurst et al10 reported a limited passive range of motion as early as 2 weeks after stroke in 43% of patients measured. Well, I figured that if we were going to tackle the problem we first needed a reliable and valid way of measuring shoulder range of motion. Not satisfied with recommendations from standard texts, we settled on the measurement of shoulder external rotation with a pendulum goniometer,11 a goniometer modified by placing a paper clip in the rivet of the instrument. Measurements obtained with the goniometer proved to be reliable and valid. Reliability coefficients were 0.88 to 0.99, range of motion was significantly less on the paretic side (65°) than the nonparetic side (92°) and was related to time since onset of stroke (r = −0.54). So, the longer patients were in rehabilitation, the worse their range in motion impairment. That was discouraging but informative as to the establishment of reasonable goals. In an effort to combat losses in shoulder range of motion, we undertook a positioning program. This involved positioning during therapy time and ostensibly at night. As an aside, I conducted at night stealth audits (complete with a flashlight) and found positioning to be almost universally neglected in spite of reminders and illustrated instructions on the wall at the head of the bed. In any case, a review of patient records revealed the loss of range to be the rule. Later I came to wonder whether or not we were alone in our experience. Based on a meta-analysis of 6 studies, Borisova and I concluded that periods of 20 to 30 minutes of positioning may not be effective at maintaining shoulder range of motion after stroke.12 The mean loss was 15° in control groups and 13.6° in positioning groups. It wasn't just we who were failing to preserve shoulder range after stroke. In a rehabilitation setting where I worked, many of our neurological patients also had impaired ankle dorsiflexion range of motion. Warren et al13 suggested the value of long-term stretching for achieving increases in tissue length and range of motion, at least in rat-tail tendons. The literature also indicated that “relaxing” of the ankle plantarflexor muscles is best achieved in standing with the ankles dorsiflexed.14 These findings notwithstanding, I did not see us targeting the ankle plantarflexors accordingly. A tilt-table with wedge boards allowed us to do so. We were able to incorporate weight-bearing through the paretic upper limb as well. By examination of a case series of 20 patients, we were able to show a mean increase in dorsiflexion range of 8°.15 In a home care setting where I worked, a big part my patient load was patients with recent total knee replacements. The presence of effusion within the knee post-arthroplasty is commonly observed and has been studied by Pua.16 He found swelling of the knee to be 35% on postoperative day 1 and to persist to a lesser 11% on postoperative day 90. Literature addressing knee effusion has shown that aspiration can result in a substantial increase in knee flexion range of motion (30.2° vs 1.8°)17 and that repeated unloaded flexions and extensions may reduce effusions.18 Seeking to assess the potential of repeated movements of the knee (both “hands on” and as part of a home exercise program), I took sequential measurements of knee circumference and knee flexion range. A graph of data from one of my patients showed there to be a concomitant decease in knee circumference (ie, effusion) and increase in flexion range of motion. Remember Feinstein's statement about n = 1 experiments? Much of my research accompanying practice has involved muscle strength in patients with stroke. Believe it or not, one of the chief “experts” in stroke rehabilitation when I was in school and thereafter, Berta Bobath, suggested that antagonist restraint rather than agonist weakness was the issue and that the measurement of strength was not appropriate.19 This is in spite of dynamometric measurements of strength after stroke by Beevor in 190920 and easily observed weakness immediately after stroke before the development of positive signs such as spasticity or excessive coactivation. Our research, involving primarily hand-held dynamometry, showed that strength can be measured reliably,21 is affected bilaterally22 is reduced in the trunk,23 increases over time,24 and is correlated with mobility.25 These facts have implications for evaluating patients and selecting interventions. In an acute care setting where I worked, numerous patients with end-stage renal disease were admitted. Some research describing the physical status of such patients was available, but it mostly focused on exercise capacity.26 The chief transplant surgeon was concerned about the patients' strength, but the patients had not been referred to us historically. Once we began seeing the patients, it became apparent that they had impaired lower limb strength, their strength was correlated significantly with their mobility (r = 0.44-0.76),27 and that their strength tended to decrease after surgery but largely return to pretransplant levels by 6 months post-surgery.28 The Institute of Outcomes Research, where I was fortunate to work while at Hartford Hospital, tended to focus on patient populations with a high incidence of admissions. Patients with community-acquired pneumonia were one such population. Way back in 1985, Martin et al29 examined grip strength in patients, among them, those who had undergone surgery or experienced moderately severe infections. The latter had reductions in strength of greater than 30% of normal. As the physical status of patients with pneumonia was not routinely examined and they were not routinely referred to physical therapy, we were uninformed as to whether patients with pneumonia had compromised physical status. We therefore examined grip strength and other variables in a consecutively admitted sample of patients with pneumonia. Nearly half had less than 10-kg grip strength, with 83.8% having grip strength that was less than predicted for healthy adults.30,31 Grip strength was correlated significantly and negatively with length of stay and positively with discharge home and survival. Interestingly, the ability to walk greater than 50 m was similarly correlated. Both grip strength and walking distance had correlations with the variables that were roughly similar to those of the 18-item Pneumonia Severity Index.30 Up to this point I have focused primarily on impairments, but mobility has certainly been a focus as well. Bed mobility is often limited in patients with stroke but tends to improve over course of rehabilitation.32 Rolling to the stronger side tends to be particularly difficult. Davies33 described a technique for accomplishing the task but provided no evidence of its effectiveness. I initiated instruction in a biomechanically based procedure that resulted in a significant improvement in rolling independence. That procedure involved flexing the knees and hips, grabbing the weaker upper limb with the stronger upper limb, turning the head, and moving the limbs toward the stronger side. The percentage of individuals who were independent increased from 35% to 85% after instruction in the technique.34 Sit-to-stand performance is another commonly limited aspect of mobility. Knee extension strength is known to be explanatory of sit-to-stand capacity,35 but specific strength requirements were not previously determined. So we looked at knee extension strength as a percentage of body weight in several studies. In a sample of more than 100 rehabilitation inpatients, the strength cut point was 40% of body weight (area under the curve = 0.93).36 In a sample of home care patients, the cut point was 46.3% of body weight (area under the curve =0 .94).37 Practically speaking, the findings mean that an older woman weighing 100 lb and having a combined knee extension force of 35 lb would be highly unlikely to achieve standing without help or use of her hands whereas if she had a combined knee extension force of 50 lb she would be highly likely to be able to achieve standing without help or use of her hands. So what about patients who lack the strength to stand up without help? We know from the work of Arborelius et al38 that arm rests can remarkably reduce the demands on lower limb muscles during sit-to-stand. However, they are not always available. For patients using a walker an Easy-up Handle (Roylan/Preston Performance Health, Narrenville, IL.) functions as a portable arm rest. I had a home care patient relegated to sleeping on the couch because of range of motion and strength impairments in her bilateral lower limbs; she required a home health aide to get up. The Handle enabled her after 2 therapy sessions to rise without physical assistance and dispense with the home health aide.39 In a larger sample of rehabilitation inpatients, 8 of 26 transitioned to independence in sit-to-stand through use of the Handle.40 According to the ICF, balance is an aspect of mobility. In 1984, some colleagues and I recommended an ordinal scale based on the ability to stand with feet apart, feet together, or on one foot. Our study only indicated the deterioration of balance with age and involved a small sample size and time ceiling (30 seconds) unconducive to norms.41 Nevertheless, the scale, which was based on time and foot status (ie, apart, together, and unilateral), was marginally reliable and showed convergent validity with gait performance.42 When applied to a larger sample of patients in acute rehabilitation, the reliability was excellent and convergent validity with mobility was confirmed.43 In a sample of patients in acute care, only half were able to balance with their feet apart.44 Our previous research showed such an inability to be clearly abnormal. In a small consecutive sample of patients I managed in a home setting, 11 were unable to balance unipedally for greater than 5 seconds.45 By using a cane they were able to balance unipedally for more than 14 seconds. This explicatory experiment demonstrated to the patients the value of using a cane. Gait is important to patients and speed has been advocated as a vital sign.46 Norms have been published47 and the minimal clinically important difference has been described.48 However, systematic reviews and meta-analyses provide a higher level of evidence. Ten years ago Andrews and I, therefore, calculated gait speed reference values using data from greater than 23 000 individuals.49 We and others have since updated that meta-analysis. Glenney and I summarized minimal clinically important differences for gait speed from 7 studies and found them to mostly range from 0.10 to 0.20 m/s.50 Thus, changes in speed in excess of 0.20 m/s may with caution be interpreted as meaningful. Gait distance is also important for managing in the community. To note just one study, Andrews et al51 reported average distances that individuals need to be able to walk to manage in the community. The distances ranged from 57 m for banks to 380 m for grocery stores, to 677 m for club warehouses. Chart reviews show that distance is often measured, but information on changes over time was lacking. Gorack and I found the distance walked over a 50-ft out-and-back course to be reliable between days (intraclass correlation coefficient = 0.95), to increase from 35.6 to 77.0 m over the course of rehabilitation, and to have a minimal clinically important difference of 28.8 to 43.6 m depending on the anchor.52 For patients with hemiparesis, quad canes and hemiwalkers are often used in spite of research questioning their value vis-à-vis single-point canes. They do not necessarily provide greater support and can decrease speed and symmetry during gait.53–55 We have examined 2 alternatives to traditional canes. One is a forearm quad crutch with a flexible base. It provides increased stability without requiring the attention to placement associated with a quad cane or hemiwalker. A rolling platform walker can be similarly advantageous. It does not have to be lifted or placed. In the case of one of my home care patients, it increased her standing time from seconds to minutes and her walking distance from a step or two to several hundred feet.56 In summary, research, loosely defined, is possible for clinicians in a clinical setting. As my examples illustrate, research is not antagonistic to practice. Rather it is synergistic. Research in practice can range from case studies to systematic reviews/meta-analysis. Integrated research can inform practice from the level of examinations to outcomes." @default.
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W3138199274 title "2021 Carole B Lewis Distinguished Lecture Address to the APTA Geriatrics Membership at the Combined Sections Meeting, February 4, 2021" @default.
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