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Knowledge Translation: Developing Evidence‐Based Clinicians in Home Care

Speaker(s): Matt Janes, PT, DPT, MHS, OCS, CSCS

Derek Nordman, MPT, ATC Laurie Otis, PT, MBA, MHA, GCS, COS‐C Patricia Scheets, PT, DPT, MHS, NCS

Session Type: Educational Sessions Session Level: Multiple Level This information is the property of the author(s) and should not be copied or otherwise used without the express written permission of the author(s).

www.homehealthsection.org

Home Health Section of the American Physical Therapy Association

of 20 total pages

KT - Janes, Nordman, Otis, Scheets 1

Knowledge Translation:

Developing Evidence-Based

Clinicians in Home Care

Matt Janes, PT, DPT, MHS, OCS, CSCS

Derek Nordman, PT, MPT, ATC

Laurie Otis, PT, MBA, MHA, GCS, COS-C

Patty Scheets, PT, DPT, MHS, NCS

Disclosure

• Matt Janes - No relevant financial relationship exists

• Derek Nordman - No relevant financial relationship exists

• Laurie Otis - No relevant financial relationship exists

• Patty Scheets - No relevant financial relationship exists

Objectives

• At the end of this section, the participant will: – Understand the systematic approach of KT applied in the

initiative and the intent of accelerating optimal use of the best available research evidence

– Describe rehabilitation as a means for developing skill in home health practice

– Describe evidence-based task-specific training principles

– Apply observational analysis during the patient examination when identifying the cause of the patient’s activity limitations

– Recognize the value of using standardized tests in clinical practice

– Identify strategies to increase intensity of a treatment session in order to maximize progress

Company

• Gentiva Health Services

• 40 States

• Greater than 200 locations nationwide

• Over 350,000 patients served/year

• Over 2500 therapy clinicians

• Proprietary Specialty offerings

• Oversight by Rehab Director

The Need

• Not unlike most Home Health Agencies – “Do more with

less.”

• Efficiency and Consistency in clinical care

• Increase the utilization of EBP

– Evaluation

– Activity and Participation Limitation Identification

(by task specific practice)

– Proper Intensity of the Intervention

– Leading to proper documentation of patient progress and

outcome

• Pre-training clinical documentation review conducted within 5 branches

to allow post-training analysis.

The Aim

Support and re-energize our therapy

field leaders and clinicians by

delivering immediate updates to

specialty content and clinical skills

based on latest science, in a way

that allow for immediate adoption into practice.


The Formula

• Five questions to be answered as posed by

Grimshaw et al

1. What knowledge should be transferred?

2. To whom should the research knowledge be

transferred?

3. By whom should the knowledge be transferred?

4. How should the knowledge be transferred?

5. With what effect should knowledge be

transferred?

Grimshaw et al. Knowledge translation of research findings. Implementation Science. 2012 7:50.

What knowledge should be transferred?

• Evidence Based Best Practice

• Skilled Examination and Evaluation

• Task Specific Practice

• Intervention Intensity

• Documentation

To whom should the research

knowledge be transferred?

• Direct to consumer! – Alternative to “Train the Trainer”

1. Clinical Leaders

(Branches with Rehab Director oversight)

2. Direct to Clinician

By whom should the knowledge be

transferred?

• Company Experts (controlled consistency)

oMatt Janes, PT, DPT, MHS, OCS, CSCS

o Laurie Otis, PT, MBA, MHA, GCS, COS-C

o Patty Scheets, PT, DPT, NCS

o Jennifer Ellis, PT, DPT, MS, GCS, COS-C

– Did allow secondary trainings at the clinician level via

Directors of Clinical Operations and Rehab Directors

How should the knowledge be

transferred?

• Stakeholder Buy-in

• Virtual Classroom

• Bite size doses

• Over a 5 month period (June through September)

• Knowledge checks modules (virtual feedback/response)

• Application learning – Mini “Labs”

• Clinical Support Tool “Gentiva Therapy Guide”

• Recorded Sessions for availability – Module 1 – 2758

– Module 2 – 2441

– Module 3 – 2146

• Post-training follow up

With what effect should knowledge be

transferred?

• Behavior Change

– Adoption of Evaluative Testing

– Activity and Participation Limitation Identification

(by task specific practice)

– Inclusion of Intensity Validation

– Post training documentation analysis


Knowledge-to-Action Process

Graham ID, Logan J, Harrison MB, et al J of Cont Education for Health Professions. 2006; 26: 13-24.

Knowledge Translation:

Task Specific Training

Laurie Otis, PT, MBA, MHA, GCS, COS-C

Skill Acquisition

Consistency

• Performance over multiple trials or sessions

Flexibility

• Performance under a variety of conditions

Efficiency

• Performance with a certain level of energy expenditure

Independent and Skilled?

DAILY ACTIVITY

• Picks up the newspaper after 7:00 AM and the mail

before 4:00 PM if delivered timely

• Ambulating with a single point cane without assistance to

and from the mailbox at the end of a 50’

driveway

• Negotiates 2 steps to go in and out of the

house

– Grasps door frame for balance and support

– Rests in a chair after negotiating the steps

• Completes the entire activity in 20 minutes

• Rates the activity a 13 on the BORG

(perceived exertion)

Task-Specific Training Defined

• What is a Task?

– Space between Body Structure/Function and Activity

• Body Structure/Function = muscle performance, timing, and balance

• Activity = walking from the living room to the kitchen for dinner and

returning to the living room

• What is Task-Specific Training?

– Goal directed

– Coordinated movements and/or sustained postures

– Replicate some component of daily activities

– Aim towards reconstruction of the whole activity

– Reinforced with positive and timely feedback

ICF Model

Common language and nomenclature for

functioning, disability and health (WHO)


Task Specific Training Continuum

Activity Limitation Walk down steps and transfer into senior

citizens’ van UB grooming and dressing

Task Space

Stair Tap Containers and Lids

Impairment

Hip Abductor Weakness Impaired Spatial Organization

Principle - Task Selection

Task Selection

Meaning and Fit

Applicable to the

Patient

Goal Directed

Targeted to Impairment

Sufficient Challenge

Principle - Task Delivery

Task Delivery

Set the Task Parameters

Focus on the desired impairment

Remediation or

Compensation

Tasks Need to Be Practiced

Monitor Response

Progress the

Challenge

Task Specific options

Sit to Stand

• Task used in wide range of activities

• Task demands:

– Force production at initiation

– Control of inter-segmental movement and shifting COM during

execution

– Ability to stabilize in a new position at termination

Sit to stand patient profiles

• Cardiopulmonary Demand

• Task Parameters • Raise seat height to diminish demand on

skeletal muscle; Repeated trials

• Borg RPE; Total min tolerated; Vitals; Dyspnea level

Cardiopulmonary - CHF

• Strength and ROM Demand

• Task Parameters • Strengthening Paradigm

• BORG RPE; Time to Complete; Timed; Pain

Musculoskeletal – Spinal Stenosis with Functional

Decline

• Balance and Strength Demand

• Task Parameters • Compliant surface to increase balance

demand

• 2-3 trials interspersed w/other activities (balance paradigm)

• X LOB; BoS; Time to Complete; Timed

Neuromuscular - DM with

Peripheral Neuropathy


Group Question - Sit to Stand Task

Musculoskeletal

• TKA – Quad weakness

• Strength Demand

• Remediation

1. Which phase of the task has the greatest strength demand?

2. What surface height is most appropriate to encourage

quad recruitment, High Medium or Low?

3. Will you allow UE support, Yes or No?

4. What will you monitor?

5. How will you progress the task?

Task - Stair Tap

• Preparation for obstacle

negotiation, stairs, and change of

direction during ambulation

• Task demands:

– Stance limb: force production

(isometric) of extensors and balance

– Swing limb: force production of hip

flexors and timing to place foot on

step

Patient Profile – Stair Tap

• Cardiopulmonary Demand

• Task Set Up • Adjust step height; Alternate sides

• Duration focus


• Posture and Timing Demand

• Task Set Up • Adjust step height; Fewer repetitions

• Cues for trunk stabilization

• Sit between sets

Musculoskeletal - Functional Decline with

Spinal Stenosis

• Balance and Timing Demand

• Task Set Up

• Alternate sides; compliant surface

• Cues for postural correction

Neuromuscular - DM with

Peripheral Neuropathy

More LE Task Ideas

Tandem Balance: Step

Up / Up; Down / Down

Step Over

Step Up / Up; Down / Down

UE Tasks

• Variability in what we do with our hands

– Reach

– Grasp

– Move or manipulate

– Release

• What is realistic for the patient’s ability given their

impairment

– Grade task so that it takes 8-15 s

TASK - Object Transport

• Element common across many

ADL/IADLs

• Task demands:

– ROM and strength proximally

(including trunk)

– Isolated movement distally

– Cardiopulmonary demand with

repeated UE movement

– Problem solving


Patient Profile – Object Transport

• Cardio Demand

• Task Set Up • Weight of object; Movement height

• Unilateral or Bilateral; Repeated Trials


• Posture Demand

• Task Set Up • UE Movement Pattern

• Weight of object; Trunk position

Musculoskeletal – Functional Decline

with Spinal Stenosis

• Balance and Timing Demand

• Task Set Up • Compliant surface

• Movement speed; COM displacement

Neuromuscular – DM with Peripheral

Neuropathy

Overall Considerations for

Task Specific Training

• Progress the challenge based

on desired outcome

• Monitor response to treatment

in a single session and across

sessions

• Identify overall progress

towards functionally based

goals using objective

measures

Challenge of the task

Task Performance (consistency; flexibility; efficiency)

Making it Work for YOU in Your Practice

• Adopt a new routine

1. Rehabilitation is about skill acquisition

• Maximize consistency, flexibility and efficiency

2. Make Task-Specific Training your priority intervention

• Differentiate what you do in treatment

from the home program

3. Develop a new task that fits with your

patient’s specific needs

Take a Closer Look

Patty Scheets, PT, DPT, MHS, NCS

The Therapist’s Clinical Examination

• Quantitative Analysis

• Qualitative Analysis

• Body Functions and Structures

• Systems Review

• Drug Regimen Review

Health Status

Impairment Tests

Standardized Measures

Observational Analysis

Standardized Measures

Baseline data for scoring

Interpretative comments from observational analysis

TUG • Sit ↔ stand; Turn to change direction

BERG

• Stair tap; Pick object up from the floor

SPPB • Sit ↔ stand; Standing balance progression


Observational Analysis

• Kinematic analysis

• Changes in joint angles and limb displacement

• Timing, range of motion, speed, inter-segmental relationships

Systematic Observation

• Initiation, Execution, Termination

Phases

• Proximal to distal

Each Joint

Which Tasks to Observe?

Varying Demands

Demands can be Generalized to other Tasks

Sufficient Challenge

Overlap with Items on Standardized Tests

• Quiet Sitting, Quiet Standing (EO/EC), STS, Stair Tap, Walking, Walking with Head Turning, Step Over, Change Direction, Reach, Grasp

Recommendations

Sit to Stand

Identifying Faulty Movement

Performance Sit to Stand Example


Sit to Stand Example Stand to Sit Example

Stand to Sit Example Sit to/from Stand Documentation

Alternate Stair Tap Identifying Faulty Movement

Performance


Cardiopulmonary Patient Cardiopulmonary Patient Example

Cardiopulmonary Patient

Documentation Musculoskeletal Patient

Musculoskeletal Patient Example Musculoskeletal Patient Documentation


Neuromuscular Patient Neuromuscular Patient Example

Neuromuscular Patient Documentation Making it Work for YOU

• Adopt a new routine

– Be thorough in your systems review

• Complete the OASIS

• Drug regimen review

– Do a complete examination

• Baseline status

• Understand the nature of the patient’s problem

• Be specific in your observations

– Develop a specific plan of care

Treatment Ideas

Bring it On!

Matt Janes, PT, DPT, MHS, OCS, CSCS


Tests and Measures

• A standardized test or measure promotes

reliability and validity through the procedures of

administering, scoring and interpreting results in

a consistent and predetermined standard

• Tests and measures are used as a measure of a

patient’s progress or relative outcome

Standardized Tests and Measures

Short Physical Performance Battery (SPPB)

2 Minute Walk Test (2MWT)

Borg Scale (Rating of Perceived Exertion (RPE))

Dyspnea Scale (Rating of Perceived Exertion (RPE))

Short Physical Performance Battery

(SPPB)

• Measures:

– Functional status

– Physical performance

– Focus on Lower

Extremities

• High correlation:

– Mobility disability

– Hospitalization

– Institutionalization

– Mortality

2MWT

• 2 minute walk test (2MWT)

• Correlation:

– function, morbidity, and mortality

• MDC90 (older adults) = 15 meters or 49.2 feet

• Equipment:

– Stopwatch or second hand

– Tape measure

– BP cuff

– Chair

k

Perception

Performance Physiology

Perceived Exertion

Perceived Exertion

Physiological variables

Physical work capacity


Rating of Perceived Exertion (RPE)

Dyspnea Scale Borg Scale

2 Minute Walk Test

PT Documentation Example

Exercise and Activity Prescription

• Progressive age related loss of

strength

• 1% to 5% loss of strength each

year after 30

• 3% to 5% loss of strength each

year after 60

• Loss of strength = loss of function

• Effective strength practice

Building LE Strength


Modified

Scale

Ordinal Borg RPE

Scale

Percent

Effort

Perceived

Work Load

6 20%

7 30%

8 40%

1 9 50%

2 10 55%

11 60%

12 65%

13 70%

14 75%

5 15 80%

6 16 85%

7 17 90%

8 18 95%

9 19 100%

10 20 Exhaustion

Hard

Very Hard

Very, very hard

3

4

Very, very light

Very light

Fairly light

Moderatly light


• Maximum Heart Rate (Max HR) = 220 – age

155 Max HR = 220 – 65

• Target Heart Rate (THR)

= Percentage of Max HR

93 THR = 155(60%)

• Heart Rate Reserve (HRR)

= Max HR – Resting HR

85 HRR = 155 – 70

• Target Heart Rate Range (THRR) = [ (Max HR – Resting HR) x % Intensity ] + Resting HR

A = [ (155 - 70) x 60% ] + 70 and B = [ (155 - 70) x 80% ] + 70

121 – 138 THRR


Exercise and Activity Prescription Exercise and Activity Prescription

Building UE Strength Exercise and Activity Prescription

Frail elderly: RPE of 11-13, 20 minutes each day, 3 days/week

Cardiac patients: RPE 11-16, multiple short sessions, 4-7 days/week

Respiratory patients: RPE 3-5, two,15-minute or one, 30-minute sessions, 4-5 days/week

Vital Sign Baseline Normative Values

American Heart Association (AHA) Standards

– Blood Pressure (BP) : Systolic 90-140 mmHg

Diastolic 60-90 mmHg

– Heart Rate (HR) : 60-90 beats per minute (bpm)

– Respirations (R) : 12-16 breaths per minute

– Oxygen Saturation (O2 Sat) : ≥ 90%

Vital Sign Response to Exercise


Normal Blood Pressure Response to

Exercise

• Increases with increasing workload

• Flattens out/decreases slightly as maximum work capacity is reached

Systolic Pressure

• Demonstrates no change and/or

• Slightly increases or decrease

Diastolic Pressure

Abnormal Blood Pressure Response to

Exercise

• Demonstrates little or no response with increasing workload,

• Slight fall, then rise with increased workload,

• Normal rise which abruptly falls

Systolic Pressure

• Increases with increasing workload and/or increase is prolonged after exercise is stopped

Diastolic Pressure

Building Activity Tolerance Building Activity Tolerance

PT Documentation Example

Indications for Termination of Exercise

• Chest pain of any type

• Severe shortness of breath

• Dizziness or faintness

• New onset or increase in mental confusion

• Sudden onset of sweating, pallor, cyanosis

• Sign of irregular heart rhythm

• Patient request to stop

• Drop in systolic BP > than 10 mmHg from baseline, despite increase in workload

• O2 saturation 85-89% & symptomatic, absolute cutoff is 85%

• Hypertensive response

• Systolic blood pressure > 210 mmHg and/or

• Diastolic blood pressure >115 mmHg

• Leg cramps or increase in leg pain

• Fatigue, shortness of breath, increased wheezing

Bring it on!

• Adopt a new routine – Utilize tests and measures for examining

exertional ability and functional performance

– Prescribe a level of optimal intensity appropriate for your

patient

– Develop a plan of care that promotes functional activity

tolerance and independence

– Monitor response to exercise

and activity


Knowledge-to-Action Process

Outcomes

Outcomes

Measures of clinician empowerment, engagement, support,

“energy” and adoption into practice

– Number of OT and PT staff who completed training

• Target: ≥ 50% of target audience

– Result: average attendance across all 3 modules 67.7%

– 2966 employees completed one or more of the modules

– “I feel I will be able to apply this information to my practice.”

• Target: ≥ 70% Agree or Strongly Agree

– Result: average across all 3 modules 89.8%

Chart Audit Results

Convenience Sample

• 4 therapists from each region

Reviewed 5 completed records prior to training and 5 completed records after training

16 behaviors associated with the first 3 modules

Calculated an adherence score for each record; averaged for each clinician

• Possible adherence scores range from 1.0 to 0.0

Home Health Section

Platform Presentation

Friday, February 6

3:00 – 5:00 pm

• 3:20 – 3:40 pm

Opportunities

• Present < 50% of the time after training

– A 2-minute walk test was completed during the Physical

Therapist’s evaluation

– Strength training was implemented using an intensity of at least

60% of a 1-repetition maximum identified using the Borg RPE

scale to identify the intensity

– An RPE rating was provided for at least 1 activity from the

Physical Therapist’s evaluation

– Sessions are of appropriate duration and intensity (using Borg

or HR) to build CP capacity if documented as a problem

– Standardized tests are used when reporting progress

Additional Opportunities

• Increase prevalence of task-specific training in post-

operative cases

• Progress strength training by adding resistance (intensity)

rather than adding repetitions

• Summarize progress in terms of skill consistency,

flexibility, and efficiency rather than advancement of

exercises

• Do more gait speed training rather than gait endurance

training


Strengths of the KT Project

• Recognized need company-wide • Therapist engagement

• Therapy practice

• Re-stabilization in company structure • Therapist in senior leadership

• Local structure for therapy support determined

• Operational support for training • Wanted to see behavior change

• Trust in the product to be produced

• Senior leadership support • Resource allocation

• Enthusiasm among local therapy leaders

• Available technology and technological expertise

• The “Therapy Guide”

Limitations of the KT Project

• Short timeline for development

• Inexperience with virtual classroom for clinical teaching

• Activities to reinforce learning were optional • Few local leaders implemented follow-up activities

• Competing priorities • EMR

Sustain

Sustainability

• Modules made available for CEUs

• Reinforced concepts and use of “Therapy Guide” in other

projects

• Intermittent chart audits • RPE ratings more consistently used now

Summary of Key Points

Large scale KT Intervention

Training converted theoretical constructs to concrete

behaviors

Clinicians did change behavior

Organization support critical

Competing priorities are a factor

Consistent clinical message with lasting clinical support

tools increases likelihood of sustaining change

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• Birkenmeier RL, Prager EM, Lang CE. Translating animal doses of task-specific training to people with chronic stroke in 1-hour therapy sessions: a proof-of-concept study. Neurorehabil Neural Repair. 2010;24(7):620-630.

• Boulay MR, Simoneau JA, Lortie G, Bouchard C. Monitoring high-intensity endurance exercise with heart rate and thresholds. Med Sci Sports Exerc. 1997;29(1):125-32.

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• Burtin C, Saey D, Saglam M, et al. Effectiveness of exercise training in patients with COPD: the role of muscle fatigue. Eur Respir J. 2012;40(2):338-44.

• Coleman E, Chalmers S. The Care Transitions Intervention, Results of a Randomized Controlled Trial. Arch Intern Med; 2006; 166.

• Connelly DM, Thomas BK, Cliffe SJ, Perry WM, Smith RE. Clinical utility of the 2-minute walk test or older adults living in long-term care. Physiother Can. 2009;61:78-87.

• DeJong G, Hsieh CH, Putman K, et al. Physical therapy activities in stroke, knee arthroplasty, and traumatic brain injury rehabilitation: their variation, similarities, and association with functional outcomes. Phys Ther. 2011:91(12):1826-37.

• DeJong S., Schaefer SY, Lang CE. Need for speed: better movement quality during faster task performance after stroke. Neurorehabil Neural Repair. 2012;26(4):362-73.

• de Vreede PL, van Meeteren NL, Samson MM, Wittink HM, Duursma SA, Verhaar HJ. Functional tasks exercise versus resistance to improve daily function in older women: A feasibility study. Arch Phys Med Rehab. 2004;85:1952-61.

Selected References con’t. • Finger M, Stoll A, Stucki G, Huber E. Identification of intervention categories for physical therapy, based on

the International Classification of Functioning, Disability and Health: a Delphi exercise. Phys Ther. 2006;86:1203–1220.

• Frese EM, Fick A, Sadowsky HS. Blood pressure measurement guidelines for physical therapists. Cardiopulm Phys Ther J. 2011;22(2):5-12.

• Garber CE, Blissmer B, Deschenes MR, et al. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exercise. 2011;43(7):1334-59.

• Graham ID, Logan J, Harrison MB, et al J of Cont Education for Health Professions. 2006; 26: 13-24.

• Horn SD, DeJong G, Smout RJ, et al. Stroke rehabilitation patients, practice, and outcomes: is earlier and more aggressive therapy better? Arch Phys Med Rehabil. 2005;86(2):S101-14.

• Jette DU, Warren RL, Wirtalla C. The relation between therapy intensity and outcomes of rehabilitation in skilled nursing facilities. Arch Phys Med Rehabil. 2005;86(3):373-9.

• Kimberley TJ, Samargia S, Moore LG, et al. Comparison of amounts and types of practice during rehabilitation for traumatic brain injury and stroke. J Rehabil Res Dev. 2010;47(9):851-62.

• Kleim JA, Jones TA. Principles of experience-dependent neural plasticity: implications for rehabilitation after brain damage. J Speech Lang Hearing Res. 2008;51:s225-s239.

• Lang CE, MacDonald JR, Reisman DS, et al. Observation of amounts of movement practice provided during stroke rehabilitation. Arch Phys Med Rehabil. 2009;90:1692-8.

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• Leung AS, Chan KK, Sykes K, Chan KS. Reliability, validity, and responsiveness of a 2-min walk test to assess exercise capacity of COPD patients. Chest. 2006;130(1):119-25.

• Littbrand H, Carlsson M, Lundinn-Olsson L, et al. Effect of a high-intensity functional exercise program on functional balance: preplanned subgroup analyses of a randomized controlled trial in residential care facilities. J Am Geriatr Soc. 2011;59(7):1274-82.

Selected References con’t. • Maughan KK, Lowry KA, Franke WD, Smiley-Oyen AL. The dose-response relationship of balance training

in physically active older adults. J Aging Phys Act. 2012;20(4):442-55.

• Mayer F, Scharhag-Rosenberger F, Carlsohn A, et al. The intensity and effects of strength training in the elderly. Dtsch Arztebl Int. 2011;108(21):359-64.

• Munin MC, Putman K, Hsieh CH, et al. Analysis of rehabilitation activities within skilled nursing and inpatient rehabilitation facilities after hip replacement for acute hip fracture. Am J Phys Med Rehabil. 2010;89(7):530-40.

• Pak S, Patten C. Strengthening to promote functional recovery poststroke: an evidence-based review. Topics Stroke Rehabil. 2008;15(3):177-199.

• Peterson MD, Rhea MR, Sen A, Gordon PM. Resistance exercise for muscular strength in older adults: a meta-analysis. Aging Res Rev. 2010; 8(3):226-37.

• Quinn, L., Gordon, J. (2010). Documentation for Rehabilitation: A Guide to Clinical Decision Making, 2nd Ed. St Louis, Missouri: Saunders.

• Schaefer SY, Patterson CB, Lang CE. Transfer of training between distinct motor tasks after stroke: implications for task-specific approaches to upper-extremity neurorehabilitation. Neurorehabil Neural Repair. 2013 Apr 2 [Epub ahead of print].

• Scheets PL, Sahrmann SA, Norton BJ. Use of movement system diagnoses in the management of patients with neuromuscular conditions: a multiple-patient case report. Phys Ther. 2007;87(6):654-669.

• Schultz AB, Alexander NB, Ashton-Miller JA. Biomechanical analyses of rising from a chair. J Biomechanics. 1992;25(12):1383-1391.

• Schwartz RS: Sarcopenia and physical performance in old age: introduction. Muscle Nerve Suppl5: S10-12, 1997.

• Valenzuela T. Efficacy of progressive resistance training interventions in older adults in nursing homes: a systematic review. J Am Med Dir Assoc. 2012;13(5):418-28.

• Wrentenberg P, Lindberg F, Arborelius UP. Effect of armrests and different ways of using them on hip and knee load during rising. Clin Biomech. 1993;8:95-101.

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Pu

she

s o

n t

hig

hs

to e

xte

nd

tru

nk

Va

lgu

s o

f kn

ee

Va

rus

of

kn

ee

Exc

ess

ive

pro

na

tio

n o

f fo

ot

Su

pin

atio

n o

f fo

ot

Po

ste

rio

r sw

ay

Ste

ps

Sh

ifts

CO

M t

o o

ne

sid

e

Sh

ifts

CO

M t

o o

ne

sid

e o

r

ba

ck; re

sist

s c

orr

ec

tio

n

Un

ab

le t

o s

hift

CO

M f

orw

ard

to f

ind

ba

lan

ce

Inc

rea

sed

lum

ba

r e

xte

nsi

on

Ina

de

qu

ate

hip

exte

nsi

on

Ina

de

qu

ate

kn

ee

exte

nsi

on

Sta

nd

to

Sit A

na

lysi

s – P

atie

nt

1

Initia

tes

with

po

ste

rio

r sw

ay

Insu

ffic

ien

t kn

ee

fle

xio

n o

n in

itia

tio

n a

nd

du

rin

g e

xe

cu

tio

n

Insu

ffic

ien

t h

ip f

lexio

n d

urin

g e

xe

cu

tio

n

Ina

de

qu

ate

co

ntr

ol o

f d

esc

en

t in

to c

ha

ir

Un

ab

le t

o m

od

ify m

ov

em

en

t st

rate

gy w

ith

cu

es/

pra

ctic

e

Imp

rov

es

pe

rfo

rma

nc

e w

ith

cu

es/

pra

ctic

e

Sta

nd

ing

Po

stu

ral C

on

tro

l A

na

lysi

s – P

atie

nt

2 (

Ca

rdio

pu

lmo

na

ry)

Str

uc

tura

l alig

nm

en

t fa

ults

(sc

olio

sis,

kyp

ho

sis,

etc

.)

Pre

fers

wid

e b

ase

of

sup

po

rt

Inc

rea

sed

sw

ay

Inc

rea

sed

sw

ay w

ith

eye

s c

lose

d

Av

ers

ion

to

eye

s c

lose

d c

on

ditio

n

UE g

ua

rdin

g o

r re

ac

hin

g

CO

M s

hifte

d le

ft, rig

ht,

or

ba

ck

Sh

ifts

CO

M a

wa

y f

rom

mid

line

; re

sist

s c

orr

ec

tio

n

He

sita

tio

n w

he

n c

ha

ng

ing

BO

S o

r in

itia

tin

g m

ov

em

en

t

Mu

ltip

le s

tart

s w

he

n c

ha

ng

ing

BO

S o

r in

itia

tin

g m

ov

em

en

t

Insu

ffic

ien

t h

ip/k

ne

e e

xte

nsi

on

du

rin

g W

B

Insu

ffic

ien

t h

ip f

lexio

n o

n s

win

g li

mb

fo

r st

air t

ou

ch

ing

Loss

of

ba

lan

ce

; st

ep

s to

re

co

ve

r

Loss

of

ba

lan

ce

; n

ee

ds

to b

e c

au

gh

t to

pre

ve

nt

a f

all

Un

ab

le t

o m

od

ify m

ov

em

en

t st

rate

gy w

ith

cu

es/

pra

ctic

e

Mo

ve

me

nt

stra

teg

y im

pro

ve

s w

ith

cu

es/

pra

ctic

e

Fa

tig

ue

s w

ith

re

pe

titio

n

Mo

du

le 2

La

b

[2

]

Sta

nd

ing

Po

stu

ral C

on

tro

l A

na

lysi

s – P

atie

nt

3 (

Mu

scu

losk

ele

tal)

Str

uc

tura

l alig

nm

en

t fa

ults

(sc

olio

sis,

kyp

ho

sis,

etc

.)

Pre

fers

wid

e b

ase

of

sup

po

rt

Inc

rea

sed

sw

ay

Inc

rea

sed

sw

ay w

ith

eye

s c

lose

d

Av

ers

ion

to

eye

s c

lose

d c

on

ditio

n

UE g

ua

rdin

g o

r re

ac

hin

g

CO

M s

hifte

d le

ft, rig

ht,

or

ba

ck

Sh

ifts

CO

M a

wa

y f

rom

mid

line

; re

sist

s c

orr

ec

tio

n

He

sita

tio

n w

he

n c

ha

ng

ing

BO

S o

r in

itia

tin

g m

ov

em

en

t

Mu

ltip

le s

tart

s w

he

n c

ha

ng

ing

BO

S o

r in

itia

tin

g m

ov

em

en

t

Insu

ffic

ien

t h

ip/k

ne

e e

xte

nsi

on

du

rin

g W

B

Insu

ffic

ien

t h

ip f

lexio

n o

n s

win

g li

mb

fo

r st

air t

ou

ch

ing

Loss

of

ba

lan

ce

; st

ep

s to

re

co

ve

r

Loss

of

ba

lan

ce

; n

ee

ds

to b

e c

au

gh

t to

pre

ve

nt

a f

all

Un

ab

le t

o m

od

ify m

ov

em

en

t st

rate

gy w

ith

cu

es/

pra

ctic

e

Mo

ve

me

nt

stra

teg

y im

pro

ve

s w

ith

cu

es/

pra

ctic

e

Fa

tig

ue

s w

ith

re

pe

titio

n

Sta

nd

ing

Po

stu

ral C

on

tro

l A

na

lysi

s – P

atie

nt

4 (

Ne

uro

mu

scu

lar)

Str

uc

tura

l alig

nm

en

t fa

ults

(sc

olio

sis,

kyp

ho

sis,

etc

.)

Pre

fers

wid

e b

ase

of

sup

po

rt

Inc

rea

sed

sw

ay

Inc

rea

sed

sw

ay w

ith

eye

s c

lose

d

Av

ers

ion

to

eye

s c

lose

d c

on

ditio

n

UE g

ua

rdin

g o

r re

ac

hin

g

CO

M s

hifte

d le

ft, rig

ht,

or

ba

ck

Sh

ifts

CO

M a

wa

y f

rom

mid

line

; re

sist

s c

orr

ec

tio

n

He

sita

tio

n w

he

n c

ha

ng

ing

BO

S o

r in

itia

tin

g m

ov

em

en

t

Mu

ltip

le s

tart

s w

he

n c

ha

ng

ing

BO

S o

r in

itia

tin

g m

ov

em

en

t

Insu

ffic

ien

t h

ip/k

ne

e e

xte

nsi

on

du

rin

g W

B

Insu

ffic

ien

t h

ip f

lexio

n o

n s

win

g li

mb

fo

r st

air t

ou

ch

ing

Loss

of

ba

lan

ce

; st

ep

s to

re

co

ve

r

Loss

of

ba

lan

ce

; n

ee

ds

to b

e c

au

gh

t to

pre

ve

nt

a f

all

Un

ab

le t

o m

od

ify m

ov

em

en

t st

rate

gy w

ith

cu

es/

pra

ctic

e

Mo

ve

me

nt

stra

teg

y im

pro

ve

s w

ith

cu

es/

pra

ctic

e

Fa

tig

ue

s w

ith

re

pe

titio

n

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