Descriptive Data Analysis Examining

M .D . Bland, PT, DPT, NCS, MSCI, H ow Standardized Assessments Are

P rogram in Physical T hera py,
D e p a rtm e n t o f
P rogram in
N e u ro lo g y ,
O c c u p a tio n a l
and
T h e r­
Used to Guide Post-Acute Discharge
apy, W a s h in g to n U niversity. M a il­
in g address: P rogram in Physical Recom m endations fo r Rehabilitation
T herapy, W a s h in g to n U niversity,
4444 Forest Park, C am pus Box Services A fter Stroke
8 5 0 2 , St Louis, M O 6 3 1 0 8 (USA).
Address all co rre s p o n d e n c e to D r Marghuretta D. Bland, Michelle Whitson, Hilary Harris, Jeff Edmiaston,
Bland at: b la n d m @ w u s m .w u s tl.
Lisa Tabor Connor, Robert Fucetola, Alexandre Carter, Maurizio Corbetta,
edu.
Catherine E. Lang
M . W h its o n , PT, M HS, M A , MBA,
Barnes Jewish H ospita l R ehabilita­
tio n Services, St Louis, M issouri.
Background. Use of standardized assessments in acute rehabilitation is continu­
H. Harris, MSPT, Barnes Jewish ing to grow, a key objective being to assist clinicians in determining services needed
H ospita l R e h a b ilita tio n Services. postdischarge.
J. E dm iaston, MS, CCC-SLP,
Barnes Jewish H ospital R ehabilita­ O bjective. The purpose of this study was to examine how standardized assess­
tio n Services. ment scores from initial acute care physical therapist and occupational therapist
L.T. C o n n o r, PhD, M SO T, D e p a rt­ evaluations contribute to discharge recommendations for poststroke rehabilitation
m e n t o f O c c u p a tio n a l T herapy, services.
M G H In s titu te o f H ealth Profes-
sions, Boston, M assachusetts.
Design. A descriptive analysis was conducted.
R. Fucetola, PhD, D e p a rtm e n t o f
N e uro log y, W ashing to n University.
M eth o d s. A total of 2,738 records of patients admitted to an acute care hospital
A. C arter, M D , PhD, D e p a rtm e n t with a diagnosis of stroke or transient ischemic attack w ere identified. Participants
of N e u ro lo g y , W a s h in g to n received an initial physical therapist and occupational therapist evaluation with
U niversity.
standardized assessments and a discharge recom m endation of hom e w ith no services,
M . C o rb e tta , M D , D e p a rtm e n t o f hom e with services, inpatient rehabilitation facility (IRF), or skilled nursing facility
N e u ro lo g y and D e p a rtm e n t of (SNF). A K-means clustering algorithm determ ined if it was feasible to categorize
R adiology, W a s h in g to n U niversity.
participants into the 4 groups based on their assessment scores. These results were
C.E. Lang, PT, PhD, P rogram in com pared with the physical therapist and occupational therapist discharge recom­
Physical T hera py, D e p a rtm e n t o f mendations to determ ine if assessment scores guided postacute care
N e u ro lo g y , and P rogram in O c c u ­
recommendations.
p a tio n a l T hera py, W a s h in g to n
U niversity.
Results. Participants could be separated into 4 clusters (A, B, C, and D) based on
[B land M D , W h its o n M , Harris H,
assessment scores. Cluster A was the least impaired, followed by clusters B, C, and D.
e t al. D e scriptive data analysis
e x a m in in g how s ta n dard ized
In cluster A, 50% of the participants w ere recom m ended for discharge to home
assessments are used to g u id e w ithout services, whereas 1% w ere recom m ended for discharge to an SNF. Clusters
p o s t-a c u te discha rge re c o m m e n ­ B, C, and D each had a large proportion of individuals recom m ended for discharge to
da tio n s fo r re h a b ilita tio n services an IRF (74%-80%). There was a difference in percentage of recom m endations across
a fte r stroke. P hys T h e r.
the clusters that was largely driven by the differences betw een cluster A and clusters
2 0 1 5 ;9 5 :7 1 0 -7 1 9 .]
B, C, and D.
© 20 15 A m erican Physical Therapy
Association Lim itations. Additional unknow n factors may have influenced the discharge
Published Ahead o f Print: recommendations.
D ecem ber 11, 2014
A ccepted: N o ve m b e r 26, 2014 Conclusions. Participants poststroke can be classified into meaningful groups
S ub m itted: A ug ust 13, 20 14
based on assessment scores from their initial physical therapist and occupational
therapist evaluations. These assessment scores, in part, guide poststroke acute care
p o s t a R apid R esponse to discharge recommendations.
f0 j th is a rtic le at:
v" • p tjo u rn a l.a p ta .o rg

710 ■ Physical T h e ra p y V o lu m e 95 Num ber 5 M ay 2015

 D escrip tive D a ta Analysis E x a m in in g S ta n d a rd iz e d Assessments

n the acute care setting, the those with severe deficits would be and occupational therapist evalua­

I median length of stay for people grouped together and would most
with stroke is 3 days.1 Rehabilita­ likely receive the recommendation
tion clinicians often see a patient for discharge to an SNF. Patients
tions. The recommendations for dis­
charge services from speech-
language pathologists were not
only once for an acute care evalua­ with mild to moderate deficits would included; participants with stroke or
tion, and a key responsibility is to be somewhere between these TIA were referred for speech-
screen for sensorimotor, cognitive, groups and would receive a recom­ language pathology therapy only if
and language deficits. Despite the mendation of home with services or they screened positive for a language
challenges of patient-, clinician-, and IRF. As standardized assessments deficit (by an occupational thera­
facility-specific barriers,2"9 use of become more routinely adminis­ pist), screened positive for a swal­
standardized assessments across the tered, the results of this study will lowing deficit (by nursing staff), or
continuum of care is continuing to provide information on the next met the criteria for further determi­
grow through multiple efforts.10-13 A step: examining how standardized nation of subtle higher-level cogni­
goal of standardized assessment is to assessments shape and guide rehabil­ tive deficits (based on the occupa­
objectively quantify deficits of itation clinical practice. tional therapy screening battery).19
impairment, activity limitations, and Typical initial evaluations at an acute
participation restrictions to assist Method care hospital for patients poststroke
rehabilitation clinicians in determin­ P a r t i c i p a n t s take an average of 20 minutes for
ing patient prognosis, appropriate This study utilized a convenience physical therapy and 39 minutes for
interventions, and the need for addi­ sample of 2,738 patient records occupational therapy.19 Discharge
tional services.4 513"16 It is assumed stored in the Brain Recovery Core recommendations were made by the
that standardized assessments com­ database and additional variables col­ physical therapists and occupational
pleted during the initial evaluation lected in the Cognitive Rehabilita­ therapists during the initial evalua­
will help clinicians in determining tion Research Group database from tion but could be revised at any time.
these factors; however, research has January 2010 through March In our review of the records, <5% of
not shown that this is the case. 2013.1017 All participants had a pri­ the discharge recommendations
mary diagnosis of stroke or transient made from the initial physical thera­
The aim of this study was to examine ischemic attack (TLA).18 Each partic­ pist or occupational therapist evalu­
if standardized assessment scores ipant provided informed consent to ation were changed prior to patient
from initial acute care physical ther­ have his or her stroke rehabilitation discharge; thus, the discharge rec­
apist and occupational therapist eval­ data stored and used for research. ommendation made as part of the
uations systematically contribute to The Washington University Human initial evaluation was used for the
discharge recommendations for Research Protection Office approved analysis. Finally, only patient records
poststroke rehabilitation services. the databases and studies using where the physical therapist and
After initial evaluation of patients in de-identified data. occupational therapist made the
our acute care facility, physical ther­ same discharge recommendation for
apists and occupational therapists Participants averaged 0 days future services were used for the
make one of the following discharge between onset of stroke to admis­ analysis. Arguably, the need for a
recommendations: (1) home with no sion to the acute care hospital. Once specific discharge service has greater
services, (2) home with services, (3) a patient is admitted to the acute credence when both the physical
inpatient rehabilitation facility (IRF), care hospital and is medically stable, therapist and occupational therapist
or (4) skilled nursing facility (SNF). If rehabilitation services for physical make the same recommendation.
the standardized assessments, which therapy and occupational therapy Figure 1 shows a flowchart of all
measure key impairments and activ­ are ordered, usually within 24 hours records screened (N =4,6l3) and
ity limitations, systematically con­ of admission. The acute care physi­ how the final sample (n = 2,738) was
tribute to discharge recommenda­ cal therapist evaluation is com­ achieved.
tions, we would expect patterns or pleted, on average, within 4 days
groupings of patients based on the (median =1 day) of admission, and V a r ia b le s A s s e s s e d
severity of the deficits. For example, the occupational therapist evalua­ At the acute care hospital, clinicians
patients with no deficits to minimal tion is completed, on average, within completed a standardized initial eval­
deficits would likely be grouped 3 days (median = 1 day) of admission. uation on all participants post-
together and would most often The recommendation for discharge stroke.1019 The assessments com­
receive the recommendation to go services for this analysis originated pleted in this evaluation are part of a
home with no services, whereas from the initial physical therapist required standardized battery of tests

May 2015 Volume 95 Number 5 Physical Therapy ■ 711

D e s c rip tiv e D a ta A n a ly s is E x a m in in g S ta n d a r d iz e d A s s ess m en ts

F ig u re 1.
Participant records utilized from the Brain Recovery Core database. Of the initial 4,61 3 patients poststroke w ho consented to
participate, 2,738 participants were included in the analysis. PT=physical therapist, O T=occupational therapist, IRF=inpatient
rehabilitation facility, SNF=skilled nursing facility.

that encompass the sensorimotor,
cognitive, and language domains and
that are com pleted across the contin­
uum of care. The assessments w ere
chosen to meet the needs of each
discipline (physical therapy, occupa­
tional therapy, and speech-language
pathology) and each service (acute,
inpatient, outpatient). In addition,
assessments had to be clinically use­
ful for the entire spectrum of stroke
severities. The following variables
along with the construct being
assessed from the initial acute care
physical therapist and occupational
therapist evaluations were: upper
and lower extremity Motricity Index
scores of the affected limb to assess
paresis,20-21 light touch on the palm
of the hand and the dorsum of the
foot of the affected limb to assess
somatosensation,22-23 Berg Balance
Scale score to assess static and
dynamic balance,24-25 10-m walk
speed to assess gait speed for those
participants w ho could walk w ithout
hands-on assistance,26-29 Short
Blessed Test score to screen for
dementia or other cognitive impair­
m ent,30 Trail Making Test A and B
scores to assess for visual scanning
and attention,31-32 Unstructured
Mesulam total score to assess
neglect,33’35 15-item Boston Naming
Test score to screen for aphasia,36' 38
and scores for Functional Indepen­
dence Measure items (gait assist,
grooming, lower body dressing, and
toileting) to assess assistance
required for activities of daily liv­
ing.28-39’41 In addition, data for other
demographic variables that could
affect the recom m endation for dis­
charge services were collected: age,
race, sex, and availability of help at
home.
D a ta A n a ly s is
We used IBM SPSS version 21 (IBM
Corporation, Armonk, New York)
for all statistical analyses, and the cri­
terion for statistical significance was
set at P<.05. The independent vari­
ables came from the initial physical
therapist or occupational therapist
evaluations archived in the Brain
Recovery Core clinical database. As
with most clinical databases, the
majority of variables w ere present
for most participants, but some data
w ere missing. Across the 2,738 par­
ticipants and 15 variables, 32%
(13,230/41,070) of the data were
missing. To limit the introduction of
selection bias and loss of information
and efficiency, multiple im putation
was utilized to account for the miss­
ing data.42' 48 Multiple imputation
allows for missing values to be
replaced through statistical algo­
rithms that capitalize on the case and
group observed values and variabil­
ity.46-47-49’52 Previous analysis of data
from the Brain Recovery Core data­
base53 has shown that clinical data
were missing at random (ie, missing
values w ere not systematically differ­
ent from those w ithout missing val­
ues).42’44’46’49’51-54 To account for
the uncertainty in missing data, mul­
tiple im putation utilized multiple

712 ■ Physical Therapy Volume 95 N um bers May 2015

 Descriptive Data Analysis Examining Standardized Assessments

Table 1.
K-Means Cluster Analysis0

V a ria b le C lu s te r A C lu s te r B C lu s te r C C lu s te r D W it h in -im p u t a t io n B e tw e e n -im p u ta tio n

(A ffe c te d Side as A p p lic a b le ) (n = 9 0 1 ) (n = 8 1 4 ) (n = 6 8 6 ) (n = 3 3 7 ) V a ria n c e V a ria n c e

Age (y) 58 (0 ) 66 (0.51) 68 (0.48) 69 (0.69) 0.009 7.73

Race Caucasian Caucasian Caucasian Caucasian 0 0

Sex Male Female Female Female 0 0.08

Help at home Yes Yes Yes Yes 0 0

UE Motricity Index* 84 (0.32) 67 (0.94) 54 (1.62) 38 (2.45) 0.096 128.27

LE Motricity Index* 86 (0.32) 70 (1.07) 58 (1.77) 42 (3.16) 0.143 115.20

Palm light touch sensation1- Normal Normal Normal Impaired 0.002 0.04

Dorsum foot light touch sensation4 Normal Impaired Impaired Impaired 0.002 0.11

Short Blessed Test* 3 (0.42) 9 (0 ) 15 (0.67) 20 (0.47) 0.008 17.49

Trail Making Test A (s) 47 (0.82) 117(3.83) 207 (5.54) 304 (9.36) 1.336 4,137.57

Trail Making Test B (s) 110(1.89) 277 (6.83) 440 (11.14) 632(17.90) 4.946 16,619.82

Unstructured Mesulam total score§ 4 (0 ) 14 (0.63) 28 (0.74) 42 (1.83) 0.042 93.39

Boston Naming Test® 13 (0 ) 10 (0.42) 8 (0.52) 5 (0.53) 0.007 5.69

FIM, walking assist# 5 (0 ) 3 (0.48) 3 (0 ) 2 (0 ) 0.002 0.55

FIM, groom ing# 6 (0 ) 4 (0 ) 3 (0 ) 3 (0.48) 0.002 0.74

FIM, dressing* 5 (0 ) 3 (0 ) 2 (0 ) 2 (0 ) 0 0.66

FIM, toileting* 5 (0.52) 3 (0 ) 2 (0 ) 2 (0.42) 0.004 0.91

Berg Balance Scale** 37 (0.57) 1 3 (0.48) 7 (0.48) 4 (0.48) 0.010 75.44

10-m walking speed (m/s) 1 (0) 0 (0 ) 0 (0 ) 0 (0 ) 0 0.08

“ The K-means cluster analysis produced 4 distinct clusters (A, B, C, and D) for each of the 10 imputations. The cluster center is the overall mean of a
particular cluster. The pooled final cluster centers averaged across the 10 imputations are shown in the table. Values are expressed as means (rounded to
whole numbers) and standard deviations, and additional parameter estimates are included. The value in the parentheses is the standard deviation of the
cluster center (across the 10 imputations), not the standard deviation of the entire cluster. UE=upper extremity, LEHower extremity, FIM = Functional
Independence Measure. Variable scales for reference: * 0 is complete paresis, 100 is normal strength; * normal, impaired, absent; * 0 is normal, 28 is severe
dementia; 5 total score is left plus right omissions, 0 is no omissions, 60 is all symbols o m itte d ;110 is severe aphasia, 15 is normal; * 1 is total assist, 7 is
independent; ** 0 is severe balance deficits, 56 is normal.

imputed data sets as opposed to a
single data set.52 Ten imputations
w ere run, producing 10 im puted
data sets of the assessment variables.
The decision to run 10 imputations
was based on concepts from previ­
ous studies suggesting that 10 impu­
tations can provide sufficient effi­
ciency of the estimate.42-44'50'51
The next step was a K-means cluster­
ing algorithm run on each of the 10
im puted data sets to examine if par­
ticipants could be categorized into
relatively homogeneous groups
based on their initial assessment
scores. The K-means m ethod parti­
tioned participants into a cluster if
their respective variables (assess­
ment scores) w ere closest in dis­
tance to the center (overall mean) of
that particular cluster compared
w ith the other clusters.55 The vari­
ables used in the analysis included
the impairment- and activity-level
assessments listed previously, plus
the demographic variables of age,
race, sex, and help at home. Because
a K-means cluster analysis expects
the num ber of clusters to be speci­
fied prior to the analysis, 2-, 3-, 4-,
and 5-cluster solutions w ere
explored. Although each solution
was statistically feasible, the
4-cluster solution was ultimately cho­
sen to align with clinical constructs
(4 discharge recom m endations are
commonly made).43'55"57 Each analy­
sis assigned participants to a partic­
ular cluster and defined that cluster
based on the assessment and demo­
graphic variables analyzed. Once the
K-means cluster analysis was run on
each of the 10 im puted data sets, the
results w ere combined. Using the
most common cluster assignment
(mode) across the 10 imputations,
each participant was partitioned into
his or her final cluster. In addition,
each im putation produced 4 slightly
different clusters; therefore, the clus­
ter center for each of the 4 clusters
was averaged across all 10 imputa­
tions, creating the final cluster cen­
ters. Both within-imputation and
between-imputation variance also
w ere calculated to help with the
interpretation of the analysis.48'50 52

May 2015 Volume 95 Number 5 Physical Therapy ■ 713

D e s c rip tiv e D a ta A n a ly s is E x a m in in g S ta n d a r d iz e d A s s ess m en ts

F ig u re 2.
R e c o m m e n d a tio n fo r fu tu re re h a b ilita tio n services across all 4 clusters. (A) S um m ary o f discharge re c o m m e n d a tio n as a p e rcentage
o f each cluster. (B) S u m m a ry o f discharge re c o m m e n d a tio n as a perce n ta g e o f th e w h o le sam ple. D ischarge re co m m e n d a tio n s
in clu d e : h o m e w ith o u t services, h o m e w ith services, in p a tie n t re h a b ilita tio n fa c ility (IRF), o r skilled nu rsin g fa c ility (SNF).

Finally, the results of the cluster anal­ Results These results are contrasted with
ysis (ie, relatively homogeneous Figure 1 presents a flow chart of how cluster D, which contained the old­
groups based on the independent the 2,738 participants were identi­ est patients (final cluster center of 69
variables) were compared with the fied. Of these, 490 participants (18%) years) and had the greatest amount
therapy discharge recommendations were recommended by both physi­ of impairment, with the center
for future rehabilitation services. cal therapists and occupational ther­ defined as affected upper and lower
The percentage of people assigned apists to discharge home without extremity Motricity Index scores of
to each discharge recommendation services, 261 (10%) to discharge 38 and 42 (out of 100 points),
within each cluster was calculated. home with services (home health or respectively; maximal assist required
Percentages were compared across outpatient), 1,727 (63%) to dis­ on functional tasks; and positive
clusters using a chi-square analysis. charge to an IRF, and 260 (10%) to screens for severe dementia and
We anticipated that the cluster that discharge to an SNF. neglect. Overall, cluster A was least
centered on minimal or no deficits impaired based on assessment
would have a high percentage of par­ The K-means cluster analysis pro­ scores, followed by clusters B, C, and
ticipants referred to home with no duced 4 distinct clusters: A, B, C, and D, which was the most impaired. In
services. In contrast, the cluster that D. Table 1 presents the pooled final addition, the greatest proportion of
centered on the more severe deficits cluster centers (mean and standard the sample was allocated to cluster A
across the sensorimotor, cognition, deviation of cluster center for A, B, (n=901), followed by cluster B
and language domains might have C, and D across the 10 imputations) (n=8l4), cluster C (n=686), and
the highest percentage of partici­ and parameter estimates of the impu­ cluster D (n=337).
pants referred to an SNF. Clusters tations. Cluster A contained the
that centered on participants with youngest participants, with a final Assignment of participants to the 4
mild to moderate deficits might have cluster center for age of 58 years. clusters was compared with the actual
greater percentages of participants Cluster A had those with the least discharge recommendations made by
recommended to go home with ser­ amount of impairment on the stan­ the clinicians (home without services,
vices or to an IRF. dardized assessment battery, with home with services, IRF, or SNF). Fig­
the center defined as affected upper ure 2 shows the discharge recommen­
R o le o f t h e F u n d in g S o u rc e and lower extremity Motricity Index dation percentages across all 4 clus­
Funding was provided by the Barnes scores of 84 and 86 (out of 100 ters, expressed as the percentage per
Jewish Hospital Foundation and the points), respectively; modified inde­ cluster (Fig. 2A) and as a percentage of
Washington University McDonnell pendence or supervision on func­ the whole sample (Fig. 2B). In cluster
Center for Systems Neuroscience. tional activities; and a negative A, 50% of the participants were rec­
screen for dementia and neglect. ommended to go home without ser-

714 ■ Physical Therapy Volum e 95 N um ber 5 May 2015


Table 2.
C lin ic a l R e p re s e n ta tio n o f P a rtic ip a n ts in Each o f th e 4 C lu s te rs 0
C lu s te r A
Im p a ir m e n t, S e n s o rim o to r
• M o to r : fu ll u p p e r a n d lo w e r
e x tr e m ity m o v e m e n t a g a in s t
g r a v ity w ith m o d e ra te to
m a x im a l resistance
• S en sa tio n : lig h t to u c h in ta c t
Im p a ir m e n t, C o g n itio n
• D e m e n tia : n o t p re s e n t
• N e g le c t: n o t p re se n t
Im p a ir m e n t, L a n g u a g e
• N o t p re s e n t
A c tiv ity
• Basic A D L: m o d ifie d
in d e p e n d e n c e o r su p e rv is io n
• B alance: m in im a l t o m o d e ra te
im p a irm e n t
• W a lk in g : a m b u la te s a t fu ll
c o m m u n ity speeds
° C lusters are d e sc rib e d in g e n e ra l te rm s o f s o m e o f th e key im p a ir m e n t a n d a c tiv ity lim ita tio n d e fic its . A D L = a c tiv itie s o f d a ily liv in g .
vices, whereas 1% were recom­
mended to go to skilled nursing.
Clusters B, C, and D each had a large
proportion of individuals recom­
mended to go to IRF (74%-80%).
There was a difference in percentage
of recommendations across the clus­
ters (y2=1334, PC.001) that was
largely driven by the differences
between cluster A and clusters B, C,
and D. The data in Figure 2 indicate
that assessment results (severity based
on sensorimotor, cognitive, and lan­
guage deficits) and demographic vari­
ables were partially steering discharge
recommendations. To check that mul­
tiple imputation did not alter the
results, the analysis was re-run on the
nonimputed data. The resulting clus­
ters and comparison with discharge
recommendations were similar.
D is c u s s io n
This study provides new information
about the contributions of standard­
ized assessment scores to the post­
acute discharge rehabilitation ser­
vice recommendations made by
physical therapists and occupational
therapists for people poststroke.
M ay 2015
D e s c rip tiv e D a ta A n a ly s is E x a m in in g S ta n d a r d iz e d A s s e s s m e n ts
C lu s te r B
Im p a ir m e n t, S e n s o rim o to r Im p a ir m e n t , S e n s o rim o to r
• M o to r: fu ll u p p e r a n d lo w e r
e x tr e m ity m o v e m e n t a g a in s t
g ra v ity , s o m e a b le to take
m o d e ra te resistance
• S ensa tion: lig h t to u c h in ta c t
a n d im p a ire d
Im p a ir m e n t, C o g n itio n Im p a ir m e n t , C o g n itio n
• D e m e n tia : m in im a l
im p a irm e n t
• N e g le c t: m in im a l im p a irm e n t
Im p a ir m e n t, L a n g u a g e Im p a ir m e n t , L a n g u a g e
• M in im a l im p a irm e n t
A c tiv ity A c tiv ity
• Basic A D L: m in im a l to
m o d e ra te assistance
• Balance: m o d e ra te to m a x im a l
im p a irm e n t
• W a lk in g : u n a b le to a m b u la te
in d e p e n d e n tly
Through the use of a K-means clus­
tering algorithm, standardized assess­
ment scores from initial evaluation
plus demographic variables were
used to divide participants into 4
meaningful clusters. These 4 clusters
represent different levels of stroke
severity characterized by sensorimo­
tor, cognitive, and language deficits.
Physical therapist and occupational
therapist recommendations for post­
stroke rehabilitation services were
somewhat different across the clus­
ters, suggesting that standardized
assessments, in part, are guiding
poststroke acute care discharge rec­
ommendations for rehabilitation
services.
Although recovery poststroke is het­
erogeneous, multiple studies suggest
that general recovery of function can
be reasonably predicted in the first
few days after stroke.58-64 In the
majority of these studies, standard­
ized assessments were the founda­
tion of these prediction rules. The
K-means cluster analysis run in this
study supports this concept. Table 2
is a clinical representation of the
C lu s te r C C lu s te r D
Im p a ir m e n t , S e n s o rim o to r
• M o to r : u p p e r a n d lo w e r • M o to r : lim ite d u p p e r an d
e x tr e m ity m o v e m e n t b u t n o t lo w e r e x tr e m ity m o v e m e n t
fu ll ra n g e o f m o tio n • S ensa tion: lig h t to u c h
• S ensa tion: lig h t to u c h in ta c t im p a ire d
a n d im p a ire d
Im p a ir m e n t , C o g n itio n
• D e m e n tia : m o d e ra te • D e m e n tia : m a jo r im p a irm e n t
im p a irm e n t • N e g le c t: m a jo r im p a irm e n t
• N e g le c t: m in im a l im p a irm e n t
Im p a ir m e n t , L a n g u a g e
• M o d e ra te im p a irm e n t • M a jo r im p a irm e n t
A c tiv ity
• Basic A D L: m o d e ra te to • Basic A D L: m a x im a l assistance
m a x im a l assistance • B alance: m a jo r im p a irm e n t
• B alance: m a jo r im p a irm e n t • W a lk in g : u n a b le to a m b u la te
• W a lk in g : u n a b le t o a m b u la te in d e p e n d e n tly
in d e p e n d e n tly
types of participants who were clas­
sified in each of the 4 clusters. In this
figure, the scores from the mean
cluster centers have been trans­
formed into descriptors of a partici­
pant in each category. When the par­
ticipants were characterized by
impairments and activity limitations
across the sensorimotor, cognitive,
and language domains, 4 distinct
groups were present. Thus, informa­
tion from the standardized assess­
ments can quantify participants’ def­
icits into different levels of severity;
we expected that discharge recom­
mendations for additional rehabilita­
tion services would largely match
this pattern.
Discharge recommendations varied
somewhat across clusters, but not as
much as expected. There were indi­
viduals in cluster A who were recom­
mended to go to an IRF and large,
similar percentages in clusters B, C,
and D, who also were recommended
to go to an IRF, despite increasing
severity and other factors predictive
of poorer outcomes. Several reasons
may exist as to why clusters from the
V o lu m e 95 N um ber 5 Physical T h e ra p y ■ 715
 Descriptive Data Analysis Examining Standardized Assessments
standardized assessments do not
more uniformly align with discharge
recommendations. First, more ther­
apy has been shown to produce bet­
ter outcomes poststroke.65-67 Of the
possible discharge recommenda­
tions, an IRF offers the most therapy
per day (3 hours). It is possible that
clinicians refer the bulk of patients
with any amount of impairment or
activity limitation to an IRF to foster
the greatest opportunity for recov­
ery.68 Second, an IRF may be more
often recommended, anticipating
that if a patient is discharged home,
he or she may not ultimately receive
necessary services at a later point in
time. For example, when a patient is
discharged home with orders for ser­
vices, it may inherently be harder to
obtain those services (eg, calling,
scheduling, transportation, availabil­
ity of an appointment) compared
with if the patient was admitted to
an IRF. Finally, although the stan­
dardized assessments are adminis­
tered by clinicians, the score value of
the assessment and its relationship to
predictive models may not be com­
pletely understood or utilized by the
clinician when making discharge
recommendations. In addition, clini­
cians practicing in the acute care
environment do not necessarily see
the extent to which their patients
improve by the end of their rehabil­
itation, making it more difficult to
see the relationship between assess­
ment at the acute hospital stay and
final outcome. Thus, more education
about the utility of these measures to
the clinicians may be needed.
Study Limitations
Four limitations are important to
consider when interpreting these
results. The first is that the data came
from a clinical database with missing
data. The physical therapists and
occupational therapists have been
trained in the administration of the
assessments, were monitored for
consistency, and complete annual
competencies on the assessments.10
716 ■ Physical Therapy Volume 95
Although the clinicians strive to approach explains the higher per­
complete 100% of assessments, it is centage of overall IRF recommenda­
not always possible to administer all tions (largest group of participants)
of measures in a prescribed assess­ but does not explain why 74% to
ment battery in all circumstances in a 80% of individuals were still recom­
clinical setting. Use of multiple mended to go to IRF across clusters
imputation statistical methods to B, C, and D, which have varying lev­
limit the loss of data and to decrease els of deficits.
the introduction of selection bias is
continuing to grow in the litera­ The third limitation is the selection
ture,69-71 although it is still under­ of 4 clusters as part of the analysis.
utilized in rehabilitation studies. We selected 4 clusters to match the
Although we saw similar results number of discharge recommenda­
when run on the nonimputed data, tions, although other numbers of
we cannot completely rule out the clusters also were statistically feasi­
possibility that the imputation biased ble. It is possible that the true num­
our data in some unknown, unpre­ ber of clusters could be different
dictable way. from 4. Other acute care hospitals
may have different classifications of
A second limitation is the exclusion discharge recommendations (ie,
of 1,196 participants from the study more or less than 4). Our use of 4
due to disagreement between physi­ clusters might limit the generalizabil-
cal therapist and occupational thera­ ity of these results to facilities using
pist discharge recommendations. different recommendations.
For 385 participants, physical thera­
pists and occupational therapists did The final limitation is that the dis­
not agree on the discharge location charge recommendation may have
(home, IRF, SNF), and for 811 partic­ been influenced by factors not
ipants, physical therapists and occu­ included in this analysis. The dis­
pational therapists did not agree on charge recommendation is made at
whether the participant should the time of the initial evaluation,
receive services at home. However, when the clinician knows the results
each discipline assesses somewhat of his or her own assessment, but
different domains, so it is not surpris­ may have varying amounts of infor­
ing that differences in discharge rec­ mation about the patient’s history
ommendation exist. For example, a and availability of family support.
participant with a score of 45 on the Additional factors such as clinical
Berg Balance Scale and minimal information from other disciplines,
assist to walk may receive the recom­ medication, medical needs, or insur­
mendation from the physical thera­ ance could and should have
pist to discharge home with services. informed the discharge recommen­
If this participant has significant cog­ dation. It is unlikely, however, that
nitive dysfunction, the occupational across the 2,738 participants, these
therapist may recommend an IRF. As potential confounders would have
the recommendation for future ser­ outweighed the clinician’s assess­
vices was the same for the majority ment of impairment or activity limi­
of patients, the decision was made to tations so much as to modify or deny
exclude participants where physical needed services.
therapists and occupational thera­
pists did not agree. Exclusion was Future Studies
done to strengthen the analysis by Rehabilitation poststroke has the
eliminating some of the variability. In potential to save many people from
excluding participants, however, disability,72'73 with the goal of return­
bias may have been introduced. This ing people to home and community
Number 5 May 2015

life with as much independence as
possible.65 For patients to receive
the maximum benefit from rehabili­
tation, the clinician must be able to
determine additional rehabilitation
services that are needed and the best
setting for their delivery. As high­
lighted in a recent study,68 the pre­
diction of discharge destination is a
fundamental part of the clinician’s
role in acute care, and the predicted
discharge recommendation is a cen­
tral driver for all future rehabilita­
tion care and the quality of that care
that a patient poststroke receives.
Therefore, our study is an important
first step in examining how dis­
charge recommendations are made
and the types of information clini­
cians are utilizing to make these deci­
sions. Future studies are needed to
examine additional factors that may
be contributing to the discharge rec­
ommendations made as well as to
further probe the utility of the stan­
dardized assessments in clinical deci­
sion making.
It is also important to determine if
the 4 resultant clusters in this analy­
sis could be replicated at other insti­
tutions and if similar patterns exist in
physical therapist and occupational
therapist discharge recommenda­
tions. This information would fur­
ther increase the generalizability of
these results. In addition, this study
analyzed only the recommendation
for future discharge services, not
where participants actually went or
long-term outcomes. It would be
important to compare the recom­
mendation for services and the types
of services that the patient actually
received.
In conclusion, use of standardized
assessment in clinical rehabilitation
is continuing to grow and is becom­
ing a mechanism for prediction of
patient outcomes. These assess­
ments are quick and efficient and
can objectively classify deficits of
impairment and activity limitations
M a y 20 15
D e s c rip tiv e D a ta A n a ly s is E x a m in in g S ta n d a r d iz e d A s s e s s m e n ts
across the sensorimotor, cognitive,
and language domains. These results
suggest that standardized assessment
scores partially guide poststroke
acute care discharge recommenda­
tions for additional poststroke reha­
bilitation services.
D r Bland, Ms W h its o n , D r C o n n o r, D r Fuce-
to la , D r C arter, D r C o rb e tta , and D r Lang
p ro v id e d c o n c e p t/id e a /re s e a rc h de sig n. D r
B land, D r C o n n o r, D r C o rb e tta , and D r Lang
p ro v id e d w ritin g . D r Bland, D r Fucetola, and
D r Lang p ro v id e d data c o lle c tio n . D r Bland
and D r Lang p ro v id e d da ta analysis. D r Bland
and D r C o n n o r p ro v id e d p ro je c t m a n a g e ­
m e n t. D r C o rb e tta and D r Lang p ro v id e d
fu n d p ro c u re m e n t. M s W h its o n and Ms H ar­
ris p ro v id e d p a rticip a n ts. Ms W h itso n , Ms
Harris, M r E dm iaston, an d D r Lang p ro vid e d
fa c ilitie s /e q u ip m e n t. Ms W h itso n , Ms Harris,
an d D r C o n n o r p ro v id e d in s titu tio n a l lia i­
sons. M s Harris, M r E dm iaston, D r C o n n o r,
D r Fucetola, and D r C a rte r p ro v id e d c o n su l­
ta tio n (in c lu d in g review of m a n u scrip t
before subm issio n). T he a u thors th a n k th e
staff, a d m in is tra to rs, and da ta e n try te a m at
Barnes Jewish H ospital, The R e h a bilitatio n
In s titu te o f St Louis, and W a sh in g to n U n iver­
sity fo r th e ir e nthusiasm , s u p p o rt, and efforts
on this p ro je ct.
F u n d in g w as p ro v id e d b y th e Barnes Jewish
H ospital F o u n d a tio n and th e W a s h in g to n
U n iversity M c D o n n e ll C e n te r fo r Systems
N euroscience.
D O I: 1 0 .2 5 2 2 /p tj.2 0 1 4 0 3 4 7
R eferences
1 Go AS, Mozaffarian D, Roger VL, et al;
American Heart Association Statistics Com­
mittee and Stroke Statistics Subcommittee.
Heart disease and stroke statistics—2014
update: a report from the American Heart
Association. Circulation. 20l4;129:e28-
e292.
2 Bayley MT, Hurdowar A, Richards CL, et al.
Barriers to implementation of stroke reha­
bilitation evidence: findings from a multi-
site pilot project. Disabil Rehabil. 2012;
34:1633-1638.
3 Deyo RA, Patrick DL. Barriers to the use of
health status measures in clinical investi­
gation, patient care, and policy research.
Med Care. 1989;27(3 suppl):S254-S268.
4 Jette DU, Halbert J, Iverson C, et al. Use of
standardized outcome measures in physi­
cal therapist practice: perceptions and
applications. Phys Ther. 2009;89:125-135.
5 Potter K, Fulk GD, Salem Y, Sullivan J.
Outcome measures in neurological physi­
cal therapy practice, part 1: making sound
decisions. JNPT. 2011;35:57-64.
V o lu m e 95
6 Stevens JG, Beurskens AJ. Implementation
of measurement instruments in physical
therapist practice: development of a tai­
lored strategy. Phys Ther. 2010;90:953-
961
.
7 Swinkels RA, Van Peppen RP, Wittink H,
et al. Current use and barriers and facilita­
tors for implementation of standardised
measures in physical therapy in the Neth­
erlands. BMC Musculoskelet Disord. 2011;
12 : 106 .
8 Van Peppen RP, Maissan FJ, Van Genderen
FR, et al. Outcome measures in physio­
therapy management of patients with
stroke: a survey into self-reported use, and
barriers to and facilitators for use. Phys-
iotber Res Int. 2008;13:255-270.
9 Wedge FM, Braswell-Christy J. Brown CJ,
et al. Factors influencing the use of out­
come measures in physical therapy prac­
tice. Physiother Theory Pract. 2012;28:
119-133.
10 Lang CE, Bland MD, Connor LT, et al.The
brain recovery core: building a system of
organized stroke rehabilitation and out­
comes assessment across the continuum
of care. JNPT. 2011;35:194-201.
11 Kinney CL, Eikenberry iMC, Noll SF, et al.
Standardization of interdisciplinary clini­
cal practice and assessment in stroke reha­
bilitation. Int J Phys Med Rehabil. 2013;
1:7.
12 Moore JL, Raad J, Ehrlich-Jones L, Heine-
mann AW. Development and use of a
knowledge translation tool: the rehabilita­
tion measures database. Arch Phys Med
Rehabil. 2014;95:197-202.
13 Shields RK, Leo KC, Miller B, et al. An
acute care physical therapy clinical prac­
tice database for outcomes research. Phys
Ther. 1994;74:463-470.
14 Garland AF, Kruse M, Aarons GA. Clini­
cians and outcome measurement: what’s
the use? J Behav Health Serv Res. 2003;
30:393-405.
15 Vogel AP, Maruff P, Morgan AT. Evaluation
of communication assessment practices
during the acute stages post stroke. J Eval
Clin Pract. 2010;16:1183-1188.
16 World Health Organization. International
Classification o f Functioning, Disability
and Health (ICF). 2002. Available at:
http ://www. w ho.int/classification/icf/en/.
Accessed June 18, 2014.
17 Harris PA, Taylor R, Thielke R, et al.
Research electronic data capture (RED-
Cap): a metadata-driven methodology and
workflow process for providing transla­
tional research informatics support.
J B io m e d Inform. 2009;42:377-381.
18 Bland MD, Sturmoski A, Whitson M, et al.
Prediction of discharge walking ability
from initial assessment in a stroke inpa­
tient rehabilitation facility population.
Arch Phys Med Rehabil. 2012;93:1441-
1447.
19 Bland MD, Sturmoski A, Whitson M, et al.
Clinician adherence to a standardized
assessment battery across settings and dis­
ciplines in a poststroke rehabilitation pop­
ulation. Arch Phys Med Rehabil. 2013;94:
1048-1053el.
Num ber 5 Physical T h e ra p y ■ 717
D e s c rip tiv e D a ta A n a ly s is E x a m in in g S ta n d a r d iz e d A s s ess m en ts
20 Collin C, Wade D. Assessing motor impair­
ment after stroke: a pilot reliability study.
J Neurol Neurosurg Psychiatry. 1990;53:
576-579.
21 Veerbeek JM, Van Wegen EE, Harmeling-
Van der Wei BC, Kwakkel G; EPOS Inves­
tigators. Is accurate prediction of gait in
nonambulatory stroke patients possible
within 72 hours poststroke? The EPOS
study. Neurorehabil Neural Repair. 2011;
25:268-274.
22 Sullivan JE, Hedman LD. Sensory dysfunc­
tion following stroke: incidence, signifi­
cance, examination, and intervention. Top
Stroke Rehabil. 2008;15:200-217.
23 Winward CE, Halligan PE, Wade DT. Cur­
rent practice and clinical relevance of
somatosensory assessment after stroke.
Clin Rehabil. 1999;13:48-55.
24 Berg KO, Wood-Dauphinee S, Williams JI.
The Balance Scale: reliability assessment
with elderly residents and patients with an
acute stroke. Scand J Rehabil Med. 1995;
27:27-36.
25 Berg KO, Wood-Dauphinee S, Williams JI,
Maki B. Measuring balance in the elderly:
validation of an instrument. Can J Public
Health. 1992. 83(suppl 2):S7-S11.
26 Dean CM, Richards CL, Malouin F. Walk­
ing speed over 10 metres overestimates
locomotor capacity after stroke. Clin
Rehabil. 2001;15:415-421.
27 Dobkin BEI. Short-distance walking speed
and timed walking distance: redundant
measures for clinical trials? Neurology.
2006;66:584-586.
28 Finch E, Brooks D, Stratford PW, Mayo NE.
Physical Rehabilitation Outcome Mea­
sures: A Guide to Enhanced Clinical Deci­
sion Making. 2nd ed. Hamilton, Ontario,
Canada: Lippincott Williams & Wilkins;
2002.
29 Schmid A, Duncan PW, Studenski D, et al.
Improvements in speed-based gait classifi­
cations are meaningful. Stroke. 2007;38:
2096-2100.
30 Katzman R, Brown T, Fuld P, et al. Valida­
tion of a short Orientation-Memory-
Concentration Test of cognitive impair­
ment. Am ] Psychiatry. 1983; 140:734-
739.
31 Seshadri S, Wolf PA, Beiser A, et al. Stroke
risk profile, brain volume, and cognitive
function: the Framingham Offspring
Study. Neurology. 2004;63:1591-1599.
32 Tombaugh TN. Trail Making Test A and B:
normative data stratified by age and edu­
cation. Arch Clin Neuropsychol. 2004; 19:
203-214.
33 Rengachary J, d’Avossa G, Sapir A, et al. Is
the Posner Reaction Time Test more accu­
rate than clinical tests in detecting left
neglect in acute and chronic stroke? Arch
Phys Med Rehabil. 2009;90:2081-2088.
34 Mesulam M. Principles o f Behavioral and
Cognitive Neurolog)’. 2nd ed. Cambridge,
MA: Oxford University Press; 2000.
35 Mesulam M. Principles o f Behavioral
Neurology. Philadelphia, PA: FA Davis Co;
1985.
718 ■ Physical Therapy Volum e 95 Num ber 5
36 Calero MD, Arnedo ML, Navarro E, et al.
Usefulness of a 15-item version of the Bos­
ton Naming Test in neuropsychological
assessment of low-educational elders with
dem entia./ Gerontol B Psychol Sci Soc Sci.
2002;57:P187-P191.
37 Goodglass H, Kaplan E, Barresi B. Boston
Diagnostic Aphasia Examination. 3rd
ed. Philadelphia, PA: Lippincott, Williams
& Wilkins; 2001.
38 Lopez MN, Arias GP, Hunter MA, et al. Bos­
ton Naming Test: problems with adminis­
tration and scoring. Psychol Rep. 2003;92:
468-472.
39 Hsueh IP, Lin JH, Jeng JS, Hsieh CL. Com­
parison of the psychometric characteris­
tics of the Functional Independence Mea­
sure, 5-item Barthel Index, and 10-item
Barthel Index in patients with stroke.
J Neurol Neurosurg Psychiatry. 2002;73:
188-190.
40 Keith RA, Granger CV, Hamilton BB, Sher-
win FS. The Functional Independence
Measure: a new tool for rehabilitation. Adv
Clin Rehabil. 1987;1:6-18.
41 Linacre JM, Heinemann AW, Wright BD,
et al. The structure and stability of the
Functional Independence Measure. Arch
Phys Med Rehabil. 1994;75:127-132.
42 Barzi F, Woodward M. Imputations of
missing values in practice: results from
imputations of serum cholesterol in 28
cohort studies. Am f Epidemiol. 2004; 160:
34-45.
43 Basagana X, Barrera-Gomez J, Benet M,
et al. A framework for multiple imputation
in cluster analysis. Am J Epidemiol. 2013;
177:718-725.
44 Kneipp SM, McIntosh M. Handling missing
data in nursing research with multiple
imputation. Nurs Res. 2001;50:384-389.
45 McCleary L. Using multiple imputation for
analysis of incomplete data in clinical
research. Nurs Res. 2002;51:339-343.
46 He Y. Missing data analysis using multiple
imputation: getting to the heart of the mat­
ter. Circ Cardiovasc Qual Outcomes.
2010;3:98-105.
47 Meng X. Multiple-imputation inferences
with uncongenial sources of input. Stat
Sci. 1994;9:538-573.
48 Rubin DB. Multiple imputation after 18+
years .J Am Stat Assoc. 1996;91:16.
49 Donders AR, van der Heijden DC, Stijnen
T, Moons KG. Review: a gentle introduc­
tion to imputation of missing values./ Clin
Epidemiol. 2006;59:1087-1091.
50 Rubin DB. Multiple Imputation fo r Non­
response in Surveys. New York, NY: John
Wiley & Sons Inc; 1987:258.
51 Schafer JL, Graham JW. Missing data: our
view of the state of the art. Psychol Meth­
ods. 2002;7:147-177.
52 Baraldi AN, Enders CK. An introduction to
modern missing data analyses. J Sch Psy­
chol. 2010;48:5-37.
53 Aufman EL, Bland MD, Barco PP, et al. Pre­
dictors of return to driving after stroke.
Am J Phys Med Rehabil. 2013;92:627-
634.
54 Schafer JL. Analysis o f Incomplete Multi­
variate Data. London, United Kingdom:
Chapman & Hall/CRC Press; 1997.
55 Moffroid MT, Haugh LD, Henry SM, Short
B. Distinguishable groups of musculoskel­
etal low back pain patients and asymptom­
atic control subjects based on physical
measures of the NIOSH Low Back Atlas.
Spine (Phila Pa 1976). 1994/9:1350-
1358.
56 Armstrong JJ, Zhu M, Hirdes JP, Stolee P.
K-means cluster analysis of rehabilitation
service users in the Home Health Care Sys­
tem of Ontario: examining the heteroge­
neity of a complex geriatric population.
Arch Phys Med Rehabil. 2012;93:2198-
2205.
57 Steinley D. K-means clustering: a half-
century synthesis. B rJ Math Stat Psychol.
2006;59(pt l):l-3 4 .
58 Jongbloed L. Prediction of function after
stroke: a critical review. Stroke. 1986;17:
765-776.
59 Jorgensen HS, Nakayama H, Raaschou HO,
Olsen TS. Recovery of walking function in
stroke patients: the Copenhagen Stroke
Study. Arch Phys Med Rehabil. 1995;76:
27-32.
60 Kwakkel G, Veerbeek JM, Harmeling-Van
der Wei BC, et al; Early Prediction of Func­
tional Outcome After Stroke (EPOS) Inves­
tigators. Diagnostic accuracy of the Bar­
thel Index for measuring activities of daily
living outcome after ischemic hemi­
spheric stroke: does early poststroke tim­
ing of assessment matter? Stroke. 2011;42:
342-346.
61 Loewen SC, Anderson BA. Predictors of
stroke outcome using objective measure­
ment scales. Stroke. 1990;21:78-81.
62 Veerbeek JM, Kwakkel G, Van Wegen EE,
et al. Early prediction of outcome of activ­
ities of daily living after stroke: a system­
atic review. Stroke. 2011;42:1482-1488.
63 Veerbeek JM, Van Wegen EE, Harmeling-
Van der Wei BC, Kwakkel G; EPOS Inves­
tigators. Is accurate prediction of gait in
nonambulatory stroke patients possible
within 72 hours poststroke? the EPOS
study. Neurorehabil Neural Repair. 2011;
25:268-274.
64 Rymer MM, Anderson CS, Harada M, et al.
Stroke service: how can we improve and
measure outcomes? Consensus summary
from a global stroke forum. Acta Neurol
Scand. 2014;130:73-80.
65 Kwakkel G, Kollen B, Lindeman E. Under­
standing the pattern of functional recov­
ery after stroke: facts and theories. Restor
Neurol Neurosci. 2004;22:281-299.
66 Veerbeek JM, Van Wegen EE, Van Peppen
RP, et al. What is the evidence for physical
therapy poststroke? A systematic review
and meta-analysis. PLoS One. 2014;9:
e87987.
67 Lohse KR, Lang CE, Boyd LA. Is more bet­
ter? Using metadata to explore dose-
response relationships in stroke rehabilita­
tion. Stroke. 2014;45:2053-2058.
M ay 2015
 D e s c rip tiv e D a ta A n a ly s is E x a m in in g S ta n d a r d iz e d A s s e s s m e n ts

68 Luker JA, Bernhardt J, Grimmer KA,
Edwards I. A qualitative exploration of dis­
charge destination as an outcome or a
driver of acute stroke care. BMC Health
Serv Res. 2014; 14:193.
69 Castillo RC, Wegener ST, Heins SE, et al;
LEAP Study Group. Longitudinal relation­
ships between anxiety, depression, and
pain: results from a two-year cohort study
of lower extremity trauma patients. Pain.
2013;154:2860-2866.
70 Latham NK, Harris BA, Bean JF, et al. Effect
of a home-based exercise program on
functional recovery following rehabilita­
tion after hip fracture: a randomized clin­
ical trial. JAMA. 2014;311:700-708.
71 Vergouw D, Heymans MW, van der Windt
DA, et al. Missing data and imputation: a
practical illustration in a prognostic study
on low back pain. JM anipulative Physiol
Ther. 2012;35:464-471.
72 Donnan GA, Davis SM, Levi CR. Strategies
to improve outcomes after acute stroke.
Med J Aust. 2003;178:309-310.
73 Gilligan AK, Thrift AG, Sturm JW, et al.
Stroke units, tissue plasminogen activator,
aspirin and neuroprotection: which stroke
intervention could provide the greatest
community benefit? Cerebrovasc Dis.
2005;20:239-244.

May 2015 Volume 95 Number 5 Physical Therapy ■ 719

Copyright of Physical Therapy is the property of American Physical Therapy Association and
its content may not be copied or emailed to multiple sites or posted to a listserv without the
copyright holder's express written permission. However, users may print, download, or email
articles for individual use.