Abstract
Background Providing patients with optimal discharge disposition and follow-up services could prevent unplanned readmissions. Despite their qualifications, physical therapists are rarely represented on the interdisciplinary team.
Objective This study aimed to determine the relationship between the participation of physical therapists in interdisciplinary discharge rounds and readmission rates.
Methods In this retrospective observational study, patients discharged by 2 interdisciplinary teams with or without a physical therapist's participation were followed for 5 months. Adherence to the physical therapist's recommendations for follow-up services and unplanned 30-day readmissions were tracked. Multiple logistic regression and random forest models were used to determine factors contributing to 30-day readmission rates.
Results The odds of 30-day readmissions were 3.78 times greater when a physical therapist was absent from the interdisciplinary team compared with the odds of 30-day readmissions when a physical therapist participated in the interdisciplinary team. In addition, the odds of 30-day readmission for patients discharged to their home were 2.47 times greater than those who were not discharged to their home. An increased lack of postdischarge services was noted when a physical therapist was not included in the interdisciplinary team.
Limitations The nonrandom selection of patients into groups, the small sample size, and the inability to adjust risk for unknown factors (eg, medical diagnoses, comorbidities, funding, and functional measures) limited interpretation of the results.
Conclusion Significantly higher readmission rates were noted for patients whose interdisciplinary team did not have a physical therapist and for those patients who were discharged to their home. These preliminary findings suggest that discharge from the acute care setting is an elaborate process and should be designed carefully. In order to identify the optimal discharge process, future research should account for patient complexities in addition to the composition of the interdisciplinary discharge team.
Acute care hospitals have made significant efforts toward increasing patient satisfaction and quality of care while decreasing health care costs.1 Although patient satisfaction is crucial in determining the efficacy of rendered services, the commonly used outcome measure to determine the quality of patient care is the unplanned 30-day readmission rate.2–4 Lower readmission rates have been related to increased patient satisfaction.3 Lower readmission rates also result in up to 34% lower costs for hospital utilization and outpatient care within 30 days of discharge.5 In addition, the Centers for Medicaid and Medicare Services (CMS) uses the 30-day readmission rate to determine hospital performance and payment adjustments.6 As a result, numerous studies have investigated the process of discharge planning to determine the most effective processes for minimizing readmission rates.2,7–9
The ultimate goal of discharge planning is to identify the optimal location and services that a patient requires in order to continue recovery. In the majority of health care systems, discharge planning in an acute care environment begins shortly after admission. Although there are many variations (eg, the health care disciplines involved) to the customized discharge plan, an interdisciplinary approach is a common element across each practice.10–13 The interdisciplinary approach results in increased communication, which improves staff awareness and streamlines discharge planning.2 For example, Evans and Hendricks14 found that readmission rates and length of stay following readmission were significantly decreased when geriatric patients were assigned to an interdisciplinary discharge team rather than a standard discharge team. In another study,10 increased communication across medical teams through a trained coordinator significantly increased patient satisfaction and reduced length of stay.
Overall, the existing literature delineates the role of different disciplines for coordinated discharge planning. These disciplines include registered nurses,15,16 clinical case managers,17,18 social workers,9–21 and physicians.22–24 Despite ample evidence regarding unique skills of physical therapists in the acute care setting,25–27 their role in discharge planning is less clear.
Physical therapists possess sufficient education and skills to draw out valid conclusions and form appropriate clinical reasoning.25,27,28 The foundation of the clinical reasoning formed by acute care physical therapists involves critical elements that can be used “dynamically” to achieve the optimal discharge disposition of patients.29 Physical therapists have a direct role in the evaluation and treatment of functional limitations that commonly occur with hospitalization.25,26 With this knowledge, physical therapists have a direct role in educating patients, families, and other health care professionals regarding follow-up services and equipment needed for the next level of care.1 Physical therapists can effectively communicate with other disciplines30 and exceed their job requirements to ensure patient welfare and satisfaction.31 These findings justify a potential role for physical therapists in providing discharge recommendations in the acute setting, but currently there is insufficient evidence regarding their role in the interdisciplinary team.
To our knowledge, only one study28 has investigated the role of physical therapists in interdisciplinary discharge care. The study by Smith et al28 demonstrated that recommendations by a physical therapist could have a direct impact on reducing readmission rates. The study was carried out in an acute care level 1 trauma center. All patients within a 4-week period with a physical therapy evaluation order were included in this study. In the study by Smith et al,28 a practice management coordinator reviewed the physical therapists' discharge recommendations, which were made at the top of every evaluation, and subsequent progress notes in their electronic documentation. After reviewing documents from all disciplines, the practice management coordinators then decided whether additional forms of communication, such as interdisciplinary meetings, were needed. This process varied based on patient complexity, the hospital unit involved, and the assigned care coordinator. Smith et al28 noted the variability of the communication type between disciplines for discharge planning was a limitation of their research. Despite such variability, it was reported that, when the discharge plan did not match the recommendations of the physical therapist, a patient was 2.9 times more likely to be readmitted within 30 days.
The purpose of this preliminary study was to determine the relationship between the participation of physical therapists in interdisciplinary discharge teams and hospital readmission rates. The results of this study will contribute to the development of strategies for appropriate discharge planning in the acute setting, which may help to reduce 30-day readmission rates and improve quality of care. Based on the literature, we hypothesized that a physical therapist's presence on the interdisciplinary discharge team will increase consistency between their recommendations and the implemented discharge plan. Furthermore, we hypothesized that when a physical therapist is directly involved in discharge decision making, 30-day readmission rates are decreased. The physical therapist's determination of a patient's functional level and needs can provide perspective that can further optimize the existing discharge plan.
Method
This preliminary study was performed utilizing electronic records from the patients at a level 1 trauma hospital within a county health system. This location was selected due to the investigators' assignments and accessibility to resources as neurological physical therapy residents. Approval from the institutional review board was attained with an exemption from the consent procedure. In order to address the objectives of this study, the investigators identified 2 interdisciplinary discharge teams that operated with and without the participation of a physical therapist (physical therapist participation and physical therapist absent groups, respectively) at the level 1 trauma hospital. During the study period, the existing discharge process had a standardized interdisciplinary format for only 3 particular services. The interdisciplinary teams of the general surgery and neurosurgery services had a combined weekly team meeting that included physical therapists and became the physical therapist participation group. The neurology service also had a weekly interdisciplinary meeting that did not include a physical therapist, and this service became the physical therapist absent group. The groups, therefore, were not randomly assigned. Both teams involved the consistent presence of case manager, social worker, charge nurse, dietitian, and medical resident. Furthermore, both teams had weekly meetings in order to coordinate care and implement a discharge plan. Similar to the study conducted by Smith et al,28 the clinical case manager contacted representatives from any disciplines after discharge rounds if additional information were needed. No additional interdisciplinary meetings were called to obtain the required information.
The process of physical therapy consultation, evaluation, treatment, and documentation of the discharge recommendation in the current study also was similar to that of Smith et al.28 At the time of this study, physical therapist involvement in the discharge planning was initiated with an electronic consultation by the medical or surgical team. The physical therapy visit entailed the same examination, evaluation, intervention, and re-examination as Smith et al.28 Physical therapists included discharge recommendations in the electronic medical record in the first line of their evaluation or progress note.
In the physical therapist absent group, the interdisciplinary team met weekly to determine the discharge plan. Physical therapists were not represented in this meeting, and there was no formalized contact between the physical therapist treating a patient and the interdisciplinary team. Per hospital protocol, the clinical case manager in the physical therapist absent group identified the physical therapist's discharge recommendations from the evaluation or progress notes in the electronic medical record. The treating physical therapists for each patient were tasked with contacting the case manager or physician to discuss the patient's needs. The case manager documented each meeting in the electronic medical record. Although the interdisciplinary meetings were intended to complete discharge planning, the medical doctors ultimately determined the discharge plan, which was then coordinated by case management and social work.
In the physical therapist participation group, interdisciplinary rounds took place once a week. The morning of rounds, each primary physical therapist completed a form detailing current functional status and discharge recommendations for each patient seen in the physical therapist participation group. This information was brought to the rounds meeting, which consisted of 1 or 2 representatives from the case management, social work, nursing, and dietary services, as well as the medical residents for each service. The case manager presented each patient, who was then discussed by the team. The participating physical therapist only provided input on patients with physical therapy orders. If information on a patient was not provided by the primary physical therapist, the electronic medical record was accessed immediately to examine the primary physical therapist's documentation for discharge recommendations. At least one physical therapist representative participated in all round meetings during the study period. During the first 2 months of data collection, 2 neurological physical therapy residents attended the rounds meeting (Z.K., A.E.). Three staff physical therapists with more than 3 years of acute care experience at the hospital underwent training by the residents detailing information discussed in rounds. In subsequent months, the trained therapists rotated monthly to attend rounds.
The goal of the interdisciplinary discharge team was to discuss and finalize discharge planning. Discussion included all aspects of discharge planning related to each discipline. In the physical therapist participation group, the physical therapist would discuss various issues, including, but not limited to, functional status and safety for discharge home, level of assistance needed, durable medical equipment (DME) needs, and follow-up rehabilitation services needed. Clinical case management coordinated requests for referrals from physicians as needed for home or outpatient physical therapy. The representing physical therapist also facilitated the communication with primary physical therapist regarding any concerns or needs for further assessment or documentation by serving as the primary contact person.
The study followed patients receiving care by neurology, neurosurgery, and general surgery services who also received physical therapy between December 2013 and May 2014. Inclusion criteria included patients with a referral to physical therapy for consultation. The patients must have been present in the hospital for at least one interdisciplinary rounds meeting. Patients were excluded if they did not have a physical therapy consultation, were discharged prior to rounds, were discharged prior to the physical therapy consultation, refused physical therapy evaluation, or if they died before a 30-day readmission.
For both the physical therapist participation and physical therapist absent groups, the investigators updated the patient list weekly through the secure electronic medical record system. Weekly discharges were tracked for both groups. The physical therapists' final discharge recommendations were determined via the electronic medical records. Thereafter, electronic discharge notes placed by physicians, case managers, or social workers were used to identify the actual discharge location and referrals. These findings were used to determine match versus mismatch status between recommendations. If actual discharge location and referrals placed were the same as the physical therapist's recommendations, the status was deemed a match. If discharge location was different, or if recommended referrals for further rehabilitative services were not placed, the status was deemed a mismatch. A mismatch for the recommended discharge disposition was further investigated by determining the underlying reason behind the mismatch. See Table 1 for operational definitions of “match” and “mismatch.” Eight main categories of mismatch were determined according to common experience of the investigators (Tab. 2).
Operational Definitions of Terminology Used for Discharge Planning and Readmission
Reasons for Mismatch Between Recommended and Actual Discharge Disposition
In order to track readmission rates, each patient also was followed for 30 days after discharge to determine any unplanned readmissions through the hospital system. Planned readmissions were not included in the analysis. Emergency department visits without admission were not considered in this study.
Data Analysis
All data were organized using Microsoft Excel 2011 (Microsoft Corp, Redmond, Washington) and statistical analysis was performed using SAS software (version 9.4, SAS Institute Inc, Cary, North Carolina) and R software (http://www.r-project.org). Descriptive analysis was used to summarize data including the frequency of discharge disposition, match and mismatch frequency, and the reason behind mismatch (Tabs. 1 and 2). The explanatory variables (covariates) included: group (physical therapist participation, physical therapist absent) and discharge disposition (home vs inpatient facility). The control variables in the model included the length of stay (in days) in acute care, sex, age, and adherence status (match versus mismatch). A significance level of .05 was used for all analyses. Given the binomial response variable (30-day readmission: yes=1, no=0) and the 6 explanatory variables, a multiple logistic regression model was used for analysis.
Furthermore, as an alternative and confirmatory approach, a classification tree-based model was also fit. Classification trees are computer intensive (machine learning) methods for constructing prediction models from data. A tree is built by recursively partitioning the data using a “greedy” algorithm that yields a simple prediction model within each partition. Consequently, the partitioning can be viewed graphically as a decision tree. The word “greedy” is used because splits are chosen on the explanatory (or control) variables to minimize misclassification error, among all variables and potential splits within each variable. The introductory book on statistical learning by James et al32 is an excellent resource. Classification tree models are useful in capturing nonlinear (interactive) behavior among covariates, they can fit both continuous and factor covariates, and they have the added benefit of providing a simple way to summarize the data structure. The classification tree can be further improved by an ensemble method called random forest, which essentially “votes” on readmission status through “majority rule” models by building many tree models into a forest. Such an approach also helps to reduce variance of single tree and improves prediction accuracy. This approach also allows for accessing variable importance, because each tree in the forest applies the “greedy algorithm” to a slightly perturbed data set and available explanatory variables (using bootstrap samples).
Results
Three hundred ninety-eight patients were followed: 250 patients belonged to the physical therapist participation group, and 148 belonged to the physical therapist absent group. Of these patients, 27 and 11 patients were eliminated from the physical therapist participation and physical therapist absent groups, respectively, because they did not meet the inclusion criteria. As a result, 223 and 137 patients from the physical therapist participation and physical therapist absent groups, respectively, were included in the data analysis. Group characteristics and the prevalence of disposition recommendations are presented in Table 3.
Characteristics of Physical Therapist Absent and Physical Therapist Participation Groups
Readmission
Multiple logistic regression analysis indicated that group (physical therapist absent or physical therapist participation) and discharge disposition were the only significant predictive factors for readmission (Tab. 4). The odds of readmission were 3.78 times greater (278% increase in odds) for patients in the physical therapist absent group compared with those in the physical therapist participation group, while controlling for the other variables in the model. The covariate of discharge disposition also had a significant effect on readmission. The odds of 30-day readmission for patients discharged to their home were 2.47 times greater (147% increase in odds) than for patients who were discharged to other inpatient facilities, while controlling for other variables (Tab. 4). Other factors did not have a statistically significant predictive value for readmission.
Analysis of Maximum Likelihood Estimates for the Full Logistic Regression Model Related to Odds of Readmission
Results from the confirmatory classification tree-based model also indicated that physical therapist participation and discharge disposition were the 2 most important covariates for percent correct readmission classification. See Figure 1 for the complete decision tree, which was built using all covariates (but did not find sex useful for splitting). Simply put, patients were less likely to be readmitted if they belonged to the physical therapist participation group compared with the physical therapist absent group. It is noteworthy that physical therapist participation is the root node, and the split to the left creates a terminal leaf so that 201/223 or approximately 90% of patients in the physical therapist participation group did not experience 30-day readmissions. The next important covariate was discharge disposition, which only recursively splits on the physical therapist absent group. As shown in Figure 1, 47/59 (80%) of patients in the physical therapist absent group with disposition of “inpatient” did not experience readmission within 30 days after discharge. As we move farther and farther down the tree, fewer and fewer patients are being partitioned and classified. It is also interesting to note that the “greedy” algorithm found the splits for length of stay at 10.5 days and for age at 48.5 years. For example, the left terminal node states that 10/17 (59%) of patients who were in the physical therapist absent group, with disposition of inpatient, with matching adherence, with a length of stay of 10.5 days or more, and who were 48.5 years of age or older did not experience readmission. The level of importance of the aforementioned variables was further highlighted by the random forest analysis that is depicted in Figure 2, which further supports physical therapist group and discharge disposition as important factors related to readmission. Note that Figure 1 does not directly relate to either Figure 2 or logistic regression. Logistic regression, classification trees, and random forests yield consistent and compelling findings related to the links between physical therapist presence in the discharge decision making and disposition and the odds of readmission.
Classification tree analysis. The figure starts at the root of the tree related to the variable group. This node terminates on the left. The remaining patients are then partitioned by other variables.
A summary of the random forest analysis, including variable importance. The x axis depicts the percentage of variable importance rescaled to 35% for an easier depiction, where the sum of all variable importance equals 100%.
Descriptive Analysis
Group characteristics are presented in Table 3 and indicate differences in the proportion of patients with home discharge disposition (physical therapist absent group=50%, physical therapist participation group=66%), length of stay <10.5 days (physical therapist absent group=63%, physical therapist participation group=40%), mismatch status (physical therapist absent group=40%, physical therapist participation group=27%), and younger than 48.5 years of age (physical therapist absent group=24%, physical therapist participation group=50%). Thirty percent of patients in the physical therapist absent group who were discharged home were readmitted to the hospital, whereas only 12% of patients in the physical therapist participation group were readmitted. The top mismatch reason for both groups was “no outpatient physical therapy referral given” (Tab. 2).
Discussion
The results of this preliminary study indicate that several factors may predict the 30-day readmission rate of patients discharged from the physical therapist participation and physical therapist absent groups. Patients had 3.78 times greater odds of being readmitted if they were in the physical therapist absent group than if they were in the physical therapist participation group, while controlling for other variables. Given that adherence to discharge recommendations was not a significant predictive factor in readmission, this finding could not be directly linked to the participation of physical therapists. However, the tree-based model and the random forest analysis indicated that mismatch status could potentially be an important variable in increasing the likelihood of readmission (Figs. 1 and 2).
In addition, our descriptive analysis indicated that the physical therapist participation group had a greater adherence rate (73% compared with 60% in the physical therapist absent group). Further investigation of a larger sample size is warranted to further validate this assumption. Analysis of 760 patients by Smith et al28 indicated that patients were 2.9 times more likely to be readmitted when physical therapy discharge recommendations were not implemented by the discharge team. Lack of services had a significant contribution to the overall number of mismatches reported by Smith et al. In our study, lack of follow-up services recommended for a home discharges (outpatient or home health rehabilitation) was the primary reason behind mismatches (Tab. 2). Lack of services for outpatient and home health rehabilitation services combined explained 47% and 54% of reasons behind mismatch for the physical therapist participation and physical therapist absent groups, respectively. Smith et al28 rightfully argued that patients receiving neurosurgery have a higher likelihood of unplanned readmission that may impose a greater demand on discharge planning and lead to increased likelihood of mismatches. The study by Shah et al33 also indicated a greater likelihood of unplanned readmission in patients receiving neurosurgery. In our study, patients receiving neurosurgery were part of the physical therapist participation group and had fewer mismatches and lower readmission rates (Tab. 3). Therefore, it is possible that differences in readmission rates could be linked to physical therapist participation and their contribution to a comprehensive discharge planning.
In addition to the above findings, the overall agreement between physical therapist recommendations and patients' actual discharge disposition for the physical therapist participation group was relatively high (73%). The findings in this study support the high accordance rate found in previous work.28 This result may be because the physical therapist's recommendations are valued and discussed during a collaborative process, or because of agreement between disciplines independent of interdisciplinary communication.
Similar to the study by Smith et al,28 this study was conducted in a level 1 trauma and teaching hospital. However, the higher agreement (83%) noted by Smith et al may be the result of the study population, the larger sample size (762 versus 359), or differences in the discharge planning process.6 Smith et al noted that patients receiving surgical or neurology care comprised 27% and 7% of their patient population, respectively. Furthermore, their discharge planning team had established additional forms of communication, including additional meetings for patients with complex conditions or for different hospital units. To our knowledge, no additional interdisciplinary meetings outside the weekly discharge planning rounds occurred in our study. In addition, at the time of this study, only the neurology, neurosurgery, and general surgery units had the formalized interdisciplinary team meetings, which limits the sample size.
Another unique finding of this study was the increased likelihood of readmission (odds ratio=2.47) for patients who were directly discharged home from the acute care setting compared with patients discharged to inpatient facilities, while controlling for other variables. Smith et al28 reported a 6.9 times greater likelihood of readmission for patients discharged to an extended care facility. This discrepancy could be unique to each facility, and the difference between reporting probability (relative risk) and odds ratio results. In our study, fewer than 2% of patients from each group were discharged to an extended care facility. This result could be due, in part, to the fact that the majority (64%) of the payer mix in the hospital system in our study is unfunded and may not have the financial support to consider extended care facilities. Our study showed that a greater percentage of patients were discharged home from the physical therapist participation group (66%) than from the physical therapist absent group (50%). However, the physical therapist absent group had higher readmission rates (30%) for patients who were discharged home compared with the physical therapist participation group (12%) (Tab. 3). In addition to the fact that lack of follow-up services was the primary reason behind mismatches, the increased readmissions in the case of a home discharge may further underline the importance of the physical therapist's presence in discharge planning.
It is reasonable to assume that, by participating in discharge planning, physical therapists reinforced the importance of follow-up services, leading to better compliance with follow-up care in the physical therapist participation group. Home health and outpatient rehabilitation services could play a role in preventing unwanted outcomes (eg, falls) and readmissions. Home health services can be crucial in modifying a patient's environment and provide necessary treatment and education to return to prior level of function. Similarly, outpatient physical therapy is important in helping patients reach their goals and attaining their maximum functional capacity. Other psychosocial factors, access to care, and patient/family education and understanding of postdischarge needs also could contribute to readmissions following home discharge. This may indicate the need for a more comprehensive discharge planning for patients discharged to home and those who may have a higher readmission risk.
We are aware that other factors inherent to individual differences—such as age, length of stay, and medical complications—also could have contributed to the differences observed. Our tree-based model indicated that patients experienced fewer readmissions if length of stay was greater than 10.5 days (Fig. 1). Smith et al28 observed a similar relationship with an increased likelihood of readmission for shorter length of stay. It is possible that shorter length of stay is associated with insufficient time for interdisciplinary planning and discharge care. Our results also indicate that older patients (≥48.5 years of age) were less likely to be readmitted. However, this was the least significant covariate in the multiple logistic regression model. In this study, the group receiving neurosurgery had the highest number of young patients. Explaining the results of the covariate may be unique to this facility or to the surgical population. Further discussion of this topic is beyond the scope of this study. Given that the admitting diagnoses were not tracked beyond attending services, additional studies are needed to understand the potential role of age and length of stay.
The overall readmission rate in our study was 16%, very similar to the previously reported rate of 18%.28 As of 2012, the national average 30-day readmission rate for Medicare beneficiaries is reported to be 18.4%.6 In our study, the readmission rate for the physical therapist participation group (9.95%) was far below the national average. These findings, coupled with substantial literature regarding the benefits of individualized discharge planning,2,7–9 support the conclusion that the presence of a physical therapist in discharge planning rounds may help reduce readmission rates and the resulting costs to the health care system.
Limitations
The main limitation of this study is the nonrandom selection of patient in each group. This study was a retrospective and observational investigation of 2 existing interdisciplinary discharge teams. The physical therapist participation group followed patients receiving neurosurgical and general surgery. The physical therapist absent group followed patients receiving neurology services. Patients, therefore, were not randomly assigned to groups. Furthermore, the current study did not control for disease severity, comorbidities, demographics, or psychological factors. The existing selection bias and lack of valid risk adjustment between groups does not allow one to make solid conclusions regarding the relationship between a physical therapist's participation in discharge planning rounds and 30-day readmission rates. It is important to account for differences in patient diagnoses; comorbidities, and complexities in order to better understand and identify all factors that could potentially contribute to readmission rates. Therefore, further research with valid risk adjustment and comparison of similar patient populations is warranted to identify the true impact of physical therapists' participation in discharge planning.
Additional limitations of this study include the small sample size unique to our facility and the population that it serves. This small sample size limits the ability to generalize these findings and make conclusions or decisions based on these findings alone. It also is important to note that we were unable to track readmissions occurring outside the hospital system in the current study. It is possible, therefore, that patients were misclassified in the nonreadmission group. Without follow-up with each individual patient or the participation of additional facilities, we were not able track and account for readmissions that may have occurred in other hospitals.
Finally, we were unable to confirm whether readmissions were due to a preventable medical cause or due to the disregard of the physical therapist's recommendations in cases of mismatch. The CMS states that a readmission is considered to be potentially preventable if it is related to inadequate discharge planning or discharge follow-up or to poor coordination between inpatient and outpatient health care teams.34 Therefore, we suggest that readmissions that occur as a result of falls associated with a lack of follow-up physical therapy or home health services could be considered preventable. Further studies are needed to directly investigate the role of follow-up rehabilitation services in preventing medical complications and readmissions. The overall results of this investigation indicate the importance of interdisciplinary discharge planning.
In conclusion, the findings from this study indicated a significant increase in the odds of unplanned readmissions and lack of recommended follow-up services when physical therapists were absent from the interdisciplinary discharge team compared with when they participated in the team. Accurate identification of a patient's functional capacity, need for appropriate DME, rehabilitation needs, and safety for return to home is unique to the physical therapy discipline. As a result, a physical therapist's recommendations could have a significant impact on patient satisfaction and have a net effect of reduced health care costs. It is important to note that results from this study are preliminary and only offer a starting point for additional research into the role of physical therapists as a part of the discharge planning team in acute care settings. Further research is needed to identify how other factors—including specific diagnoses, comorbidities, insurance coverage, and frequency of physical therapy treatments in the acute care setting—affect readmission rates. Additional research could provide much-needed evidence regarding the vital role of physical therapists in discharge planning of patients from the acute care setting.
Footnotes
Dr Kadivar and Dr English provided concept/idea/research design, data collection, and consultation (including review of manuscript before submission). All authors provided writing. Dr Kadivar and Professor Marx provided data analysis. Dr English provided institutional liaisons and administrative support.
Dr Kadivar and Dr English are Neurologic Certified Specialists.
The authors acknowledge physical therapists Holly Brown, Alicia Bogan, and Lorna Bautista for their contribution to data collections. They also thank managers T.J. Pelton and Anne Miller for helping to facilitate the research project.
- Received April 23, 2015.
- Accepted May 4, 2016.
- © 2016 American Physical Therapy Association
References
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