American Physical Therapy Association Research Articles

Physical Therapy Management of Children With Developmental Coordination Disorder: An Evidence-Based Clinical Practice Guideline From the Academy of Pediatric Physical Therapy of the American Physical Therapy Association.

Developmental coordination disorder (DCD), classified as a neurodevelopmental disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), affects approximately 5% to 6% of school-aged children. Characteristics of DCD include poor motor coordination and delayed development of motor skills, not explained by other conditions. Motor deficits negatively affect school productivity, performance in activities of daily living, and recreation participation. Children with coordination problems, at risk for or diagnosed with DCD, should be evaluated by a team of professionals, including a physical therapist (PT). This clinical practice guideline (CPG) provides management strategies for PTs and informs clinicians and families about DCD. It links 13 action statements with specific levels of evidence through critical appraisal of the literature and provides recommendations for implementation. The DCD CPG addresses examination, referral, first choice and supplemental interventions, discharge, compliance audits, implementation, and research recommendations. Supplemental tools are provided to support PT management.

International Experiences in Physical Therapist Education: A Descriptive Study

International service and learning are growing phenomena in physical therapist education (PTE) and programs are developing new opportunities in all corners of the world. With this growth comes risks of duplicative efforts and harmful consequences. Purpose. This study is seeking to describe: 1) the proportion of US-based PTE programs sponsoring international experiences; 2) the number of physical therapist students participating in these activities annually; 3) the location of these programs; and 4) whether outcomes are formally collected. Methods. A 36-item survey was distributed to the American Physical Therapy Association's list of 243 accredited programs. A total of 109 programs responded (44.9%). Results. Seventy-three percent of respondent programs reported offering international experiences in 60 different countries during one academic year. It is estimated that 2,316 students participated in these experiences. Most international experiences were offered in low- and middle-income countries, with 24 different experiences being hosted in Guatemala alone. Student outcomes were collected for nearly all experiences, whereas host community outcomes were collected by less than 20% of programs. Discussion and Conclusion. This study confirms a growing trend of physical therapist students traveling the world. The high concentration of experiences in specific countries, regions, and low-resourced communities magnifies the importance of working alongside community and academic partners to share ideas and resources. Although the collection of student outcomes is critically important to academic programs, the collection of community outcomes should be considered equally, if not more important in assessing the potential benefit of international experiences.

Objectives to Assess Student Readiness for First, Full-Time Clinical Education Experiences in Physical Therapist Education

Introduction.To date, there is a lack of standardization across physical therapist education programs (PTEPs) in the United States as to what qualifies students to be ready for first, full-time clinical education experiences (CEEs). This study aimed to develop readiness objectives for first, full-time CEEs that will be applicable to all clinical settings, based on input from regional clinical faculty.Methods.Clinical faculty (n = 50) accepted an email invitation from the New England Consortium of Clinical Educators to participate in the study. Academic faculty (n = 20) served as facilitators and scribes during the in-person data collection and also completed the survey. Data saturation and consensus building were used in a 2-round modified-Delphi process. Readiness objectives were developed in-person, during the initial round, using the categories of the American Physical Therapy Association'sClinical Performance Instrument(CPI) and Bloom's Taxonomy to inform the process. The second round of data collection asked participants to rate the previously developed readiness objectives for degree of importance and appropriateness of performance level for first, full-time CEEs. This phase was completed via electronic survey.Results.Participants agreed that 22 readiness objectives were “very important.” Eleven of these readiness objectives were within the affective domain, specifically in theCPIcategories of Accountability, Professional Behaviors, Communication, and Cultural Competence. Of the remaining readiness objectives, 5 were directly related to patient safety.Discussion and Conclusion.The results of this study are consistent with other health care professional literatures that indicate clinical faculty prioritize students' behaviors in the affective domain and their ability to maintain patient safety. It is incumbent on the PTEPs to provide students opportunities for development and practice in these areas and assess performance related to these readiness objectives before the first, full-time CEEs. Utilization of these 22 readiness objectives is one method by which PTEPs may meet this expectation.

Work-related musculoskeletal disorders in physical therapists attributable to manual therapy

ABSTRACT Background: Use of manual therapy (MT) is a risk factor for the development of work-related musculoskeletal disorders (WRMDs) in physical therapists (PTs) although the current evidence is limited on this topic. Objectives: The purpose of this study was to understand the type, association, and prevalence of WRMDs among practitioners of MT, explore relationships between MT and WRMD, and determine impacts of WRMDs on PTs. Design: Cross-sectional survey design. Methods: A web-based survey was distributed through the Academy of Orthopaedic Physical Therapy of the American Physical Therapy Association. The survey gathered information on the respondents’ professional profiles, any WRMDs sustained, and how those injuries affected their professional and personal lives. Results: Overall, 38.5% of PT respondents using MT reported having sustained an MT attributable WRMD. Female respondents reported a greater rate of MT attributable injuries. Although exposure risk is cumulative, novice practitioners are also injured. Limitations: Generalizability of these results may be limited because of the sample size and specific population responding. Conclusion: Over one-third of PT survey respondents reported WRMDs attributable to MT. The results indicated WRMDs may begin early in one’s career and tend to accumulate over years of practice. MT educational programming at all levels warrants emphasis on practitioner safety.

Moving Toward Equitable Health Care for Lesbian, Gay, Bisexual, Transgender, and Queer Patients: Education and Training in Physical Therapy Education

Introduction. Disparities in health and health care experienced by sexual and gender minorities in the United States (US) are well documented, and physical therapists (PTs) play a role in perpetuating them. This study aimed to determine to what degree lesbian, gay, bisexual, transgender, and queer (LGBTQ) health education and training is integrated into physical therapy education curricula. Studies in medicine and nursing have led to increased curricular attention to LGBTQ health topics; yet, similar physical therapy education research has not been published. Methods. A link to an anonymous Google Forms survey was emailed to Program Directors (PDs) of US physical therapist education programs accredited by the Commission on Accreditation in Physical Therapy Education for the academic years of 2015–2017. The survey gathered information on the current and optimal number of curricular hours spent on equitable care for LGBTQ patients and perceived barriers to inclusion of LGBTQ curriculum. Results. Seventy-two of 229 (31%) programs responded to the survey. Half of the respondents reported inclusion of LGBTQ-related topics in the curriculum. The average number of current hours was 1.43 per year. The average number of optimal hours was 2.82 per year. Eighty-nine percent reported that one or more curricular hours per year should be included. Barriers to LGBTQ health education and training include perceived lack of time and adequate faculty training. Discussion. Most PDs believe that more hours should be dedicated to LGBTQ health topics. Open-ended question responses reflect various perspectives held by PDs regarding the importance of including LGBTQ health topics and barriers to inclusion. The development of core competencies may facilitate the inclusion of LGBTQ-specific health education in Doctor of Physical Therapy program curricula. Conclusion. Resources to educate faculty and students on LGBTQ health topics are readily available. These topics may be effectively woven into existing curricula, making it an attainable goal to increase the competency of entry-level PTs to assist in meeting the American Physical Therapy Association's mandate to provide nondiscriminatory care.

Telehealth and Nutrition Support During the COVID-19 Pandemic

Telehealth and Nutrition Support During the COVID-19 Pandemic

Increasing the clinical utility of exercise training as a modality in the oncology setting—What we learned in 2019

For the past several years’ oncology focused programing presented at the Combined Sections Meeting (CSM) of the American Physical Therapy Association (APTA) has included a session entitled “Oncology Research Update: A Year in Review”. Speakers for this peer reviewed educational session select clinical studies and literature reviews published in the preceding year which, in their opinions, were particularly clinically relevant. For the 2020 CSM the speakers selected several publications which greatly enhanced the clinical utility of exercise training as a therapeutic modality for cancer survivors. The purpose of this review is to present the salient points and clinical importance of these selected publications in an effort to improve the level of care physical therapists and physical therapist assistants can offer cancer survivors.

Choosing Wisely Initiative: Analysis Of Twelve Years Of Therapeutic Ultrasound

In 2014, the Choosing Wisely Initiative partnered with the American Physical Therapy Association to produce a list of low-value physical therapy (PT) practices, titled “Five Things Physical Therapists and Patients Should Question.” This publication described the limited value of deep heat, or therapeutic ultrasound (TUS), to improve long term outcomes for a myriad of musculoskeletal conditions, yet TUS continues to be used. It is unclear how often TUS is used in contemporary PT practice, how its use has changed after this initiative and for what specific conditions it is most used. PURPOSE: To assess the historical use of TUS by physical therapists before and after the Choosing Wisely Initiative across a regional health network. METHODS: A de-identified Clinical Research Data Warehouse was queried using i2B2 software to collect the history of TUS usage by PTs between 2008 and 2019. The specific CPT code 97035 was used to identify TUS episodes of care. In addition, the total number of unique patients in PT each year was collected. Indications for individual TUS treatment units were analyzed in 2018 and 2019 to yield the most frequent ICD-10 codes for which TUS was performed. RESULTS: Episodes of TUS were standardized by the total number of patients seen in PT each year to account for the growth of the health network. The percentage of patients who received TUS each year was reported. TUS usage rates between 2008 and 2019 were compared using Pearson's two proportion Z-test. Utilization was significantly lower in 2019 (5.2%) than it was in 2008 (24.0%) (χ 2 = 2059.6, p-value < 2.2e-16). Between 2018 and 2019, 5,936 units of TUS were performed by 118 unique PT providers. TUS was commonly performed for shoulder pain (13.0%), ankle or foot pain (9.6%), neck pain (9.6%), knee pain (7.7%), hip pain (6.1%), low back pain (6.0%), unspecified chronic pain (4.3%), and Achilles tendinopathy (4.1%). CONCLUSION: Over the last 12 years, there has been a significant decrease in use of TUS by PTs. This decline coincides with the Choosing Wisely Initiative. However, TUS continues to be used, albeit at a significantly lower frequency, for treating musculoskeletal conditions despite having little evidence in improving long term clinical outcomes. Supported by NIH Grant UL1TR001436.

Spurling’s test – inconsistencies in clinical practice

ABSTRACT Objective: The purpose of this study was to investigate the methodology, interpretation, and perceived value of Spurling’s test toward diagnosis/classification and treatment. Methods: An anonymous web-based survey was made available to physical therapist members of the Academy of Orthopaedic Physical Therapy of the American Physical Therapy Association. Based on video demonstrations of technique and symptom distribution, questions included preferred method, criteria for test interpretation, and perceived value of Spurling’s test and other examination findings toward clinical decision-making. Professional profile data were also collected. Results: Among the 452 participants completing the survey, no method of testing was preferred by more than 37%, with ipsilateral lateral flexion, rotation, and extension with compression being most frequently preferred followed by ipsilateral lateral flexion with compression at 32%. Proximal provocation of symptoms only without distal symptoms was interpreted as a positive test by 67%. Participants rated Spurling’s test of moderate to low value toward diagnosis/classification and treatment. Discussion: Inconsistency with methodology and interpretation of Spurling’s test is suggested to be pervasive in physical therapist practice. While an optimal test methodology has yet to be identified, result interpretation does have a basis for clarification toward diagnosis/classification and reduction of unwanted variance in practice.

Interventions for Breast Cancer-Related Lymphedema: Clinical Practice Guideline From the Academy of Oncologic Physical Therapy of APTA.

A work group from the American Physical Therapy Association (APTA) Academy of Oncologic Physical Therapy developed a clinical practice guideline to aid clinicians in identifying interventions for people with breast cancer–related lymphedema, targeting volume reduction, beginning at breast cancer diagnosis and continuing through cancer treatments and survivorship. Following a systematic review of published studies and a structured appraisal process, recommendations were developed to guide physical therapists and other health care clinicians in their intervention selection. Overall, clinical practice recommendations were formulated based on the evidence for each intervention and were assigned a grade based on the strength of the evidence. The evidence for each specific intervention was synthesized and appraised by lymphedema stage, when the information was available. In an effort to make recommendations clinically applicable, they were presented by modality throughout the care trajectory. Methodology and research populations varied significantly across studies, and it will be important for future research to use standardized definitions for participant characteristics, diagnostic criteria, and interventions.

Referral patterns for surgical consult in the management of patients with foot drop due to acute lumbar disc herniation: a survey study of physical therapists in the United States

ABSTRACT Background There is a lack of consensus for optimal management of patients with foot drop due to acute lumbar disc herniation (LDH) with lumbar radiculopathy (LR), which is a clinical scenario that may be encountered by physical therapists. Consequently, it is important to explore physical therapists’ referral practice patterns for surgical consult. Currently, physical therapist referral patterns for surgical consult in this patient population are unknown. Objectives To describe physical therapist referral patterns for immediate neurosurgical consult in patients with foot drop due to suspected acute LDH with LR. Design Cross-sectional descriptive research design using an electronic, internet-based survey that utilized two clinical vignettes. Method An electronic survey was developed by an expert peer review panel. Survey participants were licensed physical therapists in the United States and members of the Orthopedic Section of the American Physical Therapy Association. Results Of the individuals receiving the survey invitation, 2172 completed the survey. Depending on the severity of foot drop, 34–61% were likely to refer for immediate neurosurgical consult. Presence of imaging to confirm suspected clinical diagnosis slightly affected the likelihood of referral (4–12% increase) for immediate neurosurgical consult. Conclusion In patients with foot drop due to suspected acute LDH with LR, this study found that physical therapist referral patterns for immediate neurosurgical consult varied and are likely influenced by the severity of weakness and availability of MRI findings. Further research regarding the optimal management of this patient population and potential reasons for variation in practice is warranted.

Immediate effects of a lumbar spine manipulation on pain sensitivity and postural control in individuals with nonspecific low back pain: a randomized controlled trial

BackgroundAccording to the American Physical Therapy Association, there is strong evidence to show that vertebral mobilization and manipulation procedures can be used to improve spinal and hip mobility and reduce pain and incapacity in low back pain patients that fit the clinical prediction rule. Objectives: To evaluate the immediate effects of high-velocity low-amplitude (HVLA) manipulation on pain and postural control parameters in individuals with nonspecific low back pain.MethodsThis study used a participant-blinded and assessor-blinded randomized controlled clinical trial involving a single session, in which 24 participants were randomly distributed into control (simulated manipulation) and intervention (HVLA lumbar manipulation) groups. The primary (pain: subjective pain intensity and pressure pain threshold) and secondary outcomes (postural control: ellipse area, center of pressure [COP] excursion, COP RMS velocity, and differences between the COP and center of projected gravity) were evaluated before and after the session using a numerical pain scale, algometer, and a force platform. For all outcomes, multiple mixed 2 (group) × 2 (time) ANOVAs were performed.ResultsFor the subjective pain intensity, only time was significant as a main effect, where pre-intervention presented a greater value then post-intervention (F [1.44] = 4.377; p = 0.042; r = 0.30). For the pressure pain threshold no significant effect was found. For the postural control parameters, as a main effect, only the ellipse area was significantly greater in the control group (F [1.44] = 6.760; p = 0.013; effect size = 0.36).ConclusionsThere was a reduction in subjective pain intensity, evaluated using a numerical scale, in both the intervention and control groups immediately after the intervention, suggesting that the spinal manipulation had a similar effect to the placebo procedure. No effect of HVLA lumbar manipulation was identified for postural control variables in either the intervention or control groups.Trial registrationThe study was registered at ClinicalTrials.gov under the number NCT02312778, registered at 14 September 2014.

4025 Fall Risk Screening and Referrals to Community-Based Programs among Physical Therapy Professionals

OBJECTIVES/GOALS: To describe trends in fall risk screening and referrals to community-based programs among physical therapy professionals.To compare fall risk screening practices to clinical practice guidelines amongTo identify gaps in fall risk screening and referrals to community-based programs among physical therapy professionals.METHODS/STUDY POPULATION: A panel of experts between the American Physical Therapy Association (APTA) - Geriatrics, and the National Council on Aging (NCOA) developed a web-based survey to identify practices among physical therapy professionals (PTs) for fall risk screenings and community-based referrals for older adults. The web-based survey was disseminated to PTs via email, e-blasts, and social media. The survey focused on questions related to knowledge of fall risk screening tools, fall risk management for older adults, and knowledge of and referrals to community-based interventions. RESULTS/ANTICIPATED RESULTS: To date, 453 PTs representing 50 states completed the survey. The majority of PTs (50.9%) had over 20 years of experience in various settings. Eighty-three percent regularly screen older adults for fall risk. Approximately 40% conduct community-based screenings. The majority (81.3%) were somewhat to very familiar with the CDC-recommended STEADI (Stopping Elderly Accidents, Deaths, and Injuries) screening toolkit. Despite familiarity, only 32% responded to the question if they used STEADI for screening. Of those, 83.4% used the tool. The majority (73.4%) of PTs were aware that NCOA recommends evidence-based programs to address health needs of aging adults and 59.6% refer. PTs did not refer due to lack of knowledge that programs existed (21.3%) or lack of knowledge of availability (33.3%). DISCUSSION/SIGNIFICANCE OF IMPACT: Although PTs are have some familiarity with the STEADI for fall risk screening, the tool is not common in practice. PTs are lacking awareness of local evidence-based community programs to address health needs of aging adults. Educational efforts should target these knowledge gaps and provide additional resources to improve referrals.

Pedagogy for Effective Learning of Clinical Skills: An Integrated Laboratory Model

Background and Purpose. The teaching, learning, and assessment of clinical skills is a critical component of entry-level physical therapy education. The intention of this article was to describe a successful model for teaching clinical skills in the context of the patient and client management model across the domains of physical therapist education with emphasis on motor learning principles, experiential learning, and clinical reasoning. Method/Model Description and Evaluation. The model describes a cohesive laboratory learning environment that integrates skills from the clinical science courses that coincide each semester. A laboratory director coordinates with faculty teaching clinical sciences in a given semester to ensure the necessary psychomotor content is included, creates experiential learning opportunities that integrate skills across content areas, and promotes clinical reasoning in the context of the patient and client management model. Success of this model was measured through student outcomes on skills competency tests (SCTs), Clinical Competence Performance Examinations (CCPEs), American Physical Therapy Association (APTA) Clinical Performance Instrument (CPI) benchmarks, and the National Physical Therapy Examination (NPTE). Outcomes. Each student passed SCTs administered during semesters 1–6 given a maximum of 3 trials. Every student passed the CCPE administered at the end of each semester in one of 3 trials except for one student in semester 6. Each student met expectations for performance as measured on the CPI for 4 clinical education experiences including entry-level performance for the final 2terminal experiences. All students were successful on the NPTE. Discussion and Conclusion. Implementation of this model has prepared students for authentic physical therapy practice by promoting integration of curriculum content and has fostered faculty collaboration. While initial student and curricular outcomes have been positive, assessment of the model is ongoing.

Comparing expert opinion within the care team regarding postoperative rehabilitation protocol following rotator cuff repair

There is no established consensus regarding the optimal rehabilitation protocol following rotator cuff repair, including duration of immobilization, timing to initiate range of motion and resistance exercises, and the importance of supervised, formal therapy. The purpose of this study was to determine agreement in opinion regarding rotator cuff rehabilitation between orthopedic surgeons and physical therapists (PTs). A 50-question survey was created on a secure data capture system and distributed via e-mail to members of professional organization affiliations. Surgeon participants were recruited from the American Shoulder and Elbow Surgeons, and PTs were recruited from the American Society of Shoulder and Elbow Therapists and the Academy of Orthopaedic Physical Therapy of the American Physical Therapy Association. Survey responses were analyzed for interprofessional differences in majority opinion and distribution of answer choices. A total of 167 surgeons and 667 PTs responded to the survey. Of the 39 questions evaluated, surgeons and PTs reached intraprofessional majority agreement in 26 (67%) and 28 (72%) statements, respectively, with agreements matching in 17 instances and differing in 4. The 2 groups had different answer preferences in 32 questions (82%). PTs were more likely to support shorter immobilization intervals (P < .001), earlier strengthening (P < .001), and more frequent home exercises (P = .002), whereas surgeons endorsed more conservative weight-bearing restrictions (P < .001), time-based phase transitions (P < .001), and web-based technological platforms for rehabilitation (P < .001). Our findings show that although significant discrepancy of opinion exists within professions, greater differences in preferences exist between surgeons and PTs regarding rotator cuff repair rehabilitation.

Impact of COVID-19 on Physical Therapist Practice in Portugal.

© The Author(s) 2020. Published by Oxford University Press on behalf of the American Physical Therapy Association. All rights reserved. For permissions, please email: journals.permissions@oup.com

Bridge the Divide: Create Your Connection from Research to Practice

Bridge the Divide: Create Your Connection from Research to Practice

Management of Osteoarthritis of the Hip.

The American Academy of Orthopaedic Surgeons, in collaboration with the American Association of Hip and Knee Surgeons, the Hip Society, the American College of Radiology, the American Physical Therapy Association, the Limb-lengthening and Reconstruction Society, and the Pediatric Orthopaedic Society of North America, released Management of Osteoarthritis of the Hip: Evidence-Based Clinical Practice Guideline. The complete guideline is available on OrthoGuidelines (www.orthoguidelines.org). The guideline is intended to assist those taking care of patients with osteoarthritis of the hip in making decisions regarding the most appropriate treatment. A group of experts with knowledge of orthopaedic surgery, physical therapy, and musculoskeletal radiology developed 18 recommendations for nonoperative and operative treatment based on relevant literature. A companion article illustrates the use of these guidelines by discussing specific case examples and evidence-based treatments for osteoarthritis of the hip.

Navigating the Intersection Between Persistent Pain and the Opioid Crisis: Population Health Perspectives for Physical Therapy.

The physical therapy profession has recently begun to address its role in preventing and managing opioid use disorder (OUD). This topic calls for discussion of the scope of physical therapist practice, and the profession's role, in the prevention and treatment of complex chronic illnesses, such as OUD. OUD is not just an individual-level problem. Abundant scientific literature indicates OUD is a problem that warrants interventions at the societal level. This upstream orientation is supported in the American Physical Therapy Association's vision statement compelling societal transformation and its mission of building communities. Applying a population health framework to these efforts could provide physical therapists with a useful viewpoint that can inform clinical practice and research, as well as develop new cross-disciplinary partnerships. This Perspective discusses the intersection of OUD and persistent pain using the disease prevention model. Primordial, primary, secondary, and tertiary preventive strategies are defined and discussed. This Perspective then explains the potential contributions of this model to current practices in physical therapy, as well as providing actionable suggestions for physical therapists to help develop and implement upstream interventions that could reduce the impact of OUD in their communities.

Growing Academic Physiatry: The Comparative Impact of Baruch Grants to Harvard Medical School and Columbia College of Physicians and Surgeons. Part I

Growing Academic Physiatry: The Comparative Impact of Baruch Grants to Harvard Medical School and Columbia College of Physicians and Surgeons. Part I