Number Of Physical Therapy Visits Research Articles

Comparing Outcomes After Referral to Physical Therapy for Patients With Glenohumeral Osteoarthritis Based on the Radiographic Osteoarthritis Severity: A Retrospective Analysis.

Introduction Glenohumeral osteoarthritis (GHOA) is a common cause of musculoskeletal pain (MSP) that can frequently lead to pain and functional disability in patients throughout the world. GHOA can be managed with conservative or surgical interventions, although conservative interventions, such as physical therapy (PT), are generally first-line interventions depending on the severity of GHOA. The purpose of this retrospective analysis was to examine how conventional PT impacts outcomes for patients with GHOA based on the severity of radiographic GHOA findings. Methods This study is a retrospective chart review of patients who were referred to PT for MSP and received PT in the outpatient setting between 2016 and 2022. Inclusion criteria were patients who received PT in the outpatient setting, received PT for MSP, had shoulder radiograph imaging within two years of initial PT evaluation, had more than one PT visit (i.e. attended a follow-up session after initial evaluation), and did not have a history of shoulder surgery. Primary outcome measures were pain, abduction active range-of-motion (AROM), and disability via the quick disabilities of the arm, shoulder, and hand (DASH). Patients were divided into the No GHOA group (n=104), Mild GHOA group (n=61), and Moderate/Severe GHOA group (n=55) based on the radiographic GHOA severity. Results All included patients (n=220) had a mean age of 62.2 ± 12.4 years old with a mean number of PT visits of 7.8 ± 4.5 visits. There was initially a significant difference in the magnitude of pain improvement between the three groups based on radiographic severity of GHOA (Kruskal-Wallis H=6.038; p=0.049); however, post hoc testing revealed no significant difference between any of the three groups for pain improvement (p=0.061 to p=1.000). There was also no significant difference in the magnitude of abduction AROM improvement between the three groups based on the radiographic severity of GHOA (Kruskal-Wallis H=2.887; p=0.236). Finally, there was no significant difference in the magnitude of disability improvement via the Quick DASH between the three groups based on the radiographic severity of GHOA (Kruskal-Wallis H=0.156; p=0.925). Conclusion Patients with GHOA referred to PT experience small but statistically significant short-term improvements in pain, abduction AROM, and disability regardless of GHOA radiographic severity. There is no significant association between the magnitude of clinical improvement and the severity of radiographic GHOA. However, despite statistically significant improvements in pain, only patients with mild GHOA experienced clinically significant improvements in pain.Patients with GHOA, regardless of severity, may or may not experience clinically significant improvements in disability after PT.

Clinical Outcomes Associated With the Addition of a Physical Therapist Assistant to a Rehabilitation Team When Treating Musculoskeletal Shoulder Pain in the Outpatient Setting: A Retrospective Cohort Study.

Introduction Musculoskeletal shoulder pain (MSP) is a common condition frequently treated in an outpatient setting by a physical therapy rehabilitation team. Treatment teams can consist of physical therapists (PTs) with or without physical therapist assistants (PTAs).It is currently unknown how different physical therapy team compositions can impact patient outcomes in the outpatient setting. The purpose of this study is to examine how the addition of PTAs to a physical therapy treatment team would impact clinical outcomes when treating patients with MSP in the outpatient setting. Methods This study is a retrospective cohort analysis comparing clinical outcomes for pain, active range of motion (AROM), and disability for patients with MSP when treated by physical therapy treatment teams with or without the presence of PTAs.Inclusion criteria were patients treated for MSP in an outpatient physical therapy clinic without a history of shoulder surgery. Depending on the rehabilitation team composition, patients were divided into a PT-only group or a PTAgroup. Results Total patients (n = 238) had a mean age of 62.6 ± 12.6 years (median: 64 years) with a mean total number of physical therapy visits of 7.8 ± 4.9 visits (median: 7.0 visits). Of the entire cohort, the PT-only group had 100 patients and the PTA group had 138 patients. There was no significant difference in the magnitude of pain improvement (mean: 1.5 versus 1.9 points, p = 0.177), the magnitude of abduction AROM improvement (mean: 17.6 versus 13.9 degrees, p = 0.173), and the magnitude of disability improvement (mean: 18.9 versus 13.4 percentage points, p = 0.221) between the PT-only group and the PTA group. However, the PT-only group had significantly fewer total visits as compared to the PTA group (6.7 versus 8.6 visits, p < 0.001). Conclusion The addition of PTAs to a rehabilitation team when treating patients with MSP in the outpatient setting does not appear to adversely impact pain, AROM, or disability outcomes. However, patients treated only by PTs had significantly less visits with similar outcomes. More research is needed to determine the interplay between cost, healthcare utilization, and patient outcomes to maximize quality care.

Factors Affecting Postoperative Rehabilitation Therapy Utilization After Arthroscopic Rotator Cuff Repair: An Epidemiological Analysis.

Background and objective Rotator cuff tear (RCT) is an orthopedic shoulder pathology commonly managed via arthroscopic rotator cuff repair (ARCR) after the failure of conservative treatment options. Physical therapy (PT) after ARCR is an important component of patient recovery. Postoperative complications, such as postoperative shoulder stiffness (POSS), are frequent among these patients and place a significant burden on patients and clinicians. The purpose of this study is to analyze temporal PT utilization among patients after ARCRand its potential to improve patient outcomes and examine possible factors affecting postoperative complication rates. Methods An epidemiological study was performed by using a large de-identified national health research network (TriNetX) within the United States to search for patients with a diagnosis of partial or complete RCT and subsequent ARCR. Data were collected on patient demographics, number of postoperative PT visits, and PT visitsdistribution in the early postoperative period. Statistical analysis was performed to analyze factors that impacted the utilization of postoperative PT after ARCR. Results A total of 21,540 patients underwent ARCR with 11,312 receiving ARCR for partial RCT and 10,228for complete RCT. Of all ARCR patients, 6,923 (32.1%) received postoperative PT within one year of ARCR. Patients with partial RCT had a greater number of PT visits (mean ±SD: 3.85 ± 8.33; min-max: 0-110; t= 15.2) compared to patients with complete RCT (2.90 ± 7.97; min-max: 0-125) after ARCR (p<0.001). Patients with ARCR for partial RCT also had more visits within the first 12 weeks after ARCR as compared to patients with ARCR for complete RCT (p<0.001). Female patients had more visits than male patients after ARCR, regardless of the RCT extent (p<0.001). Conclusion Partial RCT and female sex are associated with increased postoperative PT usage after ARCR. Postoperative PT utilization has high variability after ARCR, regardless of the RCT extent. More research is needed to further explore the impact of PT utilization on postoperative complications after ARCR.

Paper 23: The Impact of Graft Choice on Return to Sport Testing After Adolescent ACL Reconstruction

Objectives:The number of anterior cruciate ligament (ACL) injuries and reconstructions observed in the adolescent population continues to rise. While the use of quadriceps tendon autograft has increased in popularity in this population, there remains no consensus on the ideal graft for pediatric ACL reconstruction. The objective of this study was to compare three commonly used ACL graft types with respect to i) performance on return to sport assessments and ii) timing to clearance for return to sports in an adolescent population.Methods:All patients, less than or equal to 19 years of age, who underwent reconstruction for ACL tears between 2016 and 2020 at a large, urban, academic institution were identified. Graft choice was made in a shared decision-making model with patient, parents, and surgeon. Patient demographics, laterality, graft type, time from surgery to clearance, number of physical therapy (PT) visits, and presence of concomitant meniscus injuries were collected from the electronic medical record. At a minimum of 6 months postoperatively, patients completed a formal return to sport test (RTS) including isometric strength assessments, Y- balance testing, and hop testing. Treatment cohorts based on graft type were compared with respect to RTS performance and timing to clearance. Associations between patient demographics and return to sport timing and performance were also assessed. Clearance for return to sport was determined by the treating surgeon with limb symmetry index of 90% on RTS as the goal for clearance.Results:A total of 110 adolescents, 44 female (40%), with a mean age of 16.3 years (SD, 1.7; range, 10-19) met our inclusion criteria (Table 1). Average time to first RTS assessment was 280 days (9.3 months) and average time to clearance was 371 days (12.2 months) after surgery. ACL grafts included 58 (52.7%) hamstring autografts, 26 (23.6%) bone-patellar tendon-bone (BPTB) autografts, 21 (19.1%) bone quadriceps (BQT) autografts, and 5 (4.6%) iliotibial band (ITB) autografts. ITB patients were younger on average (12.5 years old) than those receiving hamstring, BPTB or BQT grafts. There were no significant differences between groups with respect to laterality, number of physical therapy visits, or rate of concurrent meniscus surgery.Patients receiving BQT grafts were more likely to be cleared within 1 year of surgery compared to hamstring graft patients (82.4% vs. 39.6%, p=0.002) and had similar rates of clearance within 1 year compared to BPTB patients (82.4% vs. 65.2%, p=0.230). Patients with BQT and BPTB grafts both demonstrated significantly better hamstring strength symmetry compared to hamstring graft patients (5.8% strength deficit compared to healthy side vs. 1.3% vs. 29.3%, p<0.001) (Table 2). There were no differences in quadriceps strength or hop test asymmetry between graft types. Multivariate regression with age, gender, and number of PT sessions included as covariates demonstrated that hamstring graft choice was associated with decreased odds of clearance at 1 year.Conclusions:In this study of 110 adolescent ACL reconstruction patients who underwent return to sport evaluations, we found no significant difference between BPTB and BQT autografts with respect to RTS performance and time to clearance. Hamstring autograft was associated with significantly worse hamstring strength asymmetry and significantly lower rates of clearance within 1 year. Concurrent meniscus surgery, age, gender, and number of PT sessions completed prior to RTS evaluation were not significantly associated with timing of clearance or performance on the RTS assessment.Table 1.Patient Demographics and Surgical CharacteristicsTable 2.Patient Demographics and Performance by 3 Common Graft Types

Predicting the number of physical therapy visits and patient satisfaction in individuals with temporomandibular disorder: A cohort study.

Temporomandibular disorders (TMD) can be challenging to manage for clinicians and patients alike. It is unclear which factors are associated with prolonging conservative care and patient dissatisfaction with treatment outcomes. To examine factors collected during a physical therapy (PT) evaluation in a cohort of individuals with TMD to determine factors associated with an increased number of PT visits and reduced patient satisfaction. Records of 511 patients referred to PT over 18 months were reviewed to extract 27 variables to develop a predictive model. Outcomes were patient satisfaction following PT and number of PT visits. Linear and zero inflated negative binomial regressions were used, and a multivariate regression model was built for both outcomes. Two factors were associated with both lower patient satisfaction and an increased number of PT visits: higher patient rated functional neck disability and a greater number of healthcare professionals seen. Other factors associated with patient satisfaction were duration of symptoms, subluxation, and referral from an oral surgeon. Only patient rated functional neck disability score was a significant predictive factor in the multivariate model. Factors associated with number of PT visits were gender, educational level, time between initial visit and discharge, number of pain areas, bruxism, biopsychosocial factors, dizziness, pain rating, and presence of neck pain. In the multivariate model, gender, number of healthcare professionals seen, and resting pain rating were significant predictors of number of PT visits. Considering key factors on initial evaluation, specifically functional neck disability and the number of prior healthcare professionals seen before starting PT, can help to predict a higher number of PT visits and reduced patient satisfaction with outcomes.

Joint Corticosteroid Injection Associated With Higher Physical Therapy Compliance in Knee Osteoarthritis.

BackgroundKnee corticosteroid injection (KCSI) and physical therapy (PT) are two efficacious treatments for knee osteoarthritis (KOA). However, poor adherence to PT in resource-limited communities might limit its effectiveness. KCSI prior to PT might improve adherence in this population.MethodologyThis was a retrospective cohort analysis of patients referred to PT for KOA from January 01, 2018 to December 31, 2019 from an adult primary care resident clinic in Hartford, Connecticut, USA. Patients were divided into two groups, namely, those who had a KCSI around the time of the referral versus those who did not. PT adherence was evaluated in both groups.ResultsA total of 143 patients referred to PT were selected, and 11 patients were excluded. In total, 38/132 patients had a KCSI within a four-month window of the PT referral. Patients were mostly Hispanic (no injection 79.8% vs. injection 78.9%) females (80.9% vs. 71.1%), the average age was in the 60s, and over 90% were insured by either Medicaid or Medicare. In the injection group, 18/38 patients completed at least one PT visit (47.4%) versus 21/94 patients (22.3%) in the noninjection group. The odds ratio of undergoing PT was 1.38 (95% confidence interval [CI] = 1.14-1.69; p = 0.002), and the rate ratio of PT visits was 2.50 (95% CI = 1.82-3.42; p = 1.36 × 10-8), both adjusted for age, sex, and severity. Among those who attended at least one session, the mean number of PT visits was 5.4 in both injection and noninjection groups (median 5 versus 4). ConclusionsIn a predominantly Hispanic patient population, those who underwent KCSI were more likely to undergo PT and, as a group, attend more sessions.

Implementation of Direct Access Physical Therapy Within the Military Medical System.

Readiness is the Army's number one priority. Physical therapists (PTs) are musculoskeletal (MSK) experts and have been serving as physician extenders in a direct access role in the military since Vietnam. Utilizing a PT in the direct access role has demonstrated a reduction in imaging, medication prescribed, number of physical therapy visits, and overall reduction in healthcare utilization. The Joint Base Lewis-McChord physical therapy service line initiated a readiness-focused direct access initiative in May 2018. A simple algorithm was developed to help screen and identify appropriate service members for direct access physical therapy sick call. Physical therapy sick call hours were established at seven Joint Base Lewis-McChord Physical Therapy clinics. During the initial 18 months of this direct access PT initiative, a total of 3,653 initial physical therapy evaluations were completed. Injury location included 26% (953) knee, 26% (945) ankle, 16% (585) low back, 15% (551) shoulder, 9% (316) hip, and 8% (303) leg. In the military, where readiness is the number one priority, it is essential that we optimize the medical resources available to our service members in order to minimize lost duty days and overall long-term disability. This project demonstrates a way to optimize the military healthcare system in order to reduce cost and healthcare utilization and minimize duty days lost to MSK injuries. Utilizing a conservative estimate, $3.6 million was potentially saved in military healthcare utilization costs. The subanalysis performed at one clinic comparing referral-based care with the direct access model demonstrated a reduction in imaging, days on profile, cost savings, reduction in referral to specialty care, and decreased long-term disability. In the military healthcare system, where our primary care team resources are limited, it is important to consider the PT as part of the acute MSK injury management team.

ROLE OF PHYSICAL THERAPY IN THE TREATMENT OF POSTERIOR ANKLE IMPINGEMENT IN PEDIATRIC ATHLETES - A PROSPECTIVE STUDY

Background:Posterior ankle impingement (PAI) is a known cause of posterior ankle pain in athletes performing repetitive plantarflexion motion. Even though empirically recommended in adult PAI, there is minimal literature related to the role of conservative physical therapy (PT) in pediatric patients.Purpose:To identify patient characteristics and determine if there is a difference in pediatric patients with PAI who were successful with conservative PT and those who were unsuccessful, requiring surgical intervention.Methods:Prospective study at a tertiary children’s hospital included patients <18 years diagnosed with PAI and underwent PT. Patients who received PT at an external facility were excluded. Collected data included demographics, initial presentation at PT evaluation, treatment throughout PT, patient presentation at PT discharge, time to return to sport (RTS) from initial PT evaluation (if successful), time to surgery from initial PT evaluation (if unsuccessful). Visual Analogue Scale (VAS) and American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores were collected. Group comparisons were conducted using independent t-tests or chi-square analyses (alpha level set at .05).Results:31 (12 males, 19 females) patients diagnosed with PAI were enrolled with a mean age 12.61 years (range: 8-17). Gymnastics, football, and basketball were the most commonly implicated sports (42% patients). All patients underwent initial conservative PT for an average of 16.24 weeks (9.23 visits ±7.73). 20/31(64.5%) patients failed conservative management and underwent arthroscopic debridement. PAI pathology was predominantly bony in 61.3% and soft tissue 38.7%. Between the successful PT group and unsuccessful PT group, there was no difference in the proportion of athletes/non-athletes (p=.643). Average RTS time for successful group was 11.47 weeks and average time to surgery for unsuccessful group was 17.82 weeks. There were no significant differences in sex (p=.332), age (p=.674), number of PT visits (p=.945), initial weight-bearing status (p=.367), use of manual therapy (p=.074) including manipulation (p=.172) and mobilization (p=.507), sport (p=.272), initial evaluation ankle ROM (p>.05). Initial AOFAS scores for pain, function, alignment, or total were not significantly different (p=.551, .998, .555, .964 respectively).Conclusion:The first prospective study in pediatric patients with PAI demonstrates that even though success of PT is not dependent on age, sex, sport or PAI pathology, a notable proportion of patients who undergo PT do not need surgery. Conservative management including PT should be the initial line of management for PAI. PT treatment and surgery (if unsuccessful with PT) allowed patients to return to prior level of activity/sports.Tables/Figures:

POST-CONCUSSION PHYSICAL THERAPY REFERALS

Background:Treating a concussion is complex, requiring a multi-disciplinary patient-centered approach for optimal outcomes. Physical therapy (PT) is a treatment utilized to facilitate concussion recovery, however little is known about those patients referred to PT.Purpose/Hypothesis:The purpose of this study was to report the demographics and other outcome measures of patients referred to PT from an attached specialty concussion clinic.Methods:Retrospective data were extracted from medical records for patients who were referred for physical therapy (PT) from its specialty concussion clinic. Patients included in this study were aged 8-18, diagnosed with a concussion, and referred to PT. Demographic data (age, gender, ethnicity, race) were patient reported. Other patient outcome measures (total injury recovery in days, total number of PT visits, total days between the first and last PT visit, positive VOMS score (symptom increase of 2 from baseline on any symptom and/or convergence on any trial >6cm). Statistical analyses included summary statistics and were reported appropriately as proportions, medians (interquartile range [IQR]), and means (± standard deviation [SD]).Results:Of the 88 patients referred to PT, the mean (± SD) age was 14.31 (± 2.58), 27.3% were children (8-12 years), 72.7% were adolescents (13-18 years), 65.9% were female, 87.5% were white race, 6.8% were black race, and 12.5% were Hispanic in ethnicity. A total of 84.1% patients had a positive VOMS, 9.1% had a negative VOMS, and 6.8% had an invalid VOMS. On average, patients were seen for 4 (± 2.60) total visits, spanning across an average of 18 (± 14.83) days between initial and last PT visits, with the median recovery between date of injury and medical clearance being 48 days (SD=175).Conclusions:This is the first study to provide preliminary demographics of post-concussive PT patients referred from its specialty concussion clinic. These results will be useful in establishing future protocols for future studies to examine the effect of early PT intervention on pediatric concussion recovery.

Predictors of Co-occurring Cardiovascular and Gastrointestinal Disorders among Elderly with Osteoarthritis

ObjectiveTo identify the leading predictors of co-occurring cardiovascular or gastrointestinal disorders (CV-GID) in a real-world cohort of elderly with osteoarthritis (OA). MethodAn observational retrospective cohort study using data from Optum’s deidentified Clinformatics® Data Mart was conducted. Elderly with OA were identified in 2015 and were followed for two years to identify co-occurring CV-GID including ischemic heart disease, stroke, heart failure, dyspepsia, gastroesophageal reflux disorder, and peptic ulcer disease. Random Forest (RF) and Partial Dependence Plots (PDP) were used to identify the leading predictors of CV-GID and to examine their associations. Multivariable logistic regression was also used to examine the association of the leading predictors with CV-GID. ResultsOur study cohort consisted of 45,385 elderly with OA (mean age 76.0 years). CV-GID were present in 59% of elderly. Using RF, age was found to be the strongest predictor of CV-GID followed by cardiac arrhythmia, duration of opioid use, number of orthopedist or physical therapy visits, number of intra-articular corticosteroid injections, polypharmacy, duration of non-selective nonsteroidal anti-inflammatory drugs or oral corticosteroids, and hypertension. The PDPs demonstrated that higher age, cardiac arrhythmia, longer durations of opioid or oral corticosteroids, higher number of physical therapy visits or intra-articular corticosteroid use, polypharmacy, and hypertension were associated with a higher risk of CV-GID. ConclusionCV-GIDs are common among elderly with OA and can be predicted based on certain clinical factors. Machine learning methods with PDPs can be used to improve the interpretability and inform decision-making.

Physical Therapy Use, Costs, and Value for Latent Classes of Good vs Poor Outcome in Patients Who Catastrophize About Their Pain Prior to Knee Arthroplasty

ObjectiveTo examine use, costs, and value of physical therapy (PT) among subgroups. DesignWe conducted an observational study of data from a randomized trial of a pain coping skills intervention. Good and poor outcome subgroups were determined based on Western Ontario and McMasters Universities Osteoarthritis Index (WOMAC) Pain and Physical Function scores. The use and costs of PT care as well as changes in WOMAC Pain and Physical Function scores over 4 time periods during a 1-year follow-up were reported. We compared the number of PT visits, total PT costs, and cost per 1-unit improvement in WOMAC scores for the 2 latent subgroups. SettingFive academic medical centers. ParticipantsPatients who catastrophized about their pain prior to knee arthroplasty (N=384). InterventionsPain coping skills training, arthritis education, and usual care. Main Outcome MeasuresThe WOMAC Pain Scale was the primary outcome. ResultsThe value of PT was lower and the cost of PT was higher for poor vs good outcome subgroups beginning 2 months after knee arthroplasty. For example, during the 2- to 6-month period, participants in the poor outcome subgroup incurred a PT cost of $5181.22 per 1-unit improvement in WOMAC Pain compared with $437.87 per 1-unit improvement in WOMAC Pain for the good outcome subgroup (P<.001). From the 6- to 12-month period, WOMAC scores worsened for the poor outcome subgroup, indicating no benefit from PT. ConclusionsPatients in 2 latent classes demonstrated clinically important differences in value of PT. Future research should identify rehabilitation-based interventions that reduce utilization and enhance effectiveness for patients at high risk for poor outcome.

Physical Therapy and Discharge Disposition Following Acute Hospitalization for UTI in Community-Dwelling Older Adults

Background: Bed rest during acute hospitalization is associated with new-onset mobility impairments in community-dwelling older adults, resulting in discharge to skilled nursing facilities rather than home. Purpose: The purpose of this retrospective study is to determine whether the number of physical therapy (PT) visits is related to discharge disposition following an acute hospitalization for urinary tract infection (UTI) in the older adult population. Methods: Medical records over a 3-year period of 523 community-dwelling older adults (65 years and older) admitted from home functionally independent were reviewed. Demographic and patient characteristics, including age, gender, living status, length of stay (LOS), discharge disposition, and the number of PT visits, were collected. Multinomial regression was conducted to determine predictors of disposition. Results: The multinomial logistic regression model was statistically significant, χ2(2) = 6.90, P = .032. Older age, longer LOS with fewer PT visits during acute hospitalization, and a higher comorbidity score were significant predictors of hospital discharge to subacute rehabilitation facilities than those who were able to return home with home health PT. These variables were not predictors of the disposition for younger patients with fewer comorbidities. Limitations: Due to the retrospective nature of this study, assessment of potential preexisting levels of frailty, standardized delivery of PT, and level of activity outside of PT could not be performed. Conclusions: Reduced frequency of physical therapist intervention for older adults hospitalized with UTI was associated with discharge to rehabilitation in a skilled nursing facility compared with those of similar age with increased PT intervention frequency.

Temporal Utilization of Physical Therapy Visits After Anterior Cruciate Ligament Reconstruction.

Background:Physical therapy (PT) rehabilitation is critical to successful outcomes after anterior cruciate ligament reconstruction (ACLR). Later-stage rehabilitation, including sport-specific exercises, is increasingly recognized for restoring high-level knee function. However, supervised PT visits have historically been concentrated during the early stages of recovery after ACLR.Purpose/Hypothesis:To assess the number and temporal utilization of PT visits after ACLR in a national cohort. We hypothesized that PT visits would be concentrated early in the postoperative period.Study Design:Descriptive epidemiological study.Methods:The Humana PearlDiver database was searched to identify patients who underwent ACLR between 2007 and 2017. Patients with additional structures treated were excluded. The mean ± SD, median and interquartile range (IQR), and range of number of PT visits for each patient were determined for the 52 weeks after ACLR. PT visits over time were also assessed in relation to patient age and sex.Results:In total, 11,518 patients who underwent ACLR met the inclusion criteria; the mean age was 32.62 ± 13.70 years, and 42.7% were female patients. Of this study cohort, 10,381 (90.4%) had documented PT postoperatively; the range of PT visits was 0 to 121. On average, patients had 16.90 ± 10.60 PT visits (median [IQR], 16 [9-22]) after ACLR. Patients completed a mean of 52% of their PT visits in the first 6 weeks, 75% in the first 10 weeks, and 90% in the first 16 weeks after surgery. Patients aged 10 to 19 years had the highest number of PT visits (mean ± SD, 19.67 ± 12.09; median [IQR], 18 [12-25]), significantly greater than other age groups (P < .001).Conclusion:PT after ACLR is concentrated in the early postoperative period. Physicians, therapists, and patients may consider adjusting the limited access to PT to optimize patient recovery.Clinical Relevance:As supervised PT visits may be limited, the appropriate temporal utilization of supervised PT visits must be maximized. Strategies to ensure sessions for later neuromuscular and activity-specific rehabilitation are needed.

A Portable System for Remote Rehabilitation Following a Total Knee Replacement: A Pilot Randomized Controlled Clinical Study.

Rehabilitation has been shown to improve functional outcomes following total knee replacement (TKR). However, its delivery and associated costs are highly variable. The authors have developed and previously validated the accuracy of a remote (wearable) rehabilitation monitoring platform (interACTION). The present study’s objective was to assess the feasibility of utilizing interACTION for the remote management of rehabilitation after TKR and to determine a preliminary estimate of the effects of the interACTION system on the value of rehabilitation. Specifically, we tested post-operative outpatient rehabilitation supplemented with interACTION (n = 13) by comparing it to a standard post-operative outpatient rehabilitation program (n = 12) using a randomized design. Attrition rates were relatively low and not significantly different between groups, indicating that participants found both interventions acceptable. A small (not statistically significant) decrease in the number of physical therapy visits was observed in the interACTION Group, therefore no significant difference in total cost could be observed. All patients and physical therapists in the interACTION Group indicated that they would use the system again in the future. Therefore, the next steps are to address the concerns identified in this pilot study and to expand the platform to include behavioral change strategies prior to conducting a full-scale randomized controlled trial. Trial registration: ClinicalTrials.gov NCT02646761 “interACTION: A Portable Joint Function Monitoring and Training System for Remote Rehabilitation Following TKA” 6 January 2016.

Associations Between Physical Therapy Visits and Pain and Physical Function After Knee Arthroplasty: A Cross-Lagged Panel Analysis of People Who Catastrophize About Pain Prior to Surgery.

Physical therapy visit number and timing following knee arthroplasty (KA) are variable in daily practice. The extent to which the number and timing of physical therapy visits are associated with current and future pain and function-and, alternatively, whether pain and function are associated with the number of future physical therapy visits following KA-are unknown. The purpose of this study was to determine temporal and reciprocal associations between the number of physical therapy visits and future pain and function in people with KA. A cross-lagged panel design was applied to a secondary analysis of data from a randomized clinical trial of patients with pain catastrophizing. The 326 participants underwent KA and completed at least 7 of 9 health care diaries over the year following surgery. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and physical function subscales were completed preoperatively and multiple times during follow-up. Separate cross-lagged panel analyses were conducted for WOMAC pain and physical function. From surgery to 2months postsurgery, reciprocal associations were generally not found between physical therapy visit number and future pain or function. From 2 to 6months postsurgery, a greater number of physical therapy weekly visits were associated with higher (worse) 6-month pain and function. Higher (worse) WOMAC pain at 2 and 6months led to more visits from 2 to 6 and 6 to 12months, respectively. Higher pain scores 2months postsurgery were associated with higher physical therapy use in the 2 to 6months following surgery. However, patients with increased physical therapy use from 2 to 6months had significantly higher pain scores 6months postsurgery. Those patients with persistent pain 6months postsurgery were higher users of physical therapy 6 to 12months postsurgery. This reciprocal positive association between pain and physical therapy during this time period suggests minimal benefit of physical therapy despite an increased physical therapy use for patients with higher pain. This is the first study to determine the association between the number and timing of physical therapy visits and current and future pain and function. Based on the results, physical therapy might not be a cost-effective strategy to treat patients with persistent pain following KA.

Cost-Minimization Analysis and Treatment Trends of Surgical and Nonsurgical Treatment of Proximal Humerus Fractures

Recent evidence demonstrated similar outcomes between nonsurgical and surgical management of displaced proximal humerus fractures. We analyzed treatment trends and performed a cost-minimization analysis comparing nonsurgical treatment, open reduction and internal fixation, reverse total shoulder arthroplasty, and hemiarthroplasty. We hypothesized that rates of surgical treatment have increased and that the costs associated with surgery are greater compared with nonsurgical management of proximal humerus fractures. We used a US private-payer claims database of 22 million patient records from 2007 to 2016 to compare (1) cost for the episode of care from the payer perspective between each surgical group and nonsurgical treatment of proximal humerus fractures, and (2) annual trends and complication rates of each group. Cost data, including facility fees, physician fees, physical therapy, and clinic visits, were used to complete a cost-minimization analysis. Nonsurgical treatment was associated with lower average total costs compared with surgical intervention. Facility and physician fees accounted for most of this difference. Physical therapy costs and number of physical therapy visits were higher in each surgical group compared with nonsurgical treatment. Surgical treatment was associated with higher complications, revision rates, and length of stay. There was a small but statistically significant decrease in nonsurgical management of proximal humerus fractures between 2007 and 2016. No change was observed in rates of open reduction and internal fixation, whereas rates of reverse total shoulder arthroplasty increased and rates of hemiarthroplasty decreased. Nonsurgical management of proximal humerus fractures decreased during the study period. In the setting of treatment equipoise, cost-minimization analysis favors nonsurgical management of proximal humerus fractures. Surgical management is associated with higher complication rates, revision rates, and length of stay. Economic Decision Analysis IV.

The effect of different physical therapy procedures in ultramarathons

Abstract Aims: To analyze the effects of physical therapy procedures in reducing acute pain in runners. A second aim was to investigate the impact of weather conditions on the number of physical therapy visits during the Ultramarathon Rio24 h. Methods: This retrospective study was performed at the Physical Education Center Admiral Adalberto Nunes (CEFAN). Medical records were analyzed. The participants were athletes that were attended by the Physical therapy team during three editions of the Ultramarathon Rio24 h. The variation in the Visual Analog Scale score (VAS) before and after each treatment were analyzed. After the evaluation procedure, another professional had decided the best procedure for the assessed athlete: massotherapy, cryotherapy by immersion, or stretching. An ANOVA was performed to assess which procedures produce pain reduction immediately after the procedure. Results: A total of 1,995 care services (228 in women) were performed in 602 athletes (84 women). Analyzing the treatments that used only one modality (n = 512 visits), the final pain decreased significantly over the initial pain for the three treatments. It was verified that massotherapy, cryotherapy, and stretching promote significant intragroup differences, with no intergroup differences. The environmental conditions were not associated with the number of visits. Conclusion: Massotherapy, cryotherapy, and stretching are effective treatments for acute pain reduction during ultramarathons. The weather conditions are not associated with the number of physical therapy visits.

UTILIZATION OF ELECTRONIC HEALTH RECORD TO IMPROVE MOBILITY IN A SURGICAL ICU

SESSION TITLE: Tuesday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM PURPOSE: Early mobilization in intensive care units has become standard practice with widely recognized benefits. Achieving inter-professional communication among clinicians, nurses, and physical therapists can be challenging. We hypothesize that development of a novel integrated electronic health record (EHR) tool will help in increased mobility and decreased hospital length of stay (LOS) by clearly communicating patient’s mobility goals of the day with various disciplines. METHODS: A new EHR tool was designed to capture and track mobility goals established on rounds and achievements documented by both nursing staff and physical therapists. We conducted a retrospective cohort study comparing mobility progression of critically ill patients during surgical intensive care unit (SICU) stay for 3 months prior (November to January 2017-2018) and 3 months after (November to January 2018-2019) implementation of the new tool. Data collected included total number of physical therapy (PT) visits, mobility progression, and hospital LOS. RESULTS: We reviewed 298 SICU patients in our retrospective cohort study; 172 pre-intervention, 126 post-intervention. In the pre-intervention cohort, 95/172 (55%) patients progressed to the preset mobility level while 83/126 (66%) progressed in the post-intervention group (p=.06). The mean hospital LOS decreased from 35.26 days pre-intervention to 26.84 days post-intervention (p = 0.17). The number of total PT visits increased from 202 total visits pre-intervention to 245 post-intervention although this was not statistically significant (p = 0.09). The number of PT orders placed in the ICU in the pre-intervention group was 142 and in the post-intervention group was 187 (p=.0005). CONCLUSIONS: Mobility goals can vary on daily basis for an individual patient. Inability to establish these daily goals and communicate them to staff leads to inconsistent expectations and can hinder a patient’s progress. By clearly identifying mobility goals on rounds, tracking them and their achievement with reasons goals were not met, a deeper insight into the patient’s functional status and barriers for progression is gained. We utilized EHR tools including specific flowsheets, reports, dashboard and graphic displays to capture these elements. This intervention led to improvement in interdisciplinary communication and tracking, increased number of PT visits, improved mobility progression approaching statistical significance, and decreased hospital LOS. CLINICAL IMPLICATIONS: Utilization of integrated EHR mobility tools as an effective communication resource led to increased utilization of PT, increase in mobility progression, and improved hospital LOS. DISCLOSURES: No relevant relationships by Adel Bassily-Marcus, source=Web Response No relevant relationships by Roopa Kohli-Seth, source=Web Response No relevant relationships by Scott Leikin, source=Web Response No relevant relationships by Anthony Manasia, source=Web Response No relevant relationships by Amira Mohamed, source=Web Response No relevant relationships by John Oropello, source=Web Response

Does Physical Therapy Produce Value for Post-Operative and/or Non-Operative Foot and Ankle Patients?

Category:OutcomesIntroduction/Purpose:Healthcare is at a unique time in history where patient reported outcomes have become important in assessing value and subsequent reimbursement with pay-4-performance initiatives. It is unclear whether physical function, pain and depressive symptoms can assist providers determine if additional physical therapy may improve care for foot and ankle patients considering post-op and/or non-operative care. The purpose of this research was to examine symptom severity (PROMIS PF, PI, and Dep) after surgery or with non-operative care at the start of formal physical therapy to determine if this symptom severity presentation and/or change in symptoms over time are predictors of improvement in physical function as assessed by PROMIS PF.Methods:PROMIS scales were available at the start and end of physical therapy treatment for 377 patients with foot and ankle ICD10 codes. The mean age (40.2±18.1 years), body mass index (BMI) (28.9±7.9 kg/m2), and proportion of females (62.1%) were recorded. The median number of physical therapy visits was 5 (interquartile range=5). Clinical categories of greater than 20 were identified for 7 groups including: Achilles rupture (n=24), Fracture (n=34), Ankle Pain (n=105), Foot Pain (n= 50), Ankle Sprain (n=51), Achilles Non-Rupture (n=45) and Other (n=68). Two multivariate linear regression models; 1) solely using data available at the start of therapy (age, gender, BMI, diagnosis category, PROMIS scores at the start of physical therapy); And, 2) a second model adding change in PROMIS PI, DP and completed visits to model 1 were examined for their ability to predict change in PF (Start to end of physical therapy).Results:The average change in PROMIS PF was 6.5±8.8 with a range of -20 to 49.1. Correlations of PROMIS scales at the start of therapy with change in PROMIS PF were r-values <0.48. Correlations among change in PROMIS PI and Dep with PF scales were r- values <0.38. The first model predicting change in PF based on available data at the start of physical therapy included PROMIS PF(p<0.01), PI(p<0.01) and Dep(p=0.03) at the start of physical therapy (r-value = 0.58 an r-value increase of 0.1 over univariate correlations). No other variables were significant. The second model included PROMIS PF(p<0.01), PI(p<0.01) and Dep (p=0.05) and change in PI(p<0.01), Dep(p=0.01) and visits completed (p<0.01) achieving an r-value = 0.75 (an r-value increase of 0.27 over univariate values) (Figure 1).Conclusion:Providers should consider patients who present with more severe symptoms as good candidates for formal physical therapy. Positive trends during therapy suggest that patient may continue to improve. Severity of PI and Dep at the start of PT were independent predictors of improvements in PF. Using PROMIS assessments, appropriate referrals can be made to physical therapy to improve physical function and add value to the health of our patients.

Level of participation in physical therapy or an internet-based exercise training program: associations with outcomes for patients with knee osteoarthritis

BackgroundTo examine whether number of physical therapy (PT) visits or amount of use of an internet-based exercise training (IBET) program is associated with differential improvement in outcomes for participants with knee osteoarthritis (OA).MethodsA secondary analysis was performed using data from participants in 2 arms of a randomized control trial for individuals with symptomatic knee OA: PT (N = 135) or IBET (N = 124). We examined associations of number of PT visits attended (up to 8) or number of days the IBET website was accessed during the initial 4-month study period with changes in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total, pain and function subscales, as well as a 2-min Step Test, at 4-month and 12-month follow-up.ResultsParticipants with more PT visits experienced greater improvement in WOMAC total score (estimate per additional visit = − 1.18, CI 95% = − 1.91, 0.46, p < 0.001) and function subscore (estimate = − 0.80, CI 95% = − 1.33, − 0.28, p < 0.001) across follow-up periods. For WOMAC pain subscale, the association with number of PT visits varied significantly between 4- and 12-month follow-up, with a stronger relationship at 4-months. There was a non-significant trend for more PT visits to be associated with greater improvement in 2-min Step Test. More frequent use of the IBET website was not associated with greater improvement for any outcome, at either time point.ConclusionIncreased number of PT visits was associated with improved outcomes, and some of this benefit persisted 8 months after PT ended. This provides guidance for PT clinical practice and policies.Trial registrationNCT02312713, posted 9/25/2015.