Outpatient Orthopedic Setting Research Articles

Perception and Satisfaction of Undergraduate Medical Students of the Mini Clinical Evaluation Exercise Implementation in Orthopedic Outpatient Setting.

PurposeThe Mini Clinical Evaluation Exercise (mini-CEX) is a brief and direct observational assessment of trainee-patient interactions that helps to assess several clinical domains. There is limited evidence of mini-CEX implementation in orthopedics and undergraduate perceptions toward such an approach. This study investigated the perception of mini-CEX among undergraduate medical students through a questionnaire-based survey in an orthopedic outpatient setting.Patients and MethodsUndergraduate medical students completing their orthopedic clinical posting were invited to participate in an anonymous, self-administered questionnaire written in English to evaluate their perceptions toward mini-CEX implementation in the orthopedic outpatient setting for the 2016–2017 academic session. The questionnaire comprised 28 closed-ended questions with a five-point Likert rating-scale, and five open-ended questions. The survey responses were analyzed for reliability, validity, and quantitative and qualitative analyses.ResultsA total of 350 students completed the questionnaire; the questionnaire was proven to be valid and reliable. The closed-ended questions were designed to assess the knowledge of the mini-CEX as an assessment tool. The participants demonstrated a satisfactory understanding of the mini-CEX methodology, purpose, clarity, comprehensiveness, and as a self-assessment tool for undergraduate medical students. Instructor support for the implementation of mini-CEX appeared inadequate and was rated with non-confidence among most students. Most participants appreciated better clinical skills, which was reflected through improvements in clinical exam preparation, the Objective Structured Clinical Examination, and clinical judgment.ConclusionUndergraduate medical students perceived the mini-CEX as an effective tool for clinical teaching in an outpatient orthopedic setting. However, most students indicated suboptimal instructor involvement in the teaching and assessment process; this raises concerns regarding inadequate direct observation and limited feedback for student performance. Additional measures are needed to ensure high quality clinical encounters, teacher training, integration with other assessment tools, and standardized coverage mini-CEX implementation in orthopedics.

A Digital Mental Health Intervention in an Orthopedic Setting for Patients With Symptoms of Depression and/or Anxiety: Feasibility Prospective Cohort Study

BackgroundSymptoms of depression and anxiety commonly coexist with chronic musculoskeletal pain, and when this occurs, standard orthopedic treatment is less effective. However, mental health intervention is not yet a routine part of standard orthopedic treatment, in part because of access-related barriers. Digital mental health intervention is a potential scalable resource that could be feasibly incorporated into orthopedic care.ObjectiveThis study’s primary purpose was to assess the feasibility of introducing a digital mental health intervention (Wysa) in an outpatient orthopedic setting to patients with coexisting symptoms of depression and/or anxiety. The secondary purpose was to perform a preliminary effectiveness analysis of the intervention.MethodsIn this single-arm, prospective cohort study, participants included adult patients (18 years and older) who presented to a nonsurgical orthopedic specialist at a single tertiary care academic center for evaluation of a musculoskeletal condition and who self-reported symptoms of depression and/or anxiety (Patient-Reported Outcomes Measurement Information System [PROMIS] Depression and/or Anxiety score ≥55). Face-to-face enrollment was performed by a research coordinator immediately after the participant’s encounter with an orthopedic clinician. Participants were provided 2 months of access to a mobile app called Wysa, which is an established, multicomponent digital mental health intervention that uses chatbot technology and text-based access to human counselors to deliver cognitive behavioral therapy, mindfulness training, and sleep tools, among other features. For this study, Wysa access also included novel, behavioral activation–based features specifically developed for users with chronic pain. Primary feasibility outcomes included the study recruitment rate, retention rate, and engagement rate with Wysa (defined as engagement with a therapeutic Wysa tool at least once during the study period). Secondary effectiveness outcomes were between-group differences in mean longitudinal PROMIS mental and physical health score changes at 2-month follow-up between high and low Wysa users, defined by a median split.ResultsThe recruitment rate was 29.3% (61/208), retention rate was 84% (51/61), and engagement rate was 72% (44/61). Compared to low users, high users reported greater improvement in PROMIS Anxiety scores (between-group difference −4.2 points, 95% CI −8.1 to −0.2; P=.04) at the 2-month follow-up. Between-group differences in PROMIS Depression (−3.2 points, 95% CI −7.5 to 1.2; P=.15) and Pain Interference scores (−2.3 points, 95% CI −6.3 to 1.7; P=.26) favored high users but did not meet statistical significance. Improvements in PROMIS Physical Function scores were comparable between groups.ConclusionsDelivery of a digital mental health intervention within the context of orthopedic care is feasible and has the potential to improve mental health and pain-related impairment to a clinically meaningful degree. Participants’ engagement rates exceeded industry standards, and additional opportunities to improve recruitment and retention were identified. Further pilot study followed by a definitive, randomized controlled trial is warranted.Trial RegistrationClinicalTrials.gov NCT04640090; https://clinicaltrials.gov/ct2/show/NCT04640090

Determinants of caregiver satisfaction in pediatric orthopedics.

This study investigates determinants of pediatric orthopedic surgery patients' parent or guardian (caregiver) satisfaction with the physician in an outpatient office setting. This was a cross-sectional survey study of 200 English-speaking caregivers of pediatric patients that checked into the pediatric orthopedic clinic at the authors' institution from 1 March 2017 to 1 November 2018. Questionnaires given in clinic include the Newest Vital Sign and The Literacy in Musculoskeletal Problems survey to measure general and musculoskeletal health literacy, respectively, demographic information, expected/estimated wait time, Consultation and Relational Empathy Measure, and Consumer Assessment of Healthcare Providers and Systems Clinician and Group. After multivariate regression, only perceived physician empathy as measured by the Consultation and Relational Empathy Measure score was significantly correlated with caregiver satisfaction (P < 0.0001), accounting for 56% of the variability of caregiver satisfaction scores. The odds of a satisfaction score of at least 9 out of 10 were 21% higher for every unit increase of the Consultation and Relational Empathy Measure score [odds ratio = 1.21 (P < 0.0001)]. After logistic regression, the caregiver's gender was also correlated with patient satisfaction and the odds of a patient satisfaction score ≥9 for males was less than 1/4th that of females [odds ratio = 0.16 (P = 0.040)]. The most important determinant of caregiver satisfaction with the physician in an outpatient pediatric orthopedic setting is perceived physician empathy. This accounts for the majority of the caregiver's satisfaction. This is the first study to determine this relationship in pediatric orthopedic surgery.

Patient Attitudes and Preferences for Orthopaedic Surgeon Greetings.

Numerous studies have demonstrated that patient-centered interaction promotes higher satisfaction and improved health outcomes, whereas poor communication behaviors have been associated with decreased satisfaction and an increased risk of malpractice claims. To our knowledge, no such study has investigated patient preferences for greetings and handshakes in the outpatient orthopaedic setting. A survey was generated with ranking and Likert scale questions regarding the initial patient-orthopaedic surgeon outpatient interaction. The survey was offered to adult patients at an urban, academic, outpatient orthopaedic surgery clinic. Surveys were completed by subjects while in the waiting room and returned before the first interaction with their orthopaedic surgeon. Completed surveys were collected from 160 patients over a 3-month period. Overall, medical knowledge was valued above other physician attributes, including the physician greeting (P < 0.001). Subjects preferred a more formal introduction by their physician, with the use of title and first and last name preferred to the physician's first name only (P < 0.001), first and last name only (P < 0.001), and title and last name only (P < 0.001). Patients strongly preferred their physician address them by their first name only compared with first and last name (P < 0.001). Shaking hands was determined to be moderately important and did not vary by any demographic category. Patients in this cohort considered their orthopaedic surgeon's greeting to be less important than their surgeon's medical knowledge, but more important than their appearance and attire. Respondents preferred their orthopaedic surgeon introduce themselves with their title, first name, and last name but to use the patient's first name only. The results of our study should be taken into consideration when greeting patients to facilitate rapport-building and improve the patient experience. Level IV, cross-sectional survey study.

PMS51 TRAJECTORIES OF FOLLOW-UP COMPLIANCE AND THEIR PREDICTORS IN A FRACTURE LIAISON SERVICE

Fracture Liaison Services (FLSs) aim to improve fragility fracture (FF) care for secondary prevention status. A systematic follow-up (FU) of FLS patients could help reduce the refracture rate. This study aims to identify groups of patients with similar FU compliance patterns over a systematic FU in a high-intensity FLS, and the factors influencing these FU trajectory patterns. Clinical data from a FLS with a 2-year systematic FU were merged to health administrative data. Participants (women and men aged >40 years with an incident FF) were recruited in an outpatient orthopedic setting, investigated for bone fragility and started on treatment when appropriate. Group-based trajectory modelling (GBTM) was used to identify trajectory groups of FU compliance over time. Patients were assigned to a trajectory group according to their posterior probability of group-membership. Predictors of trajectory groups were identified using multinomial logistic regressions. Of 532 participants, almost 86% were women and mean age was 63±11 years. Three trajectory groups of FU visit compliance were identified from GBTM: 1) 48.9% were high followers, 20.7% were intermediate followers, 30.4% were low followers. A lower femoral bone mineral density (OR=2.24, 95%CI 1.04-4.82), previous exposure to osteoporosis therapy (OR=1.76, 95%CI 1.02-3.04) and polypharmacy (OR=2.00, 95%CI 1.32-3.04) were predictors of being in the high followers’ compared to the low followers’ group; and those for being in the intermediate followers’ group were polypharmacy (OR=1.89, 95%CI 1.14-3.14) and referral to a bone specialist at baseline (OR=2.51, 95%CI 1.45-4.33). Results show that despite a high-intensity intervention, half the FLS patients will have an intermediate or low FU compliance pattern. This is important in the context of secondary prevention where subsequent FF risk is increased. Investigating the behavioural patterns of FU compliance with patient-centered research may help understand this phenomenon.

The Dimension of the Press Ganey Survey Most Important in Evaluating Patient Satisfaction in the Academic Outpatient Orthopedic Surgery Setting.

Many studies have examined modifiable and nonmodifiable patient factors influencing patient satisfaction scores. The objective of this study was to evaluate which of the 6 domains making up the Press Ganey Survey had a greater magnitude of relative importance in the expected relationship with patient satisfaction in outpatient orthopedic surgery encounters. Press Ganey Survey satisfaction scores from 4737 clinical encounters from adult reconstructive surgery, sports medicine, hand, foot and ankle, trauma, and general orthopedic clinics at a single academic center from November 2010 to May 2017 were reviewed. Multiple patient factors, modifiable and nonmodifiable, were recorded. The Press Ganey Survey was divided into 6 domains to evaluate the relative importance of each to total patient satisfaction. The standardized parameter estimates from the multiple linear regression revealed that of the 6 domains making up the Press Ganey Survey, care provider had the greatest magnitude of relative importance in the expected relationship with total patient satisfaction (ß=0.53972). Approximately 80% of the variance in total patient satisfaction was accounted for by the care provider. The relative importance of the remaining 5 domains was as follows: access (ß=0.23483), personal issues (ß=0.16796), moving through the visit (ß=0.16795), nurse/assistant (ß=0.10010), and special services/valet (ß=0.06302). A principal components analysis suggested a 6-factor solution for the Press Ganey total satisfaction scale; care provider was the most dominant factor, and valet parking services was the least. The care provider had the most influence on the patient's overall satisfaction. Altogether, access, personal issues, moving through the visit, nurse/assistant, and special services/valet accounted for only approximately 20% of the total variance in patient satisfaction. This knowledge can be used by providers in the current health care climate, where patient consumerism is developing into the driver of care. This could allow resources to be focused on areas of influence, yielding a greater impact on patient satisfaction scores. [Orthopedics. 2019; 42(4):198-204.].

Orthopaedic Physician Attire Influences Patient Perceptions in an Urban Inpatient Setting.

Prior research suggests that physician attire has an important effect on patient perceptions, and can influence the patient-physician relationship. Previous studies have established the effect of specialty, location, and setting on patient preferences for physician attire, and the importance of these preferences and perceptions on both the physician-patient relationship and first impressions. To date, no studies have examined the influence of attire in the inpatient orthopaedic surgery setting on these perceptions. (1) Do differences in orthopaedic physician attire influence patient confidence in their surgeon, perception of trustworthiness, safety, how caring their physician is, how smart their surgeon is, how well the surgery would go, and how willing they are to discuss personal information with the surgeon? (2) Do patients perceive physicians who are men and women differently with respect to those endpoints? Ninety-three of 110 patients undergoing orthopaedic surgery at an urban academic medical center participated in a three-part survey. In the first part, each patient was randomly presented 10 images of both men and women surgeons, each dressed in five different outfits: business attire (BA), a white coat over business attire (WB), scrubs alone (SA), a white coat over scrubs (WS), and casual attire (CA). Respondents rated each image on a five-point Likert scale regarding how confident, trustworthy, safe, caring, and smart the surgeon appeared, how well the surgery would go, and the patient's willingness to discuss personal information with the surgeon. In the second part, the respondent ranked all images, by gender, from the most to least confident based on attire. Pair-wise comparisons for women surgeons demonstrated no difference in patient preference between white coat over business attire compared with white coat over scrubs or scrubs alone, though each was preferable to business attire and casual attire (WS versus WB: mean difference [MD], 0.1 ± 0.6; 95% CI, 0.0-0.2; p = 1.0; WS versus SA: MD, 0.2 ± 0.7; 95% CI, 0-0.3; p = 0.7; WB versus SA: 0.1 ± 0.9; 95% CI, -0.1 to 0.2; p = 1.0). The same results were found when rating the surgeon's perceived intelligence, skill, trust, confidentiality, caring, and safety. In the pair-wise comparisons for male surgeons, white coat over scrubs was not preferred to white coat over business attire, scrubs alone, or business attire (WS versus WB: MD, -0.1 ± 0.6; 95% CI, 0-0.1; p = 1.0; WS versus SA: MD, 0 ± 0.4; 95% CI, -0.2 to 0; p = 1.0; WS versus BA: MD, 0.2 ± 0.8; 95% CI, 0-0.4; p = 0.6). WB and SA were not different (MD, 0.0 ± 0.6; 95% CI, -0.1 to 0.2; p = 1.0), though both were preferred to BA and CA (WB versus BA: MD, 0.3 ± 0.8; 95% CI, 0.1-0.5; p = 0.02; WB versus CA: 1.0 ± 1.0; 95% CI, 0.8-1.2; p < 0.01). We found no difference between SA and BA (MD, 0.3 ± 0.7; 95% CI, 0.1-0.4; p = 0.06). We found that each was preferred to CA (SA versus CA: 0.9 ± 1.0; 95% CI, 0.7-1.2; p < 0.01; BA versus CA: 0.7 ± 1.0; 95% CI, 0.5-0.9; p < 0.01), with similar results in all other categories. When asked to rank all types of attire, patients preferred WS or WB for both men and women surgeons, followed by SA, BA, and CA. Similar to findings in the outpatient orthopaedic setting, in the inpatient setting, we found patients had a moderate overall preference for physicians wearing a white coat, either over scrubs or business attire, and, to some extent, scrubs alone. Respondents did not show any difference in preference based on the gender of the pictured surgeon. For men and women orthopaedic surgeons in the urban inpatient setting, stereotypical physician's attire such as a white coat over either scrubs or business attire, or even scrubs alone may improve numerous components of the patient-physician relationship and should therefore be strongly considered to enhance overall patient care. Level II, therapeutic study.

An Evaluation of Digital Imaging Studies in an Outpatient Orthopedic Setting.

Distribution of radiographic images in the outpatient setting on compact discs-recordable (CD-R) is commonplace. Opening, manipulating and interpreting these can be challenging. This study evaluated the availability and ease of use of CD-R to evaluate digital images in an outpatient orthopedic setting. 118 CD-R containing diagnostic studies were evaluated by seven board certified orthopaedic surgeons. Surgeon age and self-perceived "tech savvy" scores were tabulated using a visual analog scale (VAS). Surgeons evaluated: ability and number of computers to open, autorun, and specific reader software. Time to load was recorded in seconds, type of study, presence of "not for diagnostic use", and if the disc required additional software. Studies were graded using a VAS for ease of opening, ability to move from image to image and/or between series, to manipulate the image, and to zoom and pan. There were 79 radiographs, 29 MRI's, and 10 CT scans. Seven (6%) had to be manually opened and four (3%) required software installation. Thirteen (11%) contained a warning that the studies should not be used for diagnostic purposes. Six (5%) of the studies could not be opened. For the opened studies, average time from disk insertion to image was 43.7 seconds overall (range 3-350), 65.3 seconds (range 21-191) for MRI and CT, and 35.2 seconds (range 5-177) for radiographs. The present digital imaging systems include different software types and a variety of interfaces. Improving this would decrease time and effort necessary to open and evaluate these studies, and improve efficiency. III.

Patient Preferences in Office-Based Orthopedic Care: A Prospective Evaluation.

Patient satisfaction has become a topic of interest within orthopedics as the landscape of provider reimbursement continues to evolve to reward value of care. Online internet physician rating sites are becoming increasingly popular ways for patients to subjectively express their provider experience. Understanding what patients value during their episode of care is important in the modern healthcare environment. The purpose of this study is to determine what preferences, if any, patients have when selecting their physician and how they experience care in an outpatient orthopedic setting. A prospective survey was electronically administered to 212 patients in an adult reconstruction clinic. One hundred ninety-six patients (92.5%) completed the survey. Demographic questions regarding age, sex, ethnicity, and prior adult reconstruction surgical history were obtained. When patients were asked how much time they would like the doctor to spend with them on a routine visit, the most common answer was 10 to 15 minutes (41.3%), with only 10.2% patients desiring >20 minutes. The majority of patients (83.1%) believe ≥30 minutes is too long to wait to see their surgeon. Less than half of patients (41.8%) stated that they would feel as though they were receiving below average care if seen only by a nurse practitioner or physician's assistant at a postoperative visit. Patients reported no significant age, gender, or ethnicity preferences for their physician. Recommendations from friends or other physicians was the most common (66.4%) way for patients to find their physicians, while 12.2% utilized online rating sites during their search. Optimizing patient experiences in the office may include keeping wait times to <30 minutes and educating patients on the roles of physician extenders. More work needs to be done to further elucidate variables influencing the subjective patient experience with their orthopedic care.

Extrapolation of Normative KOOS, JR Data for the Young Patient Population Undergoing Knee Arthroplasty Procedures

BackgroundThe Knee Injury and Osteoarthritis Outcome (KOOS), JR is a patient-reported outcome measure that is validated for patients undergoing total knee arthroplasty. The objective of this study was to provide normative data for the KOOS, JR in a relatively healthy US population visiting an outpatient orthopedic setting. This study is a cross-sectional study. MethodsNormative data from the KOOS questionnaire was used to calculate the subscale (pain, activity of daily living, and symptoms), raw, and interval scores for the KOOS, JR. The participants who completed the KOOS were devoid of current complaints of the hip, knee, and ankle. The means, standard deviations, medians, interquartile ranges, and percentiles for the KOOS, JR subscale, raw and interval scores were calculated by age decades, sex, laterality, and history of knee injuries in the past year. ResultsFour hundred two men and 598 women were involved in the analysis. The lowest mean interval scores were noted in the 56- to 64-year group with the greatest disparity between male and female compared to the rest of the age cohorts. Females scored high in all 3 subscales with a higher score in the pain subscale, denoting a lower normative value. Patients with hypertension scored with a significantly lower mean interval score than those without hypertension. In all subscales, tobacco use and hypertension were associated with a statistically significant negative effect on the normative scores. ConclusionThe normative values for the KOOS, JR can be used to set goals and follow the progress of patient satisfaction in regard to the knee after a knee arthroplasty procedure.

Does the use of ultrasound affect contamination of musculoskeletal injections sites?

Therapeutic musculoskeletal injections require a clean or sterile skin preparation to minimize the risk of infections. Ultrasound guidance for this procedure requires the use of transmission gel in proximity to the injection site, and its effect on maintaining sterility is unknown. We asked: (1) Does sterile ultrasound transmission gel increase skin contamination during therapeutic orthopaedic injections? (2) Does nonsterile gel application result in increased contamination? (3) Does a manufacturer-approved ultrasound probe disinfecting agent in the form of 17.2% isopropanol and 0.28% diisobutylphenoxyethoxyethyl dimethyl benzyl ammonium chloride wipes adequately decontaminate the ultrasound transducer? (4) Does 70% isopropyl alcohol effectively decontaminate skin for administration of musculoskeletal injections? Twenty-six healthy volunteers in an outpatient orthopaedic clinical setting were recruited. The subjects' skin was prepared to simulate a therapeutic intraarticular shoulder injection under ultrasound guidance. Four skin swabs for culture from each subject were taken: one sample before preparation with isopropyl alcohol, one sample after skin preparation, one after simulated injection procedure with sterile ultrasound transmission gel using the transducer, and one after mock procedure with nonsterile ultrasound transmission gel. In addition, samples were taken from the nonsterile ultrasound transmission gel and the transducer for culture analysis. Aerobic and anaerobic cultures were incubated during a 5-day period for bacterial species identification. Sterile ultrasound gel use results in an increase in skin contamination (odds ratio [OR], 9; 95% CI, 1.4-57.1; p=0.005). Compared with sterile gel use, application of nonsterile gel did not increase contamination proportion (OR, 1.1; 95% CI, 0.8-1.7; p=0.56). All cultures from nonsterile gel were negative. None of the samples cultured directly from the ultrasound probe were positive for bacteria (0%). Skin preparation with 70% alcohol decreased the proportion of contamination when compared with unprepared skin (OR, 21.0; 95% CI, 3.1-142.2; p=0.001). Use of ultrasound probes and transmission gel results in greater contamination in simulated intraarticular injections of the shoulder. As such, sterile preparation of the entire injection field, including the adjacent skin where the gel and probe are applied, may be prudent. Future studies are needed to determine if such a preparation decreases contamination and thereby infection rates related to musculoskeletal injections. Level II, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Anterograde Percutaneous Treatment for Lesser Metatarsal Fractures

Metatarsal (MTT) fractures are common injuries in the outpatient orthopedic setting. Lesser MTT fractures, although often technically simple, can lead to an inordinate number of unsatisfied patients. The objective of our study was to evaluate the results obtained using an anterograde percutaneous technique for lesser MTT fractures. To our knowledge, there are no previous publications about this technique. We performed a prospective study with 14 patients from 2003 to 2008, in which we evaluated the fracture location, mechanism of trauma, associated comorbidities, and American Orthopaedic Foot and Ankle Society’s functional score for postoperative clinical assessments. The most common fracture location was the MTT neck (79%). Involvement of multiple MTTs (53%) was more common than isolated fractures (47%), and low-energy trauma (79%) was more frequent than highenergy trauma (21%). Female patients with diabetes had the worst functional postoperative results. There were no postoperative complications related to our chosen technique. The surgical technique proposed was effective for treating lesser MTT fractures and had lower complication rates compared with other established techniques.

Secondary prevention of fragility fracture in patients with fracture neck of femur – Are we following nice guideline

s / Injury Extra 43 (2013) 71–127 123 new osteoporosis related fractures in the outpatient orthopaedic setting. A lead clinician for osteoporosis had been appointed at 46% of responding Trusts, with a consultant rheumatologist the lead at most. Conclusion: A large number of NHS Trusts across England do not have someone employed to identify fragility fractures associated with osteoporosis other than the orthopaedic doctor, and a lead clinician overseeing osteoporosis management is not appointed in more than half of responding Trusts in this study. We feel that this will lead to patients with osteoporotic fractures not being identified, as well as lack of assessment and overall treatment. Consequently, there is a missed chance for secondary prevention measuresandpotentiallypreventionof futureosteoporotic fragility fractures. http://dx.doi.org/10.1016/j.injury.2012.07.346

Diabetes and Associated Risk Factors in Patients Referred for Physical Therapy in a National Primary Care Electronic Medical Record Database

The prevalence of diabetes (type 2) in the general population has increased dramatically over the last decade, yet patients with diabetes are rarely referred for physical therapy management of their condition. The majority of patients referred for outpatient physical therapy have musculoskeletal-related conditions. Secondary conditions, such as diabetes, may be prevalent in this population, and physical therapists need to be aware of this to adjust interventions and treatment. The purpose of this article is to describe the prevalence of diabetes and the associated risk factors in adults referred for physical therapy in a primary care outpatient setting. Patients aged 18 years or older referred for physical therapy were identified from the Centricity Electronic Medical Records database during the period of December 13, 1995, to June 30, 2007. Patients were evaluated on the basis of clinical (height, weight, blood pressure, laboratory values), treatment (prescriptions), and diagnostic (ICD-9 codes) criteria to identify the presence of diabetes or associated risk factors (eg, hypertension, elevated triglycerides, low high-density lipoprotein, body mass index, and prediabetes). There were 52,667 patients referred for physical therapy, the majority of whom were referred for a musculoskeletal-related condition. Approximately 80% of the total study population had diabetes, prediabetes, or risk factors associated with diabetes. The prevalence of diabetes in the study population was 13.2%. Of the diabetes-associated risk factors evaluated, hypertension was the most prevalent (70.4%), and less than half (39.1%) of the study population had an elevated body mass index. Only 20% of the study population had values within normal limits for all clinical, treatment, and diagnostic criteria. Clinical and treatment measurements available to physical therapists identified the majority of associated risk factors. Although not the primary indications for referral, diabetes and associated risk factors were identified in a high proportion of the study population. The evaluation of associated conditions in the outpatient orthopedic setting needs to be considered for treatment planning adjustments and to optimize care.

Effective Osteoporosis Education in the Outpatient Orthopaedic Setting

Background: The orthopaedic surgeon may be the first medical specialist to interact with a patient with clinically important osteoporosis, providing an opportunity to educate that patient about this disease. The purpose of the present study was to investigate whether patients could be effectively educated with regard to osteoporosis and lifestyle modification during their outpatient visits to an orthopaedic surgeon's office. Methods: Eighty female patients ranging from fifteen to seventy-three years of age completed an eleven-question quiz that included items regarding their knowledge of osteoporosis, calcium intake, menopausal status, exercise, smoking, and whether or not they had had a bone mineral density scan. The quiz was completed during a visit to an outpatient sports medicine/general orthopaedic clinic. After the quiz, an educational intervention was performed by providing the patients with an informational handout. The patients were followed at an average interval of six months and were reassessed either in the office or over the telephone with use of the same quiz to evaluate increases in knowledge and modification of lifestyle. Results: Fifty-four premenopausal and twenty-six postmenopausal patients were available for follow-up. The premenopausal and postmenopausal groups differed at the beginning of the study, with premenopausal patients having a higher daily calcium intake (p = 0.008) and a better ability to define osteoporosis (p = 0.004) and postmenopausal patients having a higher rate of having had a prior bone mineral density scan (p < 0.001). In response to the educational intervention, significant improvements were seen in terms of the patients' ability to define osteoporosis (p = 0.004), the ability to identify being female as a major risk factor (p < 0.001), and the understanding that females should begin adequate calcium intake at a young age (p < 0.001). Significant increases in daily calcium intake (p < 0.001) and exercise level also occurred (p < 0.003). The postmenopausal group demonstrated a less robust response to the educational intervention. Conclusions: The outpatient orthopaedic sports medicine office setting represents a prime opportunity for education regarding osteoporosis prevention and lifestyle modification that can be performed in an inexpensive fashion and that can be easily replicated in most offices both in the community and in academic settings. Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Effective Osteoporosis Education in the Outpatient Orthopaedic Setting

The orthopaedic surgeon may be the first medical specialist to interact with a patient with clinically important osteoporosis, providing an opportunity to educate that patient about this disease. The purpose of the present study was to investigate whether patients could be effectively educated with regard to osteoporosis and lifestyle modification during their outpatient visits to an orthopaedic surgeon's office. Eighty female patients ranging from fifteen to seventy-three years of age completed an eleven-question quiz that included items regarding their knowledge of osteoporosis, calcium intake, menopausal status, exercise, smoking, and whether or not they had had a bone mineral density scan. The quiz was completed during a visit to an outpatient sports medicine/general orthopaedic clinic. After the quiz, an educational intervention was performed by providing the patients with an informational handout. The patients were followed at an average interval of six months and were reassessed either in the office or over the telephone with use of the same quiz to evaluate increases in knowledge and modification of lifestyle. Fifty-four premenopausal and twenty-six postmenopausal patients were available for follow-up. The premenopausal and postmenopausal groups differed at the beginning of the study, with premenopausal patients having a higher daily calcium intake (p = 0.008) and a better ability to define osteoporosis (p = 0.004) and postmenopausal patients having a higher rate of having had a prior bone mineral density scan (p < 0.001). In response to the educational intervention, significant improvements were seen in terms of the patients' ability to define osteoporosis (p = 0.004), the ability to identify being female as a major risk factor (p < 0.001), and the understanding that females should begin adequate calcium intake at a young age (p < 0.001). Significant increases in daily calcium intake (p < 0.001) and exercise level also occurred (p < 0.003). The postmenopausal group demonstrated a less robust response to the educational intervention. The outpatient orthopaedic sports medicine office setting represents a prime opportunity for education regarding osteoporosis prevention and lifestyle modification that can be performed in an inexpensive fashion and that can be easily replicated in most offices both in the community and in academic settings.

Guide to outcomes measurement for patients with low back pain syndromes.

The Guide for Physical Therapist Practice states that the physical therapist determines the expected outcomes for each intervention and engages in outcomes data collection and analysis. Outcomes tracking provides a systematic way for therapists to monitor treatment effectiveness and efficiency. A familiarity with outcome measures for the patient with low back pain is indispensable for therapists in the outpatient orthopaedic setting, where patients with lumbar pain often comprise the majority of the caseload. The therapist must be able to evaluate and choose appropriate measurement tools and understand the clinical meaning of measurements to successfully employ these instruments. The purpose of this article is to review measurement instruments for patients with low back pain and to offer practical guidelines for selection and use of outcome measures for this population. The reliability, validity, sensitivity to change, and utility of common outcome measures are discussed. An overview of generic, disease-specific, and patient-specific tools is provided with specific commentary on the use of the SF-36, SF-12, Oswestry Questionnaire, Roland-Morris Questionnaire, and patient-specific tools. Practical guidelines for utilizing outcome measures in clinical practice and the overall benefits of outcomes tracking are highlighted.

Clinical Reasoning of Expert and Novice Physiotherapists in an Outpatient Orthopaedic Setting

Summary The purpose of this qualitative study was to investigate the clinical reasoning of expert and novice physiotherapists in an outpatient orthopaedic setting. Ten experienced clinicians and ten students were observed and audiotaped as they examined and treated a real, previously unseen, patient. The audiotape was reviewed immediately afterwards with the therapists by means of a semi-structured interview. The subsequent analysis showed that all used a hypothetico-deductive reasoning process. However, the experts and novices went beyond this essentially diagnostic process to include reasoning focused on treatment. In particular, manual therapy treatment was used as a method of further hypothesis testing. In addition to hypothetico-deductive reasoning the experts also made use of pattern recognition. The clinical reasoning of the physiotherapists in this study was found to be a dynamic, cyclical process. The results of the study support the model of clinical reasoning proposed by Jones (1992) .