Outpatient Physical Therapists Research Articles

Pelvic Osteomyelitis Presenting as Groin and Medial Thigh Pain: A Resident's Case Problem

Resident's case problem. Groin pain represents a diagnostic challenge and requires a diagnostic process that rules out life-threatening illness or disease processes. Osteomyelitis is a potential fatal disease process that requires accurate diagnosis and medical management. Osteomyelitis presents a problem for the outpatient physical therapist, as the described physical findings for the diagnosis of osteomyelitis are nonspecific. A 67-year-old man with groin and bilateral medial thigh pain was referred for physical therapy care to address right adductor weakness and generalized deconditioning. He had undergone extensive treatment for bladder cancer, with a recent radical cystoprostatectomy and cutaneous urinary diversion with an Indiana pouch. Postsurgical magnetic resonance imaging indicated normal findings, and the patient was currently being managed by an orthopaedic surgeon, who diagnosed the patient as having obturator nerve palsy. The physical therapist's examination produced findings inconsistent with this diagnosis. Subsequently, nuclear medicine studies revealed pubic symphysitis/osteomyelitis with secondary myositis, predominantly affecting the right adductor muscles. Osteomyelitis represents a difficult problem for the outpatient physical therapist. Careful consideration of red-flag symptoms and inconclusive physical testing indicate the need for further medical work-up. In this case, appropriate medical management led to improvement in patient function, highlighting the need for early diagnosis. Differential diagnosis, level 4.

Implementing treatment frequency and duration guidelines in a hospital-based pediatric outpatient setting: administrative case report.

Determining treatment frequency and duration of physical therapist services is an important component of outpatient pediatric physical therapist practice, yet there is little research available to inform these decisions. Treatment frequency guidelines (TFG) can assist decision making in guiding pediatric physical therapy. The purpose of this project was to examine the feasibility and application of implementing TFG in hospital-based pediatric outpatient physical therapy. Previously developed TFG were modified for use in our pediatric outpatient physical therapy department to include duration and were referred to as treatment frequency and duration guidelines (TFDG). In order to successfully implement the TFDG, there were 2 phases to the project. In phase 1, the staff were provided the guidelines and procedures in a staff meeting and via email using a PowerPoint presentation. Phase 2 was initiated due to the poor response of the staff in implementing the guidelines in their practice after phase 1. The format was changed to include formal re-education via small-group and one-on-one education sessions (phase 2). Chart reviews were completed to assess therapists' adherence to using TFDG. Therapists' adherence to use of TFDG increased following re-education: phase 1 (n=225 charts, 31% adherence) and phase 2 (n=197 charts, 90% adherence). Treatment frequency and duration guidelines may assist in guiding frequency and duration decisions in pediatric physical therapy. Education via in-person meetings may improve adherence among staff.

Physical Therapistsʼ Perceptions of Knowledge and Clinical Behavior Regarding Cardiovascular Disease Prevention

The study purpose was to assess perceptions of physical therapists (PTs) regarding the role of physical therapy in cardiovascular disease (CVD) prevention. A 25-item survey, validated by expert cardiovascular/pulmonary (CVP) PTs, was sent electronically to 2,673 PTs. Each item represented an element of clinical practice behavior: education of CVD/risk factors (EDCVD), administration of primary CVD prevention (PRECVD), identifying underlying CVD/risk factors (IDCVD), monitoring CV status in patients with CVD (MONCVD). Responses were assigned numeric values (strongly agree = 5 to strongly disagree = 1), and mean element scores were analyzed. Most of the 516 respondents were APTA Section members (34% CVP Section, 42% other Section membership) and worked in academia (53%). Items showing a high (> 95%) level of agreement included patient education of smoking (97%) and monitoring exercise intensity (99%), assessing exercise benefits (99%), clinically identifying obesity (97%) and hypertension (97%), and monitoring CV response to exercise (99%). Items failing to reach 80% overall agreement were patient education of CVD medications (79%) and blood chemistry (72%), and assessing CVD family history (75%), patient BMI (60%), and body composition (33%). Identifying underlying CVD (77.2%) was the only practice behavior failing to reach 80% agreement. Outpatient PTs agreed significantly less to all elements vs. academics, and to IDCVD vs. all PTs except home health. Physical therapists support most CVD prevention behaviors, but not given elements of patient education and identifying underlying CVD/risk factors.

Differential diagnosis of a patient with low back and toe pain

Low back pain is one of the most commonly treated conditions by outpatient orthopedic physical therapists. The management of low back pain is also responsible for a large economic burden in the United States and internationally, which highlights one of the many reasons why appropriate medical screening and referral is important in the physical therapy setting. The purpose of this case report is to describe the successful physical therapist screening and subsequent medical differential diagnosis of a 36- year-old male with chronic lower back and toe pain. Initial physical therapy evaluation supported a diagnosis of mechanical low back pain, but symptom progression through two treatment sessions indicated that a non-mechanical source of pain was instead the likely cause of the patient’s symptoms. The referring physician was contacted by the physical therapist and the patient was scheduled for further medical examination. A consult to rheumatology was placed and through compilation of clinical, laboratory, and imaging findings, a diagnosis of human leukocyte antigen B-27-positive spondyloarthropathy was made. Even with physician referral, it is imperative for clinicians to be proficient in screening for non-mechanical low back pain that may mimic a musculoskeletal origin of symptoms.

Physical Therapists’ Use of Interventions With High Evidence of Effectiveness in the Management of a Hypothetical Typical Patient With Acute Low Back Pain

Evidence-based practice aims to improve patient care and service delivery, particularly in the management of individuals with low back pain (LBP), the largest client group seen by outpatient physical therapists. The purpose of this study was to determine the prevalence of use of interventions with evidence of effectiveness in the management of acute nonspecific LBP by physical therapists. A multicenter cross-sectional study was conducted on 100 physical therapists working with patients with LBP. Using a telephone-administered interview, therapists described their current and desired treatment practices for a typical case of LBP. Each intervention reported was coded according to its evidence of effectiveness (strong, moderate, limited, or none). Information on clinician, workplace, and client characteristics also was obtained. The prevalence of use of interventions with strong or moderate evidence of effectiveness was 68%. However, 90% to 96% of therapists also used interventions for which research evidence was limited or absent. Users of interventions with high evidence of effectiveness, as compared with nonusers, had graduated more recently and had taken a higher number of postgraduate clinical courses. Although most therapists use interventions with high evidence of effectiveness, much of their patient time is spent on interventions that are not well reported in the literature. The results indicate the need for improvement in the quality of clinical research as well as its dissemination and implementation in a way that is appealing to therapists, such as through practice-related courses.

Current Status and Correlates of Physicians' Referral Diagnoses for Physical Therapy

Randomized multicenter retrospective chart review of medical referral diagnoses and corresponding referral, patient, and physician demographic data. To examine the information content of medical referral diagnoses provided to outpatient physical therapists with respect to physician and patient characteristics. Previous studies indicate that physicians commonly provide nonspecific referral diagnoses to physical therapists. The effects of patient and physician characteristics on information contained in referral diagnoses are not well elucidated. A team of blinded raters categorized the information content of referral diagnoses (n = 2183) using a classification system adapted from a previous study. One third (32%) of analyzed diagnoses were anatomically oriented and reported specific pathology. These specific diagnoses were provided significantly more commonly by specialist physicians (odds ratio [OR], 3.4; 95% confidence interval [CI], 2.7-4.2; P < .001), male physicians (OR, 2.2; 95% CI, 1.6-3.1; P < .001), both early- and late-career physicians (P < .001), and for male patients (OR, 1.3; 95% CI, 1.1-1.6; P < .05). Nonspecific referral diagnoses are frequently provided to physical therapists by physicians. The practice of evidence-based physical therapy seems challenged by the high rate of nonspecific referral diagnoses. Physical therapists may also have the responsibility to conduct differential diagnosis of pathology more commonly than formally recognized by many state practice acts and third-party payers.

Exercise therapy for low back pain: A small-scale exploratory survey of current physiotherapy practice in the Republic of Ireland acute hospital setting

A small-scale exploratory cross-sectional survey investigated the current use of a range of exercise therapy approaches for low back pain (LBP) by outpatient physiotherapists in the acute hospital setting in the Republic of Ireland, where the majority of publicly funded treatment is delivered. Of the 120 postal questionnaires distributed to 24 physiotherapy departments, 87 were returned (72.5% response rate). The results showed specific spinal stabilization exercises were the most popular exercise therapy for acute (39%; n = 35 ) and chronic (51%; n = 48 ) LBP, followed by the McKenzie approach (acute LBP (ALBP) 35.6%; n = 32 : chronic LBP (CLBP) 17%; n = 16 ), and abdominal exercise (ALBP 11.1%; n = 10 : CLBP 9.6%; n = 9 ). The most popular forms of exercise therapy used by outpatient physiotherapists in acute hospital settings in Ireland lack support from evidence-based clinical guidelines, and further large-scale high quality randomized controlled trials of these approaches are warranted. Further research should also establish the use of exercise therapy and attitudes to clinical guidelines of physiotherapists in other countries and healthcare settings.

Chronic Lateral Epicondylitis: Survey of current practice in the outpatient departments in Scotland

Summary Chronic lateral epicondylitis has been identified as one of the most common lesions of the upper limb ( Thurston, 1999 Thurston AJ ‘Conservative and surgical treatment of tennis elbow: A study of outcome’. Australian and New Zealand Journal of Surgery. 1999; 68: 568-572 Crossref Scopus (22) Google Scholar ). However, a literature search of Medline, Embase (Exerpta Medica) and CINAHL revealed limited published evidence regarding treatment protocols used by physiotherapists in the management of this condition. A survey of opinions of outpatient physiotherapists regarding their current practice of chronic lateral epicondylitis was therefore carried out in a random sample of National Health Service outpatient departments in Scotland. The questionnaire was completed by 120 physiotherapists, giving a response rate of 80%. According to 77.3% of respondents, lateral epicondylitis patients always or frequently present with chronic symptoms. A sizeable proportion of respondents (67.5%) indicated that their chronic lateral epicondylitis patients have a poor understanding of their condition. The importance of joint protection techniques was highlighted with 83.3% of the respondents reporting that they demonstrated protection techniques to patients. Only 1.7%, however, provided written information about these techniques for future reference. Respondents identified pain upon resisted wrist extension (88.3%) and palpation of the wrist extensor origin (63.3%) as diagnostic tests for chronic lateral epicondylitis. Differential diagnosis tests were identified as cervical spine examination and radial nerve tension test by 67.5% and 66.7% of respondents, respectively. Range of motion was the most commonly used outcome measure with 83.3% of respondents using it always or frequently. Only one respondent indicated a defined departmental protocol regarding the management of chronic lateral epicondylitis, although much agreement was found regarding treatment. Progressive stretching (88%) and strengthening exercises (75.8%) were always or frequently used by respondents. This study has provided information regarding current physiotherapeutic approaches to chronic lateral epicondylitis and identified the latest published evidence. However, this condition will continue to be a therapeutic challenge until more evidence regarding best practice is available and physiotherapists acknowledge that it is a multi-factorial condition. Chronic lateral epicondylitis has been identified as one of the most common lesions of the upper limb ( Thurston, 1999 Thurston AJ ‘Conservative and surgical treatment of tennis elbow: A study of outcome’. Australian and New Zealand Journal of Surgery. 1999; 68: 568-572 Crossref Scopus (22) Google Scholar ). However, a literature search of Medline, Embase (Exerpta Medica) and CINAHL revealed limited published evidence regarding treatment protocols used by physiotherapists in the management of this condition. A survey of opinions of outpatient physiotherapists regarding their current practice of chronic lateral epicondylitis was therefore carried out in a random sample of National Health Service outpatient departments in Scotland. The questionnaire was completed by 120 physiotherapists, giving a response rate of 80%. According to 77.3% of respondents, lateral epicondylitis patients always or frequently present with chronic symptoms. A sizeable proportion of respondents (67.5%) indicated that their chronic lateral epicondylitis patients have a poor understanding of their condition. The importance of joint protection techniques was highlighted with 83.3% of the respondents reporting that they demonstrated protection techniques to patients. Only 1.7%, however, provided written information about these techniques for future reference. Respondents identified pain upon resisted wrist extension (88.3%) and palpation of the wrist extensor origin (63.3%) as diagnostic tests for chronic lateral epicondylitis. Differential diagnosis tests were identified as cervical spine examination and radial nerve tension test by 67.5% and 66.7% of respondents, respectively. Range of motion was the most commonly used outcome measure with 83.3% of respondents using it always or frequently. Only one respondent indicated a defined departmental protocol regarding the management of chronic lateral epicondylitis, although much agreement was found regarding treatment. Progressive stretching (88%) and strengthening exercises (75.8%) were always or frequently used by respondents. This study has provided information regarding current physiotherapeutic approaches to chronic lateral epicondylitis and identified the latest published evidence. However, this condition will continue to be a therapeutic challenge until more evidence regarding best practice is available and physiotherapists acknowledge that it is a multi-factorial condition.

A controlled trial of behavioural education to promote exercise among physiotherapy outpatients

This pilot study aimed to test a behavioural intervention by outpatient physiotherapists to promote moderate physical activity among their clients for general health reasons. A quasi-experimental study was conducted with 204 subjects. The intervention consisted of behavioural counselling, information brochures and a physical activity diary. Self-reported physical activity was measured at baseline and at six weeks follow-up. At follow-up, the improvements in total minutes of physical activity using the preceding week as the recall period were substantial in both the control and intervention groups, but not significantly different. In the average weekly physical activity reported by subjects for the preceding six months, intervention subjects were significantly more likely to report a 60min/wk improvement than controls (adjusted odds ratio 2.97, 95% confidence interval [CI] 1.36-6.46). However, this was the only significant difference evident between the groups in the average weekly physical activity measures. Pre- and post-surveys completed by participating physiotherapists showed marked improvements in their knowledge and confidence regarding physical activity promotion. While the capacity of outpatient physiotherapists to educate clients about physical activity for non-therapeutic reasons can be improved, the most effective intervention model for clients in this setting remains unclear.

Physical therapists' recognition of battered women in clinical settings.

The purposes of this study were to describe physical therapists' knowledge regarding battered women and to determine whether physical therapists recognize these patients in clinical settings. Two hundred questionnaires were distributed to outpatient physical therapists in northern California. One hundred fifty-one usable questionnaires (76%) were returned. Although 43% of the respondents reported treating a patient they identified or strongly suspected as having been battered, only two respondents (1%) reported they routinely asked patients about physical abuse. Less than 50% of the respondents correctly identified that battering injuries are more likely to occur in a central pattern (ie, head, neck, chest, abdomen). The results of this survey suggest that physical therapists have treated patients who are battered. Many physical therapists, however, may not be fully educated to detect the signs of abuse. This study is the first step in initiating physical therapy research in domestic violence identification and education.

DO OUTPATIENT PHYSIOTHERAPISTS IN WALES HAVE ADEQUATE KNOWLEDGE AND EXPERIENCE OF INTELLECTUAL DISABILITY

AbstractAs people with an intellectual disability are resettled from institutions, the likelihood increases that physiotherapists working in outpatient departments will have patients who have an intellectual disability. This study, therefore, sought to establish from a sample of 88 outpatient physiotherapists the degree of their knowledge of the All Wales Strategy for the Development of Services for the Mentally Handicapped, die adequacy of their experience and knowledge to treat this particular client group effectively and their attitudes towards people with intellectual disabilities. Although physiotherapists were generally aware of the principles of the AWS, 88% did not know its specific objectives. They had very little experience and knowledge of intellectual disability, 77% believing themselves inexperienced. Nevertheless, a large majority held positive attitudes towards this client group and agreed in principle with integration into the community. Training with respect to people who exhibit challenging behaviour was identified as necessary.