Outpatient Physical Therapy Practice Research Articles

Doing things you never imagined: Professional and ethical issues in the U.S. outpatient physical therapy setting during the COVID-19 pandemic

ObjectiveDespite being the most prevalent physical therapy practice setting in the United States, no literature to date has examined the professional and ethical issues faced by outpatient physical therapists during the COVID-19 pandemic. The purpose of this study was to explore professional and ethical issues experienced by outpatient physical therapists in the United States during the COVID-19 pandemic. DesignAn explorative semi-structured interview study using reflexive thematic analysis MethodsVirtual semi-structured interviews explored physical therapists’ experiences during COVID-19 in the OP setting. Data was analyzed using reflexive thematic analysis as described by Braun and Clarke. ResultsRespondents worked predominantly with patients with orthopaedic impairments. Six primary themes and associated subthemes were identified: 1) Disruption of routine professional and personal life. 2) Negative impacts on health and wellbeing (physical, mental, and social). 3) Barriers to relationships, communication, and providing quality care. 4) Telehealth as a safe option to increase access with opportunities and challenges. 5) Discomfort practicing in an environment of misinformation, mistrust, and divisiveness. 6) New & pre-existing ethical issues in the COVID-19 context. ConclusionsResults of this study indicate that physical therapists in the outpatient setting wrestled with critical questions regarding outpatient physical therapy practice during the COVID-19 pandemic: the role of touch in professional identity, challenges to the therapeutic alliance, effect of productivity and fiscal expectations and whether outpatient physical therapy is essential during public emergencies.

Recognition of a Severe Pathology in a Runner Presenting With Atraumatic Neck Pain: A Case Report

Background Acute neck pain is one of the most prevalent musculoskeletal disorders in the general population; however, neck pain may hide more serious pathologies. Case Presentation This case report describes the history, clinical presentation, and relevant findings of a 63-year-old male runner who presented to an outpatient private physical therapy practice for acute, atraumatic neck pain. After referral, the patient was diagnosed with a C2 lytic bone lesion (solitary plasmacytoma) and was stabilized with surgical spine fusion (C1-C5). Outcome and Follow-Up At the 3-month postsurgery follow-up, the patient completely resolved his pain and accepted loss of cervical rotation as a valuable compromise. Discussion This case report underlines the need for cautious evaluation in patients presenting with an apparent musculoskeletal disorder. Physical therapists should be able to identify red flags and rule out severe pathologies, guaranteeing the best health care assistance. JOSPT Cases 2021;1(3):161–165. doi:10.2519/josptcases.2021.10604

The Prevalence of No-Shows and Cancellations Rate in Outpatient Physical Therapy Practice and Its Relationship to Age and Gender

Background: No-Show and late canceled appointments significantly impact out-patient Physical therapist productivity, patient clinical outcomes, and the clinic's revenue-generating capacity. No-show and appointment cancelation cost the out-patient Physical Therapy practice in this case study $114,505.58CAD in 2017. This study seeks to understand, identify, and provide solutions unique to our local setting for the problem of no-shows and appointment cancellation.Methods: This study uses the 2017 de-identified patient’s attendance records of an out-patient Physical Therapy clinic in Calgary, Canada. Patient data, including sex, age, scheduled appointment, no-show, and cancellation history, were examined. The data were analyzed using chi-square to determine any significant differences in attendance patterns among these groups.Results: A total of 6,162 scheduled appointments were aggregated from the EHR. The overall no-show and cancelation was 20.6%. Male had a slightly higher rate of no-show/cancelation (20.8%) versus females (20.6%), which was not statistically significant (p = 0.734). In the adult age groups, no-show and cancelation rates were highest for 12-20y/o (31.4%), 21-30y/o (31.3%), and 41-50y/o (22.3%). These groups accounted for 50.6% of total revenue loss. There was a significant overall difference among the age groups (p < 0.0001) in no-show/cancelation. The top four reasons for no-show and cancellation include forgetting the appointment, family and personal emergency, lack of transportation, and a scheduling conflict with another equally important appointment.Conclusion: Evidence indicates that no-show and appointment cancelation rates are high in Canadian health institutions leading to poor productivity, inefficiency, and revenue loss. This study seeks to provide an evidence-based intervention.

The Long-Term Effectiveness of Trigger Point Dry Needling and Exercise for Individuals With Shoulder Pain: A Critically Appraised Topic.

Clinical Scenario: Shoulder pain is a very common symptom encountered in outpatient physical therapy practice. In addition to therapeutic exercise and manual therapy interventions, trigger point dry needling (TDN) has emerged as a possible treatment option for reducing shoulder pain and improving function. Dry needling consists of inserting a thin stainless-steel filament into a myofascial trigger point with the intention of eliciting a local twitch response of the muscle. It is theorized that this twitch response results in reduced muscle tension and can aid in reduced pain and disability. To this point, multiple studies have found TDN to be effective at reducing pain and improving function in the short-term, but the long-term outcomes remain unknown. Clinical Question: Does the addition of TDN to an exercise program result in better long-term pain intensity and disability reduction in patients with shoulder pain? Summary of Findings: Improvement in long-term pain and function can be expected regardless of the addition of TDN to an evidence-based exercise program for patients with shoulder pain. Clinical Bottom Line: Either TDN or an evidence-based therapeutic exercise program elicits improved long-term pain and disability reduction in patients with shoulder pain, which suggests that clinicians can confidently use either approach with their patients. Strength of Recommendation: Strong evidence (level 2 evidence with PEDro scores >8/10) suggesting that TDN does not outperform therapeutic exercise regarding long-term pain reduction.

Impact of electrodiagnostic (EMG/NCS) tests on clinical decision-making and patient perceived benefit in the outpatient physical therapy practice

BackgroundUtilizing Electromyography and Nerve Conduction Study (EMG/NCS) tests, when indicated, may have implications for efficient patient management and assist in more efficient referral to appropriate providers or specialists.Objective: To investigate the impact of Electromyography and Nerve Conduction Studies (EMG/NCS) on clinical decision-making and patient perspectives within PT practice settings. Methods462 patients, who were candidates for diagnostic testing (EMG/NCS) were included in this outcome study and questionnaire-based survey design. Pre-test diagnosis was compared to post-test diagnosis. Post-test, patients were asked to rate their perceived benefit of the testing. ResultsManagement was changed in 60.61% of patients post EMG/NCS testing (p < 0.0001). The diagnosis was changed post-EMG/NCS test in 39% of the patients with a change in management, which is greater than expected (p < 0.0004). There was no effect of gender or age (p > 0.05) on change in treatment (tx) or diagnosis (dx). 89.8% of patients agreed, or strongly agreed, that they were better able to understand their condition; 92.4% strongly agreed, or agreed, that they were reassured about their condition; 89.1% strongly agreed, or agreed, that they were better able to manage their condition and 92% reported very high, or high, value perceived from the EMG/NCS test administered. ConclusionThis study demonstrates that EMG/NCS testing appears to have a significant impact on clinical decision-making, and higher scores on the patient perceived benefit.

Illness perceptions associated with patient burden with musculoskeletal pain in outpatient physical therapy practice, a cross-sectional study

IntroductionMusculoskeletal pain (MSP) is a burden to patients and to society. In addition to well-known prognostic factors, illness perceptions (IPs) may be associated with pain intensity and physical functioning in MSP but their role is not fully understood. Our research focused on these questions: 1) Do IPs differ between patients with acute, sub-acute and persistent MSP 2) Are IPs, in addition to well-known prognostic factors, associated with pain intensity and with limitations in physical functioning? MethodsEligible MSP patients from 29 physical therapy practices were invited to participate in a cross-sectional study. IPs were measured with the Brief IPQ-DLV. We compared IPs between patients with acute, sub-acute and persistent MSP (1-way ANOVA with Tukey post-hoc tests). Secondly, associations between IPs with pain intensity and physical functioning were assessed (multiple linear regression). ResultsWith 658 participants, most IP dimensions showed small differences between acute, sub-acute or persistent pain. For pain intensity, the IP dimensions Consequences, Identity and Comprehensibility explained an additional 13.3% of the variance. For physical functioning, the dimensions Consequences, Treatment Control, Identity and Concern explained an additional 26.5% of the variance.Discussion/conclusion: Most IP dimensions showed small differences between acute, sub-acute or persistent pain. In addition to some well-known prognostic variables, higher scores on some IP dimensions are associated with higher pain intensity and more limitations in physical functioning in patients with MSP. Longitudinal studies are needed to explore the longitudinal associations.

2405 The Cult of the Occult Hernia and the Endometriosis Population

Study Objective Endometriosis is a condition in which tissue similar to but not the same as the lining of the uterus is found throughout the pelvic cavity. Pelvic Physical Therapy is a sub specialty of physical therapy focused on the hip, lower abdomen, and pelvis from the bones, to the muscles, including the pelvic floor, to the nerves and fascia. Ongoing pelvic pain post excision of endometriosis by a gynecology specialist may be treated by a pelvic physical therapist. In one year, a pelvic physical therapy practice specializing in endometriosis issues, multiple patients were suspected to have occult, or no bulge, hernias as sources of pelvic pain. The objective of this study is to examine in a retrospective analysis the impact of occult female hernia on pelvic pain post excision of endometriosis. Design Retrospective Analysis. Setting Outpatient Private Physical Therapy Practice specializing in endometriosis. Patients or Participants 35 Interventions Patients were evaluated based on nerve mapping and then were sent for MRI with a General Surgeon confirming presence of defect in the pre-peritoneal space. Measurements and Main Results In a one year period in a private physical therapy practice specializing primarily in endometriosis, out of 35 patients with endometriosis were screened for occult hernia's, no bulge hernias not seen within the retro-peritoneal space during excision of endometriosis, 22 were positive for nerve compressions onto either the ilioinguinal or genitofemoral nerves. Conclusion Occult hernia may contribute to pain during sex, genital pain, groin pain, pelvic floor pain, increased lower abdominal pain during menstruation, perceived urinary pressure and leg pain. In the patient with endometriosis hernia may be missed during follow-up visits and surgery with the gynecologist. As a driver in pelvic pain, occult hernia should become more widely recognized as a source of pelvic pain.

2406 The Role of Exercise in Decreasing Ongoing Pain in the Post-Excision Endometriosis Population

Study Objective Endometriosis is a painful disease affecting quality of life in nearly 176 million women worldwide. Even post excision of endometriosis patients may continue to experience pain across multiple systems from gynecological pain to abdominal and musculoskeletal pain. Current best practices leaves women with the disease few options beyond surgery, especially for those suffering with central sensitization and nerve up-regulation due to the long term adaptations of the disease. Pelvic Physical Therapy can be a critical component to mobilize the body post operatively. An exercise prescription designed by a physical therapist may help integrate and quiet long standing nerve patterns thereby returning the woman with endometriosis back to her best possible quality of life. Design 35 women with endometriosis following excision of endometriosis were given a specific exercise program to help with nerve and pain not reduced by surgery alone. The CHPPS questionnaire was administered at onset of physical therapy and then at the 3 and 9 month mark. Setting Outpatient Private Physical Therapy Practice. Patients or Participants People with Endometriosis, post excision of the disease by a specialist. Interventions Specific Exercise prescription was given to 35 patients with endometriosis. Measurements and Main Results Of the 35 women, 24 reported increases in quality of life, 6 reported changes in pain but no increase in quality of life and 5 did not complete the study either due to compliance. Conclusion Women with endometriosis experience on average an 8 year diagnostic delay from onset of symptoms to treatment. This delay may increase issues within the central nervous system, additionally the overwhelming pain may cause a patient to become deconditioned. Even after the disease is removed, pain may remain. An exercise prescription by a pelvic physical therapist may help increase quality of life.

Examining Work-Related Functioning in a Physical Therapy Outpatient Clinic: Validity and Reliability of the Work Rehabilitation Questionnaire (WORQ).

Purpose Musculoskeletal disorders (MSDs) are often associated with long-term sick leave, productivity loss, and reduced work functioning. However, measures that assess work-related functioning are sparse. Objective To assess the psychometric properties of the Work Rehabilitation Questionnaire (WORQ)-German version in patients with MSDs in an outpatient physical therapy practice. Methods Psychometric study including patients with MSDs with restricted work participation. Data was collected in a single physical therapy outpatient clinic. For construct validity, we developed a priori hypotheses on the correlation between the functioning part of WORQ (40 items) and other questionnaires with similar concepts. For test-retest reliability, WORQ was administered twice, 7days apart. We examined internal consistency (Cronbach's Alpha) and Minimal Detectable Change (MDC). Feasibility of WORQ was examined using feedback from patients and physical therapists. Results There were 51 study participants. Test-retest of WORQ sum score was 0.80 (p < 0.01) (Spearman's rho). Internal consistency was 0.94 and MDC established at 9.2%. WORQ correlated with general health (r = - 0.49), with HADS (r = 0.55), and with quality of life (WHOQOL) (r = - 0.47). WORQ had the highest correlation with WHODAS 2.0 (r = 0.81). Patients rated WORQ as easy to answer and meaningful to their experience. Conclusions When evaluating self-reported work-related functioning, the WORQ-German version was demonstrated to be a valid, reliable, and easy to administer questionnaire for our sample of patients with MSDs in an outpatient PT clinic.

The use of STarT back screening tool to predict functional disability outcomes in patients receiving physical therapy for low back pain

BACKGROUND CONTEXTThe STarT Back Screening Tool (SBST) categorizes risk of future disability in patients with low back pain (LBP). Previous studies evaluating the use of SBST in physical therapy (PT) populations do not reflect the ethnic and socioeconomic diversity occurring in clinical practice and lack statistical power to evaluate factors associated with outcomes within each SBST risk category. PURPOSEThe purpose of this study is to further refine SBST risk categorization for predicting improvements in functional disability with attention toward patient level factors that might guide SBST use in routine outpatient physical therapy practice. STUDY DESIGN/SETTINGThis was a retrospective cohort study that took place within a large academic, tertiary-care health system. PATIENT SAMPLEThe study cohort consisted of 1,169 patients with LBP who completed a course of outpatient physical therapy from June 1, 2014 to May 31, 2015 and who completed the patient-reported SBST and modified low back pain disability questionnaire (MDQ) questionnaires as part of standard of care. OUTCOME MEASURESImprovement in functional disability defined as decrease in 10 or more points in the MDQ. METHODSMultivariable logistic regression was performed to evaluate independent predictors of improvement after PT, which included SBST risk category, baseline MDQ, a two-way interaction term between SBST category and baseline MDQ, prior level of function (independent vs. required assistance), demographic characteristics, number of completed PT visits, and duration of PT episode of care. In exploratory analyses, additional two-way interaction terms between SBST category and the significant predictors were added to the regression model. RESULTSMean age of patients in the study cohort was 55.1 years (SD 16.1); 657 (56.2%) were female, 117 (10.0%) were black race, 127 (10.9%) had Medicaid insurance, and 353 (30.2%) had previously received PT for back pain. In all, 35.8% (n=419) patients categorized as low risk SBST category, 40.7% (n=476) medium risk SBST category, and 23.4% (n=274) high risk SBST category. There was an interaction between baseline MDQ and SBST risk category and improvement with PT. For all three SBST categories, higher baseline MDQ was associated with higher probability of improvement, but the effect was less pronounced as SBST risk category increased. Additional factors independently associated with reduced odds of improvement after PT included black race (odds ratio [OR] 0.44, 95% confidence interval [CI] 0.28–0.72), Medicaid insurance (OR=0.58, 95% CI 0.36–0.95), and prior PT (OR=0.48, 95% CI 0.34–0.67). In exploratory analyses, there was a significant interaction between insurance type and SBST risk category in predicting functional improvement after PT. Patients with Medicare and Medicaid insurance had similar rates of improvement in low and high risk SBST categories but different rates of improvement in the medium risk categories. CONCLUSIONSThe SBST tool predicts outcomes of PT in a cohort of patients receiving outpatient PT for LBP. The odds of improvement varied according to baseline disability and SBST risk status. Race, insurance type, and history of previous PT influenced prediction independent of SBST risk status. Incorporating these variables and the interaction between SBST and baseline disability in outcome models has the potential to refine prediction of outcomes after PT.

Seeing the site of treatment improves habitual pain but not cervical joint position sense immediately after manual therapy in chronic neck pain patients.

Visual analgesia refers to the phenomena where people report decreased pain intensity when they see the painful or painfully stimulated body part. Alongside pain, sensorimotor impairment (i.e., disturbed proprioception) is also evident in chronic pain. This study aims to investigate whether real-time visual feedback offers additional pain relief and proprioceptive improvement when used in combination with recommended therapies in neck pain patients who received manual therapy with or without real-time visual feedback. A total of 29 neck pain patients were recruited in an outpatient physical therapy practice. Patients were randomly allocated to receive manual therapy of the cervical spine with real-time visual feedback or to a control group where patients received manual therapy without real-time visual feedback. Habitual pain intensity, the pressure pain threshold at the zygapophyseal joint of C2-C3 and the superior angle of the scapulae and cervical proprioception were assessed before and immediately after the intervention by a blinded assessor. A between-group comparison revealed a significant reduction in habitual pain in the real-time visual feedback group. No differences were found for the pressure pain threshold or proprioceptive performance. Real-time visual feedback combined with manual therapy enhanced the analgesic effect of manual therapy in neck pain patients, but had no positive effect on the pressure pain threshold and cervical joint position sense. The technical demands for integrating real-time visual feedback into daily practice to reduce habitual pain are low, have low costs and are easy to apply. Real-time visual feedback reduces habitual pain immediately after the intervention. Due to its easy integration, it may be an effective adjunct to recommended interventions (i.e., manual therapy) in patients with neck pain.

Orthopaedic Section Poster Presentations (Abstracts OPO1-OPO300).

These abstracts are presented here as prepared by the authors. The accuracy and content of each abstract remain the responsibility of the authors. In the identification number above each abstract, OPO designates an Orthopaedic Section poster presentation. J Orthop Sports Phys Ther 2018;48(1):A67-A202. doi:10.2519/jospt.2018.48.1.A67.

Innovative physical therapy practice: a qualitative verification of factors that support diffusion of innovation in outpatient physical therapy practice.

Background and purposeNew ideas, methods, and technologies spread through cultures through typical patterns described by diffusion of innovation (DOI) theory. Professional cultures, including the physical therapy profession, have distinctive features and traditions that determine the adoption of practice innovation. The Consolidated Framework for Implementation Research (CFIR) proposes a framework of innovation implementation specific to health care services. While the CFIR has been applied to medical and nursing practice, it has not been extended to rehabilitation professions. The purpose of this qualitative study was to verify the CFIR factors in outpatient physical therapy practice.DesignThrough a nomination process of area rehabilitation managers and area directors of clinical education, 2 exemplar, outpatient, privately owned physical therapy clinics were identified as innovation practices. A total of 18 physical therapists (PTs), including 3 owners and a manager, participated in the study.MethodsThe 2 clinics served as case studies within a qualitative approach of directed content analysis. Data were collected through observation, spontaneous, unstructured questioning, workflow analysis, structured focus group sessions, and artifact analysis including clinical documents. Focus group data were transcribed. All the data were analyzed and coded among 4 investigators.ResultsThrough data analysis and alignment with literature in DOI theory in health care practice, the factors that determine innovation adoption were verified. The phenomena of implementation in PT practice are largely consistent with models of implementation in health care service. Within the outpatient practices studied, patient-centered care and collaborative learning were foundational elements to diffusion of an innovation.ConclusionInnovation in outpatient physical therapy practice can be understood as a social process situated within the culture of the physical therapy professional that follows predictable patterns that strongly align with DOI theory and the CFIR.

Characteristics of 511 patients with temporomandibular disorders referred for physical therapy.

This study aimed (1) to identify the diagnostic subsets of a patient population with temporomandibular disorders (TMD) referred from dental professionals to a physical therapist (PT) in an outpatient physical therapy practice and (2) to use the characteristics of this TMD population to assist clinical decision making in the management of TMD. This was an institutional review board-approved, retrospective study of 511 patients referred to a PT. The PT followed the diagnostic guidelines of axis I of the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD). All 8 diagnostic subsets of the RDC/TMD were diagnosed among the 511 patients. Concurrent diagnostic subsets, cervical spine involvement, and oral appliance use were described. PTs in an outpatient practice should be proficient in the use of the RDC/TMD. Characteristics identified with this patient population suggest that dentists should involve the services of PTs early in the management of patients with TMD and cervical symptoms.

Criterion validity, reliability and clinical responsiveness of the CareConnections Functional Index

This study established the criterion validity, test–retest reliability and responsiveness of the CareConnections Functional Index (CCFI). The CCFI is composed of four body-region specific subscales, measuring functional ability. Reference standards included the Neck Disability Index; Modified Oswestry Disability Index; Quick Disabilities of the Arm, Shoulder and Hand and the Lower Extremity Functional Scale. One hundred subjects per body region were enrolled. Subject’s rated their perceived improvement based on the 15-point Global Rating of Change questionnaire. Minimal clinically important differences (MCID) were calculated via receiver operator characteristic curve. Test–retest reliability coefficients were good to excellent. Validity correlations with the reference standard measures were acceptable (r > 0.7) for all subscales. MCID for the cervical subscale = 7 points, lumbar = 8 points, upper extremity = 16 points and lower extremity = 11 points. The results of this study support the use of the CCFI in outpatient physical therapy practice as a responsive tool with good reliability and validity. The results also indicate that future work should focus on the impact of baseline patient factors that may affect future outcome.

Facilitators and Barriers to Implementation of the Ankle Brachial Index in Outpatient Physical Therapy Practice: A Qualitative Study

The ankle brachial index (ABI) is a valid and reliable measurement of lower extremity circulation and can be used as a screening tool for peripheral arterial disease (PAD), but the usage pattern in physical therapy practice is virtually unknown. This study was performed to describe the phenomenon of using the ABI in outpatient physical therapy practice. Nine participants from 3 different outpatient physical therapy clinics were provided with a hand held Doppler and education on how to accurately perform an ABI. Over a 3-month period, participants performed the ABI on any patient presenting with age > 50 with at least two risk factors for PAD. Immediately following the 3-month data collection period, two focus group interviews were performed to examine the therapist's experience using the ABI. Transcripts were analyzed to identify facilitators and barriers to implementation. Facilitators identified include familiarity, ease of use, accuracy, and confidence with results. Barriers included flow and routine disruption, patient did not want/refused, and issues related to direct access. Although some barriers to use of the ABI in an outpatient clinical setting need to be considered, most participants found the experience of using the ABI positive and feasible.

Associations Between Treatment Processes, Patient Characteristics, and Outcomes in Outpatient Physical Therapy Practice

Deutscher D, Horn SD, Dickstein R, Hart DL, Smout RJ, Gutvirtz M, Ariel I. Associations between treatment processes, patient characteristics, and outcomes in outpatient physical therapy practice. Objective To identify how treatment processes are related to functional outcomes for patients seeking treatment for musculoskeletal impairments while controlling for demographic and health characteristics at intake. Design Prospective, observational cohort study. Treatment processes were not altered. Data were collected continuously from June 2005 to January 2008. Descriptive statistics were applied to compare patient characteristics, interventions, and outcomes between impairment categories. Ordinary least-squares multiple regressions were used to examine associations between patient characteristics at intake, treatment processes, and functional outcomes. Setting Fifty-four community-based outpatient physical therapy clinics of Maccabi Healthcare Services, a public health plan in Israel. Participants A consecutive sample of 22,019 adult patients (mean age 51.2y, standard deviation=15.7, range 18–96, 58% women) seeking treatment due to lumbar spine, knee, cervical spine, or shoulder impairments with functional measurements at intake and discharge. Interventions Not applicable. Main Outcome Measure Functional status at discharge. Results Explanatory power ranged from 30% to 39%. Better outcomes were associated with patient compliance with self-exercise and therapy attendance, application of therapeutic exercise and manual therapy, and completion of 3 or more functional surveys during the episode of care. Worse outcomes were associated with women, electrotherapy for pain management, and therapeutic ultrasound for shoulder impairments. Mixed results were found for group exercise programs. Conclusions The study of associations between treatment processes, patient characteristics, and outcomes helps to describe practice and can be used to suggest ways to improve outcomes in outpatient physical therapy practice.

Retrospective Comparison of Outcomes for Patients with Benign Paroxysmal Positional Vertigo Based on Length of Postural Restrictions

Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo in older adults. The effectiveness of the repositioning maneuver as an intervention has been established in the literature; however, the efficacy of the posttreatment instructions has not been established. The purpose of this retrospective study was compare treatment outcomes for patients receiving 24 hour postural restrictions posttreatment versus 48 hour restrictions. Medical records of 76 patients diagnosed with BPPV at an outpatient physical therapy practice were reviewed. The average age was 61.05 years (SD 16.16). A positive outcome was determined by partial or complete resolution of symptoms, defined as a reduction in the number of special tests or positions that provoked symptoms from initial examination to discharge, as well as a reduction in vertigo intensity ratings. Patients in both groups experienced significant reductions in the number of symptom provoking positions, positive special tests, and ratings of vertigo intensity following treatment. Mean ratings of vertigo intensity on a 10 point scale were 5.71 pre and 1.83 post for the 24 hour group, and 6.75 pre and 3.00 post for the 48 hour group. Positive treatment outcomes were experienced by 95.4% of patients in the 24 hour group (n=63), with 53% (n=35) achieving complete resolution. Patients experienced positive treatment outcomes regardless of the length of postural restrictions following repositioning maneuver for BPPV. Therapists can reduce the length of postural restrictions to 24 hours upright following a repositioning maneuver without adversely affecting patient outcomes.

Comparing patient characteristics and treatment processes in patients receiving physical therapy in the United States, Israel and the Netherlands: Cross sectional analyses of data from three clinical databases

BackgroundMany assume that outcomes from physical therapy research in one country can be generalized to other countries. However, no well designed studies comparing outcomes among countries have been conducted. In this exploratory study, our goal was to compare patient demographics and treatment processes in outpatient physical therapy practice in the United States, Israel and the Netherlands.MethodsCross-sectional data from three different clinical databases were examined. Data were selected for patients aged 18 years and older and started an episode of outpatient therapy between January 1st 2005 and December 31st 2005. Results are based on data from approximately 63,000 patients from the United States, 100,000 from Israel and 12,000 from the Netherlands.ResultsAge, gender and the body part treated were similar in the three countries. Differences existed in episode duration of the health problem, with more patients with chronic complaints treated in the United States and Israel compared to the Netherlands. In the United States and Israel, physical agents and mechanical modalities were applied more often than in the Netherlands. The mean number of visits per treatment episode, adjusted for age, gender, and episode duration, varied from 8 in Israel to 11 in the United States and the Netherlands.ConclusionThe current study showed that clinical databases can be used for comparing patient demographic characteristics and for identifying similarities and differences among countries in physical therapy practice. However, terminology used to describe treatment processes and classify patients was different among databases. More standardisation is required to enable more detailed comparisons. Nevertheless the differences found in number of treatment visits per episode imply that one has to be careful to generalize outcomes from physical therapy research from one country to another.

Clinical outcomes measurement: Interrater & interdevice reliability of physical therapist & client rating of low back pain with a visual analogue scale & a picture scale

The purposes of this study were to assess congruence between 1) physical therapist and client perception of low back pain and 2) Visual Analogue Scale (VAS) and Picture Scale (PS) pain ratings. Congruence of practitioner and client pain rating is essential in clinical decision making. Clinical use of these scales is widespread. However, there is limited research regarding their reliability in rehabilitation medicine. The sample of convenience (n = 28) consisted of volunteer subjects (median age = 40.5 years), from one outpatient orthopedic physical therapy practice, that were experiencing low back pain. A physical therapist and client simultaneously rated the client’s pain with the VAS and PS. Each was blinded to the other’s rating. The VAS was standard (10 cm. line) and the PS consisted of eight (8) hierarchically arranged realistic facial expressions. Descriptive statistics were used to summarize demographic and pain rating data. The Spearman (rho) Rank Correlation was used to determine the relationship between therapist and client pain ratings, and between VAS and PS scores. The Wilcoxon Signed Rank (α2=.05) was used to determine if there were corresponding significant differences. There was high correlation between physical therapist and client using the VAS (rranks=.80) and the PS (rranks=.75), and between VAS and PS values for physical therapists (rranks=.93) and clients (rranks=.83. There was no statistically significant difference (p>.05) between physical therapist and client pain ratings using either scale. However, there was a statistically significant difference between client VAS and PS ratings. Interrater reliability of the VAS and PS is high, suggesting that physical therapists can rely upon their judgement of client pain using either of these scales, in clinical decision making. However, interdevice reliability of these scales is questionable suggesting that the scales are interpreted differently and should not be used interchangeably.