Outpatient Physical Therapy Settings Research Articles

Test-Retest Reliability and Concurrent Validity of the Health Leads Screening Tool in Outpatient Orthopedic Physical Therapy Patients

OBJECTIVE: To determine the test-retest reliability and concurrent validity of the Health Leads Screening Tool. DESIGN: Primary survey data collected between September 2021 and May 2022 with participants who received outpatient orthopedic physical therapy in a public hospital system. Participants completed the Health Leads Screening Tool (HLST) and the Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) at 1 physical therapy visit to examine the concurrent validity of the HLST. They completed the HLST again at a follow-up visit to examine its test-retest reliability. METHODS: Paper surveys were used to collect information from participants who were over 18 years of age, spoke and read English or Spanish, and were receiving outpatient orthopedic physical therapy. Fifty-two participants completed the surveys to examine concurrent validity and 50 participants completed the surveys for test-retest reliability. Cohen’s kappa statistics were used to examine agreement. RESULTS: The HLST had excellent test-retest reliability for all 9 domains, with kappa values ranging from 0.91 to 1.00. It had greater than moderate concurrent validity (k>0.6) with the PRAPARE for 6 of 9 domains, including food, utilities, health care, transportation, employment, and mental health. CONCLUSIONS: The Health Leads Screening Tool demonstrated excellent test-retest reliability and moderate concurrent validity for 6 out of 9 domains and, thus, could be a feasible social needs screening tool in outpatient orthopedic physical therapy settings. JOSPT Open 2024;2(4):340-347. Epub 24 May 2024. doi:10.2519/josptopen.2024.1241

Validation of the Keele STarT MSK Tool for Patients With Musculoskeletal Pain in United States-based Outpatient Physical Therapy Settings

The STarT MSK tool was developed to enable risk stratification of patients with common musculoskeletal (MSK) pain conditions and help identify individuals who may require more targeted interventions or closer monitoring in primary care settings, however, its validity in U.S.-based outpatient physical therapy settings has not been investigated. The 10-item Keele STarT MSK risk stratification tool was tested for construct (convergent and discriminant) and predictive validity using a multicenter, prospective cohort study design. Participants (n = 141) receiving physical therapy for MSK pain of the back, neck, shoulder, hip, knee, or multisite regions completed intake questionnaires including the Keele STarT MSK tool, Functional Comorbidity Index (FCI), Optimal Screening for Prediction of Referral and Outcome Review-of-Systems and Optimal Screening for Prediction of Referral and Outcome Yellow Flag tools. Pain intensity, pain interference, and health-related quality of life (Medical Outcomes Study 8-item Short-Form Health Survey (SF-8) physical [PCS] and mental [MCS] component summary scores) were measured at 2- and 6-month follow-up. Participants were classified as STarT MSK tool low (44%), medium (39%), and high (17%) risk. Follow-up rates were 70.2% (2 months) and 49.6% (6 months). For convergent validity, fair relationships were observed between the STarT MSK tool and FCI and SF-8 MCS (r = .35–.37) while moderate-to-good relationships (r = .51–.72) were observed for 7 other clinical measures. For discriminant validity, STarT MSK tool risk-dependent relationships were observed for Optimal Screening for Prediction of Referral and Outcome Review-of-Systems, Optimal Screening for Prediction of Referral and Outcome Yellow Flag, pain interference, and SF-8 PCS (low < medium < high; P < .01) and FCI, pain intensity, and SF-8 MCS (low < medium-or-high; P < .01). For predictive validity, intake STarT MSK tool scores explained additional variability in pain intensity (11.2%, 20.0%), pain interference (7.5%, 14.1%), and SF-8 PCS (8.2%, 12.8%) scores at 2 and 6 months, respectively. This study contributes to the existing literature by providing additional evidence of STarT MSK tool cross-sectional construct validity and longitudinal predictive validity. PerspectiveThis study presents STarT MSK risk stratification tool validity findings from a U.S. outpatient physical therapy sample. The STarT MSK tool has the potential to help physical therapists identify individuals presenting with the most common MSK pain conditions who may require more targeted interventions or closer monitoring.

Assessing Physical Therapists' Outdoor Walking Recommendations and Neighborhood Walkability for Older Adults.

Neighborhood walkability is the extent to which built and social environments support walking. Walkability influences older adults' participation in outdoor physical activity. Identifying factors that influence physical therapists' (PTs) decisions about prescribing outdoor walking is needed, especially for those who are aging in place. The purpose of this study is to describe the neighborhood walkability knowledge, perceptions, and assessment practices of PTs who work with community-dwelling older adults. A cross-sectional survey was sent via email to 5,000 PTs nationwide. The 40-item survey assessed walking prescriptions, walkability perceptions and assessments, and gathered demographic data. Categorical variables were compared using Chi-square analyses. Using a total of 122 PTs who worked in outpatient geriatric physical therapy settings, a significant difference was found between perceptions of whether PTs should assess walkability and whether they actuallyassess walkability (χ2 = 78.7, p < .001). Decisions to prescribe outdoor walking were influenced by the availability (n = 79, 64.8%) and maintenance (n = 11, 9.0%) of sidewalks, crime (n = 9, 7.4%), terrain (n = 7, 5.7%), and aesthetics (n = 6, 4.9%). Objective walkability measures were not used by the respondents. When considering the assessment of walkability, PTs prioritize the built environment over the social environment. Although most believe it is the responsibility of the PT to assess walkability, most do not. Significance/Implications: Assessment of walkability may allow PTs to identify barriers and make more informed recommendations concerning outdoor walking for older adults. Objective measures are available for PTs when prescribing outdoor walking.

Mobility Rehab visual feedback system for gait rehabilitation in older adults

BackgroundGait and balance impairments are among the main causes of falls in older adults. The feasibility and effectiveness of adding sensor-based feedback to physical therapy (PT) in an outpatient PT setting is unknown. We evaluated the feasibility and effectiveness of PT intervention combined with a therapist-assisted visual feedback system, called Mobility Rehab, (PT + MR) in older adults.MethodsTwenty-eight older adults with and without neurological diseases were assigned either PT + MR (n = 22) or PT alone (n = 6). Both groups performed 8 sessions (individualized) of 45 min long (30 min for gait training and 15 min for endurance, strength, and balance exercises) in an outpatient clinic. Mobility Rehab uses unobtrusive, inertial sensors on both wrists and feet, and at the sternum level with real-time algorithms to provide real-time feedback on five gait metrics (step duration, stride length, elevation at mid-swing, arm swing range-of-motion [ROM], and trunk coronal ROM), which are displayed on a tablet. The primary outcome was the Activities-specific Balance Confidence scale (ABC). The secondary outcome was gait speed measured with wearable inertial sensors during 2 min of walking.ResultsThere were no between-group differences at baseline for any variable (P > 0.05). Neither PT + MR nor PT alone showed significant changes on the ABC scores. PT + MR, but not PT alone, showed significant improvements in gait speed and arm swing ROM. The system was evaluated as ‘easy to use’ by the PT.ConclusionsOur preliminary results show that PT + MR improves gait speed in older adults with and without neurological diseases in an outpatient clinic.Clinical Trial Registrationwww.ClinicalTrials.gov, identifier: NCT03869879.

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.

Goal Attainment Scaling in Outpatient Physical Therapy for Chronic Low Back Pain: Protocol for a Mixed Methods Study.

BackgroundPatient engagement in decisions regarding their health care may lead to improved outcomes and improved adherence to treatment plans. While there are several options for involving patients in their health care, goal setting is a readily accessible method for physical therapists to increase the involvement of patients in health care decisions. Physical therapy goals are often generated by health care providers based on subjective information or standardized, fixed-item, patient-reported outcome measures. However, these outcome measures may not fully reveal the activity and participation limitations of individual patients. Goal attainment scaling (GAS) is a patient-centered approach that allows patients to set meaningful goals. While GAS has been shown to be reliable, valid, and sensitive to change in various populations, there is limited evidence in the United States on utilizing GAS in physical therapy for patients with chronic low back pain (LBP).ObjectiveThe purpose of this paper is to describe the protocol for a study to (1) develop a way to apply GAS procedures for physical therapists treating patients with chronic LBP in the United States and (2) test the feasibility of applying GAS procedures for chronic LBP in an outpatient physical therapy setting.MethodsThis study used a mixed methods design with 2 phases: qualitative and quantitative. The qualitative phase of the study employed focus groups of patients with chronic LBP to identify an inventory of goals that were important and measurable. A series of prompts was developed from this inventory to assist physical therapists in collaboratively establishing goals with patients in a clinical setting. The quantitative phase of the study pilot-tested the inventory developed in the qualitative phase in patients with chronic LBP to determine feasibility, reliability, validity, and responsiveness. We also plan to compare how well GAS reveals change over time relative to traditional, fixed-item, patient-reported measures.ResultsPhase 1 data collection was completed in June 2020, while data collection for phase 2 was performed between March 2021 and December 2021. We anticipate that this study will demonstrate that GAS can be implemented successfully by outpatient physical therapists, and that it will demonstrate clinically important changes in patients with chronic LBP.ConclusionsGAS represents an opportunity for patient-centered care in the physical therapy management of chronic LBP. While GAS is not new, it has never been studied in real-world physical therapy for chronic LBP in a clinical setting. Due to unique time and productivity constraints, for GAS to be successfully implemented in this environment, we must demonstrate that clinicians can be trained efficiently and reliably, that GAS can be implemented in a clinical setting in under 15 minutes, and that GAS is able to detect clinically meaningful changes in patient outcomes.International Registered Report Identifier (IRRID)DERR1-10.2196/32457

The role of Self-Efficacy in Chronic Pain—A Case Report Relating Motivation During The COVID-19 Pandemic and a Patient With Chronic Pain

Research ObjectivesTo analyze patient outcomes and traditional physical therapy interventions for chronic low back back, and discuss the benefits of incorporating self-efficacy techniques to improve patient independence.DesignRetrospective case report.SettingOutpatient physical therapy setting.Participants48-year-old female with complaints of chronic low back pain that has increased significantly over the last six months due to the societal consequences of COVID-19. The patient's past medical history included mild arthritis of her spine. The medications she was using for pain included Naproxen, and the patient also found relief with Salonpas pain relief patches.Interventions1. Trunk flexion AAROM, x 10 repetitions, by rolling swiss ball forward on plinth to promote a stretch of the lower back and eliminate fear of mobility.2. interferential electrical stimulation to low back to decrease pain x 10 min3. bilateral dynamic hip strengthening on hip abduction machine with 45#, 10 reps x 3 sets each4. Functional training such as proper lifting mechanics, 5 repetitions of box lifting5. physiological components aimed to improve self-efficacyMain Outcome Measures1.numerical pain rating scale2. Modified Oswestry Low Back Pain Disability QuestionnaireResultsThe patient's pain improved throughout the 6 weeks that she was seen at physical therapy. This is reflected on her scores on the NPRS. Her baseline pain rating was 9.5/10 and by 6 weeks her score decreased to 3/10. The patient also showed improvements on the Modified Oswestry Disability Index, as seen by a decrease from 42% disability to 10% disability. Improvements were seen in the patient's bed mobility, lumbar flexion AROM, bilateral hip strength, and lower abdominal strength.ConclusionsThis case is an example of someone with chronic low back pain that prior to the pandemic, had enough self efficacy to manager her condition independently. Interventions during physical therapy focused on traditional manual and therapeutic exercise principles as well as physiological components aimed to improve her self-efficacy.Author(s) DisclosuresI declare that I have no relevant or material financial interests that relate to the research described in this paper”.

Effectiveness of the Mobility Rehab System for Mobility Training in Older Adults: A Pragmatic Clinical Trial.

Introduction: Mobility impairments are among the main causes of falls in older adults and patients with neurological diseases, leading to functional dependence and substantial health care costs. Feedback-based interventions applied in controlled, laboratory environments have shown promising results for mobility rehabilitation, enhancing the benefits of standard therapy. However, the effectiveness of sensor-based feedback to improve gait in actual outpatient physical therapy settings is unknown. The proposed trial examines the effectiveness of a physical therapist-assisted, visual feedback system using wearable inertial sensors, Mobility Rehab, for mobility training in older adults with gait disturbances in an outpatient clinic.Methods: The study is a single site, pragmatic clinical trial in older adults with gait disturbances. Two hundred patients undergoing their outpatient rehabilitation program are assigned, by an independent assistant, for screening by one of four therapists, and assigned to either a standard physical therapy or therapist-assisted feedback therapy. Both groups train twice a week for 6 weeks. Four physical therapists were randomized and stratified by years of experience to deliver standard therapy or therapist-assisted feedback rehabilitation. Each session is 45 min long. Gait is trained for 30 min. The additional 15 min include exercises for endurance, strength, and static and dynamic balance in functional tasks. Mobility Rehab uses unobtrusive, inertial sensors on the feet and belt with real-time algorithms to provide real-time feedback on gait metrics (i.e., gait speed, double support time, foot clearance, angle at foot strike, and arm swing), which are displayed on a hand-held monitor. Blinded assessments are carried out before and after the intervention. The primary outcome measure is subjects' perception of balance as measured by the Activities-specific Balance Confidence scale. Gait speed, as measured with wearable inertial sensors during walking, is the secondary outcome measure.Discussion: We hypothesize that therapist-assisted feedback rehabilitation will be more effective than standard rehabilitation for gait. Feedback of motor performance plays a crucial role in rehabilitation and objective characterization of gait impairments by Mobility Rehab has the potential to improve the accuracy of patient-specific gait feedback.Clinical Trial Registration:www.ClinicalTrials.gov, identifier: NCT03869879.

Efficacy of whole-body vibration on balance control, postural stability, and mobility after thermal burn injuries: A prospective randomized controlled trial

Objective: To investigate the additive effects of whole-body vibration (WBV) training to the traditional physical therapy program (TPTP) on balance control, postural stability, and mobility after thermal burn injuries. Design: A single-blinded, randomized controlled study. Setting: Outpatient physical therapy setting. Participants: Forty participants, 20–45 years old, with deep second-degree thermal burn involving the lower limbs and trunk, with 35%–40% total body service area, were randomly allocated either into the study group or the control group. Intervention: The study group received WBV plus TPTP while the control group received the TPTP only. Interventions were applied three sessions a week for eight weeks. Outcome measures: Anteroposterior stability index (APSI), mediolateral stability index (MLSI), overall stability index (OSI), timed-up and go (TUG), and Berg balance scale (BBS) were measured at baseline and after eight weeks of interventions. Results: There were statistically significant differences in APSI, MLSI, OSI, BBS, and TUG in favor of the WBV group after eight weeks of intervention (P < 0.001). After eight weeks of intervention, the mean (SD) for APSI, MLSI, OSI, BBS, and TUG scores were 1.87 ± 0.51, 41.36 ± 0.18, 1.95 ± 0.56, 47.2 ± 6.12, and 8.15 ± 1.05 seconds in the WBV group, and 2.41 ± 0.71, 2.21 ± 0.54, 2.68 ± 0.73, 40.65 ± 4.7, and 10.95 ± 2.44 seconds in the control group, respectively. Conclusions: The whole-body vibration training combined with the TPTP was more beneficial in improving APS, MLS, OSI, TUG, and BBS than TPTP alone. It might be considered a useful adjunctive therapy in treating patients with healed wounds with a deep second-degree burn of the trunk and lower limbs.

Why Measure Patient Experience in Physical Therapy?

BackgroundPatient experience is an important component of quality and patient centered health care not fully explored in physical therapy.Main bodyThis article addresses (1) concept of patient experience, (2) importance of capturing the patient experience, (3) measures to capture patient experience and whether these measures exhibit psychometrically sound measurement properties, (4) relationship between patient experience and clinical effectiveness outcomes, and (5) clinical applications of patient experience measures in the outpatient physical therapy setting, including suggestions for future studies.Short conclusionEmploying patient experience measures into physical therapy practice may be an important key to improve clinical effectiveness outcomes and provide excellent patient-centered care delivery. An area of continued research should be focused on demonstrating the generalizability and measurement properties of patient reported experience measures for the musculoskeletal outpatient physical therapy population focusing first on the most common musculoskeletal conditions such as cervical, low back, and shoulder pain.

Moving Towards Patient-Centered Care in the Emergency Department: Importance of Improvement in Pain-Related Outcomes

Musculoskeletal pain is a common emergency department (ED) presentation. Patient-centered care for patients with musculoskeletal pain may improve quality-of-life, satisfaction with care, and clinical outcomes. Providing patient-centered care in the ED requires understanding patients’ goals and priorities. We conducted a cross-sectional survey of the demographic, clinical, and biopsychosocial characteristics of adult ED patients (n=215) with musculoskeletal pain. Patients completed the Patient Centered Outcomes Questionnaire (PCOQ) to quantify importance of improvements in pain, interference with daily activities, fatigue, and emotion. Improvement ratings were from 0 (unimportant) to 100 (most important) and cluster analysis identified patient subgroups by these ratings. Comparisons used Kruskal-Wallis tests for continuous measures and Chi-Square tests for categorical measures. Patients with completed PCOQ were analyzed (n=176). All domains were rated as highly important (median/mean (sd) pain, interference, fatigue, and emotion ratings 100/91 (18), 96/79 (32), 93/72 (35), and 93/69 (39)). Cluster analysis identified three subgroups: 1) Multiple domains important (MDI, n=120) characterized by high importance for all domains 2) pain and function important (PFI, n=34) with high importance in pain and interference domains, and 3) only pain domain important (PI, n=22). The MDI group reported higher psychological symptoms, (p<0.0001 for both depression and anxiety symptoms) and was more likely female (p=0.019). The PI group had the least severe clinical characteristics including lowest weekly pain intensity (p=0.029), shortest time experiencing pain (p=0.003), and fewest symptoms from other body systems (p=0.034). ED patients with musculoskeletal pain seek improvements in outcomes beyond pain relief. Furthermore, the identification of three subgroups with differing priorities for their pain care may inform delivery of patient-centered care. These findings build on previous studies of the PCOQ and mirror subgroups from outpatient physical therapy settings. Additional research is needed to better validate these PCOQ subgroups and to longitudinally investigate their clinical utility. Musculoskeletal pain is a common emergency department (ED) presentation. Patient-centered care for patients with musculoskeletal pain may improve quality-of-life, satisfaction with care, and clinical outcomes. Providing patient-centered care in the ED requires understanding patients’ goals and priorities. We conducted a cross-sectional survey of the demographic, clinical, and biopsychosocial characteristics of adult ED patients (n=215) with musculoskeletal pain. Patients completed the Patient Centered Outcomes Questionnaire (PCOQ) to quantify importance of improvements in pain, interference with daily activities, fatigue, and emotion. Improvement ratings were from 0 (unimportant) to 100 (most important) and cluster analysis identified patient subgroups by these ratings. Comparisons used Kruskal-Wallis tests for continuous measures and Chi-Square tests for categorical measures. Patients with completed PCOQ were analyzed (n=176). All domains were rated as highly important (median/mean (sd) pain, interference, fatigue, and emotion ratings 100/91 (18), 96/79 (32), 93/72 (35), and 93/69 (39)). Cluster analysis identified three subgroups: 1) Multiple domains important (MDI, n=120) characterized by high importance for all domains 2) pain and function important (PFI, n=34) with high importance in pain and interference domains, and 3) only pain domain important (PI, n=22). The MDI group reported higher psychological symptoms, (p<0.0001 for both depression and anxiety symptoms) and was more likely female (p=0.019). The PI group had the least severe clinical characteristics including lowest weekly pain intensity (p=0.029), shortest time experiencing pain (p=0.003), and fewest symptoms from other body systems (p=0.034). ED patients with musculoskeletal pain seek improvements in outcomes beyond pain relief. Furthermore, the identification of three subgroups with differing priorities for their pain care may inform delivery of patient-centered care. These findings build on previous studies of the PCOQ and mirror subgroups from outpatient physical therapy settings. Additional research is needed to better validate these PCOQ subgroups and to longitudinally investigate their clinical utility.

Balance and Fall Risk Outcome Measures for Patients 65 Years or Older in the Outpatient Physical Therapy Setting: What Are the Current Trends?

Background &amp; Objectives: Occurrence of falls in older adults contributes to increased morbidity and mortality, exponential healthcare costs, and reduced quality of life. Utilization of outcome measures for screening and assessing fall risk in older patients contributes to reduced fall-related injuries, deaths, and healthcare costs, while promoting improved mobility and health status. The purpose of this study was to explore the utilization of outcome measures assessing balance and fall risk in patients 65 years and up within the outpatient physical therapy setting. Secondary aims included determining the most frequently used outcome measures as well as examining any associations between demographic variables and clinicians’ screening habits.

Battlefield Acupuncture and Physical Therapy Versus Physical Therapy Alone After Shoulder Surgery.

Objective: Opioid pain medications are commonly prescribed postsurgically for pain. Few studies have investigated the effects of Battlefield Acupuncture (BFA) on postsurgical pain and pain-medication use. To date, no studies have investigated BFA's effectiveness for reducing postoperative shoulder pain and pain-medication use post surgery. The objective of this study was to determine if adding BFA to a rehabilitation protocol was effective for reducing pain and use of prescribed pain medications, compared to that protocol alone after shoulder surgery. Materials and Methods: Forty Department of Defense beneficiaries (ages 17-55) were randomized to either a standard-of-care group or a standard-of-care + BFA group prior to shoulder surgery. The standard BFA protocol was administered with semipermanent acupuncture needles emplaced on the subjects' ears for 3-5 days within 24 hours after shoulder surgery in an outpatient physical therapy setting. BFA was reapplied, as needed, up to 6 weeks postsurgically for pain management in the intervention group. The primary outcomes were visual analogue scale (VAS) pain rating and daily pain medication use by each subject. Secondary outcome measures were the Global Rating of Change and Patient Specific Functional scale. Outcome measures were obtained at 24 hours, 72 hours, 1 week, 2 weeks, and 6 weeks post surgery. Results: Significant differences in average and worst VAS pain change scores were noted between baseline and 7 days (P < 0.05). The main effect for time was significant (average and worst VAS pain) at all timepoints (P < 0.05), without time-group interactions seen. No significant differences between the groups in pain-medication use were observed (P > 0.05) Conclusions: BFA reduced postsurgical shoulder pain significantly between the groups' average and worst pain change scores between baseline and 7 days despite similar opioid and nonsteroidal anti-inflammatory drug use between the groups.

Physical Therapy Intervention for a Patient With Post-Surgical Shoulder Capsulorrhaphy

Background: Posterior shoulder capsulorrhaphy is a surgical procedure to help restore shoulder joint stability in patients with a history of recurrent shoulder dislocations. Physical therapy (PT) may be beneficial in outpatient rehabilitation to improve patient shoulder range of motion (ROM), muscular strength, endurance, joint stability, and return to prior level of activities after general shoulder surgery. The purpose of this case study was to describe PT intervention for a patient with shoulder posterior capsulorrhaphy in an outpatient setting. Methods: 21-year-old male with post-surgical right shoulder posterior capsulorrhaphy due to multiple posteriorshoulder dislocation. Patient’s impairments were right shoulder weakness, decreased ROM, and functional immobility due to pain and a retracted capsule. PT intervention was 2-3X per week for nine weeks and included therapeutic exercises, manual therapy, modalities, and patient education for a home exercise program (HEP). Results: Patient was seen for 13 visits in an outpatient PT setting which improved his shoulder active ROM, strength, and outcome measures. The pain was also reduced. He returned to work with light duty restrictions after the 3rd week of PT and was able to perform normal responsibilities by the 9th week. He achieved the majority of his goals. Conclusion: PT intervention may have accelerated the progression of patient’s functional mobility, strength, ROM, and reduction of pain. Compared to the currently available literature for this diagnosis, the patient returned to normal function three weeks earlier than normal, probably due to earlier internal rotation exercise. Future research should include a randomized control trial regarding effective PT interventions following shoulder capsulorrhaphy surgery.

Kinesiophobia and Its Association With Health-Related Quality of Life Across Injury Locations

ObjectiveTo compare baseline kinesiophobia levels and their association with health-related quality of life across injury locations. DesignRetrospective cross-sectional study. SettingSingle, large outpatient physical therapy clinic within an academic medical center. ParticipantsPatients (N=1233) who underwent an initial evaluation for a diagnosis related to musculoskeletal pain and completed the 11-item version of the Tampa Scale for Kinesiophobia (TSK-11) and the Medical Outcomes Study 8-Item Short-Form Health Survey (SF-8) questionnaires within 7 days of their first visit were eligible for inclusion. Three hundred eighty patients were excluded because of missing data or because they were younger than 18 years. A total of 853 patients (mean age, 43.55y; range, 18–94y) were included. InterventionsNot applicable. Main Outcome MeasuresComparison of baseline kinesiophobia levels and their association with health-related quality of life across injury locations in an outpatient physical therapy setting. ResultsSeparate analysis of variance models compared TSK-11 scores based on involved body region, and Pearson correlation coefficients were used to examine the association between TSK-11 scores and the SF-8 subscales at each body region. TSK-11 scores did not differ by body region (range, 23.9–26.1). Weak to moderate negative correlations existed between kinesiophobia and the SF-8 subscales. ConclusionsKinesiophobia levels appear elevated and negatively associated with health-related quality of life at initial physical therapy evaluation regardless of injury location. These findings suggest that physical therapists in outpatient orthopedic settings should implement routine kinesiophobia assessment and provide stratified care based on kinesiophobia levels across musculoskeletal conditions.

Evaluation of the STarT Back Screening Tool for Prediction of Low Back Pain Intensity in an Outpatient Physical Therapy Setting.

Study Design Prospective cohort study. Background Optimal management of patients with low back pain (LBP) relies on accurate prognosis of future clinical outcomes. The STarT Back Screening Tool (SBT), a prognostic index developed and validated in the primary care setting, has 3 scoring measures: SBT overall, psychosocial, and categorical scores. Objective Our study aimed to compare the predictive validity of 3 SBT measures with future pain intensity in patients receiving physical therapy for LBP. Methods Two hundred seven patients with LBP receiving physical therapy completed the SBT at initial (baseline) evaluation and were evaluated 12 weeks later for their pain intensity. Multivariable proportional odds regression was used to evaluate the associations of the various SBT measures with pain intensity at follow-up. Results Adjusting for covariates, all SBT measures were positively and significantly associated with the odds of greater pain intensity at follow-up evaluation (P<.01). Adding SBT psychosocial scores to a covariate-only model improved its predictive accuracy (concordance statistic increase, 0.03; 95% confidence interval: 0.01, 0.09), while improvements in prediction were smaller or negligible with the SBT overall and categorical scores (concordance statistic increase, 0.02 and 0.007, respectively). In mutually adjusted analyses, SBT psychosocial scores added incremental predictive value over SBT overall scores in predicting future pain intensity (P = .03). Conclusion Among the 3 SBT measures, the SBT psychosocial subscale was a significant predictor of future pain intensity in patients with LBP and had comparable, if not better, prognostic significance compared with the SBT overall score. Level of Evidence Prognosis, level 4. J Orthop Sports Phys Ther 2017;47(4):261-267. Epub 3 Mar 2017. doi:10.2519/jospt.2017.7284.

Development of a Yellow Flag Assessment Tool for Orthopaedic Physical Therapists: Results From the Optimal Screening for Prediction of Referral and Outcome (OSPRO) Cohort.

Study Design Clinical measurement, cross-sectional. Background Pain-associated psychological distress adversely influences outcomes for patients with musculoskeletal pain. However, assessment of pain-associated psychological distress (ie, yellow flags) is not routinely performed in orthopaedic physical therapy practice. A standardized yellow flag assessment tool will better inform treatment decision making related to psychologically informed practice. Objectives To describe the development of a concise, multidimensional yellow flag assessment tool for application in orthopaedic physical therapy clinical practice. Methods A 136-item yellow flag item bank was developed from validated psychological questionnaires across domains related to pain vulnerability (negative mood, fear avoidance) and resilience (positive affect/coping). Patients seeking physical therapy with neck, back, knee, or shoulder pain completed the item bank. Iterative statistical analyses determined minimal item sets meeting thresholds for identifying elevated vulnerability or low resilience (ie, upper or lower quartile, as indicated). Further item reduction yielded a concise yellow flag assessment tool to assess 11 psychological constructs measuring pain-associated psychological distress. Correlations between the assessment tool and individual psychological questionnaires were measured and compared between anatomical regions. Concurrent validity was assessed by determining variance explained in pain and disability scores by the assessment tool. Results Subjects with elevated vulnerability and decreased resilience were identified with a high degree of accuracy (minimum of 85%) using a 17-item tool. Correlations were moderate to high between the 17-item tool and individual psychological questionnaires, with no significant differences in correlations between different anatomical regions. Shorter 10- and 7-item versions of the assessment tool allow clinicians the flexibility to assess for yellow flags quickly with acceptable trade-offs in accuracy (81% and 75%, respectively). All versions of the tool explained significant additional variance in pain and disability scores (range, 19.3%-36.7%) after accounting for demographics, historical variables, and anatomical region of pain. Conclusion Concise assessment of yellow flags is feasible in outpatient physical therapy settings. This multidimensional tool advances assessment of pain-associated psychological distress through the addition of positive affect/coping constructs and estimation of full questionnaire scores. Further study is warranted to determine how this tool complements established risk-assessment tools by providing the option for efficient treatment monitoring. J Orthop Sports Phys Ther 2016;46(5):327-345. Epub 21 Mar 2016. doi:10.2519/jospt.2016.6487.

Development of a Review-of-Systems Screening Tool for Orthopaedic Physical Therapists: Results From the Optimal Screening for Prediction of Referral and Outcome (OSPRO) Cohort.

Literature review and cross-sectional study. Direct access to physical therapy necessitates greater responsibility to determine appropriateness of care by recognizing the potential for concomitant disease or systemic involvement. Recent research has identified excessive variability in the reporting of red flag symptoms. An initial step to improve the identification of red flag symptoms is the development of a standardized screening tool. To describe the development of a review-of-systems screening tool appropriate for use by orthopaedic physical therapists. First, a red flag symptom item bank was compiled from a systematic literature review to allow for further psychometric testing and development of a screening tool. Second, physical therapists in 11 outpatient clinics recruited patients presenting with primary complaints of neck, shoulder, low back, or knee pain. Patients completed the red flag symptom item bank and standard questionnaires for comorbidities, negative mood, quality of life, pain, and function. The development of the screening tool involved identifying and combining different 3-item sets that characterized the highest number of patients reporting at least 1 positive symptom response (operationally defined as "red flag symptom responder"). The literature search yielded 103 studies that met the inclusion criteria, and the final item bank consisted of 97 items representing 8 body systems. Four hundred thirty-one patients with primary complaints of neck (n = 93), shoulder (n = 108), low back (n = 119), or knee (n = 111) disorders contributed to the cross-sectional study. The number of red flag symptom responders was 393 of 431 (91.2%). These patients were older, more likely to be female, had lower income, and were more likely to report neck or back pain (all, P<.05). A 10-item review-of-systems screening tool correctly identified 372 of 393 (94.7%) responders, and a 23-item version identified all 393 (100%) responders. The review-of-systems screening tools and the complete 97-item bank had similar correlations with concurrent clinical measures, except for depressive symptoms. Concise red flag symptom identification appears to be feasible in outpatient orthopaedic physical therapy settings. Future research will determine how this review-of-systems screening tool needs refinement for different patient populations and whether it predicts clinical outcomes or the need for referral to other providers.

Collegial mentoring through routine patient consultation—a new learning strategy in outpatient physical therapy settings

(geriatric depression scale: GDS), balance (functional balance scale: FBS), and urinary incontinence were evaluated. Results: Among the 130 elderly people with disuse syndrome (mean± standard deviation age, 78.3± 10.5), 71 people were classified in the independent group and 59 in the dependent group. The mean duration of hospitalization was 21.3± 15.1 days. According to the univariate analysis, the number of days from onset to the start of rehabilitation, consciousness, transportation, grip strength, range of motion (extension of hip joint), and MMSE, GDS, and FBS scores was significantly different between the two groups. According to the multivariate logistic regression analysis, MMSE [odds ratio (OR), 1.31; 95% confidence interval (CI), 1.13–1.53; p= 0.001] and GDS (OR, 0.80; 95% CI, 0.66–0.97; p= 0.03) were factors associated with the FIM score at discharge. Conclusion(s): Our study results suggested that cognitive levels and depressive state at the start of rehabilitation were associated with the ability of elderly people with disuse syndrome to recover independent ADL. Implications: The results of this study can be used to predict the prognosis of people who are hospitalized for internal disease. In addition, an early examination of mental function may be important for elderly people who undergo rehabilitation.

Pragmatic Implementation of a Stratified Primary Care Model for Low Back Pain Management in Outpatient Physical Therapy Settings: Two-Phase, Sequential Preliminary Study.

The effectiveness of risk stratification for low back pain (LBP) management has not been demonstrated in outpatient physical therapy settings. The purposes of this study were: (1) to assess implementation of a stratified care approach for LBP management by evaluating short-term treatment effects and (2) to determine feasibility of conducting a larger-scale study. This was a 2-phase, preliminary study. In phase 1, clinicians were randomly assigned to receive standard (n=6) or stratified care (n=6) training. Stratified care training included 8 hours of content focusing on psychologically informed practice. Changes in LBP attitudes and beliefs were assessed using the Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT) and the Health Care Providers Pain and Impairment Relationship Scale (HC-PAIRS). In phase 2, clinicians receiving the stratified care training were instructed to incorporate those strategies in their practice and 4-week patient outcomes were collected using a numerical pain rating scale (NPRS), and the Oswestry Disability Index (ODI). Study feasibility was assessed to identify potential barriers for completion of a larger-scale study. In phase 1, minimal changes were observed for PABS-PT and HC-PAIRS scores for standard care clinicians (Cohen d=0.00-0.28). Decreased biomedical (-4.5±2.5 points, d=1.08) and increased biopsychosocial (+5.5±2.0 points, d=2.86) treatment orientations were observed for stratified care clinicians, with these changes sustained 6 months later on the PABS-PT. In phase 2, patients receiving stratified care (n=67) had greater between-group improvements in NPRS (0.8 points; 95% confidence interval=0.1, 1.5; d=0.40) and ODI (8.9% points; 95% confidence interval=4.1, 13.6; d=0.76) scores compared with patients receiving standard physical therapy care (n=33). In phase 2, treatment was not randomly assigned, and therapist adherence to treatment recommendations was not monitored. This study was not adequately powered to conduct subgroup analyses. In physical therapy settings, biomedical orientation can be modified, and risk-stratified care for LBP can be effectively implemented. Findings from this study can be used for planning of larger studies.