Therapist Interventions Research Articles

Effect of nurse-led screening linked brief psycho-education for improving adherence to antipsychotic medications among clients with mental illness: A quasi-experimental study

Background: Despite the significant improvements in pharmacotherapy, nonadherence to antipsychotic medication is consistently reported in the literature. Many studies evaluated the side effects of antipsychotic medications but there is scanty evidence regarding screening linked intervention. Aim: The study investigated the effect of nurse-led screening linked brief psycho-education in improving adherence to antipsychotic medication among treatment-seeking clients with mental illness. Materials and Methods: This study is a quasi-experimental study in which a total of 80 subjects were consecutively recruited as per the sampling criteria. The side effect of antipsychotic medication was measured using the Udvalg for Kliniske Undersøgelser Side Effect Rating Scale (UKU-SERS). A trained nurse delivered a 30-minute individual-based screening linked brief psychoeducation for the management of side effects as per the standard module. The outcome measures were changes in adherence to medication measured as per the medication adherence rating scale (MARS-5©Professor Rob Horne) during a 1-month follow-up. Results: Anxiety (40%), reduced duration of sleep (40%), reduced salivation (36%) were the most common moderate-to-severe side effects as per UKU-SERS. Overall, the study observed a significant improvement of self-reported medication adherence in the intervention group as compared to the control group during the 1-month follow-up (F = 46.49; P < 0.001). Conclusion: The nurse-led screening linked brief psychoeducation may be an effective strategy for improving adherence to antipsychotic medication in this setting. More studies should be conducted in similar settings for an evidence base to advocate the role of the nurse as a brief intervention therapist in the routine mental health care setting.

The TPOCS-self-reported Therapist Intervention Fidelity for Youth (TPOCS-SeRTIFY): A case study of pragmatic measure development.

Developing pragmatic assessment tools to measure clinician use of evidence-based practices is critical to advancing implementation of evidence-based practices in mental health. This case study details our community-partnered process of developing the Therapy Process Observation Coding Scale-Self-Reported Therapist Intervention Fidelity for Youth (TPOCS-SeRTIFY), a pragmatic, clinician-report instrument to measure cognitive behavioral therapy (CBT) delivery. We describe a five-step community-partnered development process. Initial goals were to create a self-report instrument that paralleled an existing direct observation measure of clinician delivery of CBT use to facilitate later assessment of measure performance. Cognitive interviews with community clinicians (n = 6) and consultation with CBT experts (n = 6) were used to enhance interpretability and usability as part of an iterative refinement process. The instrument was administered to 247 community clinicians along with an established self-reported measure of clinician delivery of CBT and other treatments to assess preliminary psychometric performance. Preliminary psychometrics were promising. Our community-partnered development process showed promising success and can guide future development of pragmatic implementation measures both to facilitate measurement of ongoing implementation efforts and future research aimed at building learning mental health systems. Developing brief, user-friendly, and accurate tools to measure how therapists deliver cognitive behavioral therapy (CBT) in routine practice is important for advancing the reach of CBT into community settings. To date, developing such "pragmatic" measures has been difficult. There is little known about how researchers can best develop these types of assessment tools so that they (1) are easy for clinicians in practice to use and (2) provide valid and useful information about implementation outcomes. As a result, there are few well-validated measures in existence that measure therapist use of CBT that are feasible for use in community practice. This paper contributes to the literature by describing our community-partnered process for developing a measure of therapist use of CBT (Therapy Process Observation Coding Scale -Self-Reported Therapist Intervention Fidelity for Youth; TPOCS-SeRTIFY). This descriptive case study outlines the community-partnered approach we took to develop this measure. This case study will contribute to future research by serving as a guide to others aiming to develop pragmatic implementation measures. In addition, the TPOCS-SeRTIFY is a pragmatic measure of clinician use of CBT that holds promise for its use by both researchers and clinicians to measure the success of CBT implementation efforts.

Effectiveness of Mechanical Traction for Lumbar Radiculopathy: A Systematic Review and Meta-Analysis.

Lumbar radiculopathy (LR) is a pain syndrome caused by compression/irritation of the lumbar nerve root(s). Traction is a well-known and commonly used conservative treatment for LR, although its effectiveness is disputed. The purpose of this systematic review and meta-analysis of randomized controlled trials was to evaluate the effects of different types of traction added to or compared with conservative treatments on pain and disability. Data were obtained from CENTRAL, PUBMED, CINAHL, Scopus, ISI Web of Science, and PEDro from their inception to April 2020. All randomized controlled trials on adults with LR, using mechanical traction, and without any restriction regarding publication time or language were considered. Two reviewers selected the studies, evaluated the quality assessment, and extracted the results. Meta-analysis used a random-effects model. Eight studies met the inclusion criteria, and 5 were meta-analyzed. Meta-analyses of results from low-quality studies indicated that supine mechanical traction added to physical therapist treatments had significant effects on pain (g=-0.58 [95% confidence interval=-0.87 to -0.29]) and disability (g=-0.78 [95% confidence interval =-1.45 to -0.11]). Analyses of results from high-quality studies of prone mechanical traction added to physical therapist intervention for pain and disability were not significant. These results were also evident at short-term follow-up (up to 3months after intervention). The literature suggests that, for pain and disability in LR, there is short-term effectiveness of supine mechanical traction when added to physical therapist intervention. This systematic review may be relevant for clinical practice due to its external validity because the treatments and the outcome measures are very similar to those commonly used in a clinical context.

Cambio y Psicoterapia: La perspectiva del niño

La investigación a partir de la perspectiva del paciente ha brindado importante información acerca de cómo la terapia es percibida, ayudando a los terapeutas a entender algunas reacciones por parte de los pacientes. Aún hoy en día, la terapia enfocada a los niños no ha sido beneficiada por este movimiento, dada la escasez de investigaciones de este tipo en la población infantil.&#x0D; El trabajo que aquí se presenta, es de carácter empírico, con un enfoque de análisis cualitativo. En el mismo se indagó sobre las percepciones que los niños poseen sobre los distintos asuntos relacionados al proceso psicoterapéutico. Para ello, se realizaron entrevistas semi-estructuradas a 10 niños de entre 6 y 12 años que se encontraban realizando un tratamiento psicoterapéutico, o lo habían realizado en los últimos doce meses.&#x0D; Durante las entrevistas se indagó sobre elementos como “la relación terapéutica”, “las intervenciones del terapeuta”, “la valoración de la terapia”, “las nociones que poseía sobre la terapia”, “características de la terapia” y “el cambio percibido”. Las entrevistas fueron transcriptas y analizadas utilizando la metodología cualitativa consensual (CQR).&#x0D; Los resultados indican que los niños pudieron percibir los cambios en relación a su propia conducta, emociones y relaciones interpersonales y vincular dichos cambios con los terapeutas y el vínculo que con ellos habían establecido. También elementos del proceso terapéuticos, como por ejemplo la alianza con el terapeuta fueron relacionados al cambio

Physical Therapist Management of COVID-19 in the Intensive Care Unit: The West China Hospital Experience.

ObjectiveCoronavirus disease 2019 (COVID-19) has dominated the attention of health care systems globally since January 2020. Various health disciplines including physical therapists are still exploring the best way to manage this new disease. The role and involvement of physical therapists in the management of COVID-19 are not yet well defined and are limited in many hospitals. This article reports a physical therapy service specially commissioned by the Health Commission of Sichuan Province to manage COVID-19 during patients’ stay in the intensive care unit (ICU) at the Public Health Clinical Center of Chengdu in China.MethodsPatients diagnosed with COVID-19 were classified into 4 categories under a directive from the National Health Commission of the People’s Republic of China. Patients in the “severe” and “critical” categories were admitted to the ICU irrespective whether mechanical ventilation was required. Between January 31, 2020, and March 8, 2020, a cohort of 16 patients was admitted to the ICU at the Public Health Clinical Center of Chengdu. The median (minimum to maximum) hospital and ICU stays for these patients were 27 (11–46) and 15 (6–38) days, respectively. Medical management included antiviral, immunoregulation and supportive treatment of associated comorbidities. Physical therapist interventions included body positioning, airway clearance techniques, oscillatory positive end-expiratory pressure, inspiratory muscle training, and mobility exercises. All patients had at least 1 comorbidity. Three of the 16 patients required mechanical ventilation and were excluded for outcome measures that required understanding of verbal instructions. In the remaining 13 patients, respiratory outcomes—including the Borg Dyspnea Scale, peak expiratory flow rate, Pao2/Fio2 ratio, maximal inspiratory pressure, strength outcomes, Medical Research Council Sum Score, and functional outcomes (including the Physical Function in Intensive Care Test score, De Morton Mobility Index, and Modified Barthel Index)—were measured on the first day the patient received the physical therapist intervention and at discharge.ResultsAt discharge from the ICU, while most outcome measures were near normal for the majority of the patients, 61% and 31% of these patients had peak expiratory flow rate and maximal inspiratory pressure below 80% of the predicted value and 46% had De Morton Mobility Index values below the normative value.ConclusionThe respiratory and physical functions of some patients remained poor at ICU discharge, suggesting that long-term rehabilitation may be required for these patients.ImpactOur experience in the management of patients with COVID-19 has revealed that physical therapist intervention is safe and appears to be associated with an improvement in respiratory and physical function in patients with COVID-19 in the ICU.

Introduction of a psychologically informed educational intervention for pre-licensure physical therapists in a classroom setting

BackgroundThere is an increasing need for physical therapists to address psychosocial aspects of musculoskeletal pain. Psychologically informed practice is one way to deliver this type of care through the integration of biopsychosocial interventions into patient management. An important component of psychologically informed practice is patient centered communication. However, there is little research on how to effectively implement patient centered communication into pre-licensure training for physical therapists.MethodsThirty Doctor of Physical Therapy (DPT) students took part in an educational intervention that consisted of one 4-h didactic teaching session and three 1-h experiential learning sessions. Prior to the first session, students performed an examination of a standardized patient with chronic low back pain and were assessed on psychologically informed physical therapy (PIPT) adherent behaviors via a rating scale. Students also completed the Pain Attitudes and Beliefs Scale (PABS-PT). After the last experiential session, students evaluated another standardized patient and were reassessed on PIPT adherent behaviors. Students retook the PABS-PT and qualitative data was also collected.ResultsAfter the educational intervention, students had positive changes in their pain attitudes and belief scores indicating a stronger orientation toward a psychosocial approach to patient care (p < 0.05). Additionally, after the intervention, students showed improvements in their adherence to using PIPT behaviors in their simulated patient interactions (p < 0.05). Qualitatively, students reported a high acceptability of the educational intervention with common themes indicating improved confidence with treating and communicating with complex patients.ConclusionStudents had attitudes and beliefs shift towards a more psychosocial orientation and demonstrated improved PIPT behaviors in simulated patient interactions after a brief educational intervention. Future research should investigate best practices for implementation of psychologically informed physical therapy for licensed clinicians.

The efficacy of specialised rehabilitation using the Op-reha Guide for cancer patients in palliative care units: protocol of a multicentre, randomised controlled trial (JORTC-RHB02)

BackgroundAlthough rehabilitation is recommended for terminal cancer patients, the specific components and methods of such programs are poorly documented. No studies to date have examined the effectiveness of rehabilitation for terminal cancer patients. This study aims to evaluate the efficacy of a new intervention for rehabilitation therapists, using the Op-reha Guide (Guide to Optimal and Patient-Centred Rehabilitation Practice for Patients in Palliative Care Units [PCUs]) in rehabilitation practice. This guide consists of recommended actions and attitudes for rehabilitation therapists and aims to optimise therapists’ actions according to the patient’s needs and condition. It shares goals with terminal cancer patients to maintain their activities of daily living (ADL).MethodsThis study uses a multicentre, prospective, randomised controlled trial (RCT) design with two parallel groups in PCUs where specialised rehabilitation will be routinely performed for terminal cancer patients by rehabilitation therapists. Participants will be randomised (1:1) to intervention (the Op-reha Guide) and control groups (usual rehabilitation). We will then conduct an observational study in PCUs that do not perform specialised rehabilitation for terminal cancer patients; this will be considered the usual care group, and the efficacy of usual rehabilitation will be quantitatively evaluated. Inclusion criteria are hospitalisation in PCU, European Cooperative Oncology Group Performance Status of 2 or 3, and clinical estimation of life expectancy of 3 weeks or more. Patients with severe symptom burden will be excluded. We hypothesise that the Op-reha Guide will be more effective in maintaining the ADL of terminal cancer patients hospitalised in PCUs than usual rehabilitation. The primary endpoint is defined as the change in (total) modified Barthel Index from baseline to Day 22. Quality of life will be a secondary endpoint. In total, 135 patients will be recruited from 16 Japanese sites between July 2019 and December 2021.DiscussionThis will be the first trial to evaluate the efficacy of specialised rehabilitation for terminal cancer patients hospitalised in PCUs, and will contribute to the evidence on the efficacy of implementing rehabilitation for terminal cancer patients.Trial registrationUMIN-CTR, UMIN000037298 R000042525 (date of registration 7 July 2019).

Early Physical Therapist Interventions for Patients With COVID-19 in the Acute Care Hospital: A Case Report Series.

ObjectiveThe aim of this case series was to describe the experience of Swiss physical therapists in the treatment of patients with COVID-19 during their acute care hospital stay and to discuss challenges and potential strategies in the clinical management of these patients.MethodsWe report 11 cases of patients with COVID-19 from 5 Swiss hospitals that illustrate the various indications for physical therapy, clinical challenges, potential treatment methods, and short-term response to treatment.ResultsPhysical therapists actively treated patients with COVID-19 on wards and in the intensive care unit. Interventions ranged from patient education, to prone positioning, to early mobilization and respiratory therapy. Patients were often unstable with quick exacerbation of symptoms and a slow and fluctuant recovery. Additionally, many patients who were critically ill developed severe weakness, postextubation dysphagia, weaning failure, or presented with anxiety or delirium. In this setting, physical therapy was challenging and required specialized and individualized therapeutic strategies. Most patients adopted the proposed treatment strategies, and lung function and physical strength improved over time.ConclusionPhysical therapists clearly have a role in the COVID-19 pandemic. Based on our experience in Switzerland, we recommend that physical therapists routinely screen and assess patients for respiratory symptoms and exercise tolerance on acute wards. Treatment of patients who are critically ill should start as soon as possible to limit further sequelae. More research is needed for awake prone positioning and early breathing exercises as well as post-COVID rehabilitation.ImpactTo date, there are few data on the physical therapist management of patients with COVID-19. This article is among the first to describe the role of physical therapists in the complex pandemic environment and to describe the potential treatment strategies for countering the various challenges in the treatment of these patients.

Θεραπευτικές παρεμβάσεις και σημαντικές ενδοσυνεδριακές στιγμές στη συστημική οικογενειακή ψυχοθεραπεία

The purpose of this study was to investigate the psychotherapeutic process in family integrative systemic therapy that lead to therapeutic change. More specifically, the study investigated the relation between therapist interventions and in-session good moments at different phases of therapy. The sample consisted of five families with good therapeutic outcome at three different stages of therapy - beginning, middle, and ending. Results indicated the appearance of specific good moments and therapist’s interventions at different stages of therapy, as well as significant correlations between therapist interventions and client good moments. This study sheds light on the complex processes of systemic family therapy and the variables that contribute to good therapy outcome.

Frequency of Physical Therapist Intervention Is Associated With Mobility Status and Disposition at Hospital Discharge for Patients With COVID-19.

ObjectiveFor patients diagnosed with the novel coronavirus, COVID-19, evidence is needed to understand the effect of treatment by physical therapists in the acute hospital on patient outcomes. The primary aims of this study were to examine the relationship of physical therapy visit frequency and duration in the hospital with patients’ mobility status at discharge and probability of discharging home.MethodsThis retrospective study included patients with COVID-19 admitted to any of eleven hospitals in one health system. The primary outcome was mobility status at discharge, measured using the Activity Measure for Post-Acute Care 6-Clicks basic mobility (6-Clicks mobility) and the Johns Hopkins Highest Level of Mobility (JH-HLM) scales. Discharge to home vs. to a facility was a secondary outcome. Associations between these outcomes and physical therapy visit frequency or mean duration were tested using multiple linear or modified Poisson regression. Potential moderation of these relationships by particular patient characteristics was examined using interaction terms in subsequent regression models.ResultsFor the 312 patients included, increased physical therapy visit frequency was associated with higher 6-Clicks mobility (b = 3.63; 95% CI = 1.54–5.71) and JH-HLM scores (b = 1.15; 95% CI = 0.37–1.93) at hospital discharge and with increased probability of discharging home (adjusted relative risk = 1.82; 95% CI = 1.25–2.63). Longer mean visit duration was also associated with improved mobility at discharge and the probability of discharging home, though the effects were less pronounced. Few moderation effects were observed.ConclusionPatients with COVID-19 demonstrated improved mobility at hospital discharge and higher probability of discharging home with increased frequency and longer mean duration of physical therapy visits. These associations were not generally moderated by patient characteristics.ImpactPhysical therapy should be an integral component of care for patients hospitalized due to COVID-19. Providing sufficient physical therapist interventions to improve outcomes must be balanced against protection from viral spread.

The First 60Days: Physical Therapy in a Neurosurgical Center Converted Into a COVID-19 Center in Brazil.

ObjectiveThe purpose of this case report was to describe the role of physical therapists in a neurosurgical center that was converted into a COVID-19 center for critically ill patients.Methods (Case Description)On March 16, 2020, the state government of Rio de Janeiro, Brazil, determined that a neurosurgical center with 44 ICU beds equipped with mechanical ventilators should immediately transfer all patients with neurological conditions to other institutions and prepare for patients who were critically ill with COVID-19. The staff, including physical therapists, were trained to handle patients with COVID-19, many of whom were developing acute respiratory distress syndrome (ARDS) with complex and multifactorial ventilatory support needs. Adjustments were made to the physical therapy routine and protocols. Following the stabilization of patients’ respiratory condition, physical therapist interventions focused on restoring physical function.ResultsA total of 116 confirmed COVID-19 cases were treated from March 17 to May 17, 2020. Sixty percent were men (70) and 40% were women (46), with a median age of 59 years. Eighty-nine percent (103) underwent mechanical ventilation during hospitalization, of which 11% (11) were successfully extubated. Thirty percent (31) of patients underwent tracheostomy, and 26% of those (8) were successfully decannulated. Of the total patients, 57 patients died (mortality rate of 49%), 4 (3%) were transferred to another institution, 23 (20%) were discharged home, and 32 (28%) continued to be hospitalized.ConclusionPhysical therapists in the ICU can facilitate care for critical events such as intubation, patient positioning, ventilatory adjustments, extubation, and functional training.ImpactThe coronavirus pandemic has highlighted the importance of physical therapists, specifically in the care of patients who are critically ill with COVID-19. The availability and expertise of physical therapists in the ICU are important for managing critical events such as intubation, patient positioning, ventilatory adjustments, extubation, and functional training.

Desempenho ocupacional de cuidadores de crianças com transtorno do espectro autista (tea): uma revisão da literatura

Objetivo: Identificar as mudanças ocorridas no desempenho ocupacional de cuidadores de crianças com transtorno do espectro autista (TEA), e apresentar contribuições da Terapia Ocupacional para melhoria da qualidade de vida, diante das possíveis alterações. Métodos: Levantamento bibliográfico, de abordagem quanti-qualitativa, descritiva e exploratória da literatura brasileira afim de oportunizar informações sobre o desempenho ocupacional de cuidadores de crianças com TEA. Resultados: Identificou-se que ocorrem mudanças no desempenho ocupacional dos cuidadores, principalmente mudanças: físicas relacionadas a fadiga, dor, desconforto, sono, repouso e atividades físicas, psicólogicas, quanto a auto aceitação, capacidade de concentração, pensamentos e crenças pessoais e alterações na qualidade de vida. Para embasar a discussão desenvolveu-se três categorias de análise: Perfil dos cuidadores; Impacto do cuidar e o desempenho ocupacional do cuidador; Intervenção do terapeuta ocupacional. Considerações finais: os estudos identificaram que os cuidadores de crianças com TEA sofrem impactos no seu desempenho ocupacional, repercurtindo em seus aspectos físicos, psicológicos e sociais, podendo estes serem reduzidos através de intervenções e terapias direcionadas, dentre elas a terapia ocupacional.

Development and Validation of the AdT-Physio Scale: A Tool to Assess Adherence and Perception of Physical Therapist Intervention in Patients With Cystic Fibrosis.

The purpose of this study was to develop a scale to measure patient adherence to physical therapist intervention and to report psychometric properties in patients with cystic fibrosis (CF). This observational, multicenter, qualitative, and cross-sectional study was divided into 2 phases: development of scale items (content validity) and assessment of psychometric properties (construct validity, reliability, and convergent/discriminant validity). Recruited were 121 patients with CF (aged ≥16 years). Sociodemographic characteristics, lung function testing, Coping with Stress Self-Efficacy, brief Coping Orientation to Problems Experienced inventory, and the scale of Adherence to Treatment of Physiotherapy (AdT-Physio) scale were evaluated. The final version of the AdT-Physio scale consists of 15 items distributed across 2 subscales: compliance and beliefs about treatment/therapist. The scale showed high internal consistency (Cronbach α=.897; 95% CI=0.868-0.922) and subscales above 0.800. The 2-factor confirmatory factor analysis model fitted the data reasonably well: χ2 (76)=111.96, comparative fit index=0.982, Tucker-Lewis index=0.978, root mean square error of approximation=0.063, 95% CI=0.036 to 0.086, and weighted root mean square residual=0.720. No floor or ceiling effects were identified. There was a positive, significant, and moderate-low magnitude correlation with the total Coping Orientation to Problems Experienced inventory (r=.360) and Coping with Stress Self-Efficacy subscale efficacy expectations scores (r=.304). For discriminant validity, there was a positive, significant, and moderate correlation between the total and the age of the patients (r=.354). The AdT-Physio scale is psychometrically valid and reliable for use in the clinic for the assessment of adherence to physical therapy in patients with CF. Ultimately, the authors propose this documentary instrument to assess the evaluation of the therapeutic alliance in a valid and objective manner. The AdT-Physio scale provides us with a greater degree of understanding of the problems behind noncompliance with treatment to advance person-centered decisions in physical therapy and thereby enhance the effectiveness of care.

Decision-Making: Physical Therapist Intervention for Patients With COVID-19 in a Geriatric Setting.

Decision-Making: Physical Therapist Intervention for Patients With COVID-19 in a Geriatric Setting.

In-session interactive dynamics of the psychotherapy process between therapeutic alliance, therapist expertise, therapist technical intervention, patient metacognition and functioning.

Empirical research has explored different dimensions of the therapy process and their associations, often showing bidirectional links: for example, metacognition may be favoured by a positive alliance with the clinician; on the other hand, metacognitive difficulties may be an obstacle for the alliance. However, little is still known about the overall relationship between multiple dimensions during the psychotherapy process. The aim of this study is to further explore the in-session interaction of therapeutic process variables, focusing on patient metacognition, therapeutic alliance, technical intervention, therapist expertise, and patient functioning. Participants included 45 patients involved in a psychodynamic weekly treatment in two clinical centres. Therapists were both in-training and experienced clinicians. Four instruments were applied on four psychotherapy sessions (178 verbatim transcripts): Metacognition Assessment Scale-Revised (MAS-R) assessing metacognition, Collaborative Interaction Scale (CIS) assessing therapeutic alliance, Psychodynamic Intervention Rating Scale (PIRS) assessing therapist technical interventions, and Shedler-Westen Assessment Procedure (SWAP)-200 assessing patient functioning. Sequential analyses revealed that specific therapist interventions co-occurred with three different levels of therapeutic alliance: a first one characterized by positive collaboration, the second one by neutral collaboration, and the third one by ruptures. Moreover, and critically, the patient metacognition, patient functioning, and therapist expertise were found to exert different effects in the three alliance levels. These findings suggest the existence of a specific interdependence between the variables involved in the research. These results further indicate that the therapist expertise is a key element in the therapeutic process, as it can drastically affect the in-session interactive dynamic.

Time Between an Emergency Department Visit and Initiation of Physical Therapist Intervention: Health Care Utilization and Costs.

The aim of this study was to examine the association between the length of time between an emergency department (ED) visit and the subsequent initiation of physical therapist intervention for low back pain (LBP) on 1-year LBP-related health care utilization (ie, surgery, advanced imaging, injections, long-term opioid use, ED visits) and costs. This retrospective cohort study focused on individuals who consulted the ED for an initial visit for LBP. Claims from a single statewide, all-payers database were used. LBP-related health care use and costs for the 12months after the ED visit were extracted. Poisson and general linear models weighted with inverse probability treatment weights were used to compare the outcomes of patients who attended physical therapy early or delayed after the ED visit. Compared with the delayed physical therapy group (n=94), the early physical therapy group (n=171) had a lower risk of receiving lumbar surgery (relative risk [RR]=0.47, 95% CI=0.26-0.86) and advanced imaging (RR=0.72, 95% CI=0.55-0.95), and they were less likely to have long-term opioid use (RR=0.45, 95% CI=0.28-0.76). The early physical therapy group incurred lower costs (mean=$3,806, 95% CI=$1,998-$4,184) than those in the delayed physical therapy group (mean=$8,689, 95% CI=$4,653-$12,727). Early physical therapy following an ED visit was associated with a reduced risk of using some types of health care and reduced health care costs in the 12months following the ED visit. The ED is an entry point into the health care system for patients with LBP. Until now, the impact of the length of time between an ED visit and physical therapy for LBP has not been well understood. This study shows that swift initiation of physical therapy following an ED visit for LBP is associated with lower LBP-related health utilization for some important outcomes and lower LBP-related health care costs.

An Italian validation of the Comparative Psychotherapy Process Scale: Reliability and validity.

The Comparative Psychotherapy Process Scale (CPPS) is an instrument designed to measure therapist interventions in a psychotherapy session. The scale includes 20 items divided into two subscales: the PI (psychodynamic-interpersonal) scale, which describes psychodynamic-interpersonal techniques; and the CB (cognitive-behavioural) scale, which includes cognitive-behavioural interventions. The aim of the study was to examine the psychometric properties of the CPPS, comparing the PI and CB subscales with the psychodynamic, cognitive and STTP prototypes, as described by the Psychotherapy Process Q-set(PQS). The sample comprised 94 sessions (N = 94) of psychodynamic and cognitive-behavioural orientation. Two groups of independent raters with excellent interrater reliability (ICC = .78) evaluated the sessions. The results suggest that the CPPS is a valid and reliable instrument that provides a clinically sensitive and psychometrically robust evaluation of a therapist's techniques. The clinical and research implications of the results are discussed.

Factors Impacting Physical Therapy Utilization for Patients With Nonspecific Low Back Pain: Retrospective Analysis of a Clinical Data Set.

Factors predicting physical therapy utilization for lower back pain (LBP) remain unclear, limiting the development of value-based initiatives. The purpose of this study was to identify important factors that impact the number of physical therapist visits per episode of care for US adults with nonspecific LBP. This study was a retrospective observational cohort study of a clinical dataset derived from 80 clinics of a single physical therapy provider organization. Research variables were categorized at the individual (patient) level and the organization (therapist, clinic) level. A hierarchical regression model was designed to identify factors influencing the number of physical therapist visits per episode of care. Higher out-of-pocket payments per visit, receipt of "active" physical therapy, longer average visit length, earlier use of physical therapy, and sex of the therapist (male) were found to predict fewer visits per episode of care. Percent change of function, prior receipt of physical therapy by the same provider organization, self-discharge from physical therapy, level of starting function, and therapist certification were found to predict more visits. Of the variance in number of visits, 8.0% was attributable to the health care organization. Individual factors, such as higher out-of-pocket payment, have a significant impact on reducing visits per episode of care and should be considered when developing value-based initiatives to optimize clinical and utilization outcomes. Payers use consumer-directed healthcare to reduce costs by discouraging utilization of low value services and encouraging use of low-cost providers. LBP is a costly condition for which physical therapy is a high-value treatment. This study shows that non-need factors predict the number of physical therapy visits per episode of care for patients with nonspecific LBP. Insurance benefit plans with lower out-of-pocket payments for physical therapy and higher reimbursement for active physical therapist interventions may facilitate appropriate utilization of high-value treatment for LBP.

Multidimensional Cognitive Behavioral Therapy for Obesity Applied by Psychologists Using a Digital Platform: Open-Label Randomized Controlled Trial.

BackgroundDeveloping effective, widely useful, weight management programs is a priority in health care because obesity is a major health problem.ObjectiveThis study developed and investigated a new, comprehensive, multifactorial, daily, intensive, psychologist coaching program based on cognitive behavioral therapy (CBT) modules. The program was delivered via the digital health care mobile services Noom Coach and InBody.MethodsThis was an open-label, active-comparator, randomized controlled trial. A total of 70 female participants with BMI scores above 24 kg/m2 and no clinical problems besides obesity were randomized into experimental and control groups. The experimental (ie, digital CBT) group (n=45) was connected with a therapist intervention using a digital health care service that provided daily feedback and assignments for 8 weeks. The control group (n=25) also used the digital health care service, but practiced self-care without therapist intervention. The main outcomes of this study were measured objectively at baseline, 8 weeks, and 24 weeks and included weight (kg) as well as other body compositions. Differences between groups were evaluated using independent t tests and a per-protocol framework.ResultsMean weight loss at 8 weeks in the digital CBT group was significantly higher than in the control group (–3.1%, SD 4.5, vs –0.7%, SD 3.4, P=.04). Additionally, the proportion of subjects who attained conventional 5% weight loss from baseline in the digital CBT group was significantly higher than in the control group at 8 weeks (32% [12/38] vs 4% [1/21], P=.02) but not at 24 weeks. Mean fat mass reduction in the digital CBT group at 8 weeks was also significantly greater than in the control group (–6.3%, SD 8.8, vs –0.8%, SD 8.1, P=.02). Mean leptin and insulin resistance in the digital CBT group at 8 weeks was significantly reduced compared to the control group (–15.8%, SD 29.9, vs 7.2%, SD 35.9, P=.01; and –7.1%, SD 35.1, vs 14.4%, SD 41.2, P=.04). Emotional eating behavior (ie, mean score) measured by questionnaire (ie, the Dutch Eating Behavior Questionnaire) at 8 weeks was significantly improved compared to the control group (–2.8%, SD 34.4, vs 21.6%, SD 56.9, P=.048). Mean snack calorie intake in the digital CBT group during the intervention period was significantly lower than in the control group (135.9 kcal, SD 86.4, vs 208.2 kcal, SD 166.3, P=.02). Lastly, baseline depression, anxiety, and self-esteem levels significantly predicted long-term clinical outcomes (24 weeks), while baseline motivation significantly predicted both short-term (8 weeks) and long-term clinical outcomes.ConclusionsThese findings confirm that technology-based interventions should be multidimensional and are most effective with human feedback and support. This study is innovative in successfully developing and verifying the effects of a new CBT approach with a multidisciplinary team based on digital technologies rather than standalone technology-based interventions.Trial RegistrationClinicalTrials.gov NCT03465306; https://clinicaltrials.gov/ct2/show/NCT03465306

Beyond Limits: Unmasking Potential Through Movement Discovery.

Beth E. Fisher, PT, PhD, FAPTA, is a physical therapist, educator, and scholar whose clinical career has been shaped by numerous observations and experiences of patients' remarkable potential to recover ideal movement capability. Currently, Dr Fisher is a Professor of Clinical Physical Therapy in the Division of Biokinesiology and Physical Therapy at the University of Southern California. She is Director of the Neuroplasticity and Imaging Laboratory, primarily using transcranial magnetic stimulation to investigate brain-behavior relationships during motor skill learning and motor control in both individuals without disabilities and individuals with neurologic disorders. Dr Fisher previously worked at Rancho Los Amigos Medical Center on the Adult Neurology and Brain Injury Services. During her years as a clinician and rehabilitation specialist, it was her greatest ambition to be a part of developing physical therapist interventions that would maximize neural and behavioral recovery in individuals with pathological conditions affecting the nervous system. Toward this goal, she has continued to consult and teach nationally and internationally on current concepts for the treatment of adults with neurological disorders. It has been her consistent clinical observation not only that patients are limited by impairments that result from their injury, but that movement abnormalities are in part the result of a patient's automatic, implicit tendency to "respond" to those impairments via compensation.