Physical therapy clinical specialization and management of red and yellow flags in patients with low back pain in the United States

Psychological Risk Factors for Delayed Recovery Among Active Duty Service Members Seeking Treatment for Musculoskeletal Complaints at a Navy Shore-Based Military Medical Treatment Facility

INTRODUCTION

Musculoskeletal injuries (MSIs) are a leading cause of separation from the U.S. Navy. Data have shown that several psychological responses to MSI are associated with treatment outcomes. Yellow flags are maladaptive psychological responses to injury and predict delayed recovery, whereas pink flags indicate resilience after MSI and are associated with good treatment outcomes. Identifying these factors in patients with MSI would permit early targeted care to address factors that may delay their readiness for deployment and enhance factors that support recovery.

MATERIALS AND METHODS

Active duty service members with MSI who reported to physical therapy outpatient services at a naval hospital were recruited for the study. Yellow flags were assessed at baseline as part of a larger study. Participants completed the Fear Avoidance Beliefs Questionnaire (with two subscales, physical activity and work), the Pain Catastrophizing Scale, and the Hospital Anxiety and Depression Scale. Clinically relevant cut-off scores were used to indicate risk factors of delayed recovery. Pink flags were assessed with the Pain Self-Efficacy Questionnaire and a measure of positive outcome expectations for recovery.

RESULTS

Two hundred and ninety participants responded to some or all of the questionnaires. Of these, 82% exceeded the cut-off scores on the physical activity subscale of the Fear Avoidance Beliefs Questionnaire, and 39% did so on the work subscale. Pain catastrophizing exceeded the cut-off in only 4.9% of the sample. Forty-three percent of these exceeded the cut-off for the anxiety subscale of the Hospital Anxiety and Depression Scale; 27% exceeded the cut-off on the depression subscale of the Hospital Anxiety and Depression Scale. Additionally, 54% endorsed scores greater than 40 on the Pain Self-Efficacy Questionnaire, and 53% endorsed a high score on the positive outcome expectations.

CONCLUSIONS

A substantial portion of the sample endorsed elevated scores on one or more indicators of delayed recovery from MSI. Most participants showed a fear of physical activity, and approximately half reported pain-related distress (anxiety and depression). In addition, feelings of self-efficacy and positive outcome expectations of treatment were endorsed by only about half of the participants, indicating that the remaining half did not report adaptive responses to MSI. Early identification of these risk factors will allow for targeted treatment approaches that incorporate these yellow flags into treatment and support a psychologically informed approach to physical therapy. This approach is likely to reduce delayed recovery and improve deployment readiness.

Physiotherapists' awareness and use of red flags for the assessment of low back pain in Saudi Arabia

BACKGROUND

Physiotherapists must identify potential red flags that may impede recovery and function in individuals with low back pain (LBP) or put them at risk.

OBJECTIVES

This study aimed to (1) investigate physiotherapists' awareness and use of red flags for individuals with LBP in Saudi Arabia and (2) identify factors associated with their awareness and use of LBP red flags.

METHODS

This cross-sectional study collected data using an anonymous online questionnaire (February-July 2023). It included physiotherapists working in private/public hospitals in Saudi Arabia. The questionnaire asked about the participants' characteristics, their awareness of LBP red flags, and their use of red flags for LBP assessment.

RESULTS

A total of 643 participating physiotherapists (26.2 ± 3.8 years), 63.8% of whom were females, completed the survey. Most participants (94.4%) had adequate awareness of LBP red flags, and more than half (61%) had good utilization of red flags when assessing individuals with LBP. There was a positive correlation between the physiotherapists' awareness and use of LBP red flags.

CONCLUSION

The majority of the participating physiotherapists in Saudi Arabia were aware of LBP red flags, and many reported to have good use of red flags in clinical practice when assessing and managing individuals with LBP.

Diagnostic and decision-making abilities of Swiss physiotherapists in a simulated direct access setting

BACKGROUND

Direct access to physiotherapy requires physiotherapists to recognize red flags and determine adequate management plans.

PURPOSE

Investigate Swiss physiotherapists' ability to diagnose and triage patients in a simulated direct access setting and whether their characteristics were associated with correct diagnoses and decision-making.

METHODS

We conducted a national online survey using a questionnaire containing 12 first-contact case scenarios. A linear mixed model estimated scores for correct diagnoses and management decisions, differences between musculoskeletal (MSK), non-critical medical (non-CrM), and critical medical (CrM) case scenarios, and the estimated effects of physiotherapists' characteristics.

RESULTS

The linear mixed model of data from 1492 participants estimated 55.0% correct diagnoses (62.7% for non-CrM, 61.7% for MSK, and 40.5% for CrM scenarios) and 71.2% correct management decisions (78.1% for non-CrM, 73.0% for MSK, and 62.3% for CrM scenarios). For correct diagnoses, the 'academic education/continuing education' variable showed significant estimated effects for the MSK and CrM scenarios, as did 'professional experience' for the non-CrM scenarios, and the '≥ 50% musculoskeletal patients in consultations' variable for all scenario groups. For correct management decisions, 'academic education/continuing education' variable showed significant estimated effects in CrM scenarios, as did 'professional experience' in non-CrM and CrM scenarios, and the '≥ 50% musculoskeletal patients in consultations' variable in MSK scenarios.

CONCLUSION

The estimated effects of physiotherapists' characteristics on correct diagnoses and management decisions showed substantial heterogeneity. Improving Swiss physiotherapists' screening abilities remains important. Further research is required to develop innovative educational concepts and improve training for screening for red flags.

The relationships between pain-associated psychological distress, pain intensity, patient expectations, and physical function in individuals with musculoskeletal pain: A retrospective cohort study

INTRODUCTION

The presence of pain-associated psychological distress (PAPD) in musculoskeletal disorders, including negative mood, fear-avoidance, and lack of positive affect/coping, is associated with prolonged disability. The importance of considering psychological influence on pain is well known, but practical ways of addressing it are not as straightforward. Identifying relationships between PAPD and pain intensity, patient expectations, and physical function may guide the development of future studies that assess causality and inform clinical practice.

OBJECTIVE

To assess the relationship between PAPD measured by the Optimal Screening for Prediction of Referral and Outcome-Yellow Flag tool, and baseline pain intensity, expectations of treatment effectiveness, and self-reported physical function at discharge.

DESIGN

Retrospective cohort study.

SETTING

Hospital-based outpatient physical therapy.

PARTICIPANTS

Patients 18 to 90 years old with spinal pain or lower extremity osteoarthritis.

MAIN OUTCOME MEASURES

Pain intensity and patient expectations of treatment effectiveness at intake, and self-reported physical function at discharge.

RESULTS

A total of 534 patients, 56.2% female, median (interquartile range [IQR]) age 61 (21) years with an episode of care between November 2019 and January 2021 were included. A multiple linear regression showed a significant association between PAPD and pain intensity with 6.4% (p < .001) of the variance explained. PAPD explained 3.3% (p < .001) of the variance in patient expectations. One additional yellow flag present resulted in a 0.17-point increase in pain intensity and 1.3% decrease in patient expectations. PAPD was also associated with physical function with 3.2% (p < .001) of the variance explained. PAPD explained 9.1% (p < .001) of the variance in physical function at discharge in the low back pain cohort only when assessed independently by body region.

CONCLUSION

These findings support the theory that the pain experience is complex and multiple factors should be considered when evaluating a patient with musculoskeletal pain. Clinicians who have identified PAPD may consider these relationships when planning or modifying interventions and pursuing multidisciplinary collaboration.

Guideline adherent screening and referral: do third year Doctor of Physical Therapy students identify red and yellow flags within descriptive patient cases? a United States based survey study

INTRODUCTION

The need for early detection and appropriate management of flags in physical therapy has been established. The lack of early detection has been shown to lead to poor outcomes such as serious pathology, increased disability, prolonged symptoms, and increased healthcare utilization.

OBJECTIVE

The main purpose of this survey study was to assess third-year Doctor of Physical Therapy (DPT) students' adherence to clinical practice guidelines specifically in the identification and management of red and yellow flags through a case-based approach.

METHODS

A survey including three different flag case scenarios was sent to DPT students in 15 geographically diverse physical therapy programs. Previously published case scenarios measuring adherence to practice guidelines were used. Correlational analyses were performed to link student demographic details and guideline adherent management.

RESULTS

The survey was completed by 64 students. Guideline adherent management was greater for red flags (85%) than yellow flag cases (25% and 42%). No significant relationship was noted between the student details and guideline adherent management.

CONCLUSION

DPT students may need additional educational content related to yellow flag screening. Educators may consider utilizing published red and yellow flag cases to guide decision-making and highlight best screening practices.

Management of Low Back Pain: Do Physiotherapists Know the Evidence-Based Guidelines?

BACKGROUND

Clinical practice guidelines promote bio-psychosocial management of patients suffering from low back pain (LBP). The objective of this study was to examine the current knowledge, attitudes and beliefs of physiotherapists about a guideline-adherent approach to LBP and to assess the ability of physiotherapists to recognise signs of a specific LBP in a clinical vignette.

METHODS

Physiotherapists were recruited to participate in an online study. They were asked to indicate whether they were familiar with evidence-based guidelines and then to fill in the Health Care Providers' Pain and Impairment Relationship Scale (HC-PAIRS), Back Pain Attitudes Questionnaire (Back-PAQ), Neurophysiology of Pain Questionnaire (NPQ), as well as questions related to two clinical vignettes.

RESULTS

In total, 527 physiotherapists participated in this study. Only 38% reported being familiar with guidelines for the management of LBP. Sixty-three percent of the physiotherapists gave guideline-inconsistent recommendations regarding work. Only half of the physiotherapists recognised the signs of a specific LBP.

CONCLUSIONS

The high proportion of physiotherapists unfamiliar with guidelines and demonstrating attitudes and beliefs not in line with evidence-based management of LBP is concerning. It is crucial to develop efficient strategies to enhance knowledge of guidelines among physiotherapists and increase their implementation in clinical practice.

The Ability of Austrian Qualified Physiotherapists to Make Accurate Keep-Refer Decisions and to Detect Serious Pathologies Based on Clinical Vignettes: Protocol for a Cross-sectional Web-Based Survey

BACKGROUND

The recognition of serious pathologies affecting the musculoskeletal (MSK) system, especially in the early stage of a disease, is an important but challenging task. The prevalence of such serious pathologies is currently low. However, in our progressing aging population, it is anticipated that serious pathologies affecting the MSK system will be on the rise. Physiotherapists, as part of a wider health care team, can play a valuable role in the recognition of serious pathologies. It is at present unknown how accurately Austrian qualified physiotherapists can detect the presence of serious pathologies affecting the MSK system and therefore determine whether physiotherapy management is indicated (keep patients) or not (refer patients to a medical doctor).

OBJECTIVE

We will explore the current ability of Austrian qualified physiotherapists to recognize serious pathologies by using validated clinical vignettes.

METHODS

As part of an electronic web-based survey, these vignettes will be distributed among a convenience sample of qualified Austrian physiotherapists working in a hospital or private setting. The survey will consist of four sections: (1) demographics and general information, (2) the clinical vignettes, (3) questions concerning the clinical vignettes, and (4) self-perceived knowledge gaps and learning preferences from the perspective of study participants. Results will further be used for (1) international comparison with similar studies from the existing literature and (2) gaining insight into the participants' self-perceived knowledge gaps and learning preferences for increasing their knowledge level about keep-refer decision-making and detecting serious pathologies.

RESULTS

Data collection took place between May 2022 and June 2022. As of June 2022, a total of 479 Austrian physiotherapists completed the survey. Data analysis has started, and we aim to publish the results in 2023.

CONCLUSIONS

The results of this survey will provide insights into the ability of Austrian physiotherapists to make accurate keep-refer decisions and to recognize the presence of serious pathologies using clinical vignettes. The results of this survey are expected to serve as a basis for future training in this area.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/43028.

Physical Therapy and Mental Health: A Scoping Review

OBJECTIVES

Coexistence of mental and physical health conditions is prevalent. To achieve optimal physical therapy outcomes, neither should be treated in isolation. This review aimed to map intersections between physical therapy and mental health.

METHODS

This was a scoping review searching MEDLINE, CINAHL, PsycInfo, Cochrane, and PEDro databases. Two independent researchers screened studies of physical therapy practice with adolescents/adults with mental health disorders or research using primary mental health outcomes in physical health conditions or clinicians' perspective. Data were extracted on study type, participants, topics, publication year, and country.

RESULTS

The search yielded 3633 studies with 135 included. Five studies included adolescents. More than one-half were published since 2015. Studies specific to participants with mental health diagnoses included schizophrenia (n = 12), depressive disorders (n = 8), eating disorders (n = 6), anxiety disorders (n = 4), bipolar disorders (n = 1), somatic disorders (n = 5), and trauma and stressor-related disorders (n = 8) or varied mental health diagnoses (n = 14). Forty-one studies had primary mental health outcomes or clinical practice approaches with a mental health emphasis with participants with physical health conditions (musculoskeletal [n = 13], neurological [n = 7], other [n = 21]). Systematic reviews or randomized controlled trials predominantly involved exercise therapy and/or physical activity. Descriptions of physical therapists as participants (n = 35) included 4 main topics: (1) mental health screening; (2) knowledge, attitudes, and experiences; (3) key practice components; and (4) research priorities.

CONCLUSION

Physical therapy intersects with people experiencing mental health disorders across a broad spectrum of diagnoses, covering a range of interventions with a small but growing evidence base.

IMPACT

Exercise and physical activity studies dominated the highest levels of evidence and future focus, although economic evaluations and consumer-driven or patient experience studies are needed. There is a contrast between the confidence and knowledge of specialized physical therapists working within mental health settings and those in general practice settings. Inspiring, integrated education is required to further improve health care outcomes following physical therapy for people with mental health disorders or symptoms.

The Blind Men, the Elephant, and the Continuing Education Course: Why Higher Standards Are Needed in Physical Therapist Professional Development

SYNOPSIS: Evidence-based practice and implementing clinical practice guidelines are familiar themes for musculoskeletal rehabilitation clinicians. Yet, many clinicians continue to eschew recommended treatments. One explanation could be that physical therapists largely rely on continuing education courses-not research reports or standardized postprofessional education-to learn new treatments and update their practice patterns. However, continuing education courses in physical therapy have a much less rigorous review process, and interventions taught in these courses often conflict with high-quality evidence. The lack of rigor in continuing education may contribute to unwarranted variability in practice, which is a major threat to physical therapy. The current continuing competence paradigm in the United States, of which continuing education is a part, needs an overhaul to ensure clinicians learn current best evidence. Now is the time for change in professional development. We offer 3 suggestions to improve the current system of continuing competence in physical therapy. J Orthop Sports Phys Ther 2022;52(10):642-646. Epub: 27 July 2022. doi:10.2519/jospt.2022.11377.

A physical therapist-led clinical decision-making program reduced risk of adverse events after total knee arthroplasty over 3 years: A retrospective review

CONTEXT

Reducing adverse events after total knee arthroplasty has implications for newly developed bundled payment models.

OBJECTIVE

To examine the impact of a physical therapist-led clinical decision-making program on the risk of adverse events, function, visits used, or reaching knee range of motion (ROM) goals in patients after total knee arthroplasty.

METHODS

The decision-making program consisted of quarterly meetings and recommendations for early risk identification and evidence-based intervention. A retrospective review of electronic records included adult patients who underwent total knee arthroplasty postoperative rehabilitation in an 18-month baseline period from 2014 to 2015 and an intervention period from 2015 to 2018. Relative risk reduction (RRR) determined whether a reduction in risk had occurred. Discharge function was measured with the Lower Extremity Functional Scale.

RESULTS

A total of 160 patients were included, 69 from the 18-month baseline period and 91 from the 36-month intervention period. Mean (SD) age was 68 (9.2) years in the baseline period and 72 (9.7) years in the intervention period. There was an 8.4% (95% CI, 1.1%-64.9%) RRR in adverse events. The RRR for patients not reaching full knee extension was 70.5% (95% CI, 33.4%-87.0%) and the RRR for patients not reaching 120° of knee flexion was 65.5% (95% CI, 5.4%-87.4%). There was significant improvement in the discharge function score (P = 0.05), but not the number of visits used (P = 0.29).

CONCLUSION

The physical therapist-led clinical decision-making program reduced the risk of adverse events after total knee arthroplasty. The risk of not reaching ROM goals by discharge was also substantially reduced.

Primary care physiotherapists ability to make correct management decisions - is there room for improvement? A mixed method study

Background

With increasing interest in direct access to physiotherapy, it is important to consider the physiotherapists (PTs) ability to make correct management decisions, because identification of differential diagnostic pathologies and timely referral for specialist care is vital for patient safety.

The aims of the study were to investigate PTs ability to make correct management decisions in patients presenting with musculoskeletal conditions and to identify explanatory factors associated with this ability. Furthermore, we wanted to explore the PTs views on the identified factors.

Methods

The study was a mixed methods study with an explanatory sequential design consisting of a questionnaire survey and semi-structured interviews. The questionnaire comprised 12 clinical vignettes describing patient scenarios for musculoskeletal conditions, non-critical medical conditions and critical medical conditions. Based on this, the PTs indicated whether the patient should be managed by the PT or were in need of medical referral. Associations between correct decisions and explanatory variables was analyzed by mixed- effects logistic regression. Interviews were performed with nine PTs to explore their reactions to the results. A directed content analysis was performed.

Results

A total of 195 PTs participated in the questionnaire survey and 9 PTs were interviewed. Overall, PTs were more likely to make correct management decisions in the musculoskeletal conditions category, whereas wrong decisions were more often chosen for underlying medical conditions categories. Positive associations between correct management decision in the critical medical category were found for experience: odds ratio (OR) 2.73 (1.33;5.57) and passed quality audit OR 2.90 (1.50;5.58). In the interviews, PTs expressed concerns about the differential diagnostic abilities. They all noted, that experience is immensely important in the clinical reasoning process because the ability to recognise diagnostic patterns evolves over time. Furthermore, the quality audit seems to address and systematize the clinical reasoning process and workflow within the clinics.

Conclusion

The lack of ability to make correct management decision in critical medical categories and the uncertainties expressed by PT’s should raise concern, as direct access to physiotherapy is already well-established and the results indicate that patient safety could be at risk. The findings that experience and passed quality audit was associated with correct management decisions highlights the need for ongoing awareness and education into differential diagnostics.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01546-1.

Evaluation of an educational intervention that aims to improve the keep/refer decision-making abilities of Austrian undergraduate physiotherapy students: a randomised pilot study

Background/Aims

An ongoing discussion about direct access to physiotherapy for patients with musculoskeletal pain disorders in Austria requires the development of a curriculum that educates physiotherapy students to make autonomous decisions to treat the patient without the need for medical referral (keep), to treat the patient with additional medical check-up (keep and refer) or to send the patient for medical evaluation without physiotherapeutic management (refer), and to recognise the presence of serious pathologies. The aim of this study was to examine the feasibility, acceptability and potential effectiveness of an educational intervention that was provided to Austrian physiotherapy students in their final semester of the 3-year undergraduate (bachelor) degree.

Methods

An educational intervention was given to Austrian physiotherapy students in their final semester of the 3-year undergraduate (bachelor) degree, which consisted of a single, 1-hour face-to-face case-based lecture on the principles of differential diagnosis, screening for possible red flag pathologies and review of the body systems. A control group did not receive the intervention, but both groups completed 11 validated vignettes.

Results

Half of Austrian universities (n=6/12) and 116 final year Austrian undergraduate physiotherapy students took part in the study. All students from the intervention group were satisfied with the intervention and 77.6% found the intervention beneficial for making keep/refer decisions based on clinical vignettes. Overall, 89.7% did not find the intervention too time consuming. A potential effectiveness of the intervention could not be demonstrated.

Conclusions

Future similar studies need to investigate if more teaching hours and/or if different educational methods are capable of improving the keep/refer decision-making abilities of Austrian undergraduate physiotherapy students.

A Rare Consequence after Shoulder Dislocation in a Professional Cyclist: A Case Report

Background: Cycling is a popular source of recreation and physical activity for children and adults. With regard to the total number of sports injuries, cycling has the highest absolute number of injuries per year in the United States population. Cycling injuries can be classified into bicycle contact, traumatic, or overuse injuries. Aim of this study: The aims of this case report are to report a rare clinical complication of glenohumeral joint anterior dislocation that resulted in a patient experiencing continuous GHJ dislocations secondary to involuntary violent muscular spasms and emphasize the role of the physical therapist's differential diagnosis and clinical decision-making process in a patient following direct access referral. Case presentation: A professional 23-year-old cyclist presented to a physical therapist with spontaneous multidirectional dislocations to the right shoulder after the recurrence of trauma occurred during a recent cycling race. The dislocations do not occur at night, but occur during the day, randomly, and mostly associated with changes in the patient's psychological conditions. Directly from the clinical history, the physical therapist identified a neuro-physiological orange flag as well as an orthopedic red flag and, therefore, decided it was appropriate to refer the patient to a neurologist. It was determined by the physical therapist to be a priority to focus on the patient's neurologic status and then to evaluate the orthopedic problem. The neurological examination revealed a condition of spontaneous multidirectional dislocation associated with recurrent antero-posterior pain spasms of the shoulder joint. The neurologist prescribed medication. Following the second cycle of medication assumption, the patient was able to continue physiotherapy treatment and was referred to the orthopedic specialist to proceed with shoulder stabilization surgery. Discussion and conclusion: Currently, the diagnosis of this unusual clinical condition is still unclear. It is a shared opinion of the authors that the trauma during the past bicycle race awakened an underlying psychological problem of the patient that resulted in a clinical condition of weakness of all the structures of the shoulder, such that these spasms could result in multiple multidirectional dislocations.