Predictors of physical therapy clinic performance in the treatment of patients with low back pain syndromes

Effectiveness of manual therapy for patients with low back pain from the perspective of physical and psychosocial factors

[Purpose] This study aimed to determine the effectiveness of the Arthrokinematic Approach (AKA)-Hakata method for patients with low back pain (LBP). [Participants and Methods] The participants were 39 patients with LBP who visited a medical facility between June 1, 2022, and November 30, 2022. The intervention period was 8 weeks, with five treatment sessions, and the patient assessments were performed using patient self-reported measures of LBP and motor function assessment. [Results] The AKA-Hakata method showed significant differences in all of the items evaluated in the longitudinal comparison of patients. Additionally, an interaction was observed only in the Roland-Morris Disability Questionnaire between the two groups classified using the Subgrouping for Targeted Treatment Back Screening Tool. [Conclusion] The results of this study showed that treatment with the AKA-Hakata method may have an early therapeutic effect on the physical and psychosocial risks in daily life. The results of this study indicated that the AKA-Hakata method is effective for the treatment of LBP. However, this study only evaluated a relatively short treatment period of five sessions. Further research on the long-term treatment effect is needed in order to optimize the treatment duration in detail and investigate the effectiveness of the AKA-Hakata method.

Therapy Assistant Staffing and Patient Quality Outcomes in Skilled Nursing Facilities

Therapy staffing declined in response to Medicare payment policy that removes incentives for intensive physical and occupational therapy in skilled nursing facilities, with therapy assistant staffing more impacted than therapist staffing. However, it is unknown whether therapy assistant staffing is associated with patient outcomes. Using 2017 national data, we examined associations between therapy assistant staffing and three outcomes: patient functional improvement, community discharge, and hospital readmissions, controlling for therapy intensity and facility characteristics. Assistant staffing was not associated with functional improvement. Compared with employing no assistants, staffing 25% to 75% occupational therapy assistants and 25% to 50% physical therapist assistants were associated with more community discharges. Higher occupational therapy assistant staffing was associated with higher readmissions. Higher intensity physical therapy was associated with better quality across outcomes. Skilled nursing facilities seeking to maximize profit while maintaining quality may be successful by choosing to employ more physical therapy assistants rather than sacrificing physical therapy intensity.

The Impact of Level of Physical Therapist Assistant Involvement on Patient Outcomes Following Stroke

OBJECTIVE

This study investigates if higher utilization of physical therapist assistants adversely affects patient outcomes in the acute rehabilitation setting for patients following a cerebrovascular accident (CVA).

METHODS

Participants were admitted to 1 of 5 inpatient rehabilitation facilities following a CVA from 2008 to 2010. High physical therapist assistant use was defined as ≥20% of the physical therapist visits being provided by the physical therapist assistant for an episode of care. Multivariable regression techniques examined differences in functional outcome, discharge location, and length of stay between high and low physical therapist assistant use groups. Propensity scoring methods supplemented findings of the regression analyses.

RESULTS

Of the 1561 participants, 496 (32%) had high physical therapist assistant involvement. Baseline participant characteristics such as age, sex, baseline motor function, and comorbidities did not differ between high and low physical therapist assistant use groups. After adjusting for patient characteristics, rehabilitation facility, and year, higher physical therapist assistant use did not adversely affect functional outcome or length of stay. Fewer conclusions can be drawn regarding discharge location, although there was no significant difference in discharge location between groups with high and low physical therapist assistant utilization. Propensity scoring methods supported the findings of the regression analyses.

CONCLUSIONS

Higher physical therapist assistant involvement in the rehabilitation of patients following CVA did not adversely affect functional outcome, increase length of stay, or reduce the likelihood of discharge to home from an inpatient rehabilitation facility.

IMPACT

The results demonstrate the value of the physical therapist assistant in the provision of physical therapy for patients with stroke in the inpatient rehabilitation setting. Higher involvement of the physical therapist assistant may provide cost savings while maintaining patient outcomes for this setting and population.

Delegation by Allied Health Professionals to Allied Health Assistants: a mixed methods systematic review

BACKGROUND

Delegation by Allied Health Professionals (AHPs) to Allied Health Assistants (AHAs) was introduced in response to various challenges affecting modern health care delivery. However, the clinical and cost-effectiveness of using AHAs is relatively unexplored.

OBJECTIVES

The aim of this review was to synthesise the available evidence on; firstly, the clinical and cost-effectiveness of interventions delegated by AHPs to AHAs and secondly, AHPs', AHAs' and patients' attitudes and beliefs towards delegation.

DATA SOURCES

MEDLINE, AMED, CINAHL, Cochrane Library, PsycINFO, PEDro, OTseeker and Web of Science databases were searched from inception until January 2019 without restrictions.

STUDY SELECTION

Primary studies investigating the clinical and cost-effectiveness of any intervention delegated by an AHP, across the spectrum of clinical areas in relation to adult patients, as well as AHPs', AHAs' and patients' attitudes and beliefs about delegation.

DATA EXTRACTION & SYNTHESIS

Data were extracted by pairs of reviewers. Thematic analysis and synthesis of descriptive and analytical themes was conducted.

RESULTS

Thirteen publications of variable methodological quality were included. Three studies reported quantitative research and ten qualitative research. No study explored the cost-effectiveness. Only one study investigated clinical effectiveness. Training for both AHPs and AHAs and having clear processes in place were identified as important facilitators of delegation.

CONCLUSION AND IMPLICATIONS OF KEY FINDINGS

Delegation is not standardised across AHPs or within each profession. There are clear knowledge gaps regarding the clinical and cost-effectiveness of delegation by AHPs and patients' attitudes and preferences. Further research is needed to facilitate the standardisation of delegation.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42019119557.

Multifaceted Exercise Prescription in the Management of an Overhead Athlete with Suspected Distal Biceps Tendinopathy: A Case Report

BACKGROUND AND PURPOSE

Distal biceps brachii tendinopathy is an uncommon diagnosis. Various exercise prescriptions have demonstrated efficacy in the management of tendinopathy, although studies frequently focus on the effects of a specific type of muscular contraction (i.e., concentric, isometric, or eccentric). Currently, there is limited research guiding the conservative management of distal biceps tendinopathy, particularly with overhead athletes, and even less evidence reporting a multifaceted exercise prescription for individuals with tendinopathy. The purpose of this case report is to describe the integration of various modes of therapeutic exercise into a rehabilitation program for an overhead athlete with suspected distal biceps brachii tendinopathy.

CASE DESCRIPTION

A 19-year-old male collegiate baseball pitcher presented to an outpatient physical therapy clinic via direct access for left antecubital pain, which began 6 weeks prior to the evaluation while pitching during try-outs. Following physical examination, distal biceps tendinopathy was the likely clinical diagnosis. Interventions focused on early eccentric exercise eventually progressing to concentric and plyometric activity for return to sport.

OUTCOMES

The patient was seen five times over the course of 4 weeks. He had significant improvements of pain, patient-reported functional outcomes, global rating of change, strength, tenderness, and provocation testing. The patient was able to return to an off-season pitching program.

DISCUSSION

An impairment-based and task-specific exercise prescription was effective for this patient with distal biceps tendinopathy. Understanding the biomechanical demands of an individual's functional limitation, in this case baseball pitching, may assist the decision-making process and optimize outcomes. Additional research into the most effective exercise prescriptions for individuals with uncommon tendinopathies is warranted.

Risk Adjustment of the Modified Low Back Pain Disability Questionnaire and Neck Disability Index to Benchmark Physical Therapist Performance: Analysis From an Outcomes Registry

BACKGROUND

Patient-reported outcomes (PROs) have been touted as the ultimate assessment of quality medical care and have been proposed as performance measures after appropriate risk adjustment. Although spine conditions represent the most common orthopedic disorders, the most used PROs for disabilities related to the back and neck-the Modified Low Back Pain Disability Questionnaire (MDQ) and the Neck Disability Index (NDI)-have not been evaluated as performance measures.

OBJECTIVE

The objective of this study was to benchmark physical therapists' performance in the management of spine conditions not involving surgery through the use of risk-adjusted MDQ and NDI outcomes.

DESIGN

This was a retrospective observational study.

METHODS

Data were accessed for patients seeking physical therapy with no history of related surgery for back or neck pain (315,274 treatment episodes) between January 2015 and June 2018. Patients with complete data, including initial and matched final MDQ or NDI, were considered for analysis (182,276 patients; 2799 physical therapists). Linear models controlling for baseline PRO and patient characteristics predicted PRO change for each patient. An aggregated performance ratio of actual PRO change to predicted PRO change was calculated for each physical therapist, and then empirical bootstrapping was used to develop the median performance ratio and its confidence intervals. Physical therapists who met a 40-patient threshold for either cohort (MDQ or NDI) were classified as "outperforming," "meeting expectations," or "underperforming" relative to predicted values using these 95% confidence intervals.

RESULTS

Performance ratios indicated that 10% and 11% of physical therapists outperformed, 79% and 78% met expectations, and 11% and 11% underperformed relative to the risk-adjusted predicted change in the MDQ (1240 therapists; 97,908 patients) and NDI (461 therapists; 26,123 patients), respectively. To demonstrate the clinical importance of risk adjustment, clinical performance was evaluated in the seemingly homogeneous subset of 208 physical therapists within 0.5 SD of the median baseline MDQ and the median actual change in the MDQ. Following risk adjustment, 2 physical therapists were classified in each of the outperforming and underperforming cohorts.

LIMITATIONS

The secondarily obtained observational data used were not collected for research purposes. Additionally, the analyses were limited by missing baseline information and follow-up PROs.

CONCLUSIONS

The risk-adjusted performance ratios for the MDQ and NDI resulted in disparate conclusions regarding the quality of care compared with the raw, unadjusted change scores. According to the baseline and unadjusted change in the MDQ, even physical therapists in the most homogeneous sample were differentiated following appropriate risk adjustment. Clinically important improvements in actual PROs were observed in the outperforming but not in the underperforming physical therapists. Clinically meaningful differences in the performance ratio are unknown and are a limitation to clinical application and an opportunity for future research.

Effect of Low Back Pain Chronicity on Patient Outcomes Treated in Outpatient Physical Therapy: A Retrospective Observational Study

OBJECTIVE

To examine the potential relationship between physical therapy (PT) treatment outcomes and chronicity of low back pain (LBP) in the outpatient setting.

DESIGN

Retrospective observational study.

SETTING

Outpatient PT clinics across 11 states.

PARTICIPANTS

A total of 11,941 patients with LBP provided with PT services and discharged from care between January 1, 2017, and December 31, 2018.

MAIN OUTCOME MEASURES

Focus on Therapeutic Outcome Low Back Functional Status (FS) Patient-Reported Outcome Measure (PROM) was the primary outcomes measure used. It assesses the patients' perceived physical abilities for patients experiencing LBP impairments. It determined a functional score on a linear metric ranging from 0 (low functioning) to 100 (high functioning). The difference in score between the intake FS and final FS score produced the FS change, which represented the overall improvement of the episode of care.

RESULTS

The mean FS change was 16.997 (n=11,945). Patients with chronic symptoms (>90-d duration) had an FS change of 15.920 (n=7264) across 14.63 visits. Patients with subacute symptoms (15-90d) had an FS change of 21.66 (n=3631) across 14.05. Patients with acute symptoms (0-14d) had an FS change of 29.32 (n=1050) across 13.66 visits. Stepwise regression analysis revealed a significant â for chronicity (-4.155) with all models.

CONCLUSIONS

Overall, this study shows patients experiencing shorter duration of LBP symptoms before starting a PT episode of care experience significantly better outcomes than patients who waited. Furthermore, the number of treatment session and duration of care was similar between groups, indicating potential ineffective or insufficient care was provided for patients with chronic pain.

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

BACKGROUND CONTEXT

The STarT Back Screening Tool (SBST) categorizes risk of future disability in patients with low back pain (LBP). Previous studies evaluating the use of SBST in physical therapy (PT) populations do not reflect the ethnic and socioeconomic diversity occurring in clinical practice and lack statistical power to evaluate factors associated with outcomes within each SBST risk category.

PURPOSE

The purpose of this study is to further refine SBST risk categorization for predicting improvements in functional disability with attention toward patient level factors that might guide SBST use in routine outpatient physical therapy practice.

STUDY DESIGN/SETTING

This was a retrospective cohort study that took place within a large academic, tertiary-care health system.

PATIENT SAMPLE

The study cohort consisted of 1,169 patients with LBP who completed a course of outpatient physical therapy from June 1, 2014 to May 31, 2015 and who completed the patient-reported SBST and modified low back pain disability questionnaire (MDQ) questionnaires as part of standard of care.

OUTCOME MEASURES

Improvement in functional disability defined as decrease in 10 or more points in the MDQ.

METHODS

Multivariable logistic regression was performed to evaluate independent predictors of improvement after PT, which included SBST risk category, baseline MDQ, a two-way interaction term between SBST category and baseline MDQ, prior level of function (independent vs. required assistance), demographic characteristics, number of completed PT visits, and duration of PT episode of care. In exploratory analyses, additional two-way interaction terms between SBST category and the significant predictors were added to the regression model.

RESULTS

Mean age of patients in the study cohort was 55.1 years (SD 16.1); 657 (56.2%) were female, 117 (10.0%) were black race, 127 (10.9%) had Medicaid insurance, and 353 (30.2%) had previously received PT for back pain. In all, 35.8% (n=419) patients categorized as low risk SBST category, 40.7% (n=476) medium risk SBST category, and 23.4% (n=274) high risk SBST category. There was an interaction between baseline MDQ and SBST risk category and improvement with PT. For all three SBST categories, higher baseline MDQ was associated with higher probability of improvement, but the effect was less pronounced as SBST risk category increased. Additional factors independently associated with reduced odds of improvement after PT included black race (odds ratio [OR] 0.44, 95% confidence interval [CI] 0.28-0.72), Medicaid insurance (OR=0.58, 95% CI 0.36-0.95), and prior PT (OR=0.48, 95% CI 0.34-0.67). In exploratory analyses, there was a significant interaction between insurance type and SBST risk category in predicting functional improvement after PT. Patients with Medicare and Medicaid insurance had similar rates of improvement in low and high risk SBST categories but different rates of improvement in the medium risk categories.

CONCLUSIONS

The SBST tool predicts outcomes of PT in a cohort of patients receiving outpatient PT for LBP. The odds of improvement varied according to baseline disability and SBST risk status. Race, insurance type, and history of previous PT influenced prediction independent of SBST risk status. Incorporating these variables and the interaction between SBST and baseline disability in outcome models has the potential to refine prediction of outcomes after PT.

Comparison of STarT Back Screening Tool and Simmonds Physical Performance Based Test Battery in Prediction of Disability Risks Among Patients with Chronic Low-Back Pain

Objectives This study identified disability sub-groups of patients with chronic low back pain (LBP) using the Subgroup for Targeted Treatment (or STarT) Back Screening Tool (SBST) and Simmonds Physical Performance Tests Battery (SPPTB). In addition, the study investigated the divergent validity of SBST, and compared the predictive validity of SBST and SPPTB among the patients with the aim to enhance quick and accurate prediction of disability risks among patients with chronic LBP. Methods This exploratory cross-sectional study involved 70 (52.0% female and 47.1% male) consenting patients with chronic non-specific LBP attending out-patient physiotherapy and Orthopedic Clinics at the Obafemi Awolowo University Teaching Hospitals, Ile-Ife and Ladoke Akintola University of Technology Teaching Hospital, Osogbo, Nigeria. Disability risk subgrouping and prediction were carried out using the SBST and SPPTB (comprising six functional tasks of repeated trunk flexion, sit-to-stand, 360-degree rollover, Sorenson fatigue test, unloaded reach test, and 50 foot walk test). Pain intensity was assessed using the Quadruple Visual Analogue Scale. Data on age, sex, height, weight and BMI were also collected. Descriptive and inferential statistics were used to analyze data at p<0.05 Alpha level. Results The mean age, weight, height and body mass index of the participants were 51.4 ±8.78 years, 1.61 ±0.76 m and 26.6 ±3.18 kg/m2 respectively. The mean pain intensity and duration were 5.37 ±1.37 and 21.2 ±6.68 respectively. The divergent validity of SBST with percentage overall pain intensity was r = 0.732; p = 0.001. Under SBST sub-grouping the majority of participants were rated as having medium disability risk (76%), whilst SPPTB sub-grouped the majority as having high disability risk (71.4%). There was a significant difference in disability risk subgrouping between SBST and SPPTB (χ²=12.334; p=0.015). SBST had no floor and ceiling effects, as less than 15% of the participants reached the lowest (2.9%) or highest (1.4%) possible score. Conversely, SPPBT showed both floor and ceiling effects, as it was unable to detect ‘1’ and ‘9’, the lowest and highest obtainable scores. The ‘Area Under Curve’ for sensitivity (0.83) and specificity (0.23) of the SBST to predict ‘high-disability risk’ was 0.51. The estimated prevalence for ‘high-disability risk’ prediction of SBST was 0.76. The estimate for true positive, false positive, true negative and false negative for prediction of ‘high-disability risk’ for SBST were 0.77, 0.23, 0.31, and 0.69 respectively. Conclusion The Start Back Screening Tool is able to identify the proportion of patients with low back pain with moderate disability risks, while the Simmonds Physical Performance Tests Battery is better able to identify high disability risks. Thus, SBST as a self-report measure may not adequately substitute physical performance assessment based disability risks prediction. However, SBST has good divergent predictive validity with pain intensity. In contrast to SPBBT, SBST exhibited no floor or ceiling effects in our tests, and demonstrated high sensitivity but low specificity in predicting ‘high-disability risk’.

Immediate Physical Therapy Initiation in Patients With Acute Low Back Pain Is Associated With a Reduction in Downstream Health Care Utilization and Costs

BACKGROUND

Physical therapy is an important treatment option for patients with low back pain (LBP). However, whether to refer patients for physical therapy and the timing of initiation remain controversial.

OBJECTIVE

The objective of this study was to evaluate the impact of receiving physical therapy and the timing of physical therapy initiation on downstream health care utilization and costs among patients with acute LBP.

DESIGN

The design was a retrospective cohort study.

METHODS

Patients who had a new onset of LBP between January 1, 2009, and December 31, 2013, in New York State were identified and grouped into different cohorts on the basis of whether they received physical therapy and the timing of physical therapy initiation. The probability of service use and LBP-related health care costs over a 1-year period were analyzed.

RESULTS

Among 46,914 patients with acute LBP, 40,246 patients did not receive physical therapy and 6668 patients received physical therapy initiated at different times. After controlling for patient characteristics and adjusting for treatment selection bias, health care utilization and cost measures over the 1-year period were the lowest among patients not receiving physical therapy, followed by patients with immediate physical therapy initiation (within 3 days), with some exceptions. Among patients receiving physical therapy, those receiving physical therapy within 3 days were consistently associated with the lowest health care utilization and cost measures.

LIMITATIONS

This study was based on commercial insurance claims data from 1 state.

CONCLUSIONS

When referral for physical therapy is warranted for patients with acute LBP, immediate referral and initiation (within 3 days) may lead to lower health care utilization and LBP-related costs.

Comparison of 2 Multimodal Interventions With and Without Whole Body Vibration Therapy Plus Traction on Pain and Disability in Patients With Nonspecific Chronic Low Back Pain

OBJECTIVE

The purpose of this secondary data analysis was to compare the effect of 2 multimodal exercise-based physical therapy interventions (one with and one without whole-body vibration [WBV] therapy plus traction) on pain and disability in patients with nonspecific chronic low back pain (NSCLBP).

METHODS

We conducted a secondary analysis of data from 2 distinct samples. One sample was from the Focus on Therapeutic Outcomes Inc. (FOTO) group (n = 55, age 55.1 ± 19.0 years), and the other was the Illinois Back Institute (IBI) (n = 70, age 47.5 ± 13.4 years). Both groups of patients had NSCLBP for more than 3 months and a pain numeric rating scale (NRS) score of ≥7. Both groups received treatment consisting of flexibility or stretching exercises, core stability training, functional training, and postural exercises and strengthening exercises. However, the IBI group also received WBV plus traction. NSCLBP was measured before and after therapeutic trials using the NRS for pain and Oswestry Disability Index (ODI).

RESULTS

The NRS scores were significantly improved in both groups, decreasing by 2 points in the FOTO group and by 5 points in the IBI group. The ODI scores were significantly improved in both groups; the FOTO group score improved by 9 points and the IBI group improved by 22 points.

CONCLUSIONS

The results of this preliminary study suggest that NPS and ODI scores statistically improved for both NSCLBP groups receiving multimodal care. However, the group that included WBV therapy plus traction in combination with multimodal care had greater clinical results. This study had several limitations making it difficult to generalize the results from this study sample to the entire population.

Physical Therapy and Hospitalization Among Medicare Beneficiaries With Low Back Pain: A Retrospective Cohort Study

STUDY DESIGN

A retrospective cohort study.

OBJECTIVE

The aim of this study was to evaluate associations between receipt and quantity of outpatient physical therapy (PT) during an episode of care and 30-day and 180-day hospital admissions for any condition and lumbar spine conditions.

SUMMARY OF BACKGROUND DATA

Low back pain (LBP) is a common cause of hospitalization and the most common reason Medicare beneficiaries utilize outpatient PT. The association between PT and hospitalization among patients with LBP is unknown.

METHODS

A national sample of Medicare Fee-for-Service claims included 413,608 beneficiaries with an International Classification of Disease 9th revision (ICD-9) code of LBP and 1,415,037 episodes of care between June 1, 2010, and June 30, 2011. Episodes were classified as PT episodes or non-PT episodes. Relative risk of hospitalization from the episode start date was caldulated, adjusting for health status (Charlson comorbidity index), prior care utilization (number of prior hospitalizations and total number of episodes), an indicator of LBP severity (number of LBP ICD-9 codes), and demographics (sex, race/ethnicity, age).

RESULTS

The proportion of 30-day hospitalization for any condition was 3.42% for PT episodes of care and 6.54% for non-PT episodes. For 180-day hospitalization, proportions were 15.45% (PT) and 21.65% (non-PT). The adjusted relative risk reduction of PT (vs. non-PT) was 41% for 30 days [99% confidence interval (CI) 38-44] and 22% for 180 days (20-24). For admitting diagnoses of lumbar spine, reductions were 65% at 30 days and 32% at 180 days. More PT treatment days showed greater 30-day risk reductions. For any condition, compared with non-PT, reductions were 24% for 1 to 2 treatment days (lowest tertile), 45% for 3 to 7 days, and 65% for more than 8 days (highest tertile). Stronger effects were found for lumbar spine admissions. Associations between PT quantity and 180-day hospitalization were less consistent. Limitations of Medicare claims include the potential for inaccuracies, limited knowledge about disease severity, and which PT interventions were conducted.

CONCLUSION

Receipt of PT during an episode had a 22% to 65% reduced relative risk of hospitalization, with greater short-term reductions for more PT treatment days.

LEVEL OF EVIDENCE

3.

Risk Adjustment for Lumbar Dysfunction: Comparison of Linear Mixed Models With and Without Inclusion of Between-Clinic Variation as a Random Effect

BACKGROUND

Valid comparison of patient outcomes of physical therapy care requires risk adjustment for patient characteristics using statistical models. Because patients are clustered within clinics, results of risk adjustment models are likely to be biased by random, unobserved between-clinic differences. Such bias could lead to inaccurate prediction and interpretation of outcomes.

PURPOSE

The purpose of this study was to determine if including between-clinic variation as a random effect would improve the performance of a risk adjustment model for patient outcomes following physical therapy for low back dysfunction.

DESIGN

This was a secondary analysis of data from a longitudinal cohort of 147,623 patients with lumbar dysfunction receiving physical therapy in 1,470 clinics in 48 states of the United States.

METHODS

Three linear mixed models predicting patients' functional status (FS) at discharge, controlling for FS at intake, age, sex, number of comorbidities, surgical history, and health care payer, were developed. Models were: (1) a fixed-effect model, (2) a random-intercept model that allowed clinics to have different intercepts, and (3) a random-slope model that allowed different intercepts and slopes for each clinic. Goodness of fit, residual error, and coefficient estimates were compared across the models.

RESULTS

The random-effect model fit the data better and explained an additional 11% to 12% of the between-patient differences compared with the fixed-effect model. Effects of payer, acuity, and number of comorbidities were confounded by random clinic effects.

LIMITATIONS

Models may not have included some variables associated with FS at discharge. The clinics studied may not be representative of all US physical therapy clinics.

CONCLUSIONS

Risk adjustment models for functional outcome of patients with lumbar dysfunction that control for between-clinic variation performed better than a model that does not.

Physical therapists' level of McKenzie education, functional outcomes, and utilization in patients with low back pain

STUDY DESIGN

Longitudinal, prospective, observational cohort.

OBJECTIVE

To examine associations between McKenzie training, functional status (FS) at discharge, and number of physical therapy visits (utilization) in patients receiving physical therapy for low back pain.

BACKGROUND

The McKenzie method is commonly used in treating patients with low back pain.

METHODS

A McKenzie postgraduate educational program was initiated in a large outpatient physical therapy service. Functional status data were collected at intake and at discharge. Separate hierarchical linear mixed models were used to examine associations between physical therapists' McKenzie training level (none; Parts A, B, C, and D; and credentialed), FS score at discharge, and utilization, controlling for patient risk factors.

RESULTS

The final data set included 20 882 patients (mean ± SD age, 51 ± 16 years; 57% women) who completed FS surveys at both admission and discharge. Patients treated by physical therapists with any McKenzie training had better outcomes (additional 0.7 to 1.3 FS points; P<.05 to <.001) and fewer visits (0.6 to 0.9, P<.001) compared to patients treated by physical therapists with no training. For patients treated by therapists with no versus some McKenzie education, 65% versus 70% achieved at least the minimal clinically important improvement, respectively. There were no significant differences in outcomes or utilization by level of McKenzie training.

CONCLUSION

There was a slightly greater improvement of 0.7 to 1.3 points in FS at discharge in patients receiving physical therapy for low back pain by physical therapists who underwent McKenzie training. This difference was clinically important for an additional 5% of patients who achieved the minimal clinically important improvement when treated by therapists with some McKenzie training. Reduction in physical therapy utilization was 0.6 to 0.9 visits, with the fewest visits utilized by patients of physical therapists at the McKenzie Part D and credentialed levels. Together, these findings suggest improved cost-effectiveness at advanced McKenzie training levels. Ways to improve ongoing education and patient outcomes were proposed.

Assessing the influence of treating therapist and patient prognostic factors on recovery from axial pain

BACKGROUND

Limited research exists regarding the influence of a treating physical therapist on patient recovery (deemed therapist effects). Recent randomized clinical trials data provide an indication of small therapist effects for manual therapy; however, the extent to which therapist effects exist in the average outpatient facility is not clear. Moreover, patient-related prognostic factors, like fear-avoidance or pain duration, are important to consider since these may also influence the extent of therapist effects.

OBJECTIVE

To assess therapist effects and the influence of patient prognostic factors on recovery from axial pain in an outpatient orthopedic physical therapy facility.

METHODS

Clinical data were collected from consecutive patients with musculoskeletal neck and low back pain. Patient outcomes included pain intensity (visual analog scale) and functional measure (CareConnections functional outcomes index) scores. Therapist effects estimates and the influence of intake fear-avoidance (fear-avoidance beliefs questionnaire) and pain duration (days) were examined using multilevel linear or regression modeling.

RESULTS

A total of 258 patients (160 females; mean age 46.4±14.9 years) completed physical therapy and the required outcome measures. Five physical therapists (1-13 years of experience, mean 5.8 years) provided treatment. Therapists effects did not exist for discharge pain intensity or function after accounting for intake scores (P > 0.05). Further, therapist experience did not influence patient outcomes. Patient prognostic factors of fear-avoidance and pain duration did not influence therapists effects on the same patient outcome measures (P > 0.05).

DISCUSSION

Preliminary findings suggest that there are no major differences in patient outcome based on either the individual therapist (therapist effect) or therapist experience in this type of PT setting. Established prognostic factors had no influence on therapist effects for this cohort. Future analyses should consider intrinsic therapist factors (beliefs, equipoise), specific treatment parameters (dosage, type), and other patient prognostic factors (psychological, age, expectation, satisfaction) to further elucidate the influence of therapist effects.

The national sports safety in secondary schools benchmark (N4SB) study: defining athletic training practice characteristics

CONTEXT

Increased rates of sport participation and sport-related injury have led to greater emphasis on and attention to medical care of student-athletes in the secondary school setting. Access to athletic training services is seen as a critical factor for delivering adequate injury prevention and medical care to student-athletes. However, few data are available regarding practice characteristics of athletic trainers (ATs) in this setting.

OBJECTIVE

To characterize the practices of secondary school athletic trainers (ATs).

DESIGN

Descriptive study.

SETTING

Web-based survey.

PATIENTS OR OTHER PARTICIPANTS

A total of 17 558 ATs with current National Athletic Trainers' Association membership were identified for survey distribution. Of these, 4232 ATs indicated that they practiced in the secondary school setting, and 4045 completed some part of the survey.

MAIN OUTCOME MEASURE(S)

A Web-based survey was used to obtain demographic information about ATs and their secondary schools and characteristics of athletic training practice. Descriptive data regarding the athletic trainer's personal characteristics, secondary school characteristics, and practice patterns are reported as percentages and frequencies.

RESULTS

Most respondents were in the early stages of their careers and relatively new to the secondary school practice setting. Nearly two-thirds (62.4%; n = 2522) of respondents had 10 or fewer years of experience as secondary school ATs, 52% (n = 2132) had been certified for 10 or fewer years, and 53.4% (n = 2164) had 10 or fewer years of experience in any practice setting. The majority of respondents (85%) worked in public schools with enrollment of 1000 to 1999 (35.5%) and with football (95.5%). More than half of respondents were employed directly by their school. Most respondents (50.6%) reported an athletic training budget of less than $4000. The majority of ATs performed evaluations (87.5%) on-site all of the time, with a smaller percentage providing treatments (73.3%) or rehabilitation (47.4%) services all of the time.

CONCLUSIONS

This is the first study to describe secondary school athletic training that reflects national practice trends. To improve the quality of athletic training care and to support and improve current working conditions, the profession must examine how its members practice on a day-to-day basis.

The STarT back screening tool and individual psychological measures: evaluation of prognostic capabilities for low back pain clinical outcomes in outpatient physical therapy settings

BACKGROUND

Psychologically informed practice emphasizes routine identification of modifiable psychological risk factors being highlighted.

OBJECTIVE

The purpose of this study was to test the predictive validity of the STarT Back Screening Tool (SBT) in comparison with single-construct psychological measures for 6-month clinical outcomes.

DESIGN

This was an observational, prospective cohort study.

METHODS

Patients (n=146) receiving physical therapy for low back pain were administered the SBT and a battery of psychological measures (Fear-Avoidance Beliefs Questionnaire physical activity scale and work scale [FABQ-PA and FABQ-W, respectively], Pain Catastrophizing Scale [PCS], 11-item version of the Tampa Scale of Kinesiophobia [TSK-11], and 9-item Patient Health Questionnaire [PHQ-9]) at initial evaluation and 4 weeks later. Treatment was at the physical therapist's discretion. Clinical outcomes consisted of pain intensity and self-reported disability. Prediction of 6-month clinical outcomes was assessed for intake SBT and psychological measure scores using multiple regression models while controlling for other prognostic variables. In addition, the predictive capabilities of intake to 4-week changes in SBT and psychological measure scores for 6-month clinical outcomes were assessed.

RESULTS

Intake pain intensity scores (β=.39 to .45) and disability scores (β=.47 to .60) were the strongest predictors in all final regression models, explaining 22% and 24% and 43% and 48% of the variance for the respective clinical outcome at 6 months. Neither SBT nor psychological measure scores improved prediction of 6-month pain intensity. The SBT overall scores (β=.22) and SBT psychosocial scores (β=.25) added to the prediction of disability at 6 months. Four-week changes in TSK-11 scores (β=-.18) were predictive of pain intensity at 6 months. Four-week changes in FABQ-PA scores (β=-.21), TSK-11 scores (β=-.20) and SBT overall scores (β=-.18) were predictive of disability at 6 months.

LIMITATIONS

Physical therapy treatment was not standardized or accounted for in the analysis.

CONCLUSIONS

Prediction of clinical outcomes by psychology-based measures was dependent upon the clinical outcome domain of interest. Similar to studies from the primary care setting, initial screening with the SBT provided additional prognostic information for 6-month disability and changes in SBT overall scores may provide important clinical decision-making information for treatment monitoring.

Differential Item Functioning in a Computerized Adaptive Test of Functional Status for People with Shoulder Impairments is Negligible across Pain Intensity, Gender, and Age Groups

People with shoulder impairments ( N = 3,767) reported upper extremity function using a 37-item shoulder-specific computerized adaptive test (shoulder CAT). The authors determined whether items of the shoulder CAT have differential item functioning (DIF) by pain intensity (low and high), gender (men and women), and age groups (young-adult, middle-aged and old-adult). They assessed whether items have uniform and/or non-uniform DIF using an ordinal logistic regression and item response theory approaches and applied large and small DIF criteria to assess the magnitude of DIF. The analyses revealed that uniform DIF was absent in all 37 items. Only six items exhibited non-uniform DIF using the large DIF criterion. Adjusting the person-ability measures for DIF had minimal practical impact on the overall measure of shoulder function estimated using the shoulder CAT. The shoulder CAT provided a precise measurement of function without discriminating for pain intensity, gender, and age among patients referred to rehabilitation with shoulder impairment.

Initial management decisions after a new consultation for low back pain: implications of the usage of physical therapy for subsequent health care costs and utilization

OBJECTIVES

To describe the utilization of physical therapy following a new primary care consultation for low back pain (LBP) and to examine the relations between physical therapy utilization and other variables with health care utilization and costs in the year after consultation.

DESIGN

Retrospective cohort obtained from electronic medical records and insurance claims data.

SETTING

Single health care delivery system.

PARTICIPANTS

Individuals (N=2184) older than 18 years with a new consultation for LBP from 2004 to 2008.

INTERVENTIONS

Patients were categorized as receiving initial physical therapy management if care occurred within 14 days after consultation.

MAIN OUTCOME MEASURES

Total health care costs for all LBP-related care received in the year after consultation were calculated from claims data. Predictors of utilization of emergency care, advanced imaging, epidural injections, specialist visits, and surgery were identified using multivariate logistic regression. The generalized linear model was used to compare LBP-related costs based on physical therapy utilization and identify other cost determinants.

RESULTS

Initial physical therapy was received by 286 of the 2184 patients (13.1%), and was not a determinant of LBP-related health care costs or utilization of specific services in the year after consultation. Older age, mental health, or neck pain comorbidity and initial management with opioids were determinants of cost and several utilization outcomes.

CONCLUSIONS

Initial physical therapy management was not associated with increased health care costs or utilization of specific services following a new primary care LBP consultation. Additional research is needed to examine the cost consequences of initial management decisions made following a new consultation for LBP.

Primary care referral of patients with low back pain to physical therapy: impact on future health care utilization and costs

STUDY DESIGN

A retrospective cohort.

OBJECTIVE

To describe physical therapy utilization following primary care consultation for low back pain (LBP) and evaluate associations between the timing and content of physical therapy and subsequent health care utilization and costs.

SUMMARY OF BACKGROUND DATA

Primary care management of LBP is highly variable and the implications for subsequent costs are not well understood. The importance of referring patients from primary care to physical therapy has been debated, and information on how the timing and content of physical therapy impact subsequent costs and utilization is needed.

METHODS

Data were extracted from a national database of employer-sponsored health plans. A total of 32,070 patients with a new primary care LBP consultation were identified and categorized on the basis of the use of physical therapy within 90 days. Patients utilizing physical therapy were further categorized based on timing (early [within 14 d] or delayed)] and content (guideline adherent or nonadherent). LBP-related health care costs and utilization in the 18-months following primary care consultation were examined.

RESULTS

Physical therapy utilization was 7.0% with significant geographic variability. Early physical therapy timing was associated with decreased risk of advanced imaging (odds ratio [OR] = 0.34, 95% confidence interval [CI]: 0.29, 0.41), additional physician visits (OR = 0.26, 95% CI: 0.21, 0.32), surgery (OR = 0.45, 95% CI: 0.32, 0.64), injections (OR = 0.42, 95% CI: 0.32, 0.64), and opioid medications (OR = 0.78, 95% CI: 0.66, 0.93) compared with delayed physical therapy. Total medical costs for LBP were $2736.23 lower (95% CI: 1810.67, 3661.78) for patients receiving early physical therapy. Physical therapy content showed weaker associations with subsequent care.

CONCLUSION

Early physical therapy following a new primary care consultation was associated with reduced risk of subsequent health care compared with delayed physical therapy. Further research is needed to clarify exactly which patients with LBP should be referred to physical therapy; however, if referral is to be made, delaying the initiation of physical therapy may increase risk for additional health care consumption and costs.

Referral source and outcomes of physical therapy care in patients with low back pain

STUDY DESIGN

Retrospective longitudinal cohort.

OBJECTIVES

To describe the clinical characteristics of patients with low back pain according to physician referral source, and to identify associations between referral source and discharge functional status, as well as number of physical therapy visits.

BACKGROUND

Little is known about associations between physician referral source and outcomes of physical therapy care for patients with low back pain. Exploring these associations can contribute to better understanding of physician-physical therapist relationships and may lead to improved referral patterns.

METHODS

Data from a proprietary clinical database were examined retrospectively. Physician referral source was classified as primary care, specialist, or occupational medicine. Outcomes were overall health status at discharge and number of physical therapy visits. Descriptive statistics and bivariate associations between referral source and each outcome were assessed by calculating differences and 95% confidence intervals (CIs) in means and proportions. To account for potential confounding, multilevel linear regression was used to adjust for baseline clinical covariates, effects related to clustering of patients treated by individual clinicians, and clinicians working within individual clinics.

RESULTS

Bivariate and multilevel analyses revealed significant associations between referral source and discharge overall health status, as well as number of visits. After multilevel adjustment for covariate and clustering effects, primary care and occupational medicine referrals were associated, on average, with point increases of 1.6 (95% CI: 0.7, 2.6) and 4.8 (95% CI: 2.7, 6.9) in discharge overall health status scores, respectively, compared to specialist referral. Similarly, primary care and occupational medicine referrals were associated, on average, with 0.44 (95% CI: 0.27, 0.61) and 0.83 (95% CI: 0.44, 1.22) fewer visits, respectively, compared to specialist referral.

CONCLUSION

After accounting for clinical covariates and clustering, patients with low back pain who were referred by occupational medicine and primary care physicians tended to have better functional outcomes and required fewer physical therapy visits per episode of care.

LEVEL OF EVIDENCE

Prognosis, level 2c.

Influence of fear-avoidance beliefs on functional status outcomes for people with musculoskeletal conditions of the shoulder

BACKGROUND

The influence of elevated fear-avoidance beliefs on change in functional status is unclear.

OBJECTIVE

The purpose of this study was to determine the influence of fear-avoidance on recovery of functional status during rehabilitation for people with shoulder impairments.

DESIGN

A retrospective longitudinal cohort study was conducted.

METHODS

Data were collected from 3,362 people with musculoskeletal conditions of the shoulder receiving rehabilitation. At intake and discharge, upper-extremity function was measured using the shoulder Computerized Adaptive Test. Pain intensity was measured using an 11-point numerical rating scale. Completion rate at discharge was 57% for function and 47% for pain intensity. A single-item screen was used to classify patients into groups with low versus elevated fear-avoidance beliefs at intake. A general linear model (GLM) was used to describe how change in function is affected by fear avoidance in 8 disease categories. This study also accounted for within-clinic correlation and controlled for other important predictors of functional change in functional status, including various demographic and health-related variables. The parameters of the GLM and their standard errors were estimated with the weighted generalized estimating equations method.

RESULTS

Functional change was predicted by the interaction between fear and disease categories. On further examination of 8 disease categories using GLM adjusted for other confounders, improvement in function was greater for the low fear group than for the elevated fear group among people with muscle, tendon, and soft tissue disorders (Δ=1.37, P<.01) and those with osteopathies, chondropathies, and acquired musculoskeletal deformities (Δ=5.52, P<.02). These differences were below the minimal detectable change. Limitations Information was not available on whether therapists used information on level of fear to implement treatment plans.

CONCLUSIONS

The influence of fear-avoidance beliefs on change in functional status varies among specific shoulder impairments.

Use of quality indicators in physical therapist practice: an observational study

BACKGROUND

The Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 contain provisions specific to health care quality that apply to physical therapists. Published evidence examining gaps in the quality of physical therapy services is limited.

OBJECTIVE

The primary purpose of this study was to determine the use of quality indicators in physical therapist practice.

DESIGN

This was an observational study.

METHODS

All members of the Orthopaedic and Private Practice sections of the American Physical Therapy Association were invited to participate by completing an electronic survey. The survey included 22 brief patient descriptions, each followed by questions regarding the use of examinations and interventions based on the 2009 list of Medicare-approved quality measures. Separate multivariate logistic regression models were used to determine the odds ratios related to the performance of each examination and intervention on more than 90% of patients, given perceptions of its importance to care, the burden of performing it, and the level of evidence supporting its use.

RESULTS

Participants (n=2,544) reported a relatively low frequency of performing examinations and interventions supporting primary and secondary prevention (3.6%-51.3%) and use of standardized measures (5.5%-35.8%). Perceptions of high importance and low burden were associated with greater odds of performing an examination or intervention. Importance and burden were more influential factors than the perceived availability of evidence to support use of identified techniques.

LIMITATIONS

The survey was not assessed for test-retest reliability. A low response rate was a source of potential bias.

CONCLUSION

The study findings suggest that physical therapists may not see themselves as providers of primary or secondary prevention services. Patient management strategies associated with these types of services also may be perceived as relatively unimportant or burdensome.

Delivery of physical therapy in the acute care setting: a population-based study

BACKGROUND

Population-based studies on physical therapy use in acute care are lacking.

OBJECTIVES

The purpose of this study was to examine population-based, hospital discharge data from North Carolina to describe the demographic and diagnostic characteristics of individuals who receive physical therapy and, for common diagnostic subgroups, to identify factors associated with the receipt of and intensity of physical therapy use.

DESIGN

This was a cross-sectional, descriptive study.

METHODS

Hospital discharge data for 2006-2007 from the 128 acute care hospitals in the state were examined to identify the most common diagnoses that receive physical therapy and to describe the characteristics of physical therapy users. For 2 of the most common diagnoses, logistic and linear regression analyses were conducted to identify factors associated with the receipt and intensity of physical therapy.

RESULTS

Of the more than 2 million people treated in acute care hospitals, 22.5% received physical therapy (mean age=66 years; 58% female). Individuals with osteoarthritis (admitted for joint replacement) and stroke were 2 of the most common patient types to receive physical therapy. Almost all individuals admitted for a joint replacement received physical therapy, with little between-hospital variation. Between-hospital variation in physical therapy use for stroke was greater. Demographic and hospital-related factors were associated with physical therapy use and physical therapy intensity for both diagnoses, after controlling for illness severity and comorbidities.

LIMITATIONS

Data from only one state were examined, and the studied variables were limited.

CONCLUSIONS

The use and intensity of physical therapy for stroke and joint replacement in acute care hospitals in North Carolina vary by clinical and nonclinical factors. Reasons behind the association of hospital characteristics and physical therapy use need further investigation.

Using intake and change in multiple psychosocial measures to predict functional status outcomes in people with lumbar spine syndromes: a preliminary analysis

BACKGROUND

Managing patients with lumbar spine syndromes who are seeking outpatient physical therapy represents a complex problem where psychosocial constructs such as fear-avoidance beliefs regarding physical activities or work activities, somatization, and depressive symptoms may affect functional status (FS) outcomes.

OBJECTIVE

The purpose of this study was to determine whether intake or changes in fear-avoidance beliefs regarding physical or work activities, somatization, and depressive symptoms assessed simultaneously affect FS outcomes prediction.

DESIGN

This study was a secondary analysis of prospectively collected, longitudinal, observational cohort data.

METHODS

Data analyzed were from adult patients (n=323) with lumbar syndromes classified as elevated versus not elevated on single-item screening instruments for fear-avoidance beliefs regarding physical or work activities, somatization, and depressive symptoms at intake and discharge. Prediction of minimal clinically important difference in FS was assessed separately for intake and change from intake to discharge classifications using logistic regression models controlling for important variables.

RESULTS

Intake and change models were strong (McFadden rho-squared values=.31 and .49, respectively). Patients classified as not elevated in fear-avoidance beliefs regarding physical activities but elevated in fear-avoidance beliefs regarding work activities, somatization, and depressive symptoms at intake were 5 out of 100 times less likely to report clinically important outcomes compared with being elevated in each measure. Patients not elevated in fear-avoidance beliefs regarding work activities and somatization at intake and discharge were 8 to 14 times more likely to report clinically important outcomes compared with being elevated in each measure.

LIMITATIONS

Sample size was limited. Data analyses were retrospective with no control of missing data.

CONCLUSIONS

Combinations of multiple psychosocial constructs were important predictors of FS outcomes and may assist patient management by: (1) identifying patients with elevated psychosocial constructs at intake and (2) tracking change in psychosocial variables for improved outcomes prediction. This model may prove helpful for future clinical and research applications to determine optimal psychosocial screening methods.

Change in psychosocial distress associated with pain and functional status outcomes in patients with lumbar impairments referred to physical therapy services

STUDY DESIGN

Prospective, longitudinal, observational cohort design.

OBJECTIVE

The primary aim was to examine the association between changes in psychosocial distress (PD), and functional status (FS) and pain intensity at discharge from physical therapy.

BACKGROUND

Patients with lumbar impairments seeking physical therapy commonly demonstrate elevated PD. However, it is not clear if PD changes that occur during physical therapy management are associated with improved clinical outcomes.

METHODS

Data from adults (n = 692) with lumbar impairment were analyzed. Patients were screened using the Symptom Checklist Back Pain Prediction Model questionnaire (SCL BPPM) to identify patients at intake and discharge into 3 levels of risk for persistent disability (high, intermediate, or low). SCL BPPM classifications allowed for 5 patterns of change in PD during therapy (decreased, stable low, stable intermediate, stable high, or increased). Associations between PD change patterns and discharge FS and pain intensity were assessed using multivariable linear regression models, controlling for selected risk-adjustment variables.

RESULTS

Proportions of patients classified by patterns of PD change for decreased, stable low, stable intermediate, stable high, and increased were 0.34, 0.52, 0.05, 0.06, and 0.03, respectively. Compared to the decreased PD group, (1) increased, stable high, and stable intermediate PD patterns were associated with worse discharge FS scores (-7.9 [95% CI: -13.5, -2.21], -10.9 [95% CI: -15.25, -6.49], and -8.9 [95% CI: -13.65, -4.21] units, respectively), and (2) stable high and stable intermediate PD patterns were associated with higher pain intensity (2.59 [95% CI: 1.81, 3.56] and 2.14 [95% CI: 1.25, 3.04] units, respectively).

CONCLUSIONS

Lower FS and higher pain intensity outcomes were associated in similar but not identical patterns with patients whose SCL BPPM classification of PD increased, or remained at high or intermediate levels during physical therapy. Serial assessments of change in PD during rehabilitation are recommended as a possible treatment-monitoring tool.

Construct validation of a knee-specific functional status measure: a comparative study between the United States and Israel

BACKGROUND

Comparative effectiveness research (CER) requires valid outcome measures that discriminate patients by risk factors in similar ways across settings. Standardized functional status (FS) measures in physical therapy are used routinely in multiple countries, creating the potential for CER among countries.

OBJECTIVE

The purpose of this study was to assess known-groups construct validity of a knee-specific FS measure within and between 2 countries for patients receiving outpatient physical therapy due to knee impairments.

DESIGN

This was a longitudinal, observational cohort study.

METHODS

The participants were 4,972 and 2,964 adult (age ≥18 years) patients with knee impairments from Israel and the United States, respectively. Differences in patient characteristics between the 2 countries were assessed using chi-square statistics and 2-sample t tests, as appropriate. Known-groups validity within and between the countries was assessed using 2-way analysis of covariance predicting FS at discharge, with sex, age, symptom acuity, surgical and exercise history, intake medication use, and country as risk-adjustment factors. Intake FS was the covariate. To compare how FS discriminated patient groups between countries, each factor was tested separately with models including an interaction term between the factor and country.

RESULTS

Patients were different between countries but had similar discharge FS trends, including: higher outcomes in patients who were male, were younger, had acute conditions, had one surgical procedure related to their knee impairment, were more physically active, and did not use related medication at admission. Interactions were not significant for sex, symptom acuity, and exercise history but were significant for age, surgical history, and medication use. Limitations Although strict patient selection criteria were set, some patient selection bias still might have existed.

CONCLUSIONS

The results demonstrated the knee FS measures would be valid for use in CER between Hebrew-speaking patients (Israel) and English-speaking patients (United States).

Relationship between categorization with the STarT Back Screening Tool and prognosis for people receiving physical therapy for low back pain

BACKGROUND

The STarT Back Screening Tool (SBT) was recently developed for primary care providers to use as a screening tool for subgrouping people with low back pain (LBP) on the basis of modifiable prognostic factors. The use of the SBT in physical therapy has not been described.

OBJECTIVE

The aims of this study were to describe the use of the SBT in people receiving physical therapy for LBP and to describe patterns of change in clinical outcomes across the episode of care and among SBT categories.

DESIGN

This study was a prospective case series.

METHODS

A total of 214 patients receiving physical therapy for LBP were administered the SBT at the initial evaluation. Treatment was at the physical therapist's discretion. Clinical outcomes included pain intensity and disability scores collected at each session. Descriptive statistics were calculated, and baseline characteristics among SBT categories were compared. Hierarchical linear mixed models were used to examine patterns of change in predicted outcomes across the episode of care.

RESULTS

The patients' mean age was 44.3 years (SD=15.8), and 56.5% were women. The SBT categorized 33.2% of the patients as being at low risk, 47.7% as being at medium risk, and 19.2% as being at high risk. The high-risk category corresponded to the highest initial pain intensity and disability scores. The low-risk category corresponded to the lowest initial pain intensity and disability scores. Linear mixed models indicated different patterns of change in outcome scores for pain intensity (F=3.99) and disability (F=3.49) among SBT categories. Relative to the low-risk category, the high-risk category had larger improvements in predicted outcomes and the medium-risk category had similar improvements in predicted outcomes. Limitations The SBT was not administered to 24% of eligible patients. The timing of follow-up assessments was variable.

CONCLUSIONS

The SBT may provide important prognostic information for physical therapists.

Effect of fear-avoidance beliefs of physical activities on a model that predicts risk-adjusted functional status outcomes in patients treated for a lumbar spine dysfunction

STUDY DESIGN

Retrospective analysis of a prospective, longitudinal cohort study of 30 858 patients being treated for a lumbar spine dysfunction in outpatient physical therapy.

OBJECTIVES

To determine effect of adding a single-item screening variable classifying patients with elevated versus not-elevated scores of fear-avoidance beliefs of physical activities at intake, on a model predicting risk-adjusted functional status (FS) outcomes.

BACKGROUND

Outcomes must be risk-adjusted before making meaningful interpretations. Elevated fear-avoidance beliefs scores have been predictive of poor outcomes. But the importance of elevated fear-avoidance scores in a multivariable model predicting FS outcomes needs further study.

METHODS

Using retrospective analyses, predictive ability (R2) of multivariable linear regression models of discharge FS with and without classification by elevated versus not-elevated fear-avoidance scores were compared, while controlling for intake FS, age, symptom acuity, surgical history, gender, number of comorbidities, and payer. Percent variance controlled and beta coefficients (95% confidence intervals) of each variable in both models were compared. A split-half design was used for model cross-validation. Predictive ratios (predicted FS, divided by actual discharge FS) were assessed.

RESULTS

Adding fear-avoidance beliefs classification to the discharge FS model improved (P<.001) model predictive ability but only slightly (R2 without, and with, fear-avoidance classification, 0.2997 and 0.3010, respectively). Variables impacted models similarly (95% confidence intervals not different). Fear-avoidance classification added 0.2% data variance control to the existing model. Cross-validation was supported. Predictive ratios were 1.09 and 1.10, without and with fear-avoidance, respectively.

CONCLUSION

Although screening for elevated fear-avoidance beliefs of physical activities significantly improves the FS outcomes predictive model, the amount of additional meaningful interpretation of FS outcomes was minimal. Exploration of other clinically relevant variables designed to improve outcomes prediction is warranted.

LEVEL OF EVIDENCE

Prognosis, level 2c.

Utilization and clinical outcomes of outpatient physical therapy for medicare beneficiaries with musculoskeletal conditions

BACKGROUND

Medicare beneficiaries frequently receive physical therapy for musculoskeletal conditions. Little information is available about this care.

OBJECTIVE

The purposes of this study were: (1) to describe characteristics, clinical outcomes, and utilization for Medicare beneficiaries receiving physical therapy in outpatient clinics within one integrated health care system; (2) to compare characteristics, outcomes, and utilization based on the body region affected; and (3) to examine factors predictive of outcomes and utilization.

DESIGN

This was a prospective, longitudinal study.

METHODS

Medicare beneficiaries aged 65 years or older (n=1,840 episodes of care) participated in the study. Descriptive statistics were calculated for patient characteristics and outcomes. Comparisons were made based on body region. Regression models evaluated factors associated with change in pain, improved outcome, and utilization.

RESULTS

The patients' mean age was 74.2 years (SD=6.3), and 65.3% were female. The most common body regions were the lumbar spine, shoulder, and knee, collectively accounting for 71.3% of the episodes of care. Patients attended a mean of 6.8 visits (SD=4.7), and 63.9% experienced an improved outcome. Episodes of care for lumbar spine conditions had less reduction in pain, whereas shoulder conditions and foot/ankle conditions showed the greatest improvement. Care for hip conditions was least likely to result in an improved outcome. Knee conditions were most likely to have an improved outcome. Care for shoulder and knee conditions had the highest number of visits. Factors associated with greater reduction in pain and improved outcomes included greater initial pain or disability and attending more visits. Factors associated with greater utilization included a postsurgical condition and higher initial pain rating. Limitations The study was performed in one geographic region within a single health care delivery system.

CONCLUSION

The results provide information on outcomes of physical therapy for Medicare beneficiaries in one health care system. Further research is needed to examine optimal utilization and care for these patients.

Association between directional preference and centralization in patients with low back pain

STUDY DESIGN

Prospective, longitudinal, observational cohort.

OBJECTIVES

Primary aims were to determine (1) baseline prevalence of directional preference (DP) or no directional preference (no-DP) observed for patients with low back pain whose symptoms centralized (CEN), did not centralize (non-CEN), or could not be classified (NC), and (2) to determine if classifying patients at intake by DP or no-DP combined with CEN, non-CEN, or NC predicted functional status and pain intensity at discharge from rehabilitation.

BACKGROUND

Although evidence suggests that patient response classification criteria DP or CEN improve outcomes, previous studies did not delineate relations between DP and CEN findings and outcomes.

METHODS

Eight therapists classified patients using standardized definitions for DP and CEN. Prevalence rates for DP and no-DP and CEN,non-CEN, and NC were calculated. Ordinary least-squares multivariate regression models assessed whether multilevel classification combining DP and CEN (DP/CEN, DP/non-CEN, DP/NC, no-DP/non-CEN, and no-DP/NC categories) predicted discharge functional status (scale range, 0 to 100, with higher values representing better function) or pain intensity (scale range, 0 to 10, with higher values representing more pain).

RESULTS

Overall prevalence of DP and CEN was 60% and 41%, respectively. For those with DP, prevalence rates for DP/CEN, DP/non-CEN, and DP/NC were 65%, 27%, and 8%, respectively. The amount of variance explained (R2 values) for function and pain models was 0.50 and 0.39, respectively. Compared to patients classified as DP/CEN, patients classified as DP/non-CEN or no-DP/non-CEN reported 7.7 and 11.6 functional status units less at discharge (P<.001), respectively, and patients classified as no-DP/non-CEN reported 1.7 pain units more at discharge (P<.001).

CONCLUSIONS

Findings suggest that classification by pain pattern and DP can improve a therapist's ability to provide a short-term prognosis for function and pain outcomes.

LEVEL OF EVIDENCE

Prognosis, level 1b-.

Effectiveness of a 'Global Postural Reeducation' program for persistent low back pain: a non-randomized controlled trial

BACKGROUND

The aim of this non-randomized controlled trial was to evaluate the effectiveness of a Global Postural Reeducation (GPR) program as compared to a Stabilization Exercise (SE) program in subjects with persistent low back pain (LBP) at short- and mid-term follow-up (ie. 3 and 6 months).

METHODS

According to inclusion and exclusion criteria, 100 patients with a primary complaint of persistent LBP were enrolled in the study: 50 were allocated to the GPR group and 50 to the SE group. Primary outcome measures were Roland and Morris Disability Questionnaire (RMDQ) and Oswestry Disability Index (ODI). Secondary outcome measures were lumbar Visual Analogue Scale (VAS) and Fingertip-to-floor test (FFT). Data were collected at baseline and at 3/6 months by health care professionals unaware of the study. An intention to treat approach was used to analyze participants according to the group to which they were originally assigned.

RESULTS

Of the 100 patients initially included in the study, 78 patients completed the study: 42 in the GPR group and 36 in the SE group. At baseline, the two groups did not differ significantly with respect to gender, age, BMI and outcome measures. Comparing the differences between groups at short- and mid-term follow-up, the GPR group revealed a significant reduction (from baseline) in all outcome measures with respect to the SE group.The ordered logistic regression model showed an increased likelihood of definitive improvement (reduction from baseline of at least 30% in RMDQ and VAS scores) for the GPR group compared to the SE group (OR 3.9, 95% CI 2.7 to 5.7).

CONCLUSIONS

Our findings suggest that a GPR intervention in subjects with persistent LBP induces a greater improvement on pain and disability as compared to a SE program. These results must be confirmed by further studies with higher methodological standards, including randomization, larger sample size, longer follow-up and subgrouping of the LBP subjects.

TRIAL REGISTRATION

NCT00789204.

Weighted index explained more variance in physical function than an additively scored functional comorbidity scale

OBJECTIVE

1) examine association between the Functional Comorbidity Index (FCI) and discharge functional status (FS); 2) examine impact of FCI on FS when added to comprehensive models; and 3) compare additive FCI with weighted FCI and list of condition variables (list).

STUDY DESIGN AND SETTING

Patients were drawn from Focus On Therapeutic Outcomes, Inc. (FOTO) database (1/1/06-12/31/07). FS collected using computer adaptive tests. Linear regression examined association between FCI and FS. Three methods of including functional comorbidities (FC) were compared.

RESULTS

Relationship between FCI and FS varied by group (range, 0.02-0.9). Models with weighted index or list had similar R². Weighted FCI or list increased R² of crude models by <0.01 for cervical, shoulder, and lumbar; by 0.01 for wrist/hand, knee, and foot/ankle; by 0.02 for hip; by 0.03 for elbow; and by 0.08 for neurological. Addition of FCI to comprehensive models added <0.01 to R² (all groups). Weighted FCI increased R² by <0.01 for cervical, lumbar, and shoulder; by 0.01 for wrist/hand, hip, knee, and foot/ankle; by 0.02 for elbow; and by 0.04 for neurological; whereas list increased R² by <0.01 for cervical, shoulder, and lumbar; by 0.01 for knee and foot/ankle; by 0.02 for elbow, wrist/hand, and hip; and by 0.05 for neurological.

CONCLUSION

List of comorbidities or weighted FCI is preferable to using additive FCI.

Choice of treatment modalities was not influenced by pain, severity or co-morbidity in patients with knee osteoarthritis

BACKGROUND AND PURPOSE

Patients with knee osteoarthritis (OA) are commonly treated by physiotherapists in primary care. The physiotherapists use different treatment modalities. In a previous study, we identified variation in the use of transcutaneous electrical nerve stimulation (TENS), low level laser or acupuncture, massage and weight reduction advice for patients with knee OA. The purpose of this study was to examine factors that might explain variation in treatment modalities for patients with knee OA.

METHODS

Practising physiotherapists prospectively collected data for one patient with knee osteoarthritis each through 12 treatment sessions.We chose to examine factors that might explain variation in the choice of treatment modalities supported by high or moderate quality evidence, and modalities which were frequently used but which were not supported by evidence from systematic reviews. Experienced clinicians proposed factors that they thought might explain the variation in the choice of these specific treatments. We used these factors in explanatory analyses.

RESULTS

Using TENS, low level laser or acupuncture was significantly associated with having searched databases to help answer clinical questions in the last six months (odds ratio [OR] = 1.93, 95% confidence interval [CI] = 1.08-3.42). Not having Internet access at work and using more than four treatment modalities were significant determinants for giving massage (OR = 0.36, 95% CI = 0.19-0.68 and OR = 8.92, 95% CI = 4.37-18.21, respectively). Being a female therapist significantly increased the odds for providing weight reduction advice (OR = 3.60, 95% CI = 1.12-11.57). No patient characteristics, such as age, pain or co-morbidity, were significantly associated with variation in practice.

CONCLUSIONS

Factors related to patient characteristics, such as pain severity and co-morbidity, did not seem to explain variation in treatment modalities for patients with knee OA. Variation was associated with the following factors: physiotherapists having Internet access at work, physiotherapists having searched databases for the last six months and the gender of the therapist. There is a need for more studies of determinants for physiotherapy practice.

Performance-integrated self-report measurement of physical ability

BACKGROUND CONTEXT

The technology of self-report measures has advanced rapidly over the past few years. Recently, this technology was used to develop a performance-integrated self-report measure for use with patients with musculoskeletal impairments that may lead to work disability. Psychometric studies of the new measure in patient populations have been successful. A validation study of the measure with adults in good general health is necessary.

PURPOSE

The purpose of this study was to assess the concurrent validity of a new performance-integrated self-report measure, the multidimensional task ability profile (MTAP).

STUDY DESIGN/SETTING

A prospective validation study was conducted in which a self-report measure was administered online, and a physical performance test was administered at various clinics in North America.

PATIENT SAMPLE

One hundred ninety-six (34% male) adult volunteers in good general health participated in this study.

OUTCOME MEASURES

Self-report measure-MTAP. Physiologic measure-EPIC Lift Capacity test.

METHODS

The MTAP was administered online within 1 week of formal testing of lift capacity using a standardized lift capacity test, the EPIC Lift Capacity test. MTAP scores were compared with performance on the EPIC Lift Capacity test. Stepwise regression analysis was used to identify the strength of the relationship between the two measures and the relative explanation of lift capacity variance by the MTAP score, along with gender and age.

RESULTS

The combination of MTAP score, gender, and age demonstrated a regression coefficient of R=0.82, which accounts for 67.3% of the variance in lift capacity.

CONCLUSIONS

The MTAP displayed good concurrent validity compared with actual physical performance as assessed by the EPIC Lift Capacity test. Modern performance-integrated self-report measures, such as the MTAP, have the potential to provide information about functional capacity that is sufficiently useful to confirm status and help guide treatment algorithms.

Associations between treatment processes, patient characteristics, and outcomes in outpatient physical therapy practice

OBJECTIVE

To identify how treatment processes are related to functional outcomes for patients seeking treatment for musculoskeletal impairments while controlling for demographic and health characteristics at intake.

DESIGN

Prospective, observational cohort study. Treatment processes were not altered. Data were collected continuously from June 2005 to January 2008. Descriptive statistics were applied to compare patient characteristics, interventions, and outcomes between impairment categories. Ordinary least-squares multiple regressions were used to examine associations between patient characteristics at intake, treatment processes, and functional outcomes.

SETTING

Fifty-four community-based outpatient physical therapy clinics of Maccabi Healthcare Services, a public health plan in Israel.

PARTICIPANTS

A consecutive sample of 22,019 adult patients (mean age 51.2 y, standard deviation=15.7, range 18-96, 58% women) seeking treatment due to lumbar spine, knee, cervical spine, or shoulder impairments with functional measurements at intake and discharge.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Functional status at discharge.

RESULTS

Explanatory power ranged from 30% to 39%. Better outcomes were associated with patient compliance with self-exercise and therapy attendance, application of therapeutic exercise and manual therapy, and completion of 3 or more functional surveys during the episode of care. Worse outcomes were associated with women, electrotherapy for pain management, and therapeutic ultrasound for shoulder impairments. Mixed results were found for group exercise programs.

CONCLUSIONS

The study of associations between treatment processes, patient characteristics, and outcomes helps to describe practice and can be used to suggest ways to improve outcomes in outpatient physical therapy practice.

Benchmarking physical therapy clinic performance: statistical methods to enhance internal validity when using observational data

Many clinics and payers are beginning programs to collect and interpret outcomes related to quality of care and provider performance (ie, benchmarking).

OUTCOMES

assessment is commonly done using observational research designs, which makes it important for those involved in these endeavors to appreciate the underlying challenges and limitations of these designs. This perspective article discusses the advantages and limitations of using observational research to evaluate quality of care and provider performance in order to inform clinicians, researchers, administrators, and policy makers who want to use data to guide practice and policy or critically appraise observational studies and benchmarking efforts. Threats to internal validity, including potential confounding, patient selection bias, and missing data, are discussed along with statistical methods commonly used to address these limitations. An example is given from a recent study comparing physical therapy clinic performance in terms of patient outcomes and service utilization with and without the use of these methods. The authors demonstrate that crude differences in clinic outcomes and service utilization tend to be inflated compared with the differences that are statistically adjusted for selected threats to internal validity. The authors conclude that quality of care measurement and ranking procedures that do not use similar methods may produce findings that may be misleading.