A vision for society: physical therapy as partners in the national health agenda

An Anterior Cruciate Ligament (ACL) Injury Risk Screening and Reduction Program for High School Female Athletes: A Pilot Study

Background

Anterior cruciate ligament (ACL) injury causes physical, mental, and financial burdens. Therefore, it is imperative to screen, identify, and educate athletes who are at high-risk. The combination of screening and education could identify those at risk and potentially reduce future injuries.

Purpose

The purpose was to conduct a feasible community pre-season screening program for high school female athletes for the presence of known modifiable risk factors that predispose them to sustaining a non-contact ACL injury.

Study Design

Non-experimental prospective study.

Methods

A convenience sample of 15 healthy female athletes were recruited from local high schools, consisting of 11 soccer players and four basketball players.  A pre-season screening program was designed encompassing four stations that addressed modifiable neuromuscular and biomechanical risk factors including range of motion (ROM), jump-landing technique, strength, and balance. Athletes were categorized into high-risk versus low-risk groups based on cutoff scores previously established in the literature.

Results

Every athlete met the high-risk cutoff score for at least one extremity during the ROM screening, and some met high-risk cutoff scores for more than one ROM. Out of all four categories tested, lower extremity ROM demonstrated the greatest deficits.

Conclusion

This study identified athletes as having multiple modifiable risk factors that can be addressed with training and exercises. This supports implementing a pre-season program aimed at screening for injury risk factors.

Level of Evidence

Level 3.

The Relationship Between Professionalism and Leadership: Parent-Child or Sibling?

Professionalism has been the foundation of physical therapy's contract with society, with the American Physical Therapy Association's (APTA) Core Values and Code of Ethics serving as its building blocks. Professional formation has focused on professionalism and has been taught in a manner that is more implicit than explicit in doctor of physical therapy (DPT) curricula. As a domain of competence, professionalism alone has not been broad enough to meet societal needs. In reaching our centennial year, many have reflected on what competencies are needed to move forward. The need for leadership competencies is not new and has been espoused by our leaders over the past 100 years. Some advocate for the adoption of leadership as a unique domain of competence, separate from the domain of professionalism, whereas others propose that either professionalism or leadership is one domain of competence that subsumes the other. The purpose of this Perspective is twofold: to compare and contrast the concepts of professionalism and leadership, and to make recommendations regarding what constitutes domains of competence within the professional formation of physical therapists. This Perspective offers recommendations addressing professional formation and the adoption of leadership and professionalism as 2 distinct domains of competence and discusses educational and clinical implications of the recommendations. This Perspective asserts that these recommendations must be adopted to move the profession forward into the next century so that physical therapists are recognized as adding value to the health care system and the evolving needs of society.

Retrospective claims analysis of physical therapy utilization among women with stress or mixed urinary incontinence

OBJECTIVE

To describe the characteristics of women with stress or mixed urinary incontinence (SUI/MUI) receiving physical therapy (PT) services, including referral patterns and PT utilization.

METHODS

Female patients with claims associated with an SUI or MUI diagnosis (International Classification of Disease-Clinical Modification [ICD-9-CM]: 625.6, 788.33, or ICD-10-CM: N39.3, N39.46) between July 01, 2014 and June 30, 2016 were identified in International business machines (IBM)'s MarketScan Research Database. Inclusion criteria included the absence of pregnancy claims and ≥80% medical and pharmacy enrollment pre- and postindex. First SUI/MUI diagnosis claim determined index. Patients were followed for 2 years, and associated UI-associated PT encounters were identified. Descriptive statistics were calculated for patients with at least one PT visit during the postindex period.

RESULTS

In a cohort of 103,813 women with incident SUI or MUI diagnosis, 2.6% (2792/103,813) had at least one PT visit in the 2 years following their diagnosis. Mean age at index PT encounter was 50.55 years. A total of 52.36% (1462/2792) women had one to four PT visits; 21.2% (592/2792) had >8 PT visits. In subanalysis of the PT cohort (1345/2792), women who received PT only had the lowest average 2-year postindex total medical cost (mean: $12,671; SD: $16,346), compared with PT plus medications (mean: $27,394; SD: $64,481), and PT plus surgery (mean: $33,656; SD: $26,245), respectively. Over 40% had their first PT visit ≥3 months after their index date.

CONCLUSIONS

The percentage of women with a PT visit associated with an incident SUI or MUI diagnosis was low (2.6%), and 30% of this group completed three or more PT visits. This suggests poor adherence to clinical guidelines regarding supervised treatment of UI in women.

IMPACT STATEMENT

Our study suggests underutilization of PT among insured women with SUI and MUI in the 2 years following diagnosis. Interventions to improve this gap in first-line care may represent an opportunity for an increased role for PTs in the care of women with UI.

The Impact of Total Joint Arthroplasty on Long-Term Physical Activity: A Secondary Analysis of the Health and Retirement Study

OBJECTIVE

Physical inactivity is the fourth-leading cause of global mortality and is prevalent among people with lower extremity osteoarthritis. Lower extremity osteoarthritis is the most common arthritis type afflicting older adults, and total joint arthroplasty (TJA) performed to address the condition is Medicare's largest annual expense. Despite TJA intervention to address the disabling effects of osteoarthritis, physical activity (PA) level remains stable 6 months after TJA; however, the effect of TJA on long-term PA $(\ge$2 y) in a representative sample of older adults is unknown. The purpose of this study was to test the hypothesis that PA would remain stable in the long term.

METHODS

In this longitudinal observational study, a probability-weighted difference-in-differences analysis was conducted to observe the predictive margins of nontraumatic hip or knee TJA on levels of vigorous and moderate PA after 2 years. A combined Health and Retirement Study data set of community-dwelling adults who were >55 years old, had symptomatic osteoarthritis, and were in need of TJA between 2008 and 2018 (N = 4652) was used.

RESULTS

TJA was not associated with vigorous PA ($\delta$ = 2.37; SE = 5.23) or moderate PA ($\delta$ = -2.84; SE = 7.76) after 2 years.

CONCLUSION

TJA was not associated with increased long-term PA in older adults with osteoarthritis.

IMPACT

Physical therapists should not assume that there will be a natural increase in PA after functional recovery from TJA procedures. Older adults with lower extremity osteoarthritis may benefit from PA screening and promotion practices in physical therapy services.

LAY SUMMARY

Receiving a total joint replacement does not lead to increased physical activity levels 2 years after surgery.

Supporting government policies to embed and expand rehabilitation in health systems in Europe: A framework for action

Investment in action is vital to confront the challenges associated with chronic diseases and disability facing European health systems. Although relevant policy responses are being increasingly developed, most of them fail to recognize the role of rehabilitation services in achieving public health and social goals. Comprehensive guidance is thus urgently needed to support rehabilitation policy development and expand access to rehabilitation care to meet population needs effectively. This paper describes a framework to guide policy action for rehabilitation in Europe. The framework was developed in collaboration with the European Academy of Rehabilitation Medicine based on a focused literature review and expert consultations. A review in PubMed and grey literature sources identified 458 references and resulted in 135 relevant documents published between 2006 and 2019. Thematic analysis of extracted information helped summarize the findings and develop the draft policy action framework. This was circulated to a wider group of experts and discussed in three workshops in 2018-2019. The framework was revised according to their feedback. The proposed framework contains 48 options for policy action organized in six domains and twelve subdomains that address several areas of health programming. The proposed framework provides a structure to understand the policy terrain related to rehabilitation in Europe and the measures required for translating aspirational political pronouncements into targeted programmatic action and tangible health and social outcomes.

Navigating the Intersection Between Persistent Pain and the Opioid Crisis: Population Health Perspectives for Physical Therapy

The physical therapy profession has recently begun to address its role in preventing and managing opioid use disorder (OUD). This topic calls for discussion of the scope of physical therapist practice, and the profession's role, in the prevention and treatment of complex chronic illnesses, such as OUD. OUD is not just an individual-level problem. Abundant scientific literature indicates OUD is a problem that warrants interventions at the societal level. This upstream orientation is supported in the American Physical Therapy Association's vision statement compelling societal transformation and its mission of building communities. Applying a population health framework to these efforts could provide physical therapists with a useful viewpoint that can inform clinical practice and research, as well as develop new cross-disciplinary partnerships. This Perspective discusses the intersection of OUD and persistent pain using the disease prevention model. Primordial, primary, secondary, and tertiary preventive strategies are defined and discussed. This Perspective then explains the potential contributions of this model to current practices in physical therapy, as well as providing actionable suggestions for physical therapists to help develop and implement upstream interventions that could reduce the impact of OUD in their communities.

Adopting Population Health Frameworks in Physical Therapist Practice, Research, and Education: The Urgency of Now

Chronic, noncommunicable diseases have replaced acute, infectious diseases as the leading causes of global mortality and morbidity. Efforts among physical therapists to address noncommunicable diseases have primarily focused on the promotion of healthy behaviors among individual clients. However, the strongest predictors of chronic disease are tied to where we live, work, learn, and play, our families, and our communities. Population health frameworks can help us better understand the complex interrelations between individuals' health condition and their social and physical environment over time and also inform the development of effective programs and policies that improve the health of individuals and communities. The objectives of this article are to: (1) define population health, prevention, and health promotion; (2) provide a current perspective on the utility of population health frameworks in physical therapy; and (3) identify opportunities for the expanded use of population health frameworks in physical therapist practice, research, and education.

Utilization of Physical Therapy Services During Transition for Young People With Cerebral Palsy: A Call for Improved Care Into Adulthood

BACKGROUND

Many young adults with cerebral palsy (CP) face limited participation in activities, including employment and independent living. Physical therapy during the transition period can help to support participation through promotion of self-care, ambulation, and functional mobility. Thus, ensuring appropriate access to physical therapy services for young people who can benefit from them before, during, and after transition is imperative.

OBJECTIVE

The objective of this study was to identify factors contributing to the utilization of physical therapy services for youth with CP both during and after secondary school.

DESIGN

The design was a deidentified secondary analysis of the National Longitudinal Transition Study 2 (NLTS2).

METHODS

Multivariate regression models were run to examine demographic and disability characteristics influencing utilization of physical therapy services for youth with CP both during and after secondary school.

RESULTS

The total weighted population sample included 35,290 young people with CP. When all youth were in secondary school, 59.4% of the youth utilized physical therapy services; however, once all youth were out of school, only 33.7% of them were reported to have utilized physical therapy since leaving secondary school. For young people with difficulties accessing general disability support services, demographic characteristics, including sex, race, income, and parent education status, influenced use of physical therapy services in addition to disability characteristics.

LIMITATIONS

This population sample included only young people in special education with Individual Education Plans (IEPs) and may not generalize to young people with CP in general education settings.

CONCLUSIONS

Frequency of physical therapy services decreases drastically once young adults with CP leave secondary school. Future work should examine this trend in more depth to identify therapy intervention strategies to optimize participation in young adult life for persons with CP.

Beyond the individual: population health and physical therapy

Improving the health of populations is critical to meeting global health targets. The purpose of this article is to define population health and differentiate it from related concepts and introduce a framework that can be used to inform the population-based practice of physical therapists. The Population-Based Practice (PBP) Framework is modified from the Public Health Nursing Intervention Wheel and can be used to understand levels (i.e., systems, community, and individual) and types (i.e., screening and outreach, referral and follow-up, health teaching and coaching, consultation and collaboration, advocacy and policy development, and social marketing) of population-based practice. Several physical therapy examples illustrate selected cells within the model. The PBP Framework provides practitioners, educators, and scholars with a new way to envision population-based practice for physical therapists. Such a shift in both thinking and practice is needed if physical therapists are to use their unique skills to move beyond the individual, embracing population-based practice to improve health outcomes and reduce health disparities while controlling costs.

How physiotherapists perceive, interpret, and respond to the ethical dimensions of practice: A qualitative study

The profile and reach of physiotherapy has expanded in areas of extended scope of practice, and broader engagement with population needs beyond the individual treatment encounter. These changes raise increasingly complex ethical challenges evidenced by growth in physiotherapy-based ethics studies and discussions. This paper examines how a broad cross section of Australian physiotherapists perceive, interpret, and respond to ethical challenges in their work contexts and how professional codes of conduct are used in their practice. Using an interpretive qualitative methodology, purposive sampling of 88 members of national clinical special interest groups were recruited for focus group discussions. Narrative-based and thematic data analysis identified ethical challenges as emerging from specific clinical contexts, and influenced by health organizations, funding policies, workplace relationships, and individually held perspectives. Five themes were developed to represent these findings: (1) the working environment, (2) balancing diverse needs and expectation, (3) defining ethics, (4) striving to act ethically, and (5) talking about ethics. The results portray a diverse and complex ethical landscape where therapists encounter and grapple with ethical questions emerging from the impact of funding models and policies affecting clinical work, expanding boundaries and scope of practice and changing professional roles and relationships. Codes of conduct were described as foundational ethical knowledge but not always helpful for "in the moment" ethical decision-making. Based on this research, we suggest how codes of conduct, educators, and professional associations could cultivate and nurture ethics capability in physiotherapy practitioners for these contemporary challenges.

A Qualitative Study of Professional Issues in Home Health Therapy

Professional issues are experienced by physical and occupational therapists working in home health care. A grounded theory method was utilized with snowball sampling to interview 11 home health physical therapists and six occupational therapists working with a variety of populations in the home health setting. Major themes were identified separately for physical and occupational therapy using open, axial, and selective coding. The themes were then recoded for shared themes among the two professions. The major research questions included the following: What professional issues are encountered by therapists working in home health care? What type of benefits and barriers do therapists describe when providing home health services? Finally, how do professional issues compare between the different professions? The five major themes identified by physical therapists included work environment, work characteristics, communication, patient and family, and work-life balance. The themes identified by occupational therapists included the natural environment, the context of health care, client factors, and therapist factors. Common themes described by both physical and occupational therapy providers included the real-life environment of the home, the structure of home care, and autonomy of service provision. Results provide information about professional issues faced by therapists working in the home health care setting. There are a number of issues that are common to both professions, and others that appear to be discipline specific. These findings will guide professional efforts as the demands for professionals working in home care increase.

Physical Therapy Residency and Fellowship Education: Reflections on the Past, Present, and Future

The physical therapy profession continues to respond to the complex and changing landscape of health care to meet the needs of patients and the demands of patient care. Consistent with this evolution is the rapid development and expansion of residency and fellowship postprofessional programs. With the interested number of applicants exceeding the number of residency and fellowship slots available, a "critical period" in the educational process is emerging. The purposes of this perspective article are: (1) to analyze the state of residency and fellowship education within the profession, (2) to identify best practice elements from other health professions that are applicable to physical therapy residency and fellowship education, and (3) to propose a working framework grounded in common domains of competence to be used as a platform for dialogue, consistency, and quality across all residency and fellowship programs. Seven domains of competence are proposed to theoretically ground residency and fellowship programs and facilitate a more consistent approach to curricular development and assessment. Although the recent proliferation of residency and fellowship programs attempts to meet the demand of physical therapists seeking advanced educational opportunities, it is imperative that these programs are consistently delivering high-quality education with a common focus on delivering health care in the context of societal needs.

Connecting Classroom, Clinic, and Context: Clinical Reasoning Strategies for Clinical Instructors and Academic Faculty

BACKGROUND

Clinical reasoning is an essential skill in pediatric physical therapist (PT) practice. As such, explicit instruction in clinical reasoning should be emphasized in PT education.

KEY POINTS

This article provides academic faculty and clinical instructors with an overview of strategies to develop and expand the clinical reasoning capacity of PT students within the scope of pediatric PT practice. Achieving a balance between deductive reasoning strategies that provide a framework for thinking and inductive reasoning strategies that emphasize patient factors and the context of the clinical situation is an important variable in educational pedagogy.

TEACHING IMPLICATIONS

Consideration should be given to implementing various teaching and learning approaches across the curriculum that reflect the developmental level of the student(s). Deductive strategies may be helpful early in the curriculum, whereas inductive strategies are often advantageous after patient interactions; however, exposure to both is necessary to fully develop the learner's clinical reasoning abilities.

VIDEO ABSTRACT

For more insights from the authors, see Supplemental Digital Content 1, available at http://links.lww.com/PPT/A87.

Oral anatomy laboratory examinations in a physical therapy program

The process of creating and administering traditional tagged anatomy laboratory examinations is time consuming for instructors and limits laboratory access for students. Depending on class size and the number of class, sections, creating, administering, and breaking down a tagged laboratory examination may involve one to two eight-hour days. During the time that a tagged examination is being created, student productivity may be reduced as the anatomy laboratory is inaccessible to students. Further, the type of questions that can be asked in a tagged laboratory examination may limit student assessment to lower level cognitive abilities and may limit the instructors' ability to assess the students' understanding of anatomical and clinical concepts. Anatomy is a foundational science in the Physical Therapy curriculum and a thorough understanding of anatomy is necessary to progress through the subsequent clinical courses. Physical therapy curricula have evolved to reflect the changing role of physical therapists to primary caregivers by introducing a greater scope of clinical courses earlier in the curriculum. Physical therapy students must have a thorough understanding of clinical anatomy early in the education process. However, traditional anatomy examination methods may not be reflective of the clinical thought processes required of physical therapy students. Traditional laboratory examination methods also reduce student productivity by limiting access during examination set-up and breakdown. To provide a greater complexity of questions and reduced overall laboratory time required for examinations, the Physical Therapy Program at Mercer University has introduced oral laboratory examinations for the gross anatomy course series.

Physiotherapists in emergency departments: responsibilities, accountability and education

Emergency physiotherapy roles have evolved within the UK and are increasingly being adopted in Australia in response to a need for greater workforce flexibility and improved service provision to meet growing patient demand. This paper discusses the need for the physiotherapy profession to develop evidence-based regulatory, ethical and educative frameworks to keep pace with the changing clinical environment and service delivery in emergency departments. Definitions of Emergency Physiotherapy as either advanced practice or extended scope of practice are identified, and the implications for both regulation of practice and education are highlighted. Suggestions for education in areas of clinical skills, ethical understanding and legal and professional knowledge are highlighted as important areas to support physiotherapists moving into this area of practice.