Developing a wellness program for people with multiple sclerosis: description and initial results

Because multiple sclerosis (MS) is a multidimensional chronic disease, effective management of the illness requires a multidimensional approach. We describe a wellness program that was designed to facilitate positive health choices throughout the course of MS and present initial data analyses. We hypothesized that over the course of the program, participants would demonstrate improvement in the domains assessed. The wellness program included educational sessions in physical, mental, social, intellectual, and spiritual domains specifically targeting improved self-efficacy, physical functioning, coping skills, symptom management, and nutrition. An outcomes data collection software program was adapted to facilitate real-time patient self-report and clinician entry data collection for many domains throughout the wellness program. Initial assessment of serial measures (intake to discharge) from 65 people with MS showed improvement in several domains, including functional status (P < .05), fatigue (P < .05), fear-avoidance beliefs regarding physical activities (P < .05), depression (P < .05), somatization (P < .05), and pain (P < .05). In addition, using a model of risk for interpersonal distress, patients whose risk of elevated depression and anxiety decreased over the course of the program reported greater gains in functional status (P < .05). The results suggest possible future treatment strategies and indicate strengths and weaknesses of the wellness program, which are being used to improve the program.

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.

Clinician's ability to identify neck and low back interventions: an inter-rater chance-corrected agreement pilot study

OBJECTIVE

To estimate inter-rater agreement of physical therapists trained in MDT approach and participating in practice-based evidence (PBE) research to identify 72 physical therapy interventions in video demonstrations on a single model and clinical vignettes. PBE is a well designed observational study and demonstrating clinician observational consistency is an important step in conducting PBE research design.

METHODS

Two physical therapists volunteered to participate in pilot reliability testing and seven other physical therapists trained in McKenzie Mechanical Diagnosis and Therapy (MDT) methods volunteered for the inter-rater chance-corrected agreement study. All therapists identified interventions presented within 52 videos and 5 written clinical vignettes describing 20 more intervention techniques. Therapists independently identified all interventions. We assessed inter-rater chance-corrected agreement of therapists' ability to identify intervention techniques using Kappa coefficients with associated 95% confidence intervals and indices for bias and prevalence.

RESULTS

Of the 147 kappa coefficients estimated, 7% were ⩽0·6, 10% were >0·6 and ⩽0·8, and 83% were >0·8. Agreement was lowest for identifying cognitive behavioral techniques (median kappa = 0·79). The minimum and maximum prevalence and bias indices were 0·33 and 0·85 and 0 and 0·33, respectively suggesting kappa coefficient estimates were strong. Generalized kappa coefficients ranged from 0·73 to 1·00.

DISCUSSION

Results provide evidence that substantial to almost perfect inter-rater agreement could be expected when trained therapists identify physical therapy interventions used for patients with spinal impairments from staged videos and vignettes. This may be helpful to reassure clinicians of the quality of the reporting of intervention(s) performed when conducting multivariable analyses in future pragmatic PBE studies. Additional studies are needed to test whether these results can be validated using larger groups of therapists, trained and not trained in MDT methods, as well as examining different methods to examine inter-rater agreement for identifying diverse interventions commonly used for managing patients during routine practice.

Translating shoulder computerized adaptive testing generated outcome measures into clinical practice

STUDY DESIGN

Prospective longitudinal cohort study.

INTRODUCTION

Increased use of computerized adaptive tests (CATs) to generate outcome measures during rehabilitation has stimulated questions concerning score interpretation.

PURPOSE OF THE STUDY

The purpose of the study was to describe meaningful interpretations of scores from patient self-report shoulder functional status (FS) outcome measures estimated using a shoulder CAT (score range=0-100).

METHODS

We applied four approaches to the clinical interpretation of outcomes data from 30,987 patients with shoulder impairments receiving outpatient rehabilitation in 518 clinics in 30 states (United States) between August 2007 and July 2009. First, we used standard error of estimates to construct 95% confidence intervals for each CAT estimated score. Second, we estimated the percentile rank (PR) of FS scores. Third, we used two threshold approaches to define individual patient-level change: statistically reliable change (i.e., minimal detectable change or MDC) and clinically important change. Fourth, we developed and applied a functional staging model, the Shoulder Function Classification System (SFCS).

RESULTS

Precision of a single score was estimated by FS score ±4. Based on score distribution, 25th, 50th, and 75th PRs corresponded to intake FS scores of 43, 52, and 59 and discharge FS scores of 59, 68, and 80, respectively. MDC calculations indicated that changes in FS scores of 11 or more units represented statistically reliable change. FS score increments of eight or more units were estimated to represent minimal clinically important improvement based on receiver operating characteristic. The five-level SFCS was judged to be clinically logical and provide insight for clinical interpretation of patient progress.

CONCLUSIONS

Results may improve clinical interpretation of CAT-generated outcome measures and assist clinicians using patient-reported outcomes during clinical practice.

LEVEL OF EVIDENCE

Therapy level 2c.

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.

Implementing computerized adaptive tests in routine clinical practice: experience implementing CATs

This paper traces the development, testing and use of CATs in outpatient rehabilitation from the perspective of one proprietary international medical rehabilitation database management company, Focus On Therapeutic Outcomes, Inc. (FOTO). Between the FOTO data in the United States and Maccabi Healthcare Services data in Israel, over 1.5 million CATs have been administered. Using findings from published studies and results of internal public relations surveys, we discuss (1) reasons for CAT development, (2) how the CATs were received by clinicians and patients in the United States and Israel, (3) results of psychometric property assessments of CAT estimated measures of functional status in routine clinical practice, (4) clinical interpretation of CAT functional status measures, and (5) future development directions. Results of scientific studies and business history provide confidence that CATs are pertinent and valuable to clinicians, patients and payers, and suggest CATs will be prominent in the development of future integrated computerized electronic medical record systems with electronic outcomes data collection.

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.

Differential item functioning was negligible in an adaptive test of functional status for patients with knee impairments who spoke English or Hebrew

OBJECTIVE

We examined the presence and impact of differential item functioning (DIF) in a set of knee-specific functional status (FS) items administered using computerized adaptive testing (CAT) among English (United States) and Hebrew (Israel) speaking patients receiving therapy for knee impairments. DIF occurs in an item if probabilities of endorsing responses differ across groups after controlling for the FS measured.

METHODS

We analyzed data from 28,320 patients (14,160 U.S., 14,160 Israel) who completed the knee-specific CAT. Items were assessed for DIF by gender, age, symptom acuity, surgical history, exercise history, and language spoken using a hybrid technique that combines multiple ordinal logistic regression and item response theory FS estimates.

RESULTS

Several items had non-uniform DIF for covariates including language, but unadjusted and DIF-adjusted functional status estimates were in strong concordance [ICC(2,1) values >/=0.97], and differences between unadjusted and adjusted FS scores represented <0.4% of the unadjusted FS standard deviation.

CONCLUSIONS

Statistically significant DIF was identified in some items but represented negligible clinical impact. Results suggested no need to adjust items for DIF when assessing FS outcomes across groups of patients with knee impairments who answer the knee CAT items in English in the United States or Hebrew in Israel. These findings suggest negligible differences in cultural perceptions between English and Hebrew wording of these knee-specific CAT FS items.

A computerized adaptive test for patients with hip impairments produced valid and responsive measures of function

OBJECTIVES

To describe the use of a computerized adaptive test (CAT) in routine clinical practice and evaluate content coverage and construct validity, sensitivity to change, and responsiveness of hip CAT functional status (FS) measures.

DESIGN

Longitudinal, prospective observational cohort study.

SETTING

Two hundred fifty-seven outpatient rehabilitation clinics in 31 states (United States).

PARTICIPANTS

Two samples were examined: intake and discharge rehabilitation FS data from patients (N=8714) treated for hip impairments between January 2005 and June 2007 and data from patients (N=444) used to develop the hip CAT were examined for comparison (2002-2004).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Hip functional status and global rating of change.

RESULTS

The CAT used on average 7 items to produce precise estimates of FS that adequately covered the content range with negligible floor and slight ceiling effects. Test information functions and SEs supported FS measure precision. FS measures discriminated patients in clinically logical ways. Sixty-one percent of patients obtained discharge FS measures greater than or equal to minimal detectable change (95% confidence intervals). Change of 6 FS units (scale: 0-100) represented minimal clinically important improvement, which 64% of patients obtained.

CONCLUSIONS

The hip CAT was efficient; produced valid, responsive measures of FS for patients receiving therapy for hip impairments; and functioned well in routine clinical application but would benefit from more difficult items.

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

BACKGROUND AND PURPOSE

Little is known about organizational and service delivery factors related to quality of care in physical therapy. This study sought to identify characteristics related to differences in practice outcomes and service utilization.

SUBJECTS

The sample comprised 114 outpatient clinics and 1,058 therapists who treated 16,281 patients with low back pain syndromes during the period 2000-2001. Clinics participated with the Focus on Therapeutic Outcomes, Inc (FOTO) database.

METHODS

Hierarchical linear models were used to risk adjust treatment outcomes and number of visits per treatment episode. Aggregated residual scores from these models were used to classify each clinic into 1 of 3 categories in each of 3 types of performance groups: (1) effectiveness, (2) utilization, and (3) overall performance (ie, composite measure of effectiveness and utilization). Relationships between clinic classification and the following independent variables were examined by multinomial logistic regression: years of therapist experience, number of physical therapists, ratio of physical therapists to physical therapist assistants, proportion of patients with low back pain syndromes, number of new patients per physical therapist per month, utilization of physical therapist assistants, and setting.

RESULTS

Clinics that were lower utilizers of physical therapist assistants were 6.6 times more likely to be classified into the high effectiveness group compared with the low effectiveness group, 6.7 times more likely to be classified in the low utilization group compared with the high utilization group, and 12.4 times more likely to be classified in the best performance group compared with the worst performance group. Serving a higher proportion of patients with low back pain syndromes was associated with an increased likelihood of being classified in the lowest or middle group. Years of physical therapist experience was inversely associated with being classified in the middle utilization group compared with the highest utilization group.

DISCUSSION AND CONCLUSION

These findings suggest that, in the treatment of patients with low back pain syndromes, clinics that are low utilizers of physical therapist assistants are more likely to provide superior care (ie, better patient outcomes and lower service use).

Computerized adaptive test for patients with foot or ankle impairments produced valid and responsive measures of function

OBJECTIVE

We tested the item response theory (IRT) model assumptions of the original item bank, and evaluated the practical and psychometric adequacy, of a computerized adaptive test (CAT) for patients with foot or ankle impairments seeking rehabilitation in outpatient therapy clinics.

METHODS

Data from 10,287 patients with foot or ankle impairments receiving outpatient physical therapy were analyzed. We first examined the unidimensionality, fit, and invariance IRT assumptions of the CAT item bank. Then we evaluated the efficiency of the CAT administration and construct validity and sensitivity of change of the foot/ankle CAT measure of lower-extremity functional status (FS).

RESULTS

Results supported unidimensionality, model fit, and invariance of item parameters and patient ability estimates. On average, the CAT used seven items to produce precise estimates of FS that adequately covered the content range with negligible floor and ceiling effects. Patients who were older, had more chronic symptoms, had more surgeries, had more comorbidities, and did not exercise prior to receiving rehabilitation reported worse discharge FS. Seventy-one percent of patients obtained statistically significant change at follow-up. Change of 8 FS units (scale 0-100) represented minimal clinically important improvement.

CONCLUSIONS

We concluded that the foot/ankle item bank met IRT assumptions and that the CAT FS measure was precise, valid, and responsive, supporting its use in routine clinical application.

Comparing patient characteristics and treatment processes in patients receiving physical therapy in the United States, Israel and the Netherlands: cross sectional analyses of data from three clinical databases

BACKGROUND

Many assume that outcomes from physical therapy research in one country can be generalized to other countries. However, no well designed studies comparing outcomes among countries have been conducted. In this exploratory study, our goal was to compare patient demographics and treatment processes in outpatient physical therapy practice in the United States, Israel and the Netherlands.

METHODS

Cross-sectional data from three different clinical databases were examined. Data were selected for patients aged 18 years and older and started an episode of outpatient therapy between January 1st 2005 and December 31st 2005. Results are based on data from approximately 63,000 patients from the United States, 100,000 from Israel and 12,000 from the Netherlands.

RESULTS

Age, gender and the body part treated were similar in the three countries. Differences existed in episode duration of the health problem, with more patients with chronic complaints treated in the United States and Israel compared to the Netherlands. In the United States and Israel, physical agents and mechanical modalities were applied more often than in the Netherlands. The mean number of visits per treatment episode, adjusted for age, gender, and episode duration, varied from 8 in Israel to 11 in the United States and the Netherlands.

CONCLUSION

The current study showed that clinical databases can be used for comparing patient demographic characteristics and for identifying similarities and differences among countries in physical therapy practice. However, terminology used to describe treatment processes and classify patients was different among databases. More standardisation is required to enable more detailed comparisons. Nevertheless the differences found in number of treatment visits per episode imply that one has to be careful to generalize outcomes from physical therapy research from one country to another.

Clinical databases in physical therapy

Clinical databases in physical therapy provide increasing opportunities for research into physical therapy theory and practice. At present, information on the characteristics of existing databases is lacking. The purpose of this study was to identify clinical databases in which physical therapists record data on their patients and treatments and to investigate the basic aspects, data sets, output, management, and data quality of the databases. Identification of the databases was performed by contacting members of the World Confederation for Physical Therapy, searching Pubmed, searching the Internet, and snowball sampling. A structured questionnaire was used to study the characteristics of the databases. The search was restricted to North America, Australia, Israel, and Western Europe. Seven clinical databases on physical therapy were identified. Four databases collected data on specific patient categories, whereas the others collected data on all patients. All databases collected data on patient characteristics, referrals, diagnoses, treatments, and closure, whereas some databases also collected functional status information. The purposes of the databases were diverse, but they can be summarized as quality improvement, research, and performance management. Although clinical databases are new to the field, they offer great potential for physical therapy research. Potential can be increased by further cooperation among databases allowing international comparative studies.

Association between clinician-assessed lifting ability and workplace tolerance and patient self-reported pain and disability following work conditioning

OBJECTIVE

We investigated the association between clinician-assessed performance-based measures of improvement in lifting ability and workplace tolerance and patient self-reported improvement in pain and perceived disability following work conditioning (WC).

METHODS

A sample of 76 patients (42 +/- 9 yrs, 21 to 60 yrs, 74% male) was selected from a retrospective database because they had lumbar spine impairments and received treatment in a WC program. Patients completed self-report surveys for perceived disability (Oswestry), pain intensity (visual analog pain scale--VAS), and pain concerns (McGill short form) before initial functional capacity evaluation (FCE) and after termination of the WC program. During the FCE and during the WC, therapists assessed patient workplace tolerance (WT) and ability to lift from floor to waist (PDL).

RESULTS

Over the WC program that averaged 19 (6 SD) days, Oswestry and VAS scores improved (P< 0.05), but the McGill scores did not (P=0.334). 72% of patients improved their PDL, and 64% met their WT goals. None of the associations between patient self-report scores and performance-based measures were significant (P>0.05).

CONCLUSIONS

In spite of continuing pain complaints, patients decreased their perceived disability and pain intensity, increased their lifting ability, and improved their workplace tolerance while participating in a work-conditioning program.

State regulation and the delivery of physical therapy services

OBJECTIVE

The study purpose was to examine the relationship between state regulations of physical therapists (PT) and three dependent variables: physical therapist assistant (PTA) utilization more than 50 percent of the time during the treatment episode (high PTA utilization), number of visits, and patient self-reported functional health status (FHS) at discharge. We evaluated regulations governing licensure of PTAs, PT/PTA ratio, frequency of PT re-evaluation, and PTA supervision.

DATA SOURCE

The analytic sample included 63,900 patients from 38 states drawn from 395 clinics who participated in the Focus on Therapeutic Outcomes Inc. (Knoxville, TN) database in 2000 and 2001.

STUDY DESIGN

Using a Bayesian modeling approach with the Markov Chain Monte Carlo estimation method, we fitted separate multilevel multivariate regression models predicting high PTA utilization, number of visits, and discharge FHS.

DATA COLLECTION METHODS

Patients completed FHS surveys at intake and discharge. Clinicians recorded the number of visits and percentage of time a patient spent with each provider.

PRINCIPAL FINDINGS

After controlling for patient, therapist, and clinic characteristics, the presence of state regulations regarding PTA supervision was not associated with the likelihood of high PTA utilization. High PTA utilization and regulations requiring full-time onsite supervision were associated with more visits, whereas regulation of PT/PTA ratio was associated with fewer visits. Supervisory regulations were associated with better discharge FHS. High PTA utilization and use of therapy aides were associated with more visits per episode and lower discharge FHS.

CONCLUSIONS

The use of care extenders in place of PTs is likely to result in less efficient and lower quality care in outpatient rehabilitation.

Simulated computerized adaptive test for patients with lumbar spine impairments was efficient and produced valid measures of function

OBJECTIVE

To equate physical functioning (PF) items with Back Pain Functional Scale (BPFS) items, develop a computerized adaptive test (CAT) designed to assess lumbar spine functional status (LFS) in people with lumbar spine impairments, and compare discriminant validity of LFS measures (theta(IRT)) generated using all items analyzed with a rating scale Item Response Theory model (RSM) and measures generated using the simulated CAT (theta(CAT)).

METHODS

We performed a secondary analysis of retrospective intake rehabilitation data.

RESULTS

Unidimensionality and local independence of 25 BPFS and PF items were supported. Differential item functioning was negligible for levels of symptom acuity, gender, age, and surgical history. The RSM fit the data well. A lumbar spine specific CAT was developed that was 72% more efficient than using all 25 items to estimate LFS measures. theta(IRT) and theta(CAT) measures did not discriminate patients by symptom acuity, age, or gender, but discriminated patients by surgical history in similar clinically logical ways. theta(CAT) measures were as precise as theta(IRT) measures.

CONCLUSION

A body part specific simulated CAT developed from an LFS item bank was efficient and produced precise measures of LFS without eroding discriminant validity.

A 37-item shoulder functional status item pool had negligible differential item functioning

OBJECTIVE

Measures of shoulder function may differ by dominance of affected shoulder, surgical history, gender, or race. We present a technique for determining whether observed differences in function between groups are due to biased test items or real differences in function.

STUDY DESIGN AND SETTING

Four hundred patients who were receiving rehabilitation for a variety of shoulder impairments completed a survey of shoulder function. Thirty-seven items measuring shoulder function were analyzed for differential item functioning (DIF) related to demographic characteristics using an ordinal logistic regression (OLR) and item response theory (IRT) approach. When DIF was identified in an item, we modified the IRT analysis to calibrate item parameters separately in appropriate demographic groups. We compared adjusted and unadjusted patient ability measures in each demographic group.

RESULTS

Several items were found to have a modest amount of DIF related to the different demographic characteristics, especially gender; however, adjusting measures for DIF had little impact on overall measures of shoulder function and made almost no difference in average shoulder function across demographic groups.

CONCLUSION

In this pool of shoulder function items, adjustment for DIF made almost no difference in measures of function across demographic groups.

Simulated computerized adaptive test for patients with shoulder impairments was efficient and produced valid measures of function

BACKGROUND AND OBJECTIVE

To test unidimensionality and local independence of a set of shoulder functional status (SFS) items, develop a computerized adaptive test (CAT) of the items using a rating scale item response theory model (RSM), and compare discriminant validity of measures generated using all items (theta(IRT)) and measures generated using the simulated CAT (theta(CAT)).

STUDY DESIGN AND SETTING

We performed a secondary analysis of data collected prospectively during rehabilitation of 400 patients with shoulder impairments who completed 60 SFS items.

RESULTS

Factor analytic techniques supported that the 42 SFS items formed a unidimensional scale and were locally independent. Except for five items, which were deleted, the RSM fit the data well. The remaining 37 SFS items were used to generate the CAT. On average, 6 items were needed to estimate precise measures of function using the SFS CAT, compared with all 37 SFS items. The theta(IRT) and theta(CAT) measures were highly correlated (r = .96) and resulted in similar classifications of patients.

CONCLUSION

The simulated SFS CAT was efficient and produced precise, clinically relevant measures of functional status with good discriminating ability.

Centralization: association between repeated end-range pain responses and behavioral signs in patients with acute non-specific low back pain

OBJECTIVE

Tests and measures, if confounded by behavioral signs, cloud interpretation of physical test results during clinical examination. The purpose of this study was to determine whether common behavioral signs and pain responses (i.e. centralization and non-centralization) were associated during initial examination.

DESIGN

Observational and designed to cross-tabulate pain responses to behavioral signs.

PATIENTS

Data from 177 consecutive patients with acute work-related low back syndromes referred to physical therapy were analysed.

METHODS

Patients were screened for 8 baseline behavioral signs. Pain responses during initial evaluation were determined from repeated end-range trunk movement tests or loading strategies following McKenzie assessment methods. Association between centralization and non-centralization and baseline behavioral signs were assessed.

RESULTS

The physical sign of non-centralization was associated with non-organic signs, overt pain behaviors, fear of work activities, and somatization. Although depression, fear of physical activities, disability and pain intensity were not associated with non-centralization (p>0.05), upper bounds of odds ratios confidence intervals suggest that these behavioral signs may not be entirely independent of pain responses.

CONCLUSION

Presence of non-centralization is associated with many behavioral signs, and therefore when present, clinicians should consider additional psychosocial screening during the initial evaluation.

Simulated computerized adaptive tests for measuring functional status were efficient with good discriminant validity in patients with hip, knee, or foot/ankle impairments

BACKGROUND AND OBJECTIVE

To develop computerized adaptive tests (CATs) designed to assess lower extremity functional status (FS) in people with lower extremity impairments using items from the Lower Extremity Functional Scale and compare discriminant validity of FS measures generated using all items analyzed with a rating scale Item Response Theory model (theta(IRT)) and measures generated using the simulated CATs (theta(CAT)).

METHODS

Secondary analysis of retrospective intake rehabilitation data.

RESULTS

Unidimensionality of items was strong, and local independence of items was adequate. Differential item functioning (DIF) affected item calibration related to body part, that is, hip, knee, or foot/ankle, but DIF did not affect item calibration for symptom acuity, gender, age, or surgical history. Therefore, patients were separated into three body part specific groups. The rating scale model fit all three data sets well. Three body part specific CATs were developed: each was 70% more efficient than using all LEFS items to estimate FS measures. theta(IRT) and theta(CAT) measures discriminated patients by symptom acuity, age, and surgical history in similar ways. theta(CAT) measures were as precise as theta(IRT) measures.

CONCLUSION

Body part-specific simulated CATs were efficient and produced precise measures of FS with good discriminant validity.

Categorizing patients with occupational low back pain by use of the Quebec Task Force Classification system versus pain pattern classification procedures: discriminant and predictive validity

BACKGROUND AND PURPOSE

Quebec Task Force Classification (QTFC) and pain pattern classification (PPC) procedures, including centralization and noncentralization, are common classification procedures. Classification was done to estimate validity of data obtained with QTFC and PPC procedures for differentiating patient subgroups at intake and for use in predicting rehabilitation outcomes at discharge and work status at 1 year after discharge from rehabilitation.

SUBJECTS

Patients (n=171, 54% male; mean age=37 years, SD=10, range=18-62) with acute work-related low back pain referred for physical therapy were analyzed.

METHODS

Patients completed pain and psychosocial questionnaires at initial examination and discharge and pain diagrams throughout intervention. Physical therapists classified patients using QTFC and PPC data at intake. Patients were classified again at discharge by PPC (time-dependent PPC).

RESULTS

Analysis of variance of showed QTFC and PPC data could be used to differentiate patients by pain intensity or disability at intake. Analysis of covariance showed that intake PPC predicted pain intensity and disability at discharge, but QTFC did not. Logistic regression showed that PPC predicted work status at 1 year, but QTFC did not. Classifying patients over time using time-dependent PPC data reduced the false positive rate by 31% and increased percentage of change in pretest-posttest probability of return to work by 16% compared with classifying patients at intake.

DISCUSSION AND CONCLUSION

Results support the discriminant validity of the QTFC data at intake and predictive validity of the PPC data at intake. Tracking PPC over time increases predictive validity for 1-year work status.

Test-retest reliability of an abbreviated self-report overall health status measure

STUDY DESIGN

Test-retest reliability study.

OBJECTIVE

To assess test-retest reliability and estimate minimal detectable change of an overall measure and 2 summary measures of patient self-report of health status.

BACKGROUND

Change in patient self-report of health status is a common outcome measure following rehabilitation. Because collection of health status data takes time and clinicians are required to be productive, selected items from reliable instruments were used to form a new, abbreviated instrument of health status relevant to patients in outpatient rehabilitation. There are no test-retest reliability statistics of these health status measures in this population.

METHODS AND MEASURES

A convenience sample of 71 patients (mean age +/- SD, 41.9 +/- 17.9 years; age range, 15-83 years; sex, 35% male), with a variety of orthopaedic diagnoses, seeking rehabilitation in 2 outpatient facilities, volunteered. Patients completed health status questionnaires at initial evaluation and at 24 to 72 hours following evaluation. Intraclass correlation coefficients (ICC2.1) were used to estimate test-retest reliability and to estimate measurement error and minimal detectable changes.

RESULTS

ICCs with a 1-sided lower limit 95% confidence intervals (CI) of the Overall Health Status measure and the Physical and Mental Component Summary measures for patients with chronic symptoms were 0.92 (0.85), 0.82 (0.68), and 0.85 (0.74), respectively. Minimal detectable changes (90% CI) were +/-12 (scale range, 100), +/- 9 (scale range, 60), and +/- 9 (scale range, 60) scale points, respectively, for the same measures.

CONCLUSIONS

Results support the test-retest reliability of the Overall Health Status measure and summary measures for patients with chronic symptoms and demonstrate ability of the Overall Health Status and Physical Summary Scale measures to detect improvement of patient self-report of health status within the first few days of rehabilitation.

Using clinical outcomes to identify expert physical therapists

BACKGROUND AND PURPOSE

Previous studies of expert physical therapists have sampled therapists based on years of clinical experience or reputation, not on their patients' clinical outcomes. The purposes of this study were to identify expert physical therapists by using patient self-reported outcomes and to describe the characteristics of clinicians whose patients with lumbar spine syndromes reported higher health-related quality of life (HRQL) following rehabilitation.

METHODS

Retrospective data were analyzed on 24276 patients (mean age=47.8 years, SD=16, range=14-97) with lumbar spine syndromes treated by 930 physical therapists participating in the Focus On Therapeutic Outcomes database in 1999-2000. Physical therapists and staff answered questions concerning years of experience and practice setting when starting their participation in the outcomes system. Patient self-report HRQL data were collected at intake and discharge from outpatient rehabilitation. Discharge HRQL data were risk adjusted using patient characteristics. Data were aggregated by physical therapist. Risk-adjusted discharge HRQL scores were used to classify physical therapists whose patients reported mean HRQL improvement above the 90th percentile as experts and physical therapists whose patients reported mean HRQL improvement between the 45th and 55th percentiles as average.

RESULTS

Therapists classified as expert had fewer patients in the database than did therapists classified as average (mean SD) (19 +/-17 versus 29 +/-22). Mean treatment duration was different between groups (32 +/- 11 days for the expert group versus 31+/-8 days for the average group).

DISCUSSION AND CONCLUSION

The results challenge assumptions that extensive clinical experience is necessary to achieve superior patient outcomes, and they provide information about the relationship between therapist characteristics and patient outcomes.

Discriminant validity and relative precision for classifying patients with nonspecific neck and back pain by anatomic pain patterns

STUDY DESIGN

Secondary analysis of a previously described cohort of prospective, consecutive patients with acute neck or low back pain referred to outpatient rehabilitation was performed.

OBJECTIVE

To estimate discriminant validity and relative precision of two classification procedures (first visit vs multiple visit) in discriminating short-term pain intensity and perceived disability outcomes.

SUMMARY OF BACKGROUND DATA

Centralization and noncentralization are pain responses used to classify patients and predict outcomes. Different time frames have been proposed for operationally defining these responses, which are problematic for comparing outcomes across clinical trials. Classifying patients according to pain response observed from initial examination (first visit) and over time (multiple visits) influences prevalence within categories and interpretation of classification usefulness, which merits further investigation.

METHODS

Patients with acute onset of nonspecific neck or low back pain referred to two outpatient physical therapy clinics completed body pain diagrams, pain intensity ratings, and disability questionnaires at initial evaluation, during each visit, and at discharge. Therapists collected data enabling patient classification on initial examination and throughout treatment. Differences in pain and disability from intake to discharge from rehabilitation across classification categories were used to assess discriminant validity. Relative precision was estimated by determining ratios of analysis of covariance F values between classification procedures for pain and disability.

RESULTS

Both classification procedures discriminated categories for change in pain and disability. The multiple-visit classification procedure was more precise for discriminating outcomes than the first-visit classification procedure.

CONCLUSION

Multiple-visit classification of patients into specific pain pattern subgroups is recommended when pain intensity and disability outcomes are of interest.

Development of an index of physical functional health status in rehabilitation

OBJECTIVE

To describe (1) the development of an index of physical functional health status (FHS) and (2) its hierarchical structure, unidimensionality, reproducibility of item calibrations, and practical application.

DESIGN

Rasch analysis of existing data sets.

SETTING

A total of 715 acute, orthopedic outpatient centers and 62 long-term care facilities in 41 states participating with Focus On Therapeutic Outcomes, Inc.

PATIENTS

A convenience sample of 92,343 patients (40% male; mean age +/- standard deviation [SD], 48+/-17y; range, 14-99y) seeking rehabilitation between 1993 and 1999.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Patients completed self-report health status surveys at admission and discharge. The Medical Outcomes Study 36-Item Short-Form Health Survey's physical functioning scale (PF-10) is the foundation of the physical FHS. The Oswestry Low Back Pain Disability Questionnaire, Neck Disability Index, Lysholm Knee Questionnaire, items pertinent to patients with upper-extremity impairments, and items pertinent to patients with more involved neuromusculoskeletal impairments were cocalibrated into the PF-10.

RESULTS

The final FHS item bank contained 36 items (patient separation, 2.3; root mean square measurement error, 5.9; mean square +/- SD infit, 0.9+/-0.5; outfit, 0.9+/-0.9). Analyses supported empirical item hierarchy, unidimensionality, reproducibility of item calibrations, and content and construct validity of the FHS-36.

CONCLUSIONS

Results support the reliability and validity of FHS-36 measures in the present sample. Analyses show the potential for a dynamic, computer-controlled, adaptive survey for FHS assessment applicable for group analysis and clinical decision making for individual patients.

Relationships among lifting ability, grip force, and return to work

BACKGROUND AND PURPOSE

The relationship between functional capacity evaluation (FCE) data and work disability has not been studied. The validity of FCE testing results in terms of subsequent return to work (RTW) was the focus of this exploratory study.

SUBJECTS AND METHODS

Six hundred fifty adults of working age were evaluated as part of a standardized FCE. Clients were contacted by telephone 6 months after the FCE to determine their work status. Predictor variables were gender, age, time off work, maximum safe loads during 3 dynamic lifts, and isometric grip force. Other variables measured were whether or not the client returned to work (RTW-Y/N) and level of return to work (RTW level).

RESULTS

A multivariate logistic regression analysis demonstrated that the more time a worker was away from work, the less likely was RTW. Male subjects were less likely to return to work than female subjects. The more weight lifted from floor to waist, the more likely was RTW. The logistic regression equation correctly classified 80.3% of the subjects who returned to work and 56.6% of the subjects who did not return to work. Each of the 3 lift tests was related to RTW level, whereas the grip force tests were not related to either RTW-Y/N or RTW level.

DISCUSSION AND CONCLUSION

Time off work and gender were the strongest predictors of RTW, but certain FCE subtests of lifting were related to RTW and RTW level for people with work-related chronic symptoms. Grip force was not related to RTW.

Assessment of unidimensionality of physical functioning in patients receiving therapy in acute, orthopedic outpatient centers

Physical functioning is a common construct of interest for patients receiving rehabilitation. This report describes the assessment of hierarchial structure, unidimensionality and reproducibility of item calibrations along the continuum of physical functioning defined by the PF-10 of the MOS SF-36. Three new questions specific to patients with upper extremity impairments were added, and item calibrations were compared across several groups of patients with different musculoskeletal impairments. Reproducibility of item calibrations over testing times was supported. Item order was dependent on impairment in a clinically logical pattern. Construct validity of the physical functioning scale was supported and improved with the new questions for patients with upper extremity impairments as well as for patients with some lower level extremity impairments.

Centralization phenomenon as a prognostic factor for chronic low back pain and disability

STUDY DESIGN

Two hundred twenty-three consecutive adults with acute low back pain with or without referred spinal symptoms were treated conservatively and followed prospectively for 1 year.

OBJECTIVES

To investigate the predictive value of centralization phenomenon (CP) with psychosocial variables previously identified as important risk factors for patients with acute onset of nonserious or nonspecific low back pain who subsequently develop chronic pain or disability.

SUMMARY OF BACKGROUND DATA

Psychosocial factors have been shown to be predictors of chronic disability, but measures from physical examination rarely predict chronic behavior. The authors of the present study investigated whether dynamic assessment of changes in clinical measures during treatment could be used to classify patients and predict occurrence of chronic pain or disability.

METHODS

Patients with acute symptoms and no history of surgery were treated by five physical therapists trained in McKenzie evaluation/treatment methods. Seventy-three percent were receiving workers' compensation benefits. At initial evaluation and discharge, 23 independent variables were assessed representing psychosocial, clinical, and demographic factors. Pain location changes to repeated trunk movements were assessed at every visit. Patients were placed in two groups: 1) those with pain that did not centralize and 2) those who completely centralized or demonstrated partial reduction of pain location with time. Treatment was individualized and based on McKenzie methods. Patients were contacted at 12 months after discharge, and dependent variables of pain intensity, return to work status, sick leave at work, activity interference at home, and continued use of health care were assessed.

RESULTS

Nine independent variables influenced pain symptoms or disability. Pain pattern classification (noncentralization) and leg pain at intake were the strongest predictive variables of chronicity.

CONCLUSION

Dynamic assessment of change in anatomic pain location during treatment and leg pain at intake were predictors of developing chronic pain and disability.

Changes in health status for persons with wrist or hand impairments receiving occupational therapy or physical therapy

OBJECTIVE

The purpose of this study was to describe changes of health status as perceived by clients with hand or wrist impairments who received rehabilitation in acute, orthopedic outpatient facilities from occupational therapy or physical therapy personnel.

METHOD

One thousand three hundred ninety-nine adults with wrist (n = 692) or hand (n = 707) impairments who were treated between July 1996 and June 1997 were selected from the Focus On Therapeutic Outcomes, Inc. (FOTO) national rehabilitation database. Each client completed a health status questionnaire on intake and discharge. Data consisted of number of outpatient visits, duration of treatment episode, and health status scores for six functional scales. Measures of intensity, global health status, global utilization, and client satisfaction were calculated. Outcomes were evaluated across occupational therapists and physical therapists.

RESULTS

Clients perceived improvement (p < .05) in their health status over the course of therapy. Number of visits and measures of health status and client satisfaction were similar across type of therapist. Episode duration was longer (p < .05) and intensity was less (p < .05) for clients seen by occupational therapists.

CONCLUSION

Clients receiving rehabilitation in acute orthopedic outpatient centers perceived improvement in their functional abilities and health and well-being (global health status and individual functional scales) over the time during which treatment was provided. Results confirm the responsiveness of the outcomes instrument to clinical change in the clients' perception of their health status over the course of therapy and support the use of health status as a measure of clinical outcome.

Influence of orthopaedic clinical specialist certification on clinical outcomes

STUDY DESIGN

Effect of clinical specialization was studied in a retrospective analysis of a commercial outcomes database.

OBJECTIVE

To assess effectiveness of care as measured by changes in health status and efficiency as measured by visits, duration of treatment episode, and net revenue between patients treated by clinicians with and without orthopaedic clinical specialist certification (OCS).

BACKGROUND

Clinical specialization is becoming common in physical therapy, but there are no studies to support improved efficiency or effectiveness with advanced practitioner competencies.

METHODS AND MEASURES

A total of 258 adults treated in practices participating in the Focus on Therapeutic Outcomes process during 1996 comprised the data set. Seven physical therapists with OCS treated 129 patients (clinical specialist group). These patients were matched to 129 patients not treated by physical therapists with OCS (comparison group) randomly chosen from the aggregate data set. All patients completed a standardized health status questionnaire at initial evaluation and discharge. Standardized response means (SRMs) were calculated to measure change during treatment.

RESULTS

Therapists with OCS were more efficient than therapists without OCS, using fewer visits (9.1 +/- 6.7 vs 11.2 +/- 7.4) for less estimated cost ($949 +/- $736 vs $1238 +/- $1227) during the same treatment duration (35.9 +/- 48.3 vs 35.4 +/- 25.6 days) and performed fewer treatment procedures. Overall, there was no difference in effectiveness as measured by change in health status, that is, unit of functional improvement per episode (0.89 +/- 1.0 SRM for clinical specialists compared with 0.88 +/- 1.0 SRM for comparison group). The OCS group had better value (unit of functional improvement per estimated dollar) and utilization (unit of functional improvement per visit) for the constructs of physical functioning (value: 1.31 +/- 2.7 vs 0.78 +/- 1.8; utilization: 1.25 +/- 2.2 vs 0.76 +/- 1.6) and role physical (value: 1.26 +/- 2.9 vs 0.44 +/- 3.5; utilization: 1.11 +/- 1.9 vs 0.51 +/- 2.3) (SRMs for OCS group vs comparison group, respectively).

CONCLUSIONS

Our data support the conclusion that physical therapists with OCS are more efficient compared with clinicians without OCS. Study limitations in design, small sample size, and low number of clinicians are discussed.

A descriptive study of the centralization phenomenon. A prospective analysis

STUDY DESIGN

Occurrence and treatment responses associated with the centralization phenomenon were analyzed prospectively in 289 patients with acute neck and back pain with or without referred spinal symptoms.

OBJECTIVES

To document symptom changes to mechanical assessment during initial evaluation and during consecutive visits. Using standard operational definitions, patients were categorized reliably into three inclusive and mutually exclusive pain pattern groups: centralization, noncentralization, and partial reduction. It was hypothesized that the occurrence of centralization would be less than previously reported and that the centralization group would have better treatment results.

SUMMARY OF BACKGROUND DATA

Centralization has been reported to occur with high frequency during mechanical assessments of patients with acute spinal syndromes. When centralization is observed, a favorable treatment result is expected. Because centralization has not been defined consistently in the literature, the true prevalence and treatment responses associated with centralization have not been confirmed.

METHODS

Consecutive patients with neck or back pain syndromes and referred to outpatient physical therapy services were categorized into three pain pattern groups by experienced therapists trained in the McKenzie system. Changes in distal pain location were scored and documented before and after each visit. Maximal pain intensity over 24 hours, perceived functional status, and number of treatment visits were compared between groups.

RESULTS

Patients could be categorized reliably according to movement signs and symptoms. The centralization pain pattern group had significantly fewer visits than the other two groups (P < 0.001). Pain intensity rating and perceived function were different between the centralization and noncentralization groups (P < 0.001). There was no difference in treatment response between the centralization and partial-reduction groups (P = 0.306). Prevalence of patients assigned to the three groups was 30.8% in the centralization group, 23.2% in noncentralization, and 46% in the partial-reduction group.

CONCLUSION

Categorization by changes in pain location to mechanical assessment and treatment allowed identification of patients with improved treatment outcomes and facilitated planning of conservative treatment of patients with acute spinal pain syndromes. If a proximal change in pain location is not observed by the seventh treatment visit, the results of this study support additional medical evaluation for physical or nonphysical factors that could be delaying quick resolution of the acute episode.

Impact of the Dayton Tire case

Three of the more pertinent legal cases in the United States concerning the performance of ergonomists are summarized. The results of the cited cases have impact on the validity of the NIOSH lifting formulae, the lack of scientific evidence relating performance of jobs with alleged ergonomic stressors with specific medical pathology, and the gold standard for expert witness testimony. The cases, taken together, should act as a catalyst for ergonomists to improve their level of scientific justification for their work and conclusions.

Rehabilitation ergonomists: standards for development

Ergonomics, in the traditional definition, is the science of design of work sites and work methods which influence production performance. In recent years, worker complaints and reports of injuries have caused evaluation of the effect of work stressors on workers. Currently, the rehabilitation specialist plays a pivotal role in both prevention and management of physical work related complaints. Rehabilitation ergonomic practitioners combine a scientific background in function and pathology with the act of developing preventive or restorative remedies. A volunteer group of sixteen rehabilitation professionals who utilize ergonomic principles in the workplace developed a document, identifying job functions of the newly defined field. This paper presents philosophy and a model for educational development and potential credentialing areas for rehabilitation ergonomists.