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Objective Physical therapy visit number and timing following knee arthroplasty (KA) are variable in daily practice. The extent to which the number and timing of physical therapy visits are associated with current and future pain and function—and, alternatively, whether pain and function are associated with the number of future physical therapy visits following KA—are unknown. The purpose of this study was to determine temporal and reciprocal associations between the number of physical therapy visits and future pain and function in people with KA. Methods A cross-lagged panel design was applied to a secondary analysis of data from a randomized clinical trial of patients with pain catastrophizing. The 326 participants underwent KA and completed at least 7 of 9 health care diaries over the year following surgery. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and physical function subscales were completed preoperatively and multiple times during follow-up. Separate cross-lagged panel analyses were conducted for WOMAC pain and physical function. Results From surgery to 2 months postsurgery, reciprocal associations were generally not found between physical therapy visit number and future pain or function. From 2 to 6 months postsurgery, a greater number of physical therapy weekly visits were associated with higher (worse) 6-month pain and function. Higher (worse) WOMAC pain at 2 and 6 months led to more visits from 2 to 6 and 6 to 12 months, respectively. Conclusions Higher pain scores 2 months postsurgery were associated with higher physical therapy use in the 2 to 6 months following surgery. However, patients with increased physical therapy use from 2 to 6 months had significantly higher pain scores 6 months postsurgery. Those patients with persistent pain 6 months postsurgery were higher users of physical therapy 6 to 12 months postsurgery. This reciprocal positive association between pain and physical therapy during this time period suggests minimal benefit of physical therapy despite an increased physical therapy use for patients with higher pain. Impact This is the first study to determine the association between the number and timing of physical therapy visits and current and future pain and function. Based on the results, physical therapy might not be a cost-effective strategy to treat patients with persistent pain following KA.

Objective The Western Ontario and McMaster Universities Osteoarthritis (WOMAC) pain scale quantifies knee pain severity with activities of daily living, but the potential impact of pain in other body regions on WOMAC pain scores has not been explored using a causal modeling approach. The purpose of this study was to determine if pain in other areas of the body impact WOMAC pain scores, a phenomenon referred to as “crosstalk.” Methods Cross-sectional datasets were built from public use data available from the Osteoarthritis Initiative (OAI) and the Multicenter Osteoarthritis Study (MOST). The WOMAC Pain Scale and generic hip, knee, ankle, foot and back pain measures were included. Three nested regression models grounded in causally based classical test theory determined the extent of crosstalk. Improvements in the coefficient of determination across the 3 models were used to determine the presence of crosstalk. Results Causal modeling provided evidence of crosstalk in both OAI and MOST datasets. For example, in OAI, multiple statistical models demonstrated significant increases in coefficient of determination values (P Conclusions Crosstalk appears to be a clinically important source of error in the WOMAC Pain Scale, particularly for patients with a larger number of painful body regions and when contralateral knee joint pain is more severe. Impact Statement This study has important implications for arthritis research. It also should raise clinician awareness of the threat to score interpretation and the need to consider the extent of pain in other body regions when interpreting WOMAC pain scores.

Background Associative learning is the ability to discover a relationship between two or more events. We combined principles of learning and technology to develop a paradigm to assess associative learning in prone. Purpose The purpose of this study was to determine whether 3- to 6-month-old infants can demonstrate: (1) short-term learning of an association between their upper body movements in prone and activation of a toy, and (2) retention of the association learned on day 1, 24 hours later. Methods Twenty-eight infants who were 3 to 6 months of age and who were typically developing were tested for 2 consecutive days in an instrumented play gym. Both days of testing had a baseline and 4 acquisition phases (2 minutes each). During the acquisition phase, the toy activated for a maximum of 10 seconds when the infant's head was above a threshold. A criterion was set a priori to distinguish infants as short-term learners and retainers of the association learned on day 1. Results Of 28 infants, 22 and 14 infants completed all phases of the testing on day 1 and day 2, respectively. Fourteen (50%) of the infants met the criteria for short-term learners. On day 2, there was an analyzable sample of 9 short-term learners. Three of the 12 short-term learners (25%) demonstrated retention on day 2. Conclusion Consistent with prior infant motor learning research, half of the infants demonstrated associative learning in this novel assessment in prone; however, based on study criteria, the infants had limited retention of the association on day 2.

Background Out-of-pocket (OOP) expenditures are incurred as insurers and employers shift some of the burden of health care costs onto consumers. As cost-sharing increases, OOP expenditures could be a barrier to physical therapy care. Objective The purposes of this study were: (1) to identify factors associated with any OOP physical therapy spending and (2) to identify factors associated with higher spending among individuals incurring OOP costs. Design The study was a retrospective analysis using the 4 most recently available panels of data from the Medical Expenditure Panel Survey (MEPS) encompassing 2008–2012. Methods A data file containing episodes of physical therapy care for 2,189 people was created. Logistic regression was used to identify factors related to having an OOP expenditure. A multivariable generalized linear model was used to identify factors related to mean OOP expenditures. Results On average, an episode of care encompassed 9.9 visits, with mean total expenditures of $1,708 (median: $792). Fifty-four percent of episodes of care had an OOP expenditure. For individuals with OOP expenditures, the mean OOP expenditure for an episode of care was $351 (median: $144). Being female or non-Hispanic and having a higher income were associated with higher odds of incurring an OOP expenditure, whereas being in worse general health, >65 years of age, or nonwhite and having public funding were associated with lower odds of incurring an OOP expenditure. Amounts of OOP spending were higher in urban areas and in all census geographic regions relative to the Northeast region. Limitations Estimates are based on household-reported survey data, limited to ambulatory care, and do not include institutionalized individuals. Conclusions At 54%, the proportion of individuals with OOP expenditures for physical therapy is lower than for general medical care. Several predictors were found of having OOP expenditures and of the magnitude of those expenditures.

BackgroundThe Outpatient Physical Therapy Improvement in Movement Assessment Log (OPTIMAL) is a recently developed self-report outcome instrument designed to measure the extent of activity limitation as defined by the World Health Organization.ObjectiveThe purposes of the study were to replicate some aspects of the original study of the OPTIMAL Difficulty and Confidence scales and to conduct additional psychometric tests.DesignA cross-sectional design was used in the study.MethodsOf a total of 1,150 patients who received treatment at 4 outpatient centers over the study period, 1,030 patients were recruited for this study and completed the OPTIMAL instrument and previously validated region-specific functional status measures. A variety of analytic methods were used to examine the extent of redundancy between the OPTIMAL Difficulty and Confidence scales, as well as the internal consistency reliability, standard error of measurement, known-groups validity, and convergent validity of OPTIMAL Difficulty Scale scores.ResultsThe OPTIMAL Difficulty and Confidence scale scores were found in a factor analysis to be load-based on anatomical region rather than on difficulty and confidence concepts. Internal consistency reliability for the subscales of the Confidence Scale varied and was .80 or higher for the lower-extremity subscale but .50 or less for the trunk and upper-extremity subscales.LimitationsOnly cross-sectional relationships were examined, and another pure measure of activity limitation was not used for comparison.ConclusionsThe findings generally did not support the psychometric properties of the OPTIMAL instrument. Although not conclusive, the data suggested that the OPTIMAL Difficulty and Confidence scales demonstrate substantial overlap. Reliability was generally low, with the exception of the lower-extremity subscale. Scores for the subscales of the Difficulty Scale differentiated among patients with lower-extremity versus trunk or upper-extremity diagnoses, but associations with previously validated region-specific measures were generally weak or absent. Clinicians treating outpatients with musculoskeletal disorders should consider alternative measures when attempting to quantify the extent of activity limitations.

Assessing patient progress is an integral part of physical therapist practice. In an attempt to assist clinical decision making regarding a patient's change status, researchers have offered study-based threshold change values. Often researchers have provided reliability and diagnostic test–based estimates of threshold change values obtained from the same patient sample. A potential dilemma occurs when the reliability (ie, the minimal detectable change [MDC])–based threshold change value exceeds the diagnostic test–based threshold value. How can a change be detected if the threshold change value falls within the limits of error? In this situation, researchers have recommended using the larger MDC threshold change value. In this perspective article, we describe the interpretation of the threshold values provided by each of these estimation methods and consider which one offers information that is more meaningful to the challenge faced by physical therapists when making decisions concerning the change status of patients. The context for our discussion is a clinical vignette that depicts the dilemma outlined above. We conclude this perspective with suggestions for researchers concerning essential information to include when reporting threshold estimates obtained from reliability–based and diagnostic test–based studies of outcome measures.

Background Recent evidence demonstrates growth in both the quality and quantity of evidence in physical therapy. Much of this work has focused on randomized controlled trials and systematic reviews. Objective The purpose of this study was to conduct a comprehensive bibliometric assessment of Physical Therapy (PTJ) over the past 30 years to examine trends for all types of studies. Design This was a bibliometric analysis. Methods All manuscripts published in PTJ from 1980 to 2009 were reviewed. Research reports, topical reviews (including perspectives and nonsystematic reviews), and case reports were included. Articles were coded based on type, participant characteristics, physical therapy focus, research design, purpose of article, clinical condition, and intervention. Coding was performed by 2 independent reviewers, and author, institution, and citation information was obtained using bibliometric software. Results Of the 4,385 publications identified, 2,519 were included in this analysis. Of these, 67.1% were research reports, 23.0% were topical reviews, and 9.9% were case reports. Percentage increases over the past 30 years were observed for research reports, inclusion of “symptomatic” participants (defined as humans with a current symptomatic condition), systematic reviews, qualitative studies, prospective studies, and articles focused on prognosis, diagnosis, or metric topics. Percentage decreases were observed for topical reviews, inclusion of only “asymptomatic” participants (defined as humans without a current symptomatic condition), education articles, nonsystematic reviews, and articles focused on anatomy/physiology. Limitations Quality assessment of articles was not performed. Conclusions These trends provide an indirect indication of the evolution of the physical therapy profession through the publication record in PTJ. Collectively, the data indicated an increased emphasis on publishing articles consistent with evidence-based practice and clinically based research. Bibliometric analyses indicated the most frequent citations were metric studies and references in PTJ were from journals from a variety of disciplines.

The American Physical Therapy Association (APTA) has endorsed the International Classification of Functioning, Disability and Health (ICF) as a framework to be integrated into physical therapist practice. The ICF is a universal and inclusive platform for the understanding of health and disability and a comprehensive classification system for describing functioning. The APTA's Guide to Physical Therapist Practice was designed to guide patient management, given the different settings and health conditions that physical therapists encounter in their daily clinical practice. However, physical therapists may be unclear as to how to concretely apply the ICF in their clinical practice and to translate the application in a way that is meaningful to them and to their patients. This perspective article proposes ways to integrate the ICF and the Guide to Physical Therapist Practice to facilitate clinical documentation by physical therapists.

Background Several factors have been shown to influence first-time pass rates on the National Physical Therapy Examination (NPTE). It is unclear to what extent academic difficulty experienced by students in a physical therapist education program may affect NPTE pass rates. The effects of institutional status (public or private) and Carnegie Classification on NPTE pass rates also are unknown. Objective The aim of this study was to quantify the odds of failure on the NPTE for students experiencing academic difficulty and for institutional status and Carnegie Classification. Design This investigation was a retrospective population-based cohort study. Methods Quota sampling was used to recruit a random sample of 20 professional physical therapist education programs across the United States. Individual student demographic, preadmission, and academic performance data were collected, as were data on program-level variables and data indicating pass/fail performance on the NPTE. A generalized linear mixed-effects logistic regression model was used to adjust for confounding factors and to describe relationships among the key predictor variables—academic difficulty, institutional status, and Carnegie Classification—and the dependent variable, NPTE performance. Results Academic difficulty during a student's professional training was an independent predictor for NPTE failure. The odds of students who had academic difficulty (relative to students who did not experience academic difficulty) failing the NPTE were 5.89 (95% confidence interval=4.06–8.93). The odds of NPTE failure also varied depending on institutional status and Carnegie Classification. Limitations The findings related to Carnegie Classification and institutional status should be considered preliminary. Conclusions Student performance on the NPTE was influenced by multiple factors, but the most important, potentially modifiable risk factor for poor NPTE performance likely is academic difficulty during professional training.

Background and PurposeThe purpose of this study was to determine whether physical therapy interventions predicted meaningful short-term improvement in 4 measures of physical health, pain, and function for patients diagnosed with adhesive capsulitis.ParticipantsData were examined from 2,370 patients (mean age=55.3 years, SD=12.4; 65% female, 35% male) classified into ICD-9 code 726.0 who had completed an episode of outpatient physical therapy.MethodsPrincipal components factor analysis was used to define intervention categories from specific treatments applied during the episode of care. A nested logistic regression model was used to identify intervention categories that predicted a 50% or greater change in Physical Component Summary-12 (PCS-12), physical function (PF), bodily pain (BP), and hybrid function (HF) scores.ResultsNone of the patients achieved a 50% or greater improvement in PCS-12 scores. Improvement in BP scores was more likely in patients who received joint mobility interventions (odds ratio=1.35, 95% confidence interval=1.10–1.65). Improvement in HF scores was more likely in patients who received exercise interventions (odds ratio=1.50, 95% confidence interval=1.03–2.17). Use of iontophoresis, phonophoresis, ultrasound, or massage reduced the likelihood of improvement in these 3 outcome measures by 19% to 32%.LimitationsThe authors relied on clinician-identified ICD-9 coding for the diagnosis. Impairment measures were not available to support the diagnosis, and some interventions were excluded because of infrequent use by participating therapists.Discussion and ConclusionsThese results are consistent with findings from randomized clinical trials that demonstrated the effectiveness of joint mobilization and exercise for patients with adhesive capsulitis. Ultrasound, massage, iontophoresis, and phonophoresis reduced the likelihood of a favorable outcome, which suggests that use of these modalities should be discouraged.

Background and Purpose: The purpose of this study was to determine whether admissions data could be used to estimate physical therapist students' risk for academic difficulty. Subjects: A nationally representative sample of 20 physical therapist education programs provided data on 3,582 students. Methods: Programs provided data regarding student demographic characteristics, undergraduate grade point average (uGPA), quantitative and verbal Graduate Record Examination scores (qGRE, vGRE), and academic difficulty. Data were analyzed using logistic regression. Rules for predicting risk of academic difficulty were developed. Results: A prediction rule that included uGPA, vGRE, qGRE, age, and race or ethnicity was developed from the entire sample. Prediction rules for individual programs showed large variation. Discussion and Conclusion: Undergraduate grade point average, GRE scores, age, and race or ethnicity can be useful for estimating student academic risk. Programs should calculate their own estimates of student risk. Academic programs should use risk estimates in combination with other data to recruit, admit, and retain students.

PTJ strives to improve its processes to enhance readability, simplify manuscript submission for authors, and ensure that only papers with a reasonable likelihood of publication proceed to full review—all with the goal of publishing high-quality, clinically relevant content. In particular, manuscripts reporting clinical trials must be prospectively registered in a publicly accessible trial registry before participant enrollment commences. Although PTJ has required clinical trial registration since 2008, the definition of a clinical trial continues to perplex some authors. Confusion may result in failure to prospectively register a trial, thus preventing PTJ (and many other journals) from publishing the study findings once the study has been completed. So, what is a clinical trial? The National Institutes of Health (NIH) revised its definition of clinical trials in October 2014 in order to more clearly distinguish between clinical trials and clinical research studies.1 The NIH defines a clinical trial as “a research study in which one or more human subjects are prospectively assigned to one or more interventions (which may include placebo or other control) to evaluate the effects of those interventions on health-related biomedical or behavioral outcomes. ” The NIH considers prospective assignment (which may involve randomization but not necessarily) to be a predefined process specified in a protocol that stipulates the assignment of research participants (individually or …

Background and Purpose. The purpose of our study was to determine whether physical therapy interventions predicted meaningful short-term improvement in physical health for patients diagnosed with sciatica. Subjects. We examined data from 1,804 patients (age: X̄=52.1 years, SD=15.6 years; 65.7% female, 34.3% male) who had been diagnosed with sciatica and who had completed an episode of outpatient physical therapy. Methods. Principal components factor analysis was used to define intervention categories from specific treatments applied during the plan of care. A nested-model logistic regression analysis identified intervention categories that predicted meaningful improvement in physical health. Meaningful improvement was defined as a change of 14 or more points on the Physical Component Scale-12 (PCS-12) summary score. Results. Twenty-six percent (n=473) of patients had a meaningful improvement in physical health. Improvement was more likely in patients receiving joint mobility interventions (odds ratio [OR]=2.5, 95% confidence interval [CI]=1.5–4.4) or general exercise (OR=1.5, 95% CI=1.2–2.0). Patients who received spasm reduction interventions were less likely to improve (OR=0.77, 95% CI=0.60–0.98). Discussion and Conclusion. Physical therapists should emphasize the use of joint mobility interventions and exercise when treating patients with sciatica, whereas interventions for spasm reduction should be avoided.

Background and Purpose. Prompt identification of outpatients who may have proximal lower-extremity deep vein thrombosis (PDVT) is important, in part, because of the risk of pulmonary embolism. The purposes of our study were to determine the degree of accuracy of physical therapists' estimates of the probability of PDVT in hypothetical patient vignettes and to determine whether physical therapists would contact the referring physician about the hypothetical patients' condition as recommended in published evidence. Subjects and Methods. A survey instrument consisting of 6 vignettes was sent to a nationally representative random sample of 1,500 physical therapists. The clinical decision rule developed by Wells and colleagues served as the gold standard for PDVT probability. Results. A total of 969 (65% response rate) physical therapists completed the survey. We found no evidence of nonresponse bias. For the 2 high-probability vignettes, 87% and 64% of the physical therapists underestimated the probability of PDVT. For the 2 high-probability cases, 32% and 27% of the physical therapists reported that they would not have contacted the referring physician. For the 2 moderate-probability cases, 15% and 30% of the physical therapists would not have contacted the referring physician. Therapist experience, certification status, place of practice, and region of the country did not explain the findings. Discussion and Conclusion. The care of outpatients who are at risk for PDVT could potentially be improved by use of the clinical decision rule developed by Wells and colleagues, although more study is warranted.

A 68-year-old man was referred to your outpatient clinic following a cemented right hip arthroplasty procedure 3 weeks before your examination. He reports that he has had pain in his right calf and thigh since being discharged from the hospital and that these symptoms limit his ability to ambulate. He also reports difficulty getting in and out of bed. You find that he has a swollen right lower extremity and that he complains of pain when you palpate his right posterior calf and knee. You suspect that he may have a deep vein thrombosis (DVT), but you also consider that it is likely that the lower-extremity symptoms are attributable to the recent surgical procedure. Do you contact the patient's physician? The diagnosis of DVT in patients who are hospitalized is well recognized, but DVT associated with outpatient care is less frequently discussed.1 The purpose of this update is to summarize evidence-based approaches to the clinical examination of outpatients who are at risk for DVT. We also review radiological and laboratory-based diagnostic tests used to confirm or refute the diagnosis of DVT. Venous thromboembolism (VTE) is a vascular disease that manifests as DVT or pulmonary embolism (PE). Both DVT and PE can be symptomatic or asymptomatic. Newly diagnosed cases of symptomatic VTE are estimated to occur in approximately 250,000 Americans per year, and DVT accounts for approximately two thirds of these cases.2 Deep vein thrombosis most commonly appears in the lower extremity and is typically classified as being either proximal (affecting the popliteal and thigh veins) or distal (affecting the calf veins). Proximal deep vein thrombosis (PDVT) is the more dangerous form of lower-extremity DVT because it is more likely to cause life-threatening PE and may result in a greater risk of postthrombotic syndrome.3,4 Calf DVT, …

In this era of health care accountability, a need exists for a new decision-making and documentation guide in physical therapy. The original Hypothesis-Oriented Algorithm for Clinicians (HOAC) provided clinicians and students with a framework for science-based clinical practice and focused on the remediation of functional deficits and how changes in impairments related to these deficits. The HOAC II was designed to address shortcomings in the original HOAC and be more compatible with contemporary practice, including the Guide to Physical Therapist Practice. Disablement terminology is used in the HOAC II to guide clinicians and students when documenting patient care and incorporating evidence into practice. The HOAC II, like the HOAC, can be applied to a patient regardless of age or disorder and allows for identification of problems by physical therapists when patients are not able to communicate their problems. A feature of the HOAC II that was lacking in the original algorithm is the concept of prevention and how to justify and document interventions directed at prevention.

Background and Purpose. The HOAC II is a patient management algorithm designed, in part, to provide a conceptual framework for patient management for any type of patient seen by physical therapists. This case report illustrates how the HOAC II can be used in clinical practice. Case Description. The patient was a 47-year-old woman with low back pain. The report describes the patient's examination, evaluation, diagnosis, prognosis, intervention, and outcomes within the context of the HOAC II. Outcome. The patient had measurable improvements in impairments, functional limitation, and disability following an intervention designed to resolve her impairments and functional limitations. Discussion. This case report illustrates how the HOAC II can be used to assist in the management of a patient from admission to discharge. The report also demonstrates how use of a disablement model can add clarity to patient care.

We were interested to read the article by Gabel and colleagues,1 who conducted a head-to-head comparison study of the psychometric properties of the Lower Extremity Functional Scale (LEFS),2 an instrument we developed in 1999, and the Lower Limb Functional Index (LLFI), an instrument developed by the authors. We have long been advocates of head-to-head comparisons of competing instruments to determine which has the greatest potential to positively affect clinical care.3 We would like to make some general comments regarding the conceptual framework, and then make more specific comments regarding the methods and literature interpretation in Gabel and colleagues' article. We developed the LEFS2 based on the World Health Organization's model of disability and handicap.4 The more contemporary terms consistent with the current version of the International Classification of Functioning, Disability and Health (ICF)5 that guided instrument development are “activity limitations” and “participation restrictions.” Because our focus was on people with musculoskeletal disorders of the lower extremity, all of the items in our scale captured the person-level activity limitations and participation restrictions most relevant to people with disorders of the lower extremity. Notably absent from the LEFS are questions related to impairments (eg, pain, joint stiffness) or mental health status (eg, irritability, depression). Our rationale for this approach was that we saw problems with other functional status instruments available at the time because they combined questions related to impairments, such as pain and joint stiffness, with items dealing with person-level function and items related to psychological distress. An example of …

Background and Purpose. The authors examined the intertester reliability of assessments made based on a composite of 4 tests of pelvic symmetry or sacroiliac joint (SIJ) movement that are advocated in the literature for identifying people with SIJ region dysfunction. “Sacroiliac joint region dysfunction” is a term used to describe pain in or around the region of the joint that is presumed to be due to malalignment or abnormal movement of the SIJs. Subjects. Sixty-five patients with low back pain and unilateral buttock pain were seen in 1 of 11 outpatient clinics. Methods. Thirty-four therapists, randomly paired for each subject, served as examiners. Kappa coefficients and observed proportions of positive (Ppos) and negative (Pneg) agreement were calculated to estimate reliability. Results. For the composite test results, percentages of agreement ranged from 60% to 69%, kappa coefficients varied from .11 to .23, and Ppos was lower than 50%. Discussion and Conclusion. Reliability of measurements obtained with the 4 tests appears to be too low for clinical use. Given the measurement error found in this study, the authors suspect it is likely that either the proper treatment technique will not be chosen based on the test results or the intervention will be applied to the wrong side. The 4 tests probably should not be used to examine patients suspected of having SIJ region dysfunction, although the role of therapist training in use of the procedures is unclear.

Letter to the Editor: There is much more research that describes the measurement properties of evaluative measures such as the Roland-Morris (RM) scale1 today than there was a decade ago. The greater volume of studies provides more data that can be used to shape clinical decisions. This increased amount of research also increases the chance that the results of some studies, at times, may conflict with results of other studies. As the number of studies on a particular issue grows, the potential for conflicting results increases. The study of Davidson and Keating2 seems to be an illustration of this phenomenon. Davidson and Keating2 examined the reliability and responsiveness of 5 functional status questionnaires designed for patients with low back pain (LBP). One of the scales examined was the RM scale, a questionnaire that has been studied extensively by our group and many others. Davidson and Keating found that the reliability of RM scale measurements was low, with an intraclass correlation coefficient (ICC [2,1]) of .53 (95% confidence interval [CI]=.29,.71) for a sample of 47 patients with LBP who reported that their LBP was “about the same,” “a little better,” or “a little worse.” For a smaller subgroup that reported their LBP was “about the same,” the ICC (2,1) was lower at .42 (95% CI=−;.07, .75). Based in part on these findings, the authors concluded that the RM scale “appeared to lack sufficient reliability and scale width for clinical application.”2(p8) In our opinion, these results are dramatically different from the large volume of evidence reported in the literature on the reliability of RM scale scores (Table).1,2,6–17 The evidence summarized in the Table was collected on diverse samples of patients from different countries with many different LBP diagnoses. Davidson and …

Although some people in the medical community accept the premise that the sacroiliac joint (SIJ) can be a source of pain secondary to pathology (eg, spondyloarthropathy, infection, malignancy, fracture),1 whether SIJ dysfunction exists remains controversial. “Sacroiliac joint dysfunction” is a term often used to describe pain in or around the region of the joint that is presumed to be due to biomechanical disorders of the joint (eg, hypomobility, malalignment, fixation, subluxation).2,3 Some people consider the term “SIJ dysfunction” to be a misnomer because it is difficult to determine whether the joint itself is the source of the pain.4,5 Due to the anatomy and location of the SIJ, examination procedures presumed to test the joint may test other structures in the region. Others dismiss the SIJ as a source of pain because well-recognized pain-sensitive structures, such as the posterior facet joints and nerve roots, may refer pain to the SIJ region.5,6 Still other investigators have reported that 22%7 to 30%8 of subjects with pain around the SIJ region experienced some relief following anesthetic injection of the joint. Pain relief following anesthetic injection, however, does not necessarily indicate dysfunction of the joint. Structures unrelated to the joint, but in the same region, may be affected due to infiltration of anesthetic to soft tissues beyond the SIJ.9 Despite the controversy and differing views on the sources of pain in the SIJ region, we believe many therapists commonly examine some of their patients for the presence of what they call “SIJ dysfunction.” Battie and colleagues,10 for example, surveyed 186 Washington State therapists about the care of patients with low back pain (LBP) and found that 75% of the therapists would use screening procedures they believed tested SIJ function. A variety …

Background and Purpose. Physical therapists routinely assess spinal active range of motion (AROM) in patients with low back pain (LBP). The purpose of this study was to use 2 approaches to examine the relationship between impairment of lumbar spine flexion AROM and disability. One approach relied on the use of normative data to determine when an impairment in flexion AROM was present. The other approach required therapists to make judgments of whether the flexion AROM impairment was relevant to the patient's disability. Subjects. Fifteen physical therapists and 81 patients with LBP completed in the study. Methods. Patients completed the Roland-Morris Back Pain Questionnaire (RMQ), and the therapists assessed lumbar spine flexion AROM using a dual-inclinometer technique at the initial visit and again at discharge. Results. Correlations between the lumbar flexion AROM measure and disability were low and did not vary appreciably for the 2 approaches tested. Conclusion and Discussion. Measures of lumbar flexion AROM should not be used as surrogate measures of disability. Lumbar spine flexion AROM and disability are weakly correlated, suggesting that flexion AROM measures should not be used as treatment goals.

Background and Purpose. Previous research suggests that visual estimates of sacroiliac joint (SIJ) alignment are unreliable. The purpose of this study was to determine whether handheld calipers and an inclinometer could be used to obtain reliable measurements of SIJ alignment in subjects suspected of having SIJ dysfunction. Subjects. Seventy-three subjects, evaluated at 1 of 5 outpatient clinics, participated in the study. Methods. A total of 23 therapists, randomly paired for each subject, served as examiners. The angle of inclination of each innominate was measured while the subject was standing. The position of the innominates relative to each other was then derived. An intraclass correlation coefficient (ICC), the standard error of measurement (SEM), and a kappa coefficient were calculated to examine the reliability of the derived measurements. Results. The ICC was .27, the SEM was 5.4 degrees, and the kappa value was .18. Conclusion and Discussion. Measurements of SIJ alignment were unreliable. Therapists should consider procedures other than those that assess SIJ alignment when evaluating the SIJ.

Physical therapists routinely make diagnostic and prognostic decisions in the course of patient care. The purpose of this clinical perspective is to illustrate what we believe is the optimal method for interpreting the results of studies that describe the diagnostic or prognostic accuracy of examination procedures. To illustrate our points, we chose the Berg Balance Test as an exemplar measure. We combined the data from 2 previously published research reports designed to determine the validity of the Berg Balance Test for predicting risk of falls among elderly people. We calculated the most common validity indexes, including sensitivity, specificity, predictive values, and likelihood ratios for the combined data. Clinical scenarios were used to demonstrate how we believe these validity indexes should be used to guide clinical decisions. We believe therapists should use validity indexes to decrease the uncertainty associated with diagnostic and prognostic decisions. More studies of the accuracy of diagnostic and prognostic tests used by physical therapists are urgently needed.

Background and Purpose. One purpose of this study was to determine whether the Roland-Morris Back Pain Questionnaire (RMQ) could be used to detect clinically meaningful change in individual patients. The construct that served as the basis for this study was that RMQ change scores should be greater for patients meeting their treatment goals than for patients who did not meet their goals. The second purpose of the study was to determine whether sensitivity to change (STC) varies depending on the magnitude of the initial RMQ score. Subjects and Methods. Of the 143 patients with low back pain who completed the study, 104 patients achieved their goals and 39 patients did not achieve their goals. Receiver operating characteristic (ROC) curve analysis and likelihood ratios were used to determine the RMQ change scores that best classify patients as having met or not met their goals. Results. The area under the ROC curve for the entire RMQ scale was 0.68, while the curve areas for smaller RMQ intervals varied from 0.80 to 0.97. Conclusion and Discussion. The STC for the entire RMQ scale was poor for the construct examined in this study. The likelihood ratios for smaller RMQ intervals support the construct validity of the RMQ for assessing change in disability. Initial RMQ score magnitudes must be taken into account to improve the rate of making correct predictions about whether meaningful change in disability will occur following treatment.

Classification systems for patients with low back pain have become more abundant in the literature since the mid-1980s. Some classification systems are designed to determine the most appropriate treatment, some are designed to aid in prognosis, and others are designed to identify pathology. Still other classification systems categorize patients into homogeneous groups based on selected variables. The purpose of this review is to describe and critically evaluate low back pain classification systems. Several classification systems were summarized and examined. Four classification systems that were judged to be the most commonly cited and most relevant to physical therapists were critiqued using a more thorough systematic approach. The analysis suggests that future research should address the usefulness of existing classification systems as well as the development of new classification systems designed using commonly accepted measurement principles.

Background and Purpose. The purposes of this study were (1) to assess the construct validity of the Shoulder Pain and Disability Index (SPADI) and (2) to determine whether the SPADI is more responsive than the Sickness Impact Profile (SIP), a generic health status measure. Subjects. The sample consisted of 94 patients who were diagnosed with a shoulder problem and referred to six outpatient physical therapy clinics. Methods. Clinically meaningful change was determined by use of an ordinal rating scale designed to determine whether the patient's shoulder function was improved, the same, or worse following treatment. Spearman rho correlations were calculated for the initial visit SPADI and SIP scores. The standardized response mean (SRM) was used to measure responsiveness for the patients who were judged to be improved. One-tailed paired t tests (α=.01) were used to determine whether differences existed among SRM values. Results. Correlations between the SPADI and SIP scores ranged from r =.01 to r =.57. The SRM value was higher for the SPADI total score (SRM=1.38) than for the SIP total score (SRM=0.79). Conclusion and Discussion. Most correlations between SPADI and SIP scores provided support for the construct validity of the SPADI. The SPADI does not appear to strongly reflect occupational and recreational disability and is more responsive than the SIP.

Over the last 15 years, numerous self-report health status measures have appeared in the literature. An important parallel development has been the development of numerous strategies for assessing change in health status over time. The purpose of this article is to summarize and critique the more common design and analytic strategies for assessing the meaningfulness of change over time. Five commonly reported designs are presented, critiqued, and depicted using examples from the literature. Methods for analyzing results are reviewed and illustrated using two data sets. Insights into comparing competing health status measures are provided. In summary, the article suggests that some designs and analytic strategies are more adept than others at assessing change and that these methods should be considered when planning sensitivity-to-change studies.

Background and Purpose. McKenzie described a two-step process for assessing patients with low back pain for a lateral shift. The purpose of this study was to determine whether reliable judgments about lateral shifts could be obtained. Subjects. Forty-nine patients with low back pain were each examined separately by two randomly paired physical therapists. Methods. Assessments of the presence and direction of lateral shifts (step 1) were obtained by use of a simple instrument. The relevance of the lateral shifts to the patients' pain complaints (step 1) also was assessed by use of the side-glide test sequence. Results. Generalized kappa coefficients were calculated to determine reliability. The kappa value for the two-step process of lateral shift assessment was .16. The percentage of agreement was 47%. Conclusion and Discussion. Each step in this two-step process was examined separately for possible sources of error. The kappa value for determinations of the presence and direction of lateral shifts was .00, indicating very poor reliability. The kappa value for the determination of the presence of a positive side-glide test sequence was .74, indicating high reliability. The role of lateral shift assessment in the McKenzie system should be reconsidered, given the strong research evidence for poor reliability of determinations of the presence and direction of lateral shifts.

[ Editor's note: Both the letter to the editor by Stratford and Riddle and the response by Parrott and colleagues are commenting on the author manuscript version of the article that was published ahead of print on May 22, 2014. ] We read with great interest the study by Galantino et al1 that investigated the quality of life and self-reported lower extremity function of adults who are HIV+ and either with or without distal sensory polyneuropathy (DSP). The Medical Outcomes Study HIV Health Survey (MOS-HIV) measure was used to assess quality of life2; the Lower Extremity Functional Scale (LEFS)3 and Lower Limb Functional Index (LLFI)4 were applied to assess lower extremity functional status. One of the study's purposes was to “evaluate agreement (concordant validity) between the LEFS and LLFI in this population.”1 We were troubled by this attempted comparison for 2 reasons. First, …

Background and PurposePhysical therapists require a comprehensive assessment of a patient's functioning status to address multiple problems in patients with severe conditions. The International Classification of Functioning, Disability and Health (ICF) is the universally accepted conceptual model for the description of functioning. Documentation tools have been developed based on ICF Core Sets to be used in multidisciplinary rehabilitation management and specifically by physical therapists. The purposes of this case report are: (1) to apply ICF-based documentation tools to the care of a patient with spinal cord injury and (2) to illustrate the use of ICF-based documentation tools during multidisciplinary patient management.Case DescriptionThe patient was a 22-year-old man with tetraplegia (C2 level) who was 5 months postinjury. The report describes the integration of the ICF-based documentation tools into the patient's examination, evaluation, prognosis, diagnosis, and intervention while he participated in a multidisciplinary rehabilitation program for 2 months.OutcomesThe patient's comprehensive functioning status at the beginning of the program, the rehabilitation goals, the intervention plan, and his improvements in functioning following rehabilitation and the according goal achievement were illustrated with physical therapy–specific and multidisciplinary ICF-based documentation tools.DiscussionThis case report illustrates how the ICF-based documentation template for physical therapists summarizes all relevant information to aid the physical therapist's patient management and how ICF-based documentation tools for multidisciplinary care complement one another and thus can be used to enhance multidisciplinary patient management. In addition, the ICF assists in clarifying clinician roles as part of a multidisciplinary team. The case report demonstrates that the ICF can be a viable framework both for physical therapy and multidisciplinary management and for clinical documentation.

The term "manual therapy" has traditionally been associated with physical therapists who examine and treat patients who have disorders related to the musculoskeletal system. In addition to using instruments to collect patient data, these therapists use a large variety of manually applied examination procedures. Range-of-motion tests, manual muscle tests, neurological tests, and palpation tests are just a few of the categories of tests these therapists use as part of the clinical decision-making process. The major sources of error that can affect the usefulness of manually obtained measurements are discussed. The literature that provides the theoretical and clinical bases for the assessment of joint surface movement is thoroughly reviewed. Conclusions are made about what is currently known about the usefulness of accessory motion tests. Suggestions are made for future research needs in order to clarify and enhance the usefulness of accessory motion tests and other examination procedures used by manual therapists.

The purpose of this study was to examine the intratherapist and intertherapist reliability of measurements obtained with a modified version of the fingertip-to-floor method of assessing forward bending. With the modified fingertip-to-floor (MFTF) method, patients stand on a stool and forward bend so that measurements can be taken on patients who are able to touch the floor or reach beyond the level of the floor. Randomly paired physical therapists took repeated MFTF measurements on 73 patients with low back pain. Intraclass correlation coefficients (ICCs) were calculated for intratherapist and intertherapist reliability. The ICC value for intratherapist reliability was .98, and the ICC value for intertherapist reliability was .95. The results of this study suggest that measurements of forward bending obtained on patients with low back pain using the MFTF method are highly reliable.

Background and PurposeInformation about expected rate of change after arthroplasty is critical for making prognostic decisions related to rehabilitation. The goals of this study were: (1) to describe the pattern of change in lower-extremity functional status of patients over a 1-year period after total knee arthroplasty (TKA) and (2) to describe the effect of preoperative functional status on change over time.SubjectsEighty-four patients (44 female, 40 male) with osteoarthritis, mean age of 66 years (SD=9), participated.MethodsRepeated measurements for the Lower Extremity Functional Scale (LEFS) and the Six-Minute Walk Test (6MWT) were taken over a 1-year period. Data were plotted to examine the pattern of change over time. Different models of recovery were explored using nonlinear mixed-effects modeling that accounted for preoperative status and gender.ResultsGrowth curves were generated that depict the rate and amount of change in LEFS scores and 6MWT distances up to 1 year following TKA. The curves account for preoperative status and gender differences across participants.Discussion and ConclusionThe greatest improvement occurred in the first 12 weeks after TKA. Slower improvement continued to occur from 12 weeks to 26 weeks after TKA, and little improvement occurred beyond 26 weeks after TKA. The findings can be used by physical therapists to make prognostic judgments related to the expected rate of improvement following TKA and the total amount of improvement that may be expected.

Background and Purpose: The purpose of this study was to determine whether admissions data could be used to estimate physical therapist student risk for failing the National Physical Therapy Examination (NPTE). Subjects: A nationally representative sample of 20 physical therapist education programs provided data on 3,365 students. Methods: Programs provided data regarding demographic characteristics, undergraduate grade point average (uGPA), and quantitative and verbal Graduate Record Examination scores (qGRE, vGRE). The Federation of State Boards of Physical Therapy provided NPTE data. Data were analyzed using hierarchical logistic regression. Results: A prediction rule that included uGPA, vGRE, qGRE, and race or ethnicity was developed from the entire sample. Prediction rules for individual programs showed large variation. Discussion and Conclusion: Undergraduate grade point average, GRE scores, and race or ethnicity can be useful for estimating student risk for failing the NPTE. Programs should use GPA and GRE scores along with other data to calculate their own estimates of student risk.

The purpose of our study was to determine whether physical therapy interventions predicted meaningful short-term improvement in physical health for patients diagnosed with sciatica.We examined data from 1,804 patients (age: mean=52.1 years, SD=15.6 years; 65.7% female, 34.3% male) who had been diagnosed with sciatica and who had completed an episode of outpatient physical therapy.Principal components factor analysis was used to define intervention categories from specific treatments applied during the plan of care. A nested-model logistic regression analysis identified intervention categories that predicted meaningful improvement in physical health. Meaningful improvement was defined as a change of 14 or more points on the Physical Component Scale-12 (PCS-12) summary score.Twenty-six percent (n=473) of patients had a meaningful improvement in physical health. Improvement was more likely in patients receiving joint mobility interventions (odds ratio [OR]=2.5, 95% confidence interval [CI]=1.5-4.4) or general exercise (OR=1.5, 95% CI=1.2-2.0). Patients who received spasm reduction interventions were less likely to improve (OR=0.77, 95% CI=0.60-0.98).Physical therapists should emphasize the use of joint mobility interventions and exercise when treating patients with sciatica, whereas interventions for spasm reduction should be avoided.

Prompt identification of outpatients who may have proximal lower-extremity deep vein thrombosis (PDVT) is important, in part, because of the risk of pulmonary embolism. The purposes of our study were to determine the degree of accuracy of physical therapists' estimates of the probability of PDVT in hypothetical patient vignettes and to determine whether physical therapists would contact the referring physician about the hypothetical patients' condition as recommended in published evidence.A survey instrument consisting of 6 vignettes was sent to a nationally representative random sample of 1,500 physical therapists. The clinical decision rule developed by Wells and colleagues served as the gold standard for PDVT probability.A total of 969 (65% response rate) physical therapists completed the survey. We found no evidence of nonresponse bias. For the 2 high-probability vignettes, 87% and 64% of the physical therapists underestimated the probability of PDVT. For the 2 high-probability cases, 32% and 27% of the physical therapists reported that they would not have contacted the referring physician. For the 2 moderate-probability cases, 15% and 30% of the physical therapists would not have contacted the referring physician. Therapist experience, certification status, place of practice, and region of the country did not explain the findings.The care of outpatients who are at risk for PDVT could potentially be improved by use of the clinical decision rule developed by Wells and colleagues, although more study is warranted.

In this era of health care accountability, a need exists for a new decision-making and documentation guide in physical therapy. The original Hypothesis-Oriented Algorithm for Clinicians (HOAC) provided clinicians and students with a framework for science-based clinical practice and focused on the remediation of functional deficits and how changes in impairments related to these deficits. The HOAC II was designed to address shortcomings in the original HOAC and be more compatible with contemporary practice, including the Guide to Physical Therapist Practice. Disablement terminology is used in the HOAC II to guide clinicians and students when documenting patient care and incorporating evidence into practice. The HOAC II, like the HOAC, can be applied to a patient regardless of age or disorder and allows for identification of problems by physical therapists when patients are not able to communicate their problems. A feature of the HOAC II that was lacking in the original algorithm is the concept of prevention and how to justify and document interventions directed at prevention.

The HOAC II is a patient management algorithm designed, in part, to provide a conceptual framework for patient management for any type of patient seen by physical therapists. This case report illustrates how the HOAC II can be used in clinical practice.The patient was a 47-year-old woman with low back pain. The report describes the patient's examination, evaluation, diagnosis, prognosis, intervention, and outcomes within the context of the HOAC II.The patient had measurable improvements in impairments, functional limitation, and disability following an intervention designed to resolve her impairments and functional limitations.This case report illustrates how the HOAC II can be used to assist in the management of a patient from admission to discharge. The report also demonstrates how use of a disablement model can add clarity to patient care.

The authors examined the intertester reliability of assessments made based on a composite of 4 tests of pelvic symmetry or sacroiliac joint (SIJ) movement that are advocated in the literature for identifying people with SIJ region dysfunction. "Sacroiliac joint region dysfunction" is a term used to describe pain in or around the region of the joint that is presumed to be due to malalignment or abnormal movement of the SIJs.Sixty-five patients with low back pain and unilateral buttock pain were seen in 1 of 11 outpatient clinics.Thirty-four therapists, randomly paired for each subject, served as examiners. Kappa coefficients and observed proportions of positive (Ppos) and negative (Pneg) agreement were calculated to estimate reliability.For the composite test results, percentages of agreement ranged from 60% to 69%, kappa coefficients varied from.11 to.23, and Ppos was lower than 50%.Reliability of measurements obtained with the 4 tests appears to be too low for clinical use. Given the measurement error found in this study, the authors suspect it is likely that either the proper treatment technique will not be chosen based on the test results or the intervention will be applied to the wrong side. The 4 tests probably should not be used to examine patients suspected of having SIJ region dysfunction, although the role of therapist training in use of the procedures is unclear.

Background and Purpose. The purpose of this study was to assess the reliability, construct validity, and sensitivity to change of the Lower Extremity Functional Scale (LEFS). Subjects and Methods. The LEFS was administered to 107 patients with lower-extremity musculoskeletal dysfunction referred to 12 outpatient physical therapy clinics. Methods. The LEFS was administered during the initial assessment, 24 to 48 hours following the initial assessment, and then at weekly intervals for 4 weeks. The SF-36 (acute version) was administered during the initial assessment and at weekly intervals. A type 2,1 intraclass correlation coefficient was used to estimate test-retest reliability. Pearson correlations and one-way analyses of variance were used to examine construct validity. Spearman rank-order correlation coefficients were used to examine the relationship between an independent prognostic rating of change for each patient and change in the LEFS and SF-36 scores. Results. Test-retest reliability of the LEFS scores was excellent ( R =.94 [95% lower limit confidence interval (CI)=.89]). Correlations between the LEFS and the SF-36 physical function subscale and physical component score were r =.80 (95% lower limit CI=.73) and r =.64 (95% lower limit CI=.54), respectively. There was a higher correlation between the prognostic rating of change and the LEFS than between the prognostic rating of change and the SF-36 physical function score. The potential error associated with a score on the LEFS at a given point in time is ±5.3 scale points (90% CI), the minimal detectable change is 9 scale points (90% CI), and the minimal clinically important difference is 9 scale points (90% CI). Conclusion and Discussion. The LEFS is reliable, and construct validity was supported by comparison with the SF-36. The sensitivity to change of the LEFS was superior to that of the SF-36 in this population. The LEFS is efficient to administer and score and is applicable for research purposes and clinical decision making for individual patients.

How many times have you tried to assemble something, only to realize that, if you had read the instructions first, your job would have been so much easier? If you've ever tried to put together one of those furniture “kits” by gluing first and reading the instructions later, you know exactly what we mean. Assembling a manuscript for submission to a peer-reviewed scientific journal also requires a step-by-step process. And, like those furniture kits, if the instructions aren't followed, the final product might not turn out quite as expected. All journals provide authors with guidance on expectations regarding the format and content of submissions, usually through explicit instructions to authors. Some journals provide extensive guidance; others provide instructions that are quite brief. In an ideal world of peer review, all journals would agree on the best way to present (and analyze) research, so that authors could use the same set of guidelines to submit to all journals. In reality, of course, there is no consensus on the “one best way.” Each journal has to emphasize different criteria to meet its own unique mission. Schriger …

Background and Purpose. This study estimated the Roland-Morris Back Pain Questionnaire's (RMQ) change score that best classified patients as those who had achieved an important change and those who had not achieved an important change. The study also investigated whether the estimate of change was dependent on patients' initial scores. Subjects and Methods. The RMQ was administered to 226 patients with low back pain of less than 6 weeks' duration during their initial visit for physical therapy and following 3 to 6 weeks of treatment. A global rating of change was used to classify patients as those who had changed an important amount and those who had not changed. Receiver operating characteristic curves were used to identify the RMQ change score that most accurately classified patients with respect to important change. This analysis was repeated for 5 overlapping subsamples of patients with initial scores 0 to 8, 5 to 12, 9 to 16, 13 to 20, and 17 to 24. Results. The area under the receiver operating characteristic curves increased when patients' initial scores were taken into account. Estimates of important change were 2, 4, 5, 8, and 8 for the initial score intervals mentioned above. Conclusion and Discussion. Important change appears to be dependent on patients' initial RMQ scores. Subsequent inquiry using different hypotheses would add support to the estimates of important change found in this study. [ ARTICLE][1] [1]: /lookup/volpage/78/1197?iss=11