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Objective. The aims of this scoping review were to summarize the evidence regarding sex, racial, ethnic, geographic, and socioeconomic disparities in post-acute rehabilitation following total hip arthroplasty (THA) and knee arthroplasty (TKA). Methods. Literature searches were conducted in Ovid MEDLINE, EMBASE, CINAHL, Web of Science, and PEDro. Studies were included if they were original research articles published 1993 or later; used data from the US; included patients after THA and/or TKA; presented results according to relevant sociodemographic variables, including sex, race, ethnicity, geography, or socioeconomic status; and studied the utilization of post-acute rehabilitation as an outcome. Results. Twelve studies met the inclusion criteria. Five examined disparities in inpatient rehabilitation and found that Black patients and women experience longer lengths of stay after arthroplasty, and women are less likely than men to be discharged home after inpatient THA rehabilitation. Four studies examined data from skilled nursing facilities and found that insurance type and dual eligibility impact length of stay and rates of community discharge but found conflicting results regarding racial disparities in skilled nursing facility utilization after TKA. Five studies examined home health data and noted that rural agencies provide less care after TKA. Results regarding racial disparities in home health utilization after arthroplasty were conflicting. Six studies of outpatient rehabilitation noted geographic differences in timing of outpatient rehabilitation but mixed results regarding race differences in outpatient rehabilitation. Conclusion. Current evidence indicates that sex, race, ethnicity, geography, and socioeconomic status are associated with disparities in postacute rehabilitation use after arthroplasty. Impact. Rehabilitation providers across the postacute continuum should be aware of disparities in the population of patients after arthroplasty and regularly assess social determinants of health and other factors that may contribute to disparities. Customized care plans should ensure optimal timing and amount of rehabilitation is provided, and advocate for patients who need additional care to achieve the desired functional outcome. Keywords: Arthroplasty, Orthopedics, Rehabilitation, Introduction Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are among the most common surgeries in the US, with more than one million performed annually. (1) THA and TKA [...]

Objective. The aim of this study was to explore associations between the utilization of active, passive, and manual therapy interventions for low back pain (LBP) with 1-year escalation-of-care events, including opioid prescriptions, spinal injections, specialty care visits, and hospitalizations. Methods. This was a retrospective cohort study of 4827 patients identified via the Military Health System Data Repository who received physical therapist care for LBP in 4 outpatient clinics between January 1, 2015 and January 1, 2018. One-year escalation-of-care events were evaluated based on type of physical therapist interventions (ie, active, passive, or manual therapy) received using adjusted odds ratios. Results. Most patients (89.9%) received active interventions. Patients with 10% higher proportion of visits that included at least 1 passive intervention had a 3% to 6% higher likelihood of 1-year escalation-of-care events. Similarly, with 10% higher proportion of passive to active interventions used during the course of care, there was a 5% to 11% higher likelihood of 1-year escalation-of-care events. When compared to patients who received active interventions only, the likelihood of incurring 1-year escalation-of-care events was 50% to 220% higher for those who received mechanical traction and 2 or more different passive interventions, but lower by 50% for patients who received manual therapy. Conclusion. Greater use of passive interventions for LBP was associated with elevated odds of 1-year escalation-of-care events. In addition, the use of specific passive interventions such as mechanical traction in conjunction with active interventions resulted in suboptimal escalation-of-care events, while the use of manual therapy was associated with more favorable downstream health care outcomes. Impact. Physical therapists should be judicious in the use of passive interventions for the management of LBP as they are associated with greater likelihood of receiving opioid prescriptions, spinal injections, and specialty care visits. Keywords: Electric Stimulation Therapy, Exercise, Hot/Cold Pack, Low Back Pain, Manual Therapy, Needle Therapy, Traction, Introduction Low back pain (LBP) is one of the leading causes of disability in the USA. (1, 2) The prevalence of LBP has continued to increase each year, as has [...]

Objective. The purpose of this study was to establish the psychometric properties of the 9-Item Vestibular Activities Avoidance Instrument (VAAI-9), a patient-reported outcome measure developed to identify fear avoidance beliefs in persons with vestibular disorders. Methods. This prospective cohort study included 100 participants 18 years and older seeking care at a balance disorders clinic for dizziness. Participants completed the VAAI-9, the Dizziness Handicap Inventory (DHI), and other patient-reported outcomes at the initial visit and the 3-month follow-up. To measure test-retest reliability, the VAAI-9 was completed again 5 days after the initial visit and was analyzed using a 2-way mixed ICC for absolute agreement. Internal consistency was determined using the Cronbach alpha. The Spearman correlation coefficient was used to assess convergent validity of the VAAI-9 with other outcomes. Receiver operating characteristic curves were used to identify baseline VAAI-9 cutoff scores for those who reported mild (DHI 30) perceived disability at the 3-month follow-up. Results. The mean age of the study cohort was 49 (SD=16) years; 73 (73%) were women. Seventy-one participants completed the 5-day follow-up, and 68 completed the 3-month follow-up. The VAAI-9 demonstrated excellent internal consistency ([alpha] = 0.91) and test-retest reliability (ICC = 0.90). Baseline VAAI-9 scores had moderate to strong associations with other outcome measures at baseline and 3 months. A baseline VAAI-9 score of 26 or higher had a sensitivity of 80.6% and a specificity of 78.4% for identifying a DHI score of >30 at 3 months (area under the curve = 0.86). Conclusions. The results provide evidence of excellent reliability and validity for the 9-item VAAI in persons with vestibular disorders. A baseline VAAI-9 score of [greater than or equal to]26 identified individuals at risk of persistent moderate to severe disability due to dizziness. Impact. Initial levels of fear avoidance beliefs measured using the VAAI-9 provided important prognostic information about outcomes for persons with vestibular symptoms. Keywords: Balance, Dizziness, Measurement: Applied, Outcome Assessment (Health Care), Predictive Value of Tests, ROC Curve, Sensitivity and Specificity, Vertigo, Vestibular Diseases, Introduction Fear-related beliefs and behaviors can impact rehabilitation outcomes and prognosis in populations with orthopedic, neurologic, and other disorders. (1-5) For example, fear of falling impacts quality of life and [...]

Objective. Costs associated with low back pain (LBP) continue to rise. Despite numerous clinical practice guidelines, the evaluation and treatments for LBP are variable and largely depend on the individual provider. As yet, little attention has been given to the first choice of provider. Early research indicates that the choice of first provider and the timing of interventions for LBP appear to influence utilization. We sought to examine the association between the first provider seen and health care utilization. Methods. Using 2015-2018 data from a large insurer, this retrospective analysis focused on patients (29,806) seeking care for a new episode of LBP. The study identified the first provider chosen and examined the following year of medical utilization. Cox proportional hazards models were calculated using inverse probability weighting on propensity scores to evaluate the time to event and the relationship to the first choice of provider. Results. The primary outcome was the timing and use of health care resources. Total health care use was lowest in those who first sought care with chiropractic care or physical therapy. Highest health care use was seen in those patients who chose the emergency department. Conclusion. Overall, there appears to be an association between the first choice of provider and future health care use. Chiropractic care and physical therapy provide nonpharmacologic and nonsurgical, guideline-based interventions. The use of physical therapists and chiropractors as entry points into the health system appears related to a decrease in immediate and long-term use of health resources. This study expands the existing body of literature and provides a compelling case for the influence of the first provider on an acute episode of LBP. Impact. The first provider seen for an acute episode of LBP influences immediate treatment decisions, the trajectory of a specific patient episode, and future health care choices in the management of LBP. Keywords: Economics, Health Care Costs, Low Back Pain, Quality Assurance: Health Care, Utiilzation Review, Introduction In 2012, 126.6 million US adults (54%) reported the presence of a musculoskeletal condition. The most frequent complaint was low back pain (LBP). LBP accounts for 2.5% to 3.0% [...]

Keywords: Implementation of Evidence Based Practice, Value-Based Care, I enjoyed Dr George's recent PTJ editorial titled, "The Tension Not Mentioned: When Clinical Research Favors Internal Over External Validity." (1) Certainly, we can all agree on the utility of [...]

Objective. The purpose of this study was to determine the association between fear-avoidance beliefs and disability in 3 months in people with vestibular disorders while accounting for demographic and clinical characteristics. Methods. This prospective cohort study included people aged 18 to 100 years who reported dizziness. Participants were recruited from a balance disorders clinic and outpatient physical therapy clinics. All participants completed the Vestibular Activities Avoidance Instrument (VAAI) and the Hospital Anxiety and Depression Scale at baseline and the Vestibular Activities and Participation measure (VAP), dizziness Visual Analogue Scale (VAS), and 12-item Short Form Health Questionnaire at baseline and 3-month follow-up. A modified version of the VAAI included 9 items abstracted from the 81-item VAAI. The relationships between 9-item VAAI scores and follow-up measures of disability were assessed using Spearman correlation coefficients. Linear regression models were analyzed to determine the effect of fear-avoidance beliefs on follow-up VAP score while accounting for baseline outcome measures. Results. All participants (n = 404) completed the baseline assessment (mean age =54 years), and 286 (71%) completed the 3-month assessment. The mean 9-item VAAI score was 25 (SD = 14) at baseline and was significantly associated with VAP ([rho] =0.54), 12-item Short Form Health Questionnaire component scores ([rho] = -0.53; -0.44), and dizziness VAS at followup ([rho] = 0.37). Approximately 38% of the variation in VAP score at follow-up was predicted by age, number of medications, 9-item VAAI score, dizziness VAS, and Hospital Anxiety and Depression Scale-depression score when considered together ([R.sup.2] =0.38). Conclusion. Fear-avoidance beliefs are associated with measures of disability at 3 months and are predictive of activity limitations and participation restrictions at 3 months when controlling for age, medications, baseline dizziness, and depression symptom severity in people with vestibular disorders. Impact. Measurement of fear-avoidance beliefs may provide important prognostic information, suggesting that an assessment of fear-avoidance beliefs could be used by clinicians to identify individuals at greater risk of disability after a vestibular disorder. Lay Summary. Fear-avoidance beliefs in people who have vestibular disorders are associated with disability at 3 months and predict limitations in daily activities at 3 months. Keywords: Avoidance Behavior, Dizziness, Vertigo, Vestibular Rehabilitation, Introduction Fear avoidance is a behavioral response characterized by the avoidance of activities or movement due to fear. (1) Fear of bodily sensations has been associated with chronic dizziness among [...]

We present the movement control approach as part of the treatment-based classification system. This approach proposes a movement control schema that clarifies that movement control is a product of the interplay among multiple biopsychosocial components. The schema illustrates that for movement to occur in a dynamically controlled fashion, the lumbar spine requires both local mobility and global stability. Local mobility means that the lumbar spine and its adjacent regions possess adequate nerve and joint(s) mobility and soft tissue compliance (ie, the malleability of tissue to undergo elastic deformation). Global stability means that the muscles of the lumbar spine and its adjacent regions can generate activation that is coordinated with various joint movements and incorporated into activities of daily living. Local mobility and global stability are housed within the bio-behavioral and socio-occupational factors that should be addressed during movement rehabilitation. This schema is converted into a practical physical examination to help the rehabilitation provider to construct a clinical rationale as to why the movement impairments) exist. The examination findings are used to guide treatment. We suggest a treatment prioritization that aims to consecutively address neural sensitivity, joint(s) and soft tissue mobility, motor control, and endurance. This prioritization enables rehabilitation providers to better plan the intervention according to each patient's needs. We emphasize that treatment for patients with low back pain is not a static process. Rather, the treatment is a fluid process that changes as the clinical status of the patient changes. This movement control approach is based on clinical experience and indirect evidence; further research is needed to support its clinical utility., The American Physical Therapy Association (APTA) has stated that the role of the physical therapy profession is to transform society through optimizing movement. Optimized movement is a product of the [...]

The treatment-based classification (TBC) system for the treatment of patients with low back pain (LBP) has been in use by clinicians since 1995. This perspective article describes how the TBC was updated by maintaining its strengths, addressing its limitations, and incorporating recent research developments. The current update of the TBC has 2 levels of triage: (1) the level of the first-contact health care provider and (2) the level of the rehabilitation provider. At the level of first-contact health care provider, the purpose of the triage is to determine whether the patient is an appropriate candidate for rehabilitation, either by ruling out serious pathologies and serious comorbidities or by determining whether the patient is appropriate for self-care management. At the level of the rehabilitation provider, the purpose of the triage is to determine the most appropriate rehabilitation approach given the patient's clinical presentation. Three rehabilitation approaches are described. A symptom modulation approach is described for patients with a recent--new or recurrent--LBP episode that has caused significant symptomatic features. A movement control approach is described for patients with moderate pain and disability status. A function optimization approach is described for patients with low pain and disability status. This perspective article emphasizes that psychological and comorbid status should be assessed and addressed in each patient. This updated TBC is linked to the American Physical Therapy Association's clinical practice guidelines for low back pain., Despite the plethora of research on low back pain (LBP), clinical trials have not provided conclusive evidence supporting the superiority of any particular intervention. (1,2) This gap is often attributed [...]

Background and Purpose. Our nation's suboptimal health care quality and unsustainable costs can be linked to the failure to implement evidence-based interventions. Implementation is the bridge between the decision to adopt a strategy and its sustained use in practice. The purpose of this case report is threefold: (1) to outline the historical implementation of an evidence-based quality improvement project, (2) to describe the program's future direction using a systems perspective to identify implementation barriers, and (3) to provide implications for the profession as it works toward closing the evidence-to-practice gap. Case Description. The University of Pittsburgh Medical Center (UPMC) Centers for Rehab Services is a large, multicenter physical therapy organization. In 2005, they implemented a Low Back Initiative utilizing evidence-based protocols to guide clinical decision making. Outcomes. The initial implementation strategy used a multifaceted approach. Formative evaluations were used repeatedly to identify barriers to implementation. Barriers may exist outside the organization, they can be created internally, they may result from personnel, or they may be a direct function of the research evidence. Since the program launch, 3 distinct improvement cycles have been utilized to address identified implementation barriers. Discussion. Implementation is an iterative process requiring evaluation, measurement, and refinement. During this period, behavior change is actualized as clinicians become increasingly proficient and committed to their use of new evidence. Successfully incorporating evidence into routine practice requires a systems perspective to account for the complexity of the clinical setting. The value the profession provides can be enhanced by improving the implementation of evidence-based strategies. Achieving this outcome will require a concerted effort in all areas of the profession. New skills will be needed by leaders, researchers, managers, and clinicians., Improved health care value is a central theme of current reform efforts. The focus on value stems from our nation's well-chronicled problems of unwarranted clinical variation, substandard quality of care, [...]

Improving health care in our country requires simultaneous pursuit of 3 aims: improving the effectiveness of care, improving the health of our population, and reducing the per capita costs of [...]

Background. Based on changes in core physical therapy documents and problems with the earlier version, the Physical Therapist Clinical Performance Instrument (PT CPI): Version 1997 was revised to create the PT CPI: Version 2006. Objective. The purpose of this study was to validate the PT CPI: Version 2006 for use with physical therapist students as a measure of clinical performance. Design. This was a combined cross-sectional and prospective study. Methods. A convenience sample of physical therapist students from the United States and Canada participated in this study. The PT CPI: Version 2006 was used to collect CPI item-level data from the clinical instructor about student performance at midterm and final evaluation periods in the clinical internship. Midterm evaluation data were collected from 196 students, and final evaluation data were collected from 171 students. The students who participated in the study had a mean age of 24.8 years (SD = 2.3, range = 21-41). Sixty-seven percent of the participants were from programs in the United States, and 33% were from Canada. Results. The PT CPI: Version 2006 demonstrated good internal consistency, and factor analysis with varimax rotation produced a 3-factor solution explaining 94% of the variance. Construct validity was supported by differences in CPI item scores between students on early compared with final clinical experiences. Validity also was supported by significant score changes from midterm to final evaluations for students on both early and final internships and by fair to moderate correlations between prior clinical experience and remaining course work. Limitations. This study did not examine rater reliability. Conclusion. The results support the PT CPI: Version 2006 as a valid measure of physical therapist student clinical performance., In December 1997, the Physical Therapist Clinical Performance Instrument (PT CPI): Version 1997 was adopted by the American Physical Therapy Association (APTA) Board of Directors for voluntary use as an [...]

The American Physical Therapy Association (APTA) provided funding for a series of meetings among a small group of leaders representing the research and clinical communities whose task was to plan [...]

As the biopsychosocial model of health has become increasingly understood, it has become clear that there are complex, interdependent relationships between the physical and biomedical features of low back pain and the psychological and social factors that present concomitantly. Epidemiological studies have not only highlighted that psychological and social factors are associated with back pain and disability but also have shed light on the way in which these factors serve as prognostic indicators, or obstacles to recovery, predicting which patients will have a poor prognosis. Integrating the assessment of these obstacles to recovery into physical therapist practice and using this information to guide clinical decision making have the potential to improve the quality of care offered by physical therapists by improving the targeting of treatments to individuals and enhancing the therapist-patient relationship and adherence to management advice and treatment programs. In turn, such approaches may improve both patients' clinical outcomes and the efficiency and effectiveness of service provision, helping direct interventions to those who need them. This article summarizes the key challenges to embedding psychosocial perspectives within physical therapist practice for patients with low back pain and the opportunities that could be realized by doing so, and it highlights new developments in research, clinical practice, and education that are shaping future directions in this field., Given that there is some evidence of benefit for interventions that physical therapists traditionally provide for patients with low back pain, one may question the added benefit of incorporating psychosocial [...]

Dramatic changes in the health care landscape over the next few decades undoubtedly will affect rehabilitation specialists' practice. In the multidisciplinary field of regenerative medicine, cell, tissue, or organ substitutes are used to enhance the healing potential of the body. Given that the restoration of normal functioning of injured or diseased tissues is expected to be the ultimate goal of these therapies, the future of regenerative medicine is, undeniably, tightly intertwined with that of rehabilitation. Rehabilitation specialists not only must be aware of cutting-edge medical advances as they relate to regenerative medicine but also must work closely with basic scientists to guide the development of clinically relevant protocols. The purposes of this article are to provide a current perspective on biological approaches to the management of musculoskeletal disorders and to highlight the needed integration of physical therapeutics with regenerative medicine., Physical rehabilitation optimizes the quality of life for people with limitations imposed by functional loss resulting from disease or trauma. The practice of physical therapy has continued to change as [...]

Background and Purpose People with acute low back injury and fear-avoidance beliefs are at risk for remaining off work for an extended period of time. However, the effectiveness of intervention strategies for improving return-to-work status in people with acute low back pain and fear-avoidance beliefs has not been reported. The objective of this study was to determine whether education and counseling on pain management, physical activity, and exercise could significantly decrease the number of days that people with low back injury are off work. Subjects Thirty-four people who were unable to return to work following a work-related episode of low back pain and who exhibited fear-avoidance beliefs participated in this study. Methods Participants who scored 50 points or higher on the Fear-Avoidance Beliefs Questionnaire were alternately assigned to an education group or a comparison group. Both groups received conventional physical therapy intervention. Participants in the education group were given education and counseling on pain management tactics and the value of physical activity and exercise. The effectiveness of the interventions was measured by the number of days before people returned to work without restrictions. Results All participants in the education group returned to regular work duties within 45 days. One third of the participants in the comparison group remained off work at 45 days. There was a statistically significant difference between the groups with regard to the number of days before returning to work. Discussion and Conclusion Education and counseling regarding pain management, physical activity, and exercise can reduce the number of days off work in people with fear-avoidance beliefs and acute low back pain., Low back pain (LBP) claims represent the largest category of workers' compensation claims, (1) and 7% of the total cases of LBP account for 70% of all compensation costs. (2) [...]

Background and Purpose Graduates of physical therapist education programs should be expected to function as competent clinicians. Instead, the benchmark for many clinical performance assessment tools has been 'as good as an entry-level graduate.' The authors developed the Clinical Internship Evaluation Tool (CIET), which measures clinical performance of the student relative to a 'competent clinician.' The purpose of this study was to provide evidence for validity of the tool. Subjects and Methods The CIET was used to evaluate physical therapist student clinical performance from 1999 to 2003. Data from 228 student evaluations, a survey of 26 clinical instructors (CIs), and an item review by 7 faculty members were used to collect validity evidence. The relevance of items on the CIET was examined by the survey and the item review. Coefficient alpha was calculated to estimate internal consistency among the items. A Spearman correlation was used to examine the relationship between 2 measures of clinical competence. A repeated-measures analysis of variance (ANOVA) compared the student scores at each clinical time frame to confirm expected improvements in performance longitudinally. Evidence for practicality was collected by the CI survey. Results Based on the faculty item review and the CI survey, all items were representative of skills and behaviors considered important for a clinically competent physical therapist. The internal consistency (alpha) was .98 for the patient management items. The average correlation of the 2 measures of clinical competence was .76. The repeated-measures ANOVA was significant and demonstrated improved patient management scores as the student progressed through the program. The CI survey results indicated that 96% of respondents agreed or strongly agreed that the instrument was short and easy to use. Discussion and Conclusion The results of the study suggest that the CIET is representative of skills and behaviors necessary for students to perform at the level of a competent therapist and that the instrument is practical to use for busy clinicians. The CIET appears to be a valid tool for measuring student clinical performance and can be a time-efficient alternative for CIs in today's demanding clinical environment., Tools used to evaluate student clinical performance should allow for comparison of student competence against predetermined standards of practice. Standards of practice in other professions include broad, authoritative statements that [...]

Background and Purpose. Treatment-based classification (TBC) provides matched interventions for patients with acute low back pain (LBP) through key history and clinical findings. This study investigated the discriminant validity of [...]

Background: Conflicting evidence exists about the effectiveness of spinal manipulation. Objective: To validate a manipulation clinical prediction rule. Design: Multicenter randomized, controlled trial. Setting: Physical therapy clinics. Patients: 131 consecutive patients with low back pain, 18 to 60 years of age, who were referred to physical therapy. Intervention: Patients were randomly assigned to receive manipulation plus exercise or exercise alone by a physical therapist for 4 weeks. Measurements: Patients were examined according to the clinical prediction rule criteria (symptom duration, symptom location, fear-avoidance beliefs, lumbar mobility, and hip rotation range of motion). Disability and pain at 1 and 4 weeks and 6 months were assessed. Results: Outcome from spinal manipulation depends on a patient's status on the prediction rule. Treatment effects are greatest for the subgroup of patients who were positive on the rule (at least 4 of 5 criteria met); health care utilization among this subgroup was decreased at 6 months. Compared with patients who were negative on the rule and received exercise, the odds of a successful outcome among patients who were positive on the rule and received manipulation were 60.8 (95% CI, 5.2 to 704.7). The odds were 2.4 (CI, 0.83 to 6.9) among patients who were negative on the rule and received manipulation and 1.0 (CI, 0.28 to 3.6) among patients who were positive on the rule and received exercise. A patient who was positive on the rule and received manipulation has a 92% chance of a successful outcome, with an associated number needed to treat for benefit at 4 weeks of 1.9 (CI, 1.4 to 3.5). Limitations: The response rate for the 6-month follow-up resulted in inadequate power to detect statistically significant differences for some comparisons. Conclusions: The spinal manipulation clinical prediction rule can be used to improve decision making for patients with low back pain.

Background and Purpose. The purpose of this study was to examine whether there is evidence to support 2 elements of the passive-range-of-motion (PROM) portion of Cyriax's selective tissue tension scheme for patients with knee dysfunction: a capsular pattern of motion restriction and the pain-resistance sequence. Subjects. One hundred fifty-two subjects with unilateral knee dysfunction participated. The subjects had a mean age of 40.0 years (SD=15.9, range=13-82). Methods. Passive range of motion of the knee and the relationship between the onset of pain and resistance to PROM (pain-resistance sequence) were measured, and 4 tests for inflammation were used. Interrater reliability was assessed on 35 subjects. Results. Kappa values for the individual inflammatory tests ranged from .21 to .66 for categorization of the joint as inflamed, based on at least 2 positive inflammatory tests (K=.76). Reliability of PROM measurements was indicated by intraclass correlation coefficients of .72 to .97. Reliability of measurements of the pain-resistance sequence was indicated by a weighted kappa of .28. A capsular pattern, defined as a ratio of loss of extension to loss of flexion during PROM of between 0.03 and 0.50, was more likely than a noncapsular pattern in patients with an,, inflamed knee or osteoarthrosis (likelihood ratio=3.2). An association was found between a capsular pattern and arthrosis or arthritis. Conclusion and Discussion. These findings provide evidence to support the concept of a capsular pattern of motion restriction in persons with inflamed knees or evidence of osteoarthrosis. [Fritz JM, Delitto A, Erhard RE, Roman M. An examination of the selective tissue tension scheme, with evidence for the concept of a capsular pattern of the knee. Phys Ther. 1998;78:1046-1061.], Key Words: Clinical decision making, Knee, Tests and measurements. The selective tissue tension scheme of James Cyriax[1] is an evaluation method commonly used by physical therapists. Cyriax's scheme consists of [...]

Background and Purpose. The primary goal of this investigation was to describe outpatient physical therapy treatments provided to patients with lumbar, cervical, or knee impairments. Subjects. Patients in this analysis received outpatient physical therapy for a primary orthopedic complaint during July 1993 through June 1994 from one of 68 practices participating in the Focus on Therapeutic Outcomes database. Data were available on 2,598 completed physical therapy episodes of care provided by 141 therapists. Methods. At each patient's discharge, the primary physical therapist gave information on the treatments provided to each patient during the initial, middle, and final thirds of the episode of therapy as well as information on primary source of reimbursement. Patients provided information on the date of onset of their symptoms or surgery. Results. These outpatient physical therapy episodes of care were characterized by a diverse array of modalities, exercises, and manual therapy treatments. Treatment choices varied by type of impairment and across thirds of the episode. Fee-for-service versus managed care payment arrangements were associated with increased use of devices, therapeutic massage, strengthening, and endurance exercises. Conclusion and Discussion. The study's findings revealed that although physical agents were frequently used in physical therapy episodes of care, they were applied along with exercise and manual therapy interventions. Future research should relate specific treatments to variation in patient outcomes following physical therapy., [Jette AM, Delitto A. Physical therapy treatment choices for musculoskeletal impairments. Phys Ther. 1997;77: 145-154.] Key Words: Health services research, Low back pain, Musculoskeletal system, Orthopedics, Outcomes. In the United [...]

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 [...]

The purpose of this multiple-supject case report is to describe the physical impairments, disabilities, and handicaps of patients with multiple traumas and pelvic-ring fractures after management with open reduction internal fixation. Nineteen men and 12 women, with a mean age of 38 [+ or -] 16 years (X [+ or -] SD), were interviewed and examined at least 1 year (X [+ or -] 14.5 months) after sustaining multiple traumas, including an unstable pelvic-ring fracture that was repaired by open reduction internal fixation. Disabilities and handicaps were assessed using the Oswestry Low Back Pain Questionnaire and the Sickness Impact Profile (SIP). Assessments of physical performance consisted of lift capacity, the amount of forward bending, and gait. A descriptive analysis by age and pelvic fracture classification is reported. The [greater than or equal to] 50-year-old group had the best physical testing scores, except for the lifting test. The >50-year-old group had the lowest scores. Subjects with B1-class "open-book" pelvic fractures had a tendency to score higher in individual SIP categories. The average SIP scores of 9.34 [+ or -] 7.47 for the total SIP score, 7.79+/-6.93 for the physical dimension, and 8.24 [+ or -] 9.61 for the psychosocial dimension represent mild disability. The mean Oswestry score of 13.26% [+ or -] 15.41% also represents mild disability. Some subjects demonstrated impairments, disabilities, and handicaps 1 year postoperatively, but for the most part the subjects recovered almost all lost function. The data and clinical management information can be used as a basis of comparison for treatment and research with these types of patients. [Hakim RM, Gruen GS, Delitto A. Outcomes of patients with pelvic-ring fractures managed by open reduction internal fixation. Phys Ther. 1996;76:286-295., There is an absence of literature to describe the course of injury and outcome of patients following multiple traumas. Clinicians dealing with these patients do not have a basis for [...]

Spinal stenosis was described as early as 1899 by Sachs and Frankel,[1] who described patients with lumbar or lower-extremity pain who walked bent forward and whose symptoms were relieved by [...]

We present a treatment-based classification approach to the conservative management of low back syndrome. The approach has three levels of classification based on historical information, behavior of symptoms, and clinical signs. We first distinguish patients whose conservative care can be managed predominantly and independently by physical therapists versus patients who require consultation with other services (eg, psychology) or who require referral because of possible serious nonmusculoskeletal pathology. Once patients who can be managed by physical therapists are identified, the next level of classification is to stage their condition with regard to severity. We propose three stages: stage I for patients in the acute phase where the therapeutic goal is symptom relief, stage II for patients in a subacute phase were symptom relief and quick return to normal function are encouraged, and stage III for selected patients who must return to activities requiring high physical demands and who demonstrate a lack of physical conditioning necessary to perform the desired activities safely. The remainder of the article focuses on a third level of classification for stage I only in which patients are classified into distinct categories that are treatment-based and that specifically guide conservative management. The entire approach is diagnosis based, with specific algorithms and decision rules as well as examples presented., [Delitto A, Erhard RE, Bowling RW. A treatment-based classification approach to low back syndrome: identifying and staging patients for conservative treatment. Phys Ther. 1995;75:470-489.] Key Words: Backache, Classification, Decision making, [...]

Diagnosis by the physical therapist has received increased attention in the physical therapy literature. The contributions thus far are in agreement that although physical therapists do not identify disease in the sense of pathology, they certainly can identify clusters of signs, symptoms, symptom-related behavior, and other data from patient history and other testing. These clusters can be labeted as classifications or diagnoses by physical therapists and can guide management of the patient. The purpose of this article is to discuss what has yet to be included in articles about diagnosis: the diagnostic process. We first acknowledge the complexity of the diagnostic process, reviewing the study of clinical diagnosis mostly from the field of medicine, including statistical as well as process-tracing approaches. We next discuss steps we believe are important to consider in order to interface the diagnostic process into entry-level training curricula, urging teachers and mentors of future physical therapists to rethink our emphasis on the problem-oriented medical record's "SOAP" type of approach as a clinical decision-making format. We next discuss error and clinical judgment and strategies to constructively deal with error in the clinical environment. We urge physical therapists to strive to reach a point at which we can (1) identify and classify patients in such a manner that allows for more efficient treatment management and (2) demonstrate such abilities in peer-reviewed publication form., Rose[1] encouraged the study of clinical classification in physical therapy, admonishing physical therapists to follow other science-based disciplines that initially focused investigative efforts on "observing and describing phenomena of interest." [...]

Background and Purpose. The relative effectiveness of an extension program and a manipulation program with flexion and extension exercises was examined in patients with low back syndrome. Subjects. Forty-nine patients with less than a 3-month history of low back pain were seen at physical therapy clinics in western Pennsylvania, southern Mississippi, and eastern Missouri during a 6-month period Twenty-seven of the 49 patients were classified a priori into a treatment-oriented category of extension/mobilization and were then randomly assigned to participate in an extension program or a program of manipulation followed by hand-heel rocks flexion and extension). Two patients dropped out of the study (1 patient returned to work, and the other patient was unable to comply with the treatment schedule), and I patient was eliminated from the study because of magnified illness behavior. The remaining 24 patients (15 male, 9 female; mean age=44 years, SD = 15, range= 14-73) were assigned randomly and equally to the two groups. Eight physical therapists participated in the study. Methods. A randomized clinical trial comparing the two regimens was conducted for a 1-week period. Outcome was assessed using an Oswestry Low Back Pain Questionnaire initially before treatment) and at 3 and 5 days posttreatment, and data were analyzed using a 2 X 3 (group x time) analysis of variance. Results. A significant interaction of the group and time variables was demonstrated, indicating that the rate of positive response was greater in the manipulation/hand-heel rock group than in the extension group. Conclusion and Discussion. In this category of patients with low back pain, the use of manipulation as an adjunct to an ongoing exercise program appears to be warranted., With diagnoses of pathology virtually impossible in the majority of patients with low back syndrome (JBS),[1,2] classification becomes the only viable alternative for clinicians seeking guidance in managing these patients.[3] [...]

Background and Purpose. Electrical stimulation has been used to assess skeletal muscle resistance to fatigue. The purpose of this study was to test the hypothesis that 12 weeks of intense endurance exercise training on a bicycle ergometer would reduce the percentage of decline in quadriceps femoris muscle torque during an electrically elicited fatigue test. Subjects and Methods. Eleven nondisabled subjects performed 12 weeks of high-intensity endurance exercise training, and 6 subjects served as controls and did not exercise. Two electrically elicited fatigue tests, one with and one without prior voluntary fatiguing exercise, were administered to each subject before and after the 12-week training period. Results. The percentage of decline in peak torque of the quadriceps femoris muscle over 50 electrically elicited muscle contractions did not change as a result of endurance exercise training, despite significant improvements in maximal oxygen consumption and quadriceps femoris muscle endurance. The recovery of maximal isometric torque immediately after exhausting voluntary exercise followed by electrical stimulation was significantly greater after 12 weeks of intense exercise training Conclusion and Discussion. The percentage of decline in peak torque during an electrically elicited fatigue test does not detect improvements in quadriceps femoris muscle endurance induced by endurance exercise training The percentage of initial torque recovered immediately after fatiguing exercise, however, is improved by endurance training [Sinacore Dr, Jacobson RB, Delitto A. Quadriceps femoris muscle resistance to fatigue using an electrically elicited fatigue test following intense endurance exercise training. Phys Ther. 1994;74:930-942.], Electrical stimulation of skeletal muscle has been used as an evaluation tool to examine the effects and potential sites of human muscle fatigue.[1-5] To date, however, there have been few [...]

Currently, disablement due to low back syndrome (LBS) inflicts an extremely high cost to society, with yearly direct and indirect costs estimated in the billions of dollars Patients with LBS often present a challenge for Physical therapists trained in the evaluation of the physical nature of LBS. the psychosocial nature of a patient's complaint and the use of measures obtained from evaluation to guide patient management sometimes require interaction in a multidisciplinary environment. In this article, LBS will be discussed within the frameworks of Nagi's disablement pathway and an illness model described by Waddell. Both models suggest that to adequately treat LBS requires evaluation of the impairment, functional limitations, and disability using tools with adequate measurement characteristics. This article will focus on impairments and patient self-reports of quality of life and will discuss the relationship between impairments, functional limitations, and disability in LBS. Standardized quality of life measures are easily administered in everyday clinical sellings and capture the patient's perceptions of the functional limitations and disability seen with LBS. Common self-reports are reviewed, and potential barriers to their use are discussed. Lacking an identifiable disease process in the majority of cases of LBS leaves most clinicians to deal with the impairments, functional limitations, and resultant disability. Physical therapists should, therefore, measure and gauge changes in all of these dimensions. To accomplish this, physical therapists must be willing to evaluate the dimensions of functional limitations and disabilities using tools that allow adherence to the same measurement standards (eg, reliability and validity) as those used to evaluate physical impairments., Key Words: Backache; Disability evaluation; Tests and measurements, functional. Low back syndrome (LBS) and the resulting disablement cost industrialized societies billions of dollars in direct and indirect health care,[1-3] and [...]

Background and Purpose. The purpose of this study was to determine the effect of total contact casting (TCC) on dorsiflexion at the talocrural joint (TCJ) and motion (inversion/eversion) at the subtalar joint (STJ). Subjects. Thirty-seven patients (29 men, 8 women), ranging in age from 32 to 79 years ( X = 54, SD = 11), with diabetes mellitus and a unilateral plantar ulceration participated in the study. Methods. The subjects were measured with a goniometerfor dorsiflexion and STJ range of motion (ROM). The Roms for each subject's casted and noncasted legs were compared before and after treatment witb TCC for neuropathic plantar ulcers by use of a 2 X2 repeated-measures analysis of variance design. Results. Mean time of immobilization in TCC (healing time) was 42 days (SD = 43, range = 8-119). The results indicated (1) ROM was unchanged at the STJ, but dorsiflexion decreased slightly (1 [degrees]) on both the casted and noncasted sides following the last cast removal, and (2) ROM was less on the ulcerated side prior to casting compared with the nonulcerated side. Conclusion and Discussion. We believe the beneficial effects (healing of wounds) outweigh the minimal detrimental effects (decreased dorsiflexion) of treatment with TCC [Diamond JE, Mueller MJ, Delitto A. Effect of total contact cast immobilization on subtalar and talocrural joint motion in patients with diabetes mellitus. Phys Ther. 1993; 73310-3151.], Below-knee total contact casts (TCCs) are used in the treatment of neuropathic plantar ulceration.[1-5] Numerous studies, including a prospective, controlled clinical trial, have demonstrated favorable healing of neuropathic plantar ulcers [...]

Background and Purpose. The prescriptive validity of a treatment-oriented extension-mobilization category for patients with low back syndrome LBS) was examined. Subjects. Of a total of 39 patients with LBS referred for physical therapy, 24 patients (14 male, 70 female), aged 14 to 50 years (X = 31.3, SD = 11. 6), were classified as having signs and symptoms indicating treatment with an extension-mobilization approach. The remaining subjects were dismissed from the study. Patients in the extension-mobilization category were randomly assigned to either an experimental (treatment) group (n=14) or a comparison group (n = 10). Methods. The experimental and comparison group subjects were treated with either mobilization and extension (a treatment matched to the category) or a flexion exercise regimen (an unmatched treatment). Outcome was assessed with a modified Oswetry Low Back Pain Questionnaire administered initially and at 3 and 5 days after initiation of treatment. Data were analyzed with a 2 x 3 (treatment group x treatment period) analysis of variance. Results. The subjects' rate of improvement, as indicated by the Oswestry questionnaire scores, was dependent on the treatment group to which they were assigned Subjects treated with extension and mobilization positively responded at a faster rate than did those treated with a flexion-oriented program. Conclusion and Discussion. This study illustrates that a priori classification of selected patients with LBS into a treatment category of extension and mobilization and subsequently treating the patients accordingly with specified interventions can be an effective approach to conservative management of selected patients. [Delitto A, Cibulka MT, Erhard RE, et al. Evidence for use of an extension-mobilization category in acute low back syndrome: a prescriptive validation pilot study. Phys Ther. 1993;73:216-228.] Key Words: Back; Backache; Neck and trunk, back; Pain; Pain measurement., Up to 90% of patients treated by conservative management of low back syndrome (LBS) remain undiagnosed.[1,2] Traditional diagnostic testing, some of which has improved dramatically in recent times (eg, radiographic [...]

The purpose of this study was to explore the effect of various combinations of burst and carrier frequencies of neuromuscular electrical stimulation (NMES) on subjects' perception of pain intensity associated with induction of high intensity muscle contractions Twenty-seven healthy volunteers completed the study. After the initial test session, all subjects were treated in three additional sessions with nine combinations of burst frequencies (50, 70, and 90 bursts per second [bps]) and carrier frequencies (2,500, 5,000, and 10,000 Hz) at an NMES amplitude that produced torque equivalent to 50% of maximal voluntary contraction of their quadriceps femoris muscle. Subjects rated each frequency combination for perceived pain intensity with a visual analog scale. The combinations of burst frequencies (50, 70, and 90 bps) and carrier frequencies (2,500 and 5,000 Hz) do not differ from each other in perceived pain intensity but do differ significantly in perceived pain from the combinations of burst frequencies at the carrier frequency of 10,000 Hz. Thus, the clinician may have to try different stimulus combinations on patients at different current training levels to obtain the least individually perceived pain. [Rooney JG, Currier DP, Nitz AJ Effect of variation in the burst and carrier frequency modes of neuromuscular electrical stimulation on pain perception of healthy subjects. Phys Ther. 1992;72:800-809.], Key Words: Electrotherapy, electrical stimulation; Muscle performance, lower extremity; Pain. Use of neuromuscular electrical stimulation (NMES) to develop muscle strength (torque, force), to improve athletic performance, and to increase muscle [...]

The primary purpose of this study was to investigate the influence of personality variables and contractile forces on magnitude estimates of pain unpleasantness and pain intensity during varying levels of neuromuscular electrical stimulation (NMES). Thirty volunteers, according to their scores on a preferred coping-style questionnaire, were assigned to one of two groups, one designated 'monitors' (information seekers) and the other designated 'blunters' (information avoiders). All subjects were administered varying levels of two types of NMES, one causing both afferent stimulation and muscle contraction and one causing only afferent stimulation. Subjects judged the intensity and unpleasantness of each current type using magnitude estimation. Data were analyzed using a 2x2x2x3 (coping style x current type x pain descriptor x current level) analysis of variance. The results indicated that the rate of increase of magnitude estimates for unpleasantness and pain intensity that corresponded to increases in current were dependent on (1) the preferred coping style of the subject, (2) whether the stimulus caused a muscle contraction, and (3) whether the subject was judging the intensity or the unpleasantness of the applied stimulus. Behavioral styles appear to affect how subjects characterize the discomfort associated with NMES, and involuntary muscle contractions contribute to the discomfort felt from NMES. These results suggest that interventions tailored to a preferred coping style may increase a subject's level of tolerance to NMES and thus provide a more beneficial treatment [Delitto A, Strube MJ, Shulman AD, Minor SD. A study of discomfort with electrical stimulation. Phys. Ther. 1992;72:410-424.], Transcutaneous neuromuscular electrical stimulation (NMES) has many therapeutic applications, including electrically induced analgesia (usually referred to as transcutaneous electrical nerve stimulation), diagnostic uses (eg, nerve conduction studies), and the rehabilitation [...]

Patients who experience lower back pain are often found upon physical examination to demonstrate an S-shaped lateral (side-to-side) deviation of the lumbar area of the spine (lateral lumbar shift or LLS). A group of 24 patients (17 males and 7 females) with lower back pain who had an observable LLS were recruited into a study of the phenomenon. The side of symptoms were compared to the side of the LLS. The patient was also asked to bend to both sides; the side which caused pain was noted and compared with the side of the LLS. Although there was a high correlation between the direction of bending which elicited pain and the side opposite to the LLS (71 percent), a significant 21 percent of the patients demonstrated a positive pain response on the same side as the LLS. No pain was provoked by side bending in 8 percent of cases. No significant relationship was found between the side of the LLS and the side of symptoms. This study shows that there is limited value in the use of the side bending test for determining the presence of LLS. The use of these procedures and the finding of an observable LLS is helpful in documenting the presence of a lower back injury, classifying it, and developing a rational method of therapy. (Consumer Summary produced by Reliance Medical Information, Inc.), The Purpose of this study was to determine the relationship between direction of lateral lumbar shift (LLS) and 1) the occurrence of symptoms during the side-bending movement test and 2) the location of symptoms in patients with low back pain syndrome (LBS). Twenty-four patients with LBS (17 male, 7 female) with an observable LLS were studied. Side bending movement tests were performed bilaterally, and the results were recorded as Positive if symptoms occurred during the movement. The location of symptoms (right side or left side) was obtained from the patient history. Use of the chi-square statistic revealed a statistically significant relationship between the direction of the LLS and the direction of the positive side-bending movement test. Seventeen tests (71%) were Positive to the contralateral side of the LLS, and 5 (21%) were Positive to the ipsilateral side. Two tests (8%) were negative in both directions. There was no significant relationship between the side of symptoms and the direction of the LLS. The determination of presence and direction of an LLS is necessary in certain physical therapy management approaches. Pain or restricted side-bending movement bas been used to confirm the Presence of an LLS. This study confirms the clinical usefulness of the side-bending movement test for determining the presence and direction of an LLS. [Tenbula JA, Rose SJ, Delitto A. Association between direction of lateral lumbar shift, movement tests, and side of symptoms in patients with low back pain syndrome Phys Ther 1990;70:480-486.] Key Words: Backache, Classification, Scoliosis., J Tenhula, MHS/PT, OCS, is Orthopedic Clinical Specialist, Irene Walter Johnson Rehabilitation Institute, 509 S Euclid Ave, St Louis, MO 63110, and Instructor, Program in Physical Therapy, Washington UniversitY School [...]

In some cases in which the nerve supply to particular muscles has been lost or reduced, physical therapists have used external electrical stimulation to cause muscle contraction. This and other passive movement of the extremities is necessary to prevent the physical regression of muscle tissue (atrophy), which occurs when the nerve supply to a particular muscle is lost. The value of external stimulation has been debated and there has been no clear measurement of the physiologic effect of this stimulation technique on the individual muscle cells which compose a muscle. The present study uses electrical stimulation of a specific muscle by inserting a needle electrode into the muscle and evaluates the response of muscle cell glycogen (stored animal starch). To accomplish this study, a biopsy (a small sample of the subject's muscle) was evaluated using histochemical methods (a method of determining glycogen contents by the staining of cells as seen under a microscope). A 31-year-old man was used as a subject. In addition to muscle tissue samples, blood was also taken; values of blood sugar and other measurements were obtained before and after the electrical stimulation. Muscle cells are not all the same and they are classified by anatomic consideration into various groups. The results demonstrated that electrical stimulation was mainly effective in smaller type II muscle fibers, as noted by a decreased glycogen content (an indication of muscle contraction). No significant differences in the subjects pre- and post-stimulation blood tests were found. There are numerous muscle diseases that selectively affect type II muscle cells, and the authors suggest that electrical stimulation may be of particularly use in offsetting atrophy of muscle mass in these cases. (Consumer Summary produced by Reliance Medical Information, Inc.)

Neuromuscular electrical stimulation (NMES) is a well-substantiated clinical strategy to augment muscle performance. A recent review of the literature by Delitto and Robinson cites 25 references that deal specifically with [...]

For physical therapists who practice in the area of low back pain (LBP) and pride themselves on being evidence-based practitioners, the period 1995 to 2005 would seem to be the [...]

IMPORTANCE: Fear avoidance is a behavioral response to dizziness that can lead to chronic symptoms and maladaptation of the vestibular system, but there is no valid and reliable clinical measure of fear avoidance for persons with dizziness. Although the Vestibular Activities Avoidance Instrument (VAAI) was developed to identify fear avoidance beliefs in persons with dizziness, it was considered too long for clinical use. OBJECTIVE: To continue development of the VAAI for clinical use by reducing its length and by assessing the internal consistency and construct validity through associations with measures of disability, quality of life, and psychological well-being. DESIGN, SETTING, AND PARTICIPANTS: This prospective cohort study conducted from February 2018 to December 2019 at a tertiary care balance disorders clinic and in outpatient physical therapy clinics in the United States included 404 adults with dizziness. MAIN OUTCOMES AND MEASURES: Participants completed the 81-item VAAI, the Vestibular Activities and Participation (VAP) measure, the 12-Item Short Form Health Survey (SF-12), and the Hospital Anxiety and Depression Scale (HADS) at baseline. Exploratory factor analysis of the VAAI was conducted to reduce the number of items. Internal consistency of the reduced VAAI was determined by calculating the Cronbach α. Convergent validity was assessed by examining the associations between the reduced VAAI and the VAP, the SF-12, and the HADS using Spearman correlation coefficients. RESULTS: Data from 404 adults (mean [SD] age, 54.0 [17.0] years; 64.6% women) were included in the analyses. The exploratory factor analysis indicated that 2 factors explained the underlying constructs of the 81-Item VAAI. The first factor was retained and measured the construct of fear avoidance. The VAAI was reduced to 9 items (VAAI-9). The VAAI-9 showed excellent internal consistency (Cronbach α = 0.92) and was positively associated with the VAP (ρ = 0.81) and the HADS anxiety (ρ = 0.47) and depression (ρ = 0.64) subscales, and negatively associated with physical (ρ = −0.76) and mental (ρ = −0.47) health–related quality of life. CONCLUSIONS AND RELEVANCE: These findings indicate that the VAAI-9 is a short, internally consistent, valid measure of fear avoidance and is associated with quality of life, activity limitations and participation restrictions, and psychological well-being. The next steps in the development of the VAAI-9 will include validation in an external sample, assessment of test-retest validity, and prospective investigations of its association with future disability.

Clinical trials have been characterized as either explanatory or pragmatic in nature based on whether the major objective of the trial is to prioritize internal or external validity. (1) Explanatory [...]

As Guest Editor for this special series, I had the daunting task of selecting contributors whose content areas would be relevant to the clinician who manages patients with back problems [...]

•Electrical stimulation was tolerable in patients with chronic low back pain.•Stabilization exercises with NMES did not add clinical benefit for the CLBP.•Because of the small sample; clinicians should interpreting the results cautiously.

The aim of this study was to compare the feasibility and effectiveness of neuromuscular electrical stimulation (NMES) with that of high‐intensity volitional resistance training for improving muscle structure and function and physical function in patients with rheumatoid arthritis (RA). We also compared pre‐intervention and post‐intervention values of myocyte characteristics. In this 2‐group, single‐blind, randomized pilot study, adult patients with RAwere assigned to 36 sessions of NMES(n = 31 patients) or volitional training (n = 28 patients) over 16 weeks. Outcome measures included muscle structure and function (quadriceps muscle area, density, and strength), physical function (performance‐based and patient‐reported), feasibility (increased pain, increased disease activity, attrition, and adherence), and myocyte characteristics (area, proportion of type I or IImuscle fibers, and intramyocellular lipid content). Analysis of covariance was used to compare groups. The intervention intensity in the NMESgroup was less than half that in the volitional exercise group (31% versus 77% of maximum effort). Both groups experienced significant improvements in muscle structure and function (P< 0.001 to 0.019). Improvements in muscle characteristics and physical function were not different between groups. Exercise did not result in serious adverse events or increases in pain and disease activity. Attrition was 29% in the NMESgroup and 7% in the volitional exercise group. Both NMESand high‐intensity volitional resistance training can be used as effective approaches to improving muscle structure and function in patients with RA. NMESmay be a viable alternative for improving muscle function in patients in whom high‐intensity resistance exercise may not be tolerated or is contraindicated, but attrition must be considered when using this approach.

There is growing demand to increase the volume of clinic-based research in physical therapy. Special considerations, unique to the planning and conduct of clinic-based research, need to be addressed to increase the likelihood that these studies will be completed successfully. The purposes of this perspective are to discuss factors affecting clinic-based research and to offer suggestions for addressing these problems when designing and conducting research studies in a clinical setting. This perspective discusses issues such as patient management, determining the availability of target patient populations, acquiring support from physical therapists and physicians, reporting and managing research-related injury or illness, and modifying or terminating projects. Some of the points made in this perspective are illustrated using examples from the authors&apos; experiences in conducting clinical research. [Fitzgerald GK, Delitto A. Considerations for planning and conducting clinic-based research in physical therapy. Phys Ther. 2001;81:1446-1454.] Key Words: Clinical trials, Physical therapy, Research., Recently, the American Physical Therapy Association (APTA) developed its Clinical Research Agenda (CRA), which is designed to "support, explain, and enhance physical therapy clinical practice by facilitating research that is [...]

Pancreatic ductal adenocarcinoma (PDAC) is projected to become the second leading cause of cancer-related death. Hallmarks include desmoplasia with variable extracellular matrix (ECM) architecture and a complex microenvironment with spatially defined tumor, stromal, and immune populations. Nevertheless, the role of desmoplastic spatial organization in patient/tumor variability remains underexplored, which we elucidate using two technologies. First, we quantify ECM patterning in 437 patients, revealing architectures associated with disease-free and overall survival. Second, we spatially profile the cellular milieu of 78 specimens using codetection by indexing, identifying an axis of pro-inflammatory cell interactions predictive of poorer outcomes. We discover that clinical characteristics, including neoadjuvant chemotherapy status, tumor stage, and ECM architecture, correlate with differential stromal-immune organization, including fibroblast subtypes with distinct niches. Lastly, we define unified signatures that predict survival with areas under the receiver operating characteristic curve (AUCs) of 0.872–0.903, differentiating survivorship by 655 days. Overall, our findings establish matrix ultrastructural and cellular organizations of fibrosis linked to poorer outcomes.

To characterize skeletal muscle fat (SMF), intermuscular adipose tissue (IMAT), and subcutaneous adipose tissue (SAT) in individuals with rheumatoid arthritis (RA), and assess the associations between these fat depots and physical function and physical activity. In a cross‐sectional analysis from an RAcohort, SMF,IMAT, and SATwere measured using computed tomography imaging of the midthigh cross‐sectional region. Physical function was measured using the Health Assessment Questionnaire (HAQ) and a battery of performance‐based tests that included quadriceps muscle strength, gait speed, repeated chair‐stands, stair ascent, and single‐leg stance. Physical activity was assessed using an activity monitor. Associations between SMF,IMAT, and SATand physical function and activity were assessed by multiple linear regression models adjusted for potential confounders such as age, sex, body mass index (BMI), muscle area, and muscle strength. Sixty subjects with RA(82% female, mean ± SDage 59 ± 10 years, mean ± SD BMI31.79 ± 7.16 kg/m2) were included. In the adjusted models, lower SMFwas associated with greater gait speed, single‐leg stance, quadriceps strength, and physical activity, and less disability (R2Δ range 0.06–0.25; P< 0.05), whereas IMATwas not associated with physical function or physical activity and SATwas negatively associated with disability (HAQ) (R2Δ = 0.13; P< 0.05) and weakly but positively associated with muscle strength (R2Δ = 0.023; P< 0.05). Fat infiltration within the muscle seems to independently contribute to low physical function and physical activity, contrary to IMATor SATaccumulation. Longitudinal studies are necessary to confirm the impact of SMFon disability and health promotion in persons with RA.

IMPORTANCE: Parkinson disease is a progressive neurologic disorder. Limited evidence suggests endurance exercise modifies disease severity, particularly high-intensity exercise. OBJECTIVES: To examine the feasibility and safety of high-intensity treadmill exercise in patients with de novo Parkinson disease who are not taking medication and whether the effect on motor symptoms warrants a phase 3 trial. DESIGN, SETTING, AND PARTICIPANTS: The Study in Parkinson Disease of Exercise (SPARX) was a phase 2, multicenter randomized clinical trial with 3 groups and masked assessors. Individuals from outpatient and community-based clinics were enrolled from May 1, 2012, through November 30, 2015, with the primary end point at 6 months. Individuals with idiopathic Parkinson disease (Hoehn and Yahr stages 1 or 2) aged 40 to 80 years within 5 years of diagnosis who were not exercising at moderate intensity greater than 3 times per week and not expected to need dopaminergic medication within 6 months participated in this study. A total of 384 volunteers were screened by telephone; 128 were randomly assigned to 1 of 3 groups (high-intensity exercise, moderate-intensity exercise, or control). INTERVENTIONS: High-intensity treadmill exercise (4 days per week, 80%-85% maximum heart rate [n = 43]), moderate-intensity treadmill exercise (4 days per week, 60%-65% maximum heart rate [n = 45]), or wait-list control (n = 40) for 6 months. MAIN OUTCOMES AND MEASURES: Feasibility measures were adherence to prescribed heart rate and exercise frequency of 3 days per week and safety. The clinical outcome was 6-month change in Unified Parkinson’s Disease Rating Scale motor score. RESULTS: A total of 128 patients were included in the study (mean [SD] age, 64 [9] years; age range, 40-80 years; 73 [57.0%] male; and 108 [84.4%] non-Hispanic white). Exercise rates were 2.8 (95% CI, 2.4-3.2) days per week at 80.2% (95% CI, 78.8%-81.7%) maximum heart rate in the high-intensity group and 3.2 (95% CI, 2.8-3.6; P = .13) days per week at 65.9% (95% CI, 64.2%-67.7%) maximum heart rate in the moderate-intensity group (P &lt; .001). The mean change in Unified Parkinson’s Disease Rating Scale motor score in the high-intensity group was 0.3 (95% CI, −1.7 to 2.3) compared with 3.2 (95% CI, 1.4 to 5.1) in the usual care group (P = .03). The high-intensity group, but not the moderate-intensity group, reached the predefined nonfutility threshold compared with the control group. Anticipated adverse musculoskeletal events were not severe. CONCLUSIONS AND RELEVANCE: High-intensity treadmill exercise may be feasible and prescribed safely for patients with Parkinson disease. An efficacy trial is warranted to determine whether high-intensity treadmill exercise produces meaningful clinical benefits in de novo Parkinson disease. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01506479

ObjectiveThe Stand Back study evaluated the feasibility and effects of a multicomponent intervention targeting reduced prolonged sitting and pain self-management in desk workers with chronic low back pain (LBP).MethodsThis randomised controlled trial recruited 27 individuals with chronic LBP, Oswestry Disability Index (ODI) >10% and desk jobs (sitting ≥20 hours/week). Participants were randomised within strata of ODI (>10%–<20%, ≥20%) to receive bimonthly behavioural counselling (in-person and telephone), a sit-stand desk attachment, a wrist-worn activity-prompting device and cognitive behavioural therapy for LBP self-management or control. Self-reported work sitting time, visual analogue scales (VAS) for LBP and the ODI were assessed by monthly, online questionnaires and compared across intervention groups using linear mixed models.ResultsBaseline mean (SD) age was 52 (11) years, 78% were women, and ODI was 24.1 (10.5)%. Across the 6-month follow-up in models adjusted for baseline value, work sitting time was 1.5 hour/day (P<0.001) lower comparing intervention to controls. Also across follow-up, ODI was on average 8 points lower in intervention versus control (P=0.001). At 6 months, the relative decrease in ODI from baseline was 50% in intervention and 14% in control (P=0.042). LBP from VAS was not significantly reduced in intervention versus control, though small-to-moderate effect sizes favouring the intervention were observed (Cohen’s d ranged from 0.22 to 0.42).ConclusionAn intervention coupling behavioural counselling targeting reduced sedentary behaviour and pain self-management is a translatable treatment strategy that shows promise for treating chronic LBP in desk-bound employees.Trial registration numberNCT0224687; Pre-results.

In 2013, APTA's House of Delegates adopted APTA's Vision Statement for the Physical Therapy Profession: 'Transforming society by optimizing movement to improve the human experienceOne of the Guiding Principles to [...]

Despite rapidly increasing intervention, functional disability due to chronic low back pain (cLBP) has increased in recent decades. We often cannot identify mechanisms to explain the major negative impact cLBP has on patients' lives. Such cLBP is often termed non-specific and may be due to multiple biologic and behavioral etiologies. Researchers use varied inclusion criteria, definitions, baseline assessments, and outcome measures, which impede comparisons and consensus. Therefore, NIH Pain Consortium charged a Research Task Force (RTF) to draft standards for research on cLBP. The resulting multidisciplinary panel recommended using 2 questions to define cLBP; classifying cLBP by its impact (defined by pain intensity, pain interference, and physical function); use of a minimum dataset to describe research participants (drawing heavily on the PROMIS methodology); reporting 'responder analyses' in addition to mean outcome scores; and suggestions for future research and dissemination. The Pain Consortium has approved the recommendations, which investigators should incorporate into NIH grant proposals. The RTF believes that these recommendations will advance the field, help to resolve controversies, and facilitate future research addressing the genomic, neurologic, and other mechanistic substrates of chronic low back pain. We expect that the RTF recommendations will become a dynamic document and undergo continual improvement. Perspective: A task force was convened by the NIH Pain Consortium with the goal of developing research standards for chronic low back pain. The results included recommendations for definitions, a minimum dataset, reporting outcomes, and future research. Greater consistency in reporting should facilitate comparisons among studies and the development of phenotypes. Key words: Low back pain, chronic low back pain, research standards, minimum dataset, NIH Task Force., This article is available online only at: [...]