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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.

STUDY DESIGN: Secondary analysis of national survey data. OBJECTIVE: To describe the volume and characteristics of outpatient visits to physician offices, hospital outpatient departments and emergency departments, and inpatient hospital utilization for neck pain in the United States. We also examined the use of pathology-based versus symptom-based diagnoses on a national scale. SUMMARY OF BACKGROUND DATA: Descriptions of the epidemiology of neck pain will assist policy makers and clinicians in understanding the impact of neck pain on society. METHODS: Analysis of combined survey data from the 2001 and 2002 National Ambulatory Medical Care Survey, National Hospital Ambulatory Medical Care Survey, and National Hospital Discharge Survey, from the Centers for Disease Control and Prevention/National Center for Health Statistics. RESULTS: During 2001 and 2002, an average of 10.2 million visits were made annually. At 64% of visits, a symptom-based diagnosis was used. An annual average of 179,000 hospital discharges for neck pain was recorded and 94% received a pathology-based diagnosis. Most (79%) had surgery for the neck problem. CONCLUSIONS: Outpatient visits for neck pain are common in the United States, and the majority are given symptom-based rather than pathology-based diagnoses. An alternative diagnostic taxonomy may be needed to guide treatment, particularly for patients with vague, symptom-based diagnoses. Hospitalizations for neck pain often include surgical procedures, but 21% received no surgery.

Objective.Knee pain location is routinely assessed in clinical practice. We determined the patterns of patient-reported pain locations for persons with knee osteoarthritis (OA). We also examined associations between knee pain patterns and severity of self-reported pain with activity and self-reported functional status.Methods.The Osteoarthritis Initiative data were used to examine reports of pain location (localized, regional, or global) and type and extent of knee OA. Multivariable ANCOVA models were used to determine associations between the Knee Injury and Osteoarthritis Outcome Survey (KOOS) Pain and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) Function scales and pain location after adjusting for potential confounding. We also used radar graphs to illustrate pain patterns for various locations and severity of knee OA.Results.Radar graphs of 2696 knees indicated that pain pattern and location and extent of knee OA demonstrate substantial overlap. An interaction between race and pain location was found for WOMAC Function, but not for KOOS Pain scores. Global knee pain was associated (p < 0.001) with substantially worse function (by 6.5 points in African Americans) compared with pain that was localized. Knee pain reported as global was independently associated (p < 0.001) with clinically important lower (worse by 3.9 points) KOOS Pain scores compared with pain that was localized.Conclusion.Pain patterns are not useful for inferring potential location or severity of knee OA in individual patients, but knee pain patterns that are global are independently associated with worse pain and function compared with localized pain, and associations differ for function based on race.

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 …

Objective.To develop a plan for harmonizing outcomes for people undergoing total joint replacement (TJR), to achieve consensus regarding TJR outcome research.Methods.The TJR working group met during the 2014 Outcome Measures in Rheumatology (OMERACT) 12 meeting in Budapest, Hungary. Multiple conference calls preceded the face-to-face meeting. Brief presentations were made during a 1.5-h meeting, which included an overview of published systematic reviews of TJR trials and the results of a recent systematic review of TJR clinical trial outcome domains and measures. This was followed by discussion of potential core set areas/domains for TJR clinical trials (as per OMERACT Filter 2.0) as well as the challenges associated with the measurement of these domains.Results.Working group participants discussed which TJR clinical trial outcome domains/areas map to the inner versus outer core for core domain set. Several challenges were identified with TJR outcomes including how to best measure function after TJR, elucidating the source of the pre- and post-TJR joint pain being measured, joint-specific versus generic quality of life instruments and the importance of patient satisfaction and revision surgery as outcomes. A preliminary core domain set for TJR clinical trials was proposed and included pain, function, patient satisfaction, revision, adverse events, and death. This core domain set will be further vetted with a broader audience.Conclusion.An international effort with active collaboration with the orthopedic community to standardize key outcome domains and measures is under way with the TJR working group. This effort will be further developed with new collaborations.

Preoperative depressive symptoms have been shown in some but not all studies to be associated with poor self-reported pain and function outcomes. In addition, depressive symptoms after surgery have been shown to improve relative to preoperative levels.We hypothesized that (1) preoperative depressive symptoms would predict postoperative pain; (2) depressive symptoms would decrease after surgery; and (3) preoperative depressive symptoms would increase as the scheduled surgery date approached.Data from the Osteoarthritis Initiative, a National Institutes of Health-funded prospective multiyear cohort study, were used in this retrospective analysis. Persons from four communities were eligible if they had radiographic knee osteoarthritis or were at risk for developing knee osteoarthritis based on occupational, medical history, or body weight risk factors. A total of 4796 persons participated and rates of followup were 80% or greater over the course of the study. Participants completed a validated depressive symptom scale and the Knee Injury and Osteoarthritis Outcome Scale pain scale each year for 3 years before and 3 years after TKA. Latent growth curve modeling was used to model intercepts and slopes of pre- and postoperative depression and pain. Preoperative trajectories and intercepts were then used to predict postoperative pain and depressive symptoms adjusting for confounding variables.After adjustment for potential confounding, we found no evidence that preoperative depressive symptoms predicted postoperative pain with function (estimate, 0.1; 95% confidence interval, -0.31 to 0.50; p = 0.64) or that depressive symptoms were reduced after surgery (z = 0.06, p = 0.80). We also found no evidence to indicate that preoperative depressive symptoms increased as the date of surgery approached (linear slope = 0.28, SE = 0.19, p = 0.15).Preoperative and postoperative depressive symptoms in patients before and after TKA did not appreciably change over a 6-year perioperative period. Patient depressive symptoms were not reduced after surgery and did not appear to be related to less pain postoperatively. Our findings of no association between preoperative depressive symptom severity and postoperative pain and no reduction in postoperative depressive symptoms run counter to other available evidence, potentially attributable, in part, to a data collection process that occurred outside of orthopaedic surgeons' offices. Future research is needed to more fully explore the potential role of social desirability, the concept that patients respond in a way that they think the researcher or clinician wants them to respond in lieu of responding in a way that truly reflects the patient's status. Social desirability may influence a TKA patient's pain and function outcome assessment.Level I, prognostic study.

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.

The purpose of our study was to determine if a previously published clinical decision rule designed to estimate the probability of proximal deep vein thrombosis in outpatients is valid when applied exclusively to outpatients with musculoskeletal disorders. We also sought to determine whether probability estimates differed for patients with or without trauma, fracture, or recent orthopaedic surgery. Data collected from outpatients with surgical and nonsurgical musculoskeletal disorders (n = 464) were extracted from the datasets of three previously published studies done on heterogeneous groups of patients (n = 3424). Followup for all patients was 3 months. Testing of all patients for thromboembolic disease was done using validated diagnostic procedures. Probability estimates for orthopaedic outpatients were consistent with estimates from published studies. The proportion of patients who had venous thromboembolism was 5.6% (95% confidence interval, 3.5-8.7%) for the low probability group, 14.1% (95% confidence interval, 8.6-22.4%) for the moderate probability group, and 47.4% (95% confidence interval, 35.3-60%) for the high probability group. Validity estimates for patients with and without recent trauma, surgery, or fracture differed, but not dramatically. The validity of the clinical decision rule as applied to outpatients with musculoskeletal disorders was supported.

Prompt diagnosis of proximal lower extremity deep vein thrombosis in outpatients is critical because of the risk of pulmonary embolism. Our purpose was to determine the accuracy of orthopaedists' clinical decisions regarding the diagnosis of proximal deep vein thrombosis in outpatients. A nationally representative random sample of 2300 orthopaedists received a survey of six clinical vignettes. They were asked to estimate the probability of proximal lower extremity deep vein thrombosis using defined criteria and to specify their planned diagnostic tests. A clinical decision rule and evidence-based diagnostic test recommendations from the general literature served as the gold standard for comparison. Six-hundred seventy-six (29%) surgeons completed the survey. The orthopaedists' planned diagnostic tests differed from the gold standard, but these differences varied depending on the probability of deep vein thrombosis. For the moderate and high risk vignettes, the diagnostic test recommendations agreed with the gold standard approximately 70% of the time. With the exception of gender, no differences were found between respondents and nonrespondents. Orthopaedists' approach to the diagnosis of deep vein thrombosis in outpatients potentially could be improved by applying a clinical decision rule and current evidence on diagnostic test usage.

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.

Background: Plantar fasciitis is a relatively common disorder of the foot, yet little is known about its prevalence, what types of physicians see patients with the disorder, or how, on a national scale, patients are typically managed. The purpose of this study was to generate national estimates of the volume of patient visits and characteristics of care given to patients diagnosed with plantar fasciitis by medical doctors. Methods: Data from the National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS) for the years 1995–2000 were studied. These are multistage probability sample surveys of visits to office-based physicians (NAMCS) and visits to nonfederal, short-stay, and general hospitals (NHAMCS) to consult doctors of medicine and doctors of osteopathy. Sample data have been weighted to produce national estimates. Data describing the number of patient visits for plantar fasciitis and the characteristics of the care given during those visits were summarized using univariate analyses. Data were combined for the 6-year period to increase the reliability of the estimates, and figures are presented as annual averages. Results: Approximately 1 million patient visits per year were made to office-based physicians and hospital outpatient departments for the diagnosis and treatment of plantar fasciitis during 1995–2000. Approximately 62% of all visits were made to primary care practitioners, and 31% were made to orthopaedic surgeons. Patient visits for plantar fasciitis accounted for approximately 1% of all patient visits to orthopedic surgeons. Pain medication, including nonsteroidal anti-inflammatory drugs (NSAIDs), was the most frequently used intervention (47% of visits). Exercise counseling was cited at 26% of visits, and physical therapy was ordered or provided at 19% of visits. Conclusions: This research suggests that plantar fasciitis is a relatively common disorder that is seen by several physician specialties. The disorder is not managed in a consistent way. Rather, there appears to be a large amount of variation in the way that these patients are managed. These findings support the argument that additional research is needed to identify effective interventions for plantar fasciitis and to determine if physician specialty influences treatment outcome.

Clinical trial design has taken on greater importance given recent emphasis on the role and impact of pragmatic trials. In the old days (for some of us), clinical trial design was almost exclusively restricted to rigid control and strong emphasis on efficacy and mechanistic inquiry. With recent (for some of us) attention paid to comparative effectiveness research, pragmatic trials have become the focus of many clinical trial design teams, patients, and policy makers [1]. This is not to say that more explanatory trial designs have lost favor. For example, trials similar to the doubleblind, placebo-controlled trial of vertebroplasty, an invasive procedure for painful vertebral fractures by Buchbinder et al. [2], have been critical to understanding true procedural vs. placebo effects attributable to an invasive treatment. Motivated by recent momentum and interest by a variety of stakeholders, the topic of pragmatic trials has received much attention in this journal and elsewhere. With the current health care research climate in mind, Nieuwenhuis et al. [3] set out to discuss some nuanced issues related to trial design with particular emphasis on how trial design decisions across the pragmatic/explanatory continuum potentially impact trial execution and interpretation. Although the interventions discussed are pharmacologic, the issues discussed likely apply to most if not all trials of health care interventions. I will elaborate on what I believe are the critical issues addressed by Nieuwenhuis et al. and what could potentially be done to expand on these issues. The main thesis of the article by Nieuwenhuis et al. is that although recently published pragmatic explanatory

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 …

Prognostic estimates for knee osteoarthritis worsening over the full disease spectrum have not been reported. Osteoarthritis Initiative data were used to determine the association between knee radiographic osteoarthritis worsening and future knee pain and function.Yearly data over a 5-year period were analyzed. Outcome measures were the Western Ontario and McMaster Universities Osteoarthritis Index and the Knee Injury and Osteoarthritis Outcome Score pain and symptoms scales. Knees were grouped based on whether yearly Kellgren/Lawrence (K/L) grades worsened. Associations of yearly K/L worsening with knee pain, symptoms, or function scores at the end of the year and with lagged outcomes observed at least 1 year after worsening were assessed using linear models with generalized estimating equations.A total of 25,932 knee-years of observations were examined in the primary analysis. For knees with yearly K/L worsening, all outcome scores were significantly worse (P values from 0.02 to 0.001) at the end of the index year, as compared to unchanged knees. All outcomes for knees with worsened versus unchanged K/L scores exceeded the minimal clinically important difference (MCID). For lagged effects, outcomes at 1 year following the index K/L year exceeded the MCID and were statistically significant (P ≤ 0.001) for knees with baseline K/L grades of 2 or 3.K/L worsening over a 1-year period is prognostically important over the short term for all baseline K/L grades, and for knees with baseline K/L grades of 2 or 3 worsening continues over the following year.

To the editor, The study by Ayers and colleagues [1] addresses TKA utilization in the United States, a complex and important issue in healthcare. We also published work on this issue [3, 4] as have others [2]. Our comments are directed toward the basic premise of the study by Ayers and colleagues – that site variation in SF-36 and Knee Injury and Osteoarthritis Outcome Score indicate the amount of variation in selection criteria for TKA. To be methodologically sound, this basic premise requires two key considerations: (1) A determination of whether the variation in outcome scores for individual patients is acceptable or unacceptable, and (2) a determination of whether the TKA selection criteria (that is, the outcome score thresholds for determining if TKA is indicated for an individual) are defined. To judge variation in outcome scores, Ayers and colleagues determined site-based mean, median, and 25th and 75th percentile scores for 4900 patients treated by a smaller number of surgeons in 22 participating sites. The authors determined whether variation among sites differed from the grand median from all 22 sites or from the minimal clinically important change – an estimate typically used to make inferences regarding intraindividual important change [5]. Because the upper and lower quartiles of median outcome scores for the sites as compared to the grand median were generally smaller than minimal clinically important change estimates [5], the authors concluded that outcome score variation was acceptable when scheduling patients for TKA. The structure of the data in the study by Ayers and colleagues was multilevel; patients were grouped by surgeons, and surgeons were grouped by sites. The authors only presented the site level data. If one is interested in examining the extent of variation in outcome measures, the inferences should be based on patient-level data after taking into account the multilevel data structure. Data reported at the surgeon level or at the site level represents data only at the group level. Group-level data will mask individual patient variation, which is accentuated when only the middle 50% of the distributions are examined – as performed in this study. Regarding the definitions of individual patient-level TKA selection criteria for the outcome measures, the authors indicated that median scores obtained at participating sites were substantially below general population levels. However, selection criteria for applying to individual patients were not defined. Without a clear definition of outcome score thresholds for TKA selection at the individual patient level, the extent of variation in outcome scores carries little meaning, particularly when variation is described using a group-level approach and central tendency measures. In summary, while we find the overarching topic of TKA selection criteria important, the design and analytic approaches used by Ayers and colleagues do not appear to support the conclusions made in the paper.

Health literacy is related to a broad range of health outcomes. This study was designed to develop a psychometrically sound instrument designed to measure cancer health literacy along a continuum (CHLT-30), to develop another instrument designed to determine whether a patient has limited cancer health literacy (CHLT-6), and to estimate the prevalence of limited cancer health literacy. The Cancer Health Literacy Study involving 1,306 Black and White cancer patients was conducted between April 2011 and April 2013 in the Virginia Commonwealth University Massey Cancer Center and surrounding oncology clinics. A continuous latent variable modeling framework was adopted to dimensionally represent cancer health literacy, whereas discrete latent variable modeling was used to estimate the prevalence rates of limited cancer health literacy. Self confidence about engaging in health decisions was used as the primary outcome in external validation of new instruments. Results from a comprehensive analysis strongly supported the construct validity and reliability of the CHLT-30 and CHLT-6. For both instruments, measurement invariance tests ruled out item/test bias to explain gender and race/ethnicity differences in test scores. The limited cancer health literacy rate was 18%, a subpopulation consisting of overrepresented Black, undereducated, and low-income cancer patients. Overall, the results supported the conclusion that the CHLT-30 accurately measures cancer health literacy along a continuum and that the CHLT-6 efficiently identifies patients with limited cancer health literacy with high accuracy.

We determined outcomes for patients classified as appropriate, inconclusive, or inappropriate for total knee arthroplasty (TKA) using a modified version of a validated appropriateness algorithm. Outcome measurement was conceptualized as short-term postoperative change attributable primarily to surgery and rehabilitation (2 months) and as longer-term postoperative change and recovery (1 and 2 years).Preoperative and yearly postoperative Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) function, Knee Injury and Osteoarthritis Outcome Score (KOOS) symptoms and KOOS pain scores were examined for persons undergoing primary TKA in the Osteoarthritis Initiative. Multigroup, 2-piece latent growth curve modeling was used to determine differences in outcome variable changes for each group from presurgery to 2-months postsurgery, as well as over a 2-year postoperative period.Data from 167 persons with primary TKA were examined. Prevalence rates of appropriate, inconclusive, and inappropriate judgments were 47.9%, 20.8%, and 31.3%, respectively. The inappropriate group showed no change at 2 months following surgery, while appropriate and inconclusive groups had substantial improvement in all outcomes. One-year and 2-year postoperative recovery outcomes were not significantly different among the 3 groups.The inappropriate group was unchanged 2 months after surgery and on average improved by 2.3 WOMAC function points from presurgery to 1 year following surgery based on our models. Appropriate and inconclusive groups improved by an average of 19.8 WOMAC function points at 1-year postsurgery. These data provide a compelling case for consensus-building efforts to define eligibility criteria for TKA with the goals of reducing variation in patient selection and optimizing both change over time and final outcomes.

Summary Objective To assess the influence of baseline score on concordance between the Minimal Clinically Important Difference (MCID) and Patient Acceptable Symptom State (PASS) estimates obtained on persons following total knee arthroplasty (TKA). Design Patients scheduled for TKA in 15 hospitals in Spain were recruited and provided pre-operative and 1-year postoperative Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) Pain and Function scores. 1 year following surgery, patients completed questionnaires that determined the importance of any changes in status since surgery as well as the extent of satisfaction with the 1-year outcome. Kappa ( κ ) was used to determine the extent of concordance between MCID and PASS measures for the entire sample and after splitting the sample based on quartiles of the baseline WOMAC scores. Results A total of 923 patients participated in the study. The extent of concordance between MCID and PASS without regard to baseline score was κ = 0.41 (95% Confidence Interval (CI) = 0.36, 0.47) for WOMAC Function and after stratifying baseline scores into quartiles, κ = 0.72 (95%CI = 0.68, 0.77). Similar estimates were obtained for WOMAC Pain. Conclusions Baseline score has substantial influence on the extent of concordance between MCID and PASS for patients undergoing TKA. Clinicians should account for baseline score when interpreting either MCID or PASS and the extent to which these measures agree. These findings have potential to influence the interpretation of outcome following TKA.

The extent to which SF-12 scores reflect SF-36 scores has not been well studied.One purpose was to compare the sensitivity to change of the SF-36 Physical Function sub-score, and the Physical Component Summary Scores (PCS) of the SF-36 and SF-12 on patients with low back pain (LBP). A second purpose was to determine if the SF-12 could serve as a surrogate measure for the SF-36 when making decisions about individual patients.The sample consisted of 101 consecutive patients.SF-36 questionnaires were completed by patients at both initial and discharge examinations. SF-12 scores were calculated from the completed SF-36 questionnaires. Therapists' judgments of whether patients were judged to have returned to premorbid function served as the construct for meaningful clinical change.Receiver Operating Characteristic (ROC) curve analysis and repeated measures MANCOVA were used to assess sensitivity to change. Linear regression and 95% prediction bands described the extent to which SF-12 scores predict individual SF-36 scores.No significant differences were found between the ROC curve areas for the Physical Function sub-scale, the PCS-36 and PCS-12. No significant differences were found for the comparison of change scores between PF-36, PCS-36 and PCS-12 scores.The findings suggest that Physical Function sub-scores, SF-36 and SF-12 PCS scores are equally sensitive to change. SF-12 PCS scores do not adequately predict SF-36 PCS scores for individual patients. The PCS-12 should probably not be used to make judgments about the health status of individual patients with LBP.

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 …

Study design A prospective repeated-measures design was applied. Objectives To examine the measurement properties of the Back Pain Functional Scale (BPFS) and the Roland-Morris Questionnaire (RMQ) and to formulate hypotheses and sample size estimates for a subsequent comparison study. Summary of background data Although there are numerous functional status measures for patients with low back pain, most have been conceived of and validated with a group rather than an individual patient as the unit of interest. Also, little has been done to formally compare-this includes the generation of a priori hypotheses, followed by statistical hypotheses testing-the many competing measures. Methods Subjects were 77 patients with low back pain who were referred by physicians to 10 outpatient physical therapy clinics located in Canada and the United States. The questionnaires were administered at patients' initial visits, within 48 hours of the initial visit, and at 1-, 2-, and 3-week follow-up visits. Reliability, cross-sectional validity, and longitudinal validity (sensitivity to change) coefficients were calculated. Results Test-retest reliability estimates of 0.81 and 0. 88 were obtained for the RMQ and BPFS, respectively. The measures demonstrated similar levels of cross-sectional validity. Correlations of 0.56 and 0.65 were noted between a prognostic rating of change and the RMQ and BPFS, respectively. The RMQ demonstrated a ceiling effect. Approximately 180 patients are needed for a subsequent head-to-head comparison study of the measures. Conclusions The BPFS appears to have sound measurement properties, and a formal head-to-head comparison study with the RMQ is warranted.

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.

Purpose: To determine whether a difference exists between patients' self-ratings of amount of change and their self-ratings of importance of change. Methods: Eighty-eight patients receiving treatment of low-back pain completed two global rating of change (GRC) scales 4 to 6 weeks after their initial assessments. The scales were similar in format, differing only in that one asked respondents about the amount of change and the other about the importance of change. Results: Our analysis was restricted to 86 patients who reported improvement or no change. The chance-corrected agreement between patients' self-ratings of amount of change and their self-ratings of importance of change was low (κ=0.35; 95% CI, 0.23–0.48). Of 47 disagreements, 44 reported a greater importance of change than amount of change and 3 reported a greater amount of change than importance of change. Conclusions: Assessing the amount of change is not the same as assessing the importance of change. When the goal is to estimate important change, the reference standard should direct patients to judge the importance of the change.

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.

Fysiotherapeuten die gebruik maken van het systeem van McKenzie classificeren lage-rugpijn naar syndroomsoort: daarvan zijn er negen. De toestand van de patient wordt ingedeeld als syndroomtype 1 of 2, enz., aan de hand van zijn/haar voorafgaande medische geschiedenis en de houding, lumbale bewegingsuitslag en pijn in reactie op herhaalde bewegingen.s

Objective The impact of knee arthroplasty on body weight has not been fully explored. Clinically important weight gain following knee arthroplasty would pose potentially important health risks. Methods We used one of the largest US-based knee arthroplasty registries and a population-based control sample from the same geographic region to determine whether knee arthroplasty increases the risk of clinically important weight gain of ≥5% of baseline body weight over a 5-year postoperative period. Results Of the persons in the knee arthroplasty sample, 30.0% gained ≥5% of baseline body weight 5 years following surgery as compared to 19.7% of the control sample. The multivariable-adjusted (age, sex, body mass index, education, comorbidity, and presurgical weight change) odds ratio (OR) was 1.6 (95% confidence interval [95% CI] 1.2–2.2) in persons with knee arthroplasty as compared to the control sample. Additional arthroplasty procedures during followup further increased the risk for weight gain (OR 2.1, 95% CI 1.4–3.1) relative to the control sample. Specifically, among patients with knee arthroplasty, younger patients and those who lost greater amounts of weight in the 5-year preoperative period were at greater risk for clinically important weight gain. Conclusion Patients who undergo knee arthroplasty are at an increased risk of clinically important weight gain following surgery. The findings potentially have broad implications to multiple members of the health care team. Future research should develop weight loss/maintenance interventions particularly for younger patients who have lost a substantial amount of weight prior to surgery, as they are most at risk for substantial postsurgical weight gain.

To determine the trajectories of preoperative worsening and postoperative recovery for both the index knee and the contralateral knee of patients undergoing knee replacement surgery.Of the 4,796 subjects in the Osteoarthritis Initiative cohort study database, we examined 5-year data from 177 patients who underwent isolated unilateral knee replacement surgery and no other joint replacement surgery. Patient-reported outcomes captured domains defined by the International Classification of Functioning, Disability, and Health. Domains of knee structure and function, activity limitation, and participation restriction were examined using growth-curve modeling over 5-year periods prior to and following surgery.Preoperative worsening of the index knee was substantial in all domains of knee impairment, activity limitation, and societal participation. Pain intensity worsened only slightly from 5 years to 2.5 years prior to surgery, but worsened by ∼2 points (0-10-point scale) during the 2.5 years prior to surgery. Trajectories of improvement following surgery varied depending on the outcome measure. The contralateral knee also changed over time, such that by ∼2 years following surgery, pain was worse and by 3 years, activity limitation was worse in the contralateral knee as compared to the index knee.Patients who elect to undergo knee replacement surgery demonstrate perioperative trajectories of change that influence most health domains for both the index knee and the contralateral knee. After a period of no change, escalation of pain and worsening functioning in the index knee begins ∼2.5 years prior to surgery, which may be a key trigger for surgery.

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.

Full article available online at Healio.com/Orthopedics. Search: 20121217-14 Most orthopedic surgeons do not routinely use radiographic classification systems to grade the extent of joint space narrowing in patients considered for total knee arthroplasty. The authors compared the validity and reliability of radiographic measures of tibiofemoral osteoarthritis by 2 experienced and 2 inexperienced orthopedic surgeons on individu- als who subsequently underwent total knee arthroplasty. The Kellgren-Lawrence and the Osteoarthritis Research Society International classification systems were used by all sur - geons to score the radiographs in 116 individuals in the Osteoarthritis Initiative, a federally funded cohort study of individuals with or at risk of knee osteoarthritis. Validity was judged based on comparison with the criterion centrally adjudicated consensus measures obtained by Osteoarthritis Initiative investigators. Weighted kappa, a chance corrected agreement index, was used to describe validity and reliability. Validity and intrarater reliability were substantial to almost perfect for 1 experienced and 1 inexperienced surgeon, with weighted kappas ranging from 0.76 to 0.96 for the surgical knees. The other experienced and inex- perienced surgeons demonstrated moderate to substantial validity, with weighted kappas ranging from 0.43 to 0.70 and lower intrarater reliability. Interrater reliability was generally less than intrarater reliability. With minimal training, some surgeons can obtain valid and reliable measurements of knee osteoarthritis status in individuals who eventually undergo total knee arthroplasty. Measurement quality does not appear to be dependent on extent of surgeon experience. Some surgeons require additional training to become proficient in the radiographic classification systems, and future research should examine this issue.

Het eerste doel van dit onderzoek dat in verschillende praktijken werd uitgevoerd was het vergelijken van de betrouwbaarheid van evaluaties van patienten met lage-rugklachten die door fysiotherapeuten behandeld worden volgens de ‘McKenzie-methode’.

Clinicians frequently measure anterior tibial displacement on patients following surgical reconstruction for a torn anterior cruciate ligament (ACL). Little is known about the reliability of measurements of anterior tibial displacement obtained on patients following an ACL reconstruction. The purpose of this study was to describe the degree of error associated with repeated measurements of anterior tibial displacement on patients with reconstructed ACLs. Random pairs of physical therapists used the KT-1000 to measure the anterior tibial displacement of 30 subjects. Each pair of examiners took measurements according to the manufacturer's instructions. Examiners took three sets of measurements while applying 6.8, 9.1, and 13.6 kg (15, 20, and 30 lbs) of force to the handle of the KT-1000. Intraclass correlation coefficients (ICC 2,1) and the standard error of the difference (SED) were calculated to describe the intertester reliability of the mean of three measurements of anterior tibial displacement at each force level and of the individual measurements at each force level. The SED was then multiplied by 2 to provide a 95% confidence estimate of the magnitude of error present with KT-1000 measurements. The SED estimates the magnitude of change in anterior tibial displacement necessary to infer that a real change in anterior tibial displacement has occurred. Clinicians can be 95% confident that changes in anterior tibial displacement of greater than 5 mm (+/- 2 SED) during KT-1000 tests at 6.8, 9.1, or 13.6 kg (15, 20, or 30 lbs) of force indicate that a true change in anterior tibial displacement has occurred.

Knee arthroplasty traditionally is recommended for persons with substantial disability and disabling pain attributable to moderate or severe osteoarthritis (OA). Pain and functional status after arthroplasty may be influenced by the extent of knee OA before surgery and recent evidence suggests persons with less severe knee OA before undergoing TKA have greater pain levels and worse function than persons with more severe knee OA.We determined the proportion of patients undergoing knee arthroplasty who had less than moderate knee OA before surgery and who had either a radiographically normal medial or lateral joint space before surgery.One hundred sixteen persons in the Osteoarthritis Initiative underwent knee arthroplasty during a 3-year period. Ninety-seven of the 116 patients (84%) had radiographs available less than 1 year before surgery and were included. We used Z-tests to determine whether the proportion of patients with a modified Kellgren-Lawrence (KL) grade of 3 or higher differed from literature-based estimates. In addition, we described the proportion of patients with medial and lateral joint space narrowing.The proportion of patients with a modified KL grade of 3 or higher was 0.81 (95% CI, 0.73-0.89) and was less than the 0.95 estimated population proportion. Of the patients who underwent knee arthroplasty, 85% (82 of 97 knee arthroplasties) had at least one tibiofemoral joint compartment that had no joint space narrowing. One in six patients with OA who underwent knee arthroplasty had a KL grade of 2 or lower.Variation in the extent of tibiofemoral OA in patients preparing for joint arthroplasty is greater than previously described. A greater percentage of patients undergoing knee arthroplasty may be at risk for increased pain and poorer function than previously assumed after surgery because of less severe knee OA before surgery.Level I, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.

De term manuele therapie wordt traditioneel gezien geassocieerd met fysiotherapeuten die patienten onderzoeken en behandelen met aandoeningen die samenhangen met het bewegingsapparaat. Naast het gebruik van instrumenten voor het verzamelen van gegevens van de patienten

To determine if a previously published model of the influence of self-rated health on physical, mental, and social health among patients with joint replacement surgery could be generalized to persons with symptomatic knee osteoarthritis (OA). Our second purpose was to determine if self-rated health mediated changes in physical, mental, and social health.Persons with symptomatic knee OA (n = 1,127) who participated in the Osteoarthritis Initiative study completed the required measures at baseline and at 1-, 2-, and 3-year intervals. The key variable of interest was a single-item self-rated health measure. In addition, measures of physical, mental, and social health and a set of covariate measures over the 3-year period were analyzed. Structural equation modeling was used to test interrelationships among variables, as well as predictive and mediational relationships among self-rated health and mental, physical, and social health after adjusting for baseline covariates.The full model demonstrated good statistical fit. Prior self-rated health consistently predicted current mental health and social health. Prior social health predicted current self-rated health. Self-rated health also mediated changes in mental health and social health. Only social health changes were mediated by self-rated health over all time periods.Self-rated health predicts a variety of outcomes of symptomatic knee OA. In addition, self-rated health mediates changes in social health and mental health. The use of self-rated health as a simple and efficient clinical assessment has potential for clinical utility because of its predictive capability and association with multiple health domains.