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Background. Pelvic-floor dysfunction (PFD) affects a substantial proportion of individuals, mostly women. In responding to the demands in measuring PFD outcomes in outpatient rehabilitation, the Urinary Incontinence Questionnaire (UIQ) was developed by FOTO in collaboration with an experienced physical therapist who has a specialty in treating patients with PFD. Objective. The purpose of this study was to evaluate psychometric properties and practicability of the 21-item UIQ in patients seeking outpatient physical therapy services due to PFD. Design. This was a retrospective analysis of cross-sectional data from 1,628 patients (mean age=53 years, SD=16, range=18-91) being treated for their PFD in 91 outpatient physical therapy clinics in 24 states (United States). Methods. Using a 2-parameter logistic item response theory (IRT) procedure and the graded response model, the UIQ was assessed for unidimensionality and local independence, differential item functioning (DIF), discriminating ability, item hierarchical structure, and test precision. Results. Four items were dropped to improve unidimensionality and discriminating ability. Remaining UIQ items met IRT assumptions of unidimensionality and local independence. One item was adjusted for DIF by age group. Item difficulties were suitable for patients with PFD with no ceiling or floor effect. Item difficulty parameters ranged from -2.20 to 0.39 logits. Endorsed items representing highest difficulty levels were related to control urine flow, impact of leaking urine on life, and confidence to control the urine leakage problem. Item discrimination parameters ranged from 0.48 to 1.18. Items with higher discriminating abilities were those related to impact on life of leaking urine, confidence to control the urine leakage problem, and the number of protective garments for urine leakage. Limitations. Because this study was a secondary analysis of prospectively collected data, missing data might have influenced our results. Conclusions. Preliminary analyses supported sound psychometric properties of the UIQ items and their initial use for patients with PFD in outpatient physical therapy services., Pelvic-floor dysfunction (PFD) affects a substantial proportion of individuals, mostly women. (1-3) It is estimated that up to one third of adults experience one or more PFD conditions during their [...]

Background. Pelvic-floor dysfunction (PFD) affects a substantial proportion of individuals, especially women. Objective. The purposes of this study were: (1) to describe the characteristics of individuals with disorders associated with PFD who were seeking outpatient physical therapy services and (2) to identify the prevalence of specific pelvic-floor disorders in the group. Design. This was a prospective, longitudinal, cohort study of 2,452 patients (mean age=50 years, SD=16, range=18-91) being treated in 109 outpatient physical therapy clinics in 26 states (United States) for their PFD. Methods. This study examined patient demographic variables and summarized patient serf-reported responses to questions related to urinary and bowel functioning at admission prior to receiving the therapy for their PFD disorders. Results. Patients primarily were female (92%), were under 65 years of age (39%: 18 to Limitations. Because this study was a secondary analysis of data collected prospectively, the researchers were not in control of the data collection procedure. Missing data were common. Conclusions. Data suggested most patients with PFD receiving outpatient physical therapy services were female, younger than 65 years, and had disorders lasting for more than 90 days. Combinations of urinary, bowel, or pelvic-floor pain disorders were not uncommon., Pelvic-floor dysfunction (PFD) (1) may result in a group of clinical disorders that includes urinary incontinence, (2) anal incontinence, (3) pelvic organ prolapse, (4) sensory and emptying abnormalities of the [...]

Background. The influence of elevated fear-avoidance beliefs on change in functional status is unclear. Objective. The purpose of this study was to determine the influence of fear-avoidance on recovery of functional status during rehabilitation for people with shoulder impairments. Design. A retrospective longitudinal cohort study was conducted. Methods. Data were collected from 3,362 people with musculoskeletal conditions of the shoulder receiving rehabilitation. At intake and discharge, upper-extremity function was measured using the shoulder Computerized Adaptive Test. Pain intensity was measured using an 11-point numerical rating scale. Completion rate at discharge was 57% for function and 47% for pain intensity. A single-item screen was used to classify patients into groups with low versus elevated fear-avoidance beliefs at intake. A general linear model (GLM) was used to describe how change in function is affected by fear avoidance in 8 disease categories. This study also accounted for within-clinic correlation and controlled for other important predictors of functional change in functional status, including various demographic and health-related variables. The parameters of the GLM and their standard errors were estimated with the weighted generalized estimating equations method. Results. Functional change was predicted by the interaction between fear and disease categories. On further examination of 8 disease categories using GLM adjusted for other confounders, improvement in function was greater for the low fear group than for the elevated fear group among people with muscle, tendon, and soft tissue disorders (Δ= 1.37, P Limitations. Information was not available on whether therapists used information on level of fear to implement treatment plans. Conclusions. The influence of fear-avoidance beliefs on change in functional status varies among specific shoulder impairments., Every year, 4 million people receive medical care for musculoskeletal conditions of the shoulder, (1,2) resulting in direct health care costs of an estimated 7 billion dollars. (3) Pain is [...]

Background. Managing patients with lumbar spine syndromes who are seeking outpatient physical therapy represents a complex problem where psychosocial constructs such as fear-avoidance beliefs regarding physical activities or work activities, somatization, and depressive symptoms may affect functional status (FS) outcomes. Objective. The purpose of this study was to determine whether intake or changes in fear-avoidance beliefs regarding physical or work activities, somatization, and depressive symptoms assessed simultaneously affect FS outcomes prediction. Design. This study was a secondary analysis of prospectively collected, longitudinal, observational cohort data. Methods. Data analyzed were from adult patients (n=323) with lumbar syndromes classified as elevated versus not elevated on single-item screening instruments for fear-avoidance beliefs regarding physical or work activities, somatization, and depressive symptoms at intake and discharge. Prediction of minimal clinically important difference in FS was assessed separately for intake and change from intake to discharge classifications using logistic regression models controlling for important variables. Results. Intake and change models were strong (McFadden rho-squared values=.31 and .49, respectively). Patients classified as not elevated in fear-avoidance beliefs regarding physical activities but elevated in fear-avoidance beliefs regarding work activities, somatization, and depressive symptoms at intake were 5 out of 100 times less likely to report clinically important outcomes compared with being elevated in each measure. Patients not elevated in fear-avoidance beliefs regarding work activities and somatization at intake and discharge were 8 to 14 times more likely to report clinically important outcomes compared with being elevated in each measure. Limitations. Sample size was limited. Data analyses were retrospective with no control of missing data. Conclusions. Combinations of multiple psychosocial constructs were important predictors of FS outcomes and may assist patient management by: (1) identifying patients with elevated psychosocial constructs at intake and (2) tracking change in psychosocial variables for improved outcomes prediction. This model may prove helpful for future clinical and research applications to determine optimal psychosocial screening methods., Managing patients with lumbar spine syndromes to improve functional status (FS) outcomes represents a complex biopsychosocial process. We operationally defined lumbar spine syndromes as any constellation of symptoms related to [...]

Background. Comparative effectiveness research (CER) requires valid outcome measures that discriminate patients by risk factors in similar ways across settings. Standardized functional status (FS) measures in physical therapy are used routinely in multiple countries, creating the potential for CER among countries. Objective. The purpose of this study was to assess known-groups construct validity of a knee-specific FS measure within and between 2 countries for patients receiving outpatient physical therapy due to knee impairments. Design. This was a longitudinal, observational cohort study. Methods. The participants were 4,972 and 2,964 adult (age ≥ 18 years) patients with knee impairments from Israel and the United States, respectively. Differences in patient characteristics between the 2 countries were assessed using chi-square statistics and 2-sample t tests, as appropriate. Known-groups validity within and between the countries was assessed using 2-way analysis of covariance predicting FS at discharge, with sex, age, symptom acuity, surgical and exercise history, intake medication use, and country as risk-adjustment factors. Intake FS was the covariate. To compare how FS discriminated patient groups between countries, each factor was tested separately with models including an interaction term between the factor and country. Results. Patients were different between countries but had similar discharge FS trends, including: higher outcomes in patients who were male, were younger, had acute conditions, had one surgical procedure related to their knee impairment, were more physically active, and did not use related medication at admission. Interactions were not significant for sex, symptom acuity, and exercise history but were significant for age, surgical history, and medication use. Limitations. Although strict patient selection criteria were set, some patient selection bias still might have existed. Conclusions, The results demonstrated the knee FS measures would be valid for use in CER between Hebrew-speaking patients (Israel) and English-speaking patients (United States)., Construct validity often is used in health sciences to test validity of measures when no criterion standard exists. In the absence of a gold standard, a construct validation process is [...]

Background. Minimal clinically important improvement (MCII) is the smallest outcome measure change important to patients. Research suggests that MCII is dependent on patients' baseline functional status measures. Objective. The purposes of this study were: (1) to confirm whether MCII is dependent on patients' admission scores and (2) to test whether MCII is dependent on selected demographic characteristics. Study Design and Setting. This was a prospective, longitudinal, observational cohort study of 6,651 patients with orthopedic knee impairments treated in 332 outpatient rehabilitation clinics in 27 states in the United States. Outcome Measures. Patient serf-reports of functional status (FS) from the Lower Extremity Functional Scale were assessed using a computerized adaptive testing application (0-100 scale). Methods. An anchored-based longitudinal method, with a 15-point Likert-type scale (-7 to +7), was used to provide a global rating of change (GROC). The MCII threshold for the GROC was defined at a cut-score of +3 or greater and was determined using nonparametric receiver operating characteristic curve analysis for each of the following variables: sex, symptom acuity, age group, and quartile of baseline FS scores. Results. The results showed that MCII was dependent on patient baseline and demographic characteristics. Patients who were male, were younger, had more-acute symptoms, or had lower FS scores at admission required more FS change to report meaningful change. Limitations. As this study was a secondary analysis, how the length of treatment mediated the relationship between the independent and dependent variables was unclear. Conclusions. Although a single MCII index may provide a standard cut-score defining the smallest FS change that is meaningful to patients, researchers and clinicians should be aware that MCII is context specific and not a fixed attribute. Current results may help researchers, clinicians, and policy makers to interpret FS change related to the importance of the change to the patient., Measurement of patient-reported outcomes (PROs) in health care continues to evolve, with health status questionnaires increasingly being used in medical research and clinical practice. (1-5) As recommended by the US [...]

Background. Clinical guidelines advocate the routine identification of depressive symptoms for patients with pain in the lumbar or cervical spine, but not for other anatomical regions. Objective. The purpose of this study was to investigate the prevalence and impact of depressive symptoms for patients with musculoskeletal pain across different anatomical regions. Design. This was a prospective, associational study. Methods. Demographic, clinical, depressive symptom (Symptom Checklist 90 Revised), and outcome data were collected by self-report from a convenience sample of 8,304 patients. Frequency of severe depressive symptoms was assessed by chi-square analysis for demographic and clinical variables. An analysis of variance examined the influence of depressive symptoms and anatomical region on intake pain intensity and functional status. Separate hierarchical multiple regression models by anatomical region examined the influence of depressive symptoms on clinical outcomes. Results. Prevalence of severe depression was higher in women, in industrial and pain clinics, and in patients who reported chronic pain or prior surgery. Lower prevalence rates were found in patients older than 65 years and those who had upper- or lower-extremity pain. Depressive symptoms had a moderate to large effect on pain ratings (Cohen d=0.55-0.87) and a small to large effect on functional status (Cohen d=0.28-0.95). In multivariate analysis, depressive symptoms contributed additional variance to pain intensity and functional status for all anatomical locations, except for discharge values for the cervical region. Conclusions. Rates of depressive symptoms varied slightly based on anatomical region of musculoskeletal pain. Depressive symptoms had a consistent detrimental influence on outcomes, except on discharge scores for the cervical anatomical region. Expanding screening recommendations for depressive symptoms to include more anatomical regions may be indicated in physical therapy settings., Depression is recognized as one of the leading causes of disability in the United States and affects approximately 5% to 10% of the American general population. (1,2) The point prevalence [...]