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Fellinghauer C, Debelak R, Strobl C. What Affects the Quality of Score Transformations? Potential Issues in True-Score Equating Using the Partial Credit Model. EDUCATIONAL AND PSYCHOLOGICAL MEASUREMENT 2023; 83:1249-1290. [PMID: 37970488 PMCID: PMC10638984 DOI: 10.1177/00131644221143051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2023]
Abstract
This simulation study investigated to what extent departures from construct similarity as well as differences in the difficulty and targeting of scales impact the score transformation when scales are equated by means of concurrent calibration using the partial credit model with a common person design. Practical implications of the simulation results are discussed with a focus on scale equating in health-related research settings. The study simulated data for two scales, varying the number of items and the sample sizes. The factor correlation between scales was used to operationalize construct similarity. Targeting of the scales was operationalized through increasing departure from equal difficulty and by varying the dispersion of the item and person parameters in each scale. The results show that low similarity between scales goes along with lower transformation precision. In cases with equal levels of similarity, precision improves in settings where the range of the item parameters is encompassing the person parameters range. With decreasing similarity, score transformation precision benefits more from good targeting. Difficulty shifts up to two logits somewhat increased the estimation bias but without affecting the transformation precision. The observed robustness against difficulty shifts supports the advantage of applying a true-score equating methods over identity equating, which was used as a naive baseline method for comparison. Finally, larger sample size did not improve the transformation precision in this study, longer scales improved only marginally the quality of the equating. The insights from the simulation study are used in a real-data example.
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Leech JB, MacPherson KL, Klopper M, Shumway J, Salvatori RT, Rhon DI, Young JL. The relationships between pain-associated psychological distress, pain intensity, patient expectations, and physical function in individuals with musculoskeletal pain: A retrospective cohort study. PM R 2023; 15:1371-1381. [PMID: 37041723 DOI: 10.1002/pmrj.12983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 03/06/2023] [Accepted: 03/15/2023] [Indexed: 04/13/2023]
Abstract
INTRODUCTION The presence of pain-associated psychological distress (PAPD) in musculoskeletal disorders, including negative mood, fear-avoidance, and lack of positive affect/coping, is associated with prolonged disability. The importance of considering psychological influence on pain is well known, but practical ways of addressing it are not as straightforward. Identifying relationships between PAPD and pain intensity, patient expectations, and physical function may guide the development of future studies that assess causality and inform clinical practice. OBJECTIVE To assess the relationship between PAPD measured by the Optimal Screening for Prediction of Referral and Outcome-Yellow Flag tool, and baseline pain intensity, expectations of treatment effectiveness, and self-reported physical function at discharge. DESIGN Retrospective cohort study. SETTING Hospital-based outpatient physical therapy. PARTICIPANTS Patients 18 to 90 years old with spinal pain or lower extremity osteoarthritis. MAIN OUTCOME MEASURES Pain intensity and patient expectations of treatment effectiveness at intake, and self-reported physical function at discharge. RESULTS A total of 534 patients, 56.2% female, median (interquartile range [IQR]) age 61 (21) years with an episode of care between November 2019 and January 2021 were included. A multiple linear regression showed a significant association between PAPD and pain intensity with 6.4% (p < .001) of the variance explained. PAPD explained 3.3% (p < .001) of the variance in patient expectations. One additional yellow flag present resulted in a 0.17-point increase in pain intensity and 1.3% decrease in patient expectations. PAPD was also associated with physical function with 3.2% (p < .001) of the variance explained. PAPD explained 9.1% (p < .001) of the variance in physical function at discharge in the low back pain cohort only when assessed independently by body region. CONCLUSION These findings support the theory that the pain experience is complex and multiple factors should be considered when evaluating a patient with musculoskeletal pain. Clinicians who have identified PAPD may consider these relationships when planning or modifying interventions and pursuing multidisciplinary collaboration.
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Affiliation(s)
- Joseph B Leech
- Bellin College, Department of Physical Therapy, Doctor of Science in Physical Therapy Program, Green Bay, Wisconsin, USA
- The University of St. Augustine for Health Sciences, College of Rehabilitative Sciences, Doctor of Physical Therapy Program, Austin, Texas, USA
| | - Kevin L MacPherson
- Bellin College, Department of Physical Therapy, Doctor of Science in Physical Therapy Program, Green Bay, Wisconsin, USA
- South College, School of Physical Therapy, Doctor of Physical Therapy Program, Atlanta, Georgia, USA
| | - Mareli Klopper
- Bellin College, Department of Physical Therapy, Doctor of Science in Physical Therapy Program, Green Bay, Wisconsin, USA
| | - Joshua Shumway
- Bellin College, Department of Physical Therapy, Doctor of Science in Physical Therapy Program, Green Bay, Wisconsin, USA
| | - Robert T Salvatori
- Bellin College, Department of Physical Therapy, Doctor of Science in Physical Therapy Program, Green Bay, Wisconsin, USA
- The University of St. Augustine for Health Sciences, College of Rehabilitative Sciences, Doctor of Physical Therapy Program, Austin, Texas, USA
| | - Daniel I Rhon
- Bellin College, Department of Physical Therapy, Doctor of Science in Physical Therapy Program, Green Bay, Wisconsin, USA
| | - Jodi L Young
- Bellin College, Department of Physical Therapy, Doctor of Science in Physical Therapy Program, Green Bay, Wisconsin, USA
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Edmond SL, Werneke MW, Grigsby D, Young M, Harris G. The association between self-efficacy on function and pain outcomes among patients with chronic low back pain managed using the McKenzie approach: a prospective cohort study. J Man Manip Ther 2023; 31:38-45. [PMID: 35603569 PMCID: PMC9848301 DOI: 10.1080/10669817.2022.2075202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION Self-efficacy is a determinant of function and pain outcomes in patients with chronic low back pain receiving physiotherapy. The McKenzie approach is an effective intervention for patients with back pain that may affect self-efficacy. Study aims were to determine if, among patients with back pain being managed by McKenzie-credentialed physiotherapists: intake self-efficacy is correlated with intake function and pain; intake self-efficacy is associated with changes in function and pain during treatment; self-efficacy improves during treatment; and improvements in self-efficacy during treatment are associated with improvements in function and pain at discharge. METHODS Two-hundred-eighty-two subjects with chronic low back pain seen by McKenzie-credentialed clinicians provided data on self-efficacy, function and pain at intake and discharge. RESULTS Self-efficacy was correlated with function and pain at intake; however, intake self-efficacy was not associated with function or pain outcomes. Self-efficacy increased during treatment. This increase was associated with improvements in function and pain at discharge. CONCLUSION While intake self-efficacy was associated with function and pain when initiating physiotherapy, it did not result in improved treatment outcomes. Specific interventions may be necessary to improve self-efficacy. The increases in self-efficacy observed during treatment were associated with improvements in function and pain outcomes at discharge.
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Affiliation(s)
- Susan L Edmond
- Rutgers The State University of New Jersey, Physical Therapy Doctoral Programs, Newark, NJ, USA,CONTACT Susan L Edmond Doctoral Programs in Physical Therapy, Rutgers University of New Jersey, 65 Bergen Street, Suite 721, Newark, NJ07101-1709, USA
| | | | - David Grigsby
- Physical Therapy Department, MidSouth Orthopaedic Rehab, Cordova, TN, USA
| | - Michelle Young
- Valley Health Wellness and Fitness Center, Winchester, VA, USA
| | - Gary Harris
- IVY Rehab Physical Therapy, Medford, NJ, USA
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Baldwin J, Rodeghero J, Werneke MW, Mioduski JE, Jeffries L, Kucksdorf J, Shepherd M, Randall K, Dionne C, Dionne C. The effectiveness of post-professional physical therapist training in the treatment of chronic low back pain using a propensity score approach with machine learning. Musculoskeletal Care 2022; 20:625-640. [PMID: 35226394 PMCID: PMC9951186 DOI: 10.1002/msc.1626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 02/10/2022] [Accepted: 02/12/2022] [Indexed: 11/07/2022]
Abstract
RATIONALE Low back pain (LBP) is a leading cause of disability in the United States creating substantial hardships through negative social, financial, and health effects. Chronic low back pain (CLBP) accounted for above half of patients treated in physical therapy (PT) clinics for LBP. However, research shows small benefit from PT in CLBP treatment. Preliminary evidence suggests clinician-level training variables may affect outcomes, but requires further investigation to determine whether patients with CLBP benefit from treatment by providers with post-professional training. This study examined the relationship between clinician training levels and patient-reported outcomes in CLBP treatment. METHODS Physical therapies were surveyed using a large patient outcome assessment system to determine and categorise them by level of post-professional education. To account for the possibility that clinicians with higher levels of training are referred more-complex patients, a machine learning approach was used to identify predictive variables for clinician group, then to construct propensity scores to account for differences between groups. Differences in functional status score change among pooled data were analysed using linear models adjusted for propensity scores. RESULTS There were no clinically meaningful differences in patient outcomes when comparing clinician post-professional training level. The propensity score method proved to be a valuable way to account for differences at baseline between groups. CONCLUSION Post-professional training does not appear to contribute to improved patient outcomes in the treatment of CLBP. This study demonstrates that propensity score analysis can be used to ensure that differences observed are true and not due to differences at baseline.
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Affiliation(s)
- Jonathan Baldwin
- The University of Oklahoma Health Sciences Center, College of Allied Health, Department of Medical Imaging and Radiation Sciences, Oklahoma City OK, USA
| | - Jason Rodeghero
- Tufts University, Department of Public Health & Community Medicine, School of Medicine, Boston MA, USA
| | | | | | - Lynn Jeffries
- The University of Oklahoma Health Sciences Center, College of Allied Health, Department of Medical Imaging and Radiation Sciences, Oklahoma City OK, USA
| | - Joseph Kucksdorf
- Bellin Health, Orthopedics and Sports Medicine, Green Bay WI, USA
| | - Mark Shepherd
- Bellin College, Physical Therapy Department, Green Bay WI, USA
| | - Ken Randall
- The University of Oklahoma Health Sciences Center, College of Allied Health, Department of Medical Imaging and Radiation Sciences, Oklahoma City OK, USA
| | - Carol Dionne
- The University of Oklahoma Health Sciences Center, College of Allied Health, Department of Medical Imaging and Radiation Sciences, Oklahoma City OK, USA
| | - Carol Dionne
- College of Allied Health, Department of Medical Imaging and Radiation Sciences, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
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Patients' Perceptions and Outcome Measures after Undergoing the Enhanced Transtheoretical Model Intervention (ETMI) for Chronic Low Back Pain: A Mixed-Method Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19106106. [PMID: 35627641 PMCID: PMC9140490 DOI: 10.3390/ijerph19106106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 05/10/2022] [Accepted: 05/16/2022] [Indexed: 02/01/2023]
Abstract
This study aimed to evaluate the outcome measures and perceptions of patients with chronic low back pain (CLBP) after being treated with the Enhanced Transtheoretical Model Intervention (ETMI). In this process evaluation mixed-methods study, 30 patients with CLBP electronically completed self-reported measures (function, pain, and fear-avoidance beliefs) before and after ETMI treatment. Subsequently, each patient participated in one-on-one, semi-structured interviews, which were audio-recorded, transcribed, coded, and analyzed thematically. Quantitative analysis showed significant improvements in function (p < 0.001), pain (p < 0.001), and fear-avoidance beliefs (p < 0.001) after receiving ETMI treatment, with a large effect size (Cohen’s d = 1.234). Moreover, the average number of physiotherapy sessions was 2.6 ± 0.6 for the ETMI intervention, while the annual average number in Maccabi is estimated at 4.1 ± 1.5. Three main themes emerged from the thematic analysis: (1) communication between the patient and the practitioner; (2) psychosocial treatment elements, and (3) ETMI as a long-term solution for CLBP. The findings of the current study highlight patients’ perceived need for an open and sincere dialogue and for receiving reassurance and encouragement about their LBP. Notably, they had no problem with the fact that they did not receive passive treatment. Accordingly, together with the significant improvement in post-treatment outcome measures, patients perceived the ETMI method as a practical tool for self-managing their back problems in the long term.
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Werneke MW, Deutscher D, Hayes D, Grigsby D, Mioduski JE, Resnik LJ. Is Telerehabilitation a Viable Option for People With Low Back Pain? Associations Between Telerehabilitation and Outcomes During the COVID-19 Pandemic. Phys Ther 2022; 102:6535134. [PMID: 35202466 PMCID: PMC9383506 DOI: 10.1093/ptj/pzac020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 10/26/2021] [Accepted: 12/29/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The aims of this study were to examine associations between frequency of telerehabilitation (TR) and outcomes of functional status (FS), number of visits, and patient satisfaction during COVID-19 and to compare FS outcomes by TR delivery mode for individuals with low back pain. METHODS Propensity score matching was used to match episodes of care with or without TR exposure by the probability of receiving TR. FS, visits, and satisfaction were compared for individuals without TR and those who received care by TR for "any," "few," "most," or "all" frequencies (4 matched samples), and FS was compared for individuals receiving synchronous, asynchronous, and mixed TR modes (3 matched samples). Standardized differences were used to compare samples before and after matching. Outcomes between matched samples were compared using z tests with 95% CI. RESULTS The sample consisted of 91,117 episodes of care from 1398 clinics located in 46 states (58% women; mean age = 55 [SD = 18]). Of those, only 5013 episodes (5.5%) involved any amount of TR. All standardized differences between matched samples were <0.1. There was no significant difference in FS points (range = 0-100, with higher representing better FS) between matched samples, except for episodes that had ``few'' (-1.7) and ``all'' (+2.0) TR frequencies or that involved the asynchronous (-2.6) TR mode. These point differences suggest limited clinical importance. Episodes with any TR frequency involved significantly fewer visits (0.7-1.3) than episodes with no TR, except that those with the "most" TR frequency had non-significantly fewer visits (0.6). A smaller proportion of individuals with TR (-4.0% to -5.0%) than of individuals with no telerehabilitation reported being very satisfied with treatment results, except for those with the "all" TR frequency. CONCLUSIONS A positive association between TR and rehabilitation outcomes was observed, with a trend for better FS outcomes and fewer visits when all care was delivered through TR. Satisfaction tended to be lower with TR use. Overall, this observational study showed that for people with low back pain, physical therapy delivered through TR was equally effective as and more efficient than in-person care, with a trend of higher effectiveness when used for all visits during the episode of care. No differences in FS outcomes were observed between care delivered with synchronous and mixed TR delivery modes and care delivered with no TR. However, the asynchronous mode of TR was associated with worse functional outcomes than no TR. Although the majority of people were very satisfied with their treatment results with and without TR, very high satisfaction rates were reported by a slightly smaller proportion of individuals with TR versus those without TR. Our results suggest that TR is a viable option for rehabilitation care for individuals with low back pain and should also be considered in the post-COVID-19 era.
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Affiliation(s)
| | - Daniel Deutscher
- Net Health Systems, Inc., Pittsburgh, Pennsylvania, USA,MaccabiTech Institute for Research and Innovation, Maccabi Healthcare Services, Tel-Aviv, Israel
| | - Deanna Hayes
- Net Health Systems, Inc., Pittsburgh, Pennsylvania, USA
| | - David Grigsby
- MidSouth Orthopaedic Rehabilitation, Cordova, Tennessee, USA
| | | | - Linda J Resnik
- Department of Health Services, Policy and Practice, School of Public Health, Brown University Providence, Rhode Island, USA,Research, Providence VA Medical Center, Providence, Rhode Island, USA
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Cheville A, Basford JR. A View of the Development of Patient Reported Outcomes Measures, their Clinical Integration, Electronification, and Potential Impact on Rehabilitation Service Delivery. Arch Phys Med Rehabil 2021; 103:S24-S33. [PMID: 34896403 DOI: 10.1016/j.apmr.2021.10.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 10/20/2021] [Indexed: 11/25/2022]
Abstract
Recognition of the importance of a patient's perception of their status and experience has become central to medical care and its evaluation. This recognition has led to a growing reliance on the use of patient reported outcome measures (PROMs). Nevertheless, while awareness of PROMs and acceptance of their utility has increased markedly, few of us have a good insight into their development; their utility relative to clinician-rated and performance measures such as the FIM and 6-Minute Walk Test or how their "electronification" and incorporation into electronic health records (EHRs) may improve the individualization, value, and quality of medical care. In all, the goal of this commentary is to provide some insight into historical factors and technology developments that we believe have shaped modern clinical PROMs as they relate to medicine in general and to rehabilitation in particular. In addition, we speculate that while the growth of PROM use may have been triggered by an increased emphasis on the centrality of the patient in their care, future uptake will be shaped by their embedding in EHRs and use to improve clinical decision support though their integration with other sources of clinical and sociodemographic data.
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Affiliation(s)
- Andrea Cheville
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN
| | - Jeffrey R Basford
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN.
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Beneciuk JM, Brown-Taylor L, Alodaibi F, Kareha S, Holmes R, Fritz J. Patient- and Physical Therapist-Level Predictors of Patient-Reported Therapeutic Alliance: An Observational, Exploratory Study of Cohorts With Knee and Low Back Pain. Arch Phys Med Rehabil 2021; 102:2335-2342. [PMID: 34283991 DOI: 10.1016/j.apmr.2021.05.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 05/21/2021] [Accepted: 05/24/2021] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To identify patient- and physical therapist-level predictors for therapeutic alliance at the end of an episode of physical therapy for knee or low back pain (LBP). DESIGN Secondary analysis of observational cohort. SETTING Outpatient physical therapy clinics. PARTICIPANTS Patients receiving physical therapy for knee (n=189) or LBP (n=252) and physical therapists (n=19). Candidate predictor variables included demographics, patient clinical characteristics, and physical therapist attitudes and beliefs (Pain Attitudes and Beliefs Scale for Physical Therapists) and confidence in providing patient-centered care (Self-Efficacy in Patient-Centeredness Questionnaire). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Patient-reported therapeutic alliance was measured using the 12-item Work Alliance Inventory-Short Revised (WAI-SR). RESULTS Final linear mixed models indicated different patient- and physical therapist-level factor contributions in predicting final WAI-SR scores across cohorts with knee and LBP. Female sex was a consistent patient-level predictor for both knee (estimated β=1.57, P<.05) and LBP (β=1.42, P<.05), with age (β=-0.07, P<.01) and baseline function (β=0.06, P<.01) contributing to cohorts with knee and LBP, respectively. Physical therapist-level predictors included female sex (β=6.04, P<.05), Pain Attitudes and Beliefs Scale for Physiotherapists behavioral (β=0.65, P<.01), and Self-Efficacy in Patient-Centeredness Questionnaire (SEPCQ) Exploring Patient Perspective (β=-0.75, P<.01) subscale scores for LBP, with SEPCQ Sharing Information and Power subscale scores (β=0.56, P<.05) contributing to both cohorts with knee (β=0.56, P<.05) and LBP (β=0.74, P<.01). Random effects for patients nested within physical therapists were observed for both cohorts. CONCLUSIONS These findings provide preliminary evidence for inconsistent relationships among patient- and physical therapist-level factors and therapeutic alliance across cohorts with knee and LBP.
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Affiliation(s)
- Jason M Beneciuk
- Department of Physical Therapy, University of Florida, Gainesville, FL; Brooks Rehabilitation, Jacksonville, FL.
| | - Lindsey Brown-Taylor
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation VA, Salt Lake City, UT
| | - Faris Alodaibi
- Rehabilitation Science Department, King Saud University, Riyadh, Saudi Arabia
| | - Stephen Kareha
- Physical Therapy at St. Luke's University Health Network, Bethlehem, PA; Department of Physical Therapy, DeSales University, Bethlehem, PA
| | - Rett Holmes
- Physical Therapy at St. Luke's University Health Network, Bethlehem, PA
| | - Julie Fritz
- Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City, UT
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Werneke MW, Deutscher D, Grigsby D, Tucker CA, Mioduski JE, Hayes D. Telerehabilitation During the COVID-19 Pandemic in Outpatient Rehabilitation Settings: A Descriptive Study. Phys Ther 2021; 101:6224412. [PMID: 33848335 PMCID: PMC8083284 DOI: 10.1093/ptj/pzab110] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 03/18/2021] [Accepted: 03/28/2021] [Indexed: 12/26/2022]
Abstract
OBJECTIVE COVID-19 has widely affected delivery of health care. In response, telerehabilitation (TR) has emerged as alternative care model. Aims were: (1) to describe baseline patient characteristics and available unadjusted outcomes for episodes of care administered during COVID-19 using TR versus traditional in-person care, and (2) to describe TR frequency levels by condition and telecommunication modes. METHODS A descriptive retrospective observational design was used to report patient variables and outcomes including physical function, number of visits, and patient satisfaction, by TR frequency (few, most, or all visits) and telecommunication modes. Standardized differences were used to compare baseline characteristics between episodes with and without TR. RESULTS Sample consisted of 222,680 patients (59% female; mean [SD] age = 55 [18] years). Overall TR rate was 6% decreasing from 10% to 5% between second and third quarters of 2020. Outcome measures were available for 90% to 100% of episodes. Thirty-seven percent of clinicians administered care via TR. Patients treated using TR compared with in-person care were more likely to be younger and live in large metropolitan areas. From those with TR, 55%, 20%, and 25% had TR during few, most, or all visits, respectively. TR care was administered equally across orthopedic body parts, with lower use for nonorthopedic conditions such as stroke, edema, and vestibular dysfunction. TR was primarily administered using synchronous (video or audio) modes. The rate of patients reported being very satisfied with their treatment results was 3% higher for no TR compared with TR. CONCLUSIONS These results provide new knowledge about to whom and how TR is being administered during the pandemic in outpatient rehabilitation practices throughout the United States. The database assessed was found to be suitable for conducting studies on associations between TR and diverse outcome measures, controlling for a comprehensive set of patient characteristics, to advance best TR care models, and promote high-quality care. IMPACT This study provided detailed and robust descriptive information using an existing national patient database containing patient health and demographic characteristics, outcome measures, and telerehabilitation (TR) administration data. Findings support the feasibility to conduct future studies on associations between TR care and patient outcomes, adjusting for a wide range of patient characteristics and clinical setting factors that may be associated with the probability of receiving TR. The finding of limited and decreasing use of TR over the study period calls for studies aimed to better understand facilitators and inhibitors of TR use by rehabilitation therapists during everyday practice to promote its use when clinically appropriate.
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Affiliation(s)
- Mark W Werneke
- Address all correspondence to Mark Werneke PT, MS, E-mail address: , Postal address: 95-1031 Ohiaha St Mililani HI USA
| | - Daniel Deutscher
- Net Health Systems, Inc., Pittsburgh PA, USA,MaccabiTech Institute for Research & Innovation, Maccabi Healthcare Services, Tel-Aviv, Israel
| | - David Grigsby
- MidSouth Orthopaedic Rehabilitation, Cordova, TN, USA
| | - Carole A Tucker
- Department of Health and Rehabilitation Sciences, College of Public Health, Temple University, Philadelphia, PA, USA
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Alodaibi F, Beneciuk J, Holmes R, Kareha S, Hayes D, Fritz J. The Relationship of the Therapeutic Alliance to Patient Characteristics and Functional Outcome During an Episode of Physical Therapy Care for Patients With Low Back Pain: An Observational Study. Phys Ther 2021; 101:6123370. [PMID: 33513231 DOI: 10.1093/ptj/pzab026] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 09/22/2020] [Accepted: 12/29/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Research supports the relevance of the therapeutic alliance (TA) between patients and physical therapists on outcomes, but the impact of TA during routine physical therapist practice has not been quantified. The primary objective of this study was to examine the relationship between TA assessed during a physical therapy episode of care for patients with low back pain and functional outcome at the conclusion of care. The secondary objective was to examine psychometric properties of the Working Alliance Inventory-Short Revised (WAI-SR) form, a patient-reported TA measure. METHODS This study was a retrospective analysis of prospectively collected data from 676 patients (mean [SD] age = 55.6 [16.1] y; 55.9% female) receiving physical therapy for low back pain in 45 outpatient clinics from 1 health system in the United States. Participating clinics routinely collect patient-reported data at initial, interim, and final visits. The lumbar computer-adapted test (LCAT) was used to evaluate functional outcome. The TA was assessed from the patient's perspective at interim assessments using the WAI-SR, bivariate correlations were examined, and regression models were examined if interim WAI-SR scores explained outcome variance beyond a previously validated multivariate prediction model. Internal consistency and ceiling effects for the WAI-SR were examined. RESULTS Interim WAI-SR scores were not correlated with patient characteristics or initial LCAT, but they were correlated with final LCAT and LCAT change from initial to final assessment. WAI-SR total score (adjusted R2 = 0.36), and Task (adjusted R2 = 0.38) and Goal subscales (adjusted R2 = 0.35) explained additional variance in outcome beyond the base model (adjusted R2 = 0.33). Internal consistency was higher for WAI-SR total score (α = .88) than for subscales (α = .76-.82). Substantial ceiling effects were observed for all WAI-SR scores (27.2%-63.6%). CONCLUSION Findings support the importance of TA in physical therapist practice. Measurement challenges were identified, most notably ceiling effects. IMPACT This study supports the impact of the patient-physical therapist alliance on functional outcome. Results extend similar findings from controlled studies into a typical physical therapist practice setting. Better understanding of the role of contextual factors including the therapeutic alliance might be key to improving the magnitude of treatment effect for discrete physical therapist interventions and enhancing clinical outcomes of physical therapy episodes of care.
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Affiliation(s)
- Faris Alodaibi
- Rehabilitation Science Department, King Saud University, Riyadh, Saudi Arabia
| | - Jason Beneciuk
- University of Florida Department of Physical Therapy, Gainesville, Florida, USA
| | - Rett Holmes
- Physical Therapy at St Luke's University Health Network, Bethlehem, Pennsylvania, USA
| | - Stephen Kareha
- Physical Therapy at St Luke's University Health Network, Bethlehem, Pennsylvania, USA
| | - Deanna Hayes
- Focus on Therapeutic Outcomes, Inc, Knoxville, Tennessee, USA
| | - Julie Fritz
- Department of Physical Therapy and Athletic Training, University of Utah, 383 Colorow Drive, Room 391, Salt Lake City, UT 84108, USA
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Netzer O, Shechtman Z. Individual Versus Group Physical Therapy for Patients with Low Back Pain: Outcomes and Process (Therapeutic Factors). Int J Group Psychother 2020; 70:349-374. [PMID: 38449218 DOI: 10.1080/00207284.2020.1727746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Low back pain (LBP) is a common health problem usually treated individually, and requires costly physical therapy. Group treatment, besides being cost-effective, provides psychological support to the recovery of people who struggle with a physically disabling condition. The current study compares individual and group treatment of LBP, measuring differences in outcomes and process data (therapeutic factors). The study included 158 patients who participated in group (n = 71) and individual (n = 87) physical therapy, using a pre-post-follow-up design. Results indicated a significant improvement in all outcome measures at postintervention in both treatment settings, with no difference between them, which were sustained at follow-up. On a clinical level, a few differences were found: At postintervention, minimal clinically important improvement in perceived functioning and level of pain was greater among patients treated individually. On the other hand, at follow-up, only group participants gained additionally in perceived functioning and in fear avoidance. Therapeutic factors of other- versus self-focus and problem definition-change were more prevalent in group treatment.
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Are Changes in Fear-Avoidance Beliefs and Self-efficacy Mediators of Function and Pain at Discharge in Patients With Acute and Chronic Low Back Pain? J Orthop Sports Phys Ther 2020; 50:301-308. [PMID: 31905094 DOI: 10.2519/jospt.2020.8982] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To examine the mediating role of changes in fear-avoidance beliefs and self-efficacy on pain and physical functioning at discharge in patients with acute and chronic low back pain (LBP). DESIGN Retrospective study. METHODS Baseline and discharge data from 418 participants with acute and chronic LBP were analyzed. At discharge, functional status and pain intensity were analyzed to assess their role as a predictor of acute and chronic LBP status and as a mediator of fear-avoidance beliefs and self-efficacy from baseline to discharge. RESULTS In multivariable analyses, patients with chronic LBP had lower discharge functional status (β = -7.4; 95% confidence interval [CI]: -10.5, -4.3), lower self-efficacy for physical function (β = -5.3; 95% CI: -10.2, -0.4), higher pain intensity (β = 0.9; 95% CI: 0.3, 1.5), and no difference in discharge fear-avoidance beliefs compared to patients with acute LBP. Change in self-efficacy for physical function had a small indirect association (β = -1.1; 95% bias-corrected CI: -2.5, -0.004), mediating the relationship between chronic LBP and discharge functional status. CONCLUSION Fear-avoidance beliefs were not a mediator of pain or function at discharge in patients with chronic LBP. Self-efficacy may be an important mediating factor for function at discharge in patients with chronic LBP who receive physical therapy. J Orthop Sports Phys Ther 2020;50(6):301-308. Epub 6 Jan 2020. doi:10.2519/jospt.2020.8982.
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Abstract
STUDY DESIGN .: A retrospective observational study. OBJECTIVE Assess the time course of functional outcome improvements during a physical therapy (PT) episode of care for patients with low back pain. In addition, assess the impact of patient variables, such as symptom duration, on the time course of functional outcome improvements. SUMMARY OF BACKGROUND DATA Early improvement in patient-reported symptoms and functional limitations may play an important role in the eventual success of an intervention. Early improvements in pain are associated with greater improvement in disability and depression in patients with low back pain. METHODS A total 11,945 patients were included. Intake functional status (FS), FS change at discharge, predicted FS change at discharge, FS change at first progress report (FS1), duration of symptoms before treatment, and duration of PT episode of care were assessed. Pearson correlation analysis was used to assess correlation between collected variables and FS change. RESULTS The mean FS change was 16.995 units, mean FS1 was 12.024 units, total duration was 63.591 days, and duration at FS1 was 28.969 days, indicating 70.72% of FS change occurred in the first 45.45% of the episode of care. Similar results occurred in all symptom duration categories, ranging from "0 to 7 days' to "greater than 6 months' duration. Correlation analysis demonstrated that FS1 had the greatest correlation to FS. A strong correlation (r > 0.7) was demonstrated in all symptom duration categories ranging from 0.741 to 0.805. CONCLUSION The results of this study yield further support for the importance of rapid functional improvements during a PT episode of care. In addition, patients demonstrated roughly two-thirds of their improvement in the first 40% of visits regardless of their symptom duration. This study may help clinicians identify a need to modify a plan of care if insufficient early improvement is observed. LEVEL OF EVIDENCE 3.
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Walston Z, McLester C, McLester J. Effect of Low Back Pain Chronicity on Patient Outcomes Treated in Outpatient Physical Therapy: A Retrospective Observational Study. Arch Phys Med Rehabil 2019; 101:861-869. [PMID: 31874155 DOI: 10.1016/j.apmr.2019.11.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 11/14/2019] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To examine the potential relationship between physical therapy (PT) treatment outcomes and chronicity of low back pain (LBP) in the outpatient setting. DESIGN Retrospective observational study. SETTING Outpatient PT clinics across 11 states. PARTICIPANTS A total of 11,941 patients with LBP provided with PT services and discharged from care between January 1, 2017, and December 31, 2018. MAIN OUTCOME MEASURES Focus on Therapeutic Outcome Low Back Functional Status (FS) Patient-Reported Outcome Measure (PROM) was the primary outcomes measure used. It assesses the patients' perceived physical abilities for patients experiencing LBP impairments. It determined a functional score on a linear metric ranging from 0 (low functioning) to 100 (high functioning). The difference in score between the intake FS and final FS score produced the FS change, which represented the overall improvement of the episode of care. RESULTS The mean FS change was 16.997 (n=11,945). Patients with chronic symptoms (>90-d duration) had an FS change of 15.920 (n=7264) across 14.63 visits. Patients with subacute symptoms (15-90d) had an FS change of 21.66 (n=3631) across 14.05. Patients with acute symptoms (0-14d) had an FS change of 29.32 (n=1050) across 13.66 visits. Stepwise regression analysis revealed a significant â for chronicity (-4.155) with all models. CONCLUSIONS Overall, this study shows patients experiencing shorter duration of LBP symptoms before starting a PT episode of care experience significantly better outcomes than patients who waited. Furthermore, the number of treatment session and duration of care was similar between groups, indicating potential ineffective or insufficient care was provided for patients with chronic pain.
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Affiliation(s)
- Zachary Walston
- PT Solutions Physical Therapy, Atlanta, Georgia, United States.
| | | | - John McLester
- Kennesaw State University, Kennesaw, Georgia, United States
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Associations between interim patient-reported outcome measures and functional status at discharge from rehabilitation for non-specific lumbar impairments. Qual Life Res 2019; 29:439-451. [PMID: 31571028 DOI: 10.1007/s11136-019-02314-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE Identify impact of frequency and timing of interim Patient-Reported Outcome Measures (PROMs) assessments during episodes of care for rehabilitation services in outpatient clinical settings on functional status (FS) outcomes at discharge for patients with low back pain. METHODS FS outcomes of patients who had no interim PROMs were compared to outcomes of six patient groups defined by interim timing (early, mid, late) and frequency (1, 2 or more). For each comparison, patients were matched using propensity score matching for variables known to be associated with FS outcomes and for episode duration (days) and number of visits. FS was assessed using the lumbar computerized adaptive test (LCAT) where scores range from 0 to 100 with higher scores representing better physical function. RESULTS A sample of 140,336 patients was considered for matching (mean age = 58 [SD = 17] range 18-89; 60% females) with 83,101 patients (59%) having no interim PROMs. Patients who had only one interim PROM, administered during early (first 2 weeks), mid (weeks 3-4), or late (week 5 or later) timing, had 4.6, 2.7, and 1.0 additional FS score points at discharge compared to those without an interim PROM, respectively (p < 0.001). Having two or more interim PROMs was associated with an additional 1.2 FS points compared to having only one interim assessment, but only if the first interim was administered early. CONCLUSIONS Optimal utilization of interim PROM assessment during clinical practice to enhance treatment outcomes was related to administering the first interim PROM within the first 2 weeks after the initial evaluation.
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Edmond SL, Werneke MW, Young M, Grigsby D, McGill T, McClenahan B. Directional preference, cognitive behavioural interventions, and outcomes among patients with chronic low back pain. PHYSIOTHERAPY RESEARCH INTERNATIONAL 2019; 24:e1773. [PMID: 30950187 DOI: 10.1002/pri.1773] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 12/12/2018] [Accepted: 02/01/2019] [Indexed: 01/31/2023]
Abstract
OBJECTIVES Graded activity and graded exposure are recommended cognitive behavioural approaches to improve function and pain outcomes for patients receiving physiotherapy for chronic nonspecific low back pain. Directional preference identified following the McKenzie method is also associated with favourable patient outcomes. Study objectives were to examine associations between graded activity and/or graded exposure, and directional preference or no directional preference combined with or without graded activity/graded exposure subgroups, and function and pain outcomes among patients with chronic nonspecific low back pain managed by clinicians credentialed in the McKenzie approach. METHOD Cohort study: Subjects (n = 801) with chronic nonspecific low back pain completed intake surveys, that is, the Lumbar Computer Adaptive Test measuring function and the Numeric Pain Rating Scale measuring pain, and questions addressing their demographic, lifestyle, and health status. Directional preference was determined at intake. Treatment with graded activity/graded exposure during the episode of care was recorded. Function and pain measures were repeated at discharge. Two models were developed controlling for potential confounding effects. The first model examined associations between patients receiving versus not receiving graded activity/graded exposure. The second model examined interaction effects between four combinations of directional preference and graded activity/graded exposure. Outcome measures were changes in function and pain during rehabilitation. RESULTS Regarding the first objective, there were no clinically relevant differences between treatment versus no treatment with graded activity/graded exposure, and functional outcomes. Regarding the second objective, patients in the no-directional preference group were more likely to see benefits from the addition of graded activity/graded exposure to their treatment groups than those with a directional preference. CONCLUSION Clinicians using McKenzie methods might attain improved patient functional outcomes when augmenting treatment with graded activity and/or graded exposure among patients who do not demonstrate directional preference.
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Affiliation(s)
- Susan L Edmond
- Doctoral Programs in Physical Therapy, Rutgers The State University of New Jersey, Newark, New Jersey, USA
| | - Mark W Werneke
- Focus On Therapeutic Outcomes Inc., Knoxville, Tennessee, Dip MDT, Waipahu, Hawaii, USA
| | - Michelle Young
- Wellness Health, Rehabilitation Department, Winchester, Virginia, USA
| | - David Grigsby
- Physical Therapy Department, MidSouth Orthopaedic Rehabilitation, Cordova, Tennessee, USA
| | - Troy McGill
- Outpatient Therapy Department, Dip MDT, Providence Rehabilitation Services, Anchorage, Alaska, USA
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Impact of Risk Adjustment on Provider Ranking for Patients With Low Back Pain Receiving Physical Therapy. J Orthop Sports Phys Ther 2018; 48:637-648. [PMID: 29787696 DOI: 10.2519/jospt.2018.7981] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background The impact of risk adjustment on clinic quality ranking for patients treated in physical therapy outpatient clinics is unknown. Objectives To compare clinic ranking, based on unadjusted versus risk-adjusted outcomes for patients with low back pain (LBP) who are treated in physical therapy outpatient clinics. Methods This retrospective cohort study involved a secondary analysis of data from adult patients with LBP treated in outpatient physical therapy clinics from 2014 to 2016. Patients with complete outcomes data at admission and discharge were included to develop the risk-adjustment model. Clinics with complete outcomes data for at least 50% of patients and at least 10 complete episodes of care per clinician per year were included for ranking assessment. The R2 shrinkage and predictive ratio were used to assess overfitting. Agreement between unadjusted and adjusted rankings was assessed with percentile ranking by deciles or 3 distinct quality ranks based on uncertainty assessment. Results The primary sample included 414 125 patients (mean ± SD age, 57 ± 17 years; 60% women) treated by 12 569 clinicians from 3048 clinics from all US states; 82% of patients from 2107 clinics were included in the ranking assessment. The R2 shrinkage was less than 1%, with a predictive ratio of 1. Risk adjustment impacted ranking for 70% or 31% of clinics, based on deciles or 3 distinct quality levels, respectively. Conclusion Important changes in ranking were found after adjusting for basic patient characteristics of those admitted to physical therapy for treatment of LBP. Risk-adjustment profiling is necessary to more accurately reflect quality of care when treating patients with LBP. Level of Evidence Therapy, level 2b. J Orthop Sports Phys Ther 2018;48(8):637-648. Epub 22 May 2018. doi:10.2519/jospt.2018.7981.
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McCabe E, Gross DP, Bulut O. Procedures to develop a computerized adaptive test to assess patient-reported physical functioning. Qual Life Res 2018; 27:2393-2402. [DOI: 10.1007/s11136-018-1898-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2018] [Indexed: 12/16/2022]
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Wang YC, Sindhu BS, Kapellusch J, Yen SC, Lehman L. Global rating of change: perspectives of patients with lumbar impairments and of their physical therapists. Physiother Theory Pract 2018; 35:851-859. [DOI: 10.1080/09593985.2018.1458930] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Ying-Chih Wang
- Department of Occupational Science and Technology, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
| | - Bhagwant S. Sindhu
- Department of Occupational Science and Technology, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
| | - Jay Kapellusch
- Department of Occupational Science and Technology, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
| | - Sheng-Che Yen
- Department of Physical Therapy, Northeastern University, Boston, MA, USA
| | - Leigh Lehman
- Department of Occupational Therapy, Augusta University, Augusta, GA, USA
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Werneke MW, Edmond S, Young M, Grigsby D, McClenahan B, McGill T. Directional preference and functional outcomes among subjects classified at high psychosocial risk using STarT. PHYSIOTHERAPY RESEARCH INTERNATIONAL 2018. [PMID: 29536595 DOI: 10.1002/pri.1711] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND AND PURPOSE Physiotherapy has an important role in managing patients with non-specific low back pain who experience elevated psychosocial distress or risk for chronic disability. In terms of evidence-based physiotherapy practice, cognitive-behavioural approaches for patients at high psychosocial risk are the recommended management to improve patient treatment outcomes. Evidence also suggests that directional preference (DP) is an important treatment effect modifier for prescribing specific exercises for patients to improve outcomes. Little is known about the influence of treatment techniques based on DP on outcomes for patients classified as high psychosocial risk using the Subgroups for Targeted Treatment (STarT) Back Screening Tool. This study aimed to examine the association between functional status (FS) at rehabilitation discharge for patients experiencing low back pain classified at high STarT psychosocial risk and whose symptoms showed a DP versus No-DP. METHODS High STarT risk patients (n = 138) completed intake surveys, that is, the lumbar FS of Focus On Therapeutic Outcomes, Inc., and STarT, and were evaluated for DP by physiotherapists credentialed in McKenzie methods. The FS measure of Focus On Therapeutic Outcomes, Inc., was repeated at discharge. DP and No-DP prevalence rates were calculated. Associations between first-visit DP and No-DP and change in FS were assessed using univariate and multivariate regression models controlling for 11 risk-adjusted variables. RESULTS One hundred nine patients classified as high STarT risk had complete intake and discharge FS and DP data. Prevalence rate for DP was 65.1%. A significant and clinically important difference (7.98 FS points; p = .03) in change in function at discharge between DP and No-DP was observed after controlling for all confounding variables in the final model. CONCLUSION Findings suggest that interventions matched to DP are effective for managing high psychological risk patients and may provide physiotherapists with an alternative treatment pathway compared to managing similar patients with cognitive-behavioural approaches. Stricter research designs are required to validate study conclusions.
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Affiliation(s)
| | - Susan Edmond
- Doctoral Programs in Physical Therapy, Rutgers, The State University of New Jersey, Newark, NJ, USA
| | - Michelle Young
- Rehabilitation Services at The Wellness Center, Winchester Medical Center, Winchester, VA, USA
| | - David Grigsby
- MidSouth Orthopaedic Rehabilitation, Germantown, TN, USA
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Werneke M. Criteria for Recommending a Patient Self-Report Functional Outcome. Arch Phys Med Rehabil 2016; 98:191-192. [PMID: 28010779 DOI: 10.1016/j.apmr.2016.08.477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Accepted: 08/18/2016] [Indexed: 11/15/2022]
Affiliation(s)
- Mark Werneke
- Spine Rehabilitation, CentraState Medical Center, Freehold, NJ
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Item Response Theory and Computerized Adaptive Testing for Orthopaedic Outcomes Measures. J Am Acad Orthop Surg 2016; 24:750-754. [PMID: 27623193 DOI: 10.5435/jaaos-d-15-00420] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
The use of patient-reported outcome measures (PROMs) to objectively and quantifiably assess patient symptomatology allows tracking of symptoms over time, measurement of the effect of healthcare interventions, and performance of cost-effectiveness analyses to assess and compare the value of treatment options. Many of the PROMs historically used had limited versatility because they were developed using classical test theory, which generates static tests that are not comparable with other measures assessing similar outcomes. Recently developed PROMs, however, were designed according to the principles of the newer item response theory (IRT), which allows for the creation of dynamic instruments deliverable in a variety of forms that are readily comparable with similar measures. IRT also enables computerized adaptive testing to decrease the burden of using PROMs by allowing rapid and complete data acquisition. IRT-based instruments are suitable for patient care and research and have been validated in a variety of populations, many of which are relevant to orthopaedic populations.
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Marcucci M, Germini F, Coerezza A, Andreinetti L, Bellintani L, Nobili A, Rossi PD, Mari D. Efficacy of ultra-micronized palmitoylethanolamide (um-PEA) in geriatric patients with chronic pain: study protocol for a series of N-of-1 randomized trials. Trials 2016; 17:369. [PMID: 27473188 PMCID: PMC4966710 DOI: 10.1186/s13063-016-1496-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Accepted: 07/02/2016] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Chronic pain in older people is highly prevalent, often underestimated, and associated with adverse outcomes. Most available analgesic drugs are often either ineffective or not tolerated, with many side effects. Palmitoylethanolamide (PEA) is an endogenous widely distributed N-acylethanolamina involved in neuroinflammation and pain-generating processes. Formulations containing ultra-micronized palmitoylethanolamide (um-PEA) are available but their effectiveness on chronic pain in highly heterogeneous geriatric patients is not clear and probably not generalizable. We planned to adopt the N-of-1 trial approach to test the effectiveness of um-PEA objectively at the individual level in our older outpatients. METHODS/DESIGN Persons 65 years or older referring to the Geriatric Unit of the Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico of Milan complaining of noncancer chronic pain of any origin will be eligible. Each trial will be a placebo-controlled randomized crossover trial including two um-PEA (600 mg twice a day) and placebo treatment pairs. The um-PEA or placebo 3-week periods will be separated by 2-week washout intervals to overcome possible carryover effects. Pain intensity, need of on-demand analgesic medications, and impact on daily activities will be evaluated. Cognitively impaired patients will be eligible as long as an expression of pain can be recognized and its frequency assessed by a caregiver. Trial results will be discussed with the patient or caregiver and the treating physician to decide whether to continue the treatment. The impact of the N-of-1 approach on the physician's management plan and confidence will be assessed. We will secondarily meta-analyze the performed N-of-1 trials to obtain an estimate of the average effect of um-PEA compared with placebo using a frequentist and Bayesian approach. DISCUSSION While pursuing an ultimate clinical objective, i.e. to empirically and objectively decide the best treatment choice for an individual older patient with chronic pain, these series of geriatric N-of-1 trials on PEA will bring the principles of evidence-based medicine into the care of patients not usually represented in conventional randomized controlled trials, and realize a patient-centered outcome approach necessary to improve appropriate prescribing in elderly patients with multimorbidity and polypharmacy. TRIAL REGISTRATION ClinicalTrials.gov NCT02699281 . Registered on 3 March 2016.
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Affiliation(s)
- Maura Marcucci
- Geriatric Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Via Pace 9, 20122, Milan, Italy. .,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, via Francesco Sforza 35, 20122, Milan, Italy.
| | - Federico Germini
- Geriatric Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Via Pace 9, 20122, Milan, Italy
| | - Anna Coerezza
- Geriatric Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Via Pace 9, 20122, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, via Francesco Sforza 35, 20122, Milan, Italy
| | - Luca Andreinetti
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, via Francesco Sforza 35, 20122, Milan, Italy
| | - Lorenzo Bellintani
- Geriatric Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Via Pace 9, 20122, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, via Francesco Sforza 35, 20122, Milan, Italy
| | - Alessandro Nobili
- Laboratory for Quality Assessment of Geriatric Therapies and Services, IRCCS - Istituto di Ricerche Farmacologiche "Mario Negri", via Giuseppe La Masa 19, 20156, Milan, Italy
| | - Paolo Dionigi Rossi
- Geriatric Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Via Pace 9, 20122, Milan, Italy
| | - Daniela Mari
- Geriatric Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Via Pace 9, 20122, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, via Francesco Sforza 35, 20122, Milan, Italy
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Risk Adjustment for Lumbar Dysfunction: Comparison of Linear Mixed Models With and Without Inclusion of Between-Clinic Variation as a Random Effect. Phys Ther 2015; 95:1692-702. [PMID: 25908524 DOI: 10.2522/ptj.20140444] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Accepted: 04/13/2015] [Indexed: 02/09/2023]
Abstract
BACKGROUND Valid comparison of patient outcomes of physical therapy care requires risk adjustment for patient characteristics using statistical models. Because patients are clustered within clinics, results of risk adjustment models are likely to be biased by random, unobserved between-clinic differences. Such bias could lead to inaccurate prediction and interpretation of outcomes. PURPOSE The purpose of this study was to determine if including between-clinic variation as a random effect would improve the performance of a risk adjustment model for patient outcomes following physical therapy for low back dysfunction. DESIGN This was a secondary analysis of data from a longitudinal cohort of 147,623 patients with lumbar dysfunction receiving physical therapy in 1,470 clinics in 48 states of the United States. METHODS Three linear mixed models predicting patients' functional status (FS) at discharge, controlling for FS at intake, age, sex, number of comorbidities, surgical history, and health care payer, were developed. Models were: (1) a fixed-effect model, (2) a random-intercept model that allowed clinics to have different intercepts, and (3) a random-slope model that allowed different intercepts and slopes for each clinic. Goodness of fit, residual error, and coefficient estimates were compared across the models. RESULTS The random-effect model fit the data better and explained an additional 11% to 12% of the between-patient differences compared with the fixed-effect model. Effects of payer, acuity, and number of comorbidities were confounded by random clinic effects. LIMITATIONS Models may not have included some variables associated with FS at discharge. The clinics studied may not be representative of all US physical therapy clinics. CONCLUSIONS Risk adjustment models for functional outcome of patients with lumbar dysfunction that control for between-clinic variation performed better than a model that does not.
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The Development and Psychometric Properties of the Patient Self-Report Neck Functional Status Questionnaire (NFSQ). J Orthop Sports Phys Ther 2015; 45:683-92. [PMID: 26158883 DOI: 10.2519/jospt.2015.5640] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
STUDY DESIGN Retrospective analysis of cross-sectional data. OBJECTIVE To describe the development of a new self-report Neck Functional Status Questionnaire (NFSQ) and to assess its psychometric properties and practical application. The NFSQ was designed to assess functional status in patients with cervical (spine) disorders who seek outpatient therapy. BACKGROUND Many patients seek outpatient therapy due to cervical disorders. Currently, no patient-reported outcome measures exist that capture the ability to perform functional activity in a manner that reflects the experience of this patient population. METHODS Four hundred thirty-nine patients who were being treated for cervical disorders responded to a set of survey questions to assess activity-related functional outcomes associated with cervical disorders. Using item response theory, we assessed candidate items for unidimensionality and local independence, item fit, person separation, precision, targeting, and differential item functioning. We also compared discriminant validity of functional status measures estimated by the item response theory model (NFSQ fixed) and measures generated using a simulated computerized adaptive test (NFSQ computerized adaptive test). RESULTS Based on expert opinion and subsequent processing and analyses, a final set of 28 items was used to develop the NFSQ. Unidimensionality and local independence were supported. The mean ± SD sample ability level of 57.6 ± 14.3 (scale range, 0-100) matched well with the mean item difficulty of the NFSQ of 51.3 ± 7.4. Differential item functioning was negligible for levels of age group, sex, and symptom acuity. The NFSQ computerized adaptive test measures were as precise as the NFSQ fixed measures. CONCLUSION Study results supported the preliminary validity of the 28-item NFSQ for use in assessing patients with different levels of functional status related to their cervical disorders in outpatient rehabilitation settings.
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Gozalo PL, Resnik LJ, Silver B. Benchmarking Outpatient Rehabilitation Clinics Using Functional Status Outcomes. Health Serv Res 2015; 51:768-89. [PMID: 26251040 DOI: 10.1111/1475-6773.12344] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE To utilize functional status (FS) outcomes to benchmark outpatient therapy clinics. DATA SOURCES Outpatient therapy data from clinics using Focus on Therapeutic Outcomes (FOTO) assessments. STUDY DESIGN Retrospective analysis of 538 clinics, involving 2,040 therapists and 90,392 patients admitted July 2006-June 2008. FS at discharge was modeled using hierarchical regression methods with patients nested within therapists within clinics. Separate models were estimated for all patients, for those with lumbar, and for those with shoulder impairments. All models risk-adjusted for intake FS, age, gender, onset, surgery count, functional comorbidity index, fear-avoidance level, and payer type. Inverse probability weighting adjusted for censoring. DATA COLLECTION METHODS Functional status was captured using computer adaptive testing at intake and at discharge. PRINCIPAL FINDINGS Clinic and therapist effects explained 11.6 percent of variation in FS. Clinics ranked in the lowest quartile had significantly different outcomes than those in the highest quartile (p < .01). Clinics ranked similarly in lumbar and shoulder impairments (correlation = 0.54), but some clinics ranked in the highest quintile for one condition and in the lowest for the other. CONCLUSIONS Benchmarking models based on validated FS measures clearly separated high-quality from low-quality clinics, and they could be used to inform value-based-payment policies.
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Affiliation(s)
- Pedro L Gozalo
- Center for Gerontology and Health Care Research, School of Public Health, Brown University, Providence, RI.,Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, RI
| | - Linda J Resnik
- Center for Gerontology and Health Care Research, School of Public Health, Brown University, Providence, RI.,Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, RI.,Providence Veterans Administration Medical Center, Health Services Research, Providence, RI
| | - Benjamin Silver
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, RI
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Kopec JA, Sayre EC, Rogers P, Davis AM, Badley EM, Anis AH, Abrahamowicz M, Russell L, Rahman MM, Esdaile JM. Multiattribute health utility scoring for the computerized adaptive measure CAT-5D-QOL was developed and validated. J Clin Epidemiol 2015; 68:1213-20.e1-6. [PMID: 25990544 DOI: 10.1016/j.jclinepi.2015.03.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Revised: 03/11/2015] [Accepted: 03/14/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVES The CAT-5D-QOL is a previously reported item response theory (IRT)-based computerized adaptive tool to measure five domains (attributes) of health-related quality of life. The objective of this study was to develop and validate a multiattribute health utility (MAHU) scoring method for this instrument. STUDY DESIGN AND SETTING The MAHU scoring system was developed in two stages. In phase I, we obtained standard gamble (SG) utilities for 75 hypothetical health states in which only one domain varied (15 states per domain). In phase II, we obtained SG utilities for 256 multiattribute states. We fit a multiplicative regression model to predict SG utilities from the five IRT domain scores. The prediction model was constrained using data from phase I. We validated MAHU scores by comparing them with the Health Utilities Index Mark 3 (HUI3) and directly measured utilities and by assessing between-group discrimination. RESULTS MAHU scores have a theoretical range from -0.842 to 1. In the validation study, the scores were, on average, higher than HUI3 utilities and lower than directly measured SG utilities. MAHU scores correlated strongly with the HUI3 (Spearman ρ = 0.78) and discriminated well between groups expected to differ in health status. CONCLUSION Results reported here provide initial evidence supporting the validity of the MAHU scoring system for the CAT-5D-QOL.
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Affiliation(s)
- Jacek A Kopec
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, British Columbia, Canada V6T 1Z9; Arthritis Research Canada, 5591 No. 3 Road, Richmond, British Columbia, Canada V6X 2C7.
| | - Eric C Sayre
- Arthritis Research Canada, 5591 No. 3 Road, Richmond, British Columbia, Canada V6X 2C7
| | - Pamela Rogers
- Arthritis Research Canada, 5591 No. 3 Road, Richmond, British Columbia, Canada V6X 2C7
| | - Aileen M Davis
- Health Care and Outcomes Research, Toronto Western Research Institute, University Health Network, 399 Bathurst Street, Toronto, Ontario, Canada M5T 2S8; Institute of Health Policy, Management and Evaluation, University of Toronto, 55 College Street, Toronto, Ontario, Canada M5T 3M7; Departments of Physical Therapy and the Rehabilitation Science Institute, University of Toronto, 500 University Avenue, Toronto, Ontario Canada M5G 1V7
| | - Elizabeth M Badley
- Dalla Lana School of Public Health, University of Toronto, Health Sciences Building, 155 College St., Toronto, Ontario, Canada M5S 1A8
| | - Aslam H Anis
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, British Columbia, Canada V6T 1Z9; Arthritis Research Canada, 5591 No. 3 Road, Richmond, British Columbia, Canada V6X 2C7
| | - Michal Abrahamowicz
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Purvis Hall, 1020 Pine Ave. West, Montreal, Quebec, Canada H3A 1A2
| | - Lara Russell
- Centre for Health Evaluation and Outcome Sciences, University of British Columbia, 1081 Burrard Street, St. Paul's Hospital, Vancouver, British Columbia, Canada V6Z 1Y6
| | - Md Mushfiqur Rahman
- Arthritis Research Canada, 5591 No. 3 Road, Richmond, British Columbia, Canada V6X 2C7
| | - John M Esdaile
- Arthritis Research Canada, 5591 No. 3 Road, Richmond, British Columbia, Canada V6X 2C7; Department of Medicine, University of British Columbia, 1200 Burrard Street, Vancouver, British Columbia Canada V6Z 2C7
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The impact of physical therapy residency or fellowship education on clinical outcomes for patients with musculoskeletal conditions. J Orthop Sports Phys Ther 2015; 45:86-96. [PMID: 25579690 DOI: 10.2519/jospt.2015.5255] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
STUDY DESIGN A retrospective cohort design was conducted using data from an electronic survey and an existing commercial outcomes database. OBJECTIVE To compare the clinical outcomes of patients with musculoskeletal conditions treated by physical therapists who had completed residency or fellowship programs versus those who had not. BACKGROUND There is an increasing focus on specialization through postprofessional education in physical therapy residency and fellowship programs. Scant evidence exists that evaluates the influence of postprofessional clinical education on actual patient outcomes. METHODS Physical therapists using a national outcomes database were surveyed to determine their level of postprofessional education. Survey responders were categorized into 1 of 3 groups that included no residency or fellowship training, residency trained, or fellowship trained. Outcomes for 25 843 patients with musculoskeletal conditions treated by 363 therapists from June 2012 to June 2013 were extracted from the database. These data were analyzed to identify any differences in functional status change and efficiency achieved between the 3 groups. Potentially confounding variables were controlled for statistically. RESULTS The fellowship-trained group of physical therapists achieved functional status changes and efficiency that were greater than those of the other groups. No difference in functional status change was observed between the residency group and the therapists without residency or fellowship training. The group without residency or fellowship training was more efficient than the residency-trained group. Fellowship-trained therapists were more likely to achieve greater treatment effect sizes than therapists without residency or fellowship training. Residency-trained therapists were less likely to achieve greater treatment effect sizes than the therapists without residency or fellowship training. CONCLUSION These data demonstrate that fellowship training may contribute to statistically greater patient outcomes. Residency training did not appear to contribute to improved patient functional status change or efficiency. It is unknown whether the statistical differences observed would be clinically meaningful for patients.
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Physical therapists' level of McKenzie education, functional outcomes, and utilization in patients with low back pain. J Orthop Sports Phys Ther 2014; 44:925-36. [PMID: 25353260 DOI: 10.2519/jospt.2014.5272] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
STUDY DESIGN Longitudinal, prospective, observational cohort. OBJECTIVE To examine associations between McKenzie training, functional status (FS) at discharge, and number of physical therapy visits (utilization) in patients receiving physical therapy for low back pain. BACKGROUND The McKenzie method is commonly used in treating patients with low back pain. METHODS A McKenzie postgraduate educational program was initiated in a large outpatient physical therapy service. Functional status data were collected at intake and at discharge. Separate hierarchical linear mixed models were used to examine associations between physical therapists' McKenzie training level (none; Parts A, B, C, and D; and credentialed), FS score at discharge, and utilization, controlling for patient risk factors. RESULTS The final data set included 20 882 patients (mean ± SD age, 51 ± 16 years; 57% women) who completed FS surveys at both admission and discharge. Patients treated by physical therapists with any McKenzie training had better outcomes (additional 0.7 to 1.3 FS points; P<.05 to <.001) and fewer visits (0.6 to 0.9, P<.001) compared to patients treated by physical therapists with no training. For patients treated by therapists with no versus some McKenzie education, 65% versus 70% achieved at least the minimal clinically important improvement, respectively. There were no significant differences in outcomes or utilization by level of McKenzie training. CONCLUSION There was a slightly greater improvement of 0.7 to 1.3 points in FS at discharge in patients receiving physical therapy for low back pain by physical therapists who underwent McKenzie training. This difference was clinically important for an additional 5% of patients who achieved the minimal clinically important improvement when treated by therapists with some McKenzie training. Reduction in physical therapy utilization was 0.6 to 0.9 visits, with the fewest visits utilized by patients of physical therapists at the McKenzie Part D and credentialed levels. Together, these findings suggest improved cost-effectiveness at advanced McKenzie training levels. Ways to improve ongoing education and patient outcomes were proposed.
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Implications of practice setting on clinical outcomes and efficiency of care in the delivery of physical therapy services. J Orthop Sports Phys Ther 2014; 44:955-63. [PMID: 25350133 DOI: 10.2519/jospt.2014.5224] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
STUDY DESIGN Retrospective analysis of episodes of care. OBJECTIVE To assess the implications of practice setting (hospital outpatient settings versus private practice) on clinical outcomes and efficiency of care in the delivery of physical therapy services. BACKGROUND Many patients with musculoskeletal conditions benefit from care provided by physical therapists. The majority of physical therapists deliver services in either a private practice setting or in a hospital outpatient setting. There have not been any recent studies comparing whether clinical outcomes or efficiency of care differ based on practice setting. METHODS Practices that use the Focus On Therapeutic Outcomes, Inc system were surveyed to determine the specific type of setting in which outcomes were collected in patients with musculoskeletal impairments. Patient outcome data over 12 months (2011-2012) were extracted from the database and analyzed to identify differences in the functional status achieved and the efficiency of the care delivery process between private practices and hospital outpatient settings. RESULTS The data suggest that patients experience more efficient care when receiving physical therapy in hospital outpatient settings compared to private practice settings, as demonstrated by 3.1 points of greater improvement in functional status over 2.9 fewer physical therapy visits. However, the difference in improvement between settings is less than the minimum clinically important difference of 9 points in functional status outcome score. CONCLUSION In this cohort, our data suggest that more efficient care was delivered in the hospital outpatient setting compared to the private practice setting. However, we cannot conclude that care delivered in the hospital setting is more cost-effective, because it is possible that any difference in efficiency of care favoring the hospital outpatient setting is more than offset by higher costs of care.
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The self-report fecal incontinence and constipation questionnaire in patients with pelvic-floor dysfunction seeking outpatient rehabilitation. Phys Ther 2014; 94:273-88. [PMID: 24114438 DOI: 10.2522/ptj.20130062] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
BACKGROUND Fecal incontinence and constipation affect men and women of all ages. OBJECTIVE The purpose of this study was to psychometrically analyze the Fecal Incontinence and Constipation Questionnaire (FICQ) in patients seeking outpatient rehabilitation services due to pelvic-floor dysfunction (PFD). DESIGN This was a retrospective analysis of cross-sectional data from 644 patients (mean age=52 years, SD=16, range=18-91) being treated for PFD in 64 outpatient rehabilitation clinics in 20 states (United States). METHODS We assessed the 20-item FICQ for unidimensionality and local independence, differential item functioning (DIF), item fit, item hierarchical structure, and test precision using an item response theory model. RESULTS Factor analyses supported the 2-factor subscales as originally defined; items related to severity of leakage or constipation. Removal of 2 leakage items improved unidimensionality and local independence of the leakage scale. Among the remaining items, 2 items were suggestive of adjustment for DIF by age group and by number of PFD comorbid conditions. Item difficulties were suitable for patients with PFD with no ceiling or floor effect. Mean item difficulty parameters for leakage and constipation subscales ranged from 38.8 to 62.3 and 28.1 to 63.3 (0-100 scale), respectively. Endorsed leakage items representing highest difficulty levels were related to delay defecation and confidence to control bowel leakage. Endorsed constipation items representing highest difficulty levels were related to the need to strain during a bowel movement and the frequency of bowel movements. LIMITATIONS A limitation of this study was the lack of medical diagnostic criteria to classify patients. CONCLUSIONS After removing 2 items and adjusting for DIF, the results supported sound psychometric properties of the FICQ items and its initial use for patients with PFD in outpatient rehabilitation services.
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Forkmann T, Kroehne U, Wirtz M, Norra C, Baumeister H, Gauggel S, Elhan AH, Tennant A, Boecker M. Adaptive screening for depression--recalibration of an item bank for the assessment of depression in persons with mental and somatic diseases and evaluation in a simulated computer-adaptive test environment. J Psychosom Res 2013; 75:437-43. [PMID: 24182632 DOI: 10.1016/j.jpsychores.2013.08.022] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Revised: 08/27/2013] [Accepted: 08/28/2013] [Indexed: 11/24/2022]
Abstract
OBJECTIVE This study conducted a simulation study for computer-adaptive testing based on the Aachen Depression Item Bank (ADIB), which was developed for the assessment of depression in persons with somatic diseases. Prior to computer-adaptive test simulation, the ADIB was newly calibrated. METHODS Recalibration was performed in a sample of 161 patients treated for a depressive syndrome, 103 patients from cardiology, and 103 patients from otorhinolaryngology (mean age 44.1, SD=14.0; 44.7% female) and was cross-validated in a sample of 117 patients undergoing rehabilitation for cardiac diseases (mean age 58.4, SD=10.5; 24.8% women). Unidimensionality of the itembank was checked and a Rasch analysis was performed that evaluated local dependency (LD), differential item functioning (DIF), item fit and reliability. CAT-simulation was conducted with the total sample and additional simulated data. RESULTS Recalibration resulted in a strictly unidimensional item bank with 36 items, showing good Rasch model fit (item fit residuals<|2.5|) and no DIF or LD. CAT simulation revealed that 13 items on average were necessary to estimate depression in the range of -2 and +2 logits when terminating at SE≤0.32 and 4 items if using SE≤0.50. Receiver Operating Characteristics analysis showed that θ estimates based on the CAT algorithm have good criterion validity with regard to depression diagnoses (Area Under the Curve≥.78 for all cut-off criteria). CONCLUSION The recalibration of the ADIB succeeded and the simulation studies conducted suggest that it has good screening performance in the samples investigated and that it may reasonably add to the improvement of depression assessment.
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Affiliation(s)
- Thomas Forkmann
- Institute of Medical Psychology and Medical Sociology, University Hospital of RWTH Aachen, Germany.
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Leung YY, Png ME, Conaghan P, Tennant A. A systematic literature review on the application of Rasch analysis in musculoskeletal disease -- a special interest group report of OMERACT 11. J Rheumatol 2013; 41:159-64. [PMID: 24128781 DOI: 10.3899/jrheum.130814] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE The Rasch measurement model provides robust analysis of the internal construct validity of outcome measures. We reviewed the application of Rasch analysis in musculoskeletal medicine as part of the work leading to discussion in a Special Interest Group in Rasch Analysis at Outcome Measures in Rheumatology 11. METHODS A systematic literature review of SCOPUS and MEDLINE was performed (January 1, 1985, to February 29, 2012. Original research reports in English using "Rasch" or "Item Response Theory" in musculoskeletal diseases were assessed by 2 independent reviewers. The topics of focus and analysis methodology details were recorded. RESULTS Of 212 articles reviewed, 114 were included. The number of publications rose from 1 in 1991-1992 to 23 in 2011-February 2012. Disease areas included rheumatoid arthritis (28%), osteoarthritis (16.6%), and general musculoskeletal disorders (43%). Sixty-six reports (57.9%) evaluated psychometric properties of existing scales and 35 (30.7%) involved development of new scales. Nine articles (7.9%) were on methodology illustration. Four articles were on item banking and computer adaptive testing. A majority of the articles reported fit statistics, while the basic Rasch model assumption (i.e., unidimensionality) was examined in only 57.2% of the articles. An improvement in reporting qualities with Rasch articles was noted over time. In addition, only 11.4% of the articles provided a transformation table for interval scale measurement in clinical practice. CONCLUSION The Rasch model has been increasingly used in rheumatology over the last 2 decades in a wide range of applications. The majority of the articles demonstrated reasonable quality of reporting. Improvements in quality of reporting over time were revealed.
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Affiliation(s)
- Ying-Ying Leung
- From the Department of Rheumatology and Immunology, Singapore General Hospital, the Duke-National University of Singapore Graduate Medical School, Singapore; Division of Musculoskeletal and Rehabilitation Medicine, University of Leeds, Leeds, UK; and the National Institute for Health Research (NIHR) Leeds Musculoskeletal Biomedical Research Unit, Leeds, UK
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Psychometric properties and practicability of the self-report urinary incontinence questionnaire in patients with pelvic-floor dysfunction seeking outpatient rehabilitation. Phys Ther 2013; 93:1116-29. [PMID: 23580628 DOI: 10.2522/ptj.20120134] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
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.
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Gabel P, Burkett B, Yelland M. Balancing fidelity and practicality in short version musculoskeletal patient reported outcome measures. PHYSICAL THERAPY REVIEWS 2013. [DOI: 10.1179/174328809x452890] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Development of a paper-and-pencil semi-adaptive questionnaire for 5 domains of health-related quality of life (PAT-5D-QOL). Qual Life Res 2013; 22:2829-42. [DOI: 10.1007/s11136-013-0419-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2013] [Indexed: 11/30/2022]
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Sindhu BS, Wang YC, Lehman LA, Hart DL. Differential Item Functioning in a Computerized Adaptive Test of Functional Status for People with Shoulder Impairments is Negligible across Pain Intensity, Gender, and Age Groups. OTJR-OCCUPATION PARTICIPATION AND HEALTH 2013. [DOI: 10.3928/15394492-20130125-02] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
People with shoulder impairments ( N = 3,767) reported upper extremity function using a 37-item shoulder-specific computerized adaptive test (shoulder CAT). The authors determined whether items of the shoulder CAT have differential item functioning (DIF) by pain intensity (low and high), gender (men and women), and age groups (young-adult, middle-aged and old-adult). They assessed whether items have uniform and/or non-uniform DIF using an ordinal logistic regression and item response theory approaches and applied large and small DIF criteria to assess the magnitude of DIF. The analyses revealed that uniform DIF was absent in all 37 items. Only six items exhibited non-uniform DIF using the large DIF criterion. Adjusting the person-ability measures for DIF had minimal practical impact on the overall measure of shoulder function estimated using the shoulder CAT. The shoulder CAT provided a precise measurement of function without discriminating for pain intensity, gender, and age among patients referred to rehabilitation with shoulder impairment.
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Patient age is related to the types of physical therapy interventions provided for chronic low back pain: an observational study. J Orthop Sports Phys Ther 2012; 42:902-11. [PMID: 24432800 DOI: 10.2519/jospt.2012.4147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
STUDY DESIGN Retrospective analysis of a longitudinal cohort of patients treated for chronic low back pain (CLBP). OBJECTIVES To determine whether patient age is associated with types of physical therapy interventions received for CLBP. BACKGROUND Advancing age is associated with less positive treatment outcomes in patients with CLBP. If patient age influences a therapist's choice of interventions, it may partially explain the difference in treatment outcomes. METHODS Data were examined in a sample of 7392 patients (62% women, 38% men; mean ± SD age, 56.7 ± 16.5 years) with CLBP. We used a generalized estimating equation to examine the probability of each subject receiving each of the individual intervention categories in the presence of the other intervention categories. RESULTS A significant interaction between intervention category and age existed after controlling for gender, duration of symptoms, comorbidities, payer source, and functional status at initial intake (χ(2) = 130.27, df = 8, P<.0001). The changes in probability of receiving an intervention category averaged 10% as patient age increased. The probability of receiving exercise or task-specific training did not change with advancing age. The probability of receiving postural exercises, pain modalities, joint mobility techniques, ice, or McKenzie exercises decreased with advancing age. The probability of receiving augmented soft tissue mobilization and balance/mobility training increased as age increased. CONCLUSION The impact of age on physical therapist treatment choices varies depending on the type of intervention. Other variables in addition to age may have an impact on treatment choice. Further research is needed to determine how therapists incorporate age into their clinical decision making.
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Influence of fear-avoidance beliefs on functional status outcomes for people with musculoskeletal conditions of the shoulder. Phys Ther 2012; 92:992-1005. [PMID: 22628581 DOI: 10.2522/ptj.20110309] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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<.01) and those with osteopathies, chondropathies, and acquired musculoskeletal deformities (Δ=5.52, P<.02). These differences were below the minimal detectable change. 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.
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Shnayderman I, Katz-Leurer M. An aerobic walking programme versus muscle strengthening programme for chronic low back pain: a randomized controlled trial. Clin Rehabil 2012; 27:207-14. [DOI: 10.1177/0269215512453353] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: To assess the effect of aerobic walking training as compared to active training, which includes muscle strengthening, on functional abilities among patients with chronic low back pain. Design: Randomized controlled clinical trial with blind assessors. Setting: Outpatient clinic. Subjects: Fifty-two sedentary patients, aged 18–65 years with chronic low back pain. Patients who were post surgery, post trauma, with cardiovascular problems, and with oncological disease were excluded. Intervention: Experimental ‘walking’ group: moderate intense treadmill walking; control ‘exercise’ group: specific low back exercise; both, twice a week for six weeks. Main measures: Six-minute walking test, Fear-Avoidance Belief Questionnaire, back and abdomen muscle endurance tests, Oswestry Disability Questionnaire, Low Back Pain Functional Scale (LBPFS). Results: Significant improvements were noted in all outcome measures in both groups with non-significant difference between groups. The mean distance in metres covered during 6 minutes increased by 70.7 (95% confidence interval (CI) 12.3–127.7) in the ‘walking’ group and by 43.8 (95% CI 19.6–68.0) in the ‘exercise’ group. The trunk flexor endurance test showed significant improvement in both groups, increasing by 0.6 (95% CI 0.0–1.1) in the ‘walking’ group and by 1.1 (95% CI 0.3–1.8) in the ‘exercise’ group. Conclusions: A six-week walk training programme was as effective as six weeks of specific strengthening exercises programme for the low back.
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Affiliation(s)
- Ilana Shnayderman
- Department of Physiotherapy, Maccabi Healthcare Services in Lod, Tel-Aviv University, Tel-Aviv, Israel
| | - Michal Katz-Leurer
- Sackler Faculty of Medicine, School of Health Professions, Physical Therapy Department, Tel-Aviv University, Tel-Aviv, Israel
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Lumbar computerized adaptive test and Modified Oswestry Low Back Pain Disability Questionnaire: relative validity and important change. J Orthop Sports Phys Ther 2012; 42:541-51. [PMID: 22517215 DOI: 10.2519/jospt.2012.3942] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
STUDY DESIGN Retrospective analysis of longitudinal, observational cohort data. OBJECTIVES To compare discriminating ability and minimal clinically important improvement (MCII) calculated using functional status (FS) measures estimated from the lumbar computerized adaptive test (LCAT) and Modified Oswestry Low Back Pain Disability Questionnaire (ODQ). BACKGROUND The LCAT and ODQ are commonly used to estimate FS in patients seeking outpatient therapy but have not been compared directly. METHODS Data from 8198 adult patients who completed the LCAT and ODQ at intake were analyzed, 3379 (41%) of whom completed both surveys at discharge. Global ratings of change data were available for 980 patients. Discriminating ability of FS estimates from the LCAT and ODQ was estimated using relative validity, calculated by dividing F values from LCAT and ODQ analyses of covariance for important risk-adjustment variables. MCII was estimated using receiver-operating-characteristic analyses by quartiles of intake FS values, and areas under the curves were compared. RESULTS Relative validity ratios favored the LCAT for age (3.7; 95% confidence interval [CI]: 2.0, 8.9), acuity (1.3; 95% CI: 1.1, 1.6), comorbidities (1.8; 95% CI: 1.3, 2.6), and surgical history (1.8; 95% CI: 1.2, 2.9). MCII cut scores per quartile favored the LCAT. Receiver-operating-characteristic areas under the curves were not different. CONCLUSION FS measures estimated by both questionnaires had similar psychometric characteristics. The LCAT FS estimates tended to be more discriminating than ODQ FS estimates. MCII cut scores by quartile of intake FS favored the LCAT. Given the need to be efficient and precise in estimating measures of FS, particularly in older patients, results favor the LCAT in busy, automated outpatient therapy clinics, which are increasingly serving an aging population.
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Abstract
BACKGROUND Computerized adaptive tests (CATs) have abundant theoretical advantages over established static instruments, which could improve ambulatory monitoring of patient-reported outcomes (PROs). However, an empirical demonstration of their practical benefits is warranted. METHODS We reviewed the literature and evaluated existing data to discuss the potential of CATs for use in ambulatory monitoring outside clinical facilities. RESULTS Computerized adaptive tests are not being used for ambulatory monitoring, but initial results from their use in health care research allow for discussion of some issues relevant to ambulatory care. Evidence shows that CATs can capture the most relevant health outcomes as well as established static tools, with substantially decreased respondent burden. They can be more precise than static tools of similar length and can reduce floor and ceiling effects. Computerized adaptive tests can reliably measure a construct over time with different items, which yields the potential of introducing item exposure control in ambulatory monitoring. Studies have shown that CATs can be at least as valid as well-designed static tools in group comparisons, but further investigation is needed to determine whether psychometric advantages lead to increased responsiveness of CATs. CONCLUSIONS Ambulatory monitoring of PROs demands short, yet very precise measurements, which can be repeated up to many times a day. Computerized adaptive tests may address several present shortcomings in ambulatory monitoring of PROs efficiently. However, most CAT developments have primarily focused on psychometric improvements. To use the full potential of CATs for ambulatory monitoring purposes, content must also be carefully considered.
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Abstract
The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization’s International Classification of Functioning, Disability, and Health (ICF). The purpose of these low back pain clinical practice guidelines, in particular, is to describe the peer-reviewed literature and make recommendations related to (1) treatment matched to low back pain subgroup responder categories, (2) treatments that have evidence to prevent recurrence of low back pain, and (3) treatments that have evidence to influence the progression from acute to chronic low back pain and disability.
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Using intake and change in multiple psychosocial measures to predict functional status outcomes in people with lumbar spine syndromes: a preliminary analysis. Phys Ther 2011; 91:1812-25. [PMID: 22003164 DOI: 10.2522/ptj.20100377] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Total number and severity of comorbidities do not differ based on anatomical region of musculoskeletal pain. J Orthop Sports Phys Ther 2011; 41:477-85. [PMID: 21654099 DOI: 10.2519/jospt.2011.3686] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
STUDY DESIGN Secondary analysis, cross-sectional study. OBJECTIVES To (1) compare differences in individual comorbidity rates among patients with cervical, lumbar, and extremity pain complaints and (2) compare rates based on total number and severity in these same patient groups. BACKGROUND Comorbidities can impact recovery, prognosis, and potentially hinder participation in rehabilitation. Few studies have compared comorbidity rates among patients with different anatomical region of pain, to determine whether specific screening is warranted in physical therapy settings. METHODS Included in the analyses were 2375 patients who reported complete demographic, clinical, and comorbidity information using Patient Inquiry software. Comorbidity data were collected from the Functional Comorbidity Index (18 items) and 6 additional comorbidities, to assess the presence of medical disease across multiple body systems. Comorbidities were further classified as "nonsevere" or "severe," based on inclusion in the Charlson Comorbidity Index. Chi-square analyses investigated differences in the rates of total number and severe comorbidities. Odds ratios (OR) and 95% confidence intervals (CIs) were calculated on rates with statistically significant differences (P<.001), using the lumbar spine as the reference group. RESULTS Of the 24 comorbid conditions included in this analysis, 3 nonsevere medical conditions (degenerative disc disease, obesity, and headache) had different rates among anatomical region. A lower rate for degenerative disc disease was associated with the extremity conditions (χ2 = 66.3; OR = 0.40; 95% CI: 0.32, 0.50). Higher rate of headache (χ2 = 115.3; OR = 3.01; 95% CI: 2.45, 3.70) and lower rate of obesity (χ2 = 16.2; OR = 0.64; 95% CI: 0.51, 0.80) were associated with cervical conditions. There were no differences among the 3 anatomical regions for total number or severe comorbidities. CONCLUSION Focused screening for degenerative disc disease, obesity, and headache may be warranted. However, the same strategy was not supported for total number or severe comorbidities, at least when considering comparative rates from this cohort. Physical therapists should consider the potential influence of total number and severe comorbidities equally for all anatomical regions of musculoskeletal pain. LEVEL OF EVIDENCE Differential diagnosis/symptom prevalence, level 3b.
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Abstract
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 self-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.
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Effect of fear-avoidance beliefs of physical activities on a model that predicts risk-adjusted functional status outcomes in patients treated for a lumbar spine dysfunction. J Orthop Sports Phys Ther 2011; 41:336-45. [PMID: 21471649 DOI: 10.2519/jospt.2011.3534] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
STUDY DESIGN Retrospective analysis of a prospective, longitudinal cohort study of 30 858 patients being treated for a lumbar spine dysfunction in outpatient physical therapy. OBJECTIVES To determine effect of adding a single-item screening variable classifying patients with elevated versus not-elevated scores of fear-avoidance beliefs of physical activities at intake, on a model predicting risk-adjusted functional status (FS) outcomes. BACKGROUND Outcomes must be risk-adjusted before making meaningful interpretations. Elevated fear-avoidance beliefs scores have been predictive of poor outcomes. But the importance of elevated fear-avoidance scores in a multivariable model predicting FS outcomes needs further study. METHODS Using retrospective analyses, predictive ability (R2) of multivariable linear regression models of discharge FS with and without classification by elevated versus not-elevated fear-avoidance scores were compared, while controlling for intake FS, age, symptom acuity, surgical history, gender, number of comorbidities, and payer. Percent variance controlled and beta coefficients (95% confidence intervals) of each variable in both models were compared. A split-half design was used for model cross-validation. Predictive ratios (predicted FS, divided by actual discharge FS) were assessed. RESULTS Adding fear-avoidance beliefs classification to the discharge FS model improved (P<.001) model predictive ability but only slightly (R2 without, and with, fear-avoidance classification, 0.2997 and 0.3010, respectively). Variables impacted models similarly (95% confidence intervals not different). Fear-avoidance classification added 0.2% data variance control to the existing model. Cross-validation was supported. Predictive ratios were 1.09 and 1.10, without and with fear-avoidance, respectively. CONCLUSION Although screening for elevated fear-avoidance beliefs of physical activities significantly improves the FS outcomes predictive model, the amount of additional meaningful interpretation of FS outcomes was minimal. Exploration of other clinically relevant variables designed to improve outcomes prediction is warranted. LEVEL OF EVIDENCE Prognosis, level 2c.
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Depressive symptoms, anatomical region, and clinical outcomes for patients seeking outpatient physical therapy for musculoskeletal pain. Phys Ther 2011; 91:358-72. [PMID: 21233305 PMCID: PMC3048818 DOI: 10.2522/ptj.20100192] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
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.
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Wang YC, Hart DL, Cook KF, Mioduski JE. Translating shoulder computerized adaptive testing generated outcome measures into clinical practice. J Hand Ther 2011; 23:372-82; quiz 383. [PMID: 20800438 DOI: 10.1016/j.jht.2010.06.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2010] [Revised: 06/08/2010] [Accepted: 06/09/2010] [Indexed: 02/03/2023]
Abstract
STUDY DESIGN Prospective longitudinal cohort study. INTRODUCTION Increased use of computerized adaptive tests (CATs) to generate outcome measures during rehabilitation has stimulated questions concerning score interpretation. PURPOSE OF THE STUDY The purpose of the study was to describe meaningful interpretations of scores from patient self-report shoulder functional status (FS) outcome measures estimated using a shoulder CAT (score range=0-100). METHODS We applied four approaches to the clinical interpretation of outcomes data from 30,987 patients with shoulder impairments receiving outpatient rehabilitation in 518 clinics in 30 states (United States) between August 2007 and July 2009. First, we used standard error of estimates to construct 95% confidence intervals for each CAT estimated score. Second, we estimated the percentile rank (PR) of FS scores. Third, we used two threshold approaches to define individual patient-level change: statistically reliable change (i.e., minimal detectable change or MDC) and clinically important change. Fourth, we developed and applied a functional staging model, the Shoulder Function Classification System (SFCS). RESULTS Precision of a single score was estimated by FS score ±4. Based on score distribution, 25th, 50th, and 75th PRs corresponded to intake FS scores of 43, 52, and 59 and discharge FS scores of 59, 68, and 80, respectively. MDC calculations indicated that changes in FS scores of 11 or more units represented statistically reliable change. FS score increments of eight or more units were estimated to represent minimal clinically important improvement based on receiver operating characteristic. The five-level SFCS was judged to be clinically logical and provide insight for clinical interpretation of patient progress. CONCLUSIONS Results may improve clinical interpretation of CAT-generated outcome measures and assist clinicians using patient-reported outcomes during clinical practice. LEVEL OF EVIDENCE Therapy level 2c.
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Affiliation(s)
- Ying-Chih Wang
- Focus On Therapeutic Outcomes, Inc., Knoxville, TN, USA.
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Association between directional preference and centralization in patients with low back pain. J Orthop Sports Phys Ther 2011; 41:22-31. [PMID: 20972343 DOI: 10.2519/jospt.2011.3415] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
STUDY DESIGN Prospective, longitudinal, observational cohort. OBJECTIVES Primary aims were to determine (1) baseline prevalence of directional preference (DP) or no directional preference (no-DP) observed for patients with low back pain whose symptoms centralized (CEN), did not centralize (non-CEN), or could not be classified (NC), and (2) to determine if classifying patients at intake by DP or no-DP combined with CEN, non-CEN, or NC predicted functional status and pain intensity at discharge from rehabilitation. BACKGROUND Although evidence suggests that patient response classification criteria DP or CEN improve outcomes, previous studies did not delineate relations between DP and CEN findings and outcomes. METHODS Eight therapists classified patients using standardized definitions for DP and CEN. Prevalence rates for DP and no-DP and CEN,non-CEN, and NC were calculated. Ordinary least-squares multivariate regression models assessed whether multilevel classification combining DP and CEN (DP/CEN, DP/non-CEN, DP/NC, no-DP/non-CEN, and no-DP/NC categories) predicted discharge functional status (scale range, 0 to 100, with higher values representing better function) or pain intensity (scale range, 0 to 10, with higher values representing more pain). RESULTS Overall prevalence of DP and CEN was 60% and 41%, respectively. For those with DP, prevalence rates for DP/CEN, DP/non-CEN, and DP/NC were 65%, 27%, and 8%, respectively. The amount of variance explained (R2 values) for function and pain models was 0.50 and 0.39, respectively. Compared to patients classified as DP/CEN, patients classified as DP/non-CEN or no-DP/non-CEN reported 7.7 and 11.6 functional status units less at discharge (P<.001), respectively, and patients classified as no-DP/non-CEN reported 1.7 pain units more at discharge (P<.001). CONCLUSIONS Findings suggest that classification by pain pattern and DP can improve a therapist's ability to provide a short-term prognosis for function and pain outcomes. LEVEL OF EVIDENCE Prognosis, level 1b-.
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