Patient- and Physical Therapist-Level Predictors of Patient-Reported Therapeutic Alliance: An Observational, Exploratory Study of Cohorts With Knee and Low Back Pain.

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 ß=1.57, P<.05) and LBP (ß=1.42, P<.05), with age (ß=-0.07, P<.01) and baseline function (ß=0.06, P<.01) contributing to cohorts with knee and LBP, respectively. Physical therapist-level predictors included female sex (ß=6.04, P<.05), Pain Attitudes and Beliefs Scale for Physiotherapists behavioral (ß=0.65, P<.01), and Self-Efficacy in Patient-Centeredness Questionnaire (SEPCQ) Exploring Patient Perspective (ß=-0.75, P<.01) subscale scores for LBP, with SEPCQ Sharing Information and Power subscale scores (ß=0.56, P<.05) contributing to both cohorts with knee (ß=0.56, P<.05) and LBP (ß=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.

A novel movement system screen for primary care providers: a multisite, observational study.

CONTEXT: Movement of the human body is essential for the interaction of an individual within their environment and contributes to both physical and emotional quality of life. Movement system disorders (MSDs) are kinesiopathologic conditions that result from either altered movement patterns, trauma, or pathology. A screening tool may facilitate earlier diagnosis and treatment of acute MSDs. This tool could prevent progression to chronic conditions, leading to better patient outcomes and quality of life. OBJECTIVES: Our study evaluated whether a screening tool would be able to accurately screen individuals for MSDs, explore comorbidities that may predict the prevalence of MSDs, and identify why people do not discuss these problems with their primary care provider (PCP). METHODS: A multisite, observational study in a primary care setting. Data were analyzed to determine the psychometric properties of the screening question. Logistic regression was performed to explore the relationship of comorbidities with MSDs. Thematic analysis was performed to explore why patients do not discuss these issues with their PCP. RESULTS: The point prevalence of MSDs was determined to be 78%. The sensitivity of the screening question was determined to be good (70%). Arthritis, obesity, sleep disorders, and gastroesophageal reflux disease (GERD) were significant predictors for an MSD. Thematic analysis regarding why patients do not discuss the MSD with their physician revealed: (1) the perceived lack of importance of the problem; (2) the lack of access to healthcare, and (3) the acuity of the problem. CONCLUSIONS: Screening for an MSD and associated comorbidities could prevent the transition of acute conditions to chronic conditions. If PCPs can identify predictors and factors associated with an MSD, they may be able to screen for MSDs more effectively. Earlier identification of MSDs may facilitate earlier treatment and prevent costs associated with resulting chronic disorders and persistent pain and disability.

Reliability and Concurrent Validity of Shoulder Tissue Irritability Classification.

OBJECTIVE: Rating tissue irritability has been recommended to aid decision making in several recent clinical practice guidelines. An explicit method for rating tissue irritability was proposed as part of the Staged Algorithm for Rehabilitation Classification: Shoulder Disorders (STAR-Shoulder), but the reliability and validity of this classification are unknown. The purpose of this study was to examine the reliability and concurrent validity of shoulder tissue irritability ratings as part of a system designed to guide appropriate treatment strategy and intensity. METHODS: A clinical measurement, prospective repeated-measures cross-sectional design was used. The 101 consecutive participants with primary complaints of shoulder pain were assessed by pairs of blinded raters (24 raters in total) and rated for tissue irritability. Patients completed 3 patient-reported outcome (PRO) measures reflecting both pain and disability, and these scores were compared with ratings of tissue irritability. Paired ratings of irritability were analyzed for reliability with prevalence-adjusted, bias-adjusted Kappa for ordinal scales. Analysis of variance was used to compare PRO measures across different levels of irritability. Receiver operating characteristic curve analysis was utilized to derive cut-off scores for 3 PRO instruments. RESULTS: Interrater reliability was 0.69 (95% CI = 0.59-0.78), with 67% agreement. All PRO measures were significantly different among 3 levels of tissue irritability. CONCLUSION: There appears to be acceptable reliability and a strong relationship between PRO measures and therapist-rated tissue irritability, supporting the use of the STAR-Shoulder irritability rating system. IMPACT: Several clinical practice guidelines have recommended that clinicians rate tissue irritability as part of their examination. This study provides important new information supporting the reliability and validity of the STAR-Shoulder tissue irritability rating system.

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.

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.

Slipped Capital Femoral Epiphysis Presenting as Quadriceps Strain.

An active 14-year-old adolescent boy with left hip pain of 3 weeks in duration was referred for physical therapy consultation by his pediatrician, with a diagnosis of left quadriceps strain. Based on the findings during examination, the physical therapist immediately contacted the pediatrician to request radiographs, which confirmed a diagnosis of slipped capital femoral epiphysis. J Orthop Sports Phys Ther 2019;49(5):356. doi:10.2519/jospt.2019.8772.

Effect of the Scapula Reposition Test on shoulder impingement symptoms and elevation strength in overhead athletes.

STUDY DESIGN: Two group, repeated measures design. OBJECTIVES: To determine whether manually repositioning the scapula using the Scapula Reposition Test (SRT) reduces pain and increases shoulder elevation strength in athletes with and without positive signs of shoulder impingement. BACKGROUND: Symptom alteration tests may be useful in determining a subset of those with shoulder pathology who may benefit from interventions aimed at improving scapular motion abnormalities. METHODS AND MEASURES: One hundred forty-two college athletes underwent testing for clinical signs of shoulder impingement. Tests provoking symptoms were repeated with the scapula manually repositioned into greater retraction and posterior tilt. A numeric rating scale was used to measure symptom intensity under both conditions. Isometric shoulder elevation strength was measured using a mounted dynamometer with the scapula in its natural position and with manual repositioning. A paired t test was used to compare the strength between positions. The frequency of a significant increase in strength with scapular repositioning, defined as the minimal detectable change (90% confidence interval), was also assessed. RESULTS: Of the 98 athletes with a positive impingement test, 46 had reduced pain with scapular repositioning. Although repositioning produced an increase in strength in both the impingement (P=.001) and non-impingement groups (P=.012), a significant increase in strength was found with repositioning in only 26% of athletes with, and 29% of athletes without positive signs for shoulder impingement. CONCLUSION: The SRT is a simple clinical test that may potentially be useful in an impairment based classification approach to shoulder problems.

Evaluation and management of scapular dysfunction.

The scapula plays an important role in shoulder function and requires both significant mobility and stability. Normal motion is 3-dimensional, and during arm elevation consists of upward rotation, posterior tilting, and external rotation as well as clavicular elevation and retraction. Examination should include visual observation, symptom alterations tests, testing of muscle strength, and flexibility of key structures including the pectoralis minor, posterior shoulder and thoracic spine. Treatment consists of graded resistive exercise, neuromuscular retraining, stretching, manual therapy, and taping where necessary. Although several studies suggest a relationship between abnormal scapular motion and symptoms, strong evidence directly supporting a causal relationship is lacking and further work is necessary to clarify this relationship.

A clinical method for identifying scapular dyskinesis, part 1: reliability.

CONTEXT: Shoulder injuries are common in athletes involved in overhead sports, and scapular dyskinesis is believed to be one causative factor in these injuries. Many authors assert that abnormal scapular motion, so-called dyskinesis, is related to shoulder injury, but evidence from 3-dimensional measurement studies regarding this relationship is mixed. Reliable and valid clinical methods for detecting scapular dyskinesis are lacking. OBJECTIVE: To determine the interrater reliability of a new test designed to detect abnormal scapular motion. DESIGN: Correlation design using ratings from multiple pairs of testers. SETTING: University athletic training facilities. PATIENTS OR OTHER PARTICIPANTS: A sample of 142 athletes (from National Collegiate Athletic Association Divisions I and III) participating in sports requiring intense overhead arm use. INTERVENTION(S): Participants were videotaped from the posterior aspect while performing 5 repetitions of bilateral, weighted (1.4-kg [3-lb] or 2.3-kg [5-lb]) shoulder flexion and frontal-plane abduction. Videotapes from randomly chosen participants were subsequently viewed and independently rated for the presence of scapular dyskinesis by 6 raters (3 pairs), with each pair rating 30 different participants. Raters were trained to detect scapular dyskinesis using a self-instructional format with standardized operational definitions and videotaped examples of normal and abnormal motion. MAIN OUTCOME MEASURE(S): Scapular dyskinesis was defined as the presence of either winging or dysrhythmia. Right and left sides were rated independently as normal, subtle, or obvious dyskinesis. We calculated percentage of agreement and weighted kappa (kappa(w)) coefficients to determine reliability. RESULTS: Percentage of agreement was between 75% and 82%, and kappa(w) ranged from 0.48 to 0.61. CONCLUSIONS: The test for scapular dyskinesis showed satisfactory reliability for clinical use in a sample of overhead athletes known to be at increased risk for shoulder symptoms.

A clinical method for identifying scapular dyskinesis, part 2: validity.

CONTEXT: Although clinical methods for detecting scapular dyskinesis have been described, evidence supporting the validity of these methods is lacking. OBJECTIVE: To determine the validity of the scapular dyskinesis test, a visually based method of identifying abnormal scapular motion. A secondary purpose was to explore the relationship between scapular dyskinesis and shoulder symptoms. DESIGN: Validation study comparing 3-dimensional measures of scapular motion among participants clinically judged as having either normal motion or scapular dyskinesis. SETTING: University athletic training facilities. PATIENTS OR OTHER PARTICIPANTS: A sample of 142 collegiate athletes (National Collegiate Athletic Association Division I and Division III) participating in sports requiring overhead use of the arm was rated, and 66 of these underwent 3-dimensional testing. INTERVENTION(S): Volunteers were viewed by 2 raters while performing weighted shoulder flexion and abduction. The right and left sides were rated independently as normal, subtle dyskinesis, or obvious dyskinesis using the scapular dyskinesis test. Symptoms were assessed using the Penn Shoulder Score. MAIN OUTCOME MEASURE(S): Athletes judged as having either normal motion or obvious dyskinesis underwent 3-dimensional electromagnetic kinematic testing while performing the same movements. The kinematic data from both groups were compared via multifactor analysis of variance with post hoc testing using the least significant difference procedure. The relationship between symptoms and scapular dyskinesis was evaluated by odds ratios. RESULTS: Differences were found between the normal and obvious dyskinesis groups. Participants with obvious dyskinesis showed less scapular upward rotation (P < .001), less clavicular elevation (P < .001), and greater clavicular protraction (P = .044). The presence of shoulder symptoms was not different between the normal and obvious dyskinesis volunteers (odds ratio = 0.79, 95% confidence interval = 0.33, 1.89). CONCLUSIONS: Shoulders visually judged as having dyskinesis showed distinct alterations in 3-dimensional scapular motion. However, the presence of scapular dyskinesis was not related to shoulder symptoms in athletes engaged in overhead sports.