Movement System Diagnoses for Balance Dysfunction: Recommendations From the Academy of Neurologic Physical Therapy's Movement System Task Force.

The movement system was identified as the focus of our expertise as physical therapists in the revised vision statement for the profession adopted by the American Physical Therapy Association in 2013. Attaining success with the profession's vision requires the development of movement system diagnoses that will be useful in clinical practice, research, and education. To date, only a few movement system diagnoses have been identified and described, and none of these specifically address balance dysfunction. Over the past 2 years, a Balance Diagnosis Task Force, a subgroup of the Movement System Task Force of the Academy of Neurologic Physical Therapy, focused on developing diagnostic labels (or diagnoses) for individuals with balance problems. This paper presents the work of the task force that followed a systematic process to review available diagnostic frameworks related to balance, identify 10 distinct movement system diagnoses that reflect balance dysfunction, and develop complete descriptions of examination findings associated with each balance diagnosis. A standardized approach to movement analysis of core tasks, the Framework for Movement Analysis developed by the Academy of Neurologic Physical Therapy Movement Analysis Task Force, was integrated into the examination and diagnostic processes. The aims of this perspective paper are to (1) summarize the process followed by the Balance Diagnosis Task Force to develop an initial set of movement system (balance) diagnoses; (2) report the recommended diagnostic labels and associated descriptions; (3) demonstrate the clinical decision-making process used to determine a balance diagnosis and develop a plan of care; and (4) identify next steps to validate and implement the diagnoses into physical therapist practice, education, and research. IMPACT: The development and use of diagnostic labels to classify distinct movement system problems is needed in physical therapy. The 10 balance diagnosis proposed can aid in clinical decision making regarding intervention.

A Framework for Movement Analysis of Tasks: Recommendations From the Academy of Neurologic Physical Therapy's Movement System Task Force.

The American Physical Therapy Association's Vision Statement of 2013 asserts that physical therapists optimize movement in order to improve the human experience. In accordance with this vision, physical therapists strive to be recognized as experts in movement analysis. However, there continues to be no accepted method to conduct movement analysis, nor an agreement of key terminology to describe movement observations. As a result, the Academy of Neurologic Physical Therapy organized a task force that was charged with advancing the state of practice with respect to these issues, including the development of a proposed method for movement analysis of tasks. This paper presents the work of the Task Force, which includes (1) development of a method for conducting movement analysis within the context of the movement continuum during 6 core tasks (sitting, sit to stand, standing, walking, step up/down, and reach/grasp/manipulate); (2) glossary of movement constructs that can provide a common language for movement analysis across a range of tasks: symmetry, speed, amplitude, alignment, verticality, stability, smoothness, sequencing, timing, accuracy, and symptom provocation; and (3) recommendations for task and environmental variations that can be systematically applied. The expectation is that this systematic framework and accompanying terminology will be easily adapted to additional patient or client-specific tasks, contribute to development of movement system diagnostic labels, and ultimately improve consistency across patient/client examination, evaluation, and intervention for the physical therapy profession. Next steps should include validation of this framework across patient/client groups and settings.

The Conundrum of Kappa and Why Some Musculoskeletal Tests Appear Unreliable Despite High Agreement: A Comparison of Cohen Kappa and Gwet AC to Assess Observer Agreement When Using Nominal and Ordinal Data.

In clinical practice, physical therapists often use different kinds of tests and measures in the assessment of their patients. For therapists to have confidence when using their tests and measures, an important attribute is having intratester and intertester reliability. Studies that assess reliability are cases of observer agreement. Many studies have been performed assessing observer agreement in the physical therapy literature. The most commonly used method to assess observer agreement studies that use nominal or ordinal data is the statistical method suggested by Cohen and the corresponding reliability coefficient, Cohen kappa. Recently, Cohen kappa has undergone scrutiny because of what is called kappa paradox, which occurs when observer agreement is high but the resulting kappa value is low. Another paradox also occurs when asymmetries exist between raters on their disagreements, resulting in a higher kappa value. In the physical therapy literature, there are numerous examples of this problem, which can often lead to misunderstanding the meaning of the data. This Perspective examines how and why these problems occur and suggests an alternative method for assessing observer agreement.

Hybrid Ubiquitous Coaching With a Novel Combination of Mobile and Holographic Conversational Agents Targeting Adherence to Home Exercises: Four Design and Evaluation Studies.

BACKGROUND: Effective treatments for various conditions such as obesity, cardiac heart diseases, or low back pain require not only personal on-site coaching sessions by health care experts but also a significant amount of home exercises. However, nonadherence to home exercises is still a serious problem as it leads to increased costs due to prolonged treatments. OBJECTIVE: To improve adherence to home exercises, we propose, implement, and assess the novel coaching concept of hybrid ubiquitous coaching (HUC). In HUC, health care experts are complemented by a conversational agent (CA) that delivers psychoeducation and personalized motivational messages via a smartphone, as well as real-time exercise support, monitoring, and feedback in a hands-free augmented reality environment. METHODS: We applied HUC to the field of physiotherapy and conducted 4 design-and-evaluate loops with an interdisciplinary team to assess how HUC is perceived by patients and physiotherapists and whether HUC leads to treatment adherence. A first version of HUC was evaluated by 35 physiotherapy patients in a lab setting to identify patients' perceptions of HUC. In addition, 11 physiotherapists were interviewed about HUC and assessed whether the CA could help them build up a working alliance with their patients. A second version was then tested by 15 patients in a within-subject experiment to identify the ability of HUC to address adherence and to build a working alliance between the patient and the CA. Finally, a 4-week n-of-1 trial was conducted with 1 patient to show one experience with HUC in depth and thereby potentially reveal real-world benefits and challenges. RESULTS: Patients perceived HUC to be useful, easy to use, and enjoyable, preferred it to state-of-the-art approaches, and expressed their intentions to use it. Moreover, patients built a working alliance with the CA. Physiotherapists saw a relative advantage of HUC compared to current approaches but initially did not see the potential in terms of a working alliance, which changed after seeing the results of HUC in the field. Qualitative feedback from patients indicated that they enjoyed doing the exercise with an augmented reality-based CA and understood better how to do the exercise correctly with HUC. Moreover, physiotherapists highlighted that HUC would be helpful to use in the therapy process. The longitudinal field study resulted in an adherence rate of 92% (11/12 sessions; 330/360 repetitions; 33/36 sets) and a substantial increase in exercise accuracy during the 4 weeks. CONCLUSIONS: The overall positive assessments from both patients and health care experts suggest that HUC is a promising tool to be applied in various disorders with a relevant set of home exercises. Future research, however, must implement a variety of exercises and test HUC with patients suffering from different disorders.

Physiotherapists' Use of Web-Based Information Resources to Fulfill Their Information Needs During a Theoretical Examination: Randomized Crossover Trial.

BACKGROUND: The widespread availability of internet-connected smart devices in the health care setting has the potential to improve the delivery of research evidence to the care pathway and fulfill health care professionals' information needs. OBJECTIVE: This study aims to evaluate the frequency with which physiotherapists experience information needs, the capacity of digital information resources to fulfill these needs, and the specific types of resources they use to do so. METHODS: A total of 38 participants (all practicing physiotherapists; 19 females, 19 males) were randomly assigned to complete three 20-question multiple-choice questionnaire (MCQ) examinations under 3 conditions in a randomized crossover study design: assisted by a web browser, assisted by a federated search portal system, and unassisted. MCQ scores, times, and frequencies of information needs were recorded for overall examination-level and individual question-level analyses. Generalized estimating equations were used to assess differences between conditions for the primary outcomes. A log file analysis was conducted to evaluate participants' web search and retrieval behaviors. RESULTS: Participants experienced an information need in 55.59% (845/1520) MCQs (assisted conditions only) and exhibited a mean improvement of 10% and 16% in overall examination scores for the federated search and web browser conditions, respectively, compared with the unassisted condition (P<.001). In the web browser condition, Google was the most popular resource and the only search engine used, accounting for 1273 (64%) of hits, followed by PubMed (195 hits; 10% of total). In the federated search condition, Wikipedia and PubMed were the most popular resources with 1518 (46% of total) and 1273 (39% of total) hits, respectively. CONCLUSIONS: In agreement with the findings of previous research studies among medical physicians, the results of this study demonstrate that physiotherapists frequently experience information needs. This study provides new insights into the preferred digital information resources used by physiotherapists to fulfill these needs. Future research should clarify the implications of physiotherapists' apparent high reliance on Google, whether these results reflect the authentic clinical environment, and whether fulfilling clinical information needs alters practice behaviors or improves patient outcomes.

Psychometric characteristics of the BEITI - an assessment scale of daily functioning.

BACKGROUND: BEITI is a comprehensive test of a wide range of basic and extended daily functioning. It was developed for physiotherapists in the community to enable increased sensitivity in detecting changes in the functioning of patients with different diagnoses. BEITI was found to be valid, reliable and valuable in terms of the time and effort involved. Its clinical properties as a measurement in inpatients with brain lesions is yet to be determined. OBJECTIVE: To translate BEITI from Hebrew into English, and explore its psychometric properties in inpatients with brain lesions in the subacute phase. METHODS: The admission and discharge records of 131 patients hospitalized in a neurological rehabilitation department were reviewed retrospectively. The internal consistency, responsiveness, and floor and ceiling effects of BEITI were assessed. RESULTS: Excellent internal consistency was found for BEITI at admission and discharge (Cronbach's α ≥ 0.964). BEITI had high effect sizes (effect size = 1.11, standardized response mean = 1.54). Significant changes over time were found for the BEITI (p < 0.001). No floor or ceiling effects were observed. CONCLUSIONS: BEITI is a reliable and responsive scale for assessing basic and extended daily functioning in inpatients with brain injuries in the subacute phase.

Development of a Musculoskeletal Imaging Competency Examination for Physical Therapists.

OBJECTIVE: The number of physical therapists with imaging ordering privileges is increasing; however, a known level of competency and knowledge is generally lacking within the profession, as is a method to determine practitioner competency. The purpose of this study was to develop a valid musculoskeletal (MSK) imaging competency examination for physical therapists. METHODS: This 3-round Delphi method study utilized experts to reach consensus on examination content and development. Round 1 was completed by 37 experts. The last 2 rounds were completed by 35 experts. Experts rated questions on a 5-point Likert rating scale of importance (1 = not at all important, 5 = very important). Consensus was achieved with an a priori decision of (1) >75% agreement of the expert panel rating and ≥4 on the Likert scale, and (2) ≥.90 on Cronbach alpha and intraclass correlation coefficients. Experts recommended a passing score of 75%. The examination was subsequently reviewed by a panel of 5 radiologists. RESULTS: The Delphi method and radiologist panel review resulted in the 151-question Burley Readiness Examination (BRE) for MSK Imaging Competency. Interrater agreement and internal consistency of the Delphi panel were excellent, with an average intraclass correlation coefficient and Cronbach alpha of .928 and .950, respectively. CONCLUSIONS: The BRE is a tool that has the potential to demonstrate practitioners' level of baseline competency with MSK imaging. Additional testing among physical therapists will provide further validation and reliability of the examination. IMPACT: The use and application of diagnostic imaging is becoming more widespread in physical therapist practice throughout the United States. The BRE could potentially have broader implications for health care utilization and cost in the area of MSK imaging.

A Survey of Pediatric Competencies in Entry-Level Physical Therapy Programs in Australia.

PURPOSE: To describe perspectives of pediatric physical therapy clinical facilitators on contemporary curricula for Australian entry-level physical therapy programs. METHODS: Physical therapy clinical facilitators completed an online survey based on the Academy of Pediatric Physical Therapy of the APTA essential competencies. RESULTS: Conditions including cerebral palsy, cystic fibrosis, and prematurity were highly rated by most participants to include in an entry-level program. Exercise prescription, goal-directed training, and group-based physical therapy were the highest rated interventions. Outcome measures considered important to include were the Alberta Infant Motor Scale and Goal Attainment Scale. Students should demonstrate knowledge and skills using relevant frameworks and have practical opportunities to interact with children. CONCLUSION: Pediatric clinical facilitators perceived that theoretical knowledge on frameworks, human development, movement skills, pediatric conditions, exercise prescription, and outcome measurement as well as face-to-face experiences with children are important to include in Australian entry-level physical therapy programs.

The Effect of a Personalized Newsletter to Physical Therapists on Patient Recruitment: A Cluster Randomized Trial in Primary Physiotherapy Care.

OBJECTIVE: To assess the effect of a personalized newsletter compared with a standard newsletter on patient recruitment in physiotherapy research. METHODS: We performed a cluster-randomized trial including 120 physiotherapists who recruited patients for a prospective cohort and were randomly assigned to either receiving personalized feedback in a newsletter (intervention group) or a standard newsletter (control group). We calculated the difference in the number of patients included in the study corrected for inclusion time between both groups. RESULTS: The physiotherapists in the control group (n = 59) included 110 patients (35.4% of the total number of patients included) compared with an inclusion of 200 patients (64.6% of the total number of patients included) by the physiotherapists in the intervention group (n = 61), a difference of 90 patients in favor of the intervention group. However, when corrected for inclusion time and a cluster effect, we found no statistically significant difference between both groups. In addition, therapists who did not include a single patient (inactive therapists) were evenly divided between the 2 groups (n = 29 [49%] in the control group; n = 30 [49%] in the intervention group). CONCLUSIONS: A personalized newsletter does not significantly increase the number of recruited patients by physiotherapists. However, therapists receiving personalized feedback recruited nearly double the number of patients compared with the ones receiving standard feedback.

Video-Based Motion Analysis Use: A National Survey of Orthopedic Physical Therapists.

OBJECTIVES: Motion analysis is performed by physical therapists to assess and improve movement. Two-dimensional video-based motion analysis (VBMA) is available for smartphones/tablets and requires little to no equipment or cost. Research on VBMA use in clinical practice is limited. The purpose of this study was to examine the current use of VBMA in orthopedic physical therapist practice. METHODS: Members of the Academy of Orthopaedic Physical Therapy completed an online survey. Questions examined frequency of VBMA use, reasons for use, facilitators/barriers, device/apps used, practice patterns, other certificates/degrees, and demographic information. RESULTS: Among the final analysis sample of 477 respondents, 228 (47.8%) use VBMA. Of 228 VBMA users, 91.2% reported using it for ≤25% of their caseload, and 57.9% reported using their personal device to capture movement. Reasons for using VBMA included visual feedback for patient education (91.7%), analysis of movement (91.2%), and assessment of progress (51.8%). Barriers to use included lack of device/equipment (48.8%), lack of space (48.6%), and time restraint (32.1%). Those with ≤20 years of clinical experience (odds ratio [OR] = 1.83, 95% CI = 1.21-2.76), residency training (OR = 2.49, 95% CI = 1.14-5.43), and fellowship training (OR = 2.97, 95% CI = 1.32-6.66), and those from the West region of the United States (OR = 1.66, 95% CI = 1.07-2.56) were more likely to use VBMA. CONCLUSIONS: More than 50% of surveyed orthopedic physical therapists do not use VBMA in clinical practice. Future research should be directed toward assessing reliability and validity of VBMA use by smartphones, tablets, and apps and examining whether VBMA use enhances treatment outcomes. Data security, patient confidentiality, and integration into the electronic medical record should be addressed. IMPACT: This study is the first to our knowledge to describe the use of VBMA in orthopedic physical therapist practice in the United States. It is the first step in understanding how VBMA is used and might be used to enhance clinical assessment and treatment outcomes.

A Structured Goal-Setting Process to Promote Functional and Measurable Outcomes in School-Based Physical Therapy: A Knowledge Translation Study.

INTRODUCTION: Goal setting is an important component of school-based physical therapy; however, evidence suggests that therapists may not consistently write goals that are relevant, context specific, and measurable. The aims of this knowledge translation study were to evaluate implementation of a goal-setting method for school-based therapists. METHOD: This study was created to align with the Knowledge to Action framework and included 1-day training and follow-up mentorship. Goals were assessed pre- and posttraining, and questionnaires assessed barriers and facilitators. RESULTS: Twenty-two physical therapists participated. Nineteen participants (90%) strongly agreed/agreed that the training helped change their perspectives about goal setting in the school environment. There was a statistically significant difference in goal quality pre- and posttraining. Therapists identified barriers and facilitators to implementation of effective goal setting in practice. DISCUSSION: Results indicate that this method may be effective at improving goal writing that is relevant, context specific, and measurable in school settings.

Assimilation of the Pediatric Essential Core Competencies by Professional Physical Therapist Education Programs.

PURPOSE: This study examined the degree to which pediatric essential core competencies (ECCs) are meeting their intended purpose to provide guidance to pediatric educators in professional physical therapy (PT) education programs and to determine facilitators, barriers, and recommendations to implementation of ECCs in curricula. METHODS: Pediatric PT educators from professional PT education programs were recruited to participate in a survey. Descriptive statistics were used to analyze close-ended questions for frequency of responses and content analysis to generate themes. RESULTS: Of the 162 completed surveys, most participants were aware of the ECCs (96%) and used them to inform pediatric curriculum (88%). A mean proportion (86%-95%) of participants perceived their program curricula addressed the ECCs very or moderately well. Multiple themes of facilitators/barriers/recommendations to ECC implementation were determined. CONCLUSIONS: Most pediatric educators are aware of and using the ECCs to guide pediatric education to prepare graduates for pediatric patients/clients.

Coronavirus disease 2019 (COVID-19) in Brasil: information to physical therapists.

The emergence of the Coronavirus Disease 2019 (COVID-19) pandemic shows a rapid increase in cases and deaths. The World Health Organization (WHO) has shown that more than 200.000 confirmed cases have been identified in more than 166 countries/territories. Public health authorities in Brasil have reported 532 confirmed cases by March 19. Approximately 5% of the patients will require intensive care unit treatment with oxygen therapy and mechanical ventilation. Limited data are available about rehabilitation protocols for severe illness and intensive care treatment of COVID-19 increase. Thus, we aim to show current information about COVID-19, describing symptoms and the respiratory management for critical patients and preventive care. Physical therapists and all health care professionals need to recognize the challenges they will face in the coming months.

Development of quality indicators for departments of hospital-based physiotherapy: a modified Delphi study.

BACKGROUND: International hospital accreditation instruments, such as Joint Commission International (JCI) and Qmentum, focus mainly on hospital policy and procedures and do not specifically cover a profession such as hospital-based physiotherapy. This justifies the need for a quality system to which hospital-based physiotherapy can better identify, based on a common framework of quality indicators for effective quality management. OBJECTIVE: This study aimed to identify the most important quality indicators of a hospital-based physiotherapy department in the eyes of hospital-based physiotherapists and their managers. METHODS: Based on input from three focus groups and a structured literature review, a first set of quality indicators for hospital physiotherapy was assembled. After checking this set for duplicates and for overlap with JCI and Qmentum, it formed the starting point of a modified Delphi procedure. In two rounds, 17 hospital-based physiotherapy experts rated the quality indicators on relevance through online surveys. In a final consensus meeting, quality indicators were established, classified in quality themes and operationalised by describing for each theme the rationale, specifications, domain and type of indicator. RESULTS: Three focus groups provided 120 potential indicators, which were complemented with 18 potential indicators based on literature. After duplicate and overlap check and the Delphi procedure, these 138 potential indicators were reduced to a set of 56 quality indicators for hospital-based physiotherapy. Finally, these 56 indicators were condensed into 7 composite indicators, each representing a quality theme based on definitions of the European Foundation for Quality Management. CONCLUSION: A set of 56 quality indicators, condensed into 7 composite indicators each representing a quality theme, was developed to assess the quality of a hospital-based physiotherapy department.

Adherence to key domains in low back pain guidelines: A cross-sectional study of Danish physiotherapists.

OBJECTIVE: The aim of the study was threefold: Firstly, to investigate the adherence to clinical practice guidelines for low back pain (LBP) among Danish physiotherapists with regard to three key domains: (a) activity, (b) work and (c) psychosocial risk factors. Secondly, to investigate whether adherence differed between physiotherapists working in private clinics (private physiotherapists) and physiotherapists working at public healthcare centres (public physiotherapists). Thirdly, to describe the physiotherapists' treatment modalities for patients with LBP. METHODS: A cross-sectional online survey was conducted with 817 physiotherapists working in the Central Denmark Region. Adherence to the guideline domains was assessed using two vignettes. The difference in adherence between the groups was assessed using the Chi-squared test. Treatment modalities were reported using descriptive statistics. RESULTS: A total of 234 physiotherapists responded, hereof 163 private physiotherapists and 71 public physiotherapists (response rate 29%). The proportions of physiotherapists managing the patients strictly in line with the guideline domains were 32% (activity), 16% (work) and 82% (psychosocial risk factors) for Vignette 1 and 6% (activity), 53% (work) and 60% (psychosocial risk factors) for Vignette 2. Public physiotherapists were more likely to manage patients strictly in line with guidelines for assessing the psychosocial risk factors compared to private physiotherapist (Vignette 1: 92% vs. 77% p = .030; Vignette 2:70% vs. 55% p = .035). Regarding the other two domains, there was no significant difference between the two groups in terms of adherence (p > .05). Concerning treatment modalities, the majority of physiotherapists instructed the patients in adopting an exercise program or informed the patients about the benign nature and prognosis of LBP. CONCLUSION: Overall, the participating Danish physiotherapists strictly adhered to only one out of three key domains. This underlines the importance of bringing focus on implementing the current guidelines' recommendations in clinical practice.

Assessment of knowledge, attitude and practice of basic life support among physical therapy practitioners in Rawalpindi and Islamabad.

OBJECTIVE: To assess the level of knowledge, attitude and practice of basic life support among physical therapy practitioners. METHODS: The descriptive cross-sectional study was conducted at Riphah International University, Islamabad, Pakistan, from February to July 2018, and comprised data collected from physical therapy practitioners working at four public-sector hospitals in Rawalpindi and Islamabad. A 30-item structured questionnaire adapted from the American Heart Association was used. Data was analysed using SPSS 21. RESULTS: Of the 100 subjects, 65(65%) were females and 35(35%) were males. The overall mean age was 25.54±3.76 years. The mean score of BLS knowledge and practice was 7.27±1.79 and 3.77±1.65 respectively. of the total, 61(61%) had received prior basic life support training, and the difference in knowledge and practice scores between trained and untrained professionals was significant (p<0.05). Gender-based difference was significant (p=0.02). All (100%) participants showed positive attitude towards basic life support training. CONCLUSIONS: Physical therapy practitioners possessed average basic life support knowledge, but practising skills were lacking.

Risk Adjustment of the Modified Low Back Pain Disability Questionnaire and Neck Disability Index to Benchmark Physical Therapist Performance: Analysis From an Outcomes Registry.

BACKGROUND: Patient-reported outcomes (PROs) have been touted as the ultimate assessment of quality medical care and have been proposed as performance measures after appropriate risk adjustment. Although spine conditions represent the most common orthopedic disorders, the most used PROs for disabilities related to the back and neck-the Modified Low Back Pain Disability Questionnaire (MDQ) and the Neck Disability Index (NDI)-have not been evaluated as performance measures. OBJECTIVE: The objective of this study was to benchmark physical therapists' performance in the management of spine conditions not involving surgery through the use of risk-adjusted MDQ and NDI outcomes. DESIGN: This was a retrospective observational study. METHODS: Data were accessed for patients seeking physical therapy with no history of related surgery for back or neck pain (315,274 treatment episodes) between January 2015 and June 2018. Patients with complete data, including initial and matched final MDQ or NDI, were considered for analysis (182,276 patients; 2799 physical therapists). Linear models controlling for baseline PRO and patient characteristics predicted PRO change for each patient. An aggregated performance ratio of actual PRO change to predicted PRO change was calculated for each physical therapist, and then empirical bootstrapping was used to develop the median performance ratio and its confidence intervals. Physical therapists who met a 40-patient threshold for either cohort (MDQ or NDI) were classified as "outperforming," "meeting expectations," or "underperforming" relative to predicted values using these 95% confidence intervals. RESULTS: Performance ratios indicated that 10% and 11% of physical therapists outperformed, 79% and 78% met expectations, and 11% and 11% underperformed relative to the risk-adjusted predicted change in the MDQ (1240 therapists; 97,908 patients) and NDI (461 therapists; 26,123 patients), respectively. To demonstrate the clinical importance of risk adjustment, clinical performance was evaluated in the seemingly homogeneous subset of 208 physical therapists within 0.5 SD of the median baseline MDQ and the median actual change in the MDQ. Following risk adjustment, 2 physical therapists were classified in each of the outperforming and underperforming cohorts. LIMITATIONS: The secondarily obtained observational data used were not collected for research purposes. Additionally, the analyses were limited by missing baseline information and follow-up PROs. CONCLUSIONS: The risk-adjusted performance ratios for the MDQ and NDI resulted in disparate conclusions regarding the quality of care compared with the raw, unadjusted change scores. According to the baseline and unadjusted change in the MDQ, even physical therapists in the most homogeneous sample were differentiated following appropriate risk adjustment. Clinically important improvements in actual PROs were observed in the outperforming but not in the underperforming physical therapists. Clinically meaningful differences in the performance ratio are unknown and are a limitation to clinical application and an opportunity for future research.