The impact of standardized balance measurement on physical therapist decision-making in acquired brain injury: a survey.

BACKGROUND: The use of balance outcome measures (OM) is proposed to enhance physical therapy services and patient outcomes. OBJECTIVE: Explore current practices of balance OM use and OM's role in United States physical therapists' decision-making with patient's acquired brain injury (ABI). METHODS: Cross-sectional survey utilizing snowball sampling, n = 373. Survey items required ranking agreement with statements on Likert scale. Multinomial logistic regression used to determine the relationship between survey answers and participant characteristics. RESULTS: Ninety-three percent of therapists reported using outcome measures with patients with ABI. Those who reported not using outcome measures with patients with ABI were significantly different on setting, primary patient population, APTA section membership, and ANPT membership. All respondents who primarily treated neurologic diagnoses used outcome measure with clients with ABI, compared to 87% of respondents who worked primarily with orthopedic clients. Comfort, equipment availability, and psychometric properties were the most frequent reasons for choosing a measure. Therapist decision-making was impacted by outcome measures; this frequency was dependent on practice setting, primary patient population, and specialty certifications. CONCLUSIONS: Physical therapists use a low diversity of outcome measures to assess balance. Respondents rated psychometric properties as more important than past published research. This is the first study to demonstrate that outcome measures play a role for most United States PTs in decision-making in all stages of the patient management model including identification of problems, diagnosis, prognosis, intervention selection, termination of services, and discharge planning, as well justifying service delivery.

Keeping it all in balance: a qualitative analysis of the role of balance outcome measurement in physical therapist decision-making and patient outcomes.

PURPOSE: The use of outcome measures (OMs) is a hallmark of contemporary physical therapy in the USA. The effect of OM utilization on patient care decisions and the results of PT services remain poorly understood. The purpose of this study is to explore PTs perceptions about the relationship between balance OMs and decision-making and how that interaction impacts patient outcomes, particularly for patients with acquired brain injury. MATERIALS AND METHODS: This qualitative study used semi-structured phone interviews with an interview guide. Maximum variation sampling was used. Thematic analysis was situated in a priori determined theory-based categories. RESULTS: Twenty-three physical therapists (PTs) from diverse geographic areas and practice settings participated. Therapists expressed diverse views on the impact of OM use on patient outcomes, but the majority perceived that using OMs improved rehabilitation outcomes. The use of OMs was related to the selection of optimal intervention type and intensity and justified continued high-frequency rehabilitation services. OMs were important to therapists' decision-making. CONCLUSIONS: In the present study, PTs reported that they believe the use of validated, clinically useful OMs may improve patient outcomes.Implications For RehabilitationBalance outcome measures are considered an important tool to the optimal management of the profound impact of balance impairments after brain injury.Most physical therapists in this study believe that using balance outcome measures results in better outcomes for patients with brain injury.In this study, physical therapists reported using outcome measures in wide-ranging ways to guide clinical decisions about balance in those with brain injury.

Facilitators and Barriers to Providing Clinical Education Experiences Through the Lens of Clinical Stakeholders.

INTRODUCTION: Although the provision of clinical education (CE) experiences affords many benefits to clinical stakeholders, little published literature exists regarding the factors influencing decisions of site coordinators of CE (SCCE), clinical administrators, and clinical instructors (CI) to provide CE. REVIEW OF LITERATURE: Site coordinators of CE and CIs navigate workplace expectations while making decisions about their engagement in CE experiences. The purpose of this study was to determine clinical stakeholders' perceptions of facilitators and barriers to the provision of CE experiences for entry-level Doctor of Physical Therapy students. SUBJECTS: This study used survey data from a previous study on perspectives related to payment for CE experiences. The survey questions analyzed included responses provided by 501 clinical administrators, 445 SCCEs, and 657 CIs. METHODS: Retrospective analysis of survey data included frequencies and percentages of responses for nominal and categorical data. Open-ended survey questions underwent content analysis to identify overarching concepts and subordinate categories. RESULTS: Clinicians are most motivated to serve as CIs by "enjoyment of teaching" (274, 49.4%) and a sense of "professional responsibility" (147, 26.5%). Site coordinators of CEs indicated that the top challenges faced in soliciting CIs were the ability to manage challenging students (347, 69.0%), lack of experience serving as a CI (227, 63.4%), ability to maintain productivity standards (220, 61.5%), and clinician burnout (219, 61.2%). Although all participants agreed that their organization promotes a culture of teaching, clinical administrators agreed at a higher percentage than SCCEs (97.8% vs 94.3%, respectively). DISCUSSION AND CONCLUSION: Clinical instructors identified values and benefits that were, at times, in contrast to the organizational culture. The discrepancies in perceptions among stakeholders that were uncovered by this research provide a unique lens that has not been addressed in the literature to date. To provide meaningful support for CIs, it is imperative that directors of CEs, clinical administrators, and SCCEs clearly understand the perceptions of the CI.

The functional lumbar index: Validation of a novel clinical assessment tool for individuals with low back pain.

STUDY DESIGN: Retrospective Diagnostic Cohort Study. LEVEL OF EVIDENCE: Level 3b. OBJECTIVES: To examine the concurrent and predictive validity of a novel clinical assessment tool, the Functional Lumbar Index (FLI). BACKGROUND: Lumbar surgeries have increased exponentially in the past decade, adding to healthcare costs without improving outcomes. Limitations in clinicians' abilities to identify those individuals who are most likely to benefit from surgery may be enhanced with an effective physical assessment tool. METHODS: The FLI was assessed on 291 individuals (179 conservative and 113 pre-surgical) seeking care for low-back pain (LBP) over a 2.5-year period. The FLI consists of several physical performance tests (PPT) with a novel criterion-based scoring system. Pearson correlations and Poisson regression analysis were used to establish concurrent and predictive validity at alpha = 0.05. RESULTS: The subscale FLI components showed good to excellent inter-rater reliability with intraclass correlation coefficient values as follows: front plank = .993, right side plank = .824, left side plank .861, Sorensen = 0.836, overhead squat = 0.937. A statistically significant, moderate negative correlation was observed between FLI and modified Oswestry Disability Index (r = -0.540, p < .001). Regression analysis showed the FLI as the only significant predictor (p = .004) of failed conservative management for individuals with LBP. An ROC curve showed significant group prediction of the FLI with an AUC of 0.788 (p < .001) and cut-off score of 7.5. CONCLUSION: The FLI is a reliable and valid measure for predicting failed conservative care management in patients with LBP. Clinicians are encouraged to use the FLI as part of their physical assessment when screening individuals with LBP who might need surgical intervention. Further research is needed to determine validity of the FLI in other patient populations. PUBLIC TRIAL REGISTRY: N/A.

Reliability of pain scores during a body weight support protocol in individuals with knee osteoarthritis.

PURPOSE: To explore the reliability of percentage of Body Weight Support (BWS) needed for maximal pain relief and of pain scores across 12 walking conditions including pre and post-over-ground walking and an unweighting protocol from 0% to 40% BWS on a lower body positive pressure (LBPP) treadmill for individuals with knee osteoarthritis (OA). MATERIALS AND METHODS: Twenty individuals (64 ± 9.44 years) with knee OA completed over-ground walking and an unweighting protocol on an LBPP treadmill. The amount of BWS started at 0% and increased by 5% increments until it reached 40%. Pain scores were recorded at the end of each increment. RESULTS: The reliability of pain scores was assessed using a Spearman's rho. This study found moderate reliability of the percentage of BWS for maximal pain relief. Additionally, there was good reliability of pain scores with pre and post-over-ground walking and from 0% BWS to 30% BWS, but moderate reliability of pain scores was found at 35% and 40% BWS. CONCLUSION: This study supports the use of pain scores as a reliable measure during an unweighted walking session on an LBPP treadmill.IMPLICATIONS FOR REHABILITATIONBoth the OARSI and ACR recommend exercise in the treatment of individuals with knee OA but acknowledge that pain during exercise and exercise preference/accessibility are important when considering the type of exercise for an individual.LBPP treadmills decrease pain in individuals with knee OA during walking.Pain scores during unweighted walking show moderate to good reliability for individuals with knee OA.This study provides an unweighting protocol to use clinically to determine the Body Weight Support needed to decrease pain.

Reliability and validity of the modified Walking and Remembering Test in persons with multiple sclerosis.

Cognitive dysfunction can adversely impact the walking ability of people with multiple sclerosis. However, valid and reliable standardized clinical tools to measure cognitive-motor interference or dual-tasking in people with multiple sclerosis remain lacking. This study evaluated the validity and reliability of the modified Walking and Remembering Test (mWART) in people with multiple sclerosis. Eleven adults (mean ± SD age, 51.1 ± 13.4 years) with multiple sclerosis (Expanded Disability Status Score, 2.0-6.0) and six adults (mean ± SD age, 41.5 ± 17.2 years) without multiple sclerosis were administered the mWART twice over a 2-week period. Participants were tested on gait and digit span length under single-task and dual-task conditions according to the mWART procedures over a 10-m walkway. intraclass correlation coefficient2,k were 0.961 for single-task gait velocity (P < 0.001), 0.968 for dual-task gait velocity (P < 0.001), 0.829 for single-task digit span (P = 0.004), and 0.439 for dual-task digit span (P = 0.154). Single-task gait velocity (P = 0.001) and dual-task gait velocity (P = 0.002) were able to discriminate between groups but dual-task costs were similar between participants with and without multiple sclerosis. Those with severe disability demonstrated the greater dual-task cost of gait velocity (P = 0.030). This study provides preliminary evidence of the mWART's validity and reliability in measuring dual-task performance in patients with multiple sclerosis with mild to severe disability. More research is required in more heterogeneous samples of persons with multiple sclerosis.

Impact of Faculty and Programmatic Resources on the Proportion of Academic Doctoral Degrees in Professional Physical Therapist Education Programs.

OBJECTIVE: The Commission on Accreditation in Physical Therapy Education has introduced a requirement that 50% of core faculty members in a physical therapist education program should have an academic doctoral degree, which many programs are not currently meeting. Competition between programs for prestige and resources may explain the discrepancy of academic achievement among faculty despite accreditation standards. The purpose of this study was to identify faculty and program characteristics that are predictive of programs having a higher percentage of faculty with academic doctoral degrees. METHODS: Yearly accreditation data from 231 programs for a 10-year period were used in a fixed-effects panel analysis. RESULTS: For a 1 percentage point increase in the number of core faculty members, a program could expect a decline in academic doctoral degrees by 14% with all other variables held constant. For a 1% increase in either reported total cost or expenses per student, a program could expect a 7% decline in academic doctoral degrees with all other variables held constant. Programs that have been accredited for a longer period of time could expect to have proportionately more faculty members with academic doctoral degrees. CONCLUSIONS: Programs may be increasing their core faculty size to allow faculty with academic doctoral degrees to focus on scholarly productivity. The percentage of faculty with academic doctoral degrees declines as programs increase tuition and expenditures, but this may be due to programs' tendency to stratify individuals (including part-time core faculty) into teaching- and research-focused efforts to maximize their research prowess and status. IMPACT: This study illuminates existing relationships between physical therapist faculty staffing, time spent in research versus teaching, and program finances. The results of this study should be used to inform higher education policy initiatives aimed to lower competitive pressures and the costs of professional education.

Translation and Validation of the Arabic Version of the Fear-Avoidance Beliefs Questionnaire in Patients With Low Back Pain.

STUDY DESIGN: Prospective cohort study of a cross-cultural low back pain (LBP) questionnaire OBJECTIVE.: The objectives of the present study were to translate and cross-culturally adapt the Fear-Avoidance Beliefs Questionnaire (FABQ) to create a version in Arabic and to test its psychometric properties. SUMMARY OF BACKGROUND DATA: The FABQ measures the effects that fear and avoidance beliefs have on work and on physical activity. METHODS: An FABQ cross-culturally adapted for Arabic readers and speakers was created by forward translation, translation synthesis, and backward translation. Forty patients in Riyadh, Saudi Arabia, with LBP evaluated use of the questionnaire, and 70 patients from the same hospital participated in reliability, validity, and sensitivity studies. To determine test-retest reliability of the Arabic FABQ, patients completed it twice within 48 hours without receiving any active treatment between these two sessions. Patients completed the Arabic FABQ (and three other scales) at baseline and 14 days later to determine its validity and sensitivity. RESULTS: Test-retest reliability was good (FABQ-work: intraclass coefficient [ICC] = 0.74; FABQ-physical activity: ICC = 0.90; FABQ overall: ICC = 0.76). Correlations between the FABQ and three other instruments for measuring pain and disability were weak. The strongest correlation was found at the follow-up session with the Arabic Oswestry Questionnaire (r = 0.283; P ≤ 0.05). Sensitivity to change was low. CONCLUSION: The translation and adaptation of the Arabic version of the FABQ was successful. Overall, the Arabic FABQ had good test-retest reliability, acceptable construct validity, and low sensitivity to change. The Arabic version of the FABQ shows promise in the assessment of fear-avoidance beliefs among patients with LBP who speak and read Arabic. LEVEL OF EVIDENCE: 3.

Qualitative assessment of component-specific, fall-risk screening procedures to create a fall risk screening form.

BACKGROUND: The Day Center, Case Management, and Home Care components of a local senior health agency each have used different screening forms for assessing their clients for fall risk. A common instrument, easily administered by all components as part of their routine practice, would be helpful in systematically identifying elders at risk of falling. Developing a common screening instrument would be useful at other senior health agencies as well. PURPOSE: To gather information on the content and features that are most useful for fall screening, based on the needs of individual geriatric care workers in each component of a local senior health agency. METHODS: A semistructured interview was used to gather feedback from geriatric care workers on what was needed for universal fall risk screening. RESULTS: Two major themes emerged: (1) factors that are relevant in assessing fall risk and (2) factors that affect the utility of the fall risk screening procedure. Under theme 1, there were 6 categories: fall history, physical function, impairments, medications, mental and psychological status, and home environment. Under theme 2, there were 3 categories: methods of gathering information for fall risk assessment, features useful to a fall risk assessment form, and actions taken in response to fall risk assessment. The 6 fall risk categories identified in the interviews were combined with 2 other categories identified in the literature, health status and fear of falling, to produce a universal form for use by different agency components. DISCUSSION: Integrating all fall-risk categories into a universal form improves the completeness of the form used in different agency components. However, to increase the utility of fall risk screening, service plans integrated with each screening procedure need to be developed according to specific agency structures. A 3-step procedure is proposed to improve the effectiveness of fall-risk screening: (1) initial screening with an outreach worker using a quick question assessment; (2) follow-up with a more comprehensive fall risk assessment while receiving services from the Day Center, Case Management, or Home Care; and (3) a "what-to-do" action is presented for each item on the basis of each question's response on the comprehensive form. CONCLUSIONS: When designing a fall risk screening procedure, integrating all fall-risk factors into a single comprehensive form may not be the ideal strategy. The environment, the person who gathers the information, and the actions required to respond to information gathered should also be considered. On the basis of the results of this qualitative study, we have presented a 3-step procedure, with supporting forms to address these considerations.

Pain assessment and management in children with neurologic impairment: a survey of pediatric physical therapists.

PURPOSE: This study explored pain assessment measures and interventions used by physical therapists in the treatment of children with neurologic impairment. METHODS: Following extensive literature review on pain assessment and intervention, a survey was developed, pilot tested, and posted on the listserv of the Pediatric Section of the American Physical Therapy Association. RESULTS: Eighty percent of the respondents used subjective measures to assess pain, 70% used self-report scales, and 41% used behavioral and physiological measures. Behaviors frequently used included vocalizations, facial expression, and irritability. Rarely used cues included decreased attention, withdrawal, and changes in sleeping and eating behaviors. Therapists used research-supported pain interventions such as distraction and praise as well as potentially harmful distress producing measures such as procedural talk and reassurance. CONCLUSION: Further research is needed to determine the feasibility of using behavioral pain assessment measures during physical therapy sessions. Physical therapist continuing education regarding nonpharmaceutical pain interventions is indicated.

Pain in children with cerebral palsy: implications for pediatric physical therapy.

PURPOSE: This literature review explores pain assessment tools and psychosocial pain management methods that are pertinent to physical therapy (PT) for children with cerebral palsy (CP). SUMMARY OF KEY POINTS: Children with CP experience considerable pain that affects quality of life and cooperation during healthcare procedures. Physical therapist-led research on interventions to address pain in this population is limited, despite evidence for the prevalence of pain during PT interventions, and the preponderance of research supporting the use of psychosocial pain management during other healthcare-related pain-inducing procedures. STATEMENT OF CONCLUSIONS AND RECOMMENDATIONS FOR PHYSICAL THERAPY PRACTICE: Research completed primarily by non-physical therapist healthcare professionals delineate assessment tools and psychosocial pain management techniques that hold promise for evaluating and reducing pain that occurs during PT procedures for children with CP.

Effectiveness of physical therapy for patients with neck pain: an individualized approach using a clinical decision-making algorithm.

OBJECTIVE: The purpose of this study was to determine the effectiveness of an individualized physical therapy intervention in treating neck pain based on a clinical reasoning algorithm. Treatment effectiveness was examined by assessing changes in impairment, physical performance, and disability in response to intervention. DESIGN: One treatment group of 30 patients with neck pain completed physical therapy treatment. The control group of convenience was formed by a cohort group of 27 subjects who also had neck pain but did not receive treatment for various reasons. There were no significant differences between groups in demographic data and the initial test scores of the outcome measures. A quasi-experimental, nonequivalent, pretest-posttest control group design was used. A physical therapist rendered an eclectic intervention to the treatment group based on a clinical decision-making algorithm. Treatment outcome measures included the following five dependent variables: cervical range of motion, numeric pain rating, timed weighted overhead endurance, the supine capital flexion endurance test, and the Patient Specific Functional Scale. Both the treatment and control groups completed the initial and follow-up examinations, with an average duration of 4 wk between tests. RESULTS: Five mixed analyses of variance with follow-up tests showed a significant difference for all outcome measures in the treatment group compared with the control group. After an average 4 wk of physical therapy intervention, patients in the treatment group demonstrated statistically significant increases of cervical range of motion, decrease of pain, increases of physical performance measures, and decreases in the level of disability. The control group showed no differences in all five outcome variables between the initial and follow-up test scores. CONCLUSIONS: This study delineated algorithm-based clinical reasoning strategies for evaluating and treating patients with cervical pain. The algorithm can help clinicians classify patients with cervical pain into clinical patterns and provides pattern-specific guidelines for physical therapy interventions. An organized and specific physical therapy program was effective in improving the status of patients with neck pain.