Association between centralization and directional preference and functional and pain outcomes in patients with neck pain.

STUDY DESIGN: Retrospective cohort. OBJECTIVES: In subjects with neck pain, the present study aimed (1) to describe the prevalence of centralization (CEN), noncentralization (non-CEN), directional preference (DP), and no directional preference (no DP); (2) to determine if age, sex, fear-avoidance beliefs about physical activity, number of comorbid conditions, or symptom duration varies among subjects who demonstrate CEN versus non-CEN and DP versus no DP; and (3) to determine if CEN and/or DP are associated with changes in function and pain. BACKGROUND: CEN and DP are prevalent among patients with low back pain and should be considered when determining treatment strategies and predicting outcomes; however, these findings are not well investigated in patients with neck pain. METHODS: Three hundred four subjects contributed data. CEN and DP prevalence were calculated, as was the association between CEN and DP, and age, sex, number of comorbid conditions, fear-avoidance beliefs, and symptom duration. Multivariate models assessed whether CEN and DP predicted change in function and pain. RESULTS: CEN and DP prevalence were 0.4 and 0.7, respectively. Younger subjects and those with fewer comorbid conditions were more likely to centralize; however, subjects who demonstrated DP were more likely to have acute symptoms. Subjects who centralized experienced, on average, a 3.6-point (95% confidence interval: -0.3, 7.4) improvement in function scores, whereas subjects with a DP averaged a 5.4-point (95% confidence interval: 0.8, 10.0) improvement. Neither CEN nor DP was associated with pain outcomes. CONCLUSION: DP and, to a lesser extent, CEN represent evaluation categories that are associated with improvements in functional outcomes.

McKenzie lumbar classification: inter-rater agreement by physical therapists with different levels of formal McKenzie postgraduate training.

STUDY DESIGN: Inter-rater chance-corrected agreement study. OBJECTIVE: The aim was to examine the association between therapists' level of formal precredential McKenzie postgraduate training and agreement on the following McKenzie classification variables for patients with low back pain: main McKenzie syndromes, presence of lateral shift, derangement reducibility, directional preference, and centralization. SUMMARY OF BACKGROUND DATA: Minimal level of McKenzie postgraduate training needed to achieve acceptable agreement of McKenzie classification system is unknown. METHODS: Raters (N = 47) completed multiple sets of 2 independent successive examinations at 3 different stages of McKenzie postgraduate training (levels parts A and B, part C, and part D). Agreement was assessed with κ coefficients and associated 95% confidence intervals. A minimum κ threshold of 0.60 was used as a predetermined criterion for level of agreement acceptable for clinical use. RESULTS: Raters examined 1662 patients (mean age = 51 ± 15; range, 18-91; females, 57%). Data distributions were not even and were highly skewed for all classification variables. No training level studied had acceptable agreement for any McKenzie classification variable. Agreements for all levels of McKenzie postgraduate training were higher than expected by chance for most of the classification variables except parts A and B training level for judging lateral shift and centralization and part D training level for judging reducibility. Agreement between training levels parts A and B, part C, and part D were similar with overlapping 95% confidence intervals. CONCLUSION: Results indicate that level of inter-rater chance-corrected agreement of McKenzie classification system was not acceptable for therapists at any level of formal McKenzie postgraduate training. This finding raises concerns about the clinical utility of the McKenzie classification system at these training levels. Additional studies are needed to assess agreement levels for therapists who receive additional training or experience at the McKenzie credentialed or diploma levels. LEVEL OF EVIDENCE: 2.

Psychometric properties and practicability of the self-report urinary incontinence questionnaire in patients with pelvic-floor dysfunction seeking outpatient rehabilitation.

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.

Influence of fear-avoidance beliefs on functional status outcomes for people with musculoskeletal conditions of the shoulder.

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.

Characteristics of patients seeking outpatient rehabilitation for pelvic-floor dysfunction.

BACKGROUND: Pelvic-floor dysfunction (PFD) affects a substantial proportion of individuals, especially women. OBJECTIVE: The purposes of this study were: (1) to describe the characteristics of individuals with disorders associated with PFD who were seeking outpatient physical therapy services and (2) to identify the prevalence of specific pelvic-floor disorders in the group. DESIGN: This was a prospective, longitudinal, cohort study of 2,452 patients (mean age=50 years, SD=16, range=18-91) being treated in 109 outpatient physical therapy clinics in 26 states (United States) for their PFD. METHODS: This study examined patient demographic variables and summarized patient self-reported responses to questions related to urinary and bowel functioning at admission prior to receiving the therapy for their PFD disorders. RESULTS: Patients primarily were female (92%), were under 65 years of age (39%: 18 to <45 years; 39%: 45 to <65 years; 21%: 65 years or older), and had chronic symptoms (74%). Overall, 67% of the patients reported that they had urinary problems, 27% reported bowel problems, and 39% had pelvic pain. Among those who had urinary or bowel disorders, 32% and 54% reported leakage and constipation, respectively, as their only problem. Among patients who had pelvic pain, most (56%) reported that the pain was in the abdominal area. Combinations of urinary, bowel, or pelvic-floor pain disorders occurred in 31% of the patients. LIMITATIONS: Because this study was a secondary analysis of data collected prospectively, the researchers were not in control of the data collection procedure. Missing data were common. CONCLUSIONS: Data suggested most patients with PFD receiving outpatient physical therapy services were female, younger than 65 years, and had disorders lasting for more than 90 days. Combinations of urinary, bowel, or pelvic-floor pain disorders were not uncommon.

Lumbar computerized adaptive test and Modified Oswestry Low Back Pain Disability Questionnaire: relative validity and important change.

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.

Referral source and outcomes of physical therapy care in patients with low back pain.

STUDY DESIGN: Retrospective longitudinal cohort. OBJECTIVES: To describe the clinical characteristics of patients with low back pain according to physician referral source, and to identify associations between referral source and discharge functional status, as well as number of physical therapy visits. BACKGROUND: Little is known about associations between physician referral source and outcomes of physical therapy care for patients with low back pain. Exploring these associations can contribute to better understanding of physician-physical therapist relationships and may lead to improved referral patterns. METHODS: Data from a proprietary clinical database were examined retrospectively. Physician referral source was classified as primary care, specialist, or occupational medicine. Outcomes were overall health status at discharge and number of physical therapy visits. Descriptive statistics and bivariate associations between referral source and each outcome were assessed by calculating differences and 95% confidence intervals (CIs) in means and proportions. To account for potential confounding, multilevel linear regression was used to adjust for baseline clinical covariates, effects related to clustering of patients treated by individual clinicians, and clinicians working within individual clinics. RESULTS: Bivariate and multilevel analyses revealed significant associations between referral source and discharge overall health status, as well as number of visits. After multilevel adjustment for covariate and clustering effects, primary care and occupational medicine referrals were associated, on average, with point increases of 1.6 (95% CI: 0.7, 2.6) and 4.8 (95% CI: 2.7, 6.9) in discharge overall health status scores, respectively, compared to specialist referral. Similarly, primary care and occupational medicine referrals were associated, on average, with 0.44 (95% CI: 0.27, 0.61) and 0.83 (95% CI: 0.44, 1.22) fewer visits, respectively, compared to specialist referral. CONCLUSION: After accounting for clinical covariates and clustering, patients with low back pain who were referred by occupational medicine and primary care physicians tended to have better functional outcomes and required fewer physical therapy visits per episode of care. LEVEL OF EVIDENCE: Prognosis, level 2c.

Single-item screens identified patients with elevated levels of depressive and somatization symptoms in outpatient physical therapy.

OBJECTIVE: Develop efficient and accurate screening tools to identify elevated levels of depressive or somatization symptoms, which can adversely affect functional status outcomes. METHODS: We conducted a secondary analysis of prospectively collected depressive and somatization symptoms (Symptom Checklist 90-Revised) data from 10,920 patients receiving outpatient physical therapy for a variety of neuromusculoskeletal diagnoses. Item response theory methods were used to analyze data, with particular emphasis on differential item functioning among groups of patients, and to identify potential screening items. Screening item accuracy for identifying patients with elevated symptoms was assessed with receiver-operating characteristic analyses. RESULTS: Seven items for depressive and 10 items for somatization symptoms represented unidimensional scales. Differential item functioning was negligible for demographic and clinical variables known to affect functional status outcomes. Items providing maximum information at the 88th percentile for depressive and 77th percentile for somatization scales accurately dichotomized patients into elevated versus not elevated symptom levels. CONCLUSIONS: Lack of differential item functioning suggested depressive and somatization screening could be useful in routine clinical practice and allowed the development of single-item screens that accurately identified patients with elevated depressive or somatization symptoms. Item response theory-based single-item screens may facilitate evaluation and management of heterogeneous populations receiving outpatient physical therapy.

Change in psychosocial distress associated with pain and functional status outcomes in patients with lumbar impairments referred to physical therapy services.

STUDY DESIGN: Prospective, longitudinal, observational cohort design. OBJECTIVE: The primary aim was to examine the association between changes in psychosocial distress (PD), and functional status (FS) and pain intensity at discharge from physical therapy. BACKGROUND: Patients with lumbar impairments seeking physical therapy commonly demonstrate elevated PD. However, it is not clear if PD changes that occur during physical therapy management are associated with improved clinical outcomes. METHODS: Data from adults (n = 692) with lumbar impairment were analyzed. Patients were screened using the Symptom Checklist Back Pain Prediction Model questionnaire (SCL BPPM) to identify patients at intake and discharge into 3 levels of risk for persistent disability (high, intermediate, or low). SCL BPPM classifications allowed for 5 patterns of change in PD during therapy (decreased, stable low, stable intermediate, stable high, or increased). Associations between PD change patterns and discharge FS and pain intensity were assessed using multivariable linear regression models, controlling for selected risk-adjustment variables. RESULTS: Proportions of patients classified by patterns of PD change for decreased, stable low, stable intermediate, stable high, and increased were 0.34, 0.52, 0.05, 0.06, and 0.03, respectively. Compared to the decreased PD group, (1) increased, stable high, and stable intermediate PD patterns were associated with worse discharge FS scores (-7.9 [95% CI: -13.5, -2.21], -10.9 [95% CI: -15.25, -6.49], and -8.9 [95% CI: -13.65, -4.21] units, respectively), and (2) stable high and stable intermediate PD patterns were associated with higher pain intensity (2.59 [95% CI: 1.81, 3.56] and 2.14 [95% CI: 1.25, 3.04] units, respectively). CONCLUSIONS: Lower FS and higher pain intensity outcomes were associated in similar but not identical patterns with patients whose SCL BPPM classification of PD increased, or remained at high or intermediate levels during physical therapy. Serial assessments of change in PD during rehabilitation are recommended as a possible treatment-monitoring tool.

Using intake and change in multiple psychosocial measures to predict functional status outcomes in people with lumbar spine syndromes: a preliminary analysis.

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.

Total number and severity of comorbidities do not differ based on anatomical region of musculoskeletal pain.

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.

Construct validation of a knee-specific functional status measure: a comparative study between the United States and Israel.

BACKGROUND: Comparative effectiveness research (CER) requires valid outcome measures that discriminate patients by risk factors in similar ways across settings. Standardized functional status (FS) measures in physical therapy are used routinely in multiple countries, creating the potential for CER among countries. OBJECTIVE: The purpose of this study was to assess known-groups construct validity of a knee-specific FS measure within and between 2 countries for patients receiving outpatient physical therapy due to knee impairments. DESIGN: This was a longitudinal, observational cohort study. METHODS: The participants were 4,972 and 2,964 adult (age ≥18 years) patients with knee impairments from Israel and the United States, respectively. Differences in patient characteristics between the 2 countries were assessed using chi-square statistics and 2-sample t tests, as appropriate. Known-groups validity within and between the countries was assessed using 2-way analysis of covariance predicting FS at discharge, with sex, age, symptom acuity, surgical and exercise history, intake medication use, and country as risk-adjustment factors. Intake FS was the covariate. To compare how FS discriminated patient groups between countries, each factor was tested separately with models including an interaction term between the factor and country. RESULTS: Patients were different between countries but had similar discharge FS trends, including: higher outcomes in patients who were male, were younger, had acute conditions, had one surgical procedure related to their knee impairment, were more physically active, and did not use related medication at admission. Interactions were not significant for sex, symptom acuity, and exercise history but were significant for age, surgical history, and medication use. Limitations Although strict patient selection criteria were set, some patient selection bias still might have existed. CONCLUSIONS: The results demonstrated the knee FS measures would be valid for use in CER between Hebrew-speaking patients (Israel) and English-speaking patients (United States).

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.

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.

Baseline dependency of minimal clinically important improvement.

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.

Depressive symptoms, anatomical region, and clinical outcomes for patients seeking outpatient physical therapy for musculoskeletal pain.

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.

Weighted index explained more variance in physical function than an additively scored functional comorbidity scale.

OBJECTIVE: 1) examine association between the Functional Comorbidity Index (FCI) and discharge functional status (FS); 2) examine impact of FCI on FS when added to comprehensive models; and 3) compare additive FCI with weighted FCI and list of condition variables (list). STUDY DESIGN AND SETTING: Patients were drawn from Focus On Therapeutic Outcomes, Inc. (FOTO) database (1/1/06-12/31/07). FS collected using computer adaptive tests. Linear regression examined association between FCI and FS. Three methods of including functional comorbidities (FC) were compared. RESULTS: Relationship between FCI and FS varied by group (range, 0.02-0.9). Models with weighted index or list had similar R². Weighted FCI or list increased R² of crude models by <0.01 for cervical, shoulder, and lumbar; by 0.01 for wrist/hand, knee, and foot/ankle; by 0.02 for hip; by 0.03 for elbow; and by 0.08 for neurological. Addition of FCI to comprehensive models added <0.01 to R² (all groups). Weighted FCI increased R² by <0.01 for cervical, lumbar, and shoulder; by 0.01 for wrist/hand, hip, knee, and foot/ankle; by 0.02 for elbow; and by 0.04 for neurological; whereas list increased R² by <0.01 for cervical, shoulder, and lumbar; by 0.01 for knee and foot/ankle; by 0.02 for elbow, wrist/hand, and hip; and by 0.05 for neurological. CONCLUSION: List of comorbidities or weighted FCI is preferable to using additive FCI.

Association between directional preference and centralization in patients with low back pain.

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-.

Clinician's ability to identify neck and low back interventions: an inter-rater chance-corrected agreement pilot study.

OBJECTIVE: To estimate inter-rater agreement of physical therapists trained in MDT approach and participating in practice-based evidence (PBE) research to identify 72 physical therapy interventions in video demonstrations on a single model and clinical vignettes. PBE is a well designed observational study and demonstrating clinician observational consistency is an important step in conducting PBE research design. METHODS: Two physical therapists volunteered to participate in pilot reliability testing and seven other physical therapists trained in McKenzie Mechanical Diagnosis and Therapy (MDT) methods volunteered for the inter-rater chance-corrected agreement study. All therapists identified interventions presented within 52 videos and 5 written clinical vignettes describing 20 more intervention techniques. Therapists independently identified all interventions. We assessed inter-rater chance-corrected agreement of therapists' ability to identify intervention techniques using Kappa coefficients with associated 95% confidence intervals and indices for bias and prevalence. RESULTS: Of the 147 kappa coefficients estimated, 7% were ⩽0·6, 10% were >0·6 and ⩽0·8, and 83% were >0·8. Agreement was lowest for identifying cognitive behavioral techniques (median kappa = 0·79). The minimum and maximum prevalence and bias indices were 0·33 and 0·85 and 0 and 0·33, respectively suggesting kappa coefficient estimates were strong. Generalized kappa coefficients ranged from 0·73 to 1·00. DISCUSSION: Results provide evidence that substantial to almost perfect inter-rater agreement could be expected when trained therapists identify physical therapy interventions used for patients with spinal impairments from staged videos and vignettes. This may be helpful to reassure clinicians of the quality of the reporting of intervention(s) performed when conducting multivariable analyses in future pragmatic PBE studies. Additional studies are needed to test whether these results can be validated using larger groups of therapists, trained and not trained in MDT methods, as well as examining different methods to examine inter-rater agreement for identifying diverse interventions commonly used for managing patients during routine practice.

Developing a wellness program for people with multiple sclerosis: description and initial results.

Because multiple sclerosis (MS) is a multidimensional chronic disease, effective management of the illness requires a multidimensional approach. We describe a wellness program that was designed to facilitate positive health choices throughout the course of MS and present initial data analyses. We hypothesized that over the course of the program, participants would demonstrate improvement in the domains assessed. The wellness program included educational sessions in physical, mental, social, intellectual, and spiritual domains specifically targeting improved self-efficacy, physical functioning, coping skills, symptom management, and nutrition. An outcomes data collection software program was adapted to facilitate real-time patient self-report and clinician entry data collection for many domains throughout the wellness program. Initial assessment of serial measures (intake to discharge) from 65 people with MS showed improvement in several domains, including functional status (P < .05), fatigue (P < .05), fear-avoidance beliefs regarding physical activities (P < .05), depression (P < .05), somatization (P < .05), and pain (P < .05). In addition, using a model of risk for interpersonal distress, patients whose risk of elevated depression and anxiety decreased over the course of the program reported greater gains in functional status (P < .05). The results suggest possible future treatment strategies and indicate strengths and weaknesses of the wellness program, which are being used to improve the program.

Association between centralization, depression, somatization, and disability among patients with nonspecific low back pain.

STUDY DESIGN: Secondary analysis of a prospective observational cohort study. OBJECTIVES: To evaluate whether depression and somatization subscores of the Symptom Checklist-90-Revised (SCL-90-R), which have been shown to identify chronic disability in individuals with nonspecific low back pain, are applicable to a different population of individuals with low back pain; and to determine if this potential association is confounded by a combination of centralization and subsequent treatment based on centralization. BACKGROUND: To help direct management of patients with nonspecific low back pain, recommendations include performing tests designed to identify psychosocial risk factors predictive of poor patient outcomes. SCL-90-R depression and somatization subscores have been shown to predict chronic disability among patients with low back pain. METHODS: SCL-90-R depression and somatization subscores and data on centralization were collected during the initial physical therapy examination of 231 consecutive patients treated for low back pain in 2 clinics. Disability was assessed by the Oswestry Disability Questionnaire at intake and discharge from physical therapy, and work status was determined by patient self-report at 6 and 12 months after discharge. Pain intensity was assessed by the numeric pain rating scale at the initial visit, and at 6- and 12-month follow-ups. Data were analyzed using logistic regression. RESULTS: Odds ratios for the association between depression and somatization subscores and patient outcomes ranged from 0.76 to 2.93. For analyses in which the data suggested a trend toward an association, the association was less evident following adjustment for centralization and centralization-based treatment. CONCLUSIONS: In our sample, in which all individuals received physical therapy, and those who centralized received interventions based on the direction of centralization, SCL-90-R depression and somatization subscores were moderately associated with chronic pain and disability. This association was reduced when centralization and centralization-based treatment was considered in multivariable analyses.