Evaluation of a blended learning approach on stratified care for physiotherapy bachelor students.

BACKGROUND: Stratified models of care are valuable for addressing psychosocial factors which influence the outcome of patients with musculoskeletal disorders. Introducing such models in undergraduate training has the potential to propagate this knowledge with evidence and foster its implementation. The objective of this paper is to explore the perception and changes in the fear-avoidance beliefs of physiotherapy students participating in a developed blended learning course on stratified care. METHODOLOGY: A mixed-methods with a convenient sample of two consecutive cohorts were given a blended learning course on stratified care for patients with low back pain. The blended learning course comprised scientific rudiments and application of stratified care in clinical practice conceptualised using the KERN' 6-step approach. The exam scores, perceptions, performance on self-reflection-tests and pre- and post-scores on The Tampa Scale for Kinesiophobia for Physiotherapists' (TSK-PT) were obtained. After gaining clinical experience, participants were invited to discuss their clinical experiences and perceptions in workshops. The quantitative data was analysed explorative-descriptively. The qualitative data was analysed following an inductive coding system with constant comparisons. RESULTS: Ninety-one participants consented to the evaluation (mean age = 22.9 ± 1.6 years), 66% were female. Exam scores correlated with time spent in training (r = 0.30) and scores on self-reflection-tests 1 and 2 (r = 0.40 and r = 0.41). Participants in both cohorts described the learning resources as promoting their interest in the subject (72% and 94%), up-to-date (91% and 93%) and helpful (91% and 97%). The fear-avoidance scores for participants decreased from 53.5 (± 9.96) to 40.1 (± 12.4) with a large effect size (d = 1.18). The regression model [F (2, 49) = 1151.2, p < 0.001] suggests that pre-TSK-PT and the interest of participants in the training predicted post-TSK-PT. The workshop participants (n = 62) all worked in clinical practice. Emerging from the analysis were 4 categories (evolving to maturity in practice, perceiving determinants of stratified care, strategising for implementation and adopting an outlook for future practice). CONCLUSION: The quality of engagement in learning, training strategy and interest in the subject contributes immensely to learning outcomes. This blended learning course was successful in reducing kinesiophobia and influencing the participants' attitude towards care with the potential of being translated into long-term practice.

Exploratory Study of Associations and Agreement between Prognostic Patient-Registered Factors, Physiotherapists' Intuitive Synthesis, and Patient-Reported Factors in Whiplash-Associated Disorders.

BACKGROUND: A large proportion of people who sustain a whiplash injury will have persistent pain, disability, and participation problems. Several prognostic factors for functional recovery have been reported in the literature but these factors are often evaluated based on differing implementations in clinical practice. Additionally, physiotherapists also rely on their clinical intuition to estimate the functional prognosis of their patients, but this is seldom measured in experimental research. Furthermore, no study to date has explored the associations between clinical intuition, clinically estimated factors, and objectively measured factors for functional recovery of patients with Whiplash-Associated Disorders (WAD). AIM: The aim of this exploratory study is to evaluate associations between prognostic factors for functional recovery, based on routinely collected data in a specialized primary care physiotherapy practice in a consecutive sample of patients (n = 523) with WAD. METHODS: Three sources of prognostic factors were selected: (1) physiotherapists' synthesis of clinical intuition in terms of high-risk, inconclusive risk, or low-risk for functional recovery, (2) patient-registered factors from history taking, and (3) patient-reported prognostic factors derived from questionnaires. Prognostic factors were selected based on the literature, recommendations in Dutch clinical practice guidelines, and consensus between experts. Spearman's rank correlation coefficients were calculated to explore the associations between sources of prognostic factors, using a cutoff ≥0.25 for acceptable association. RESULTS: Associations between physiotherapists' intuitive synthesis and patient-registered variables were substantial (rs = 0.86), between patient-registered variables and patient-reported variables fair (ranging from 0.30 to 0.41) to substantial (ranging from 0.69 to 0.73), and between physiotherapists intuitive synthesis and patient-reported variables fair (ranging from 0.30 to 0.37). CONCLUSION: When estimating prognosis for functional recovery using clinical reasoning, physiotherapists should integrate patients' registered experience of their course of recovery, as well as the timeline after an accident, with their own synthesis of clinical intuition regarding prognostic factors in patients with WAD.

Improved quality of physiotherapy care in patients with Whiplash-Associated Disorders: Results based on 16 years of routinely collected data.

Quality improvement is now a central tenet in physiotherapy care, and quality indicators (QIs), as measurable elements of care, have been applied to analyze and evaluate the quality of physiotherapy care over the past two decades. QIs, based on Donabedian's model of quality of care, provide a foundation for measuring (improvements in) quality of physiotherapy care, providing insight into the many remaining evidentiary gaps concerning diagnostics, prognostics and treatment, as well as patient-related outcome measures. In this overview we provide a synthesis of four recently published articles from our project group on the topic of quantitative measures of quality improvement in physiotherapy care, in this context specifically focused on patients with WAD in primary care physiotherapy. A set of process and outcome QIs (n = 28) was developed for patients with WAD and linked to a database consisting of routinely collected data (RCD) on patients with WAD collected over a 16-year period. The QIs were then embedded per step of the clinical reasoning process: (a) administration (n = 2); (b) history taking (n = 7); (c) objectives of examination (n = 1); (d) clinical examination (n = 5); (e) analysis and conclusion (n = 1); (f) treatment plan (n = 3); (g) treatment (n = 2); (h) evaluation (n = 5); and (i) discharge (n = 2). QIs were expressed as percentages, allowing target performance levels to be defined ≥70% or ≤30%, depending on whether the desired performance required an initially high or low QI score. Using RCD data on primary care patients with WAD (N = 810) and a set of QIs, we found that the quality of physiotherapy care has improved substantially over a 16-year period. This conclusion was based on QIs meeting predetermined performance targets of ≥70% or ≤30%. Twenty-three indicators met the target criterium of ≥70% and three indicators ≤30%. Our recommended set of QIs, embedded in a clinical reasoning process for patients with WAD, can now be used as a basis for the development of a validated QI set that effectively measures quality (improvement) of primary care physiotherapy in patients with WAD.

Cross-cultural adaptation and validation of the German Central Sensitization Inventory (CSI-GE).

BACKGROUND: The Central Sensitization Inventory (CSI) is a screening tool designed to detect symptoms related to Central Sensitization (CS) and Central Sensitivity Syndromes (CSS) by measuring the degree of related phenomena. The objective of this study was to create a German, culturally-adapted version of the CSI and to test its psychometric properties. METHODS: A German version of the CSI (CSI-GE) was developed, culturally-adapted, and pretested for comprehensibility. The psychometric properties of the resulting version were validated in a clinical study with chronic pain and pain-free control subjects. To assess retest reliability, the CSI-GE was administered twice to a subgroup of patients. Structural validity was tested using factor analyses. To investigate construct validity a hypotheses testing approach was used, including (1) correlations between the CSI-GE and several other well-established questionnaires as well as (2) an investigation of the CSI-GE discriminative power between different subgroups of participants believed to have different degrees of CS. RESULTS: The CSI-GE showed excellent reliability, including high test-retest characteristics. Factor analyses confirmed a bi-factor dimensionality as has been determined previously. Analysing construct validity 6 out of 11 hypotheses (55%) were met. CSI-GE scores differentiated between subgroups according to expectations. Correlations between CSI-GE scores and other questionnaires suggested that none of the correlated constructs was identical, but there was overlap with other questionnaires based on symptom load. Several correlations did not fit with our current understanding of CS. CONCLUSION: The CSI-GE appears to be a reliable tool for measuring CS/CSS-related symptomatology. Whether this implies that the CSI-GE measures the degree of CS within an individual subject remains unknown. The resulting score should be interpreted cautiously until further clarification of the construct.

An Evidence-Based Guideline on Pain Assessment in Nursing Homes For Residents and Informal Caregivers.

BACKGROUND: Nursing home residents are often affected by pain. Pain assessment aims to determine pain intensity and quality. An evidence-based guideline on pain assessment in nursing homes was developed to support residents and informal caregivers in archiving an adequate pain assessment prerequisite to pain treatment. AIM: The residents' guideline presents key recommendations that is comprehensible and accessible to residents and informal carers. DESIGN: We conducted a content analysis. SETTING/SUBJECTS: Therefore, all recommendations of an evidence-based guideline for pain assessment in nursing home were evaluated on relevance for supporting residents' decision-making process. METHODS: Two researchers conducted the content analysis independently and as a result, 29 recommendations could be included. In addition, representatives of a support-group organization for patients with pain validated the derived recommendations. RESULTS: The present residents' guideline of pain assessment consists of nine thematic categories, written in laymen's terms to enable older persons to make informed choices and optimizing their own pain management process. CONCLUSIONS: The Guideline is available in print format and ready for implementation to enhance the effects on maintaining the physical and psychological well-being and optimal care of older adults in Nursing Homes.

Recommendations for a Pediatric Pain Education Curriculum for Physical and Occupational Therapists: Scoping Review and Survey.

Specialization training for physiotherapists, occupational therapists, and sports therapists involved in pediatric pain is scarce and curricula are rarely published. The objectives of this study are twofold: firstly, to perform a scoping review to derive important contents for a pediatric pain education curriculum for specialized pain therapists. Secondly, to conduct a survey on specific contents in curricula currently used by pain experts and to obtain their evaluation regarding the importance of such contents for a specialized curriculum. The review substantiated the importance of a specific curriculum in pediatric pain education, but provided little information on adequate contents. In the survey, 45 experts in pediatric pain education confirmed that specific curricula and specialized contents for pediatric pain education are missing. Their answers give a well-defined picture of the specifics needed in the interaction with a pediatric population. The most important items they classified were e.g., the biopsychosocial framework and the impact of pediatric pain on daily life. Those expert ratings were in line with the recommendations of pediatric pain management guidelines. Further curriculum work in an interdisciplinary, international network is highly recommended.

[On the move-Prevention of chronic pain with physical activity and movement]. / "On the Move" ­ Prävention chronischer Schmerzen durch körperliche Aktivität und Bewegung.

BACKGROUND: Sufficient physical activity and exercise shows a variety of health-promoting positive effects. In the context of pain therapy, promotion of physical activity could be an important contribution to primary, secondary and tertiary prevention of chronic pain. OBJECTIVES: The aim is to investigate the relationship between physical activity and chronic pain, the preventive effect of physical activity on pain and the factors to successfully promote physical activity in people with chronic pain. METHODS: For this narrative review databases of the Cochrane Library, MEDLINE (via PubMed) and the Physiotherapy Evidence Database (PEDro) were searched for reviews and studies with the keywords chronic pain, physical activity, movement, exercise and prevention. RESULTS: A total of 10 reviews, 10 clinical studies and 4 surveys were included and summarized. CONCLUSION: Although the evidence base on this topic is still insufficient, positive effects of physical activity on the prevention of chronic pain could be demonstrated. Interventions for people with chronic pain that sustainably increase physical activity should take into account individual resources, address barriers such as maladaptive beliefs, and create positive movement experiences.

Clinical Characteristics and Patient-Reported Outcomes of Primary Care Physiotherapy in Patients with Whiplash-Associated Disorders: A Longitudinal Observational Study.

BACKGROUND: Whiplash-associated disorders (WADs) constitute a state of health characterized by a wide diversity of symptoms as a result of impairments of functions, activity limitations, and participation restrictions. Patient-reported outcome measurements (PROMs) and patient-reported outcomes (PROs) seem appropriate when describing and evaluating the health status of patients with WAD. AIM: To measure the use of PROMs and PROs as quality indicators in clinical reasoning, and to analyze and evaluate pre- and post-treatment 'pain intensity' and 'functioning', and for 'perceived improvement' in patients with WAD in primary care physiotherapy practice by year of referral, with the phase after accident and prognostic health profile embedded in the clinical reasoning process. MATERIALS AND METHODS: Data were collected over a period of 10 years. Pain intensity, functioning, and perceived improvement were measured using the Visual Analogue Scale for Pain (VAS-P), the Neck Disability Index (NDI) and the Global Perceived Effect scale (GPE). Pre- and post-treatment mean differences were tested for statistical significance and compared to minimal clinically important differences (MCID). Effect sizes were expressed as Cohen's d. Multivariable regression analysis was performed to explore independent associations of year of referral, phase after the accident, and the patient's prognostic health profile with post-treatment pain intensity and functioning. RESULTS: A consecutive sample of 523 patients was included. Pre- and post-treatment mean differences on VAS-P and NDI were statistically significant (P<0.000) and clinically relevant, with 'large' effect sizes for pain intensity and functioning. MCIDs were achieved by 80% for VAS-P and for 60% for NDI. Year of referral and phase after the accident were independently associated with worse post-treatment functioning. About half of the patients (n=241 [46.1%]) perceived themselves as improved. CONCLUSION: The PROMs and PROs pain intensity, functioning and perceived improvement were integrated as quality indicators in the physiotherapy clinical reasoning process for patients with WAD. Significant differences in pain intensity and functioning were found but were unrelated to year of referral, phase after whiplash-related injury or prognostic health profile. The MCID VAS-P scores did not differ depending on experienced pain.

Relationships Between Context, Process, and Outcome Indicators to Assess Quality of Physiotherapy Care in Patients with Whiplash-Associated Disorders: Applying Donabedian's Model of Care.

BACKGROUND: Quality indicators (QIs) are measurable elements of practice performance and may relate to context, process, outcome and structure. A valid set of QIs have been developed, reflecting the clinical reasoning used in primary care physiotherapy for patients with whiplash-associated disorders (WAD). Donabedian's model postulates relationships between the constructs of quality of care, acting in a virtuous circle. AIM: To explore the relative strengths of the relationships between context, process, and outcome indicators in the assessment of primary care physiotherapy in patients with WAD. MATERIALS AND METHODS: Data on WAD patients (N=810) were collected over a period of 16 years in primary care physiotherapy practices by means of patients records. This routinely collected dataset (RCD-WAD) was classified in context, process, and outcome variables and analyzed retrospectively. Clinically relevant variables were selected based on expert consensus. Associations were expressed, using zero-order, as Spearman rank correlation coefficients (criterion: rs >0.25 [minimum: fair]; α-value = 0.05). RESULTS: In round 1, 62 of 85 (72.9%) variables were selected by an expert panel as relevant for clinical reasoning; in round 2, 34 of 62 (54.8%) (context variables 9 of 18 [50.0%]; process variables 18 of 34 [52.9]; outcome variables 8 of 10 [90.0%]) as highly relevant. Associations between the selected context and process variables ranged from 0.27 to 0.53 (p≤0.00), between selected context and outcome variables from 0.26 to 0.55 (p≤0.00), and between selected process and outcome variables from 0.29 to 0.59 (p≤0.00). Moderate associations (rs >0.50; p≤0.00) were found between "pain coping" and "fear avoidance" as process variables, and "pain intensity" and "functioning" as outcome variables. CONCLUSION: The identified associations between selected context, process, and outcome variables were fair to moderate. Ongoing work may clarify some of these associations and provide guidance to physiotherapists on how best to improve the quality of clinical reasoning in terms of relationships between context, process, and outcome in the management of patients with WAD.

Pain Assessment for Older Persons in Nursing Home Care: An Evidence-Based Practice Guideline.

Up to 80% of nursing home residents are affected by pain. Pain assessment aims to determine pain intensity, quality, and course of pain to underpin diagnostic decision making. In the nursing home population, pain assessment is frequently compromised by cognitive impairment. Characteristics of the nursing home setting, such as resident's age, staff skill mix, and overall aims of the care provided, also need to be taken into account. Therefore, an interdisciplinary evidence-based clinical practice guideline for pain assessment in the nursing home setting was developed. A systematic literature search was carried out covering publications between 2003 and 2015. Thirty-nine studies were included in the preparation of this guideline, supplemented by 12 international reference guidelines. Recommendations were subjected to a structured consensus-finding process with representatives from 37 scientific and professional organizations and patient representatives. The guideline underwent independent peer review before finalization. It comprises 62 recommendations that are grouped into 4 chapters: (1) context of pain assessment in nursing home care; (2) screening; (3) focused assessment; and (4) reassessment/monitoring of pain. Main recommendations stipulate that clinicians should assess the patient's ability to provide self-report of pain when screening for pain and that each resident should be screened for the presence of pain. A focused assessment of pain, performed during rest and activities, should include pain intensity, changed behaviors, general mobility, pain history, comorbidities, and pain medication. Pain should be re-assessed at regular intervals using the same instruments that were used for the focused assessment. Guideline development demonstrated that many aspects of pain assessment in older persons have not received adequate research attention so far. Available studies predominantly possess only low levels of evidence. Therefore, research into this area needs to be systematically developed to address questions of clinical relevance to support patient care.

Body movements as pain indicators in older people with cognitive impairment: A systematic review.

BACKGROUND AND OBJECTIVE: Pain assessment tools for cognitively impaired older people, unable to self-report pain, are commonly founded upon observation of pain behaviour, such as facial expressions, vocalizations and body movements. The scientific basis for claiming that body movements may indicate pain has not formerly been investigated in a systematic review. The objective was to explore research evidence for body movements being pain indicators in older people with cognitive impairment. DATA BASES AND DATA TREATMENT: MEDLINE, EMBASE, CINAHL, PsycINFO and the Cochrane Library were searched systematically. Two researchers independently identified and consented on studies to be included. PRISMA statement for reporting systematic reviews was followed. Mixed Methods Appraisal Tool was used for critical evaluation of study quality. RESULTS: A total of 2,096 records from the literature searches were identified, and 17 quantitative and eight qualitative studies were included in the review, the studies mainly related to older people with dementia. Quality scores ranged from 50% to 100%. We combined 62 items of body movements into 13 similar or synonymous items, and criteria for evidence were defined. Strong evidence was found for restlessness (agitation), rubbing, guarding, rigidity and physical aggression as the behaviours frequently responded (increased or decreased) to pain provoking activities, painful procedures and/or pain medication. CONCLUSIONS: Among 13 categories of body movements, we found five with strong and five with moderate evidence of validity. As few items were typically included in many studies reflecting criterion validity, all should be included in future studies of patients with different characteristics, location and duration of pain. SIGNIFICANCE: Pain assessment tools for older people with cognitive impairment or dementia should include valid pain behaviour items. Our review shows strong scientific evidence for the following body movements indicating pain: restlessness (agitation), rubbing, guarding, rigidity and physical aggression.

Has the quality of physiotherapy care in patients with Whiplash-associated disorders (WAD) improved over time? A retrospective study using routinely collected data and quality indicators.

PURPOSE: To develop valid quality indicators (QIs) for physiotherapy care based on best available evidence, and to use these QIs to explore trends in the quality of physiotherapy care of patients with Whiplash-associated disorders (WAD) using guideline-based routinely collected data (RCD) gathered between 1996 and 2011. MATERIALS AND METHODS: The study consisted of two phases: 1) development of QIs and 2) analysis of patient records. A set of QIs was developed based on recommendations in the scientific literature and the Dutch Clinical Practice Guideline (CPG) "Physiotherapy Management and WAD". QIs were expressed as percentages, allowing target performance levels to be defined (≥80% or ≤30% depending on whether desired performance required a high or low score on a QI). We then analyzed WAD patient data (N = 810) collected over a period of 16 years in two physiotherapy practices, separating patients into two groups defined as before (Group A 1996-2002; n = 353) and after (Group B 2003-2011; n = 457) implementation and transition to the Dutch CPG "Physiotherapy Management and WAD". RESULTS: Using an iterative process and input from both experts and users, 28 QIs were developed and subsequently classified per step of the clinical reasoning process for physiotherapy care. Based on 16 years of RCD, we found that the clinical reasoning process differed significantly (P ≤ 0.05) between the groups, in favor of Group B. Twelve of the 25 indicators (48.0%) in Group A and 19 of 26 indicators (73.1%) in Group B met predetermined performance targets. The number of target indicators also differed significantly between groups, favoring Group B (P ≤ 0.05). CONCLUSION: A preliminary set of novel QIs was developed. Using RCD and these QIs, we conclude that physiotherapy care in our study setting improved over the period 1996-2011. Furthermore, the QIs met the performance targets set for the clinical reasoning process after the transition to the Dutch CPG "Physiotherapy Management and WAD".

Pain-related fear of (re-)injury in patients with low back pain: Estimation or measurement in manual therapy primary care practice? A pilot study.

BACKGROUND: Manual physical therapists (MPTs) working in primary care get limited information about patient's courses of (chronic) low back pain (LBP). Identification of kinesiophobia is mostly based on clinical perception. OBJECTIVE: The aim of this study was to evaluate the association between the scores with which manual physical therapists in a primary care setting identify kinesiophobia in patients with low back pain, and the patients' self-reported measures of kinesiophobia. METHODS: The cross-sectional study comprised 104 patients with LBP and 17 MPTs. Patients first independently completed the Tampa Scale for Kinesiophobia (TSK-17). The therapists, blinded to the TSK-scores, rated their perception of a patient's kinesiophobia using the Visual Analogue Scale-Estimation (VAS-est) and the accuracy of their ratings using the Visual Analogue Scale-Accuracy (VAS-ac). Kendall's tau b was used to determine the level of correlation between scores on the TSK-17 and the VAS-est.

Graded Exposure for Chronic Low Back Pain in Older Adults: A Pilot Study.

BACKGROUND AND PURPOSE: Fear-avoidance beliefs in older adults with chronic low back pain (CLBP) can lead to disability. Graded exposure-based active physical therapy could be an option to enhance physical ability in older patients with CLBP. The purpose of this study was to develop a standardized graded exposure treatment according to the fear-avoidance model of musculoskeletal pain for older patients with CLBP and to examine its effectiveness and feasibility in the German health care system. METHODS: The study represents a phase I/phase II trial of a complex intervention. Taking a first step into the hierarchy of growing empirical evidence, a prospective 1-factor observational study was conducted with repeated measurements 1 week before and within 2 weeks after the intervention. Three physical therapists, who completed an introductory workshop, provided the treatment in the form of individual therapies. Sixteen participants 65 years or older with CLBP and perceived physical limitations were recruited. Four patient-reported outcome measures and semistructured interviews were conducted. The primary outcome was physical ability measured with the Hanover Functional Ability Questionnaire. Secondary outcomes were the numerical pain rating scale, and an age-specific and adapted 11-item short-form of the Patient Anxiety Symptom Scale, the KVS-D 65+, which quantified catastrophizing and avoidance beliefs. Fear of falling was measured with the Falls Efficacy Scale-International. For the analysis, Wilcoxon signed-rank test for paired samples and an α level of .05 were chosen. For the qualitative evaluation, semistructured interviews were conducted with the patients and physical therapists explored indicators of feasibility such as demands, acceptability, satisfaction, adaptation needs, and implementation. For content analysis, codes were primarily derived deductively and complemented by inductively derived new themes. RESULTS: A significant increase in physical ability after the treatment was observed with an effect size (ES) of 0.95 (P = .008). With regard to secondary outcomes, there was a statistically significant decrease in pain intensity (P = .029) and a reduction in catastrophizing (ES = 0.91; P = .021) and avoidance beliefs (ES = 1.37; P = .001). The interviews revealed good acceptance and satisfaction of the treatment by the patients and physical therapists. CONCLUSION: On the whole, the treatment appears effective and feasible. Apart from the benefits achieved by the participants, the study provides a basis for designing future studies at a higher level of evidence.

Manual physical therapists' use of biopsychosocial history taking in the management of patients with back or neck pain in clinical practice.

OBJECTIVE: To develop and evaluate process indicators relevant to biopsychosocial history taking in patients with chronic back and neck pain. METHODS: The SCEBS method, covering the Somatic, Psychological (Cognition, Emotion, and Behavior), and Social dimensions of chronic pain, was used to evaluate biopsychosocial history taking by manual physical therapists (MPTs). In Phase I, process indicators were developed while in Phase II indicators were tested in practice. RESULTS: Literature-based recommendations were transformed into 51 process indicators. Twenty MTPs contributed 108 patient audio recordings. History taking was excellent (98.3%) for the Somatic dimension, very inadequate for Cognition (43.1%) and Behavior (38.3%), weak (27.8%) for Emotion, and low (18.2%) for the Social dimension. MTPs estimated their coverage of the Somatic dimension as excellent (100%), as adequate for Cognition, Emotion, and Behavior (60.1%), and as very inadequate for the Social dimension (39.8%). CONCLUSION: MTPs perform screening for musculoskeletal pain mainly through the use of somatic dimension of (chronic) pain. Psychological and social dimensions of chronic pain were inadequately covered by MPTs. Furthermore, a substantial discrepancy between actual and self-estimated use of biopsychosocial history taking was noted. We strongly recommend full implementation of the SCEBS method in educational programs in manual physical therapy.