Drawing a "Perfect Circle": How Clinicians Can Become Better Communicators.

SYNOPSIS: Despite the importance of communication in person-focused care, biomedical knowledge and technical skill development are often prioritized in physical therapy education. As clinicians and educators, we contend that mindfulness and reflection nurture effective communication approaches and support physical therapists in navigating the complexity and uncertainty that comprise most clinical interactions. We suggest that clinicians be mindful of the self, the patient, and the context when interacting with patients. Although being mindful cultivates awareness and curiosity, being reflective is an active practice that can be used while deliberating about the right thing to do or say in a particular situation. In this Viewpoint, we offer clinicians and educators suggestions for engaging in mindful and reflective practices. Through the contemplative practices of mindfulness and reflection, clinicians can better cultivate their communication expertise and good practice. J Orthop Sports Phys Ther 2023;53(10):579-584. Epub: 8 September 2023. doi:10.2519/jospt.2023.11917.

Referral Decision-Making and Care Continuity in Physical Therapist Practice.

Efficient referral pathways have held promise in improving clinical outcomes, raising patient satisfaction, and reducing costs. Referral decision-making presents a distinct challenge because it requires the consideration of such variables as technology, health-care systems, and local resources. However, best practices for generating a high-value referral and improving care continuity are rarely discussed in the context of physical therapist practice. With physical therapists in some states obtaining explicit imaging privileges and a renewed focus on the physical therapist's role in primary care and patient management over the lifespan, it is time to focus on this underappreciated area of practice. This perspective discusses referral decision-making and provides recommendations for making a high-value referral and improving care continuity. Improving referral and care continuity has potential to enhance clinical outcomes and patient satisfaction and to reduce costs. This perspective explicitly defines and describes strategies to improve physical therapist decision-making about referral and care continuity to improve overall patient management.

Digital physical therapy practice and payment during the COVID-19 pandemic: A case series.

BACKGROUND: Insurance regulation and reimbursement are barriers to physical therapy-delivered digital practice. OBJECTIVE: The present case series describes the clinical reasoning, outcomes, and practical use of digital tools to improve pain and movement of patients seen for musculoskeletal pain during the COVID-19 pandemic. CASE DESCRIPTION: Three patients, 2 with low back pain and 1 with cervicogenic headache, were treated at a private outpatient clinic. Collaborative reasoning was used to determine appropriate use of digital tools. Because of the pandemic, one patient used telephone visits to complete treatment (25% of total visits), one used telehealth visits only during stay-at-home orders (33% of total visits), and one was evaluated and treated entirely using telehealth (100% of total visits). All visits were billed and paid for by the patient or insurance at the same rate as an in-person visit. OUTCOMES: All 3 patients met self-reported goals for physical therapy, met or surpassed their risk-adjusted predicted functional status score, and expressed high satisfaction with treatment. CONCLUSION: Individualized prescription and execution of digital physical therapy practice allowed patients with musculoskeletal pain to have effective physical therapy care during the COVID-19 pandemic. Removal of regulatory and payment barriers were necessary for the provision of care.

The Blind Men, the Elephant, and the Continuing Education Course: Why Higher Standards Are Needed in Physical Therapist Professional Development.

SYNOPSIS: Evidence-based practice and implementing clinical practice guidelines are familiar themes for musculoskeletal rehabilitation clinicians. Yet, many clinicians continue to eschew recommended treatments. One explanation could be that physical therapists largely rely on continuing education courses-not research reports or standardized postprofessional education-to learn new treatments and update their practice patterns. However, continuing education courses in physical therapy have a much less rigorous review process, and interventions taught in these courses often conflict with high-quality evidence. The lack of rigor in continuing education may contribute to unwarranted variability in practice, which is a major threat to physical therapy. The current continuing competence paradigm in the United States, of which continuing education is a part, needs an overhaul to ensure clinicians learn current best evidence. Now is the time for change in professional development. We offer 3 suggestions to improve the current system of continuing competence in physical therapy. J Orthop Sports Phys Ther 2022;52(10):642-646. Epub: 27 July 2022. doi:10.2519/jospt.2022.11377.

A physical therapist-led clinical decision-making program reduced risk of adverse events after total knee arthroplasty over 3 years: A retrospective review.

CONTEXT: Reducing adverse events after total knee arthroplasty has implications for newly developed bundled payment models. OBJECTIVE: To examine the impact of a physical therapist-led clinical decision-making program on the risk of adverse events, function, visits used, or reaching knee range of motion (ROM) goals in patients after total knee arthroplasty. METHODS: The decision-making program consisted of quarterly meetings and recommendations for early risk identification and evidence-based intervention. A retrospective review of electronic records included adult patients who underwent total knee arthroplasty postoperative rehabilitation in an 18-month baseline period from 2014 to 2015 and an intervention period from 2015 to 2018. Relative risk reduction (RRR) determined whether a reduction in risk had occurred. Discharge function was measured with the Lower Extremity Functional Scale. RESULTS: A total of 160 patients were included, 69 from the 18-month baseline period and 91 from the 36-month intervention period. Mean (SD) age was 68 (9.2) years in the baseline period and 72 (9.7) years in the intervention period. There was an 8.4% (95% CI, 1.1%-64.9%) RRR in adverse events. The RRR for patients not reaching full knee extension was 70.5% (95% CI, 33.4%-87.0%) and the RRR for patients not reaching 120° of knee flexion was 65.5% (95% CI, 5.4%-87.4%). There was significant improvement in the discharge function score (P = 0.05), but not the number of visits used (P = 0.29). CONCLUSION: The physical therapist-led clinical decision-making program reduced the risk of adverse events after total knee arthroplasty. The risk of not reaching ROM goals by discharge was also substantially reduced.

Who writes this stuff? Musculoskeletal information quality and authorship of popular health websites: A systematic review.

BACKGROUND: Highly trafficked health websites are major sources of information, but the quality of their musculoskeletal information has not been thoroughly evaluated or their authorship characterized. OBJECTIVES: To review information about common musculoskeletal conditions on highly trafficked websites and characterize their credibility, authorship, accuracy of information (as compared to treatment guidelines), and consistency with best practice recommendations. DESIGN: Systematic review. METHODS: We reviewed the top 15 most highly trafficked health websites, identified by web traffic data. Information about 7 common musculoskeletal conditions was identified and data extracted. Credibility was assessed using the Trust It or Trash It? tool, author backgrounds were identified, accuracy was determined by comparing webpage treatment recommendations to guidelines or systematic reviews, and consistency with best practice recommendations was assessed. RESULTS: Of 1760 webpages screened, 87 were reviewed. Less than half (44.8%, 39/87) had appropriate sources listed, but 65.5% (57/87) were updated in the previous 5 years. Journalists authored most webpages (55.2%, 48/87). Physician involvement was mostly editorial, and they often lacked expertise in musculoskeletal conditions. Information accuracy was concordant with guidelines for 49.4% (43/87) of webpages, but varied by condition. About half of best practice recommendations were followed (49.1%, 427/870). Pages were unlikely to mention psychosocial factors (16.1%, 14/87), limitations of imaging (18.4%, 16/87), or staying at work (4.6%, 4/87). CONCLUSIONS: Popular health websites scored poorly for credibility, accuracy, and consistency with best practice recommendations for musculoskeletal conditions. Authorship, bias, and unsupported information are potential sources of inaccuracies that should be addressed in future by these websites.

From Idea Cults to Clinical Chameleons: Moving Physical Therapists' Professional Identity Beyond Interventions.

SYNOPSIS: The components of clinical practice are complex, often ambiguous, and influenced by a wide variety of interrelated contextual factors. As appreciation grows for the impact of individuality, complexity, and uncertainty in health processes, effective translation into widespread clinical practice remains limited. In attempts to bring patients effective solutions, well-meaning physical therapists can get trapped in "idea cults," in which a favored idea is supported and others are disparaged. We recommend that physical therapists develop a practice of self-reflection marked by openness and humility to more successfully adapt to the unique needs, values, and preferences of each person. We highlight 4 ways physical therapists can cultivate a more mindful and adaptable clinical approach that can help recognize and navigate the complexities of everyday clinical practice. J Orthop Sports Phys Ther 2022;52(4):170-174. doi:10.2519/jospt.2022.10976.

Continuing Education Courses for Orthopedic and Sports Physical Therapists in the United States Often Lack Supporting Evidence: A Review of Available Intervention Courses.

OBJECTIVE: The purpose of this study was to characterize the extent to which orthopedic and sports-related continuing education course descriptions approved for physical therapists in the United States taught interventions supported by evidence. METHODS: A review was conducted of courses available on CEU Locker from January through December 2020, estimated to represent most courses nationally available to physical therapists. This review focused specifically on courses teaching interventions for musculoskeletal conditions in adults. Specifically, courses for orthopedic and sports populations were identified. All course information was extracted, including the intervention name, course description, and target audience. Finally, clinical practice guidelines (CPGs) and systematic reviews with at least moderate-level evidence published through May 1, 2021, were searched to determine if treatments were recommended or not recommended, or if no evidence existed. RESULTS: The review identified 2406 available courses extracted from the database. After excluding courses that did not meet inclusion criteria, duplicates, and those with incomplete or inadequate information, the final number was 319. Most courses (52.7%, n = 168) taught interventions not supported by a CPG or systematic review. Approximately one-third of courses (34.2%, n = 109) taught interventions that were recommended by a CPG. Many courses were targeted to multiple disciplines (38.9%, n = 124), whereas 89 (27.9%) were specifically for physical therapists, physical therapist assistants, or both. The specific target was unclear for 106 (33.2%) courses. Courses usually focused on multiple body regions, and exercise was the most included intervention. Soft-skill courses were the most supported by evidence (82.9%, n = 29), whereas those teaching modalities were the least supported (30.5%, n = 29). CONCLUSION: Fewer than one-half of courses that focused on management of musculoskeletal disorders taught interventions supported by a CPG or systematic review, and course descriptions often misrepresented the current state of evidence. Courses required for licensure renewal might not be meeting the intended goal of keeping clinicians current with new and emerging research. IMPACT: Relatively few continuing education courses on orthopedic and sports-related physical therapist interventions are based on evidence provided by CPGs or systematic reviews, and some continuing education options required for physical therapists to meet annual licensure renewal requirements might not be keeping therapists current with the latest evidence. This study provides data that can facilitate candid dialog within the profession about potential solutions.

Physical therapy management of a patient with persistent groin pain after total hip arthroplasty and iliopsoas tenotomy: a case report.

Background: Hip impingement syndrome can occur after total hip arthroplasty (THA). Nonoperative treatment is inconsistently recommended, and surgical options include iliopsoas tenotomy. The current case report describes the unique case of a patient with persistent groin pain after THA and iliopsoas tenotomy.Case Description: The 72-year-old male had persistent groin pain after right THA and an unsuccessful iliopsoas tenotomy. He had pain and limited right hip range of motion during active and passive hip flexion, abduction, and external rotation. Treatment consisted of high-grade joint mobilization to improve the range of motion of the right hip and an exercise program.Outcomes: The patient was treated for six visits over 3 weeks. Clinically important improvements were noted in pain, function, and perceived level of improvement. Pain during hip flexion improved on the Numeric Pain Rating Scale, and function improved on the Lower Extremity Functional Scale. Improvements in the range of motion and strength were also observed. At 6-month follow-up, he reported maintenance of improvements.Discussion: Joint mobilization and exercise were effective for improving range of motion, groin pain, and function in a patient with a 4-year history of persistent groin pain after THA and subsequent iliopsoas tenotomy.

Patient Expectations for Synchronous Telerehabilitation Visits: A Survey Study of Telerehabilitation-Naive Patients.

Introduction: The current study evaluated patient expectations for synchronous telerehabilitation. Because the coronavirus disease 2019 (COVID-19) pandemic decreased regulatory barriers and increased accessibility of telehealth, improved understanding of expectations may direct future educational efforts, improve implementation strategies, and inform future analyses of consumer adoption and utilization of telehealth. Methods: A cross-sectional survey design was used to measure ideal expectations (what they want to happen) and realistic expectations (what they think will happen) of telerehabilitation-naive patients for synchronous telerehabilitation. Participants were recruited through e-mail and social media and in person from seven outpatient private practice physical therapy clinics across the United States. Patients completed an online anonymous adaptation of the Patients' Expectations Questionnaire (PEQ) and were asked whether they expected synchronous telerehabilitation to benefit them personally. Open-ended responses were collected and analyzed for categories and themes. Results: Of 178 participants, the greatest mean difference between ideal and realistic expectations among PEQ subscales was for outcomes (0.49; 95% confidence interval [CI], 0.37-0.60), and the greatest mean difference among individual items was for symptom reduction (0.53; 95% CI, 0.41-0.66). Although participants appeared to appreciate the value of telerehabilitation visits, with 69.7% indicating that it would benefit them personally, many expressed a preference for face-to-face visits when possible. Discussion: Expectations were mostly positive. Lower outcomes expectations may be a potential barrier to adoption and utilization of telehealth and other types of digital physical therapy in some patients. Conclusions: To improve beliefs and address potential barriers, physical therapy clinicians should discuss expectations with patients before recommending telerehabilitation visits.

How people with lumbar spinal stenosis make decisions about treatment: A qualitative study using the Health Belief Model.

OBJECTIVE: Surgery rates for lumbar spinal stenosis (LSS) have increased despite inherent risks, high reoperation rates, and a lack of evidence for benefit over conservative treatment. Scant research has investigated how people make decisions about treatment, which may help clinicians better support patients during the course of care. The purpose of the present study was to explore the beliefs of people with LSS and how they make decisions about treatment. DESIGN: Cross-sectional qualitative study. METHODS: Semi-structured individual interviews were conducted with participants who had LSS (based on diagnostic imaging and recent symptoms). Transcribed interview data was analyzed using directed content analysis informed by the Health Belief Model. RESULTS: Twelve patients (mean age 75.3 years, range 63-87 years, 9 female, 6 with previous LSS surgery) participated. The Health Belief Model appeared useful for explaining decisions about treatment. Perceived threat of LSS was higher in those who had surgery. Patients who decided on surgery perceived themselves as more susceptible to surgery, often because of pathoanatomical beliefs. These patients had lower perceived control over symptoms and the treatment decision itself. Although patients saw benefit in conservative treatment because of its lower risk and ability to foster self-management, many had no or poor education and reported previous experiences with ineffective conservative treatment. CONCLUSION: Patients with LSS make decisions about treatment by weighing the perceived threat of LSS against the perceived barriers and benefits of conservative treatment. Consistent and nonthreatening educational messages from clinicians may help these patients during their decision-making process.

Alternating lumbar lateral shift: a case report.

BACKGROUND: A lumbar lateral shift (LLS) is a common clinical observation in patients with low back pain (LBP), and a shift contralateral to the side of pain is the most common presentation. An LLS that can rapidly alternate sides presents several treatment difficulties and has rarely been described. The purpose of the current case report was to describe the presentation and management of a patient with an alternating LLS. CASE DESCRIPTION: A 39-year-old male with a 7-week history of LBP and previous lower extremity radicular pain was referred to physical therapy. An alternating LLS was present. OUTCOMES: The patient was treated for six visits over 37 days. Treatment included modified self-correction of the LLS, motor control and trunk muscle endurance training, and development of an activity management program. The patient's LLS resolved, his worst pain improved from 3/10 to 0/10, and the Oswestry Disability Index improved from 26% to 4% disability. The patient reported maintenance of improvement at 6-month follow-up. DISCUSSION: The current approach produced a positive outcome in a patient with an alternating LLS. The current understanding of mechanisms and optimal treatment of an alternating LLS is limited. LEVEL OF EVIDENCE: 4.

An orthopedic manual physical therapy fellowship training's impact on professional development, involvement, personal lives, and income - A survey study.

Introduction: Little research exists investigating the personal and professional outcomes of postprofessional physical therapy (PT) training. Therefore, the purpose of the current descriptive, web-based survey study was to determine self-reported outcomes from a postprofessional PT fellowship program, including graduate professional, educational, and research involvement; perceptions of the impact of training on clinical and professional attributes; changes in employment and income; and barriers to training. Methods: Graduates of a part-time, hybrid-model, multisite orthopedic manual PT fellowship program were invited to complete the web-based survey. Descriptive data analyses were performed for all quantitative data, and responses to questions were analyzed and categorized into themes. Results: Of the 77 fellowship graduates, 75 (97%) completed the survey. Graduates were involved in teaching; 43% (32/75) filled lead instructor roles in PT education programs. Further, 75% (57/75) were involved in research. The mean (SD) and median (range) increase in annual gross income was $9560 ($17,545) and $2,500 ($0-$125,000), respectively. Perceived areas with the largest impact of training included clinical reasoning, patient-centered and evidence-based practice, and professionalism. Life balance and family commitments were frequent barriers during training. Discussion: Graduates noted substantial perceived professional, clinical, and financial benefits to fellowship training. Limitations included lack of a control group and surveying participants from a single program. Future research should determine the influence that program and participant-related factors have on personal and professional lives of graduates and on clinical outcomes. Level of Evidence: Descriptive survey, level 3.

Short-term Response to Treatment Targeting the Thoracolumbar Junction in Patients With Hip Pain: A Case Series.

BACKGROUND: In patients presenting with hip and groin symptoms, evaluation and treatment of the thoracolumbar junction (TLJ) may be underutilized. The TLJ is less recognized as a source of pain referral in these regions. The purpose of this case series was to describe the management of 3 patients with primary hip and groin pain who were treated with interventions targeting the TLJ. DIAGNOSIS: The 3 patients in this case series presented with subacute or chronic complaints of hip and groin pain that had failed to resolve with typical treatments. They had undergone several inconclusive clinical testing procedures. Each patient underwent a detailed physical therapy evaluation and was found to have pain and mobility deficits at the TLJ. Once the therapist had determined that the patients' symptoms were likely of musculoskeletal origin, treatment commenced. Joint mobilization and exercise directed at the TLJ were used in each case. Marked improvements in pain, thoracic range of motion, and functional deficits were observed within 3 to 4 weeks, after an average of 6 treatment sessions. All patients returned to prior activity levels. Patients in cases 1 and 3 had improvements in hip mobility and strength without direct treatment to the hip. DISCUSSION: This case series describes the management of 3 patients with hip and groin symptoms who were successfully treated with interventions targeting the TLJ. In patients reporting primary hip or groin pain, physical therapists should consider the TLJ as a potential source of symptoms and include treatment strategies directed at the TLJ, as warranted, after a careful examination and clinical-reasoning process. LEVEL OF EVIDENCE: Differential diagnosis, level 4. J Orthop Sports Phys Ther 2019;49(8):611-619. doi:10.2519/jospt.2019.8309.

Belt-Mounted Micro-Gas-Chromatograph Prototype for Determining Personal Exposures to Volatile-Organic-Compound Mixture Components.

We describe a belt-mountable prototype instrument containing a gas chromatographic microsystem (µGC) and demonstrate its capability for near-real-time recognition and quantification of volatile organic compounds (VOCs) in moderately complex mixtures at concentrations encountered in industrial workplace environments. The µGC comprises three discrete, Si/Pyrex microfabricated chips: a dual-adsorbent micropreconcentrator-focuser for VOC capture and injection; a wall-coated microcolumn with thin-metal heaters and temperature sensors for temperature-programmed separations; and an array of four microchemiresistors with thiolate-monolayer-protected-Au-nanoparticle interface films for detection and recognition-discrimination. The battery-powered µGC prototype (20 × 15 × 9 cm, ∼2.1 kg sans battery) has on-board microcontrollers and can autonomously analyze the components of a given VOC mixture several times per hour. Calibration curves bracketing the Threshold Limit Value (TLV) of each VOC yielded detection limits of 16-600 parts-per-billion for air samples of 5-10 mL, well below respective TLVs. A 2:1 injection split improved the resolution of early eluting compounds by up to 63%. Responses and response patterns were stable for 5 days. Use of retention-time windows facilitated the chemometric recognition and discrimination of the components of a 21-VOC mixture sampled and analyzed in 3.5 min. Results from a "mock" field test, in which personal exposures to time-varying concentrations of a mixture of five VOCs were measured autonomously, agreed closely with those from a reference GC. Thus, reliable, near-real-time determinations of worker exposures to multiple VOCs with this wearable µGC prototype appear feasible.

Use of a modified treatment-based classification system for subgrouping patients with low back pain: Agreement between telerehabilitation and face-to-face assessments.

Objective: To examine the agreement between telerehabilitation and face-to-face assessments of patients with acute and subacute low back pain (LBP) using a modified treatment-based classification (TBC) system. A secondary aim was to evaluate patient satisfaction with the telerehabilitation assessment. Methods: Patients with LBP of less than 90 days' duration underwent both telerehabilitation and face-to-face assessments. After physical examination, patients were classified into one of three intervention groups (mobilization/manipulation, specific exercise, and stabilization). The assessment order and clinicians were randomized, and the clinicians were blinded to each other's classification decision. Results: Forty-seven patients participated (mean [SD] age, 48.6 [15.0] years; 70% female). The overall rate of percentage agreement was 68.1% (κ = 0.52; 95% confidence interval, 0.32-0.72). There was no difference in classification distributions between assessments (χ2 = 2.14, p = 0.54). The percentage agreement was 48.9%-59.6% for the modified TBC algorithm variables except for straight leg raise greater than 91°, which was markedly lower at 35.1%. This was the only variable that was significantly different between the telerehabilitation and face-to-face scenarios. The overall satisfaction with the telerehabilitation assessment was good. Conclusions: The results suggest that a telerehabilitation assessment using the modified TBC system may be able to direct treatment of patients with acute and subacute LBP. However, challenges still remain in applying this approach to clinical practice.

Physical Therapy Management of Patients With Chronic Low Back Pain and Hip Abductor Weakness.

BACKGROUND AND PURPOSE: Hip abductor dysfunction is common in individuals with chronic low back pain (CLBP). Previous research investigating abductor strengthening in the heterogeneous CLBP population is sparse and has failed to target those patients most likely to benefit. The aim of the current case series was to describe the physical therapy management and outcomes of 3 patients with CLBP matching a previously identified subgroup characterized by substantial hip abductor weakness. CASE DESCRIPTION: Three nonconsecutive patients with CLBP-a 77-year-old man, a 78-year-old woman, and an 85-year-old woman-were treated in an outpatient physical therapy clinic. All 3 patients matched a previously identified CLBP subgroup characterized by substantial hip abductor weakness. INTERVENTION: Patients were treated using a targeted exercise approach consisting mostly of hip abductor strengthening for 11 to 17 visits over 8 to 10 weeks. Patients received additional treatments including heel lift and pain neuroscience education when indicated. OUTCOMES: By discharge, all patients had made clinically important improvements in pain (3- to 7-point reduction on the Numeric Pain Rating Scale), function (10- to 16-point change on the Modified Oswestry Disability Index), and perceived improvement (6-7 on Global Rating of Change Scale). Lumbar range of motion was painless, and hip abductor strength was improved from 2+/5 to 3+/5 in all 3 patients. These gains were maintained at 3-month follow-up. DISCUSSION: The current case series describes the use of a targeted exercise approach consisting mostly of hip abductor strengthening in a group of patients with CLBP and hip abductor weakness. The results indicated that this approach may be effective in reducing pain and improving function, particularly for older patients.

Telerehabilitation booster sessions and remote patient monitoring in the management of chronic low back pain: A case series.

BACKGROUND: Improvements in chronic low back pain (CLBP) seen in physical therapy do not appear to be retained over the long term. Booster sessions have been proposed, but barriers exist to their implementation. Telerehabilitation (TR) and remote patient monitoring (RPM) may be ways to circumvent these barriers. The purpose of this case series was to describe the implementation of TR booster sessions and RPM in three patients with CLBP. CASE SERIES: Three females with CLBP tracked their daily pain level and home exercise program adherence using a mobile phone application for 12 months following discharge from traditional face-to-face physical therapy. Synchronous audio and video TR booster sessions were conducted at months 1, 3, 6, and 12. OUTCOMES: All patients met their individual goals. They demonstrated excellent home exercise program adherence and self-efficacy. A temporary increase in pain was seen in all patients, but they managed solely with the TR booster sessions and without other healthcare resources. Satisfaction with the program was very high. CONCLUSIONS: This case series describes the use of TR booster sessions and RPM in three patients with CLBP. The positive results suggest this approach may be helpful in improving long-term management of patients with CLBP but demand further investigation.