Implementing Patient-Reported Outcome Measures in Outpatient Rehabilitation Settings: A Systematic Review of Facilitators and Barriers Using the Consolidated Framework for Implementation Research.

OBJECTIVE: This systematic review examines the facilitators and barriers to the use of patient-reported outcome measures (PROMs) in outpatient rehabilitation settings and provides strategies to improve care to maximize patient outcomes. DATA SOURCES: Eleven databases were systematically searched from November 2018 to May 2019. STUDY SELECTION: Two reviewers independently assessed articles based on the following inclusion criteria: English text, evaluate barriers and facilitators, include PROMs, and occur in an outpatient rehabilitation setting (physical therapy, occupational therapy, speech language pathology, or athletic training). Of the 10,164 articles initially screened, 15 articles were included in this study. DATA EXTRACTION: Data were extracted from the selected articles by 2 independent reviewers and put into an extraction template and into the Consolidated Framework for Implementation Research (CFIR) model. The Appraisal Tool for Cross-Sectional Studies (AXIS) was conducted on each study to assess study design, risk of bias, and reporting quality of the eligible studies. DATA SYNTHESIS: Ten studies were identified as high quality, according to the AXIS. Based on the CFIR model, the top barriers identified focused on clinician training and time in the implementation process, lack of recognized value and knowledge at the individual level, lack of access and support in the inner setting, and inability of patients to complete PROMs in the intervention process. Facilitators were identified as education in the implementation process, support and availability of PROMs in the inner setting, and recognized value at the individual level. CONCLUSIONS: More barriers than facilitators have been identified, which is consistent with PROM underuse. Clinicians and administrators should find opportunities to overcome the barriers identified and leverage the facilitators to improve routine PROM use and maximize patient outcomes.

Understanding social determinants of health and physical therapy outcomes in patients with low back pain: A scoping review.

BACKGROUND: Low back pain (LBP) is the number one cause of disability worldwide; however, it is not clear how social determinants of health (SDOH) impact care management and outcomes related to physical therapy (PT) services for patients with LBP. OBJECTIVE: The purposes of this scoping review are to examine and assimilate the literature on how SDOH and PT care relate to non-specific LBP outcomes and identify gaps in the literature to target for future research. METHODS: Data were extracted from eight electronic databases from January 2011 to February 2022. Reviewers independently screened all studies using the PRISMA extension for scoping review guidelines. Data related to study design, type of PT, type of non-specific LBP, patient demographics, PT intervention, SDOH, and PT outcomes were extracted from the articles. RESULTS: A total of 30,523 studies were screened, with 1961 articles undergoing full text review. Ultimately, 76 articles were identified for inclusion. Sex and age were the most frequent SDOH examined (88% and 78% respectively) followed by education level (18%). Approximately half of the studies that examined age, sex, and education level identified no effect on outcomes. The number of studies examining other factors was small and the types of outcomes evaluated were variable, which limited the ability to pool results. CONCLUSIONS: Sex and age were the most frequent SDOH examined followed by education level. Other factors were evaluated less frequently, making it difficult to draw conclusions. Study design and heterogeneity of determinants and outcomes were barriers to examining the potential impact on patients with LBP.

TIMELINE OF GAINS IN QUADRICEPS STRENGTH SYMMETRY AND PATIENT-REPORTED FUNCTION EARLY AFTER ACL RECONSTRUCTION.

BACKGROUND: Quadriceps weakness is a predictor of long-term knee function and strength recovery can vary from months to years after anterior cruciate ligament reconstruction (ACLR). However, few studies evaluate quadriceps strength and self-reported function within the first several weeks after ACLR. HYPOTHESIS/PURPOSE: To examine changes over time in quadriceps strength symmetry, quadriceps peak torque, and self-reported knee function prior to and at six, 12, and 24 weeks post-ACLR. The hypotheses were 1) quadriceps strength symmetry, bilateral quadriceps peak torque, and patient-reported function would improve over time from pre-ACLR to 24 weeks post-ACLR and 2) significant improvements in patient-reported function, but not strength symmetry, would occur between time points. STUDY DESIGN: Prospective, cohort study. METHODS: Thirty participants completed four testing sessions: pre-surgery and six, 12, and 24 weeks post-ACLR. Isometric quadriceps strength testing was performed at six weeks and isokinetic quadriceps strength was measured at all other testing points. Quadriceps index was calculated to evaluate between limb quadriceps strength symmetry. The Knee injury and Osteoarthritis Outcome Score (KOOS) and International Knee Documentation Committee Subjective Knee Evaluation Form (IKDC) were administered at each time point. A repeated-measures analysis of variance evaluated changes over time, with post-hoc comparisons to determine at which time-point significant changes occurred. RESULTS: Quadriceps strength symmetry, involved limb quadriceps peak torque and all patient-reported outcome scores increased over time (p<0.02). Post-hoc tests showed that neither self-reported outcomes, nor quadriceps index improved between pre-surgery and six-weeks post-ACLR. From six to 12 weeks post-ACLR, scores on IKDC and KOOS Pain, Symptoms, Quality of Life, and Sport subscales improved (p≤0.003). From 12 to 24 weeks post-ACLR, quadriceps strength symmetry, involved limb quadriceps peak torque, KOOS-Symptoms, Quality of Life, and Sport subscales and the IKDC improved (p≤0.01). Uninvolved limb quadriceps peak torque did not change across any time point (p≥0.18). CONCLUSION: Patient-reported knee function increased between six and 24 weeks post-ACLR, while increases in involved limb quadriceps strength and quadriceps strength symmetry were not noted until 12-24 weeks post-ACLR. LEVEL OF EVIDENCE: 2b, individual cohort study.

Improvements in Thigh Strength Symmetry Are Modestly Correlated With Changes in Self-Reported Function After Anterior Cruciate Ligament Reconstruction.

BACKGROUND: The association between quadriceps strength and functional outcomes after anterior cruciate ligament reconstruction (ACLR) is a focus of current research, while evaluations of hamstring strength are limited, despite the frequent use of hamstring autografts. PURPOSE/HYPOTHESIS: The purpose of this study was to determine the relationship between changes in quadriceps and hamstring strength symmetry and self-reported outcomes before ACLR and at 12 and 24 weeks after surgery. We hypothesized that improvements in quadriceps and hamstring strength symmetry would be correlated with improvements in self-reported outcome measures within the first 6 months after ACLR. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Thirty patients who underwent ACLR with a hamstring autograft were enrolled. Quadriceps and hamstring strength and Knee injury and Osteoarthritis Outcome Score (KOOS) values were assessed before and at 12 and 24 weeks after ACLR; limb symmetry indexes for strength were calculated at each time point. The Friedman and Wilcoxon signed-rank tests were used to analyze changes in KOOS values over time. Spearman rank-order correlations were used to test the relationship between changes in strength and KOOS values between each time point. RESULTS: Hamstring and quadriceps limb symmetry significantly increased with time (P ≤ .03). Fair correlations were observed between changes in the hamstring index and changes in the KOOS Symptoms subscore from before surgery to 12 weeks postoperatively (r = 0.48; P ≤ .05). Changes in the quadriceps index (QI) were moderately correlated with changes in the KOOS Sport/Recreation subscore (r = 0.60; P = .001), and fair correlations were seen between the QI and the KOOS Quality of Life subscore (r = 0.39; P ≤ .04) from preoperatively to 12 weeks after surgery. Moderate correlations were seen between the QI and the KOOS Sport/Recreation subscore (r = 0.57; P = .005) from 12 to 24 weeks after surgery. CONCLUSION: Improvements in quadriceps and hamstring strength symmetry were modestly associated with improvements in athletes' perceived function in the first 6 months after ACLR. Specifically, improvements in hamstring symmetry were associated with improvements in knee symptoms within the first 12 weeks postoperatively, while improvements in quadriceps symmetry were associated with improvements in self-reported sport function throughout the first 6 months after ACLR. The restoration of strength symmetry within the first 6 months may be a critical component of rehabilitation aimed at maximizing function after ACLR. Further investigation is warranted to comprehensively evaluate whether the timing of strength gains predicts future function, including those who successfully return to their preinjury activity level after ACLR.

Femoral Nerve Block after Anterior Cruciate Ligament Reconstruction.

Femoral nerve block (FNB) has been proposed for pain control following anterior cruciate ligament (ACL) reconstruction. Although numerous studies have assessed the efficacy of FNBs, there has been little to no research into the effect of such blocks on postoperative strength and patient-reported outcomes. We hypothesized that performance of an FNB would result in decreased quadriceps strength and poorer patient-reported outcome scores within the first 6 months following ACL reconstruction. A total of 30 patients scheduled to undergo hamstring autograft ACL reconstruction following an acute ACL injury were randomized to a single-shot FNB group or a control group. Preoperatively, patients completed a Knee Injury and Osteoarthritis Outcome Score (KOOS) and isokinetic quadriceps strength testing at 60 degrees/second. At 6 weeks postoperative, 29 of 30 patients completed a KOOS and isometric quadriceps strength testing at 90 degrees. At 6 months postoperative, 23 of 30 patients completed a KOOS and isokinetic strength testing. Quadriceps femoris strength limb symmetry indices (QF-LSI) were calculated at all time points. Repeated measures analysis of variance (ANOVA) models were then utilized to model the effect of FNB and time on QF-LSI as well as KOOS subscales for activities of daily living, pain, and symptoms. QF-LSI and all KOOS subscales demonstrated improvement with time following ACL reconstruction. Repeated measures ANOVA demonstrated that patients who underwent FNB had a mean QF-LSI that was 13.4% lower than the control group (p = 0.005) and poorer KOOS symptoms subscale scores (10.4 point difference, p = 0.032) at 6 weeks postoperative compared with controls. At 6 months postoperative, no differences were noted in QF-LSI or any of the KOOS subscales based on block status. FNB resulted in decreased strength and poorer KOOS symptom subscale score at 6 weeks following ACL reconstruction compared with controls. These differences resolved by 6 months postoperative. The long-term effect of delayed quadriceps recovery on movement patterns and functional outcome remains unknown and requires further study. The study is a randomized controlled trial with level of evidence 1.

Brain meningioma in a patient with complaints of low back pain and leg weakness.

BACKGROUND: Meningiomas are the most common form of benign brain tumors in adults. Due to a wide range of symptom presentation, tumors can be difficult to diagnose. For physical therapists, it is important to be aware that brain tumors can mimic other diagnoses and present in conjunction with other musculoskeletal disorders. The purpose of this case report is to describe the physical therapists' management of a patient who presented with initial signs and symptoms of low back pain (LBP) and radicular symptoms, but whose symptoms became atypical and required further diagnostic work-up and medical management. DIAGNOSIS: The patient was ultimately diagnosed with a large, benign meningioma in the left motor cortex of the brain. One week following referral from the physical therapist, the tumor was surgically excised. DISCUSSION: This case report brings attention to the importance of regular, systematic examination of the patient's clinical presentation to identify mechanical and non-mechanical signs and symptoms and make the appropriate medical referral.