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.

J Orthop Sports Phys Ther 2011;41(12):969-980. doi:10.2519/jospt.2011.3814

KEY WORDS: computerized adaptive testing, depression, functional and pain outcomes, lumbar spine, psychosocial distress, somatization

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.

J Orthop Sports Phys Ther 2011;41(7):477-485, Epub 7 June 2011. doi:10.2519/jospt.2011.3686

KEY WORDS: comorbidity, medical screening, musculoskeletal pain

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.

J Orthop Sports Phys Ther 2011;41(5):336-345, Epub 6 April 2011. doi:10.2519/jospt.2011.3534

KEY WORDS: computerized adaptive testing, outpatient rehabilitation, patient demographics, prediction models

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.

J Orthop Sports Phys Ther 2010;40(12):801-810, Epub 22 October 2010. doi:10.2519/jospt.2010.3334

KEY WORDS: lumbar spine, physical therapy, psychological risk factors, SCL-90-R

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–.

J Orthop Sports Phys Ther 2011;41(1):22-31, Epub 22 October 2010. doi:10.2519/jospt.2011.3415

KEY WORDS: computerized adaptive testing, lumbar spine, outcomes

STUDY DESIGN: Prospective cohort study of 10 287 patients with foot/ankle impairments receiving outpatient physical therapy. OBJECTIVES: To describe meaningful interpretations of functional status (FS) outcomes measures, estimated using a body-part–specific computerized adaptive test (CAT). BACKGROUND: Increased use of CATs to generate outcome measures in rehabilitation has stimulated questions concerning score interpretation. Identifying meaningful intra-individual change and reporting clinical interpretation of those generated outcomes are essential to advance the quality of rehabilitation practice. METHODS: We performed 4 approaches to clinically interpret outcomes data. First, we used the standard error of the estimate to construct a 90% confidence interval for each CAT estimated score. Second, we presented the percentile rank of FS scores. Third, we used 2 threshold approaches to define individual-patient-level change: statistically reliable change and clinically important change. Last, we illustrated a functional staging method. RESULTS: Precision of a single score was estimated by an FS score of ±4. Based on score distribution, percentile ranks at 25th, 50th, and 75th percentiles corresponded to intake FS scores of 38, 47, and 57, and discharge FS scores of 52, 64, and 77, respectively. Minimal detectable change supported 7 or more FS change units out of 100 represented statistically reliable change, and ROC analyses supported 8 or more FS change units represented minimal clinically important improvement. Using a functional staging system, we established 5 hierarchical functional status levels. CONCLUSION: CAT-generated outcome measures can be interpreted to improve clinical interpretation and to assist clinicians in using patient-reported outcomes during therapy practice.

J Orthop Sports Phys Ther 2009;39(10):753-764. doi:10.2519/jospt.2009.3122

KEY WORDS: assessment of patient-reported outcomes, computerized adaptive testing, Lower Extremity Functional Scale, outpatient rehabilitation

J Orthop Sports Phys Ther 1980;2(2):72-76.

J Orthop Sports Phys Ther 1981;2(3):137-141.

J Orthop Sports Phys Ther 1981;2(4):177-179.

J Orthop Sports Phys Ther 1981;3(2):57-61.

J Orthop Sports Phys Ther 1982;3(4):193-199.

J Orthop Sports Phys Ther 1985;6(4):229.334.

J Orthop Sports Phys Ther 1986;8(4):180-184.

Adapted from Hart DL, Peters M, Schlimmer D, Trinkle KL: Guidelines for the Use of Functional Measurements: Reference Manual for Functional Capacity Evaluations, Virginia: The Task Force on Objective Functional Measurements, 1990, with permission.

Functional capacity evaluation is an important and widely available service provided by rehabilitation professionals, including many physical therapists. In the absence of agreed-upon professional standards, guidelines for practice have been developed.

These guidelines provide a basis for the development of standards of practice that the authors believe should be undertaken on an interdisciplinary basis. These guidelines provide a baseline level of care that should be maintained by physical therapists and others who provide functional capacity evaluation services.

J Orthop Sports Phys Ther. 1993;18(6):682-686.

Key Words: industrial rehabilitation, functional capacity evaluation, guidelines

J Orthop Sports Phys Ther. 2008;38(3):116-125, published online 9 November 2007. doi:10.2519/jospt.2008.2596

Study Design: Test-retest reliability study. Objective: To assess test-retest reliability and estimate minimal detectable change of an overall measure and 2 summary measures of patient self-report of health status. Background: Change in patient self-report of health status is a common outcome measure following rehabilitation. Because collection of health status data takes time and clinicians are required to be productive, selected items from reliable instruments were used to form a new, abbreviated instrument of health status relevant to patients in outpatient rehabilitation. There are no test-retest reliability statistics of these health status measures in this population. Methods and Measures: A convenience sample of 71 patients (mean age ± SD, 41.9 ± 17.9 years; age range, 15-83 years; sex, 35% male), with a variety of orthopaedic diagnoses, seeking rehabilitation in 2 outpatient facilities, volunteered. Patients completed health status questionnaires at initial evaluation and at 24 to 72 hours following evaluation. Intraclass correlation coefficients (ICC2,1) were used to estimate test-retest reliability and to estimate measurement error and minimal detectable changes. Results: ICCs with 1-sided lower limit 95% confidence intervals (CI) of the Overall Health Status measure and the Physical and Mental Component Summary measures for patients with chronic symptoms were 0.92 (0.85), 0.82 (0.68), and 0.85 (0.74), respectively. Minimal detectable changes (90% CI) were ±12 (scale range, 100), ±9 (scale range, 60), and ±9 (scale range, 60) scale points, respectively, for the same measures. Conclusion: Results support the test-retest reliability of the Overall Health Status measure and summary measures for patients with chronic symptoms and demonstrate ability of the Overall Health Status and Physical Summary Scale measures to detect improvement of patient self-report of health status within the first few days of rehabilitation.

J Orthop Sports Phys Ther. 2003;33(12):734-742.
 

Key Words: minimal detectable change, questionnaire, reliability, SF-12, SF-36

Study Design: Effect of clinical specialization was studied in a retrospective analysis of a commercial outcomes database. Objective: To assess effectiveness of care as measured by changes in health status and efficiency as measured by visits, duration of treatment episode, and net revenue between patients treated by clinicians with and without orthopaedic clinical specialist certification (OCS). Background: Clinical specialization is becoming common in physical therapy, but there are no studies to support improved efficiency or effectiveness with advanced practitioner competencies. Methods and Measures: A total of 258 adults treated in practices participating in the Focus On Therapeutic Outcomes process during 1996 comprised the data set. Seven physical therapists with OCS treated 129 patients (clinical specialist group). These patients were matched to 129 patients not treated by physical therapists with OCS (comparison group) randomly chosen from the aggregate data set. All patients completed a standardized health status questionnaire at initial evaluation and discharge. Standardized response means (SRMs) were calculated to measure change during treatment. Results: Therapists with OCS were more efficient than therapists without OCS, using fewer visits (9.1 ± 6.7 vs 11.2 ± 7.4) for less estimated cost ($949 ± $736 vs $1238 ± $1227) during the same treatment duration (35.9 ± 48.3 vs 35.4 ± 25.6 days) and performed fewer treatment procedures. Overall, there was no difference in effectiveness as measured by change in health status, that is, unit of functional improvement per episode (0.89 ± 1.0 SRM for clinical specialists compared with 0.88 ± 1.0 SRM for comparison group). The OCS group had better value (unit of functional improvement per estimated dollar) and utilization (unit of functional improvement per visit) for the constructs of physical functioning (value: 1.31 ± 2.7 vs 0.78 ± 1.8; utilization: 1.25 ± 2.2 vs 0.76 ± 1.6) and role physical (value: 1.26 ± 2.9 vs 0.44 ± 3.5; utilization: 1.11 ± 1.9 vs 0.51 ± 2.3) (SRMs for OCS group vs comparison group, respectively). Conclusions: Our data support the conclusion that physical therapists with OCS are more efficient compared with clinicians without OCS. Study limitations in design, small sample size, and low number of clinicians are discussed.

J Orthop Sports Phys Ther. 2000;30(4):183-193.

Key Words: health-related quality of life, orthopaedic clinical specialist, outcomes

Adapted from Hart DL, Berlin S, Brager PE, Caruso M, Hejduk JF, Howar JM, Snyder KP, Susi JL, Wah MD, Standards for Performing Functional Capacity Evaluations, Work Conditioning, and Work Hardening Programs, Maryland: Joint Committee on Industrial Services, State of Maryland, 1993, with permission. Before discussing adjustments in the fees for the clinical services of industrial rehabilitation, the Medical Fee Guide Committee of the Maryland Industrial Commission requested a copy of the clinical standards for these services. However, there were no multidisciplinary standards for industrial services that had statewide approval. Therefore, a committee was formed to write the standards. Following a review of the literature and unpublished work from other associations and state organizations, standards were developed. Constructive criticism was solicited from national and local professionals and organizations with demonstrated interest and experience in providing or using these services or with experience writing standards. Further comment was solicited from individuals in the state of Maryland before final editing. Because of the dearth of outcome studies supporting the efficacy of clinical services in industrial rehabilitation, the standards describing a level of expectation from clinical services have become important for state organizations responsible for making decisions on reimbursement for clinical services. This paper summarizes the process used for the development of clinical standards of industrial rehabilitation services.

J Orthop Sports Phys Ther. 1994;19(5):232-241.

Key Words: industrial rehabilitation, standards of practice, functional capacity evaluation, work conditioning, work hardening