STUDY DESIGN: Case report. BACKGROUND: Cognitive behavioral therapy (CBT) is an effective intervention for patients with persistent pain. Recent research indicates that physical therapists self-perceive a lack of knowledge, skills, and time to provide this intervention. The purpose of this case report is to describe how specific CBT strategies can be integrated with multimodal physical therapist management of a patient with persistent low back pain. CASE DESCRIPTION: The patient was a 70-year-old female with activity limitations of walking, standing, and forward bending. Oswestry Disability Questionnaire score was 19/50 and Fear-Avoidance Belief Questionnaire physical activity subscale was 23/24. The Low Back Activity Confidence Scale revealed 19%, 100%, and 84% for function, symptom self-regulation, and exercise, respectively. CBT-based patient education was provided in combination with manual therapy and exercise. CBT techniques included cognitive restructuring, goal setting, activity pacing, problem-solving strategies, graded exposure, encouraging exposure to pleasant experiences, and maintenance strategies. OUTCOMES: The patient was discharged after 7 visits distributed over 21 weeks. Her Oswestry Disability Questionnaire score was reduced 10% and Fear-Avoidance Belief Questionnaire physical activity subscale score reduced 48%. On the Low Back Activity Confidence Scale the patient’s scores were 19%, 87%, and 94% for function, symptom self-regulation, and exercise, respectively. DISCUSSION: This case report describes the use of CBT techniques during patient education by a physical therapist. The patient demonstrated clinically measurable and significant improvements in disability. Improvements in both self-efficacy beliefs related to exercise and activity avoidance beliefs were associated with improvement in disability. Additional research is needed to determine best practices for CBT-based patient education by physical therapists. LEVEL OF EVIDENCE: Therapy, level 4.

J Orthop Sports Phys Ther 2010;40(8):494-501. doi:10.2519/jospt.2010.3264

KEY WORDS: chronic pain, graded exposure, lumbar spine

Pain is a ubiquitous symptom in physical therapy. Prior learning and emotional responses are widely known to modify patients' perception of pain. These factors may affect patients' coping of future painful episodes and willingness to place themselves in potentially pain-provoking situations. In turn, limitations in coping and willingness to manage activities despite pain may perpetuate additional activity and participation limitations. Measurements that capture the complex interrelationships among pain-related cognition, affect, and behavior are necessary to identify patients with clinically significant affective and cognitive components of pain perception. As a result, several questionnaires that are designed to measure fear of movement, injury, or reinjury in patients with pain have been described and are gaining popularity in the physical therapy clinic and literature, such as the Fear Avoidance Beliefs Questionnaire (FABQ) and Tampa Scale of Kinesiophobia (TSK). However, optimal interpretation of these questionnaires by physical therapists and, consequently, the most effective ways to use this information in clinical practice remain unclear.

J Orthop Sports Phys Ther. 2008;38(10):584-585. doi:10.2519/jospt.2008.0109

KEY WORDS: FABQ, kinesiophobia, pain, TSK

The patient was a 44-year-old male with a 5-month history of lumbar radiculopathy following a golf injury. Following magnetic resonance imaging, he received a spinal epidural injection consisting of corticosteriods from his spine surgeon 2 weeks prior to physical therapy evaluation. Five weeks postinjection, the patient noted a progressive and significant worsening of his local lumbar and radicular symptoms. Magnetic resonance imaging revealed a lumbar subcutaneous abscess, for which the patient underwent open debridement and intravenous antibiotic therapy for methicillin sensitive staphylococcus aureus. He subsequently returned to physical therapy for successful management of his residual disablement.

J Orthop Sports Phys Ther., 2008;38(5):287. doi:10.2519/jospt.2008.0405

KEY WORDS: infection, magnetic resonance imaging, staphylococcus aureus

Study Design: Randomized multicenter retrospective chart review of medical referral diagnoses and corresponding referral, patient, and physician demographic data. Objective: To examine the information content of medical referral diagnoses provided to outpatient physical therapists with respect to physician and patient characteristics. Background: Previous studies indicate that physicians commonly provide nonspecific referral diagnoses to physical therapists. The effects of patient and physician characteristics on information contained in referral diagnoses are not well elucidated. Methods and Measures: A team of blinded raters categorized the information content of referral diagnoses (n = 2183) using a classification system adapted from a previous study. Results: One third (32%) of analyzed diagnoses were anatomically oriented and reported specific pathology. These specific diagnoses were provided significantly more commonly by specialist physicians (odds ratio [OR], 3.4; 95% confidence interval [CI], 2.7-4.2; P<.001), male physicians (OR, 2.2; 95% CI, 1.6-3.1; P<.001), both early- and late-career physicians (P<.001), and for male patients (OR, 1.3; 95% CI, 1.1-1.6; P<.05). Conclusion: Physicians frequently provide nonspecific referral diagnoses to physical therapists. The practice of evidence-based physical therapy seems challenged by the high rate of nonspecific referral diagnoses. Physical therapists may also have the responsibility to conduct differential diagnosis of pathology more commonly than formally recognized by many state practice acts and third-party payers.

J Orthop Sports Phys Ther. 2005;35(9):572-579. doi:10.2519/jospt.2005.2050

Key Words: differential diagnosis, direct access, primary care

The Guide to Physical Therapist Practice affirms that physical therapists should determine the appropriateness of physical therapy to address a patient's disablement. The decision facing all therapists-during the initial evaluation and every subsequent clinic visit-is whether to treat the patient, refer the patient, or initiate both treatment and referral. This decision is based on whether the patient's clinical presentation is consistent with symptoms and signs of pathology that seem amenable to physical therapy. At minimum, deciding the appropriateness of physical therapy takes confirmation of the pathology suggested in a physician's referral diagnosis, if present. However, anecdotal evidence suggests that more extensive questioning, clinical testing, and referral to other specialists frequently are needed.

J Orthop Sports Phys Ther. 2006; 36(1):1-2. doi:10.2519/jospt.2006.0101

Key Words: diagnosis