Clinical databases in physical therapy.

Clinical databases in physical therapy provide increasing opportunities for research into physical therapy theory and practice. At present, information on the characteristics of existing databases is lacking. The purpose of this study was to identify clinical databases in which physical therapists record data on their patients and treatments and to investigate the basic aspects, data sets, output, management, and data quality of the databases. Identification of the databases was performed by contacting members of the World Confederation for Physical Therapy, searching Pubmed, searching the Internet, and snowball sampling. A structured questionnaire was used to study the characteristics of the databases. The search was restricted to North America, Australia, Israel, and Western Europe. Seven clinical databases on physical therapy were identified. Four databases collected data on specific patient categories, whereas the others collected data on all patients. All databases collected data on patient characteristics, referrals, diagnoses, treatments, and closure, whereas some databases also collected functional status information. The purposes of the databases were diverse, but they can be summarized as quality improvement, research, and performance management. Although clinical databases are new to the field, they offer great potential for physical therapy research. Potential can be increased by further cooperation among databases allowing international comparative studies.

Centralization phenomenon as a prognostic factor for chronic low back pain and disability.

STUDY DESIGN: Two hundred twenty-three consecutive adults with acute low back pain with or without referred spinal symptoms were treated conservatively and followed prospectively for 1 year. OBJECTIVES: To investigate the predictive value of centralization phenomenon (CP) with psychosocial variables previously identified as important risk factors for patients with acute onset of nonserious or nonspecific low back pain who subsequently develop chronic pain or disability. SUMMARY OF BACKGROUND DATA: Psychosocial factors have been shown to be predictors of chronic disability, but measures from physical examination rarely predict chronic behavior. The authors of the present study investigated whether dynamic assessment of changes in clinical measures during treatment could be used to classify patients and predict occurrence of chronic pain or disability. METHODS: Patients with acute symptoms and no history of surgery were treated by five physical therapists trained in McKenzie evaluation/treatment methods. Seventy-three percent were receiving workers' compensation benefits. At initial evaluation and discharge, 23 independent variables were assessed representing psychosocial, clinical, and demographic factors. Pain location changes to repeated trunk movements were assessed at every visit. Patients were placed in two groups: 1) those with pain that did not centralize and 2) those who completely centralized or demonstrated partial reduction of pain location with time. Treatment was individualized and based on McKenzie methods. Patients were contacted at 12 months after discharge, and dependent variables of pain intensity, return to work status, sick leave at work, activity interference at home, and continued use of health care were assessed. RESULTS: Nine independent variables influenced pain symptoms or disability. Pain pattern classification (noncentralization) and leg pain at intake were the strongest predictive variables of chronicity. CONCLUSION: Dynamic assessment of change in anatomic pain location during treatment and leg pain at intake were predictors of developing chronic pain and disability.

Changes in health status for persons with wrist or hand impairments receiving occupational therapy or physical therapy.

OBJECTIVE: The purpose of this study was to describe changes of health status as perceived by clients with hand or wrist impairments who received rehabilitation in acute, orthopedic outpatient facilities from occupational therapy or physical therapy personnel. METHOD: One thousand three hundred ninety-nine adults with wrist (n = 692) or hand (n = 707) impairments who were treated between July 1996 and June 1997 were selected from the Focus On Therapeutic Outcomes, Inc. (FOTO) national rehabilitation database. Each client completed a health status questionnaire on intake and discharge. Data consisted of number of outpatient visits, duration of treatment episode, and health status scores for six functional scales. Measures of intensity, global health status, global utilization, and client satisfaction were calculated. Outcomes were evaluated across occupational therapists and physical therapists. RESULTS: Clients perceived improvement (p < .05) in their health status over the course of therapy. Number of visits and measures of health status and client satisfaction were similar across type of therapist. Episode duration was longer (p < .05) and intensity was less (p < .05) for clients seen by occupational therapists. CONCLUSION: Clients receiving rehabilitation in acute orthopedic outpatient centers perceived improvement in their functional abilities and health and well-being (global health status and individual functional scales) over the time during which treatment was provided. Results confirm the responsiveness of the outcomes instrument to clinical change in the clients' perception of their health status over the course of therapy and support the use of health status as a measure of clinical outcome.

The power of outcomes: FOTO Industrial Outcomes Tool -- Initial assessment.

OBJECTIVE: To demonstrate how outcomes assessment can assist in describing clients receiving rehabilitation in occupational health rehabilitation clinics and to describe the preliminary assessment of internal consistency reliability and construct validity of the FOTO Industrial Outcomes Tool. METHODS: 266 adults referred for acute work rehabilitation (AWR), work conditioning/hardening (WC/WH) or a Functional Capacity Evaluation (FCE) comprised the data set. Clients were treated between July 1998 and January 1999 in 15 clinics from 6 states by 46 clinicians participating in the Focus on Therapeutic Outcomes (FOTO) national rehabilitation database beta test. For AWR and WC/WH, clients completed a health status questionnaire on intake and discharge, and health status was assessed prior to the FCE. Comprehensive demographic data were collected describing the clinics, clinicians, clients and work status collected 2 weeks following discharge. RESULTS: Internal consistency reliability coefficients for the health status scores ranged from 0.57 to 0.89. Construct validity was supported. CONCLUSION: Results demonstrate the power of collecting outcomes from a variety of constructs for clients receiving industrial rehabilitation services. Initial reliability and construct validity findings were adequate and support continuing data analyses.

Influence of orthopaedic clinical specialist certification on clinical outcomes.

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.

Assessment of unidimensionality of physical functioning in patients receiving therapy in acute, orthopedic outpatient centers.

Physical functioning is a common construct of interest for patients receiving rehabilitation. This report describes the assessment of hierarchial structure, unidimensionality and reproducibility of item calibrations along the continuum of physical functioning defined by the PF-10 of the MOS SF-36. Three new questions specific to patients with upper extremity impairments were added, and item calibrations were compared across several groups of patients with different musculoskeletal impairments. Reproducibility of item calibrations over testing times was supported. Item order was dependent on impairment in a clinically logical pattern. Construct validity of the physical functioning scale was supported and improved with the new questions for patients with upper extremity impairments as well as for patients with some lower level extremity impairments.

A descriptive study of the centralization phenomenon. A prospective analysis.

STUDY DESIGN: Occurrence and treatment responses associated with the centralization phenomenon were analyzed prospectively in 289 patients with acute neck and back pain with or without referred spinal symptoms. OBJECTIVES: To document symptom changes to mechanical assessment during initial evaluation and during consecutive visits. Using standard operational definitions, patients were categorized reliably into three inclusive and mutually exclusive pain pattern groups: centralization, noncentralization, and partial reduction. It was hypothesized that the occurrence of centralization would be less than previously reported and that the centralization group would have better treatment results. SUMMARY OF BACKGROUND DATA: Centralization has been reported to occur with high frequency during mechanical assessments of patients with acute spinal syndromes. When centralization is observed, a favorable treatment result is expected. Because centralization has not been defined consistently in the literature, the true prevalence and treatment responses associated with centralization have not been confirmed. METHODS: Consecutive patients with neck or back pain syndromes and referred to outpatient physical therapy services were categorized into three pain pattern groups by experienced therapists trained in the McKenzie system. Changes in distal pain location were scored and documented before and after each visit. Maximal pain intensity over 24 hours, perceived functional status, and number of treatment visits were compared between groups. RESULTS: Patients could be categorized reliably according to movement signs and symptoms. The centralization pain pattern group had significantly fewer visits than the other two groups (P < 0.001). Pain intensity rating and perceived function were different between the centralization and noncentralization groups (P < 0.001). There was no difference in treatment response between the centralization and partial-reduction groups (P = 0.306). Prevalence of patients assigned to the three groups was 30.8% in the centralization group, 23.2% in noncentralization, and 46% in the partial-reduction group. CONCLUSION: Categorization by changes in pain location to mechanical assessment and treatment allowed identification of patients with improved treatment outcomes and facilitated planning of conservative treatment of patients with acute spinal pain syndromes. If a proximal change in pain location is not observed by the seventh treatment visit, the results of this study support additional medical evaluation for physical or nonphysical factors that could be delaying quick resolution of the acute episode.

Reliability of independent observer judgments of level of lift effort in a kinesiophysical Functional Capacity Evaluation.

Functional Capacity Evaluation includes manual materials handling as a primary component. Return to work decisions are often made or influenced by both the heaviest amount of weight that can be safely lifted and the weight that can be handled repetitiously. Kinesiophysical observational criteria were developed to allow trained judges to categorize lifting in order to identify the category of lift effort. Bothinter rater and intrarater reliability were high. When light or heavy categories were isolated for accuracy there were no errors in judge's ratings.

Rehabilitation ergonomists: standards for development.

Ergonomics, in the traditional definition, is the science of design of work sites and work methods which influence production performance. In recent years, worker complaints and reports of injuries have caused evaluation of the effect of work stressors on workers. Currently, the rehabilitation specialist plays a pivotal role in both prevention and management of physical work related complaints. Rehabilitation ergonomic practitioners combine a scientific background in function and pathology with the act of developing preventive or restorative remedies. A volunteer group of sixteen rehabilitation professionals who utilize ergonomic principles in the workplace developed a document, identifying job functions of the newly defined field. This paper presents philosophy and a model for educational development and potential credentialing areas for rehabilitation ergonomists.

Impact of the Dayton Tire case.

Three of the more pertinent legal cases in the United States concerning the performance of ergonomists are summarized. The results of the cited cases have impact on the validity of the NIOSH lifting formulae, the lack of scientific evidence relating performance of jobs with alleged ergonomic stressors with specific medical pathology, and the gold standard for expert witness testimony. The cases, taken together, should act as a catalyst for ergonomists to improve their level of scientific justification for their work and conclusions.

Development of clinical standards in industrial rehabilitation.

Before discussing adjustments in the fees for the clinical services of industrial rehabilitation, the Medical Free 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 state-wide 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.

Guidelines for functional capacity evaluation of people with medical conditions.

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 which 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.