Orthopaedic Manual Physical Therapy: A Modern Definition and Description.

Currently, orthopaedic manual physical therapy (OMPT) lacks a description of practice that reflects contemporary thinking and embraces advances across the scientific, clinical, and educational arms of the profession. The absence of a clear definition of OMPT reduces understanding of the approach across health care professions and potentially limits OMPT from inclusion in scientific reviews and clinical practice guidelines. For example, it is often incorrectly classified as passive care or incorrectly contrasted with exercise-therapy approaches. This perspective aims to provide clinicians, researchers, and stakeholders a modern definition of OMPT that improves the understanding of this approach both inside and outside the physical therapist profession. The authors also aim to outline the unique and essential aspects of advanced OMPT training with the corresponding examination and treatment competencies. This definition of practice and illustration of its defining characteristics is necessary to improve the understanding of this approach and to help classify it correctly for study in the scientific literature. This perspective provides a current definition and conceptual model of OMPT, defining the distinguishing characteristics and key elements of this systematic and active patient-centered approach to improve understanding and help classify it correctly for study in the scientific literature.

Mentorship and self-efficacy are associated with lower burnout in physical therapists in the United States: a cross-sectional survey study.

PURPOSE: This study investigated the prevalence of burnout in physical therapists in the United States and the relationships between burnout and education, mentorship, and self-efficacy. METHODS: This was a cross-sectional survey study. An electronic survey was distributed to practicing physical therapists across the United States over a 6-week period from December 2020 to January 2021. The survey was completed by 2,813 physical therapists from all states. The majority were female (68.72%), White or Caucasian (80.13%), and employed full-time (77.14%). Respondents completed questions on demographics, education, mentorship, self-efficacy, and burnout. The Burnout Clinical Subtypes Questionnaire 12 (BCSQ-12) and self-reports were used to quantify burnout, and the General Self-Efficacy Scale (GSES) was used to measure self-efficacy. Descriptive and inferential analyses were performed. RESULTS: Respondents from home health (median BCSQ-12=42.00) and skilled nursing facility settings (median BCSQ-12=42.00) displayed the highest burnout scores. Burnout was significantly lower among those who provided formal mentorship (median BCSQ-12=39.00, P=0.0001) compared to no mentorship (median BCSQ-12=41.00). Respondents who received formal mentorship (median BCSQ-12=38.00, P=0.0028) displayed significantly lower burnout than those who received no mentorship (median BCSQ-12=41.00). A moderate negative correlation (rho=-0.49) was observed between the GSES and burnout scores. A strong positive correlation was found between self-reported burnout status and burnout scores (rrb=0.61). CONCLUSION: Burnout is prevalent in the physical therapy profession, as almost half of respondents (49.34%) reported burnout. Providing or receiving mentorship and higher self-efficacy were associated with lower burnout. Organizations should consider measuring burnout levels, investing in mentorship programs, and implementing strategies to improve self-efficacy.

Pain Neuroscience Education in Elementary and Middle Schools.

PURPOSE: The purpose of this study was to deliver pain neuroscience education (PNE) to participants in grades 3 to 8 to determine whether participants in these grades had positive shifts in pain knowledge and beliefs. METHODS: Three hundred twenty participants, grades 3 to 8, received a 1-time, 30-minute PNE lecture. The Neurophysiology of Pain Questionnaire and the Health Care Provider's Pain and Impairment Relationship Scale were administered before and after the PNE lecture. RESULTS: All grades improved in pain knowledge and beliefs. Higher-grade school participants (sixth to eighth grades) experienced larger shifts in pain knowledge and attitudes and beliefs than lower-grade (third to fifth grades) participants. CONCLUSION: PNE results in changes in pain knowledge and beliefs in school participants in grades 3 to 8.

Initial Validation of a Sacroiliac Joint-Specific Disability Questionnaire.

Low back pain is a multidimensional disorder that can originate from a variety of pain generators, including the sacroiliac (SI) joint. Although the Oswestry Disability Index (ODI) is often used in SI joint treatment studies, the effects of the SI joint on functional disability are likely different from those of other low back pain generators. Thus, we developed the Denver SI Joint Questionnaire (DSIJQ) and performed validation testing in patients (n=24) with SI joint-specific pain at baseline, +2 weeks, and +6 months. Psychometric analyses included test-retest reliability, internal consistency, content validity, convergent criterion validity, divergent criterion validity, and responsiveness. The DSIJQ showed good test-retest reliability (intraclass correlation coefficient=0.87), internal consistency (Cronbach's alpha=0.842), content validity (<30% floor/ceiling effects), convergent criterion validity (r=0.89; P<.001), and divergent criterion validity (r=-0.33; P=.12). The DSIJQ was correlated with performance on two physical function tests: Timed Upand-Go (r=0.53; P=.008) and 5 Minute Walk (r=-0.52; P=.009). The DSIJQ showed better responsiveness than the ODI (standardized response mean and effect size, 1.14 and 1.45 for DSIJQ and 0.75 and 0.81 for ODI). Overall, the DSIJQ performed well on all psychometrics. Importantly, we validated the DSIJQ with patients' ability to complete two tests of physical functioning. Moreover, the DSIJQ was more sensitive to changes in SI joint disability than the ODI. These psychometrics suggest the DSIJQ is appropriate for evaluating SI joint disability and detecting changes in disability after targeted SI joint treatment. [Orthopedics. 2023;46(6):345-351.].

Trajectory of patient-rated outcomes and association with patient acceptable symptom state in patients with musculoskeletal shoulder pain.

OBJECTIVE: Characterize trajectory and predictors of patient acceptable symptom state (PASS) defined recovery at 6 months. METHODS: Individuals with musculoskeletal shoulder pain (n = 140) completed patient-reported disability and PASS at baseline, 1 and 6 months. The PASS was categorized into 3 trajectory groups; 1.) Early Recovery (answered yes to PASS at 1 and 6-months), 2.) Delayed Recovery (PASS-yes only at 6-months), and 3.) Unrecovered. Mixed models characterized the trajectory between PASS-groups using SPADI and QDASH disability change scores. Logistic regression identified predictors of Early Recovery versus Delayed+Unrecovered groups. RESULTS: PASS-defined recovery rates by group were Early Recovery (58%), Delayed Recovery (22%), and Unrecovered (20%). A group main effect indicated lower disability over time in the Early Recovery versus Unrecovered (QDASH mean difference = 11(2.4); p = 0.001; SPADI mean difference = 12(3); p < 0.001). The odds of an Early Recovery slightly increased with greater change scores on the SPADI (odds ratio = 1.06, 95%CI:1.02,1.11; p = 0.004) and QDASH (odds ratio = 1.08, 95%CI:1.03,1.13; p = 0.003) over the first month of treatment. CONCLUSION: Recovery trajectories of patients indicate differing responses to treatment despite overall improvements over the first month of treatment. Incorporating both patient-reported disability (SPADI, QDASH) and acceptable satisfaction (PASS) may aid in determining recovery trajectory, but more evidence is needed to be clinically useful.

The healthcare buffet: preferences in the clinical decision-making process for patients with musculoskeletal pain.

The preferences a person has for care are associated with outcomes for patients presenting with musculoskeletal pain conditions. These include preferences for differing levels of involvement in the decision-making process, preferences for the provider attributes, and preferences for particular interventions. In this paper, we discuss these various forms of preference, as well as how they influence clinical care within shared decision-making frameworks. We also present a conceptual framing for how patient preferences can be incorporated in clinical decision-making by orthopedic manual physical therapists. Finally, research implications for interpreting findings from clinical studies are discussed.

Thoracic spine thrust manipulation for individuals with cervicogenic headache: a crossover randomized clinical trial.

OBJECTIVE: To determine if thoracic spine manipulation (TSM) improves pain and disability in individuals with cervicogenic headache (CeH). METHODS: A randomized controlled crossover trial was conducted on 48 participants (mean age: 34.4 years) with CeH symptoms. Participants were randomized to 6 sessions of TSM or no treatment (Hold) and after 4-weeks, groups crossed over. Outcomes were collected at 4, 8 and 12 weeks and included: headache disability inventory (HDI), neck disability index (NDI), and the global rating of change (GRC). Outcomes were analyzed using a linear mixed-effects model with Bonferroni correction. Odds of achieving the minimal clinically important difference (MCID) on the GRC of +4 or greater were also calculated. Scores at 4 weeks represent the only timepoint where 1 group is fully treated and other group has not received any treatment. RESULTS: Comparing hold to active treatment, HDI were not significantly different between groups (mean difference = 7.39, 95 CI: -4.39 to 19.18; P = 0.214) at any timepoint; the NDI was significant (mean difference = 6.90, 95 CI: 0.05 to 13.75; P = 0.048) at 4 weeks. Odds of achieving the +4 MCID on the GRC (OR = 38.0, 95 CI: 6.6 to 220.0; p < 0.001) favored TSM at 4 weeks. CONCLUSION: TSM had no effect on headache-related disability but resulted in significant improvements in neck-related disability and participant reported perceived improvement. Future studies are needed to examine the long-term impact of TSM in this population.

Accuracy of long head of the biceps tendon palpation by physical therapists; an ultrasonographic study.

[Purpose] Examination and treatment of the long head of the biceps tendon (LHBT) requires accurate palpation. The purpose of this study was to determine physical therapists' reliability and ability to accurately palpate the LHBT in two arm positions with ultrasound as the gold standard. [Participants and Methods] Examiners palpated the LHBT within the intertubercular groove (ITG) of the humerus on the bilateral shoulders of 32 asymptomatic (21 female; 24.3 ± 1.9 years) participants in 2 arm positions. The magnitude of distance between a marker and the border of the ITG was compared between 2 positions using an independent t-test. Percent accuracy was calculated. [Results] Inter-rater reliability was poor (position 1, k=1.04; position 2, k=0.016). Overall accuracy rate was 45.7% (117/256). Accuracy was 49.2% (63/128) and 42.2% (54/128) for testing position 1 and position 2 respectively. Mean distance palpated from the groove was M=2.58 mm (± 6.2 mm) for position 1 and M=3.77 mm (± 6.6 mm) for position 2. Inaccurate palpation occurred medially 72.3% (47/65) and 93.2% (69/74) in position 1 and position 2 respectively. [Conclusion] Results of this study did not support one arm position being more accurate over another for LHBT palpation.

Integrating Motivational Interviewing in Pain Neuroscience Education for People With Chronic Pain: A Practical Guide for Clinicians.

Pain neuroscience education (PNE) and motivational interviewing (MI) have been widely implemented and tested in the field of chronic pain management, and both strategies have been shown to be effective in the short term (small effect sizes) for the management of chronic pain. PNE uses contemporary pain science to educate patients about the biopsychosocial nature of the chronicity of their pain experience. The goal of PNE is to optimize patients' pain beliefs/perceptions to facilitate the acquisition of adaptive pain-coping strategies. MI, on the other hand, is a patient-centered communication style for eliciting and enhancing motivation for behavior change by shifting the patient away from a state of indecision or uncertainty. Conceptually, PNE and MI appear to be complementary interventions, with complementary rather than overlapping effects; MI primarily improves cognitive and behavioral awareness and, potentially, adherence to treatment principles, whereas PNE potentially increases pain knowledge/beliefs, awareness, and willingness to explore psychological factors that are potentially associated with pain. Therefore, combining PNE with MI might lead to improved outcomes with larger and longer-lasting effect sizes. The combined use of PNE and MI in patients having chronic pain is introduced here, along with a description of how clinicians might be able to integrate PNE and MI in the treatment of patients experiencing chronic pain. Clinical trials are needed to examine whether combining PNE with MI is superior to PNE or MI alone for improving pain and quality of life in patients having chronic pain.

Treatment of individuals with chronic bicipital tendinopathy using dry needling, eccentric-concentric exercise and stretching; a case series.

Objectives: To describe the outcomes of 10 patients with chronic biceps tendinopathy treated by physical therapy with the novel approach of dry needling (DN), eccentric-concentric exercise (ECE), and stretching of the long head of the biceps tendon (LHBT). Methods: Ten individuals reporting chronic anterior shoulder symptoms (> 3 months), pain with palpation of the LHBT, and positive results on a combination of tests including active shoulder flexion, Speed's, Hawkins Kennedy, Neer, and Yergason's tests participated in this case series. Validated self-reported outcome measures including the mean numeric pain rating scale (NPRS) and Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) were taken at baseline. Participants were treated with two to eight sessions of DN to the LHBT and an ECE program and stretching of the biceps muscle. At discharge, patients completed the global rating of change (GROC), QuickDASH and NPRS. Results: Patients had an improved mean NPRS of 3.9 (SD, 1.3; p < 0.001), QuickDASH of 19.01% (SD, 10.8; p < 0.02) and GROC +5.4 (SD, 1.3). Conclusion: Findings from this case series suggest that DN and ECE may be beneficial for the management of patients with chronic LHBT tendinopathy. Further research on the efficacy of this novel treatment approach is warranted.

Effectiveness of Physical Therapy Combined With Epidural Steroid Injection for Individuals With Lumbar Spinal Stenosis: A Randomized Parallel-Group Trial.

OBJECTIVE: To examine the effectiveness of epidural steroid injection (ESI) and back education with and without physical therapy (PT) in individuals with lumbar spinal stenosis (LSS). DESIGN: Randomized clinical trial. SETTING: Orthopedic spine clinics. PARTICIPANTS: A total of 390 individuals were screened with 60 eligible and randomly selected to receive ESI and education with or without PT (N=54). INTERVENTIONS: A total of 54 individuals received 1-3 injections and education in a 10-week intervention period, with 31 receiving injections and education only (ESI) and 23 additionally receiving 8-10 sessions of multimodal PT (ESI+PT). MAIN OUTCOME MEASURES: Disability, pain, quality of life, and global rating of change were collected at 10 weeks, 6 months, and 1 year and analyzed using linear mixed model analysis. RESULTS: No significant difference was found between ESI and ESI+PT in the Oswestry Disability Index at any time point, although the sample had significant improvements at 10 weeks (P<.001; 95% confidence interval [CI], -18.01 to -5.51) and 1 year (P=.01; 95% CI, -14.57 to -2.03) above minimal clinically important difference. Significant differences in the RAND 36-Item Short Form Health Survey 1.0 were found for ESI+PT at 10 weeks with higher emotional role function (P=.03; 95% CI, -49.05 to -8.01), emotional well-being (P=.02; 95% CI, -19.52 to -2.99), and general health perception (P=.05; 95% CI, -17.20 to -.78). CONCLUSIONS: Epidural steroid injection plus PT was not superior to ESI alone for reducing disability in individuals with LSS. Significant benefit was found for the addition of PT related to quality of life factors of emotional function, emotional well-being, and perception of general health.

Factors shaping expectations for complete relief from symptoms during rehabilitation for patients with spine pain.

OBJECTIVE: Patient expectations are related to treatment outcome across a broad variety of patient conditions. Here we sought to examine factors associated with the expectation of complete relief from treatment for spinal pain. DESIGN: Secondary analysis of data pooled from two randomized controlled trials of conservative rehabilitation interventions. PATIENTS: 252 patients (103 men, 149 women) with neck (n = 140) or back (n = 112) pain. METHODS: We used logistic regression model with backward elimination to test which patient clinical or demographic factors were most related to the expectation of complete relief. MAIN OUTCOME MEASURES: The expectation of complete recovery, which was collected at the baseline examination visit in the primary trials. RESULTS: The final model examining the contributions of patient and clinical characteristics to the expectation of complete relief included two significant interactions. First, increasing disability was associated with increased odds of expecting complete recovery in women while there was very little change for men across levels of disability (OR 0.9 [95%CI 0.8, 0.9]). Second, patients with low fear and a sudden onset of pain had higher odds of expecting recovery than patients with a gradual onset of pain (OR 0.7 [95%CI 0.5, 0.97]). A main effect for education level of the patient was also significant with better odds for expecting complete recovery for college educated patients compared to those with graduate school education (OR 5.0 [95%CI 1.9, 13.4]). CONCLUSION: The results should assist physical therapists to recognize patients who may have lower expectations of recovery and plan pre-treatment education interventions.

Manual Therapy Cures Death: I Think I Read That Somewhere.

Predatory journals are compromising the scientific credibility of "published" research. Past concerns with predatory journals have included the lack of a peer-review process, lack of an editorial board, and little to no description of the publication's ethical standards. In this editorial, we describe the ease with which bogus information can be published in predatory journals, and outline 3 risks to credible science associated with published information and downstream referencing, which may occur through source amnesia bias. J Orthop Sports Phys Ther 2018;48(11):830-832. doi:10.2519/jospt.2018.0107.

Impact of expectations on functional recovery in individuals with chronic shoulder pain.

STUDY DESIGN: Retrospective cohort. OBJECTIVES: To examine general expectations for treatment by physical therapists and specific expectations for common interventions in patients with shoulder pain. A secondary objective was to assess the extent to which patients' general and specific expectations for treatment affect clinical outcomes. METHODS: We performed a secondary analysis of data from a clinical trial of interventions for shoulder pain. Prior to beginning treatment for shoulder pain, 140 patients were asked their general expectations of benefit and their specific expectations for individual interventions. Next we examined how these expectations related to the patients' ratings of the success of treatment at one and six months after treatment. RESULTS: Patients had positive general expectations for treatment by a physical therapist. Specific manual therapy interventions of range of motion and strengthening had the highest proportion of patients who expected these interventions to significantly improve shoulder pain. Seventy-two patients (58%) reported themselves to be improved using the global rating of change (GROC) at one month and six months. In the full model predicting one-month GROC, only the expectation of moderate relief (p = 0.012) and body mass index (BMI) (p = 0.013) had significant effects. Overall, the Shoulder Pain and Disability Index (SPADI) significantly decreased over time (p = 0.004); however, a significant interaction did occur between time and BMI (p = 0.021). DISCUSSION: Patients expect common interventions used by physical therapists to be effective to manage shoulder pain. In conclusion, patients with shoulder pain had high general expectations for physical therapy. LEVEL OF EVIDENCE: Prognosis, level 2b.

Physical Therapists' Role in Solving the Opioid Epidemic.

An estimated 116 million Americans suffer from chronic pain, at a cost of over $600 billion per year, or roughly $2000 per person per year. In this Viewpoint, the authors highlight the challenges of the current opioid epidemic and outline strategies that the physical therapy profession may adopt to be part of the solution. These strategies include facilitating and providing patient education, early access to physical therapy services, and the promotion of health, wellness, and prevention. J Orthop Sports Phys Ther 2018;48(5):349-353. doi:10.2519/jospt.2018.0606.

Use of Pain Neuroscience Education, Tactile Discrimination, and Graded Motor Imagery in an Individual With Frozen Shoulder.

Study Design Case report. Background Aggressive physical therapy in the freezing stage of frozen shoulder may prolong the course of recovery. Central sensitization may play a role in the early stages of frozen shoulder. Pain neuroscience education, tactile discrimination, and graded motor imagery have been used in a number of conditions with central sensitization. The purpose of this case report was to describe the examination and treatment of a patient in the freezing stage of frozen shoulder using pain neuroscience education, tactile discrimination, and graded motor imagery. Case Description A 54-year-old woman with a diagnosis of frozen shoulder was referred by an orthopaedic surgeon following lack of progress after 4 weeks of intensive daily physical therapy. Pain at rest was 7/10, and her Shoulder Pain and Disability Index score was 64%. She had painful and limited active range of motion and elevated fear-avoidance beliefs. Tactile discrimination and limb laterality were impaired, with signs of central sensitization. A "top-down" approach using pain neuroscience education, tactile discrimination, and graded motor imagery was used for the first 6 weeks, followed by a "bottom-up" impairment-based approach. Outcomes The patient was seen for 20 sessions over 12 weeks. At discharge, her Shoulder Pain and Disability Index score was 22%, resting pain was 0/10, and fear-avoidance beliefs improved. Improvements in active range of motion, laterality, and tactile discrimination were also noted. Discussion Intensive physical therapy in the freezing stage of frozen shoulder may be detrimental to long-term outcomes. This case report suggests that a top-down approach may allow a quicker transition through the freezing stage of frozen shoulder. Level of Evidence Therapy, level 5. J Orthop Sports Phys Ther 2018;48(3):174-184. Epub 19 Dec 2017. doi:10.2519/jospt.2018.7716.

Physiological effects of physical therapy interventions on lumbar intervertebral discs: A systematic review.

BACKGROUND CONTEXT: The use of physical therapy has been recommended in the treatment of low back pain based on primarily mechanical and neurophysiological effects. Recent studies have measured the physiological effects of physical therapy interventions, including manual therapy and traction, on the intervertebral discs (IVD), and these findings may have implications for the long-term management or even prevention of low back pain. PURPOSE: The objective of this systematic review is to investigate the literature regarding possible physiological effects of physical therapy interventions on the intervertebral disc (IVD). STUDY DESIGN: Systematic Review. METHODS: A literature search of published articles through December 2014 resulted in the retrieval of 8 clinical studies assessing the influence of physical therapy interventions on the physiology of the IVD. RESULTS: Three studies, including two using animal models, investigated the effects of 30-minute intermittent traction on disc height. One in vivo animal study and two studies using human subjects assessed changes of disc height associated with static traction. Three studies investigated the effects of lumbar spine manipulation and mobilization on changes in water diffusion within the IVD. All studies confirmed, either directly or indirectly, that their respective intervention influenced disc physiology primarily through water flow. CONCLUSION: Physical therapy interventions may have an effect on the physiology of the IVD, primarily through water diffusion and molecular transport, which are important for the health of the IVD.