• News New Blog Banner

  • Study: Return-to-Play Predictions for Hamstring Injuries Hamstrung by Variability

    Think you can predict how long it will take an athlete with a hamstring injury to return to play based on the athlete's history and an initial clinical examination? Some researchers say you probably can't—and magnetic resonance imaging (MRI) probably won't help.

    In a study published in the British Journal of Sports Medicine(pdf) researchers followed the progress of 180 male athletes with acute hamstring injury in an effort to analyze the predictive value of patient history and initial clinical examination, as well as any additional insight added by MRI. All of the athletes participated in a supervised physical therapy program, and were cleared for return to sport by either a physician or a physical therapist (PT).

    Using a more in-depth statistical analysis than in previous studies, the investigators calculated that patient history and clinical examination explained only 29% of the total variance in time to return to sport among the participants. Adding MRI increased that variance by just 2.8%—for a total of 31.8%.

    Based on their findings, the authors write, “Clinicians cannot provide an accurate time to return to sport” based on patient history, initial examination, or MRI. However, they add, “this is not a call to abandon MRI in clinical practice,” a resource that could be valuable for confirming the diagnosis and informing patients about their injuries.

    The initial examination included pain experienced during range-of-motion testing, manual muscle testing, the active slump test, and measuring length and width of the injury through tenderness to palpation. The variables that were correlated with length of time before return to sport included pain score at the time of injury, being forced to stop within 5 minutes of the onset of pain, painful resisted knee flexion, and length of injury.

    One of the limitations of the study is that the criteria for determining return to sport were determined by the individual physicians and PTs. But, the investigators note, while scientifically not optimal, this may better reflect the reality of patient care.

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Systematic Review: Physical Therapy in Hospice and Palliative Settings Supported by Limited Research

    A review of recent research on the role of physical therapy in hospice and palliative care supports the idea that physical therapy can go a long way toward improving patients' physical, social, and emotional well-being. The problem, according to authors, is that the research itself has a long way to go.

    In a systematic review published in the American Journal of Hospice & Palliative Medicine (abstract only available for free), authors reviewed 13 articles—mainly qualitative—that looked at the use of physical therapy among patients diagnosed with a critical or terminal illness. Authors focused on 5 major components addressed in the various studies—age of participants, types of physical therapy interventions used, assessment tools used, efficacy of treatment, and patient-reported satisfaction and quality of life. Authors of the study include Ahmed Radwan, PT, DPT, PhD.

    Age. Participants ranged in age from 17 to 95. Most subjects were 40-70 years old.

    Interventions. The most frequently discussed interventions were strengthening/therapeutic exercises, patient and family/caregiver education, balance and falls training, and transfer training.

    Assessment tools and outcome measures. Though a variety of outcome measures were used, the most common tools used in the studies were ones that rated patients' pain levels—mostly numeric scales; however, no single tool or measure was used in more than 1 study.

    Efficacy of treatment. "Throughout all of the 13 reviewed articles, it was reported that physical therapy resulted in improvements in a variety of aspects of patients' function and symptoms," authors write. Not surprisingly, most of the improvements were related to pain, although some studies noted improvements in mobility, activities of daily living, endurance, mood, fatigue, and lymphedema.

    Patient satisfaction. Among the studies reviewed, only 5 directly addressed satisfaction or quality of life. All found that these factors had improved.

    While the findings are encouraging, authors of the review also include a long list of limitations to their analysis, most having to do with the current dearth of information on the role of physical therapy in hospice and palliative care.

    Primary among the limitations is what authors believe is a general lack of quantitative research on the topic. When it comes to the reviewed studies themselves, authors cited limitations that include a lack of specificity around the types of treatment provided; multidisciplinary care approaches that, though "realistic," made it difficult to precisely identify the impact of physical therapy; a lack of discussion of treatment costs; high dropout rates; and the fact that every study used a different outcome measure.

    Despite those problems, authors believe that their review sheds some light on how physical therapy is used in hospice and palliative care, and the ways in which it can improve quality of life for patients and caregivers.

    "It is apparent that there is benefit in utilizing physical therapy in end-of-life and palliative care settings," authors write. "This study confirms that physical therapists serve a vital role in [these] settings and should be active members of the multidisciplinary team providing care for this critical patient population."

    APTA advocates for the use of physical therapy in hospice and palliative care, and offers a webpage devoted to the topic. Resources include guides, podcasts, and links to information from Medicare and Medicaid. In addition, PTNow's resources include a health care guideline on palliative care.

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Survey: 1 in 20 Children Have Problems with Balance or Dizziness

    In what they describe as the first-ever study among children in the US, authors of an epidemiology review estimate that 3.3 million children—about 1 in 20—suffer from some kind of dizziness or balance problem, with 600,000 experiencing symptoms that result in "moderate" or "very big" problems.

    The results are based on a probability sample of 10,954 children aged 3-17 years, by way of survey responses supplied by parents or caregivers. Respondents answered questions about whether, during the past 12 months, their children were bothered by vertigo, poor balance, poor coordination, frequent falls, light-headedness, or any other kind of dizziness or balance problems. Responses were then cross-referenced with other demographic and health information to create a picture of prevalence and potential risk factors. The full report is published in The Journal of Pediatrics (abstract only available for free).

    Among the findings:

    • Overall prevalence for dizziness and balance problems was 5.3% and increased with age, from 4.1% at 3-5 years to 7.5% for ages 15-17. Girls had a 5.7% prevalence, compared with boys' prevalence of 5.0%.
    • "Poor coordination" was the most often-reported symptom (46%), followed by light-headedness (35.1%), poor balance (30.9%), vertigo (29%), frequent falls (25%), and "other" (8.5%). Children were more likely to have 2 or more symptoms than a single symptom.
    • Among the children with balance and dizziness problems, 32.8% had received a diagnosis, a rate that increased to 59.6% for children with moderate to very big problems. Overall rates for being seen by a health care professional in the past year were 36%, and 71.6% among children who had moderate to very big problems.
    • Identified risk factors include being aged 12-17, household education less than high school, family income below the poverty level, low and very low birth weight, first steps without support at 15 months or later, and various developmental or illness conditions.
    • The most strongly associated risk factors, in order, were problems that limited a child's ability to crawl, walk, run, or play; frequent headaches/migraines; "other" developmental delays; seizures during the past 12 months; stuttering/stammering; hearing difficulty; and anemia during the past 12 months.
    • Low and very low birth weight was "significantly associated" with some, but not all, dizziness and balance symptoms—specifically, poor balance, poor coordination, and frequent falls, but not with vertigo or light-headedness. "This suggests that birth weight is more strongly associated with motor problems," authors write.
    • Prevalence of dizziness and balance problems among children with difficulty hearing was 20.9%. For children with vision problems (including those addressed by corrective lenses), prevalence was 14.4%.
    • The results are drawn from a survey funded by the National Institute on Deafness and Other Communication Disorders in 2012, and will be used as baseline data in the National Institutes of Health Healthy People 2020 initiative.

    Authors hope that the results will help with what they describe as a "poorly understood" health problem for a significant number of children in the US, and assert that the ways parents responded to the survey shed much light on the work that needs to be done.

    "Among the one-third of children in this study whose parents/caregivers reported they had been given a diagnosis, 49% replied that the dizziness and balance problems were due to 'other' unspecified causes," authors write. "This finding is not surprising. Almost 90% of children with balance disorders are categorized as 'unspecified dizziness,' indicating that the diagnostic accuracy and methods of physicians treating children with balance problems should be improved."

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Physical Therapy 'Ineffective' for PD? Headlines Overstate Study's Conclusions

    A recent study from England involving physical therapy, occupational therapy, and individuals with Parkinson Disease (PD) has generated plenty of dramatic headlines about physical therapy's supposed "ineffectiveness." But as is often the case with dramatic headlines, there's more to the story.

    The study in question, published in JAMA Neurology (abstract only available for free), aimed to evaluate the clinical effectiveness of individualized physical and occupational therapy for individuals with PD by comparing outcomes at baseline and 3 months among 381 participants who received treatment with an equally sized control group that didn't.

    Researchers found little to no difference in outcomes primarily based on the Nottingham Extended Activities of Daily Living (NEADL) scale, and secondarily based on the Parkinson Disease Questionnaire-39 and the EruoQol-5D, writing that "physiotherapy and occupational therapy were not associated with immediate or medium-term clinical improvements in [activities of daily living] or quality of life in mild to moderate PD."

    Headlines ensued. "Parkinson's patients may not benefit from physical therapy," wrote United Press International. "Physical, Occupational Therapy Ineffective in Parkinson," was how Medscape framed the study. "Millions of pounds wasted providing physiotherapy for Parkinson's say researchers," was the headline at the UK newspaper The Telegraph. Several other news outlets took a similar approach.

    While dramatic, the headlines may be off the mark. According to researcher and physical therapy professor Theresa Ellis, PT, PhD, NCS, the study may have more to say about a particular intervention model used in England than it does about the effectiveness of physical therapy on individuals with PD.

    Ellis identifies several issues that may not make the study suitable for generalization. Among them: a low dosage of physical therapy (median number of physical therapy sessions received was 4, meaning that half of all treatment participants received fewer than 4 sessions); widely variable expertise among the physical therapists (PTs) delivering services; the use of 38 different sites for interventions; a wide range of severity among participants; the use of an outcome measure (NEADL) that has not been validated for use in PD; and little attention paid to participants' follow-through, particularly in relation to any homework assigned. "Essentially, most participants had 1 to 2 therapy sessions followed by nothing over 15 months," Ellis said.

    "The very low dose of therapy—below what is typically provided in the US—and the absence of an ongoing home exercise program contribute substantially to the lack of improvement observed," Ellis said. "Other studies in Parkinson, in which larger doses of physical therapy were provided, reveal improvements in walking, functional mobility, and balance."

    Authors of the study admit that the number of sessions was relatively low, but argue that the dosage reflects common practice in England, and that other studies that incorporated more sessions yielded results similar to theirs. Still, they were careful to limit their conclusions only to the effectiveness of low-dose physical and occupational therapy that uses "an individual goal-setting approach" on patients with mild-to-moderate PD, and then only to short and medium-term benefits in activities of daily living or quality of life.

    According to Ellis, even those more narrow conclusions may be questioned. For Ellis, 1 potential problem is the fact that about a third of the patients in the study were in the more severe stages of PD. Another issue: among the mild-to-moderate group, "a substantial number scored at the upper limits of their measure [at baseline], making it impossible to show any progress in these participants," Ellis said.

    While authors of the study hold to their conclusions about the effectiveness of low-dose physical and occupational therapy for individuals with mild-to-moderate PD, they acknowledge that more research is needed—particularly around "the development and testing of more structured … therapy programs in patients with all stages of PD"—the kind of nuance that apparently isn't the stuff of headlines.

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Supervised Exercise (Still) Beneficial for Knee OA

    Most clinical practice guidelines recommend exercise as a first-line treatment for stiffness and pain in knee osteoarthritis (OA), and an updated Cochrane systematic review published in the British Journal of Sports Medicineindicates there's even more reason to do so.

    The authors examined 54 randomized clinical trials (RCTs) involving over 5,000 participants to determine the effectiveness of land-based exercise in improving pain, physical function, and quality of life in individuals with knee OA. Participants who completed exercise programs experienced moderate improvement in pain and physical function immediately after treatment, about the same as that of analgesics and nonsteroidal anti-inflammatory drugs.

    While pain relief from exercise was still significant at 2 to 6 months after treatment, the effect was smaller, and benefits were minimal after 6 months. Physical function improvement was "better sustained," according to authors, producing small yet significant results even at 6 months.

    New to this review was an analysis of data related to quality of life, where pooled results of 13 studies showed a statistically significant benefit of exercise immediately post treatment—"equivalent to an improvement of four points … on a 0–100-point scale," authors write.

    The review included studies that compared “any land-based non-perioperative therapeutic exercise regimen” with a non-exercise control group. This wide variation in exercise type, duration, frequency, and intensity didn't allow the authors to evaluate the benefits of one program over another. Also, these findings only pertain to strengthening or weight-bearing exercises—the authors found no studies that examined high-impact exercise as an intervention for knee OA.

    Researchers did find that supervised individual exercise programs were more effective than group exercise or home-based programs, with the authors writing that “the magnitude of immediate treatment effects of exercise on pain and physical function increases with the number of face-to-face contact occasions with the healthcare professional.”

    The new review updated an earlier Cochrane study on the topic completed in 2008. That study pointed to the positive effects of exercise for pain and physical function in individuals with knee OA.

    Eight years and 22 studies later, the evidence still supports that idea.

    "Health care professionals and people with OA can be reassured that any type of exercise program that is performed regularly and is closely monitored by healthcare professionals can improve pain, physical function and quality of life related to knee OA in the short term," they write.

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Separate Studies Support Exercise to Treat, Prevent LBP

    Research continues to support the effectiveness of exercise when it comes to low back pain (LBP)—not only as a way to treat existing LBP, but as a way to prevent it.

    A new systematic review and meta-analysis in JAMA Internal Medicine (abstract only available for free) assessed research into the value of exercise as a way to prevent episodes of LBP. It found that exercise alone was linked to a 35% reduction in risk, while a combination of exercise and education was associated with a 45% risk reduction for up to 1 year. The use of exercise was also found to result in a 78% reduction in sick leave for LBP.

    The review was based on 23 published studies involving 30,850 participants, and looked at the preventive qualities not only of exercise and education (both combined and separately), but also of back belts and orthotic shoe insoles. In the end, only exercise was linked to a reduced risk of LBP: authors of the study found that while education helped to further reduce that risk when combined with exercise, education alone didn't seem to have much effect.

    The problem: the risk reduction benefits of exercise "disappeared" after 1 year. Authors attribute the dropoff to some individuals discontinuing the exercise program.

    "The finding raises the important issue that, for exercise to remain protective against future LBP, it is likely that ongoing exercise is required," authors write. "Prevention programs focusing on long-term behavior change in exercise habits seem to be important."

    Also Works for Treatment of Chronic LBP
    While the JAMA authors focused on prevention, researchers whose findings were included in a recently updated Cochrane review ( currently, abstract only available for free; complete article will be made available via APTA's ArticleSearch in the coming weeks) aimed at evaluating the evidence supporting exercise—specifically motor control exercise (MCE) to coordinate and stabilize deep trunk muscles—as a treatment for chronic LBP.

    Their conclusion was that MCE "probably provides better improvements in pain, function, and global impression of recovery" than minimal intervention at all follow-up periods (these varied by study), and that it "may" provide better improvements than exercise and electrophysical agents. Authors found results to be about the same when it came to MCE versus manual therapy, and MCE versus "other forms of exercise." The analysis was based on 29 trials involving 2,431 participants.

    "Given the minimal evidence that MCE is superior to other forms of exercise, the choice of exercise for chronic LBP would probably depend on patient or therapist preferences, therapist training, costs, and safety," authors write.

    'Uncommonly Prescribed'
    In an invited commentary on the JAMA article, authors Timothy Carey, MD, and Janet Freburger, PT, PhD, focus on the LBP prevention study, but the main point they raise—the need for more widespread use of exercise prescriptions—could apply to the MCE study as well.

    "If a medication or injection were available that reduced LBP recurrence by [the amounts cited in the JAMA article], we would be reading the marketing materials in our journals and viewing them on television," commentary authors write. "However, formal exercise instruction after an episode of LBP is uncommonly prescribed by physicians." They describe the gap as part of a pattern in the treatment of musculoskeletal problems "in which effective but lower-technology and often lower-reimbursed activities are underused."

    Carey and Freburger describe several barriers to more common use of exercise instruction that include a lack of consensus around "standard, efficient, and acceptable bundled intervention" for LBP, unclear understandings of the role of patient education, questions about how best to motivate patients, a paucity of cost-effectiveness studies, hesitancy among payers to support exercise programs, and a shortage of clinicians "able to describe, with confidence, the benefits of easily accessible exercise programs to diverse patient populations."

    "To address these barriers, payers, professional societies, consumers, and members of health care delivery systems will need to work together," write Carey and Freburger, adding that if they do, "the potential benefits to the health system, patients, and employers are substantial."

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    'First Fruits' of APTA Program Provides Clinical Guidelines on VTE

    An APTA clinical practice guideline (CPG) development process that began in 2012 is now paying off, with the upcoming publication of a new CPG on the role of the PT in management of patients with venous thromboembolism (VTE). The guidelines were jointly produced by the APTA Cardiovascular and Pulmonary Section and the association's Acute Care Section, with funding and support provided by APTA.

    The 32-page document (.pdf) includes algorithms for screening for risk of VTE, determining the likelihood of a lower extremity deep vein thrombosis (LE DVT), and mobilizing patients with LE DVT, as well as 14 "action statements" that outline best practices. First e-published ahead of print in October in Physical Therapy (PTJ), APTA's research journal, a draft of the CPG was shared during the 2015 APTA Combined Sections Meeting. The final version, set for publication in the February issue of PTJ, will be used to develop pocket guides, patient brochures, podcasts, and "checklists and sample evaluation forms incorporating the recommendations of the CPG,” according to guideline authors.

    The CPG was developed through a program, started in 2012, in which APTA facilitates (and provides funding for) the creation of guidelines in partnership with sections. The assistance includes workshops and other training, and helps to shepherd the CPG all the way to final publication. The importance of CPGs—and APTA's role in their development—was featured as part of APTA's series "Physical Therapy: A Profession in Transformation" published in 2015. Also produced through the APTA program: a clinical guidance statement on the management of falls in community-dwelling older adults, developed by the Academy of Geriatric Physical Therapy.

    "This CPG and the falls guidance statement are the first fruits in what we believe will be a series of high-quality resource documents that are focused specifically on connecting PTs and PTAs with the best available research, and making it easy for them to put that research into practice," said APTA's Anita Bemis-Dougherty, PT, DPT, MAS, vice president in the Department of Practice. "We're looking forward to much more in the months and years to come."

    The CPG was written by Ellen Hillegass, PT, PhD, FAPTA, CCS, Michael Puthoff, PT, PhD, GCS, Ethel Frese, PT, DPT, CCS, Mary Thigpen, PT, PhD, Dennis Sobush, PT, MA, DPT, CCS, and Beth Auten, MLIS, MA, AHIP.

    Study: FES and Fast-Walk Training May Help Keep Individuals Walking After Rehab Ends

    Authors of a new study say that for individuals poststroke, community walking ability may have more to do with reducing the energy cost of walking, and less to do with changes to timed walking evaluations such as the 6-minute walk test (6MWT). And they believe that functional electrical stimulation (FES) coupled with rehabilitation training at faster speeds can play a big role in helping to decrease that energy cost.

    The study focused on 50 individuals who had experienced a stroke 6 or more months earlier and demonstrated "observable gait deficits," but were able to walk without support for at least 6 minutes. Participants were assigned to 1 of 3 12-week rehabilitation programs: gait training at self-selected speeds (SS), gait training at fast speeds (FS), or gait training at fast speeds with the addition of FES (FastFES). Sessions were held 3 times a week for 36 weeks and comprised 5 bouts of 6 minutes of treadmill walking, followed by 1 bout of 6 minutes of overground walking (with breaks in-between). The training speeds of the FS and FastFES groups were based on each participant's maximum overground walking speed (MWS).

    While the SS and FS groups received similar sessions (albeit at different speeds), the FastFES group also received FES for 15 of the 30 minutes of the treadmill walking sessions. The FES was targeted to the paretic ankle plantarflexors during late stance phase and dorsiflexors during swing phase, triggered by switches attached to the sole of the participant's shoe, in an alternating pattern of 1 minute on and 1 minute off. Results of the study were published in Neurorehabilitation and Neural Repair (abstract only available for free). Authors of the study include APTA members Darcy S. Reisman, PT, PhD, and Stuart Binder-Macleod, PT, PhD, FAPTA.

    To evaluate the energy cost (EC) of walking, participants' oxygen consumption was measured after the participants walked overground at their comfortable walking speed for 5 minutes at baseline, at the conclusion of the 12-week program, and again 3 months later. Researchers found that the FastFES group reduced the energy cost of walking by 24%—a change that researchers describe as "substantial" given that at the beginning of the study, all participants averaged 61% more oxygen consumption per meter ambulated than healthy older adults.

    Authors of the study also conducted oxygen consumption tests after ambulation at fast walking speeds for the FS and FastFES groups. They found that the FastFES group reduced energy cost at that speed by 19%, while the group that did not receive FES recorded no significant reduction—"additional evidence supporting [the use of FES] during gait training," they write.

    Yet despite the reduction in energy costs, the FastFES group did not significantly outperform the other groups in the 6MWT, authors noted. All 3 groups improved, with both the FS and FastFES groups recording improvements slightly above the minimal detectable change. Authors write that this apparent "disconnect" between improvements in energy expenditure and 6MWT results "suggests that the 6MWT may not be sensitive to changes in EC" and that "persons poststroke may improve 6MWT performance through metabolically expensive compensatory mechanisms."

    That "disconnect" also prompted researchers to question how well the 6MWT really correlates to community walking after a stroke.

    "Walking performance in ecological contexts may be markedly different than what is observed during the 6MWT because individuals may not engage in long-distance walking-related activities that would necessitate frequent rests," authors write. "EC, in contrast, has been posited to be a variable able to bridge the disconnect between clinical measures of walking function and real-world walking performance."

    Authors acknowledged that their study has several limitations, among them the fact that participants were not blinded to the interventions used and that factors other than participants' baseline walking speed may have affected results. Additional studies, with larger sample sizes, would help to clarify whether these limitations had an effect, they write.

    Still they argue, results from this study show that FES coupled with faster-speed training does increase the energy efficiency of walking for individuals poststroke and that this important improvement may be overlooked by "gross measurers of walking function" such as the 6MWT. "A better understanding of how reductions in the energy cost of walking contribute to improved community walking participation is needed," they write.

    The value of FES was the subject of the 2015 Maley Lecture presented by Gad Alon, PT, PhD, during APTA's NEXT Conference and Exposition. In that lecture, Alon advocated for personalized rehabilitation programs in which FES is "a standard-of-care intervention option in rehabilitation medicine."

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Is Physical Therapy Cost-Effective? It's Complicated

    A new systematic review takes on the question "is physical therapy cost-effective?" and responds with a definitive "it depends." But the equivocation isn't about whether physical therapy treatment actually makes a difference in patients as it is about the definition of "cost-effective"—and particularly, whether that definition includes societal costs.

    According to authors of the review, e-published ahead of print in the December issue of Physical Therapy (PTJ), APTA's research journal, there is little doubt that physical therapy improved health in nearly all 18 studies reviewed. But the question of whether the therapy was cost-effective is a little harder to pin down, with authors of this study applying a fairly rigorous definition of "cost-effectiveness" and finding that about half the studies cleared the bar.

    Researchers analyzed studies between 1998 and 2014 that compared physical therapy with usual care only, as well as studies that compared physical therapy added to usual care with usual care only. Of the 18 studies, 13 were classified as focusing on musculoskeletal issues, 2 were linked to "internal conditions" (urinary incontinence and intermittent claudication), 2 were related to neurological conditions, and 2 to what authors called "internal medicine" (falls prevention and the intermittent claudication study, which was also included in the internal conditions category). Studies reviewed were limited to only those that included data that would allow for an analysis of cost-effectiveness.

    Authors of the study found that in the 8 physical therapy vs usual care settings, the physical therapy approach was cost-effective in 5 studies—4 of those related to musculoskeletal conditions. Among the 11 studies that compared physical therapy plus usual care with usual care only, the addition of physical therapy was cost-effective in 4 of 11 studies.

    Authors of the study arrived at a cost-effectiveness determination by analyzing the cost difference between the intervention and the usual care divided by the difference in health outcome provided by the 2 treatments. Authors explain that this could at times be a difficult thing to nail down, as several studies didn't analyze data this way, and the manner in which outcomes are measured can vary.

    In the end, authors employed what they describe as a "very strict" definition of cost-effectiveness.

    "To be cost-effective, an intervention has to be cheaper than the standard treatment," authors write. "Usually, a more expensive intervention is accepted if additional costs are not too high. However, there is no clear defined cutoff above which costs should be considered as too high, hence our choice."

    That strict definition helped with the analysis, but doesn't necessarily capture the idea that physical therapy can be even more cost-effective when societal costs and long-term outcomes are factored in, according to the analysis.

    "Physical therapy sessions added to usual care increases health care costs," authors write. "However, when the analysis includes societal costs, such as costs related to absence from work, then the total costs are not higher for the group who received physical therapy added to usual care …. Therefore, cost-effectiveness analyses should not be limited to health care costs; total costs which consider both aspects are more relevant." Authors also noted that the strongest links to the cost-effectiveness of physical therapy—musculoskeletal conditions—are in an area of health care that affects large populations and generates considerable costs over time.

    Can a PT's Personality Traits Affect Outcomes for Patients With Chronic Disease? This Study Says Yes

    Want to improve physical therapy outcomes for patients with chronic diseases? Have a "calmer, more relaxed, secure, and resilient" personality, according to Dutch researchers.

    In an article published in the December 16 issue of BioMed Central's Health Services Research, researchers from the Netherlands compared treatment outcomes from patients with chronic disease such as arthritis, cardiovascular disease, cancer, chronic respiratory disease, and diabetes with the ways their treating physiotherapists (PTs) scored on "The Big 5" Index (BFI), a widely used personality test (you can take the test here).

    Authors of the study hoped to get a full picture of how the 5 personality dimensions measured in the test—neuroticism, agreeableness, conscientiousness, extraversion, and openness to experiences—played into patient outcomes. In the end, they found that only neuroticism seemed to have an impact.

    The neuroticism scale is essentially a measure of emotional stability, impulse control, and the tendency to express unpleasant emotions. A lower neuroticism score indicates "being more calm, relaxed, secure, and hardy," according to the study's authors.

    What researchers found was that worse patient outcomes seemed to be linked to PTs with a higher neuroticism score. The lack of any measurable link between the other personality dimension scores and outcomes "contradicts previous research in psychotherapy suggesting that traits including being empathetic, cautious, non-intrusive, respectful, being able to adjust, and exuding warmth … improve treatment outcomes," authors write.

    Treatment outcomes were measured using the Numeric Rating Scale (NRS), a "widely used Dutch outpatient practice tool for evaluating treatment effect by looking at the course of complaints during treatment." Scores were recorded at the beginning and end of physical therapy.

    In addition to scores on the personality test, researchers also looked at whether the PT experienced a "major life event" (a yes/no question with no accompanying explanation from the PT) during the past 3 years, as well as demographic features of the PTs. They found that having experienced a major life event correlated to better patient outcomes, as did being a male PT, but cited few reasons for the connections.

    Authors admit that the voluntary nature of the study led to a significant amount of missing data and relatively small PT sample size (39). They also acknowledge that there may be better personality tests but that the BFI was chosen "for practical reasons, since it does not take too long for a therapist to fill out."

    Despite these limitations, authors assert that their study supports the idea that "if a therapist does not feel mentally stable, it is reasonable to assume that this might have consequences for his or her attitude when interacting with the patient."

    Authors suggest that more research into personality dimensions could underscore the importance of self-reflection among providers—and the development of educational components that strengthen this ability.

    "Tools like communication skills training might be used as supplement to reflection, but [we] believe that self-awareness and reflection training during the early stages of study are needed before these tools can be used effectively," they write.

    APTA emphasizes the importance of prevention, wellness, and disease management, and offers resources for physical therapists (PTs) and their patients at MoveForwardPT.com in addition to online continuing education on disease management models. This year, the APTA House of Delegates emphasized the PT's important role in chronic disease management and treatment by adopting an official position titled "Health Priorities for Populations and Individuals" (RC 11-15).

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.