Physical Therapy

James, Khara A; von Heideken, Johan; Iversen, Maura D

doi: 10.1093/ptj/pzab195pmid: 34730830

ObjectiveThe purpose of this study was to describe adverse events (AEs) and dropouts (DOs) in randomized controlled trials of therapeutic exercise for hip osteoarthritis (HOA) and to identify whether Consolidated Standards of Reporting Trials (CONSORT) guidelines were followed.MethodsThe Cochrane Library, Embase, PubMed, and CINAHL databases were searched. Randomized controlled trials of therapeutic exercise for HOA published in English from January 1, 1980 to August 1, 2020 were included. Studies were excluded if other interventions were provided, if participants had previous hip arthroplasty, or if AEs and DOs for HOA participants were not reported separately. The internal validity of each study (Physiotherapy Evidence Database [PEDro] scoring) was assessed, participant and intervention characteristics were extracted, and the existence of a clear statement and reasons for AEs and DOs was reported. Descriptive statistics characterized results. Data heterogeneity prohibited the use of meta-analysis.ResultsFourteen studies (mean PEDro score = 7.4; range = 6-10) from 10 countries were included, with 707 participants exercising. Exercise intensity was unspecified in 72.2% of exercise arms. Six studies (42.9%) included a statement of AEs, and 32 AEs were reported. All studies had a DO statement, but 29.0% of DOs occurred for unknown reasons. Six studies (42.9%) gave reasons for DOs that could be classified as AEs in 9 participants; 41 participants (5.8%) experienced exercise-related AEs.ConclusionReports of AEs were inconsistent, some DOs were potentially misclassified, and primary components of exercise interventions were frequently unreported. Despite these limitations, the overall low number of nonserious AEs suggests that the exercise-related risk of harm is minimal for individuals with HOA.ImpactUnderstanding the risk of harm associated with exercise for HOA can better inform safe dosing of exercise, clinical implementation, and replicability. Informative, consistent reporting of AEs, DOs, and exercise is needed. Greater use of the CONSORT harms-reporting checklist is warranted.

Smith, Lesley E; Annis-Young, Janine E; Kimberley, Teresa Jacobson

doi: 10.1093/ptj/pzab241pmid: 34850205

The rehabilitation trinity of physical therapy, occupational therapy, and speech-language pathology is the foundation of neurologic recovery. Collaboration among these 3 disciplines supports the common goal of optimizing recovery. Although the sharing of expertise has long been considered best practice, the specifics of interprofessional collaboration deserve deeper consideration. In the perspective article by Schwab and colleagues,1 the authors identify the lack of collaborative research between physical therapy and speech-language pathology, despite the potential reciprocal influences of the therapies and the complementary goals. We applaud the authors’ effort in initiating an important conversation. A core focus of the article is the benefit of interprofessional collaboration through cotreatment. We believe that the focus on cotreatment, however, is a missed opportunity to mobilize the physical therapy profession to investigate the potential impact of more clinically realistic collaborative approaches with their speech-language pathology counterparts. Although cotreatment has its place in neurological rehabilitation, there are also considerable limitations, including (1) practical barriers to implementation in most clinical settings and (2) a reduction in overall therapy duration, which may limit neurorecovery opportunities. The clinical impracticality of the cotreatment focus in this article risks losing the attention of a large part of the authors’ intended audience. Reimbursement guidelines and productivity demands are significant barriers to recommending cotreatment in clinical practice in the United States. If 2 disciplines are treating a patient concurrently, the billable time is divided between the clinicians. Occasional cotreatments may be absorbable into a facility’s budget but would be financially unsustainable if they occurred with any regularity. The resultant reduced productivity might adversely impact performance metrics. Furthermore, the logistics of scheduling clinicians simultaneously undermines implementation. Another limitation of cotreatment is that total treatment time and intensity are reduced, which is counter to current thinking on optimal practice for neurorecovery. Therapists across all disciplines struggle to achieve treatment goals with limited lengths of inpatient stays or outpatient visits. Thus, a further reduction in active therapy time is undesirable. Carryover of collaborative practice from one discipline’s session to another’s, when compared with cotreatment, results in increased repetition and provides opportunities to explore strategies in various contexts, addressing additional neuroplasticity principles of specificity, saliency, and transference. Collaboration between physical therapists and speech-language pathologists allows for the identification of patients who would benefit most from specific rehabilitation approaches, thereby individualizing treatment and maximizing the potential for optimal recovery. For example, a physical therapist might use a trial-and-error approach that allows failure and problem solving to happen as a key component of motor learning in a patient who has been determined by a speech-language pathologist to have adequate executive function. Another patient, meanwhile, might be identified as having more compromised cognitive skills and therefore might benefit from “errorless” learning as part of the physical therapist’s approach. By increasing the opportunities for supported learning without the direct “expert” support, long-lasting functional change is promoted, yet does not require both disciplines to be present simultaneously during a treatment session. More discussion is needed regarding how to utilize each other’s expertise to scaffold each discipline’s respective treatment sessions for greater efficacy from both research and clinical perspectives. There is opportunity for discussion at multiple levels. Both the American Physical Therapy Association and the American Speech-Language-Hearing Association are involved with organizations such as the Interprofessional Education Collaborative, which promotes interprofessional education and practice initiatives. Substantial progress has been made toward framing the dialogue (ie, collaboration is good and how to collaborate effectively), but the next steps need to point toward action and the integration of ideas—moving on from how to provide patient-centered care as an interdisciplinary team to how to promote targeted interprofessional collaborative interventions delivered to patients with identified deficits. For example, how can breathing patterns or self-vocalization strategies identified by speech-language pathologists be used by physical therapists when working on postural control or functional training? How can intensity of activity during a physical therapy session “prime” responsiveness to interventions in the subsequent speech-language pathology session? Likewise, opportunities for exposure to each discipline’s expertise in professional (entry-level) education curricula should be discussed. At the MGH Institute of Health Professions pro bono Impact Center for Health and Wellness Promotion, student physical therapists and speech-language pathologists (along with student occupational therapists and nurses) observe each other’s treatment sessions with mutual clients. The knowledge acquired not only is used to support subsequent individual sessions but can help identify future opportunities for collaboration. Professional education is important to lay the foundation for the awareness of interprofessional collaborative benefit, but how can the collaboration be incorporated into clinical practice within the fiscal boundaries of the US health care system? Does it start with new hire orientation? Is it discussed at in-services or during annual reviews? At Spaulding Rehabilitation Hospital Cape Cod, for instance, electronic medical records facilitate, encourage, and coordinate communication of collaborative efforts and opportunities. Embracing technology to help overcome collaborative challenges has been well received by all parties (clinicians, patients, and administrators.) To be impactful, all well-intended initiatives need to be empowered by evidence, which has not been well explored within our fields. Nevertheless, our professions should consider publishing current “Best Practice” guidelines to catalyze deeper exploration of the “PT-SLP” relationship. We are in full agreement with Schwab et al that there are reciprocal influences between speech-language pathology and physical therapy. There is an immense opportunity for interprofessional work to explore these influences and to capitalize on the complementary contributions of each discipline. We further recommend investigation into broader and more clinically feasible approaches to support the translation of evidence into physical therapist and speech-language pathologist practice and to ultimately optimize our patients’ neurologic recovery and participation in society. References 1. Schwab SM , Dugan S, Riley MA. The reciprocal influence of mobility and speech-language: advancing physical therapy and speech therapy cotreatment and collaboration for adults with neurologic conditions . Phys Ther . 2021 ; 101 :pzab196. https://doi.org/10.1093/ptj/pzab196. Google Scholar OpenURL Placeholder Text WorldCat Author notes Dr Kimberley is a PTJ Editorial Board member © The Author(s) 2021. Published by Oxford University Press on behalf of the American Physical Therapy Association. All rights reserved. For permissions, please email: [email protected] This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

Van Wyngaarden, Joshua J; Archer, Kristin R; Spencer, Alex; Matuszewski, Paul E; Brightwell, Benjamin; Jacobs, Cale; Noehren, Brian

doi: 10.1093/ptj/pzab194pmid: 34403485

ObjectiveDisability is common after lower extremity fracture (LEF). Although psychosocial factors have been associated with patient-reported outcomes after LEF, they have not been associated with objective measures of function. Aberrant gait patterns are important markers of function, but are poorly defined after LEF. The primary purpose of this study was to explore whether pain catastrophizing and fear of movement 6 weeks after surgery were associated with injured limb loading outcomes and 6-minute walk test (6MWT) distance 12 months after femur or tibia fracture. The secondary purpose was to determine if limb loading characteristics differed between injured and uninjured limbs.MethodsAt 6 weeks after LEF, patients completed validated measures of pain catastrophizing, fear of movement, and depression. At 12 months, patients completed a 6MWT while wearing instrumented insoles that recorded the limb loading outcomes of stance time, impulse, and loading rate. Bivariate correlations assessed how patient and psychosocial characteristics at 6 weeks were associated with injured limb loading outcomes and 6MWT distance. Multivariable regression analyses were performed to determine if psychosocial variables were associated with each outcome after controlling for depression and patient demographic and clinical characteristics. Finally, paired t tests compared limb loading outcomes between limbs.ResultsForty-seven participants completed the 6MWT at 12 months (65%), and 38 completed the 6MWT with the instrumented insoles. Fear of movement carried a poor relationship (r = 0.11–0.32) and pain catastrophizing a moderate relationship (r = 0.46–0.54) with 12-month outcomes. The regression results indicated that pain catastrophizing continued to be associated with all outcomes. Finally, the injured limb had significantly lower limb loading outcomes than the uninjured limb at 12 months (Cohen d = 0.54–0.69).ConclusionPain catastrophizing early after LEF was associated with impaired limb loading and 6MWT distance at 12 months.ImpactImpaired limb loading persists 12 months after LEF. Further research is needed to determine whether rehabilitative efforts focused on pain catastrophizing can restore limb loading after LEF.

Hoogeboom, Thomas J; Jette, Alan M

doi: 10.1093/ptj/pzab235pmid: 34865127

Evidence-based practice (EBP) dictates that decisions about health care are based on patient values, clinical expertise, and the best available, relevant evidence.1 But what actually constitutes “best” in rehabilitation interventional research evidence? The fundamental view of the EBP movement is that not all evidence offers the same degree of support to make causal claims about a clinical intervention.2 To identify the best evidence from the huge volume and diversity of available evidence, evidence hierarchies are used. An evidence hierarchy is a heuristic used to rank the relative strength of results obtained from scientific research. One of the best-known evidence hierarchies is the evidence pyramid. This pyramid typically holds systematic reviews and meta-analyses of randomized controlled trials (RCTs) at the top, single RCTs near the top, nonrandomized cohort and case–control studies lower, and fundamental studies and case reports near or at the bottom. The general idea behind the evidence pyramid is that the best available evidence is the evidence closest to the top. In this editorial, we argue that the application of evidence hierarchies to distinguish bad and good evidence might actually be harmful to advancing EBP. But, before we get to that, we want to introduce you to Procrustes. According to ancient Greek mythology, Procrustes was a rather remarkable innkeeper. Procrustes, whose name translates into “he who stretches,” managed an inn on the side of the road. In this inn, he invited passing strangers to enjoy a copious meal and a night’s rest in his very special bed. He told his guests that his bed had a unique property: the length of the bed would always exactly match the person who slept in it. What Procrustes failed to mention, however, was how this bed was tailored to a guest’s length. Rather than adjusting the bed to the length of his guest, Procrustes would adjust the length of his guests to his bed. If guests were too short, Procrustes would stretch them on the rack. If guests were too long, Procrustes would cut off their legs. None of Procrustes’s guests survived the night, and he would rob his victims afterwards. According to the Encyclopedia Britannica,3 the Procrustean bed “has become proverbial for arbitrarily—and perhaps ruthlessly—forcing someone or something to fit into an unnatural scheme or pattern.” The evidence pyramid, which nowadays comes in many shapes and forms, might be an example of a Procrustean bed.4–6 On the one hand, the idea behind these hierarchies is appealing; they are intuitive and easy to understand, and, above all, they help to easily “weed out” the bad from the good intervention research evidence. On the other hand, the overtly strict and inflexible nature of these hierarchies might actually harm the thing we want to nurture. Over the years, several philosophers and researchers have questioned the utility of using evidence hierarchies for a wide range of reasons.7–10 We highlight 3 arguments against the use of hierarchies. Hierarchies Are Inherently Simplistic Hierarchies are inherently simplistic, as they categorize quality of research evidence primarily on the basis of a study’s design. Ask yourself, does a poorly designed and conducted RCT produce “better evidence” than a well-designed and performed case–control study? There are scenarios where this isn’t the case. To adequately determine the quality of evidence from a study, the conduct and detailed description of the performed research should be weighed against the specific research question posed as well as the potential for its significance and impact. We believe that such a quality assessment should prevail over judging the quality of evidence based on the general name of the study design, especially knowing that researchers are notoriously poor at adequately naming their study designs.11 Hierarchies Over-Appreciate Internal Validity Hierarchies over-appreciate internal validity of a study’s design and largely neglect its external validity. An internally valid study confers a high probability of truth on the result of the study, whereas external validity reveals the degree to which the results established in the study will be true elsewhere. Alas, these 2 concepts are not independent and cannot be jointly maximized in a single study.9,12 Due to hierarchical thinking and subsequent study selection, external validity can suffer at the expense of internal validity. For example, a guideline panel ignores, due to hierarchical thinking, a large cohort study that contradicts a well-conducted but very selective trial. The latter might reduce the applicability of the research for the whole target population or even, to put it in Procrustes’s vocabulary, maim the potential effectiveness of treatment as a result of overstandardizing the studied intervention.13,14 Although it is never a good idea to use a single study to inform decision making in practice,7 systematically reviewing multiple studies won’t necessarily solve the problems of reduced external validity,15 especially when we cling to hierarchical thinking—which brings us to the third point. The Use of Hierarchies Can Lead Us to Discard Valuable Evidence The use of hierarchies can lead us to discard valuable, complementary evidence that might be useful for decision making. Perhaps the most important question that health care research aims to address is: “Is this intervention safe and efficacious for this person?” However, there is not one single research design that can answer all relevant research questions about a rehabilitation intervention. Different types of evidence are required to answer different types of research questions, such as an intervention’s timeliness, equity, cost-effectiveness, or patient centeredness.16 When we systematically review evidence, we typically just try to answer one research question: “Is this intervention efficacious somewhere?” (ie, in a controlled experimental setting). Evidence hierarchies lack a methodological inclusiveness to review all the evidence relevant to answer that overall research question. The notion that one research question is “better,” “more valuable,” or “stronger” than the other is misleading, as is the notion that the answers to more deductive questions produce “better” or “stronger” evidence. Different research simply produces different answers and diverse knowledge.9 Regardless, many of the published systematic reviews still answer very narrow questions related solely to the efficacy of interventions. One might argue, “Aren’t you being unnecessarily harsh about a practical tool?” or “Shouldn’t we perceive these hierarchies more like guides rather than tools?”17 This seems logical—except for the fact that nowadays nearly every systematic review or guideline in the medical sciences uses some form of evidence hierarchy, consciously or unconsciously. The one-size-fits-all approach of evidence hierarchies makes us disqualify useful evidence, thereby robbing from us our most precious ambition, which is to determine whether a rehabilitation intervention is valuable for that new client in front of us. We need to start tailoring the “bed” to meet our needs, rather than the other way around. In the ancient Greek myth, Procrustes was brought to justice by Theseus, son of Poseidon. We realize PTJ plays an important role in bringing our own Procrustes to justice. The editors and Editorial Board, therefore, welcome a wide range of research designs related to our rehabilitation interventions. In addition to clinical trials, clinical trial protocols, and systematic reviews of clinical trials, PTJ publishes a range of research using cohort, case‐control, and cross-sectional designs; single-subject designs; diagnostic studies; implementation investigations; feasibility pilot studies; qualitative studies; and measurement psychometric investigations. We believe that all designs contribute to the growing evidentiary base of physical therapy and rehabilitation clinical interventions. Acknowledgments Dr Jette and Dr Hoogeboom thank Sijmen Hacquebord for introducing them to the story of Procrustes. References 1. Dawes M , Summerskill W, Glasziou P, et al. Sicily statement on evidence-based practice . BMC Med Educ . 2005 ; 5 : 1 – 7 . Google Scholar Crossref Search ADS PubMed WorldCat 2. Howick JH . The Philosophy of Evidence-Based Medicine . Oxford, United Kingdom : BMJ Books/Wiley-Blackwell ; 2011 . Google Scholar Crossref Search ADS Google Preview WorldCat COPAC 3. The Editors of Encyclopaedia Britannica . Procrustes. Encyclopedia Britannica . Published July 20 , 1998 . Updated January 4, 2011 . https://www.britannica.com/topic/Procrustes. 4. Haynes RB . Of studies, summaries, synopses, and systems: the “4S” evolution of services for finding current best evidence . ACP J Club . 2001 ; 134 : A11 – A13 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 5. Guyatt GH , Oxman AD, Vist GE, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations . BMJ . 2008 ; 336 : 924 – 926 . Google Scholar Crossref Search ADS PubMed WorldCat 6. Alper BS , Haynes RB. EBHC pyramid 5.0 for accessing pre-appraised evidence and guidance . Evid Based Med . 2016 ; 21 : 123 – 125 . Google Scholar Crossref Search ADS PubMed WorldCat 7. Glasziou P , Vandenbroucke JP, Chalmers I. Assessing the quality of research . BMJ . 2004 ; 328 : 39 – 41 . Google Scholar Crossref Search ADS PubMed WorldCat 8. Walach H , Falkenberg T, Fønnebø V, Lewith G, Jonas WB. Circular instead of hierarchical: methodological principles for the evaluation of complex interventions . BMC Med Res Methodol . 2006 ; 6 : 29 . Google Scholar Crossref Search ADS PubMed WorldCat 9. Walach H , Loef M. Using a matrix-analytical approach to synthesizing evidence solved incompatibility problem in the hierarchy of evidence . J Clin Epidemiol . 2015 ; 68 : 1251 – 1260 . Google Scholar Crossref Search ADS PubMed WorldCat 10. Cartwright N . Are RCTs the gold standard? BioSocieties . 2007 ; 2 : 11 – 20 . Google Scholar Crossref Search ADS WorldCat 11. Lang TA , Stroup DF. Who knew? The misleading specificity of “double-blind” and what to do about it . Trials . 2020 ; 21 : 697 . Google Scholar Crossref Search ADS PubMed WorldCat 12. IntHout J , Ioannidis JP, Borm GF. Obtaining evidence by a single well-powered trial or several modestly powered trials . Stat Methods Med Res . 2016 ; 2 : 538 – 552 . Google Scholar OpenURL Placeholder Text WorldCat 13. Dörenkamp S , Mesters EPE, Nijhuis-van der Sanden MWG, Teijink JAW, de Bie RA, Hoogeboom TJ. How well do randomized controlled trials reflect standard care: a comparison between scientific research data and standard care data in patients with intermittent claudication undergoing supervised exercise therapy . PLoS One . 2016 ; 11 : e0157921 . Google Scholar Crossref Search ADS PubMed WorldCat 14. Hoogeboom TJ , Kousemaker MC, van Meeteren NL, et al. I-CONTENT tool for assessing therapeutic quality of exercise programs employed in randomised clinical trials . Br J Sports Med . 2020 ; 55 : bjsports-2019 – bjsports-101630 Online ahead of print . Google Scholar OpenURL Placeholder Text WorldCat 15. Kittelson AJ , Loyd BJ, Graber J, et al. Examination of exclusion criteria in total knee arthroplasty rehabilitation trials: influence on the application of evidence in day-to-day practice . J Eval Clin Pract . 2021 . https://doi.org/10.1111/jep.13564 Online ahead of print . Google Scholar OpenURL Placeholder Text WorldCat 16. Committee on Quality Health Care in America , Institute of Medicine . Crossing the Quality Chasm . Washington, DC : National Academy Press ; 2001 . Google Scholar PubMed OpenURL Placeholder Text Google Preview WorldCat COPAC 17. Shaneyfelt T . Pyramids are guides not rules: the evolution of the evidence pyramid . Evid Based Med . 2016 ; 21 : 121 – 122 . Google Scholar Crossref Search ADS PubMed WorldCat Author notes Dr Hoogeboom is a member of PTJ’s Editorial Board. © The Author(s) 2021. Published by Oxford University Press on behalf of the American Physical Therapy Association. All rights reserved. For permissions, please email: [email protected] This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

doi: 10.1093/ptj/pzab251pmid: N/A

Start Your Scholarship and Fellowship Applications Today! FPTR is once again accepting scholarship and fellowship applications. Potential applicants should visit the FPTR website (https://foundation4pt.org/foundation-funding-opportunities/) to view all open opportunities. Eligibility guidelines and instructions are posted for each application available for 2021. For questions, email [email protected]. Launching the 2021–2022 VCU-Marquette Challenge The student-led VCU-Marquette Challenge (https://marquettechallenge.com/) is an annual fundraiser that connects students with research in a meaningful way while benefiting the profession and those we serve. All funds raised support FPTR’s mission to fund the next generation of physical therapist researchers. Each year, hundreds of physical therapist and physical therapist assistant students—with the support of program directors, faculty, and community—hold fundraising events across the U.S. To learn more about the participating schools and how you can get involved, visit MarquetteChallenge.com. 2022 Call for Fellowships Coming Soon The FPTR-funded Center on Health Services Training and Research (CoHSTAR) is pleased to announce a new round of fellowship opportunities for physical therapist researchers interested in developing their careers as health services researchers. CoHSTAR will offer a range of fellowship opportunities, including faculty fellowships (some co-sponsored with other organizations), and postdoctoral fellowships. CoHSTAR will select 1 or 2 new fellows in 2021, contingent on available and matching funding. Interested parties are encouraged to reach out in advance of the deadline to discuss potential projects. Support the Foundation With a Gift Research strengthens the profession of physical therapy. Researchers examine the effectiveness of treatments and pioneer new interventions. Research also defines the value of physical therapy to government agencies and health care payers. Your support—now more than ever—is needed as we emerge from the current health crisis together. Visit Foundation4pt.org/Give to support our mission. Share Your Alumni News and Announcements With the Foundation Would you like to share your FPTR funding alumni updates? Please email Yaman Shalabi at [email protected]. Stay Connected with the Foundation in 4 Easy Ways: Visit our website: Foundation4PT.org Connect with us on Facebook: www.facebook.com/foundation4PT Follow us on Twitter: @Foundation4pt. Subscribe to our newsletter for updates on the latest in physical therapy research, donors, Foundation Alumni, events, and much more! © The Author(s) 2021. Published by Oxford University Press on behalf of the American Physical Therapy Association. All rights reserved. For permissions, please email: [email protected] This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

Mañago, Mark M; Swink, Laura A; Hager, Emily R; Gisbert, Robyn; Earhart, Gammon M; Christiansen, Cory L; Schenkman, Margaret

doi: 10.1093/ptj/pzab203pmid: 34473303

Objectivehe purpose of the study was to determine the impact of novel coronavirus 2019 (COVID-19) restrictions on community-based exercise classes for people with Parkinson disease (PD) and their instructors.MethodsData were collected via custom-designed electronic surveys for people with PD and class instructors who reported attending or teaching PD-specific exercise class ≥1 time/week for ≥3 months prior to pandemic restrictions (March 2020). The PD group also completed the Godin Leisure-Time Questionnaire, Self-Efficacy for Exercise scale, Schwab-England scale, and Parkinson’s Disease Questionnaire 8.ResultsEighty-seven people with PD (mean = 70 [7.3] years old) and 43 instructors (51 [12.1] years old) from the United States completed surveys (October 2020 to February 2021). Mean Schwab-England (84 [16]) and Parkinson’s Disease Questionnaire 8 (21 [15]) scores indicated low-to-moderate disability in the PD group. Ninety-five percent of the PD group had COVID-19 exposure concerns, and 54% reported leaving home ≤1 time/week. Although 77% of the PD group scored “active” on the Godin Leisure-Time Questionnaire, the mean Self-Efficacy for Exercise Scale score (55 [24]) indicated only moderate exercise self-efficacy, and >50% reported decreased exercise quantity/intensity compared with pre-COVID. There was decreased in-person and increased virtual class participation for both groups. The top in-person class barrier for the PD (63%) and instructor (51%) groups was fear of participant COVID-19 exposure. The top virtual class barriers were lack of socialization (20% of PD group) and technology problems (74% of instructor group).ConclusionDuring COVID-19, there has been less in-person and more virtual exercise class participation in people with PD and decreased exercise quantity and intensity. Virtual classes may not fully meet the needs of people with PD, and primary barriers include technology and lack of socialization.ImpactAs COVID-19 restrictions wane, it is imperative to help people with PD increase exercise and activity. The barriers, needs, and facilitators identified in this study might help inform approaches to increase participation in exercise and activity for people with PD.Lay SummaryDuring COVID-19, there has been less in-person and more virtual exercise class participation in people with PD and a decrease in exercise quantity and intensity. If you have PD, virtual classes might not fully meet your needs. Primary barriers may include technology problems and lack of social interaction.

Felter, Cara E; Cicone, Jonathan; Mathis, Lindsey; Smith, Deanna L

doi: 10.1093/ptj/pzab210pmid: 34499180

 The COVID-19 pandemic has negatively impacted the health of people from communities of color and people of limited socioeconomic means in a disproportionate way due to social determinants of health (SDoH). The Centers for Disease Control defines SDoH as the “conditions in the places where people live, learn, work, and play that affect a wide range of health and quality-of life-risks and outcomes.” A related construct, social determinants of learning (SDoL), includes contextual conditions and variables that impact students’ ability to optimally participate in their education, including academic and clinical development. SDoL directly impact students’ ability to participate in the educational process. During the COVID-19 pandemic, students struggling with SDoH and, by extension SDoL, may be more likely to have sick family members, caregiving responsibilities, food and housing insecurity, and obligations to supplement lost family wages. SDoL are also influenced by individual experiences within and outside of the classroom. Beyond bringing this matter to the attention of our profession, especially clinical and academic educators, we must take action to reach and support students who are at higher academic risk due to the SDoL. The purpose of this paper is to (1) define SDoL, (2) explain how SDoL are impacting doctor of physical therapy and physical therapist assistant students, and (3) discuss actions that physical therapists and physical therapist assistants can take to mitigate the effects of SDoL on current doctor of physical therapy and physical therapist assistant students.ImpactThis Perspective is one of the first explorations of how SDoL affect physical therapy students during the pandemic and provides concrete suggestions on how educators in both academic and clinical settings can help students succeed when they are negatively affected by SDoL.

dos Santos, Flávia Franciele; Braga, Morgana Lopes; Barroso, Micaelen Mara Ferreira; Oliveira, Vinícius Cunha; Oliveira, Murilo Xavier

doi: 10.1093/ptj/pzab201pmid: 34499157

ObjectiveAlthough commonly prescribed, exercise therapy alone is insufficient for the treatment of low back pain (LBP). Thus, studies recommend a combination of interventions. Photobiomodulation therapy (PBMT) involving low-level laser is an effective intervention for relieving LBP; however, scientific evidence on the effects of laser therapy combined with exercise therapy is scarce and contradictory. The aim of this clinical trial is to evaluate the short-term and long-term effects of the combination of PBMT and an exercise protocol in individuals with persistent nonspecificLBP.MethodsThis 2-armed, randomized, placebo-controlled trial with blinded participants, assessors, and therapists will be conducted in the outpatient physical therapy clinic of a university in Diamantina, Brazil. Participants are 90 individuals between 18 and 65 years of age with self-reported LBP. The participants will be randomly allocated to (1) a 6-week exercise program combined with active PBMT at a frequency of twice per week, totaling 12 sessions (n = 45), or (2) a 6-week exercise program combined with placebo PBMT (n = 45). Clinical outcomes will be measured at baseline as well as at 8 and 20 weeks and 12 months after randomization. The primary outcomes will be pain intensity and disability. The secondary outcomes will be mental health, mobility, disability, and strength of the trunk extensor muscles.ImpactThe findings will help determine whether adding PBMT to a physical therapist–supervised exercise protocol is more effective than the exercise protocol alone for persistent LBP. This study has the potential to guide clinical practice toward innovative ways of providing health care.

Alghamdi, Nabeel Hamdan; Pohlig, Ryan T; Lundberg, Mari; Silbernagel, Karin Grävare

doi: 10.1093/ptj/pzab178pmid: 34289066

ObjectiveKinesiophobia has been proposed to influence recovery in individuals with Achilles tendinopathy. However, whether there are differences in outcomes in individuals with different levels of kinesiophobia is unknown. The purpose of this study was to compare the characteristics of patients at baseline and recovery over time in individuals with Achilles tendinopathy and various levels of kinesiophobia.MethodsThis study was a secondary analysis of a prospective observational cohort study of 59 individuals with Achilles tendinopathy. The participants were divided into 3 groups on the basis of scores on the Tampa Scale for Kinesiophobia (TSK) (those with low TSK scores [≤33; low TSK group], those with medium TSK scores [34–41; medium TSK group], and those with high TSK scores [≥42; high TSK group]). All participants were evaluated with self-reported outcomes, clinical evaluation, tendon morphology, viscoelastic property measurements, and a calf muscle endurance test at baseline, 6 months, and 12 months. No treatment was provided throughout the study period.ResultsThere were 16 participants (8 women) in the low TSK group (age = 51.9 [SD = 15.3] years, body mass index [BMI] = 24.3 [22.3–25.4]), 28 participants (13 women) in the medium TSK group (age = 52.7 [SD = 15.2] years, BMI = 26.4 [22.5–30.8]), and 15 participants (8 women) in the high TSK group (age = 61.1 [SD = 11.1] years, BMI = 28.1 [25.2–33.6]). Among the groups at baseline, the high TSK group had significantly greater BMI and symptom severity and lower quality of life. All groups showed significant improvement over time for all outcomes except tendon viscoelastic properties and tendon thickening when there was an adjustment for baseline BMI. The high and medium TSK groups saw decreases in kinesiophobia at 6 months, but there was no change for the low TSK group.ConclusionDespite the high TSK group having the highest BMI and the worse symptom severity and quality of life at baseline, members of this group showed improvements in all of the outcome domains similar to those of the other groups over 12 months.ImpactEvaluating the degree of kinesiophobia in individuals with Achilles tendinopathy might be of benefit for understanding how they are affected by the injury. However, the degree of kinesiophobia at baseline does not seem to affect recovery; this finding could be due to the patients receiving education about the injury and expectations of recovery.

Unsgaard-Tøndel, Monica; Søderstrøm, Sylvia

doi: 10.1093/ptj/pzab187pmid: 34339506

ObjectiveThe aim of this study was to explore patients’ expectations before and experiences after physical therapy for low back pain.MethodsQualitative in-depth, semi-structured interviews with patients attending physical therapy were performed before, immediately after, and 6 months after treatment. Data were analyzed from a hermeneutical perspective with decontextualization, recontextualization, and identification of themes.ResultsPatients’ pretreatment expectations to physical therapy focused around exercises and a body-oriented diagnosis. After treatment, reassurance, active listening with explanations, and personally adapted strategies for self-managing pain and regaining control over everyday activity were expressed as decisive for a meaningful therapeutic alliance.ConclusionExpectations before treatment focused on exercises and diagnosis. Empathetic and personally adapted education aimed at empowerment was experienced as a meaningful aspect of the therapeutic alliance after treatment. The therapeutic alliance provided a basis to integrate knowledge on the complexity of pain.ImpactOur findings indicate that patients emphasize physical therapists’ interactional and pedagogical skills as meaningful aspects of the therapeutic alliance, which has implications for clinical practice and training physical therapist students.