Physical Therapy最新文献

While health systems science (HSS) is now recognized as a foundational pillar in medical education, the profession of physical therapy has yet to fully integrate this unifying framework into its educational models. Health systems science offers a structured lens through which the profession can align its long-standing values such as patient-centered care, equity, and interprofessional collaboration, with the demands of a health care system that is complex, fragmented, and driven by accountability, data, and value. Without explicit incorporation of HSS into Doctor of Physical Therapy (DPT) curricula, the profession may have a diminished voice in critical conversations around health care equity, health system innovation, policy reform, and care redesign. This perspective presents an example from the University of Miami's DPT program, where HSS was systematically embedded across the curriculum using Kern's 6-step model for curriculum development. The process included comprehensive content mapping and intentional faculty development to promote a shared understanding of systems thinking and its relevance to physical therapist practice. As a result, DPT students are now engaged in learning that situates their clinical decision making within the broader structures, policies, and processes that shape patient outcomes at both individual and population levels. Health systems science enables physical therapists to move beyond implicit alignment with health system goals to active participation in advancing them. A physical therapist educated in HSS is positioned to contribute to population health by designing community-based interventions, participating in cross-sector partnerships, addressing social determinants of health, and applying data to reduce disparities in function and access. The framework also supports engagement in value-based care delivery, quality improvement initiatives, health informatics, and health policy development; areas central to the sustainability and evolution of health care. To remain relevant and impactful, this perspective offers a call to action for physical therapist educators to integrate HSS as a core component of professional formation and practice readiness.

Importance: The trunk and lower extremities are the most common locations for injury in the military, but they are managed as isolated regions. This study suggests these regions are connected, and utilization of therapeutic exercise is protective of lower extremity injury following low-back-pain diagnosis.

Objective: The objective of this study was to determine whether therapeutic exercise for low back pain reduces risk of subsequent lower extremity injury.

Design: This study utilized a longitudinal cohort design based on routinely collected health information.

Setting: This study was conducted within the Military Health System.

Participants: Patients aged 18 to 65 who sought care for low back pain between January 2015 and July 2019 were identified using diagnosis codes from electronic medical records and claims data.

Interventions: Participants were dichotomized based on whether they received therapeutic exercise.

Main outcomes and measures: Cox proportional hazards regression with hazard ratios (HRs) was used to model the relationship between therapeutic exercise use and dosing and risk of subsequent hip, knee, and ankle injury.

Results: Out of 452,668 patients (34.8% female; age 35.5 [12.3] years), 74,912 (16.5%) received at least 1 therapeutic exercise session, with a median (IQR) of 3 (1-6) sessions. Therapeutic exercise receipt significantly decreased subsequent lower extremity injury risk (hip: HR = 0.84, 95% CI = 0.825-0.852; knee: HR = 0.77, 95% CI = 0.756-0.777; and ankle/foot: HR = 0.80, 95% CI = 0.788-0.809), and that risk decreased further with each additional exercise session (hip: HR = 0.95, 95% CI = 0.942-0.948; knee: HR = 0.96, 95% CI = 0.956-0.963; and ankle/foot: HR = 0.96, 95% CI = 0.961-0.967).

Conclusions: Patients with low back pain not treated with therapeutic exercise had an increased risk of subsequent lower extremity injury. For those who received therapeutic exercise, the risk for subsequent injury was reduced with additional sessions.

Relevance: Treating low-back-pain patients with therapeutic exercise may decrease the health-care burden.

Importance: The physical therapy profession is being called to adopt a competency-based education (CBE) model, following the lead of other health professions. A key element of CBE is workplace-based assessment, in which clinicians evaluate learners' readiness to perform essential clinical tasks through entrustable professional activities (EPAs). Although a common set of EPAs exist for the profession, none currently guide assessment and learning in specialty areas like pain.

Objective: The objective of this study was to describe the development and initial validation of pain-specific entrustable professional activities (Pain EPAs) designed to assess physical therapist clinical competency in managing pain within a CBE framework.

Design: This was a developmental study following published recommendations for EPA creation, including preparation, drafting, quality control, and curriculum alignment.

Setting: The study was conducted across 4 American universities.

Participants: Five American-based physical therapists collaborated on EPA development and gathered feedback from educators, clinicians, and an 8-person reactor panel.

Intervention: The intervention involved developing Pain EPAs through expert consensus and external review for alignment with competency frameworks.

Main outcome: The main outcome was a set of Pain EPAs reviewed for clarity, observability, and assessability using the EQual rubric, with external feedback guiding their categorization.

Results: Twenty-one Pain EPAs were developed and aligned with pain competency frameworks, with feedback organizing them into 4 levels of increasing complexity and autonomy: generalist, pain-specific entry-level, specialty clinic entry-level, and advanced practice.

Conclusions: This study outlines a structured, replicable approach for developing EPAs aligned with CBE principles. The Pain EPAs provide an initial framework to assess readiness for autonomous pain management tasks. Further research is needed to establish their validity and support implementation in entry-level and post-professional training.

Relevance: The Pain EPAs support CBE workplace-based assessment in physical therapist education. This approach can be adapted for other specialty areas within physical therapist practice.

Importance: Older adults and those with low back pain (LBP) are at increased risk of research-related adverse events (AEs); yet, Cochrane reviews show AE under-reporting in rehabilitation trials.

Objective: To inform AE practices in future rehabilitation trials, details are provided on novel AE surveillance and reporting practices used in the Manual Therapy and Strengthening for the Hip (MASH) trial.

Design: The study design was a secondary analysis of a multisite, single-masked, randomized controlled trial comparing 2 exercise-inclusive interventions.

Setting: The study was conducted at research-based physical therapist sites.

Participants: Participants were older adults with moderate-intensity, chronic LBP with hip pain and muscle weakness.

Interventions or exposures: Participants were randomly assigned to receive 16 sessions of hip-focused or spine-focused physical therapy over 8 weeks. Active AE monitoring was facilitated with standardized interviews during each treatment session and at 8-week, 3-, 4-, 5-, and 6-months. Common terminology criteria for AEs classification was used. AEs were adjudicated by a site investigator and reviewed at multisite meetings.

Main outcomes and measures: AE classification, relatedness, expectedness, severity, timing, recurrence, duration, and intervention impact were evaluated between interventions.

Results: Among 184 participants, there were 243 AEs (n = 128 hip-focused group, n = 115 spine-focused group) in 112 participants; 38.3% were unexpected, with 47 occurring in the hip-focused and 46 in the spine-focused group. AE relatedness, expectedness, and severity were similar between groups. Of the 243 AEs, 157 were mild, 71 were moderate, and 15 were severe/life threatening. Most AEs (80.2%) occurred early and were classified as musculoskeletal and connective tissue disorders (MSKCT), with shorter MSKCT AE duration in the hip-focused group. Within each group, 15 MSKCT AEs resulted in study modification.

Conclusions and relevance: This analysis describes a framework to improve upon active AE surveillance during rehabilitation trials to better inform risk-to-benefit analyses. Data can also be used to inform clinical decision-making related to risks from MASH trial interventions.

Importance: Arthritis is a chronic condition affecting hundreds of millions of people worldwide, often leading to pain and functional limitations.

Objective: This study aimed to investigate the direct and indirect effects of pain on functional dependence in individuals with arthritis. Depressive symptoms and physical activity were examined as potential mediators of this relationship.

Design: This study was a longitudinal cohort study.

Setting: The study setting included community-dwelling adults participating in the Canadian Longitudinal Study on Aging.

Participants: This study sample consisted of 6972 participants with arthritis, including 4930 with osteoarthritis and 694 with rheumatoid arthritis.

Exposure: The exposure was the usual presence of pain or discomfort at baseline, with depressive symptoms (CESD-10) and physical activity (PASE) tested as mediators.

Main outcome and measure: The main outcome was functional dependence in basic activities of daily living (ADL) and instrumental activities of daily living (IADL) at follow-up, measured with a modified version of the Older Americans' Resources and Services Multidimensional Functional Assessment Questionnaire (OARS).

Results: Baseline pain was positively associated with depressive symptoms (b = 0.356 [95% CI = 0.310 to 0.402]) and negatively associated with physical activity (b = -0.083 [95% CI = -0.125 to -0.042]). Functional dependence at follow-up was significantly predicted by baseline pain (log OR = 0.607 [95% CI = 0.261 to 0.952]), depressive symptoms (log OR = 0.358 [95% CI = 0.184 to 0.533]), and physical activity (log OR = -0.598 [95% CI = -0.818 to -0.378]). Mediation analysis showed that 23.3% of the total effect of pain on functional dependence was accounted for by the indirect effect through depressive symptoms (16.2%), physical activity (6.3%), and their serial combination (0.8%).

Conclusions: The presence of pain at baseline was associated with higher odds of functional dependence in basic and instrumental activities of daily living after a mean follow-up period of 6.3 years, with depressive symptoms and lower physical activity acting as mediators.

Relevance: The findings highlight the need for arthritis care to extend beyond pain management by incorporating strategies that address depressive symptoms and promote physical activity to preserve functional independence.

Importance: Plantar heel pain (PHP) contributes to reduced quality of life and is costly to manage. Persons with PHP are infrequently referred to a physical therapist after presenting to primary care or podiatry.

Objective: The study objective was to compare the cost-effectiveness of usual podiatry care (uPOD) plus physical therapist treatment with that of uPOD alone in the management of PHP.

Design: A cost-effectiveness analysis from societal and health care sector perspectives and a 3-year time horizon was performed alongside a randomized clinical trial. Intention to treat was used as the base case, and sensitivity analyses were used to assess the impact of adherence to treatment (ie, per protocol) and PHP-specific costs.

Setting: The setting was a multidisciplinary outpatient clinic in the United States.

Participants: Participants were 95 eligible patients with PHP.

Interventions: uPOD consisted of a stretching handout, medication, injections, and orthotics; uPOD plus physical therapist treatment also included physical therapist intervention consisting of manual therapy, exercise, foot taping, and iontophoresis.

Main outcomes and measures: Cost-effectiveness was determined by between-group differences in costs relative to quality-adjusted life-years (QALYs). Cost-effectiveness at different thresholds of decision maker willingness to pay was illustrated using the cost-effectiveness acceptability curve.

Results: uPOD plus physical therapist treatment reduced societal costs by $2708 (95% CI = -$294 to $5709) relative to uPOD and increased QALYs by 0.09 (95% CI = -0.01 to 0.18). The cost-effectiveness acceptability curve demonstrated 98%, 99%, and 97% probabilities of cost-effectiveness of uPOD plus physical therapist treatment in the base-case, per-protocol, and PHP-specific cost analyses using a willingness-to-pay threshold of $50,000 per QALY.

Conclusions: Adding physical therapist treatment to uPOD lowered total costs and improved quality of life despite increased short-term health care utilization. Results were not altered when considering adherence to treatment or PHP-specific costs.

Relevance: This study informs shared decision-making between providers and patients with PHP about the costs and benefits of adding physical therapist treatment and provides support for the economic value of physical therapist treatment for PHP.

Importance: Rehabilitation is a key in managing Parkinson disease (PD), but access barriers remain, and the benefits of telerehabilitation (TR) are still unclear.

Objective: The objective of this systematic review and meta-analysis was to examine the effect of TR in adults with PD through the International Classification of Functioning, Disability, and Health.

Data sources: An electronic database search (PubMed, EMBASE, SCOPUS, PEDro, Cochrane) was performed for data published from inception to April 2025.

Data selection: Inclusion criteria were randomized controlled trials involving adults with PD, assessing remotely delivered physical activity or physical rehabilitation interventions, compared to control groups not exposed to TR, and reporting outcomes of interest. Exclusion criteria included studies involving additional neurological disorders.

Data extraction and synthesis: Data extraction was guided by the PRISMA guidelines. This review was registered with PROSPERO (CRD42023475545). A risk of bias assessment (RoB-2) and methodological quality assessment (PEDro) tools were used. Data were analyzed using random-effects models.

Main outcomes and measures: The outcomes of interest were balance, gait, functional mobility, physical activity, quality of life (QOL), and social support.

Results: Eighteen studies were included in the final analysis, involving 731 individuals with PD. The most common types of TR included remote-based exergaming and using video conferencing platforms. The results indicated no statistically significant difference between TR and control groups on balance (standardized mean difference [SMD] = 0.31, 95% CI = -0.02 to 0.65), gait speed (SMD = -0.07, 95% CI = -0.33 to 0.19), and functional mobility (SMD = 0.05, 95% CI = -0.27 to 0.37) outcomes. However, the results were statistically in favor of TR for improving QOL (SMD = 0.26, 95% CI = 0.05 to 0.47).

Conclusions and relevance: TR yielded similar or superior results compared to non-exposed control conditions across the 5 outcomes evaluated. Health care providers can decide which method of care delivery they prefer based on patients' preferences and resources.

Importance: Physical activity can improve clinical outcomes among people with neurological conditions; however, people with these conditions rarely engage in recommended levels of activity. Remote monitoring (RM) with the incorporation of behavior change strategies is purported to be an effective approach to promote increased physical activity in the home setting, however, its effectiveness in promoting activity for people with neurological conditions is unclear.

Objectives: The objectives of this review were to examine the effectiveness of behaviorally informed RM interventions on physical activity in the home and community and to identify usage and impact of specific behavior change techniques (BCTs) implemented with RM interventions.

Data sources: PubMed, PsycINFO, and CINAHL were searched in March 2024.

Study selection: This study included a selection of randomized controlled trials on behaviorally informed RM interventions that use wearable sensors or digital applications to target physical activity for patients with neurological diseases.

Data extraction and synthesis: Data extraction was performed by 2 independent reviewers and data synthesis was performed with random effects meta-analysis. BCT were classified using Michie's behavior change technique taxonomy. Promising BCTs were identified by examining the proportion of statistically significant studies for each technique. Risk of bias was assessed with the risk of bias 2 tool.

Main outcomes and measures: The main outcomes and measures included physical activity measured by self-report and accelerometers.

Results: Fourteen studies were included with some concerns of bias, encompassing individuals with multiple sclerosis, stroke, Parkinson disease, and spinal cord injury. Behaviorally informed RM interventions resulted in statistically significant improvements in self-reported physical activity (SMD = 0.27, 95% CI = 0.06 to 49), but not accelerometry outcomes (SMD = 0.52, 95% CI = -0.07 to 1.11). Promising BCTs included self-monitoring, problem solving, goal setting, graded tasks, social support, and adding objects to the environment.

Conclusions and relevance: RM shows initial promise to increase physical activity of people living with neurological conditions when paired with behavior change consultation.