Jill S. Boissonnault

The Role of Exercise in the Management of Pelvic Girdle and Low Back Pain in Pregnancy: A Systematic Review of the Literature

Objective:Assess literature on exercise as treatment for pelvic girdle and low back pain in pregnancy. Study Design:A systematic review. Background:Pregnancy-related pelvic girdle and low back pain are common. Prevalence rates average near 50%. Assessment of exercise intervention studies may provide evidence to manage this dysfunction. Materials and Methods:Systematic review of prospective clinical trials on exercise for pregnancy-related pelvic and low back pain. CINAHL, MEDLINE, PEDro, and Cochrane databases were searched; reference screening was conducted. Three reviewers used consensus process to select articles for final review. Two of the reviewers independently reviewed the selected articles according to the PEDro Scale. Where available, the reviewers results were compared against PEDro Reviews; reviewer scores were altered if both reviewers agreed that the published PEDro Score was more accurate. Results:Eleven studies were reviewed. Three were good quality (range, 7–8/10); 6, moderate quality (range, 4–6/10); and 2, poor quality (range, 0–3/10). High-quality studies support the intervention of exercise, either alone or combined with advice or other treatment (support belts, acupuncture) as a means of prevention or management of pelvic girdle and low back pain. One study found aquatic exercise to be of greater benefit than land-based exercise. Another found acupuncture superior to exercise, which was, in turn, more effective than “standard treatment.” Addition of pelvic support belts to exercise intervention did not further decrease pain. Utilization of sick leave conflicted across studies. Conclusions:Exercise may decrease low back or pelvic girdle pain in pregnancy. Heterogeneity of methodology and outcome assessment makes comparison difficult. Most studies were of moderate to poor quality.

Technical Report of Specialty Practice in Womenʼs Health Physical Therapy

Objective: To perform a nationwide analysis of specialty practice in womens health physical therapy in order for the Section on Womens Health (SOWH) of the American Physical Therapy Association to create a Description of Specialty Practice (DSP) and apply to the American Board of Physical Therapist Specialists (ABPTS) for approval of specialist certification in womens health. Study Design: Survey. Background: A nationwide survey was fielded based on a previous practice analysis survey on womens health conducted in 2004, the Normative Model of Physical Therapist Professional Education, the Guide to Physical Therapist Practice, and input from an 8‐member Task Force. Methods and Measures: The survey contained 4 sections. Sections 1 through 3 addressed knowledge areas expected, professional behavior expectations, and patient/client management expectations of the womens health physical therapy specialist. Items in Section 1 were rated on: Frequency (5 point Likert‐type scale), Importance, and Level of Judgment (4 point Likert‐type scales). Items in both sections 2 and 3 were rated on the same scale of Frequency as well as Level of Criticality (4 point Likert‐type scale). Section 4 requested demographic information. Results: The practice analysis survey was completed electronically on‐line by 176 of 432 advanced practitioners in womens health physical therapy who met the criteria to complete and volunteered to complete the survey. The survey response rate was 40.7%. Ordinal data were analyzed descriptively, based on frequency responses. According to previously agreed upon decision rules, 9 items were eliminated from Sections 1, 2, and 3 of the survey and were not included in the Description of Specialty Practice. Categorically the items eliminated were identified as not performed differently at the specialist level or performed as well by a physical therapist assistant. The frequency ratings from the survey were designed to be used to develop weighting of items in future specialty exams. Conclusions: Results of the practice analysis suggest that a specialist in womens health physical therapy performs a wide range of examination and intervention skills specifically for the female population.

Survey on Curricular Content for Doctor of Physical Therapy Guidelines for Womenʼs Health Content in Professional Physical Therapist Education: 2014 Update

Objective:To conduct a survey using evidence from community stakeholders in order to update the Doctor of Physical Therapy Guidelines for Womens Health Content in Professional Physical Therapist Education (Guideline). Study Design:Survey research report. Background:The original content Guideline was published in 2005 with expectations that it would be updated every 5 years. A task force appointed in 2011 undertook this work. Methods and Measures:A survey was developed and fielded electronically to all 202 accredited academic programs in December 2011. A modified academic survey was fielded to the clinical community. The clinician survey was sent electronically to 1951 members of the Section on Womens Health in April 2012. Analysis of results and percent agreement were used to define elements included in the updated Guideline. Results:There was a high agreement on content to be taught in Doctor of Physical Therapy entry-level curricula. Response rate was 102 (51%) for the academic survey and 340 (17%) for the clinician survey. Areas with equivocal input were evaluated by the task force. Conclusion:Key stakeholder input attained via survey data assisted the task force in its efforts to produce the Doctor of Physical Therapy Guidelines for Womens Health Content in Professional Physical Therapist Education: 2014 Update.

Technical Report on Using the Systems and Patient Management Model in Womenʼs Health DPT Curricular Guidelines

Background:The Board of Directors of the Section on Womens Health of the American Physical Therapy Association appointed a task force to provide an update to the 2005 “Guidelines for Womens Health Content in Professional Physical Therapist Education” (2005 Guideline) using best evidence and clinical expertise. Study Design:The task force developed and implemented a survey to all accredited physical therapy education programs in the United States as well as all womens health (WH) certified physical therapists. Survey data and qualitative data from facilitated discussion were analyzed, prioritized, and organized into an updated version of the Guideline. Case Description:The task force based the updated WH curricular guideline on both systems and patient-client management models. Outcome:The updated Guideline includes the following systems: cardiopulmonary, endocrine, gastrointestinal, immune, integumentary, musculoskeletal, neurologic/psychological, reproductive, and urogynecologic. In addition, each condition was organized using the patient-client management model, with key content knowledge or skill paired with educational objectives that could be incorporated into course syllabi. Key content areas also include the level of competence expected of an entry-level student. Discussion:The updated Guideline should serve as a comprehensive resource for all providers of WH curricular content.

Development of a Physical Therapy Patient-Interview Student Assessment Tool: A Pilot Study

Background and Purpose. While multiple medical school patient‐interviewing tools exist for assessment of student competence in conducting patient histories, no validated or reliable physical therapy‐specific tool has been found in the literature. Physical therapist education requires assessment and attainment of patientinterviewing competence before physical therapist students begin patient care. The purpose of this qualitative study was to develop and validate a physical therapy‐specific tool to assess student patient‐interviewing skill and to pilot its reliability. Method/Model Description and Evaluation. Literature review, qualitative assessment of existing medical tools for patient interviews, tool development, content validation, and pilot estimation of test‐retest intrarater reliability were performed. Literature review results for history taking, expert clinical practice. and medical‐based interviewing assessment instruments served as basis for the ECHOWS tool (E [Establishing Rapport], C [Chief Complaint], H [Health history], O [Obtain Psychosocial Perspective], W [Wrap‐Up], and S [Summary of Performance[). Content validity was established using 5 content experts, including entry‐level and residency/fellowship faculty. These experts reviewed ECHOWS twice, leading to final revision and creation of a user guide. Five different reviewers assessed a convenience sample of 5 taped interviews for reliability. This pilot testing of ECHOWS allowed for the determination of necessary tool modifications, and an estimate of the variability of the inter and intrarater scores, which will be used to calculate a sample size for future reliability studies. Outcomes. ECHOWS and Guide to ECHOWS were developed and validated. Pilot testing revealed the need for additional alterations to ECHOWS. Statistical analysis revealed moderate to good instrument intrarater reliability. Discussion and Conclusion. The ECHOWS physical therapy studentassessment instrument for patient interviews also has the potential to provide PT faculty with additional strategies to teach patient interviewing skills. Future research will need to establish interrater reliability and construct validity.

A Review of Self-Report Functional Outcome Measures in Selected Obstetric Physical Therapy Interventions

Objective: Self‐report functional status scales and questionnaires can be clinically important measures of patient outcome in physical therapy. This paper reviews the application and utilization of such measures in the area of obstetric physical therapy and presents, where available, information on the psychometric characteristics of these measures. Study Design: Literature review via Cinahl and Pubmed databases, author queries of advanced practitioners in the field. Background: Physical therapists who specialize in womens health commonly treat pregnant women with back and pelvic‐ring pain as well as counsel and advise women about activity re‐integration after prolonged bed rest for high risk pregnancy. In recent years research into these areas has increased. Review of the utilization of pre‐established, validated outcome measures used in such studies has yet to be conducted. Development of population‐specific measures appropriate for clinical or research use with obstetric clients in PT has not occurred. The validation of commonly used functional outcome measures and tools for this specific population has also not occurred. Methods: A Data Base search using common terms in obstetric physical therapy was conducted with focus on self‐report functional outcome measures specific to the population and to those generic tools appropriated to the population. MESH terms such as: ‘outcome in pregnancy,’ ‘physical therapy (PT) and pregnancy‐related back pain,’ ‘high risk pregnancy maternal outcomes,’ ‘bed rest and postpartum function’ were used. Published research on such tools was examined for validity, reliability, and responsiveness to clinical change. Results: Twenty tools demonstrating adequate reliability and validity were found to be routinely used in research related to physical therapy for back or pelvic‐ring pain during pregnancy. The search did not reveal any studies that attempted to develop functional outcome tools specific to clients seen in physical therapy clinics for pregnancy or postpartum‐related back or pelvic‐ring pain. In the pregnancy population, the search found 2 population‐specific functional measurement tools related to activity level. The search found no evidence of general health measures, disability questionnaires, pain scales, or quality of life tools validated for the obstetric population. Conclusions: Researchers use validated and reliable self‐report functional outcome measures to evaluate outcomes in physical therapy for back/pelvic‐ring pain in the child‐bearing year. No population‐specific tools have been developed and the generic tools have yet to be validated on the obstetric population with back and pelvic ring pain. Two tools specific to activity level in pregnant women are reported in the literature.

Prevalence and Risk of Inappropriate Sexual Behavior of Patients Toward Physical Therapist Clinicians and Students in the United States

Background For health care providers in the United States, the risk for nonfatal violence in the workplace is 16 times greater than that for other workers. Inappropriate patient sexual behavior (IPSB) is directed at clinicians, staff, or other patients and may include leering, sexual remarks, deliberate touching, indecent exposure, and sexual assault. Inappropriate patient sexual behavior may adversely affect clinicians, the organization, or patients themselves. Few IPSB risk factors for physical therapists have been confirmed. The US prevalence was last assessed in the 1990s. Objective The objectives of this study were to determine career and 12-month exposure to IPSB among US physical therapists, physical therapist assistants, physical therapist students, and physical therapist assistant students and to identify IPSB risk factors. Design This was a retrospective and observational study. Methods An electronic survey was developed; content validity and test-retest reliability were established. Participants were recruited through physical therapist and physical therapist assistant academic programs and sections of the American Physical Therapy Association. Inappropriate patient sexual behavior risk models were constructed individually for any, mild, moderate, and severe IPSB events reported over the past 12 months. Open-ended comments were analyzed using qualitative methods. Results Eight hundred ninety-two physical therapist professionals and students completed the survey. The career prevalence among respondents was 84%, and the 12-month prevalence was 47%. Statistical risk modeling for any IPSB over the past 12 months indicated the following risks: having fewer years of direct patient care, routinely working with patients with cognitive impairments, being a female practitioner, and treating male patients. Qualitative analysis of 187 open-ended comments revealed patient-related characteristics, provider-related characteristics, and abusive actions. Limitations Self-report, clinician memory, and convenience sampling are limitations of this type of survey research. Conclusions The extremely high prevalence of IPSB among physical therapist professionals warrants practitioner and student education as well as clear workplace policy and support.

Reliability of the ECHOWS Tool for Assessment of Patient Interviewing Skills

Background History taking is an important component of patient/client management. Assessment of student history-taking competency can be achieved via a standardized tool. The ECHOWS tool has been shown to be valid with modest intrarater reliability in a previous study but did not demonstrate sufficient power to definitively prove its stability. Objective The purposes of this study were: (1) to assess the reliability of the ECHOWS tool for student assessment of patient interviewing skills and (2) to determine whether the tool discerns between novice and experienced skill levels. Design A reliability and construct validity assessment was conducted. Methods Three faculty members from the United States and Australia scored videotaped histories from standardized patients taken by students and experienced clinicians from each of these countries. The tapes were scored twice, 3 to 6 weeks apart. Reliability was assessed using interclass correlation coefficients (ICCs) and repeated measures. Analysis of variance models assessed the ability of the tool to discern between novice and experienced skill levels. Results The ECHOWS tool showed excellent intrarater reliability (ICC [3,1]=.74–.89) and good interrater reliability (ICC [2,1]=.55) as a whole. The summary of performance (S) section showed poor interrater reliability (ICC [2,1]=.27). There was no statistical difference in performance on the tool between novice and experienced clinicians. Limitations A possible ceiling effect may occur when standardized patients are not coached to provide complex and obtuse responses to interviewer questions. Variation in familiarity with the ECHOWS tool and in use of the online training may have influenced scoring of the S section. Conclusion The ECHOWS tool demonstrates excellent intrarater reliability and moderate interrater reliability. Sufficient training with the tool prior to student assessment is recommended. The S section must evolve in order to provide a more discerning measure of interviewing skills.

A Survey of United States Physical Therapy Faculty on Entry-Level Womenʼs Health Currricular Content

28 genitalia (p=0.0172), identifying the puborectalis muscle (p=0.0313), ability to grade a levator ani muscle contraction (p-0.0313), and in ability to perform a pelvic floor muscle examination (p=0. 0313). Differences approached significance in regard to student’s perception of feeling prepared to practice in this area upon graduation (p=0.0625). All students demonstrated the ability to perform all components of the examination independently. Conclusions: The use of standardized patient models provides an opportunity for physical therapy students to improve their confidence in performance of a pelvic floor muscle examination. Future research should investigate the impact of the use of standardized patients in influencing student’s future area of practice. Clinical Relevance: Women’s health physical therapy practice is growing. There is a predicted increasing demand for physical therapists skilled in the evaluation and management of pelvic floor dysfunction. Teaching pelvic floor muscle examination techniques to physical therapy students poses many challenges. The use of standardized patient models is one potential solution to these problems that should be investigated further in larger student populations.

Influence of a Short-Term Disability Awareness Program on Knowledge and Attitudes of School-Aged Children in Southern Belize: Results of a Community-University Partnership

Background Little is known about the attitudes of children living in Central America toward people with disabilities or the effectiveness of a disability awareness program in influencing their knowledge and attitudes. Objective The study objectives were to evaluate the effectiveness of a disability awareness program in influencing Belizean childrens knowledge of and attitudes toward people with disabilities in the immediate short term and to describe the development of a university-community partnership that resulted in the development of a culturally appropriate disability awareness program. Design This was a single-group pretest-posttest quasi-experimental study with cluster sampling. Methods Study participants included 247 children (11-14 years old) from 8 primary schools in Toledo District, Belize. A paper-based disability awareness survey measuring knowledge of and attitudes toward people with disabilities was administered before and after an intervention. The intervention was a 90-minute multimodal disability awareness program. Hierarchical linear modeling was used to model the influence of the intervention on knowledge of and attitudes toward people with disabilities. Results Significant improvements in knowledge of and attitudes toward people with disabilities were evident immediately after the intervention. Limitations Children were not randomized to a control group. Although this feature was a limitation in terms of study design, the researchers believed that respecting the wishes of the school principals by providing the disability awareness intervention to all students was important. Conclusions This study provided an example of how a university-community partnership can positively influence community outcomes. Further research is needed to assess long-term changes in Belizean childrens knowledge of, attitudes toward, and behaviors toward people with disabilities, as well as the social inclusion and participation of children with disabilities.