IMPORTANCE:Changes in peak metabolic capacity (Vo2peak) and gait efficiency at matched speeds (Vo2match) are often observed in individuals after stroke following locomotor training, although it is uncertain how those changes are achieved. OBJECTIVE:The objective of this study was to evaluate the effects of locomotor training on changes in Vo2peak and Vo2match in individuals after stroke and their associations with changes in locomotor kinematics and kinetics. DESIGN:This study was a secondary analysis of a randomized trial. SETTING:The setting was an outpatient clinic/laboratory. PARTICIPANTS:Participants were individuals >6 months after stroke with self-selected walking speeds of <1.0 m/s with assistive devices and ankle-foot orthoses as needed. INTERVENTIONS:Participants were randomized to receive ≤30 sessions of locomotor training at higher intensities (>70% of heart rate reserve) either in variable contexts (multiple tasks/environments) or during forward walking (treadmill/overground) or at lower intensities (<40% of heart rate reserve) in variable contexts. MAIN OUTCOMES AND MEASURES:As changes in Vo2match masked gains in Vo2peak, both measures were evaluated during graded exercise tests and their difference calculated (Vo2gain), with subsequent determination of associations with changes in locomotor kinematics and kinetics. Between-group differences in changes in metabolic and biomechanical outcomes were evaluated using 1-way analyses of variance, with subsequent correlation and stepwise regression analyses. RESULTS:Data from 45 participants with baseline and posttraining data indicated no between-group differences in changes in Vo2peak or Vo2match. However, larger changes in Vo2gain were observed following either higher-intensity paradigm, consistent with faster treadmill speeds. Correlation and regression analyses revealed limited associations with changes in Vo2peak, with greater associations between Vo2gain and selected spatiotemporal parameters, joint kinematics, and nonparetic joint powers. Conversely, changes in Vo2match were associated primarily with paretic ankle powers. CONCLUSIONS:High-intensity training resulted in significant improvements in Vo2gain, which were related to improvements in multiple biomechanical variables at higher treadmill speeds, while gains in gait efficiency were related to improved paretic limb power. RELEVANCE:Alterations in peak metabolic capacity and efficiency are associated with distinct biomechanical changes.
IMPORTANCE:Home health and outpatient physical therapy are important for recovery after lower extremity joint replacement (LEJR), yet their use may be influenced by social determinants of health (SDOH). OBJECTIVE:The objective of this study was to identify SDOH factors at the patient, hospital, and regional levels that are associated with the use of home health and outpatient physical therapy after LEJR. DESIGN:This cross-sectional study used 100% Medicare fee-for-service claims. Hierarchical regression models assessed associations of patient-, hospital-, and regional-level SDOH with home health and outpatient physical therapy utilization. SETTING:Not applicable. PARTICIPANTS:Medicare beneficiaries who were 66 years old and older in 2018 and who were eligible for participation in the Comprehensive Care for Joint Replacement (CJR) program. EXPOSURE(S):SDOH at the patient level (race, dual eligibility status), hospital level (percentage of Disproportionate Share Hospital patients), and regional level (themes from the Social Vulnerability Index). MAIN OUTCOME AND MEASURE(S):Number of physical therapy visits in home health and outpatient settings within 90 days after discharge following a LEJR surgery, stratified by hip replacement and knee replacement. RESULTS:This study included 74,937 patients undergoing joint replacement from January 1 to September 30, 2018. At the patient level, Black patients had more home health and outpatient physical therapy visits than White patients following both knee and hip replacement. Dual-eligibility status was associated with more home health visits but fewer outpatient physical therapy visits. At the regional level, greater socioeconomic vulnerability was associated with more home health visits and outpatient physical therapy visits. Greater vulnerability in housing type and transportation was associated with more home health visits but fewer outpatient physical therapy visits. CONCLUSIONS:SDOH were associated with greater home health and outpatient physical therapy utilization following hospital discharge after joint replacement. RELEVANCE:Incorporating SDOH into discharge planning may promote equitable access to community-based rehabilitation following LEJR.
IMPORTANCE:Physical activity (PA) is a cornerstone in cancer rehabilitation, yet evidence in oral cancer remains limited and heterogeneous, despite the significant functional impairments and morbidity associated with treatment. OBJECTIVE:This systematic review synthesizes evidence on PA in people living with or beyond oral cancer (PLWBOC), focusing on its association with recovery-related outcomes across the cancer care continuum. DATA SOURCES:A comprehensive systematic search was conducted in 9 databases (PubMed, Embase, CENTRAL, CINAHL, Web of Science, Scopus, PEDro, ClinicalTrials.gov and the International Clinical Trials Registry Platform (ICTRP)) on October 26, 2024. The review followed PRISMA 2020 and SwiM guidelines and was registered with PROSPERO (CRD42024591662). STUDY SELECTION:Eligible studies included randomized controlled trials (RCTs), quasi-experimental designs, and observational studies examining the associations between postoperative PA and recovery-related outcomes in PLWBOC. DATA EXTRACTION AND SYNTHESIS:Two reviewers independently extracted data on PA characteristics, outcomes, and study quality using a standardized form. Risk of bias was assessed using the Revised Cochrane Risk of Bias tool for randomized trials (RoB 2) for RCTs and Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) for non-randomized studies, visualized with Risk-of-bias Visualization tool (ROBVIS). Twenty-four studies met the inclusion criteria, which encompassed RCTs, pilot trials, and cohort studies. MAIN OUTCOME(S) AND MEASURE(S):Primary outcomes include physical function, fatigue, health-related quality of life (HRQoL), and treatment-related morbidity. RESULTS:PA consisted of resistance training, aerobic exercise, and multimodal programs combining PA with education or behavioral support. PA was associated with improved functional performance, reduced fatigue, and moderate HRQoL gains. Resistance training increased lean body mass and strength. Early-phase and 12 to 24 week programs showed prominent effects. Supervised, individualized programs yielded higher adherence rates and better functional outcomes. Nonetheless, heterogeneity in protocols, outcome measures, and study quality limited comparability and precluded meta-analysis. CONCLUSIONS AND RELEVANCE:PA-supervised, multimodal, and early-initiated-offers promising benefits for PLWBOC. Future research should prioritize RCTs, standardized outcome measures, extended follow-up, and digital outreach to establish tailored exercise guidelines for this populations.
IMPORTANCE:By identifying which factors impact the physical function outcomes of pain therapies, health care providers can more effectively match therapies to individuals. This approach will ultimately improve the overall quality of pain management for diverse patient populations. OBJECTIVE:The objective of this study was to test the following research question: Does the effectiveness of complementary and integrative health (CIH) versus standard rehabilitative care (SRC) in improving physical function differ on the basis of participant characteristics? DESIGN:The study design was a moderator analysis of data collected during a pragmatic clinical trial using a sequential multiple assignment randomized trial design. SETTING:The setting was an interdisciplinary pain management center at a military medical center. PARTICIPANTS:The participants were a complete case sample of 249 active-duty service members with chronic pain. INTERVENTIONS:The interventions included a 3-week program of CIH therapies, consisting of twice-weekly chiropractic, acupuncture, yoga, and massage therapies, as well as a 3-week program of SRC, consisting of twice-weekly physical and occupational therapies. MAIN OUTCOMES AND MEASURES:Functional measure t scores were calculated from a treadmill, lift, and carry battery. RESULTS:Multiple linear regression models showed that the effect of CIH versus SRC on the functional performance measure was moderated by race, pain impact, pain catastrophizing, and satisfaction with social roles. CONCLUSIONS:CIH interventions may be most effective for individuals who are non-Hispanic White, and SRC interventions may be more effective for individuals who are non-Hispanic Black. Psychosocial factors that may improve intervention effectiveness include lower baseline pain impact and pain catastrophizing and higher satisfaction with social roles. RELEVANCE:This research underscores the importance of tailoring interventions to the individual. By considering individuals' demographics as well as their psychological and social factors, health care providers can more effectively match individuals with the most appropriate treatment approach, ultimately improving outcomes across multiple dimensions of physical function.
IMPORTANCE:Musculoskeletal (MSK) pain is common during pregnancy but referral rates to physical therapy and the influence of MSK pain management on satisfaction with prenatal care are unknown. OBJECTIVE:The objective was to obtain patient reports of pain during pregnancy, its impact on biopsychosocial wellbeing, health care management of pain (including referral to physical therapy), and the influence of pain management on satisfaction with prenatal care. DESIGN:The study design was an internet survey. SETTING:An e-survey was distributed internationally via social media, word-of-mouth, and flyers. PARTICIPANTS:Six hundred seventy-one female respondents from 6 continents who had given birth <25 months before survey completion participated in the study. INTERVENTIONS OR EXPOSURES:No interventions or exposures were included in this study. MAIN OUTCOMES & MEASURES:Presence and description of pain, influence of pain on daily life, pain management, birth experiences, and patient satisfaction were reported. Descriptive statistics were used to report frequencies. Comparisons between care provider types were made using non-parametric statistics (Fisher Exact Test, 2-tailed; or Fisher-Freedman-Halton Exact Test, 2-tailed). RESULTS:MSK pain was reported by 90% of participants, with more than 50% reporting pain in multiple body regions. Those who saw an Obstetrician-gynecologist were more likely to report pain, though both provider groups had high pain rates (92.7% vs 85%). Thermal therapy was the most common pain management recommendation (33.7%); physical therapy was recommended to only 29.4% of individuals with pregnancy-related musculoskeletal pain. Pain caused negative feelings/emotions in 77.2% of respondents and difficulty with performance of physical activity, household, and childcare tasks in approximately 50% of respondents. Care providers' response to pain influenced patient satisfaction in 49% of respondents. CONCLUSIONS AND RELEVANCE:Pregnancy MSK pain influences physical functioning, psychosocial wellbeing, and satisfaction with prenatal care. Patients report poor pain management by perinatal care providers, highlighting needs for better education, more pain management options, and multidisciplinary care. Physical therapists need to develop working relationships with prenatal care providers to improve care during pregnancy.
IMPORTANCE:Low back pain (LBP) clinical practice guidelines (CPGs) recommend using evidence-based active and manual treatments within a psychologically informed physical therapy (PIPT) framework, but the effectiveness of a combined, CPG-adherent approach remains understudied. OBJECTIVE:This trial evaluated the effectiveness of a CPG and PIPT (CPG+PIPT) implementation strategy in reducing LBP-related disability, pain, and downstream health care utilization. DESIGN:This was a multisite, stepped-wedge, cluster-randomized trial. SETTING:The locations were military and veteran health care settings. PARTICIPANTS:Data from patients seeking LBP care were collected during usual care, training, and post-training (CPG+PIPT) periods. INTERVENTIONS:Physical therapists from 6 clinics received CPG+PIPT training and monthly feedback reports regarding practice patterns and patient outcomes. MAIN OUTCOMES AND MEASURES:Primary outcomes were the Oswestry Disability Index (ODI) and the Defense and Veterans Pain Rating Scale (DVPRS), obtained at intake and regular intervals throughout treatment. LBP-related health care utilization data (opioid prescriptions, spinal injections, specialty care visits, hospitalizations, imaging) were extracted from medical databases 12 months after the index visit. Linear mixed models were used to test whether ODI and DVPRS trajectories improved after training. Generalized linear mixed models were used to compare LBP-related health care utilization between usual care and CPG+PIPT periods. RESULTS:Analysis included data from 2320 patients seen by 74 physical therapists. Patients reported moderate disability (ODI) and pain (DVPRS) at intake, which persisted throughout follow-up. Patients treated during the CPG+PIPT period had slightly more ODI and DVPRS improvements over time but no clinically meaningful differences at 6 and 12 weeks. The CPG+PIPT period was associated with a 30% reduction in 12-month opioid prescriptions, but patterns of other LBP-related encounters and physical therapist treatments were similar across periods. CONCLUSIONS:Despite promising improvements in opioid prescription rates, minimal changes in other practice patterns were observed, and differences in outcomes did not translate to clinically meaningful improvements. RELEVANCE:Findings underscore the complexity of implementing high-value LBP management strategies in military and veteran health care settings.
IMPORTANCE:The pragmatic clinical trial, Fibromyalgia TENS In Physical Therapy Study (FM-TIPS), includes 4 private practice physical therapy (PT) health care systems (HCS). Private practice HCS are the largest employers of physical therapists (43%) in the United States. This novel study shares the perspectives of the 4 private practice PT-HCS in the clinical trial - as most clinical research is completed at academic centers. These results may benefit both clinicians and researchers considering inclusion of physical therapy from non-academic settings in research. OBJECTIVES:This study shares perspectives and lived-experiences of the 4 private practice PT-HCS in FM-TIPS. DESIGN:A generic qualitative study including semi-structured, individual interviews and a focus group discussion. SETTING:An electronic platform and in-person observations were utilized. PARTICIPANTS:The directors of the four private PT-HCS in FM-TIPS participated. INTERVENTIONS:Individual interviews and focus group discussions were recorded electronically. Surveys of clinician characteristics were completed. MAIN OUTCOME AND MEASURES:Transcriptions were reviewed, coded, and analyzed. A priori codes were compared and combined into themes. Analysis of workforce characteristics compared study trained clinicians to national averages from the American Physical Therapy Association (APTA) for an understanding of clinics. RESULTS:Four themes emerged: Participation is not a burden; Private practice directors see benefits; Participation brings challenges and new opportunities; Private practice PT-HCS should participate in future research. The secondary analysis demonstrated clinicians had higher rates of professional membership and advanced training. CONCLUSION:With study team support, private practice PT-HCS participation is feasible and successful, provides benefits to the practice and clinicians, and should be considered for future research. RELEVANCE:These results are important information for all aspects of the physical therapy community- from clinicians to academic researchers. The viewpoints of these private practice physical therapy clinics differ from previous research experiences. Understanding facilitators and barriers can inform future clinical research.
Physical therapists are considered movement experts, yet many physical therapists lack the knowledge, training, and confidence to incorporate bioenergetic considerations when prescribing aerobic exercise and resistance training interventions. Additionally, clinical practice guidelines (CPGs) omit bioenergetic considerations reflecting a fundamental gap in how the profession conceptualizes rehabilitation, one that individual clinicians cannot be expected to bridge when CPGs themselves exclude the bioenergetic dimensions of health conditions. As this perspective outlines, bioenergetics are essential for propelling human movement and should inform physical therapist interventions. A bioenergetically informed approach to physical therapist interventions empowers physical therapists to design interventions that integrate physiologic systems critical to bioenergetic capacities more fully, optimizing both the mechanical components and fuel systems that power movement. This perspective uses recovery as a model framework to emphasize the benefits of a bioenergetically informed approach, and importantly, it serves as a component of rehabilitation that can be immediately acted on by clinicians, recognizing that optimal therapeutic outcomes require adequate bioenergetic capacity to support the intended applications. While physical therapists have traditionally excelled as biomechanical practitioners who address the structural and mechanical aspects of human movement, the integration of comprehensive bioenergetic principles represents a transformative opportunity to elevate clinical practice by understanding not only the machinery, but also the metabolic systems that fuel optimal performance.
IMPORTANCE:Although the Trunk Impairment Scale (TIS) is widely used in stroke rehabilitation, the quality and certainty of evidence regarding its measurement properties have been unclear. OBJECTIVE:The objective was to systematically evaluate the measurement properties of the TIS in individuals with stroke, using the COSMIN (COnsensus-based Standards for the selection of health Measurement INstruments) methodology. DATA SOURCES:Five electronic databases (PubMed, EBSCOhost, CINAHL, MEDLINE, and ICHUSHI) were searched from their inception dates to January 14, 2025. STUDY SELECTION:Studies assessing the psychometric properties of the TIS in individuals with stroke were included. DATA EXTRACTION AND SYNTHESIS:The studies' methodological quality was evaluated using the COSMIN Risk of Bias checklist. The certainty of evidence was rated using a modified GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach, and meta-analyses were conducted when appropriate. MAIN OUTCOMES AND MEASURES:The measurement properties evaluated were content validity, structural validity, cross-cultural validity, internal consistency, reliability, measurement error, criterion validity, construct validity, and responsiveness. RESULTS:Thirteen studies from 7 countries met the inclusion criteria, with sample sizes of 28 to 201 participants. Based on the modified GRADE approach, internal consistency showed "low" certainty of evidence, whereas all other measurement properties were rated as "very low" certainty due to methodological limitations, including lack of unidimensionality testing, insufficient hypothesis formulation, and poor reporting. A meta-analysis indicated acceptable pooled Cronbach α-values (mean α = .88) and high intra and interrater reliability (mean intraclass correlation coefficient [ICC] = 0.98), although heterogeneity and risk of bias reduced confidence in these findings. CONCLUSIONS AND RELEVANCE:Despite its widespread use, the TIS lacks high-quality psychometric evidence. Further validation studies using COSMIN-aligned methodology are needed to establish its reliability and validity in diverse stroke populations.
IMPORTANCE:Rural communities face poor health outcomes due to limited health care access and provider shortages. Physical therapists are increasingly recognized as potential contributors to primary care delivery, yet little is known about their actual roles in rural settings. OBJECTIVE:The objective of this study was to explore the unique professional experiences of physical therapists in the rural Upper Midwest. DESIGN:A qualitative, exploratory case study design was used. Data were collected through semi-structured interviews and field observations. Analysis included inductive, in-vivo coding methods and thematic analysis guided by the Culturally Sustaining Pedagogy theoretical framework. SETTING:This study was situated in 5 communities in a rural, Upper Midwest state. PARTICIPANTS:Five physical therapists with over 4.5 years of rural clinical experience were included in this study. RESULTS:Four key themes and associated subthemes were derived regarding the role of rural physical therapists: (1) operating as a primary care provider: physical therapists filled primary care roles through rurality-imposed autonomy, health care coordination, and health education; (2) employing a wide breadth of practice: therapists required broad generalist knowledge across practice settings; (3) patient-centeredness: patient-centered care involved fostering cultural norms and decentering of the therapist's own values; and (4) community integration: community engagement beyond their role as a physical therapist and understanding local culture were crucial for community acceptance and providing appropriate care. CONCLUSIONS:Physical therapists in rural communities in an Upper Midwest state are fulfilling expanded primary care roles to address health care shortages while deeply integrating within communities to provide appropriate and acceptable care. Their experiences highlight the complexity of rural health care delivery and potential for physical therapists to help alleviate provider shortages. RELEVANCE:As health care shortages persist in rural areas and the understanding the role of the primary care physical therapist continues to grow, this study shows that physical therapists are uniquely positioned to support primary care delivery.
IMPORTANCE:Anterior cruciate ligament (ACL) injury is a common sports injury with substantial physical and psychological consequences. Qualitative studies have explored patient experiences, but most studies use cross-sectional designs, limiting insight into how experiences evolve throughout rehabilitation. OBJECTIVE:The purpose of this study was to explore patients' experiences of ACL injury and recovery using a prospective, narrative approach, from injury to achievement of self-defined rehabilitation goals. DESIGN:This was a longitudinal qualitative study with narrative analysis. SETTING:The study was conducted at an outpatient sports rehabilitation clinic in Sweden. Participants: Four adults (ages 20 to 29 years; 2 male, 2 female) undergoing ACL reconstruction were included using consecutive sampling. INTERVENTION(S) OR EXPOSURE(S):Serial 1-to-1 semi-structured interviews were conducted around injury, pre-surgery, early post-surgery, and every 2 months until each participant achieved a rehabilitation goal defined at study entry. Interviews were analyzed using Narrative Oriented Inquiry with attention to story structure, tone, positioning, and context. MAIN OUTCOME(S) AND MEASURE(S):The main outcome were the evolving narratives of participants' recovery experiences, expressed through first-person interpretative stories. RESULTS:The longitudinal narratives revealed shifting identities, emotions, and meanings attached to rehabilitation milestones. One participant described moving from helplessness to renewed athletic identity; another portrayed a pragmatic recovery marked by monotony and team reintegration; a third experienced progress until a second ACL injury reframed priorities; and the fourth navigated prolonged knee pain, missed timelines, and gradual acceptance. Across cases, rehabilitation was experienced not as a linear sequence but as an ongoing negotiation of trust, belonging, and confidence. CONCLUSIONS AND RELEVANCE:Prospective narrative inquiry illuminated how recovery after ACL reconstruction is lived as a personal, evolving story. For physical therapists, recognizing the temporal dynamics of identity, trust, and confidence may support more individualized rehabilitation, complementing standardized protocols. These findings highlight the importance of attending to both physical and narrative dimensions of ACL recovery in clinical practice.
IMPORTANCE:Evidence-based practice (EBP) is a core competency in physical therapy. In 2015, France implemented a major reform of physical therapist education, extending training from 3 to 5 years and embedding EBP throughout the curriculum. However, whether this reform translates into improved EBP competencies remains unclear. OBJECTIVE:This study aimed to determine the impact of evidence-informed curriculum changes on EBP competencies among physical therapist graduates. DESIGN:This study was a national cross-sectional survey. SETTING:This study was conducted in France. PARTICIPANTS:The participants were French physical therapists trained under the pre-reform (1989 to 2015) and post-reform (2015 to present) curricula. INTERVENTION(S) OR EXPOSURE(S):The exposures included the 2015 reform of entry-level physical therapist education and participation in continuing education related to EBP. MAIN OUTCOME(S) AND MEASURE(S):EBP competencies were assessed using the Evidence-Based Practice Profile questionnaire (EBP2) and the Knowledge of Research Evidence Competencies test (K-REC). The EBP2 evaluates self-reported attitudes, confidence, EBP use, and understanding of research terminology. The K-REC measures applied knowledge of research evidence using a clinical scenario. RESULTS:A total of 168 physical therapists participated. Compared with pre-reform graduates, post-reform graduates had higher scores across most EBP domains, with the largest improvement in the "Knowledge" domain (effect size = 0.50). Moderate gains were observed in "Terminology" and smaller but significant improvements in "Confidence" and attitudes toward EBP. Despite these gains, only 35.1% of respondents achieved a passing score on the knowledge test, and self-reported EBP practice remained limited. Continuing education and curriculum reform exerted independent and additive effects. CONCLUSIONS AND RELEVANCE:The curriculum reform was associated with meaningful improvements in EBP competencies, particularly knowledge. However, important gaps remain between knowledge acquisition and routine clinical application, indicating that entry-level reform alone is insufficient to ensure sustained EBP implementation. These findings suggest that lifelong learning and supportive clinical environments remain necessary to achieve durable integration of evidence-based physical therapy.
OBJECTIVE:This study aimed to compare the effects of 7 physical therapy interventions delivered with Home Exercise Program (HEP) versus HEP alone on pain and function in plantar fasciitis (PF). DATA SOURCES:Studies were identified through PubMed, Embase, the Cochrane Library, Web of Science, and Scopus from database inception to January 2026. STUDY SELECTION:Randomized controlled trials (RCTs) comparing physical therapy interventions delivered with HEP versus HEP alone in individuals with PF were included. DATA EXTRACTION AND SYNTHESIS:A frequentist random-effects network meta-analysis was conducted.Outcomes were assessed at short-term (≤6 weeks), medium-term (6-12 weeks), and long-term (≥12 weeks) follow-up periods. Eight treatment nodes were analyzed: extracorporeal shock wave therapy, ultrasound therapy, manual therapy, taping, low-level laser therapy, orthoses, and dry needling, all delivered with HEP, and HEP alone as the control. Risk of bias was assessed using the Cochrane Risk-of-Bias tool, and the certainty of evidence was evaluated with the Confidence in Network Meta-Analysis framework. MAIN OUTCOMES AND MEASURES:Pain and functional outcomes were evaluated using standardized mean differences (SMDs) with 95% CIs. RESULTS:Twenty-four RCTs (1240 participants) were included. For pain outcomes, dry needling (DN) (SMD = -1.26, 95% CI = -2.25 to -0.28), low-level laser therapy (-1.54, -2.82 to -0.27), and manual therapy (MT) (-1.02, -1.82 to -0.21), delivered with HEP, resulted in clinically significant improvements in short-term pain (moderate-quality evidence). The pain-relieving effects of DN delivered with HEP were sustained in the medium term (-1.14, -1.62 to -0.66; high-quality evidence). For functional outcomes, DN (0.66, 0.13 to 1.19) and taping (0.84, 0.27 to 1.40), delivered with HEP, resulted in clinically significant improvements in short-term function (moderate-quality evidence). Additionally, DN with HEP sustained significant clinical improvements in medium-term function (1.06, 0.24 to 1.87; moderate-quality evidence). CONCLUSIONS AND RELEVANCE:When delivered with HEP, DN, low-level laser therapy, and MT provided clinically significant short-term improvements in pain compared to HEP alone, with DN and taping improving short-term functional outcomes. Dry needling further sustained its benefits in both pain and function into the medium term.
