BackgroundClinicians need innovative educational programs to enhance their capacity for using research evidence to inform clinical decision-making. This paper and its companion paper introduce the Physical therapist-driven Education for Actionable Knowledge translation (PEAK) program, an educational program designed to promote physical therapists’ integration of research evidence into clinical decision-making. This, second of two, papers reports a mixed methods feasibility study of the PEAK program among physical therapists at three university-based clinical facilities.MethodsA convenience sample of 18 physical therapists participated in the six-month educational program. Mixed methods were used to triangulate results from pre-post quantitative data analyzed concurrently with qualitative data from semi-structured interviews and focus groups. Feasibility of the program was assessed by evaluating change in participants’ attitudes, self-efficacy, knowledge, skills, and self-reported behaviors in addition to their perceptions and reaction to the program.ResultsAll 18 therapists completed the program. The group experienced statistically significant improvements in evidence based practice self-efficacy and self-reported behavior (p < 0.001). Four themes were supported by integrated quantitative and qualitative results: 1. The collaborative nature of the PEAK program was engaging and motivating; 2. PEAK participants experienced improved self-efficacy, creating a positive cycle where success reinforces engagement with research evidence; 3. Participants’ need to understand how to interpret statistics was not fully met; 4. Participants believed that the utilization of research evidence in their clinical practice would lead to better patient outcomes.ConclusionsThe PEAK program is a feasible educational program for promoting physical therapists’ use of research evidence in practice. A key ingredient seems to be guided small group work leading to a final product that guides local practice. Further investigation is recommended to assess long-term behavior change and to compare outcomes to alternative educational models.

BackgroundEvidence is needed to develop effective educational programs for promoting evidence based practice (EBP) and knowledge translation (KT) in physical therapy. This study reports long-term outcomes from a feasibility assessment of an educational program designed to promote the integration of research evidence into physical therapist practice.MethodsEighteen physical therapists participated in the 6-month Physical therapist-driven Education for Actionable Knowledge translation (PEAK) program. The participant-driven active learning program consisted of four consecutive, interdependent components: 1) acquiring managerial leadership support and electronic resources in three clinical practices, 2) a 2-day learner-centered EBP training workshop, 3) 5 months of guided small group work synthesizing research evidence into a locally relevant list of, actionable, evidence-based clinical behaviors for therapists treating persons with musculoskeletal lumbar conditions--the Best Practices List, and 4) review and revision of the Best Practices List, culminating in participant agreement to implement the behaviors in practice. Therapists’ EBP learning was assessed with standardized measures of EBP-related attitudes, self-efficacy, knowledge and skills, and self-reported behavior at baseline, immediately-post, and 6 months following conclusion of the program (long-term follow-up). Therapist adherence to the Best Practice List before and after the PEAK program was assessed through chart review.ResultsSixteen therapists completed the long-term follow-up assessment. EBP self-efficacy and self-reported behaviors increased from baseline to long-term follow-up (p < 0.001 and p = 0.002, respectively). EBP-related knowledge and skills showed a trend for improvement from baseline to long-term follow-up (p = 0.05) and a significant increase from immediate-post to long-term follow-up (p = 0.02). Positive attitudes at baseline were sustained throughout (p = 0.208). Eighty-nine charts were analyzed for therapist adherence to the Best Practices List. Six clinical behaviors had sufficient pre- and post-PEAK charts to justify analysis. Of those, one behavior showed a statistically significant increase in adherence, one had high pre- and post-PEAK adherence, and four were change resistant, starting with low adherence and showing no meaningful improvement.ConclusionsThis study supports the feasibility of the PEAK program to produce long-term improvements in physical therapists’ EBP-related self-efficacy and self-reported behavior. EBP knowledge and skills showed improvement from post-intervention to long-term follow-up and a trend toward long-term improvements. However, chart review of therapists’ adherence to the participant generated Best Practices List in day-to-day patient care indicates a need for additional support to facilitate behavior change. Future versions of the PEAK program and comparable multi-faceted EBP and KT educational programs should provide ongoing monitoring, feedback, and problem-solving to successfully promote behavio...

Study Design Cross-sectional. Background The scapular dyskinesis test (SDT) has demonstrated reliability and validity, but its utility for clinical decision making is unclear. Objectives To characterize the prevalence of scapular dyskinesis in participants with and without shoulder pain, and to determine the influence of blinding to the presence of shoulder pain on prevalence of scapular dyskinesis. Methods Participants (n = 135), 67 with shoulder pain and 68 healthy controls, were included in this study. The SDT was performed by 2 examiners, from a total of 21 physical therapists. The second examiner was blinded to the participant's presence of shoulder pain. The SDT involved participants performing 5 repetitions of shoulder flexion and abduction, while the clinician observed for scapular dyskinesis, as characterized by scapular winging or dysrhythmia. Dyskinesis was rated as normal, subtle, or obvious. Ratings were collapsed into 2 groups, dyskinesis (subtle and obvious) and no dyskinesis (normal), as recommended by expert consensus. Results There were no significant differences for scapular dyskinesis prevalence between the shoulder pain group and control group during the SDT in abduction (shoulder pain, 67.2%; 95% confidence interval [CI]: 0.55, 0.77 and control group, 52.9%; 95% CI: 0.41, 0.64; P = .09) or flexion (shoulder pain, 67.2%; 95% CI: 0.55, 0.77 and control group, 61.8%; 95% CI: 0.50, 0.72; P = .51). There were significant differences (P ≤001) between the examiners' SDT ratings in the shoulder pain group. The unblinded examiner reported a higher prevalence when testing the involved shoulder for dyskinesis in flexion (blinded, 67.7%; 95% CI: 0.56, 0.78 and unblinded, 80%; 95% CI: 0.69, 0.88) and during abduction (blinded, 66.2%; 95% CI: 0.54, 0.76 and unblinded, 78.5%; 95% CI: 0.67, 0.87). Conclusion Scapular dyskinesis as assessed with the SDT is not more prevalent in those with shoulder pain. Rating was influenced by an examiner's knowledge of shoulder pain presence. Scapular dyskinesis may represent normal movement variability. Level of Evidence Diagnosis, level 4. J Orthop Sports Phys Ther 2017;47(8):530-537. Epub 6 Jul 2017. doi:10.2519/jospt.2017.7268.

A 15-year-old baseball pitcher presented to physical therapy with a 1-week history of acute right shoulder pain experienced during the acceleration phase of throwing. The week after physical therapy evaluation, the patient returned with radiographs and magnetic resonance imaging results that revealed lateral physeal widening with adjacent edema. Additionally, a nondisplaced labral tear was noted. In this case, imaging was necessary for an accurate diagnosis of lateral physeal widening, commonly referred to as "Little League shoulder." J Orthop Sports Phys Ther 2018;48(1):51. doi:10.2519/jospt.2018.7369.

Background:Rehabilitation after repair of the anterior cruciate ligament (ACL) is complicated by the loss of leg muscle mass and strength. Prior studies have shown that preoperative rehabilitation may improve muscle strength and postoperative outcomes. Testosterone supplementation may likewise counteract this muscle loss and potentially improve clinical outcomes.Purpose:The purpose was to investigate the effect of perioperative testosterone administration on lean mass after ACL reconstruction in men and to examine the effects of testosterone on leg strength and clinical outcome scores. It was hypothesized that testosterone would increase lean mass and leg strength and improve clinical outcome scores relative to placebo.Study Design:Randomized controlled trial; Level of evidence, 1.Methods:Male patients (N = 13) scheduled for ACL reconstruction were randomized into 2 groups: testosterone and placebo. Participants in the testosterone group received 200 mg of intramuscular testosterone weekly for 8 weeks beginning 2 weeks before surgery. Participants in the placebo group received saline following the same schedule. Both groups participated in a standard rehabilitation protocol. The primary outcome was the change in total lean body mass at 6 and 12 weeks. Secondary outcomes were extensor muscle strength, Tegner activity score, and Knee injury and Osteoarthritis Outcome Score.Results:There was an increase in lean mass of a mean 2.7 ± 1.7 kg at 6 weeks postoperatively in the testosterone group compared with a decrease of a mean 0.1 ± 1.5 kg in the placebo group (P = .01). Extensor muscle strength of the uninjured leg also increased more from baseline in the testosterone group (+20.8 ± 25.6 Nm) compared with the placebo group (–21.4 ± 36.7 Nm) at 12 weeks (P = .04). There were no significant between-group differences in injured leg strength or clinical outcome scores. There were no negative side effects of testosterone noted.Conclusion:Perioperative testosterone supplementation increased lean mass 6 weeks after ACL reconstruction, suggesting that this treatment may help minimize the effects of muscle atrophy associated with ACL injuries and repair. This study was not powered to detect differences in strength or clinical outcome scores to assess the incidence of testosterone-related adverse events.Clinical Relevance:Supraphysiological testosterone supplementation may be a useful adjunct therapy for counteracting muscle atrophy after ACL reconstruction. Further investigation is necessary to determine the safety profile and effects of perioperative testosterone administration on leg strength and clinical outcomes after surgery.Registration:NCT01595581 (ClinicalTrials.gov).

BackgroundThe anterior cruciate ligament (ACL) is one of four major ligaments in the knee that provide stability during physical activity. A tear in the ACL is characterized by joint instability that leads to decreased activity, knee dysfunction, reduced quality of life and a loss of muscle mass and strength. While rehabilitation is the standard-of-care for return to daily function, additional surgical reconstruction can provide individuals with an opportunity to return to sports and strenuous physical activity. Over 200,000 ACL reconstructions are performed in the United States each year, and rehabilitation following surgery is slow and expensive. One possible method to improve the recovery process is the use of intramuscular testosterone, which has been shown to increase muscle mass and strength independent of exercise. With short-term use of supraphysiologic doses of testosterone, we hope to reduce loss of muscle mass and strength and minimize loss of physical function following ACL reconstruction compared to standard-of-care alone.Methods/designThis study is a double-blinded randomized control trial. Men 18–50 years of age, scheduled for ACL reconstruction are randomized into two groups. Participants randomized to the testosterone group receive intramuscular testosterone administration once per week for 8 weeks starting 2 weeks prior to surgery. Participants randomized to the control group receive a saline placebo intramuscularly instead of testosterone. Lean mass, muscle strength and physical function are measured at 5 time points: 2 weeks pre-surgery, 1 day pre-surgery, and 6, 12, 24 weeks post-surgery. Both groups follow standard-of-care rehabilitation protocol.DiscussionWe believe that testosterone therapy will help reduce the loss of muscle mass and strength experienced after ACL injury and reconstruction. Hopefully this will provide a way to shorten the rehabilitation necessary following ACL reconstruction. If successful, testosterone therapy may also be used for other injuries involving trauma and muscle atrophy.Trial registrationNTC01595581, Registration: May 8, 2012

Objectives:Surgical reconstruction of the anterior cruciate ligament (ACL) is essential for those who wish to resume athletic activity following ACL rupture. However, the trauma of surgical repair and post-operative immobility can exacerbate muscle loss and strength. This study investigated the effect of perioperative testosterone administration on lean mass recovery following ACL reconstruction in men. The effects of testosterone on leg strength and clinical outcome scores were also investigated. We hypothesized that testosterone would increase lean mass and leg strength, and improve clinical outcome scores 6 and 12 weeks after surgery to a greater degree than placebo.Methods:This was a randomized, controlled, double blinded clinical trial comparing testosterone and placebo for recovery from ACL repair. Thirteen male subjects scheduled for ACL reconstruction were randomized into two groups, testosterone (n=6) and placebo (n=7). Participants in the testosterone group received 200 mg of testosterone administration weekly for 8 weeks starting 2 weeks prior to surgery. Participants in the control group received a saline placebo intramuscularly following the same schedule. Both intervention groups underwent standard physical rehabilitation. The primary outcome was change in total lean body mass at 6 and 12 weeks, measured by whole-body dual-energy x-ray absorptiometry. Secondary outcomes were extensor muscle strength measured using a Cybex Dynamometer, and the Tegner Activity Score (TAS) and Knee Injury and Osteoarthritis Outcome Score (KOOS).Results:Total testosterone levels in the blood increased from baseline to an average of 860 ± 254 ng/dL by 1 day prior to surgery and 746 ± 173 ng/dL at 6 weeks post-surgery for the testosterone group. The differences in serum testosterone levels between the placebo and testosterone groups at 1 day prior to surgery and 6 weeks post-surgery were both statistically significant (p<0.001). We found that testosterone increased lean mass by 2.8 ± 1.7 kg from baseline at 6 weeks following surgery, while the placebo group had a decrease in lean muscle mass of 0.1 ± 1.5 kg (p=0.01) (Figure 1). Extensor strength of the non-injured leg had a greater increase from baseline in the testosterone group (20.8 ± 25.6 Nm) than the placebo group (-21.4 ± 36.7 Nm) at 12 weeks (p=0.02). There were no significant differences in injured leg strength or clinical outcome scores throughout the study period.Conclusion:Despite a catabolic environment, acute testosterone supplementation increased lean mass 6 weeks after ACL reconstruction, and strength of the non-injured leg 12 weeks after surgery, to a greater degree than placebo. These results suggest that testosterone may be a novel, useful adjunct to physical therapy for knee surgery rehabilitation by offsetting perioperative muscle loss from surgery and immobility. Larger studies are now necessary to elucidate the effects of perioperative testosterone administration on injured leg strength and clinical outcomes following surgery.

Differential diagnosis, level 4.