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1.  Therapist Factors and Outcomes in CBT for Anxiety in Youth 
This study examined the relationship between therapist factors and child outcomes in anxious youth who received cognitive–behavioral therapy (CBT) as part of the Child–Adolescent Anxiety Multimodal Study (CAMS). Of the 488 youth who participated in the CAMS project, 279 were randomly assigned to one of the CBT conditions (CBT only or CBT plus sertraline). Participants included youth (ages 7–17; M = 10.76) who met criteria for a principal anxiety disorder. Therapists included 38 cognitive–behavioral therapists. Therapist style, treatment integrity, and therapist experience were examined in relation to child outcome. Child outcome was measured via child, parent, and independent evaluator report. Therapists who were more collaborative and empathic, followed the treatment manual, and implemented it in a developmentally appropriate way had youth with better treatment outcomes. Therapist “coach” style was a significant predictor of child-reported outcome, with the collaborative “coach” style predicting fewer child-reported symptoms. Higher levels of therapist prior clinical experience and lower levels of prior anxiety-specific experience were significant predictors of better treatment outcome. Findings suggest that although all therapists used the same manual-guided treatment, therapist style, experience, and clinical skills were related to differences in child outcome. Clinical implications and recommendations for future research are discussed.
PMCID: PMC4240521  PMID: 25419042
cognitive-behavioral therapy; child anxiety; therapist factors; collaboration; coach style
2.  Can Psychotherapists Function as Their Own Controls? Meta-Analysis of the “Crossed Therapist” Design in Comparative Psychotherapy Trials 
Clinical trials sometimes have the same therapists deliver more than one psychotherapy, ostensibly to control for therapist effects. This “crossed therapists” design makes controlling for therapist allegiance imperative, as therapists may prefer one treatment they deliver to the other(s). Research has established a strong relationship between principal investigators’ allegiances and treatment outcome. Study therapists’ allegiances probably also influence outcome, yet this moderating factor on outcome has never been studied.
Data Sources
English language abstracts in Psychinfo and MedLine from January 1985 to December 2011 were searched for keywords “psychotherapy” and “randomized trial.”
Study Selection
The search yielded 990 abstracts that were searched manually. Trials using the same therapists in more than one condition were included.
Data extraction
Thirty-nine studies fulfilled inclusion criteria. Meta-regression analyses assessed the influence of researchers’ allegiance on treatment outcome, testing the hypothesis that studies poorly controlling for therapist allegiance would show stronger influence of researcher allegiance on outcome. A single-item measure assessed researchers’ reported attempts to control for therapist allegiance.
Only one (3%) of 39 studies measured therapist treatment allegiance. Another five (13%) mentioned controlling for, without formally assessing, therapist allegiance. Most publications (64%) did not even mention therapist allegiance. In studies not controlling for therapist allegiance, researcher allegiance strongly influenced outcome, whereas studies reporting control for therapist allegiance showed no differential researcher allegiance. Cognitive-behavioral trials less frequently described controlling for therapist allegiance.
The “crossed therapist” design is subject to bias due to differential psychotherapist allegiance. Worrisome results suggest that researchers strongly allied to a treatment may ignore therapist allegiance, potentially skewing outcomes. All clinical trials, and especially “crossed therapist” designs, should measure psychotherapist allegiance to evaluate this possible bias. One of the sacrosanct assumptions of a client is that their therapist believes in the treatment being delivered. -- Wampold, 2001 (1, p159)
PMCID: PMC3683365  PMID: 23146326
3.  Assessing the influence of treating therapist and patient prognostic factors on recovery from axial pain 
Limited research exists regarding the influence of a treating physical therapist on patient recovery (deemed therapist effects). Recent randomized clinical trials data provide an indication of small therapist effects for manual therapy; however, the extent to which therapist effects exist in the average outpatient facility is not clear. Moreover, patient-related prognostic factors, like fear-avoidance or pain duration, are important to consider since these may also influence the extent of therapist effects.
To assess therapist effects and the influence of patient prognostic factors on recovery from axial pain in an outpatient orthopedic physical therapy facility.
Clinical data were collected from consecutive patients with musculoskeletal neck and low back pain. Patient outcomes included pain intensity (visual analog scale) and functional measure (CareConnections functional outcomes index) scores. Therapist effects estimates and the influence of intake fear-avoidance (fear-avoidance beliefs questionnaire) and pain duration (days) were examined using multilevel linear or regression modeling.
A total of 258 patients (160 females; mean age 46.4±14.9 years) completed physical therapy and the required outcome measures. Five physical therapists (1–13 years of experience, mean 5.8 years) provided treatment. Therapists effects did not exist for discharge pain intensity or function after accounting for intake scores (P > 0.05). Further, therapist experience did not influence patient outcomes. Patient prognostic factors of fear-avoidance and pain duration did not influence therapists effects on the same patient outcome measures (P > 0.05).
Preliminary findings suggest that there are no major differences in patient outcome based on either the individual therapist (therapist effect) or therapist experience in this type of PT setting. Established prognostic factors had no influence on therapist effects for this cohort. Future analyses should consider intrinsic therapist factors (beliefs, equipoise), specific treatment parameters (dosage, type), and other patient prognostic factors (psychological, age, expectation, satisfaction) to further elucidate the influence of therapist effects.
PMCID: PMC3822318  PMID: 24421631
Therapist effects; Fear-avoidance; Pain; Function
4.  Promoting physical therapists’ use of research evidence to inform clinical practice: part 2 - a mixed methods evaluation of the PEAK program 
BMC Medical Education  2014;14:126.
Clinicians 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.
A 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.
All 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.
The 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.
PMCID: PMC4080990  PMID: 24965574
Knowledge translation; Evidence based practice; Education; Post-graduate training; Physical therapy; Mixed methods
5.  A formative evaluation of the implementation of an upper limb stroke rehabilitation intervention in clinical practice: a qualitative interview study 
The Graded Repetitive Arm Supplementary Program (GRASP) is a hand and arm exercise programme designed to increase the intensity of exercise achieved in inpatient stroke rehabilitation. GRASP was shown to be effective in a randomised controlled trial in 2009 and has since experienced unusually rapid uptake into clinical practice. The aim of this study was to conduct a formative evaluation of the implementation of GRASP to inform the development and implementation of a similar intervention in the United Kingdom.
Semi-structured interviews were conducted with therapists who were involved in implementing GRASP at their work site, or who had experience of using GRASP. Normalisation Process Theory (NPT), a sociological theory used to explore the processes of embedding innovations in practice, was used to develop an interview guide. Intervention components outlined within the GRASP Guideline Manual were used to develop prompts to explore how therapists use GRASP in practice. Interview transcripts were analysed using a coding frame based on implementation theory.
Twenty interviews were conducted across eight sites in British Columbia Canada. Therapists identified informal networks and the free online availability of GRASP as key factors in finding out about the intervention. All therapists reported positive opinions about the value of GRASP. At all sites, therapists identified individuals who advocated for the use of GRASP, and in six of the eight sites this was the practice leader or senior therapist. Rehabilitation assistants were identified as instrumental in delivering GRASP in almost all sites as they were responsible for organising the GRASP equipment and assisting patients using GRASP. Almost all intervention components were found to be adapted to some degree when used in clinical practice; coverage was wider, the content adapted, and the dose, when monitored, was less.
Although GRASP has translated into clinical practice, it is not always used in the way in which it was shown to be effective. This formative evaluation has informed the development of a novel intervention which aims to bridge this evidence-practice gap in upper limb rehabilitation after stroke.
Electronic supplementary material
The online version of this article (doi:10.1186/s13012-014-0090-3) contains supplementary material, which is available to authorized users.
PMCID: PMC4156624  PMID: 25112430
6.  Training family therapists: an experimental analysis. 
This study implemented and evaluated a training program (a written manual, videotaped models, rehearsal, role plays, and performance feedback) designed to teach five subjects the skills to become effective family therapists. The study examined the therapists' use of three target behaviors: instructing, informing, and praising. The therapists, each paired with a parent and a preschool-aged child (2 1/2-4 1/2 yr old), were trained in the clinic to use, and to teach to the parents, several behavioral skills (e.g., praising, planned ignoring, and time-out) relevant to teaching children compliance to parental instructions. A multiple-baseline design across triads (therapist/parent/child) demonstrated that after the training program was instituted, the therapists increased their rates of instructing, praising, and informing the parents; all parents increased attention to compliance, decreased attention to noncompliance, and increased rates of praise to their children; and all children increased their compliance and decreased their noncompliance.
PMCID: PMC1308298  PMID: 7153188
7.  Embracing change: practical and theoretical considerations for successful implementation of technology assisting upper limb training in stroke 
Rehabilitation technology for upper limb training of stroke patients may play an important role as therapy tool in future, in order to meet the increasing therapy demand. Currently, implementation of this technology in the clinic remains low. This study aimed at identifying criteria and conditions that people, involved in development of such technology, should take into account to achieve a (more) successful implementation of the technology in the clinic.
A literature search was performed in PubMed and IEEE databases, and semi-structured interviews with therapists in stroke rehabilitation were held, to identify criteria and conditions technology should meet to facilitate (implementation of) technology-assisted arm-hand skills training in rehabilitation therapy of stroke patients. In addition, an implementation strategy frequently applied in general health care was used to compose a stepwise guidance to facilitate successful implementation of this technology in therapy of stroke patients. Implementation-related criteria mentioned by therapists during the interviews were integrated in this guidance.
Results indicate that, related to therapy content, technology should facilitate repetition of task-related movements, tailored to the patient and patient’s goals, in a meaningful context. Variability and increasing levels of difficulty in exercises should be on offer. Regarding hardware and software design of technology, the system should facilitate quick familiarisation and be easily adjustable to individual patients during therapy by therapists (and assistants). The system should facilitate adaptation to individual patients’ needs and their progression over time, should be adjustable as to various task-related variables, should be able to provide instructions and feedback, and should be able to document patient’s progression. The implementation process of technology in the clinic is provided as a stepwise guidance that consists of five phases therapists have to go through. The guidance includes criteria and conditions that motivate therapists, and make it possible for them, to actually use technology in their daily clinical practice.
The reported requirements are important as guidance for people involved in the development of rehabilitation technology for arm-hand therapy of stroke patients. The stepwise guide provides a tool for facilitating successful implementation of technology in clinical practice, thus meeting future therapy demand.
PMCID: PMC3480833  PMID: 22856548
Stroke; Brain injury; Rehabilitation; Upper limb; Upper extremity; Therapy; Technology; Implementation
8.  Therapist Interventions in Early Sessions of Brief Supportive-Expressive Psychotherapy for Depression 
Although psychotherapy manuals provide treatment guidelines, detailed descriptions of therapist interventions in manual-guided therapies are lacking. The purpose of the present investigation was to evaluate the types of therapist interventions in Supportive-Expressive (SE) psychotherapy for depression by using a molecular method of assessment and then to compare the results with those attained with a molar method. Four percent of therapist statements per session early in treatment were interpretations, which most often focused on the patient's parents, significant others, and self in the present time frame. This molecular method for assessing therapist interventions did converge with the molar adherence/competence method. (The Journal of Psychotherapy Practice and Research 1998; 7:290–300)
PMCID: PMC3330510  PMID: 9752640
9.  OSCE-based Clinical Skill Education for Physical and Occupational Therapists 
Journal of Physical Therapy Science  2014;26(9):1387-1397.
[Purpose] The aim of this study was to examine the applicability of the Objective Structured Clinical Examination (OSCE) to postgraduate education systems for novice and mid-career therapists in workplaces. [Subjects] Physical and occupational therapists with 1 to 5 years of clinical experience took the OSCE to assess their learning, with a physical or occupational therapy faculty member and a clinical supervisor as examiners. Another clinical supervisor acted as a simulated patient. [Methods] A Wilcoxon signed-rank test was performed to compare skills between before and after OSCE-based learning, and a Mann-Whitney U test was used to compare them between therapists with 1 to 2 years (novice) and 3 to 5 years (mid-career) of clinical experience. [Results] While no experience-related differences were observed in behavioral aspects, mid-career therapists exhibited markedly higher scores compared with novices in technical aspects, such as skills to guide patients for standing up, transfer, and dressing. [Conclusion] The OSCE may be sufficiently applicable to postgraduate education systems in workplaces.
PMCID: PMC4175242  PMID: 25276021
OSCE; Clinical skill; Physical and occupational therapists
10.  Development and Initial Evaluation of an Internet-Based Support System for Face-to-Face Cognitive Behavior Therapy: A Proof of Concept Study 
Evidence-based psychological treatments, such as cognitive behavior therapy (CBT), have been found to be effective in treating several anxiety and mood disorders. Nevertheless, issues regarding adherence are common, such as poor patient compliance on homework assignments and therapists’ drifting from strictly evidence-based CBT. The development of Internet-delivered CBT (ICBT) has been intensive in the past decade and results show that guided ICBT can be as effective as face-to-face CBT but also indicate a need to integrate the two forms of CBT delivery.
In this study, we developed and tested a new treatment format in which ICBT and face-to-face therapy were blended. We designed a support system accessible via the Internet (using a computer or an Apple iPad) for patients and therapists delivering CBT face-to-face. The support system included basic CBT components and a library of interventions gathered from existing ICBT manuals.
The study involved 15 patients with mild to moderate anxiety or depression (or both). Eight therapists conducted the treatments. All participants were interviewed after the nine-week intervention. Further, patients provided self-reports on clinical measures pre- and post-trial, as well as at a 12-month follow-up.
A reduction was found in symptom scores across all measures. The reliable change index ranged from 60% to 87% for depression and anxiety. Large effect sizes (Cohen’s d) ranging from 1.62 (CI 95% 0.59-2.66) to 2.43 (CI 95% 1.12-3.74) were found. There were no missing data and no treatment dropouts. In addition, the results had been maintained at the 12-month follow-up. Qualitative interviews revealed that the users perceived the support system as beneficial.
The results suggest that modern information technology can effectively blend with face-to-face treatments and be used to facilitate communication and structure in therapy, thus reducing therapist drift.
PMCID: PMC3868964  PMID: 24326065
cognitive behavior therapy; Internet; anxiety; depression; Apple iPad
11.  Mapping intended spinal site of care from the upright to prone position: an interexaminer reliability study 
Upright examination procedures like radiology, thermography, manual muscle testing, and spinal motion palpation may lead to spinal interventions with the patient prone. The reliability and accuracy of mapping upright examination findings to the prone position is unknown. This study had 2 primary goals: (1) investigate how erroneous spine-scapular landmark associations may lead to errors in treating and charting spine levels; and (2) study the interexaminer reliability of a novel method for mapping upright spinal sites to the prone position.
Experiment 1 was a thought experiment exploring the consequences of depending on the erroneous landmark association of the inferior scapular tip with the T7 spinous process upright and T6 spinous process prone (relatively recent studies suggest these levels are T8 and T9, respectively). This allowed deduction of targeting and charting errors. In experiment 2, 10 examiners (2 experienced, 8 novice) used an index finger to maintain contact with a mid-thoracic spinous process as each of 2 participants slowly moved from the upright to the prone position. Interexaminer reliability was assessed by computing Intraclass Correlation Coefficient, standard error of the mean, root mean squared error, and the absolute value of the mean difference for each examiner from the 10 examiner mean for each of the 2 participants.
The thought experiment suggesting that using the (inaccurate) scapular tip landmark rule would result in a 3 level targeting and charting error when radiological findings are mapped to the prone position. Physical upright exam procedures like motion palpation would result in a 2 level targeting error for intervention, and a 3 level error for charting. The reliability experiment showed examiners accurately maintained contact with the same thoracic spinous process as the participant went from upright to prone, ICC (2,1) = 0.83.
As manual therapists, the authors have emphasized how targeting errors may impact upon manual care of the spine. Practitioners in other fields that need to accurately locate spinal levels, such as acupuncture and anesthesiology, would also be expected to draw important conclusions from these findings.
PMCID: PMC4046139  PMID: 24904747
12.  Is Low Therapist Empathy Toxic? 
One of the largest determinants of client outcomes is the counselor who provides treatment. Therapists often vary widely in effectiveness, even when delivering standardized manual-guided treatment. In particular, the therapeutic skill of accurate empathy originally described by Carl Rogers has been found to account for a meaningful proportion of variance in therapeutic alliance and in addiction treatment outcomes. High-empathy counselors appear to have higher success rates regardless of theoretical orientation. Low-empathy and confrontational counseling, in contrast, has been associated with higher drop-out and relapse rates, weaker therapeutic alliance and less client change. The authors propose emphasis on empathic listening skills as an evidence-based practice in the hiring and training of counselors to improve outcomes and prevent harm in addiction treatment.
PMCID: PMC3558610  PMID: 23025709
Background and Purpose:
Distal biceps brachii tendinosis is a relatively uncommon clinical diagnosis seen by physical therapists. As a result, there is little evidence guiding clinical decisions regarding best practice or effective treatment options to restore individuals to their previous level of function. The purpose of this case report is to describe the use of eccentric training as the primary intervention in the rehabilitation of a patient with distal biceps tendinosis.
Case Description:
A 41-year-old male electrician and collegiate wrestling coach presented to a university outpatient physical therapy clinic with a two month duration of pain in the right antecubital space which occurred when the patient was performing close-grip body weight curl ups for the first time. Sharp pain was noted in the right arm during the lowering phase of the exercise. Following the examination, distal biceps tendinosis appeared to be the likely diagnosis. The patient was educated in eccentric exercise principles and was prescribed eccentric loading exercises for the distal biceps brachii tendon in two different positions of elbow flexion.
The patient was seen in physical therapy for three visits over the course of four weeks. Following eccentric training, the patient reported decreased pain, demonstrated increased right elbow flexion and forearm supination strength, was no longer tender to palpation of the distal biceps tendon and showed clinically significant improvement in QuickDASH scores.
Given the lack of available research on the rehabilitation of distal biceps tendinosis, eccentric training showing benefits with other upper quarter tendinoses and the positive outcomes in this case, it may be appropriate for physical therapists to employ eccentric training for patients with distal biceps tendinosis.
Level of Evidence:
5 (Single case report)
PMCID: PMC3414073  PMID: 22893861
distal biceps; eccentric exercise; tendinosis
14.  Blending online therapy into regular face-to-face therapy for depression: content, ratio and preconditions according to patients and therapists using a Delphi study 
BMC Psychiatry  2014;14(1):355.
Blending online modules into face-to-face therapy offers perspectives to enhance patient self-management and to increase the (cost-)effectiveness of therapy, while still providing the support patients need. The aim of this study was to outline optimal usage of blended care for depression, according to patients and therapists.
A Delphi method was used to find consensus on suitable blended protocols (content, sequence and ratio). Phase 1 was an explorative phase, conducted in two rounds of online questionnaires, in which patients’ and therapists’ preferences and opinions about online psychotherapy were surveyed. In phase 2, data from phase 1 was used in face-to-face interviews with therapists to investigate how blended therapy protocols could be set up and what essential preconditions would be.
Twelve therapists and nine patients completed the surveys. Blended therapy was positively perceived among all respondents, especially to enhance the self-management of patients. According to most respondents, practical therapy components (assignments, diaries and psycho-education) may be provided via online modules, while process-related components (introduction, evaluation and discussing thoughts and feelings), should be supported face-to-face. The preferred blend of online and face-to-face sessions differs between therapists and patients; most therapists prefer 75% face-to-face sessions, most patients 50 to 60%. The interviews showed that tailoring treatment to individual patients is essential in secondary mental health care, due to the complexity of their problems. The amount and ratio of online modules needs to be adjusted according to the patient’s problems, skills and characteristics. Therapists themselves should also develop skills to integrate online and face-to-face sessions.
Blending online and face-to-face sessions in an integrated depression therapy is viewed as a positive innovation by patients and therapists. Following a standard blended protocol, however, would be difficult in secondary mental health care. A database of online modules could provide flexibility to tailor treatment to individual patients, which asks motivation and skills of both patients and therapists. Further research is necessary to determine the (cost-)effectiveness of blended care, but this study provides starting points and preconditions to blend online and face-to-face sessions and create a treatment combining the best of both worlds.
PMCID: PMC4271498  PMID: 25496393
15.  Therapist Predictors of Treatment Delivery Fidelity in a Community Based Trial of 12-Step Facilitation 
Background and aims
Therapist characteristics may be associated with variation in consistency, quality and effectiveness of treatment delivery. We examined associations between treatment fidelity and therapist education, experience, treatment orientation, and perceived skills in a randomized, multi-site trial of Twelve Step Facilitation (TSF).
Raters scored audio-recorded, TSF sessions (n = 966; 97% of TSF sessions) from 32 community-based, trained therapists for adherence, competence, empathy, and global session performance.
Therapists with graduate degrees had significantly higher adherence and global performance fidelity ratings. Therapists reporting more positive attitudes towards 12-Step groups had lower adherence ratings. Being in recovery was associated with lower fidelity in univariate tests, but higher adherence in multivariate analysis. Fidelity was higher for therapists reporting self-efficacy in basic counseling skills and lower for self-efficacy in addiction-specific counseling skills. Fidelity was also superior in group relative to individual TSF sessions.
Results have implications for therapist selection, training and supervision in community-based, effectiveness trials and community implementation of evidence-based treatments. To obtain high fidelity and improve outcomes, it may be preferable to choose masters level therapists who are open to learning new treatments and have good, general counseling skills.
PMCID: PMC3959728  PMID: 23837717
Treatment fidelity; Twelve-Step Facilitation; therapist characteristics
16.  Reducing therapist contact in cognitive behaviour therapy for panic disorder and agoraphobia in primary care: global measures of outcome in a randomised controlled trial. 
BACKGROUND: Panic disorder, with and without agoraphobia, is a prevalent condition presenting in general practice. Psychological treatments are effective but are limited by restricted availability. Interest has grown in methods by which the efficiency and thus availability of psychological treatments can be improved, with particular emphasis on reduced therapist contact formats. AIM: To evaluate the relative efficacy in a primary care setting of a cognitive behaviour therapy (CBT) delivered at three levels of therapist contact: standard contact, minimum contact, and bibliotherapy. METHOD: A total of 104 patients were randomly allocated to receive standard therapist contact, minimum therapist contact or bibliotherapy, with 91 patients completing treatment. All patients received an identical treatment manual and were seen by the same psychologist therapist. Outcome was reported in terms of brief global ratings of severity of illness, change in symptoms, and levels of social disruption. These brief measures were chosen to be suitable for use in general practice and were used at treatment entry and endpoint. RESULTS: The standard therapist contact group had the strongest and most comprehensive treatment response, showing significant differences from the bibliotherapy group on all, and the minimum therapist contact group on some, endpoint measures. Some reduction in efficacy was therefore found for the reduced therapist contact groups. CONCLUSION: The standard therapist contact group showed the greatest treatment efficacy in the present study. As it was of notably shorter duration than many other current formulations of CBT, it represents a useful and efficient treatment for panic disorder and agoraphobia in primary care.
PMCID: PMC1313882  PMID: 11224967
17.  Active Prospective Control Is Required for Effective Sensorimotor Learning 
PLoS ONE  2013;8(10):e77609.
Passive modeling of movements is often used in movement therapy to overcome disabilities caused by stroke or other disorders (e.g. Developmental Coordination Disorder or Cerebral Palsy). Either a therapist or, recently, a specially designed robot moves or guides the limb passively through the movement to be trained. In contrast, action theory has long suggested that effective skill acquisition requires movements to be actively generated. Is this true? In view of the former, we explicitly tested the latter. Previously, a method was developed that allows children with Developmental Coordination Disorder to produce effective movements actively, so as to improve manual performance to match that of typically developing children. In the current study, we tested practice using such active movements as compared to practice using passive movement. The passive movement employed, namely haptic tracking, provided a strong test of the comparison, one that showed that the mere inaction of the muscles is not the problem. Instead, lack of prospective control was. The result was no effective learning with passive movement while active practice with prospective control yielded significant improvements in performance.
PMCID: PMC3806834  PMID: 24194891
18.  Perspective Is Everything 
The predictive validity of instruments commonly used to measure the therapeutic alliance was evaluated, using 46 sessions drawn from a clinical trial comparing manual-guided therapies for substance use. The California Psychotherapy Alliance Scale, Penn Helping Alliance Rating Scale, Vanderbilt Therapeutic Alliance Scale, and Working Alliance Inventory (Observer, Therapist, and Client versions) were rated for participants receiving either cognitive-behavioral therapy or twelve-step facilitation. All observer-rated instruments were significantly correlated with outcome; however, therapist-rated and client-rated instruments did not predict outcome. Findings suggest that the different observer-rated instruments are minimally different with respect to predictive validity, whereas patient- and therapist-rated measures may have a weaker relationship to outcome when highly objective outcome measures are used.
PMCID: PMC3330662  PMID: 11696653
Rating Instruments; Alliance, Therapeutic
19.  Quality of Working Alliance in Psychotherapy 
Therapist characteristics were explored as possible predictors of working alliance, rated early and later in therapy both by therapists (n=59) and patients (n=270) in an ongoing multisite project on process and outcome of psychotherapy. Patients and therapists had divergent perspectives on the working alliance. Therapists' experience, training, skill, and progress as therapists did not have any significant impact on alliance as rated by patients. Training and skill were positively related to alliance as rated by therapists. Interpersonal relationships on the cold–warm dimension had a moderate impact for both patients' and therapists' alliance ratings. Some implications for therapist training are discussed.
PMCID: PMC3330657  PMID: 11696646
Working Alliance; Therapist Characteristics; Patient/Therapist Similarity
20.  Indicating spinal joint mobilisations or manipulations in patients with neck or low-back pain: protocol of an inter-examiner reliability study among manual therapists 
Manual spinal joint mobilisations and manipulations are widely used treatments in patients with neck and low-back pain. Inter-examiner reliability of passive intervertebral motion assessment of the cervical and lumbar spine, perceived as important for indicating these interventions, is poor within a univariable approach. The diagnostic process as a whole in daily practice in manual therapy has a multivariable character, however, in which the use and interpretation of passive intervertebral motion assessment depend on earlier results from the diagnostic process. To date, the inter-examiner reliability among manual therapists of a multivariable diagnostic decision-making process in patients with neck or low-back pain is unknown.
This study will be conducted as a repeated-measures design in which 14 pairs of manual therapists independently examine a consecutive series of a planned total of 165 patients with neck or low-back pain presenting in primary care physiotherapy. Primary outcome measure is therapists’ decision about whether or not manual spinal joint mobilisations or manipulations, or both, are indicated in each patient, alone or as part of a multimodal treatment. Therapists will largely be free to conduct the full diagnostic process based on their formulated examination objectives. For each pair of therapists, 2×2 tables will be constructed and reliability for the dichotomous decision will be expressed using Cohen’s kappa. In addition, observed agreement, prevalence of positive decisions, prevalence index, bias index, and specific agreement in positive and negative decisions will be calculated. Univariable logistic regression analysis of concordant decisions will be performed to explore which demographic, professional, or clinical factors contributed to reliability.
This study will provide an estimate of the inter-examiner reliability among manual therapists of indicating spinal joint mobilisations or manipulations in patients with neck or low-back pain based on a multivariable diagnostic reasoning and decision-making process, as opposed to reliability of individual tests. As such, it is proposed as an initial step toward the development of an alternative approach to current classification systems and prediction rules for identifying those patients with spinal disorders that may show a better response to manual therapy which can be incorporated in randomised clinical trials. Potential methodological limitations of this study are discussed.
PMCID: PMC4074830  PMID: 24982754
Manual therapy; Motion assessment; Diagnostics; Decision-making; Reliability; Clinical reasoning; Neck pain; Back pain
21.  The inter-tester reliability of physical therapists classifying low back pain problems based on the Movement System Impairment classification system 
Classification of patients with LBP may be important for improving clinical outcomes and research efficiency. The purpose of this study was to examine the inter-tester reliability of two trained physical therapists to classify patients with low back pain (LBP) using the standardized Movement System Impairment (MSI) classification system. The five proposed MSI classifications are based on the most consistent patterns of movement and alignment observed throughout the examination that correlate with the patient’s symptom behavior.
Test-retest to assess reliability
Academic healthcare center outpatient facility
Thirty subjects with chronic, recurrent LBP (mean age 31.1 ± 12.9 years, 21 F:9 M) were examined independently by two experienced physical therapists.
Training consisted of self-study of a procedure manual, supervised practice of examination procedures and classification rules and discussion. Subjects were examined independently by each therapist using a test-retest design. Each therapist assigned a LBP classification upon completion of the examination. Both therapists were blinded to the other therapist’s findings.
Main Outcome Measures
Inter-tester reliability of therapists classifying the LBP problems was indexed by the percent agreement and kappa coefficient.
Overall percent agreement on the classification assigned was 83% with kappa =.75 (95% CI =.51 to.99; P<.0001).
Inter-tester reliability of classification of patients with LBP using a standardized clinical examination based on the MSI classification system is substantial.
PMCID: PMC2752279  PMID: 19627885
Physical therapy; Low back pain; Classification; Spine; Consistency
22.  Work-related complaints and diseases of physical therapists – protocol for the establishment of a “Physical Therapist Cohort” (PTC) in Germany 
Only few studies deal with the workload of physical therapists and the health consequences, although this occupational group is quite important for the health care system in many industrialized countries (e.g. ca. 136 000 people are currently employed as physical therapists in Germany). Therefore, the current state of knowledge of work-related diseases and disorders of physical therapists is insufficient. The aim of the "Physical Therapist Cohort" (PTC) study is to analyze the association between work-related exposures and diseases among physical therapists in Germany. This article describes the protocol of the baseline assessment of the PTC study.
A cross-sectional study will be conducted as baseline assessment and will include a representative random sample of approximately 300 physical therapists employed in Germany (exposure group), and a population-based comparison group (n = 300). The comparison group will comprise a sample of working aged (18–65 years) inhabitants of a German city. Variables of interest will be assessed using a questionnaire manual including questions regarding musculoskeletal, dermal, and infectious diseases and disorders as well as psychosocial exposures, diseases and disorders. In addition to subjective measures, a clinical examination will be used to objectify the questionnaire-based results (n = 50).
The study, which includes extensive data collection, provides a unique opportunity to study the prospective association of work-related exposures and associated complaints of physical therapists. Baseline results will give first clues with regard to whether and how prevalent main exposures of physiotherapeutic work and typical work areas of physical therapists are associated with the development of work-related diseases. Thereby, this baseline assessment provides the basis for further investigations to examine causal relationships in accordance with a longitudinal design.
PMCID: PMC3878737  PMID: 24330548
Study protocol; Cohort study; Physical therapist; Occupational exposure; Occupational health; Occupational disease
23.  Specifying content and mechanisms of change in interventions to change professionals’ practice: an illustration from the Good Goals study in occupational therapy 
It is widely agreed that interventions to change professionals’ practice need to be clearly specified. This involves (1) selecting and defining the intervention techniques, (2) operationalising the techniques and deciding their delivery, and (3) formulating hypotheses about the mechanisms through which the techniques are thought to result in change. Descriptions of methods to achieve these objectives are limited. This paper reports methods and illustrates outputs from a study to meet these objectives, specifically from the Good Goals study to improve occupational therapists’ caseload management practice.
(1) Behaviour change techniques were identified and selected from an existing matrix that maps techniques to determinants. An existing coding manual was used to define the techniques. (2) A team of occupational therapists generated context-relevant, acceptable modes of delivery for the techniques; these data were compared and contrasted with previously collected data, literature on caseload management, and the aims of the intervention. (3) Hypotheses about the mechanisms of change were formulated by drawing on the matrix and on theories of behaviour change.
(1) Eight behaviour change techniques were selected: goal specified; self-monitoring; contract; graded tasks; increasing skills (problem solving, decision making, goal setting); coping skills; rehearsal of relevant skills; social processes of encouragement, support, and pressure; demonstration by others; and feedback. (2) A range of modes of delivery were generated (e.g., graded tasks’ consisting of series of clinical cases and situations that become increasingly difficult). Conditions for acceptable delivery were identified (e.g., ‘self-monitoring’ was acceptable only if delivered at team level). The modes of delivery were specified as face-to-face training, task sheets, group tasks, DVDs, and team-based weekly meetings. (3) The eight techniques were hypothesized to target caseload management practice through eleven mediating variables. Three domains were hypothesized to be most likely to change: beliefs about capabilities, motivation and goals, and behavioural regulation.
The project provides an exemplar of a systematic and reportable development of a quality-improvement intervention, with its methods likely to be applicable to other projects. A subsequent study of the intervention has provided early indication that use of systematic methods to specify interventions may help to maximize acceptability and effectiveness.
PMCID: PMC3502268  PMID: 23078918
Complex interventions; Developing interventions; Behaviour change; Professionals’ practice; Goal setting; Occupational therapy
24.  Effects of a Brief Intervention for Reducing Violence and Alcohol Misuse Among Adolescents: A Randomized Trial 
The Emergency Department (ED) visit presents an opportunity to deliver brief interventions (BIs) to reduce violence and alcohol misuse among urban adolescents at risk for future injury.
To determine the efficacy of BIs addressing violence and alcohol among adolescents presenting to an urban ED.
Design, Setting, and Participants
Patients (ages 14–18; 12 pm–11 pm; 7 days/week) at a Level 1 ED in Flint, MI, completed a computerized survey. Adolescents reporting past year alcohol use and aggression were enrolled in a randomized trial (SafERteens) which included: a computerized baseline assessment, randomization to a control group, or a 35-minute brief intervention delivered by a computer or therapist in the ED, and follow-up assessments at 3 and 6 months.
Combining motivational interviewing with skills training, the BI for violence and alcohol included: review of goals, tailored feedback, decisional balance exercise, role plays, and referrals.
Main Outcome Measures
Self-report measures included peer aggression and violence, violence consequences, alcohol use, binge drinking, alcohol consequences.
3338 adolescents were screened (n=446, 12% refused): 1452 (43.5%) male; 1866 (55.9%) African-American. Of those, 829 (24.8%) screened positive for both alcohol and violence; 726 were randomized. As compared to the control, participants in the therapist intervention showed self-reported reductions in the occurrence of peer aggression (−34.3% therapist, −16.4% control; RR=0.74, CI=0.61–0.90), experience of peer violence (10.4% therapist, +4.7% control; RR=0.70, CI=0.52–0.95), and violence consequences (30.4% therapist, −13.0% control; RR=0.76, CI=0.64–0.90) at three months. At 6 months, participants in the therapist intervention showed self-reported reductions in peer aggression (−37.7% therapist, −28.4% control; RR=0.85, CI=0.68–1.06) and alcohol consequences (−32.2% therapist, −17.5% control; RR=0.56, CI=0.34–0.91) as compared to controls. At 6 months, participants in the computer intervention also showed self-reported reductions in alcohol consequences (−29.1% computer, −17.5% control; RR=0.62, CI=0.39–0.98).
Among adolescents identified in the ED with self-reported alcohol use and aggression, a brief intervention resulted in a decrease in the prevalence of self-reported aggression and alcohol consequences.
Trial Registration Identifier NCT00251212.
PMCID: PMC3560393  PMID: 20682932
25.  Correlation of Digital Palpation and Transabdominal Ultrasound for Assessment of Pelvic Floor Muscle Contraction 
Pelvic floor muscle (PFM) dysfunction has been commonly associated with urinary disorders and lumbo-pelvic pain. Transabdominal (TA) ultrasound is currently used by physical therapists to assess PFM function. Controversy exists regarding the correlation between TA ultrasound measurement and vaginal palpation for assessment of PFM contraction, and this relationship has not yet been examined concurrently during the same contraction. The purpose of this study was to determine the correlation of digital palpation and TA ultrasound to assess PFM contraction when recorded 1) simultaneous to digital palpation during one contraction and 2) following digital palpation testing in another contraction. A descriptive correlational design was used to describe the relationship between variables. A total of 19 women (both asymptomatic women and those with incontinence or lumbo-pelvic pain) participated in the study. The modified Oxford scale was used to grade PFM contraction in digital palpation testing. The amount of bladder base movement on ultrasound was measured and considered as an indicator of PFM activity. Two trials were performed for TA ultrasound measurement: 1) simultaneous to digital palpation during one contraction, and 2) following digital palpation testing in another contraction. Spearman's correlation coefficient was used for analysis. There was a significant correlation between digital palpation and TA ultrasound for PFM assessment when measured simultaneously in one contraction (rho=0.62, p=0.01) and separately in a different contraction (rho=0.52, p=0.02), with a stronger correlation found in simultaneous testing. In conclusion, digital palpation and TA ultrasound measurement are significantly correlated and measure comparable parameters in evaluation of PFM contraction.
PMCID: PMC2755109  PMID: 20046616
Digital Palpation; Modified Oxford Scale; Pelvic Floor Muscles; Transabdominal Ultrasound

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