THE ASSESSMENT AND UTILIZATION OF PATIENTS’ SELF-EFFICACY FOR EXERCISE DURING REHABILITATION

Patient adherence to in-clinic rehabilitation is between 30-70% and even lower for home exercise programs (HEPs). Barriers to patient adherence have been identified and include but are not limited to anxiety, depression, lack of positive feedback, lack of social support, lack of time, low levels of physical activity at baseline, pain during exercise, and low self-efficacy. As clinicians prescribing rehabilitation may not be able to influence all of the identified barriers, they may positively influence others. Self-efficacy, or an individual’s belief in his/her ability to successfully complete a task, is a patient barrier that may be addressed by a clinician when aware of low self-efficacy and have tools to improve this barrier. Interventions to overcome this specific barrier have demonstrated an increase in not only self-efficacy but patient adherence as well. Although interventions have proven to be successful, patient adherence has yet to increase according to the literature. At this time, there is no evidence to suggest that clinicians are assessing an individual’s level of self-efficacy prior to prescribing HEPs. In addition, there is no known metric to measure self-efficacy for HEPs in patients rehabilitating musculoskeletal conditions. Assessment of patient barriers, specifically self-efficacy, needs to be a standard of care in order to increase adherence, in turn, improve patient outcomes and to reduce the cost to our healthcare system. The first purpose of this dissertation was to determine in patients with musculoskeletal conditions what scales have been developed and evaluated for assessing self-efficacy in conjunction with adherence. In addition, to determine if a tool exists specifically to assess self-efficacy for HEPs. Due to the task and situation-specific nature of self-efficacy, it is important that this construct is reflected in the assessments utilized by clinicians. The second purpose was to determine the importance and utilization of patients’ self-efficacy to physical therapists when addressing patient barriers. This included determining how physical therapists assess patient self-efficacy and barriers to assessment. The third purpose was to develop the Self-Efficacy for Home Exercise Programs Scale and determine the psychometric properties of the instrument. This also allowed for the examination of how self-efficacy relates to patient adherence in a musculoskeletal patient population. The results of the first study suggest that within the musculoskeletal literature, a number of scales are being used to assess patient self-efficacy. These scales are either task, situation, or condition specific. No scale was found to assess self-efficacy for HEPs. This finding indicates the need to develop a scale to assess self-efficacy for HEPs. In the second study, 71% (n = 329/464) of physical therapists, disclosed assessing self-efficacy prior to prescribing HEPs and rated self-efficacy as very to extremely important when it comes to their patients’ adherence. Verbal discussion is the most common method of self-efficacy assessment (50%), followed by observation of the patient (38%), then patient self-report questionnaires (10%). Commonly, physical therapists report using verbal discussion and observation in combination. Of the 29% of the physical therapists that do not assess self-efficacy, 40% report not knowing how to assess self-efficacy, 19% are not sure what to do with the information once self-efficacy is assessed, 16% claim there are other barriers to assessment, 15% claim that assessing self-efficacy will not change their practice, another 9% claim assessing self-efficacy takes too much time, and the last 1% do not know what self-efficacy is. These results further suggest the need for a scale to assess self-efficacy for HEPs. The purpose of the final study was to developed a Self-Efficacy for Home Exercise Programs Scale. The scale was found to have high internal consistency (α = 0.96), acceptable test-retest reliability (ICC = 0.8, SEM = 5, MDC = 7), and strong convergent validity with the Self-Efficacy for Exercise scale (rho(ρ) = 0.83, p \u3c 0.01). Unique to this scale, a cutoff score was determined to be 59 points with a positive likelihood ratio of 2.0 (95% CI 1.1 – 2.5) indicating those who score below 59 points on the SEHEPS would be 2 times more likely to be non-adherent than adherent to their HEP. A weak to moderate, positive relationship was detected between the patients’ initial level of self-efficacy for their HEP and adherence (rho(ρ) = 0.38, p = 0.03). These results suggest that the Self-Efficacy for Home Exercise Programs Scale may be utilized by rehabilitation clinicians to assess self-efficacy for HEPs. Clinically, this scale may provide clinicians the ability to decipher patients who are not likely to adhere to their prescribed HEP, allowing clinicians to intervene immediately. Early intervention to improve self-efficacy may increase adherence to HEPs and eventually patient outcomes

Calculation of Resistive Loads for Elastic Resistive Exercises

Context: What is the correct resistive load to start resistive training with elastic resistance to gain strength? This question is typically answered by the clinician\u27s best estimate and patient\u27s level of discomfort without objective evidence. Objective: To determine the average level of resistance to initiate a strengthening routine with elastic resistance following isometric strength testing. Design: Cohort. Setting: Clinical. Participants: Thirty-four subjects (31±13yrs, 73±17kg, 170±12cm). Interventions: The force produced was measured in Newtons (N) with an isometric dynamometer. The force distance was the distance from center of joint to location of force applied was measured in meters to calculate torque that was called Test Torque for the purposes of this report. This torque data was converted to Exercise Load in pounds based on the location where the resistance was applied, specifically the distance away from the center of rotation of the exercising limb. The average amount of exercise load as percentage of initial Test Torque for each individual for each exercise was recorded to determine what the average level of resistance that could be used for elastic resistance strengthening program. Main Outcome Measures: The percentage of initial test torque calculated for the exercise was recorded for each exercise and torque produced was normalized to body weight. Results: The average percentage of maximal isometric force that was used to initiate exercises was 30 ± 7% of test torque. Conclusions: This provides clinicians with an objective target load to start elastic resistance training. Individual variations will occur but utilization of a load cell during elastic resistance provides objective documentation of exercise progression

Line Hops and Side Hold Rotation Tests Load Both Anterior and Posterior Shoulder: A Biomechanical Study

Background: Clinical tests should replicate the stressful positions encountered during sport participation. Evaluating the kinetic and electromyographical demands of clinical tests enables clinicians to choose appropriate tests for specific sports. Purpose: To describe the shoulder forces and muscle activation levels during closed chain functional tests of Line Hops (LH) and Side Hold Rotation (SHR). Study Design: Descriptive biomechanical study. Methods: Ten asymptomatic participants were examined in a university laboratory. Two functional tests were evaluated using three-dimensional video analysis and electromyography to measure shoulder forces, moments, and muscular activity levels. Results: SHR produced a peak average posterior translation force of 4.84 N/kg (CI95 4.32-5.36N/kg) and a peak average anterior translational force of 1.57 N/kg (CI95 1.10-2.01N/kg). High levels of serratus anterior (98% maximum voluntary isometric contraction (MVIC) and infraspinatus (52 %MVIC) were recorded during SHR. LH produced a posterior translational force of 4.25 N/kg (CI95 3.44–5.06N/kg). High levels of serratus anterior (105 %MVIC) and infraspinatus (87 %MVIC) were recorded during the push off phase of this activity. Conclusions: LH and SHR placed large posterior translational forces that approached half of a person\u27s bodyweight on shoulder structures. SHR produced an anterior translation force at extremes of horizontal abduction placing approximately 18% of bodyweight on shoulder structures. The LH test required the serratus anterior to provide power to push the upper torso of the ground while both the serratus and the infraspinatus provides scapular and humeral stability, respectively. Level of Evidence: 4: Case series

Elastic Resistance Effectiveness on Increasing Strength of Shoulders and Hips

Elastic resistance is a common training method used to gain strength. Currently, progression with elastic resistance is based on the perceived exertion of the exercise or completion of targeted repetitions; exact resistance is typically unknown. This study\u27s objective is to determine if knowledge of load during elastic resistance exercise will increase strength gains during exercises. Participants were randomized into two strength training groups, elastic resistance only and elastic resistance using a load cell (LC) that displays force during exercise. The LC group used a Smart Handle (Patterson Medical Supply, Chicago, IL) to complete all exercises. Each participant completed the same exercises three times weekly for 8 weeks. The LC group was provided with a set load for exercises whereas the elastic resistance only group was not. Participant\u27s strength was tested at baseline and program completion, measuring isometric strength for shoulder abduction (SAb), shoulder external rotation (SER), hip abduction (HAb), and hip extension (HEx). Independent t-tests were used to compare the normalized torques between groups. No significant differences were found between groups. Shoulder strength gains did not differ between groups (SAb p\u3e0.05; SER p\u3e0.05). Hip strength gains did not differ between groups (HAb p\u3e0.05; HEx p\u3e0.05). Both groups increased strength due to individual supervision, constantly evaluating degree of difficulty associated with exercise and providing feedback while using elastic resistance. Using a LC is as effective as supervised training and could provide value in a clinic setting when patients are working unsupervised

Line Hops and Side Hold Rotation Tests Load Both Anterior and Posterior Shoulder: A Biomechanical Study

# Background Clinical tests should replicate the stressful positions encountered during sport participation. Evaluating the kinetic and electromyographical demands of clinical tests enables clinicians to choose appropriate tests for specific sports. # Purpose To describe the shoulder forces and muscle activation levels during closed chain functional tests of Line Hops (LH) and Side Hold Rotation (SHR). # Study Design Descriptive biomechanical study # Methods Ten asymptomatic participants were examined in a university laboratory. Two functional tests were evaluated using three-dimensional video analysis and electromyography to measure shoulder forces, moments, and muscular activity levels. # Results SHR produced a peak average posterior translation force of 4.84 N/kg (CI~95~ 4.32-5.36N/kg) and a peak average anterior translational force of 1.57 N/kg (CI~95~ 1.10-2.01N/kg). High levels of serratus anterior (98% maximum voluntary isometric contraction (MVIC) and infraspinatus (52 %MVIC) were recorded during SHR. LH produced a posterior translational force of 4.25 N/kg (CI~95~ 3.44–5.06N/kg). High levels of serratus anterior (105 %MVIC) and infraspinatus (87 %MVIC) were recorded during the push off phase of this activity. # Conclusions LH and SHR placed large posterior translational forces that approached half of a person’s bodyweight on shoulder structures. SHR produced an anterior translation force at extremes of horizontal abduction placing approximately 18% of bodyweight on shoulder structures. The LH test required the serratus anterior to provide power to push the upper torso of the ground while both the serratus and the infraspinatus provides scapular and humeral stability, respectively. # Level of Evidence 4: Case serie

Physical Therapists’ Assessment of Patient Self-Efficacy for Home Exercise Programs

# Background Patient adherence to home exercise programs (HEPs) is low, and poor patient self-efficacy is a barrier clinicians can influence. However, little evidence suggests that clinicians assess level of patient self-efficacy before prescribing HEPs. # Purpose To determine the importance of patient self-efficacy to physical therapists (PTs) when addressing patient barriers, determine how PTs assess and use patient self-efficacy for HEPs, and describe the barriers facing PTs when assessing patient self-efficacy for HEPs. # Study Design Survey. # Methods Practicing PTs were recruited from the American Physical Therapy Association’s Orthopedic Section and emailed the electronic survey. # Results Email invitations were sent to 17730 potential participants, and 462 PTs completed the survey over one month. PTs rated self-efficacy as “very” to “extremely” important for patient adherence (58%, 265/454). Most (71%, 328/462) reported assessing self-efficacy before prescribing HEPs and did so through verbal discussion and observation of the patient (50% and 38% respectively). Half of respondents individualized HEPs through self-efficacy related themes. PTs not assessing self-efficacy reported not knowing how (51%, 68/134), being unsure what to do with the information (24%, 32/134), or reporting other barriers (21%, 28/134). # Conclusions Most PTs indicated that self-efficacy was important for patient adherence, but assessment strategies reported, such as verbal discussion and observation, may not be the most accurate. PTs who did not assess self-efficacy reported not knowing how or what to do with the information once collected. These findings suggest that there is a gap in knowledge related to how to evaluate self-efficacy for HEPs. Better assessment of self-efficacy may lead to more appropriate and effective implementation strategies. # Level of Evidence Level I

Does Cold Water Immersion Improve Recovery of Strength, Power, and Endurance Following Exhaustive Exercise?

Content: The physiological effects of cyrotherapy include; decreased cell metabolism, vasoconstriction, decrease nerve conduction, decrease muscle spasms, and decrease tissue temperature. In immediate care of injuries, cryotherapy is used to prevent inflammation, stimulate delta-A nerve fibers to reduce pain, and slow cell metabolism, which will decrease secondary tissue death due to hypoxia. In competitive athletics some athletes and coaches believe that the use of cold water immersion will accelerate recovery and enhance subsequent performance. This accelerated recovery appears to be at odds with the known physiologic effects of cryotherapy. Objective: The purpose of this study is to determine whether or not cold water immersion has an effect on the strength, power, or endurance of college-age male lacrosse athletes following an exhaustive exercise bout. Design: Randomized controlled experimental design. Subjects: Twelve male (mean age=19.9, SD =1.29) subjects from a University club LaCrosse team volunteered to participate in this study. Setting: A university athletic training facility and equipment were used for data collection. Results: Data collection is ongoing at this time; preliminary data via comparison of the means shows no difference in among the control and variable group subjects on objective measures. Subjectively all subjects in the experimental group reported feeling improvement in their post-test performance compared to their pre-test. Conclusion: There was no difference between the control and variable groups on objective measures. Subjectively the subject‘s perception of improvement following cold water immersion could be due to the widespread belief in the use of cold immersion as a means of improving recovery

Calculation of Resistive Loads for Elastic Resistive Exercises

Context: What is the correct resistive load to start resistive training with elastic resistance to gain strength? This question is typically answered by the clinician\u27s best estimate and patient\u27s level of discomfort without objective evidence. Objective: To determine the average level of resistance to initiate a strengthening routine with elastic resistance following isometric strength testing. Design: Cohort. Setting: Clinical. Participants: Thirty-four subjects (31±13yrs, 73±17kg, 170±12cm). Interventions: The force produced was measured in Newtons (N) with an isometric dynamometer. The force distance was the distance from center of joint to location of force applied was measured in meters to calculate torque that was called Test Torque for the purposes of this report. This torque data was converted to Exercise Load in pounds based on the location where the resistance was applied, specifically the distance away from the center of rotation of the exercising limb. The average amount of exercise load as percentage of initial Test Torque for each individual for each exercise was recorded to determine what the average level of resistance that could be used for elastic resistance strengthening program. Main Outcome Measures: The percentage of initial test torque calculated for the exercise was recorded for each exercise and torque produced was normalized to body weight. Results: The average percentage of maximal isometric force that was used to initiate exercises was 30 ± 7% of test torque. Conclusions: This provides clinicians with an objective target load to start elastic resistance training. Individual variations will occur but utilization of a load cell during elastic resistance provides objective documentation of exercise progression