ABSTRACT
Background
Despite physical activity being a major component of managing chronic low back pain, < 50% of patients receive physical activity interventions. Electronic Health Records can deepen our understanding about this clinical gap.
Objective
We aimed to: 1) develop and test a data abstraction form that captures physical activity documentation; and 2) explore physical therapists’ documentation of physical activity assessments and interventions.
Methods
We developed a data abstraction form using previously published practice guidelines. After identifying the forms’ inter-rater reliability, we used it to explore physical therapists’ documentation related to physical activity assessments and interventions for patients with chronic low back pain.
Results
The final data abstraction form included information about physical activity history, assessments, interventions, general movement discussion, and plan. Our inter-rater reliability was high. Of the 18 patients, 66.7% had documentation about their PA history. Across the 56 encounters, 14 (25.0%) included an assessment, 18 (32.1%) an intervention, 18 (32.1%) a general movement discussion, and 12 (21.4%) included a plan.
Conclusion
Using our reliable data abstraction form we identified a lack of documentation about physical activity assessments and interventions among patients with chronic low back pain. A larger study is needed to examine the generalizability of these results.
Acknowledgments
We sincerely thank and acknowledge the following individuals for their contribution to this manuscript: Dr. Sharon Henry, PT, PhD (Department of Rehabilitation and Movement Science, University of Vermont, Burlington, Vermont) for her willingness to share data from her clinical trial; and Jonathan P. Bona, PhD (Department of Biomedical Informatics, University of Arkansas for Medical Sciences, Little Rock, Arkansas) for his willingness to provide expert knowledge on Natural Language Processing.
Disclosure statement
No potential conflict of interest was reported by the author(s).