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The purpose of this study was to evaluate whether physical therapy use influenced subsequent use of musculoskeletal-related surgeries, injections, magnetic resonance imaging (MRI), and other imaging. We conducted a retrospective cohort study of patients aged 18 to 64 years who had an ambulatory care visit at the University of Utah system, after implementation of the 10th revision of the International Statistical Classification of Diseases and Related Health Problems with adequate data collection in the system at the time of the data pull, between October 1, 2015, and September 30, 2018. We identified patients (n = 85 186) who received care for a musculoskeletal condition (lower back pain, cervical, knee, shoulder, hip, elbow, ankle, wrist/hand, thoracic, and arthritis diagnoses). Regression analyses were used to evaluate the association between physical therapy use and medical care use while controlling for relevant factors. In patients referred to physical therapy (n = 15 870), physical therapy use (n = 3812) was associated with increased MRI use (incidence rate ratio, 1.24; 95% confidence interval, 1.15-1.33; P <.001) and surgery use (incidence rate ratio, 1.11; 95% confidence interval, 1.00-1.23; P <.001). Several other factors were also associated with increased health care use, including being referred by an orthopedic provider, obesity, non–lower back pain diagnoses, and having 1 or more comorbidities. Outpatient physical therapy use for musculoskeletal conditions in adult patients younger than 65 years at the University of Utah system, a mountain west United States academic health care system, was associated with increased rates of MRI and surgery. This finding is contrary to prior research suggesting that physical therapy improves outcomes in some diagnosis groups. A referral from an orthopedic provider, non–lower back pain diagnoses, and obesity were also associated with increased medical care utilization. [ABSTRACT FROM AUTHOR]

The aim of this study was to examine: (1) motivations of patients with chronic low back pain to attend physical therapy; (2) relationships between competence perceptions, motivational regulations, and pain/disability; and (3) whether patient motivations to attend physical therapy mediate the relationship between competence perceptions and pain/disability. A sample of 64 participants completed baseline assessment (1-week prior to initiation of physical therapy) and 6-week follow-up assessment. Differences between motivation variables at baseline were examined using one-way within-person ANOVA. Relationships between competence perceptions, motivation subscales, and pain/disability were calculated using bivariate correlations and multiple mediation analyses. Participants reported significantly higher levels of autonomous versus controlled motivation (mean difference = 3.5, p < 0.001, d = 2.3) and amotivation (mean difference = 3.6, p < 0.001, d = 2.4). Competence was positively associated with autonomous motivation (r = 0.45, p ≤ 0.05) and negatively associated with controlled motivation (r = −0.26, p ≤ 0.05), amotivation (r = −0.57, p ≤ 0.05), pain (r = −0.35, p ≤ 0.05), and disability (r = −0.34, p ≤ 0.05). Amotivation significantly mediated the competence–pain relationship (Amotivation IE = −0.19, 95% CI (−0.44, −0.06), p < 0.05) and the competence–disability relationship (Amotivation IE = −0.07, 95% CI (−0.17, −0.01), p < 0.05). Findings highlight the role of competence perceptions in mitigating amotivation for physical therapy and the deleterious implications of amotivation for patient-centered outcomes. While it is normal for patients to experience periods where they lack motivation for rehabilitation exercises, practitioners can encourage patients to assume responsibility for their recovery by informing them that amotivated states may increase the likelihood of increased pain perceptions and disability. Health-care practitioners should seek to foster competence perceptions in patients about to undergo physical therapy. Competence building strategies such as patient education, goal setting, and role modeling may be valuable in facilitating autonomous motivation and reducing amotivation for physical therapy. [ABSTRACT FROM AUTHOR]

Objective The aim of this study was to examine the association between the length of time between an emergency department (ED) visit and the subsequent initiation of physical therapist intervention for low back pain (LBP) on 1-year LBP-related health care utilization (ie, surgery, advanced imaging, injections, long-term opioid use, ED visits) and costs. Methods This retrospective cohort study focused on individuals who consulted the ED for an initial visit for LBP. Claims from a single statewide, all-payers database were used. LBP-related health care use and costs for the 12 months after the ED visit were extracted. Poisson and general linear models weighted with inverse probability treatment weights were used to compare the outcomes of patients who attended physical therapy early or delayed after the ED visit. Results Compared with the delayed physical therapy group (n = 94), the early physical therapy group (n = 171) had a lower risk of receiving lumbar surgery (relative risk [RR] = 0.47, 95% CI = 0.26–0.86) and advanced imaging (RR = 0.72, 95% CI = 0.55–0.95), and they were less likely to have long-term opioid use (RR = 0.45, 95% CI = 0.28–0.76). The early physical therapy group incurred lower costs (mean = $3,806, 95% CI = $1,998–$4,184) than those in the delayed physical therapy group (mean = $8,689, 95% CI = $4,653–$12,727). Conclusion Early physical therapy following an ED visit was associated with a reduced risk of using some types of health care and reduced health care costs in the 12 months following the ED visit. Impact Statement The ED is an entry point into the health care system for patients with LBP. Until now, the impact of the length of time between an ED visit and physical therapy for LBP has not been well understood. This study shows that swift initiation of physical therapy following an ED visit for LBP is associated with lower LBP-related health utilization for some important outcomes and lower LBP-related health care costs. [ABSTRACT FROM AUTHOR]

Objective Poor knowledge of the relationships between physical function (PF) in the hospital and patient outcomes in an inpatient rehabilitation facility (IRF) limits the identification of patients most appropriate for discharge to an IRF. This study aimed to test for independent associations between PF measured via the AM-PAC "6-clicks" basic mobility short form in the hospital and outcomes in an IRF. Methods This was a retrospective cohort study. Primary data were collected from an acute hospital and IRF at 1 academic medical center. Associations were tested between PF at hospital admission or discharge and PF improvement in the IRF, discharge from the IRF to the community, and 30-day hospital events by estimating adjusted relative risk (aRR) using modified Poisson regression and the relative difference in IRF length of stay (LOS) using Gamma regression. Results A total of 1323 patients were included. Patients with moderately low, (aRR = 1.50; 95% CI = 1.15–1.93), moderately high (aRR = 1.52; 95% CI = 1.16–2.01), or high (aRR = 1.37; 95% CI = 1.02–1.85) PF at hospital discharge were more likely than those with very low PF to improve their PF while in the IRF. These same patients were more likely to discharge from IRF to the community and had significantly shorter IRF LOS. Hospital-measured PF did not differentiate risk for 30-day hospital events. Conclusion Patients with moderate—but not very low or very high—PF measured near the time of acute hospital discharge were likely to achieve meaningful PF improvement in an IRF. They also had a shorter IRF LOS so may be ideal candidates for discharge to IRF. Prospective studies with larger samples are necessary to test this assertion. Impact Providers in the hospital should identify patients with moderate PF near the time of hospital discharge as those who may benefit most from post-acute rehabilitation in an IRF. [ABSTRACT FROM AUTHOR]

Background Stepped care approaches are emphasized in guidelines for musculoskeletal pain, recommending less invasive or risky evidence-based intervention, such as manual therapy (MT), before more aggressive interventions such as opioid prescriptions. The order and timing of care can alter recovery trajectories. Objective To compare one-year downstream health care utilization in patients with spine or shoulder disorders who received only MT vs MT and opioids. The secondary aim was to compare differences based on order and timing of opioids and MT. Design Retrospective observational cohort. Methods Patients with an initial consultation for a spine or shoulder disorder who received at least one visit for MT were included. Person-level data from the Military Health System Management and Reporting Tool (M2) database were aggregated by a senior health care analyst at Madigan Army Medical Center. Groups were created based on the order and timing of interventions provided. Outcomes included health care utilization (medical costs and visits) over the year following initial consultation. Control measures included metabolic, mental health, chronic pain, sleep, and substance abuse comorbidities, as well as prior opioid prescriptions. Generalized linear models with gamma log links were run due to the heavily skewed nature of cost data. Results From 1,876 unique patients with spine or shoulder disorders receiving MT, 1,162 (61.9%) also received prescription opioids. Mean one-year costs in the MT-only group ($5,410, 95% confidence interval [CI] = $5,109 to $5,730) were significantly lower than in the MT+opioid group ($10,498, 95% CI = $10,043 to $10,973). When patients had both treatments, mean one-year costs in the MT-first ($10,782, 95% CI = $10,050 to $11,567) were significantly lower (P  = 0.030) than opioid-first ($11,938, 95% CI = $11,272 to $12,643), and MT-first had a significantly lower mean days' supply of opioids (34.2 vs 70.9, P  < 0.001) and mean number of unique opioid prescriptions (3.1 vs 6.5, P  < 0.001). Conclusions MT alone resulted in lower downstream costs than with opioid prescriptions. Both the order of treatment (MT before opioid prescriptions) and the timing of treatment (MT < 30 days) resulted in a significant reduction of resources (costs, visits, and opioid utilization) in the year after initial consultation. Clinicians should consider the implications of first-choice decisions and the timing of care for treatment choices utilized for patients with spine and shoulder disorders. [ABSTRACT FROM AUTHOR]

Background: Several known demographic and functional characteristics combine to predict physical function after hip fracture. Long-term weight-bearing asymmetries, evident during functional movements after hip fracture, contribute to limited mobility and large asymmetries in muscle function are linked to a high rate of injurious falls. Although postfracture mobility is commonly measured as whole body movement, a force-plate imbedded chair can identify individual limb contributions to an important task like moving from a sitting to standing position. The modified Physical Performance Test (mPPT) and stair climb test (SCT) are reliable, valid measures of function that predict independence after hip fracture. The purpose of this study was to determine to what extent asymmetry during a sitto-stand task (STST) predicts function (mPPT, 12-step SCT), above and beyond other known predictors. Methods: Thirty-one independent community-dwelling older adults, recently discharged from usual care physical therapy (mean [standard deviation], 77.7 [10.5] years, 10 male), within 2 to 8 months postfracture, volunteered for this study. Participants performed an STST on a force-plate-imbedded chair designed to identify individual limb contributions during an STST. Asymmetry magnitude during the STST was determined for each individual. In addition, mPPT and SCT were assessed and regression analyses were performed to determine the contribution of asymmetry to the variance in these physical function scores beyond other factors predicting function. Results: Demographic factors (sex, time since fracture, repair type, and body mass index) were not significantly related to function in this sample. Age, gait speed, knee extension strength, balance confidence, and functional self-report were each significantly related to both mPPT (r = 0.43-0.86) and SCT (r = 0.40-0.83), and were retained in the regression model. Included variables accounted for 83.4% of the variance in mPPT score, and asymmetry during the STST did not significantly contribute to explaining variability in mPPT (P = .23). Variables in the regression model accounted for 78.0% of the variance in SCT score, and STST asymmetry explained 7.1% (P < .005) of the variance in SCT score. Discussion: In this small sample, asymmetry contributed significantly to explaining the variability in SCT performance, but not mPPT score. The SCT requires greater unilateral strength and control than the battery of items that comprise the mPPT. This contributes to the disproportionate number of falls occurring during stair ambulation (>10% of all fall-related deaths), relative to the minimal time typically involved in stair negotiation. Our results indicate potential benefit to identifying injured limb asymmetries as they predict function in challenging, high-risk functional tasks after hip fracture. Conclusion: Although gait speed is the best explanator of physical function in older adults after hip fracture, lower extremity asymmetry during an STST provides a unique contribution to explaining high-level ambulatory performance after hip fracture. Efforts to reduce weight-bearing asymmetry during rehabilitation following hip fracture may improve function and recovery. [ABSTRACT FROM AUTHOR]

Objectives: The objectives of this study were to (1) evaluate differences between patients with lumbar intervertebral disc herniation who received physical therapy (PT) and those who did not; (2) identify factors associated with receiving PT; and (3) examine the influence of PT on clinical outcomes over the course of 1 yr. Design: An observational cohort study using data from the Spine Patient Outcomes Research Trial was conducted. This study included 363 patients with intervertebral disc herniation who received nonsurgical management within 6 wks of enrollment. Baseline characteristics were compared between patients who received PT and those who did not. Multivariate logistic regression examined factors predictive of patients receiving PT. Mixed effects models were used to compare primary outcomes (Short-Form Survey 36 bodily pain and physical function and modified Oswestry Index) at 3 and 6 mos and 1 yr after enrollment. Results: Forty percent of the nonsurgical cohort received PT. Higher disability scores, neurological deficit, and patient preference predicted PT use. Compared with other nonsurgical management strategies, standard care PT was not associated with a significant difference in pain, disability, or surgery over 1 yr. Conclusions: Many patients with intervertebral disc herniation seek secondary care for persisting symptoms and pursue nonsurgical management. The best management strategy is unclear and further research is needed to examine appropriate sequencing and selection of treatment. [ABSTRACT FROM AUTHOR]

Background. The impact of physical therapy on the outcomes of patients with acute low back pain (LBP) stratified by the STart Back Screening Tool (SBST) is unclear. Objective. The purpose of this study was to compare the outcomes of patients with acute LBP who were stratified as medium or high risk. Design. This was a secondary analysis of a randomized trial. Setting. Patients were recruited between March 2011 and November 2013 from primary care clinics in Salt Lake City, Utah. Participants. One hundred eighty-one participants with acute LBP who were strati- fied as medium risk (n = 120) or high risk (n = 61) by the SBST were included. They were aged 18 through 60 years, with duration of symptoms less than 16 days, no symptoms below the knee, no treatment for LBP in the past 6 months, and an Oswestry Disability Index (ODI) score of 20% or greater. Intervention. After participants received education on how to manage their LBP, they were randomized to receive usual care (n = 97) by their primary care provider or early intervention (n = 84) by a physical therapist. Measurements. The primary (3-month ODI score) outcome measure was obtained at baseline and at 4 weeks, 3 months, and 1 year. Results. No differences were detected in the effect of intervention between participants stratified as medium or high risk. For the high-risk subgroup, there was a significant difference between the early intervention and usual care groups for the 3-month ODI (mean difference = -5.87 [95% CI = -11.24, -0.50]) favoring early intervention. Limitations. The primary study was not designed to examine the SBST. Conclusions. Patients with acute LBP stratified as high risk seem likely to respond well to one session of education. They may experience additional benefit by 3 months from evidence-based physical therapy treatments. These effects disappear at 1 year. [ABSTRACT FROM AUTHOR]

Rationale, aims and objective Low back pain ( LBP) care can involve many providers. The provider chosen for entry into care may predict future health care utilization and costs. The objective of this study was to explore associations between entry settings and future LBP-related utilization and costs. Methods A retrospective review of claims data identified new entries into health care for LBP. We examined the year after entry to identify utilization outcomes (imaging, surgeon or emergency visits, injections, surgery) and total LBP-related costs. Multivariate models with inverse probability weighting on propensity scores were used to evaluate relationships between utilization and cost outcomes with entry setting. Results 747 patients were identified (mean age = 38.2 (± 10.7) years, 61.2% female). Entry setting was primary care ( n = 409, 54.8%), chiropractic ( n = 207, 27.7%), physiatry ( n = 83, 11.1%) and physical therapy ( n = 48, 6.4%). Relative to primary care, entry in physiatry increased risk for radiographs ( OR = 3.46, P = 0.001), advanced imaging ( OR = 3.38, P < 0.001), injections ( OR = 4.91, P < 0.001), surgery ( OR = 4.76, P = 0.012) and LBP-related costs (standardized Β = 0.67, P < 0.001). Entry in chiropractic was associated with decreased risk for advanced imaging ( OR = 0.21, P = 0.001) or a surgeon visit ( OR = 0.13, P = 0.005) and increased episode of care duration (standardized Β = 0.51, P < 0.001). Entry in physical therapy decreased risk of radiographs ( OR = 0.39, P = 0.017) and no patient entering in physical therapy had surgery. Conclusions Entry setting for LBP was associated with future health care utilization and costs. Consideration of where patients chose to enter care may be a strategy to improve outcomes and reduce costs. [ABSTRACT FROM AUTHOR]

STUDY DESIGN: Randomized clinical trial. BACKGROUND: The recommended initial management strategy for patients with low back pain and signs of nerve root compression is conservative treatment, but there is little evidence to guide the most appropriate management strategy. Preliminary research suggests that a treatment protocol of mechanical traction and extension- oriented exercises may be effective, particularly in a specific subgroup of patients. OBJECTIVE: To examine the effectiveness of mechanical traction in patients with lumbar nerve root compression and within a predefined subgroup. METHODS: One hundred twenty patients with low back pain with nerve root compression were recruited from physical therapy clinics. Using predefined subgrouping criteria, patients were stratified at baseline and randomized to receive an extension-oriented treatment approach with or without the addition of mechanical traction. During a 6-week period, patients received up to 12 treatment visits. Primary outcomes of pain and disability were collected at 6 weeks, 6 months, and 1 year by assessors blinded to group allocation. Outcomes were examined using linear mixed- model analyses examining change over time by treatment and the interaction between treatment and subgrouping status. RESULTS: The mean ± SD age of participants was 41.1 ± 11.3 years, median duration of symptoms was 62 days, and 57% were male. No significant differences in disability or pain outcomes were noted between treatment groups at any time point, nor was any interaction found between subgroup status and treatment. CONCLUSION: Patients with lumbar nerve root compression presenting for physical therapy can expect significant changes in disability and pain over a 6-week treatment period. There is no evidence that mechanical lumbar traction in combination with an extension-oriented treatment is superior to extension-oriented exercises alone in the management of these patients or within a predefined subgroup of patients. The study protocol was registered with ClinicalTrials.gov (NCT00942227). [ABSTRACT FROM AUTHOR]

* STUDY DESIGN: A factorial randomized controlled trial. * OBJECTIVES: To investigate the addition of manual therapy to exercise therapy for the reduction of pain and increase of physical function in people with knee osteoarthritis (OA), and whether "booster sessions" compared to consecutive sessions may improve outcomes. *BACKGROUND: The benefits of providing manual therapy in addition to exercise therapy, or of distributing treatment sessions over time using periodic booster sessions, in people with knee OA are not well established. * METHODS: All participants had knee OA and were provided 12 sessions of multimodal exercise therapy supervised by a physical therapist. Participants were randomly allocated to 1 of 4 groups: exercise therapy in consecutive sessions, exercise therapy distributed over a year using booster sessions, exercise therapy plus manual therapy without booster sessions, and exercise therapy plus manual therapy with booster sessions. The primary outcome measure was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC score; 0-240 scale) at 1-year follow-up. Secondary outcome measures were the numeric pain-rating scale and physical performance tests. *RESULTS: Of 75 participants recruited, 66 (88%) were retained at 1-year follow-up. Factorial analysis of covariance of the main effects showed significant benefit from booster sessions (P = .009) and manual therapy (P = .023) over exercise therapy alone. Group analysis showed that exercise therapy with booster sessions (WOMAC score, -46.0 points; 95% confidence interval [CI]: -80.0, -12.0) and exercise therapy plus manual therapy (WOMAC score, -37.5 points; 95% CI: -69.7, -5.5) had superior effects compared with exercise therapy alone. The combined strategy of exercise therapy plus manual therapy with booster sessions was not superior to exercise therapy alone. *CONCLUSION: Distributing 12 sessions of exercise therapy over a year in the form of booster sessions was more effective than providing 12 consecutive exercise therapy sessions. Providing manual therapy in addition to exercise therapy improved treatment effectiveness compared to providing 12 consecutive exercise therapy sessions alone. Trial registered with the Australian New Zealand Clinical Trials Registry (ACTRN12612000460808). * LEVEL OF EVIDENCE: Therapy, level 1b-. [ABSTRACT FROM AUTHOR]

STUDY DESIGN: Longitudinal, prospective, observational cohort. OBJECTIVE: To examine associations between McKenzie training, functional status (FS) at discharge, and number of physical therapy visits (utilization) in patients receiving physical therapy for low back pain. BACKGROUND: The McKenzie method is commonly used in treating patients with low back pain. METHODS: A McKenzie postgraduate educational program was initiated in a large outpatient physical therapy service. Functional status data were collected at intake and at discharge. Separate hierarchical linear mixed models were used to examine associations between physical therapists' McKenzie training level (none; Parts A, B, C, and D; and credentialed), FS score at discharge, and utilization, controlling for patient risk factors. RESULTS: The final data set included 20 882 patients (mean ± SF age, 51 ± 16 years; 57% women) who completed FS surveys at both admission and discharge. Patients treated by physical therapists with any McKenzie training had better outcomes (additional 0.7 to 1.3 FS points; P<.05 to p < .001) and fewer visits (0.6 to 0.9, P<.001) compared to patients treated by physical therapists with no training. For patients treated by therapists with no versus some McKenzie education, 65% versus 70% achieved at least the minimal clinically important improvement, respectively. There were no significant differences in outcomes or utilization by level of McKenzie training. CONCLUSION: There was a slightly greater improvement of 0.7 to 1.3 points in FS at discharge in patients receiving physical therapy for low back pain by physical therapists who underwent McKenzie training. This difference was clinically important for an additional 5% of patients who achieved the minimal clinically important improvement when treated by therapists with some McKenzie training. Reduction in physical therapy utilization was 0.6 to 0.9 visits, with the fewest visits utilized by patients of physical therapists at the McKenzie Part D and credentialed levels. Together, these findings suggest improved cost-effectiveness at advanced McKenzie training levels. Ways to improve ongoing education and patient outcomes were proposed. [ABSTRACT FROM AUTHOR]

•STUDY DESIGN: Cross-sectional diagnostic accuracy study. •OBJECTIVES: To investigate the relationship between history and physical examination findings and the outcome of electrodiagnostic testing in patients with sciatica referred to physical therapy. •BACKGROUND: Electrodiagnostic testing is routinely used to evaluate patients with sciatica. Recent evidence suggests that the presence of radiculopathy identified with electrodiagnostic testing may predict better functional outcomes in these patients. While some patient history and physical examination findings have been shown to predict the presence of disc herniation or neurological insult, little is known about their relationship to the results of electrodiagnostic testing. •METHODS: Electrodiagnostic testing was performed on 38 patients with sciatica who participated in a randomized trial that compared different physical therapy interventions. The diagnostic gold standard was the presence or absence of radiculopathy, based on the results of the needle electromyographic examination. Diagnostic sensitivity and specificity values were calculated, along with corresponding likelihood ratios, for select patient history and physical examination variables. •RESULTS: No significant relationship was found between select patient history and physical examination findings, analyzed individually or in combination, and the outcome of electrodiagnostic testing. Diagnostic sensitivity values ranged from 0.03 (95% confidence interval [Cl]: 0.00, 0.24) to a high of 0.95 (95% Cl: 0.72, 0.99), and specificity values ranged from 0.10 (95% Cl: 0.02, 0.34) to a high of 0.95 (95% Cl: 0.72, 0.99). Positive likelihood ratios ranged from 0.15 (95% Cl: 0.01,2.87) to a high of 2.33 (95% Cl: 0.71, 7.70), and negative likelihood ratios ranged from 2.00 (95% Cl: 0.35, 11.48) to a low of 0.50 (95% Cl: 0.03,8.10). •CONCLUSION: In this investigation, the relationship between patient history and physical examination findings and the outcome of electrodiagnostic testing among patients with sciatica was not found to be statistically significant or clinically meaningful. However, given the small sample size and corresponding large CIs, these results should be considered with caution, recognizing that some of the history and physical examination variables may prove useful in future research. These findings suggest that electrodiagnostic testing is essential to identify the subgroup of patients with sciatica who have measurable nerve injury consistent with radiculopathy, which may be an important prognostic factor for recovery. [ABSTRACT FROM AUTHOR]

STUDY DESIGN: Randomized clinical trial. OBJECTIVES: To examine the effectiveness of cervical traction in addition to exercise for specific subgroups of patients with neck pain. BACKGROUND: Cervical traction is frequently used, but its effectiveness has not been adequately examined. Existing studies have failed to target patients most likely to respond. Traction is typically recommended for patients with cervical radiculopathy. A prediction rule has been described to identify a narrower subgroup of patients likely to respond to cervical traction. METHODS: Patients with neck pain and signs of radiculopathy were randomized to 4 weeks of treatment with exercise, exercise with mechanical traction, or exercise with over-door traction. Baseline assessment included subgrouping-rule status. The primary outcome measure (Neck Disability Index, scored 0-100) and secondary outcome measure (neck and arm pain intensity) were assessed at 4 weeks, 6 months, and 12 months after enrollment. The primary analyses examined 2-way treatment-by-time interactions. Secondary analyses examined validity of the subgrouping rule by adding 3-way interactions. RESULTS: Eighty-six patients (53.5% female; mean age, 46.9 years) were enrolled in the study. Intention-to-treat analysis found lower Neck Disability Index scores at 6 months in the mechanical traction group compared to the exercise group (mean difference between groups, 13.3; 95% confidence interval: 5.6, 21.0) and over-door traction group (mean difference between groups, 8.1; 95% confidence interval: 0.8, 15.3), and at 12 months in the mechanical traction group compared to the exercise group (mean difference between groups, 9.8; 95% confidence interval: 0.2, 19.4). Secondary outcomes favored mechanical traction at several time points. The validity of the subgrouping rule was supported on the Neck Disability Index at the 6-month time point only. CONCLUSION: Adding mechanical traction to exercise for patients with cervical radiculopathy resulted in lower disability and pain, particularly at long-term follow-ups. The study protocol was registered at http://clinicaltrials.gov (NCT00979108). [ABSTRACT FROM AUTHOR]

Background. A treatment-based classification algorithm for low back pain (LBP) was created to help clinicians select treatments to which people are most likely to respond. To allow the algorithm to classify all people with LBP, additional criteria can help therapists make decisions for people who do not clearly fit into a subgroup (ie, unclear classifications). Recent studies indicated that classifications are unclear for approximately 34% of people with LBP. Objective. To guide improvements in the algorithm, it is imperative to determine whether people with unclear classifications are different from those with clear classifications. Design. This study was a secondary analysis of data from 3 previous studies investigating the algorithm. Methods. Baseline data from 529 people who had LBP were used (3 discrete cohorts). The primary outcome was type of classification, that is, clear or unclear. Univariate logistic regression was used to determine which participant variables were related to having an unclear classification. Results. People with unclear classifications had greater odds of being older (odds ratio [OR]=1.01, 95% confidence interval [CI]=1.003-1.033), having a longer duration of LBP (OR=1.001, 95% CI=1.000 -1.001), having had a previous episode(s) of LBP (OR=1.61, 95% CI=1.04 -2.49), having fewer fear-avoidance beliefs related to both work (OR=0.98, 95% CI=0.96-0.99) and physical activity (OR=0.98, 95% CI=0.96-0.996), and having less LBP-related disability (OR=0.98, 95% CI=0.96- 0.99) than people with clear classifications. Limitations. Studies from which participant data were drawn had different inclusion criteria and clinical settings. Conclusions. People with unclear classifications appeared to be less affected by LBP (less disability and fewer fear avoidance beliefs), despite typically having a longer duration of LBP. Future studies should investigate whether modifying the algorithm to exclude such people or provide them with different interventions improves outcomes. [ABSTRACT FROM AUTHOR]

Background. The STarT Back Screening Tool (SBT) was recently developed for primary care providers to use as a screening tool for subgrouping people with low back pain (LBP) on the basis of modifiable prognostic factors. The use of the SBT in physical therapy has not been described. Objective. The aims of this study were to describe the use of the SBT in people receiving physical therapy for LBP and to describe patterns of change in clinical outcomes across the episode of care and among SBT categories. Design. This study was a prospective case series. Methods. A total of 214 patients receiving physical therapy for LBP were administered the SBT at the initial evaluation. Treatment was at the physical therapist's discretion. Clinical outcomes included pain intensity and disability scores collected at each session. Descriptive statistics were calculated, and baseline characteristics among SBT categories were compared. Hierarchical linear mixed models were used to examine patterns of change in predicted outcomes across the episode of care. Results. The patients' mean age was 44.3 years (SD=15.8), and 56.5% were women. The SBT categorized 33.2% of the patients as being at low risk, 47.7% as being at medium risk, and 19.2% as being at high risk. The high-risk category corresponded to the highest initial pain intensity and disability scores. The low-risk category corresponded to the lowest initial pain intensity and disability scores. Linear mixed models indicated different patterns of change in outcome scores for pain intensity (F=3.99) and disability (F=3.49) among SBT categories. Relative to the low-risk category, the high-risk category had larger improvements in predicted outcomes and the medium-risk category had similar improvements in predicted outcomes. Limitations. The SBT was not administered to 24% of eligible patients. The timing of follow-up assessments was variable. Conclusions. The SBT may provide important prognostic information for physical therapists. [ABSTRACT FROM AUTHOR]

Background. Several studies have investigated criteria for classifying patientswith low back pain (LBP) into treatment-based subgroups. A comprehensive algorithm was created to translate these criteria into a clinical decision-making guide. Objective. This study investigated the translation of the individual subgroup criteria into a comprehensive algorithm by studying the prevalence of patients meeting the criteria for each treatment subgroup and the reliability of the classification. Design. This was a cross-sectional, observational study. Methods. Two hundred fifty patients with acute or subacute LBP were recruited from the United States and Australia to participate in the study. Trained physical therapists performed standardized assessments on all participants. The researchers used these findings to classify participants into subgroups. Thirty-one participants were reassessed to determine interrater reliability of the algorithm decision. Results. Based on individual subgroup criteria, 25.2% (95% confidence interval [CI]19.8%-30.6%) of the participants did not meet the criteria for any subgroup, 49.6% (95% CI43.4%-55.8%) of the participants met the criteria for only one subgroup, and 25.2% (95% CI19.8%-30.6%) of the participants met the criteria for more than one subgroup. The most common combination of subgroups was manipulation specific exercise (68.4% of the participants who met the criteria for 2 subgroups). Reliability of the algorithm decision was moderate (kappa0.52, 95% CI0.27- 0.77, percentage of agreement67%).Limitations. Due to a relatively small patient sample, reliability estimates aresomewhat imprecise. Conclusions. These findings provide important clinical data to guide future research and revisions to the algorithm. The finding that 25% of the participants met the criteria for more than one subgroup has important implications for the sequencing of treatments in the algorithm. Likewise, the finding that 25% of the participants did not meet the criteria for any subgroup provides important information regarding potential revisions to the algorithm's bottom table (which guides unclear classifications). Reliability of the algorithm is sufficient for clinical use. [ABSTRACT FROM AUTHOR]

Background. Medicare beneficiaries frequently receive physical therapy for musculoskeletal conditions. Little information is available about this care.Objective. The purposes of this study were: (1) to describe characteristics, clinical outcomes, and utilization for Medicare beneficiaries receiving physical therapy in outpatient clinics within one integrated health care system; (2) to compare characteristics, outcomes, and utilization based on the body region affected; and (3) to examine factors predictive of outcomes and utilization.Design. This was a prospective, longitudinal study. Methods. Medicare beneficiaries aged 65 years or older (n1,840 episodes of care) participated in the study. Descriptive statistics were calculated for patient characteristics and outcomes. Comparisons were made based on body region. Regression models evaluated factors associated with change in pain, improved outcome,and utilization. Results. The patients' mean age was 74.2 years (SD6.3), and 65.3% were female. The most common body regions were the lumbar spine, shoulder, and knee, collectively accounting for 71.3% of the episodes of care. Patients attended a mean of 6.8 visits (SD4.7), and 63.9% experienced an improved outcome. Episodes of care for lumbar spine conditions had less reduction in pain, whereas shoulder conditions and foot/ankle conditions showed the greatest improvement. Care for hip conditions was least likely to result in an improved outcome. Knee conditions were most likely to have an improved outcome. Care for shoulder and knee conditions had the highest number of visits. Factors associated with greater reduction in pain and improved outcomes included greater initial pain or disability and attending more visits. Factors associated with greater utilization included a postsurgical condition and higher initial pain rating. Limitations. The study was performed in one geographic region within a single health care delivery system. Conclusion. The results provide information on outcomes of physical therapy or Medicare beneficiaries in one health care system. Further research is needed to examine optimal utilization and care for these patients. [ABSTRACT FROM AUTHOR]

Background. Therapeutic selective nerve root blocks (SNRBs) are a common intervention for patients with sciatica. Patients often are referred to physical therapy after SNRBs, although the effectiveness of this intervention sequence has not been investigated. Objective. This study was a preliminary investigation of the effectiveness of SNRBs, with or without subsequent physical therapy, in people with low back pain and sciatica. Design. This investigation was a pilot randomized controlled clinical trial. Setting. The settings were spine specialty and physical therapy clinics. Participants. Forty-four participants (64% men; mean age 38.5 years, SD 11.6 years) with low back pain, with clinical and imaging findings consistent with lumbar disk herniation, and scheduled to receive SNRBs participated in the study. They were randomly assigned to receive either 4 weeks of physical therapy (SNRB PT group) or no physical therapy (SNRB alone [SNRB group]) after the injections. Intervention. All participants received at least 1 SNRB; 28 participants (64%) received multiple injections. Participants in the SNRB PT group attended an average of 6.0 physical therapy sessions over an average of 23.9 days. Measurements. Outcomes were assessed at baseline, 8 weeks, and 6 months with the Low Back Pain Disability Questionnaire, a numeric pain rating scale, and the Global Rating of Change. Results. Significant reductions in pain and disability occurred over time in both groups, with no differences between groups at either follow-up for any outcome. Nine participants (5 in the SNRB group and 4 in the SNRB PT group) underwent surgery during the follow-up period. Limitations. The limitations of this study were a relatively short-term follow-up period and a small sample size. Conclusions. A physical therapy intervention after SNRBs did not result in additional reductions in pain and disability or perceived improvements in participants with low back pain and sciatica. INSET: The Bottom Line. [ABSTRACT FROM AUTHOR]

Background. A clinical prediction rule (CPR) purported to identify patients with neck pain who are likely to respond to thoracic spine thrust manipulation has recently been developed, but has yet to be validated. Objective. The purpose of this study was to examine the validity of this CPR. Design. This was a multi-center randomized clinical trial. Methods. One hundred forty patients with a primary report of neck pain were randomly assigned to receive either 5 sessions of stretching and strengthening exercise (exercise-only group) or 2 sessions of thoracic spine manipulation and cervical range of motion exercise followed by 3 sessions of stretching and strengthening exercise (manipulation + exercise group). Data on disability and pain were collected at baseline, 1 week, 4 weeks, and 6 months. The primary aim (treatment group X time X status on the prediction rule) was examined using a linear mixed model with repeated measures. Time, treatment group, and status on the rule, as well as all possible 2-way and 3-way interactions, were modeled as fixed effects, with disability (and pain) as the dependent variable. Effect sizes were calculated for both pain and disability at each follow-up period. Results. There was no 3-way interaction for either disability or pain. A 2-way (group X time) interaction existed for both disability and pain. Pair-wise comparisons of disability demonstrated that significant differences existed at each follow-up period between the manipulation + exercise group and the exercise-only group. The patients who received manipulation exhibited lower pain scores at the 1-week follow-up period. The effect sizes were moderate for disability at each follow-up period and were moderate for pain at the 1-week follow-up. Limitations. Different exercise approaches may have resulted in a different outcome. Conclusions. The results of the current study did not support the validity of the previously developed (-PR. However, the results demonstrated that patients with mechanical neck pain who received thoracic spine manipulation and exercise exhibited significantly greater improvements in disability at both the short- and long- term follow-up periods and in pain at the 1-week follow-up compared with patients who received exercise only. INSET: The Bottom Line. [ABSTRACT FROM AUTHOR]

Objectives: To describe a program to translate evidence into practice for the use of manipulation with a sub-group of patients with low back pain and report the program's outcomes following implementation. We compared outcomes based on appropriate inclusion in the program and compliance with the evidence being translated. Methods: The evidence translation program was based on evidence that patients meeting two criteria (duration of symptoms <16 days, no symptoms distal to knee) were likely to respond to a physical therapy that included manipulation in the first two visits. Implementation addressed potential barriers with referring physicians, physical therapists, and scheduling staff to this evidence. Outcomes for patients in the program were tracked following implementation. Process outcomes were appropriateness of inclusion (met both criteria), compliance with evidence for providing thrust manipulation in the first two visits, and number of physical therapy visits. Clinical outcomes were based on Oswestry scores from the first, interim (after two to three visits), and final visit. Results: A total of 577 patients entered the evidence translation program (mean age = 43.0, 56.8% female); 79.5% were appropriate inclusions and 83.0% received manipulation. The use of manipulation was associated with fewer visits (mean difference = 0.54 visits, 95% CI: 0.037, 1.04, P = 0.035), and appropriate inclusion was associated with greater Oswestry change (mean difference at the final visit = 6.6 points, 95% CI: 1.6, 11.6; P = 0.010). Discussion: Implementing evidence into practice is difficult; however, barriers can be anticipated and overcome. Tracking the outcomes of an implementation program is critical to evaluating its benefit to patients. Additional research using experimental designs are necessary to evaluate the effectiveness of various treatments implemented in physical therapy practice. [ABSTRACT FROM AUTHOR]