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Objective The purpose of this study was to determine the proportion of patients with low back pain who achieved clinical improvement in disability within 3 or 6 physical therapy visits, identify factors that predicted improvement, and predict the probability of improvement by the third and sixth visits. Methods This retrospective, observational study looked at patients (N = 6523) who completed a numeric pain scale and Modified Low Back Disability Questionnaire (MDQ) at every visit. Four prediction models were developed: 30% improvement by visit 3 and by visit 6 and 50% improvement by visit 3 and by visit 6. A logistic regression model was fit to predict patients' improvement in disability using the MDQ. Predictive models used age, disability scores, sex, symptom duration, and payer type as factors. Receiver operating characteristic curves and area under the curve were computed for the models. Nomograms illustrate the relative impacts of the predictor variables. Results Disability improved 30% in 42.7% of patients by visit 3 and 49% by visit 6. Disability improved 50% in 26% of patients by visit 3 and 32.9% by visit 6. First visit score (MDQ1) was strongest factor to predict 30% improvement by visit 3. The visit 3 score (MDQ3) was strongest factor to predict a 30% or 50% improvement by visit 6. The combination of MDQ1 and MDQ3 scores was strongest overall predictive factor for visit 6. The area under the curve values for models using only the MDQ1 and MDQ3 scores to predict 30% or 50% improvement by the sixth visit were 0.84 and 0.85, respectively, representing excellent overall diagnostic accuracy of the prediction models. Conclusion Excellent discrimination to predict patients' significant clinical improvement by visit 6 using 2 outcome scores was demonstrated. Gathering outcomes routinely enhances assessment of prognosis and clinical decision making. Impact Understanding prognosis of clinical improvement supports physical therapists' contribution to value-based care. [ABSTRACT FROM AUTHOR]

Objective We assessed whether race or ethnicity was associated with the incidence of high-impact chronic low back pain (cLBP) among adults consulting a primary care provider for acute low back pain (aLBP). Methods In this secondary analysis of a prospective cohort study, patients with aLBP were identified through screening at seventy-seven primary care practices from four geographic regions. Incidence of high-impact cLBP was defined as the subset of patients with cLBP and at least moderate disability on Oswestry Disability Index [ODI >30]) at 6 months. General linear mixed models provided adjusted estimates of association between race/ethnicity and high-impact cLBP. Results We identified 9,088 patients with aLBP (81.3% White; 14.3% Black; 4.4% Hispanic). Black/Hispanic patients compared to White patients, were younger and more likely to be female, obese, have Medicaid insurance, worse disability on ODI, and were at higher risk of persistent disability on STarT Back Tool (all P  < .0001). At 6 months, more Black and Hispanic patients reported high-impact cLBP (30% and 25%, respectively) compared to White patients (15%, P  < .0001, n = 5,035). After adjusting for measured differences in socioeconomic and back-related risk factors, compared to White patients, the increased odds of high-impact cLBP remained statistically significant for Black but not Hispanic patients (adjusted odds ration [aOR] = 1.40, 95% confidence interval [CI]: 1.05–1.87 and aOR = 1.25, 95%CI: 0.83–1.90, respectively). Conclusions We observed an increased incidence of high-impact cLBP among Black and Hispanic patients compared to White patients. This disparity was partly explained by racial/ethnic differences in socioeconomic and back-related risk factors. Interventions that target these factors to reduce pain-related disparities should be evaluated. ClinicalTrials.gov Identifier NCT02647658. [ABSTRACT FROM AUTHOR]

Objective This study sought to develop and validate an original prediction formula that estimated the probability of success for patients with low back pain (LBP) to achieve a minimal clinically important difference (MCID) on the Modified Low Back Disability Questionnaire (MDQ). Methods Patients were 10 to 90 years old in this retrospective cohort study. Data were extracted from Intermountain Healthcare's registry, Rehabilitation Outcomes Management System: 62,858 patients admitted to physical therapy from 2002 to 2013 formed the training dataset, and 15,128 patients admitted 2015 to 2016 formed the verification dataset. Predicted probability to achieve MCID was compared with the actual percentage who succeeded. Two models were developed: 6-point improvement and 30% improvement. MDQ assessed disability, and numeric pain score assessed pain intensity. Predictive models used restricted cubic splines on age, initial pain, and disability scores for non-linear effects. Sex, symptom duration, and payer type were included as indicator variables. Predicted chance of success was compared with the actual percentage of patients that succeeded. Relative change in R -squared was calculated to assess variable importance in predicting success. Odds ratios for duration of injury and payer were calculated. Results A positive trend was observed in both models between predicted and actual success achieved. Both "verification" models appear accurate and closely approximate the "training dataset." Baseline MDQ score was the most important factor to predict a 6-point improvement. Payer type and injury duration were important factors to predict 30% improvement. Best odds to achieve an MCID was having a workers compensation insurance payer and seeking care within 14 days. Conclusion The 2 models demonstrated an accurate visualization of the chance of patients achieving significant improvement compared with the usual representation of the average rate of improvement for all patients. Impact Enhancing physical therapists' understanding of the probability of a patient achieving significant clinical improvement can enhance decision-making processes and help physical therapists manage a patient's care more effectively. [ABSTRACT FROM AUTHOR]

Background. Limited information exists regarding the cost-effectiveness of rehabilitation strategies for individuals with knee osteoarthritis (OA). Objective. The study objective was to compare the cost-effectiveness of 4 different combinations of exercise, manual therapy, and booster sessions for individuals with knee OA. Design. This economic evaluation involved a cost-effectiveness analysis performed alongside a multicenter randomized controlled trial. Setting. The study took place in Pittsburgh, Pennsylvania; Salt Lake City, Utah; and San Antonio, Texas. Participants. The study participants were 300 individuals taking part in a randomized controlled trial investigating various physical therapy strategies for knee OA. Intervention. Participants were randomized into 4 treatment groups: exercise only (EX), exercise plus booster sessions (EX+B), exercise plus manual therapy (EX+MT), and exercise plus manual therapy and booster sessions (EX+MT+B). Measurements. For the 2-year base case scenario, a Markov model was constructed using the United States societal perspective and a 3% discount rate for costs and quality- adjusted life years (QALYs). Incremental cost-effectiveness ratios were calculated to compare differences in cost per QALY gained among the 4 treatment strategies. Results. In the 2-year analysis, booster strategies (EX+MT+B and EX+B) dominated no-booster strategies, with both lower health care costs and greater effectiveness. EX+ MT+B had the lowest total health care costs. EX+B cost $1061 more and gained 0.082 more QALYs than EX+MT+B, for an incremental cost-effectiveness ratio of $12,900/QALY gained. Limitations. The small number of total knee arthroplasty surgeries received by individuals in this study made the assessment of whether any particular strategy was more successful at delaying or preventing surgery in individuals with knee OA difficult. Conclusions. Spacing exercise-based physical therapy sessions over 12 months using periodic booster sessions was less costly and more effective over 2 years than strategies not containing booster sessions for individuals with knee OA. [ABSTRACT FROM AUTHOR]

Background. The Centers for Medicare and Medicaid Services (CMS) require physical therapists document patients' functional limitations. The process is not standardized. A systematic approach to determine a patient's functional limitations and responsiveness to change is needed. Objective. The purpose of this study is to compare patient-reported outcomes (PROs) responsiveness to change using 7-level severity/complexity modifier scale proposed by Medicare to a derived scale implemented by Intermountain Healthcare's Rehabilitation Outcomes Management System (ROMS). Design. This was a retrospective, observational cohort design. Methods. 165,183 PROs prior to July 1, 2013, were compared to 46,334 records from July 1, 2013, to December 31, 2015. Histograms and ribbon plots illustrate distribution and change of patients' scores. ROMS raw score ranges were calculated and compared to CMS' severity/complexity levels based on score percentage. Distribution of the population was compared based on the 2 methods. Sensitivity and specificity were compared for responsiveness to change based on minimal clinically important difference (MCID). Results. Histograms demonstrated few patient scores placed in CMS scale levels at the extremes, whereas the majority of scores placed in 2 middle levels (CJ, CK). ROMS distributed scores more evenly across levels. Ribbon plots illustrated advantage of ROMS' using narrower score ranges. Greater chance for patients to change levels was observed with ROMS when an MCID was achieved. ROMS narrower scale levels resulted in greater sensitivity and good specificity. Limitations. Geographic representation for the United States was limited. Without patients' global rating of change, a reference standard to gauge validation of improvement could not be provided. Conclusions. ROMS provides a standard approach to identify accurately functional limitation modifier levels and to detect improvement more accurately than a straight across transposition using the CMS scale. [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]

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]

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]