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Background Context: The North American Spine Society's (NASS) Evidence-Based Clinical Guideline for the Diagnosis and Treatment of Adults with Osteoporotic Vertebral Compression Fractures features evidence-based recommendations for diagnosing and treating adult patients with osteoporotic vertebral compression fractures. The guideline is intended to reflect contemporary treatment concepts for osteoporotic vertebral compression fractures as reflected in the highest quality clinical literature available on this subject as of September 2020., Purpose: The purpose of the guideline is to provide an evidence-based educational tool to assist spine specialists when making clinical decisions for adult patients with osteoporotic vertebral compression fractures. This article provides a brief summary of the evidence-based guideline recommendations for diagnosing and treating patients with this condition., Study Design: This is a guideline summary review., Methods: This guideline is the product of NASS' Clinical Practice Guidelines Committee. The methods used to develop this guideline are detailed in the complete guideline and technical report available on the NASS website. In brief, a multidisciplinary work group of spine care specialists convened to identify clinical questions to address in the guideline. The literature search strategy was developed in consultation with a medical librarian. Upon completion of the systematic literature search, evidence relevant to the clinical questions posed in the guideline was reviewed. Work group members utilized NASS evidentiary table templates to summarize study conclusions, identify study strengths and weaknesses, and assign levels of evidence. Work group members participated in recommendation meetings to update and formulate evidence-based recommendations and incorporate expert opinion when necessary. The draft guideline was submitted to an internal and external peer review process and ultimately approved by the NASS Board of Directors., Results: Twenty-nine clinical questions were addressed, and the answers are summarized in this article. The respective recommendations were graded according to the levels of evidence of the supporting literature., Conclusions: The evidence-based clinical guideline has been created using techniques of evidence-based medicine and best available evidence to aid practitioners in the diagnosis and treatment of adult patients with osteoporotic vertebral compression fractures. The entire guideline document, including the evidentiary tables, literature search parameters, literature attrition flowchart, suggestions for future research, and all of the references, is available electronically on the NASS website at http://www.spine.org/guidelines., (Copyright © 2025. Published by Elsevier Inc.)

Background Context: Clinical outcomes are directly related to patient selection and treatment indications for improved quality of life. With emphasis on quality and value, it is essential that treatment recommendations are optimized., Purpose: The purpose of the North American Spine Society (NASS) Appropriate Use Criteria (AUC) is to determine the appropriate (ie, reasonable) multidisciplinary treatment recommendations for patients with metastatic neoplastic vertebral fractures across a spectrum of more common clinical scenarios., Study Design: A Modified Delphi process., Patient Sample: Systematic Review OUTCOME MEASURES: Final rating for cervical fusion recommendation as either "Appropriate," "Uncertain," or "Rarely Appropriate" based on the median final rating among the raters., Methods: The methodology was based on the AUC development process established by the Research AND Development (RAND) Corporation. The topic of neoplastic vertebral fracture was selected by NASS for its Clinical Practice Guideline development (CPG). In conjunction, the AUC work group determined key modifiers and adopted the standard definitions developed by CPG, with minimal modifications. A literature search and evidence analysis performed by the CPG were reviewed by the AUC work group. A separate multidisciplinary rating group was assembled. Based on the literature, provider experience, and group discussion, each scenario was scored on a 9-point scale on 2 separate occasions, once without discussion and then a second time following discussion based on the initial responses. The median rating for each scenario was then used to determine if indications were rarely appropriate (1-3), uncertain / maybe appropriate (4-6), or appropriate (7-9). Consensus was not mandatory., Results: Medical management was essentially always appropriate. Radiation therapy was appropriate 50% of the time and uncertain otherwise, and directly related to radiosensitivity of the tumor. Ablation was never rated appropriate with agreement, and about 50% of the time was rated as uncertain. For cement augmentation, the scenarios without stenosis or neurological changes, stable fractures with less than 80% height loss and intact posterior wall, and higher VAS pain scores accounted for 88% probability of an appropriate rating. Otherwise, cement augmentation was uncertain 68% of the time. Surgery was rated as appropriate with agreement in 35%, and uncertain or appropriate with disagreement in 59% of scenarios. The most important variables determining final rating for surgery (in order) were stability, spinal stenosis, and prognosis., Conclusions: Multidisciplinary appropriate treatment criteria were generated based on the RAND methodology. Recommendations were made for medical treatment, ablation, radiation, cement augmentation, and surgery based on 432 practical clinical scenarios. This document provides comprehensive evidence-based recommendations for evaluation and treatment of metastatic neoplastic vertebral fractures. The document in its entirety will be found on the NASS website (https://www.spine.org/Research-Clinical-Care/Quality-Improvement/Appropriate-Use-Criteria)., Competing Interests: Declaration of competing interest One or more of the authors declare financial or professional relationships on ICMJE-TSJ disclosure forms., (Copyright © 2025 Elsevier Inc. All rights reserved.)

Objective: To perform a secondary review of low back pain (LBP) clinical practice guidelines (CPG) identified in a recently conducted systematic review and to synthesize and summarize low-value recommendations as practices that may be candidates for deimplementation., Literature Survey: LBP (subacute or chronic) CPGs in English (symptom based, created by a governmental or professional society, published between January 1990 and May 2020) were previously identified using MEDLINE, EMBASE, CINAHL, Ortho Guidelines, CPG Infobase, Emergency Care Research Institute, Guidelines International Network, National Institute of Health and Care Excellence, and Scottish Intercollegiate Guideline Network., Methodology: Twenty-one CPGs were reviewed from a systematic review (previously published). Full-text review of all 21 CPGs was conducted, and three recommendation categories indicative of low value (recommend strongly against, recommend weakly against, inconclusive/insufficient evidence) were identified using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) language and approach., Synthesis: One hundred thirty-five low-value recommendations were identified and classified under eight intervention categories: orthotics/support, traction, physical modalities, pharmacological interventions, injections, surgery, bed rest, and miscellaneous. Traction, transcutaneous electrical nerve stimulation (TENS), therapeutic ultrasound (TUS), and selective serotonin reuptake inhibitors (SSRI) had the most CPGs recommend strongly against their usage. Opioids were recommended strongly against by four CPGs. No significant difference (p > .05) was found between CPG quality and a specific deimplementation recommendation or between CPG quality and the number of strongly against, weakly against, and inconclusive/insufficient evidence recommendations., Conclusions: Clinicians managing patients with chronic LBP should consider deimplementing these low-value interventions (traction, TENS, TUS, and SSRI)., (© 2024 The Author(s). PM&R published by Wiley Periodicals LLC on behalf of American Academy of Physical Medicine and Rehabilitation.)

As health care attempts to bridge the gap between evidence and practice, the concept of the learning health system (LHS) is becoming increasingly relevant. LHS integrates evidence with health systems data, driving health care quality and outcomes through updates in policy, practice, and care delivery. In addition, LHS research is becoming critically important as there are several initiatives underway to increase research capacity, expertise, and implementation, including attempts to stimulate increasing numbers of LHS researchers. Physical Medicine & Rehabilitation (PM&R) physicians (physiatrists), nurses, therapists (physical therapists, occupational therapists, speech therapists, clinical psychologists), and scientists are affiliated with LHSs. As LHS research expands in health care systems, better awareness and understanding of LHSs and LHS research competencies are key for rehabilitation professionals including physiatrists. To address this need, the Agency of Healthcare Research and Quality (AHRQ) identified 33 core competencies, grouped into eight domains, for training LHS researchers. The domains are: (1) Systems Science; (2) Research Questions and Standards of Scientific Evidence; (3) Research Methods; (4) Informatics; (5) Ethics of Research and Implementation in Health Systems; (6) Improvement and Implementation Science; (7) Engagement, Leadership, and Research Management; and the recently added (8) Health and Healthcare Equity and Justice. The purpose of this commentary is to define LHS and its relevance to physiatrists, present the role of implementation science (IS) in LHSs and application of IS principles to design LHSs, illustrate current LHS research in rehabilitation, and discuss potential solutions to improve awareness and to stimulate interest in LHS research and IS among physiatrists in LHSs., (© 2024 The Authors. PM&R published by Wiley Periodicals LLC on behalf of American Academy of Physical Medicine and Rehabilitation. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.)

Telehealth refers to the use of telecommunication devices and other forms of technology to provide services outside of the traditional in-person health care delivery system. Growth in the use of telehealth creates new challenges and opportunities for implementation in clinical practice. The American Academy of Physical Medicine and Rehabilitation (AAPM&R) assembled an expert group to develop a white paper to examine telehealth innovation in Physical Medicine and Rehabilitation (PM&R). The resultant white paper summarizes how telehealth is best used in the field of PM&R while highlighting current knowledge deficits and technological limitations. The report identifies new and transformative opportunities for PM&R to advance translational research related to telehealth and enhance patient care., (© 2023 American Academy of Physical Medicine and Rehabilitation.)

Objective: To summarize the recommendations on the interventional management of subacute and chronic nonradicular low back pain (LBP) from the 21 quality-appraised clinical practice guidelines (CPGs) identified in a previously published paper: "Quality of Clinical Practice Guidelines on Interventional Management of Low Back Pain: A Systematic Review." By disseminating this information, we aimed to facilitate the implementation of these recommendations into clinical practice. TYPE: Systematic Review LITERATURE SURVEY: Electronic bibliographic databases, guideline databases, and gray literature were searched from January 2016 to January 2020 to identify CPGs that met study criteria., Methodology: A total of 21 CPGs were quality appraised and interventional management recommendations were extracted and organized into several treatment categories including epidural steroid injections, radiofrequency procedures (RF), facet injections, sacroiliac injections, and prolotherapy. Within each treatment category, the recommendations were organized based on two factors: quality of CPG and strength of recommendation., Synthesis: Overall, there was no consistency in recommendations for or against any interventional procedure, even when accounting for the quality of the CPG. In all of the CPGs reviewed, the most common strength of recommendation was weakly for. The second, third, and fourth most common strength of recommendations were inconclusive, weakly against, and strongly against, respectively, and the least common was strongly for. The treatment categories with the greatest number of recommendations were RF procedures (most common strength of recommendation was weakly for) and facet procedures. Among the high-quality CPGs, the most common strength of recommendation was inconclusive., Conclusions: Most of the interventional management recommendations for management of nonradicular LBP in the 21 CPGs appraised in this review were either weakly for, weakly against, or inconclusive, with several recommendations within each treatment category contradicting each other. Appraisal of Guidelines for Research & Evaluation Instrument quality appraisals of CPGs on interventional management of LBP were of unclear utility in guiding clinical implementation., (© 2022 American Academy of Physical Medicine and Rehabilitation. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.)

Objective: To appraise the quality of low back pain (LBP) clinical practice guidelines (CPG) that include interventional management recommendations and to associate their quality with characteristics including publication year and creating organization. TYPE: Systematic Review., Literature Survey: LBP (subacute or chronic) CPGs in English (symptom based, governmental or professional society created, January 1990-May 2020) were found using MEDLINE, EMBASE, CINAHL, Ortho Guidelines, CPG Infobase, ECRI, Guidelines International Network, NICE, and SIGN., Methodology: In this third order systematic review, search results were deduplicated, title and abstract screened by two independent reviewers, and full texts reviewed by four reviewers. Discrepancies were resolved by a third reviewer. Resulted CPGs were appraised using the Appraisal of Guidelines for Research and Evaluation (AGREE II) Tool by four appraisers each. Association of their quality with creating organization, geographical region, and year of creation was calculated., Synthesis: Seven hundred fourteen screened documents resulted in 21 final CPGs. On appraisal, average overall CPG quality was 5.2 (range 2.5-6.75). Domain 5 (applicability) had the lowest average (44%) and domain 4 (clarity of presentation) had the highest average score (82%). For overall recommendation, 16 received "yes" or "yes with modifications," six received unanimous "yes" and two unanimous "no" votes. The interrater agreement of domain scoring was excellent (0.8-1.0; p < .001). There was no association found between quality of CPG and (1) year of publication (R 2  = 0.0006), (2) whether the CPG was updated or new (p = .17), and (3) region of publication (p = .37)., Conclusions: The majority of the 21 CPGs identified in this systematic review were of high quality, but overall quality and recommendation ratings were variable. The quality of appraised CPGs showed no association with their characteristics. Some domains such as "applicability" scored uniformly lower, revealing opportunity for improvement in future CPG development. LBP CPGs should be scrutinized before adopting their recommendations., (© 2022 American Academy of Physical Medicine and Rehabilitation. This article has been contributed to by US Government employees and their work is in the public domain in the USA.)

Introduction: Utilization of telemedicine for health care delivery increased rapidly during the coronavirus disease 2019 (COVID-19) pandemic. However, physical examination during telehealth visits remains limited. A novel telerehabilitation system-The Augmented Reality-based Telerehabilitation System with Haptics (ARTESH)-shows promise for performing synchronous, remote musculoskeletal examination., Objective: To assess the potential of ARTESH in remotely examining upper extremity passive range of motion (PROM) and maximum isometric strength (MIS)., Design: In this cross-sectional pilot study, we compared the in-person (reference standard) and remote evaluations (ARTESH) of participants' upper extremity PROM and MIS in 10 shoulder and arm movements. The evaluators were blinded to each other's results., Setting: Participants underwent in-person evaluations at a Veterans Affairs hospital's outpatient Physical Medicine and Rehabilitation (PM&R) clinic, and underwent remote examination using ARTESH with the evaluator located at a research lab 30 miles away, connected via a high-speed network., Patients: Fifteen participants with upper extremity pain and/or weakness., Interventions: Not applicable., Main Outcome Measures: Inter-rater agreement between in-person and remote evaluations on 10 PROM and MIS movements and presence/absence of pain with movement was calculated., Results: The highest inter-rater agreements were noted in shoulder abduction and protraction PROM (kappa (κ) = 0.44, confidence interval (CI): -0.1 to 1.0), and in elbow flexion, shoulder abduction, and shoulder protraction MIS (κ = 0.63, CI: 0 to 1.0)., Conclusions: This pilot study suggests that synchronous tele-physical examination using the ARTESH system with augmented reality and haptics has the potential to provide enhanced value to existing telemedicine platforms. With the additional technological and procedural improvements and with an adequately powered study, the accuracy of ARTESH-enabled remote tele-physical examinations can be better evaluated., (© 2022 American Academy of Physical Medicine and Rehabilitation. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.)

Abstract: Blinding in research is important, and the field of physical medicine and rehabilitation poses special consideration owing to the patient populations and treatment methodologies used. Historically, blinding has been increasingly relevant to conducting good-quality research. The main reason to blind is to reduce bias. There are several strategies to blinding. At times, when blinding is not possible, alternatives to blinding include sham control and description of study and control groups. Illustrative examples of blinding used in physical medicine and rehabilitation research are described in this article, along with how to assess success and fidelity of blinding., Competing Interests: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To describe a novel 3-dimensional (3D) exergames system and the results of a clinical feasibility study of stroke survivors needing in-home rehabilitation., Materials and Methods: The customisable Personalized In-home eXErgames for Rehabilitation (PIXER) system captures the user's image, generates a live model, and incorporates it into a virtual exergame. PIXER provides a recording system for home exercise programs (HEPs) by adapting virtual objects, customizes the exergame and creates a digital diary. Ten persons with stroke, performed HEPs with PIXER for 1 month, and without PIXER for 2 additional months. In-game performance data, measures of physical functioning (PF) including Stroke Impact Scale (SIS), Timed Up & Go (TUG) and Goal Attainment (GA) Scale obtained at baseline, 1- and 3 months were evaluated., Results: Seventy percent of participants completed the 1-month timepoint, 50% completed all timepoints. In-game data: Number of repetitions completed; Anomalies reported; and Percentage of bubbles hit showed positive trends. Compared to baseline, all SIS physical functioning (PF) scores were higher at 1 month, TUG scores showed no overall improvement and GA scale scores were 77% at 3 months., Conclusion: It is feasible for community-dwelling patients to perform HEP after stroke using PIXER, a novel, exergames system, and potentially improve their function.IMPLICATIONS FOR REHABILITATIONHome Exercises performed using a novel, 3-dimensional, customizable Personalized In-home eXErgames for Rehabilitation (PIXER) system is feasible for community-dwelling patients after stroke.In-game performance data obtained in this clinical pilot study showed positive trends of improvement in several study participants.PIXER has potential to improve functional outcomes for community-dwelling adults with stroke.

Introduction: Mirror therapy for phantom limb pain (PLP) is a well-accepted treatment method that allows participants to use a mirror to visually perceive the missing limb. Mixed reality options are now becoming increasingly available, but an in-home virtual mirror therapy option has yet to be adequately investigated., Methods: We had previously developed a mixed reality system for Managing Phantom Pain (Mr. MAPP) that registers the intact limb and mirrors it onto the amputated limb with the system's visual field, allowing the user to engage with interactive games targeting different large lower limb movements. Feasibility and pilot outcomes of treating patients with lower extremity PLP by using Mr. MAPP at home for 1 month were evaluated in this study. Pain intensity and interference were assessed using the McGill Pain Questionnaire, Brief Pain Inventory, and a daily exercise diary. Function was assessed using the Patient Specific Functional Scale (PSFS). The clinical trial registry number for this study is NCT04529083., Results: This pilot study showed that it was feasible for patients with PLP to use Mr. MAPP at home. Among pilot clinical outcomes, statistically significant differences were noted in mean current pain intensity [1.75 (SD = 0.46) to 1.125 (SD = 0.35) out of 5, P  = .011] and PSFS goal scores [4.28 (SD = 2.27) to 6.22 (SD = 2.58) out of 10, P  = .006], with other outcome measures showing non-significant trends towards improvement., Discussion: This pilot study revealed that in-home use of Mr. MAPP has potential to provide pain relief and improve function in patients with lower extremity PLP and is feasible. Each scale used provided unique perspective on the functional impact of PLP. Further expanded studies and investigation, including a fully powered clinical trial, with these scales are warranted., Clinical Trial Registration: https://www.clinicaltrials.gov/ct2/show/NCT04529083, Identifier: NCT04529083., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Annapureddy, Annaswamy, Raval, Chung and Prabhakaran.)

Objective: The Learning Health Systems Rehabilitation Research Network (LeaRRn), an NIH-funded rehabilitation research resource center, aims to advance the research capacity of learning health systems (LHSs) within the rehabilitation community. A needs assessment survey was administered to inform development of educational resources., Methods: The online survey included 55 items addressing interest in and knowledge of 33 LHS research core competencies in 7 domains and additional items on respondent characteristics. Recruitment targeting rehabilitation researchers and health system collaborators was conducted by LeaRRn, LeaRRn health system partners, rehabilitation professional organizations, and research university program directors using email, listservs, and social media announcements., Results: Of the 650 people who initiated the survey, 410 respondents constituted the study sample. Respondents indicated interest in LHS research and responded to at least 1 competency item and/or demographic question. Two-thirds of the study sample had doctoral research degrees, and one-third reported research as their profession. The most common clinical disciplines were physical therapy (38%), communication sciences and disorders (22%), and occupational therapy (10%). Across all 55 competency items, 95% of respondents expressed "a lot" or "some" interest in learning more, but only 19% reported "a lot" of knowledge. Respondents reported "a lot" of interest in a range of topics, including selecting outcome measures that are meaningful to patients (78%) and implementing research evidence in health systems (75%). "None" or "some" knowledge was reported most often in Systems Science areas such as understanding the interrelationships between financing, organization, delivery, and rehabilitation outcomes (93%) and assessing the extent to which research activities will improve the equity of health systems (93%)., Conclusion: Results from this large survey of the rehabilitation research community indicate strong interest in LHS research competencies and opportunities to advance skills and training., Impact: Competencies where respondents indicated high interest and limited knowledge can inform development of LHS educational content that is most needed., (© The Author(s) 2023. Published by Oxford University Press on behalf of the American Physical Therapy Association. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: To assess the clinical feasibility of a virtual mirror therapy system in a pilot sample of patients with phantom pain., Methods: Our Mixed reality system for Managing Phantom Pain (Mr. MAPP) mirrors the preserved limb to visualize the amputated limb virtually and perform exercises. Seven patients with limb loss and phantom pain agreed to participate and received the system for 1-month home use. Outcome measures were collected at baseline and 1 month., Results: Four (of seven recruited) participants completed the study, which was temporarily suspended due to COVID-19 restrictions. At 1 month, in-game data showed a positive trend, but pain scores showed no clear trends. Functioning scores improved for 1 participant., Conclusions: Mr. MAPP is feasible and has the potential to improve pain and function in patients with phantom pain., Trial Registration: Clinical Trials Registration, NCT04529083., (© 2022. The Author(s).)

Abstract: Although the physiatric community increasingly embraces evidence-based medicine (EBM), the current state of EBM training for trainees in physiatry is unclear. The purposes of this article are to report the results of the Association of Academic Physiatrists' surveys of physiatry residency programs in the United States, to discuss the implications of their findings, and to better delineate the "baseline" upon which sound and clear recommendations for systematic EBM training can be made. The two Association of Academic Physiatrists surveys of US physiatry residency programs reveal that most survey respondents report that they include EBM training in their programs that covers the five recommended steps of EBM core competencies. However, although most respondents reported using traditional pedagogic methods of training such as journal club, very few reported that their EBM training used a structured and systematic approach. Future work is needed to support and facilitate physiatry residency programs interested in adopting structured EBM training curricula that include recommended EBM core competencies and the evaluation of their impact., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Our objectives were to explore the association between phosphodiesterase 5 inhibitor use and lumbar decompression surgery by evaluating the prevalence of lumbar decompression surgery in a treatment group of patients with lumbar spinal stenosis compared with a control group., Design: We performed database review and extracted data including lumbar decompression surgery prevalence, phosphodiesterase 5 inhibitor dosage, and fill dates. Treatment group was defined as those with phosphodiesterase 5 inhibitor fill dates of less than 30 days before surgery, and control group was defined as those with phosphodiesterase 5 inhibitor fill dates at any other time. Lumbar decompression surgery prevalence rates for both groups were calculated., Results: Our study found 599 lumbar spinal stenosis patients who were prescribed phosphodiesterase 5 inhibitor. Three hundred thirty-eight underwent lumbar decompression surgery. Of these, 71 (21%) filled their prescription of less than 30 days before surgery, whereas 267 (79%) filled their prescription during a different period. The majority (94.6%) of surgical patients received decompression at two or more spinal levels., Conclusions: Prevalence of lumbar decompression surgery for lumbar spinal stenosis was significantly lower in patients in the treatment group on phosphodiesterase 5 inhibitor therapy compared with the control group. Among many potential explanations, the vasodilatory effect of phosphodiesterase 5 inhibitor may have contributed to a lower surgical rate. This is the first study to explore this novel association. Future prospective studies are necessary to better define the utility of phosphodiesterase 5 inhibitor in lumbar spinal stenosis., Competing Interests: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: The aim of this study was to assess the current and future adequacy of physiatrist supply in the United States., Design: A 2019 online survey of board-certified physiatrists (n = 616 completed, 30.1% response) collected information about demographics, practice characteristics, hours worked, and retirement intentions. Microsimulation models projected future physiatrist supply and demand using data from the American Board of Physical Medicine and Rehabilitation, national and state population projections, American Community Survey, Behavioral Risk Factor Surveillance System, Medical Expenditure Panel Survey, and other sources., Results: Approximately 37% of 8853 active physiatrists indicate that their workload exceeds capacity, 59% indicate that workload is at capacity, and 4% indicate under capacity. These findings suggest a national shortfall of 940 (10.6%) physiatrists in 2017, with substantial geographic variation in supply adequacy. Projected growth in physiatrist supply from 2017 to 2030 approximately equals demand growth (2250 vs. 2390), suggesting that without changes in care delivery, the shortfall of physiatrists will persist, with a 1080 (9.7%) physiatrist shortfall in 2030., Conclusion: Without an increase in physiatry residency positions, the current national shortfall of physiatrists is projected to persist. Although a projected increase in physiatrists' use of advanced practice providers may help preserve access to comprehensive physiatry care, it is not expected to eliminate the shortfall., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: The aim of the study was to describe the current physiatrist workforce in the United States., Design: An online, cross-sectional survey of board-certified physiatrists in 2019 (N = 616 completed, 30.1% response) collected information about demographic and practice characteristics, including age, sex, practice area, practice setting, hours worked, patient characteristics, staffing, and work responsibilities. Physiatrists were stratified by substantive practice patterns using a cluster analysis approach. Survey responses were arrayed across the practice patterns and differences noted., Results: The practice patterns identified included musculoskeletal/pain medicine, general/neurological rehabilitation, academic practice, pediatric rehabilitation, orthopedic/complex conditions rehabilitation, and disability/occupational rehabilitation. Many differences were observed across these practice patterns. Notably, primary practice setting and the extent and ways in which other healthcare staff are used in physiatry practices differed across practice patterns. Physiatrists working in musculoskeletal/pain medicine and disability/occupational rehabilitation were least likely to work with nurse practitioners and physician assistants. Physiatrists working in academic practice, general/neurological rehabilitation, and pediatric rehabilitation were most likely to have primary practice settings in hospitals., Conclusions: Physiatry is an evolving medical specialty affected by many of the same trends as other medical specialties. The results of this survey can inform policy discussions and further research on the effects of these trends on physiatrists and physiatry practice in the future., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: We performed this study to evaluate the effect of back bracing to treat patients with chronic low back pain., Methods: This was a prospective, unblinded, randomized controlled trial of 61 adults with uncomplicated chronic low back pain (>12 wks) and imaging findings of degenerative spondylosis, to assess the effectiveness of a semirigid back brace. All study participants received back school instruction. The treatment group also received a lumbar orthosis and was instructed to wear it as needed for symptom relief. At baseline, 6 wks, 12 wks, and 6 mos after intervention, we collected: Numerical Rating Scale to measure pain intensity, Pain Disability Questionnaire, Patient-Reported Outcome Measurement Information System, and EuroQol 5-Dimension (EQ-5D) to measure patient-reported function and quality of life., Results: An interim analysis at the halfway point in enrollment (61 of 120 planned participants) revealed the Pain Disability Questionnaire, Patient-Reported Outcome Measurement Information System, and EQ-5D scores in the treatment group to be worse than in the control group, but no significant group differences in Numerical Rating Scale scores. Outcome differences between groups analyzed over time revealed (effect [P]): Pain Disability Questionnaire = 0.84 (0.04); Patient-Reported Outcome Measurement Information System = 0.78 (0.005); EQ-5D = 0.06 (0.01); and Numerical Rating Scale = 0.02 (0.6). We halted the study because continuation was unlikely to produce significant changes to the results., Conclusions: In patients with uncomplicated chronic low back pain, a back brace when combined with education and exercise instruction did not provide any pain relief compared with education and exercise instruction alone., To Claim Cme Credits: Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME., Cme Objectives: Upon completion of this article, the reader should be able to: (1) Describe the effect of lumbar back bracing on pain intensity in patients with chronic low back pain; (2) Discuss the effects of lumbar back bracing on pain-related disability, function, and quality of life in patients with chronic low back pain; and (3) Understand the role of lumbar back bracing in the treatment of patients with chronic low back pain., Level: Advanced., Accreditation: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity., Competing Interests: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

This article discusses the use of physical and biometric sensors in telerehabilitation. It also discusses synchronous tele-physical assessment using haptics and augmented reality and asynchronous physical assessment using remote pose estimation. The article additionally focuses on computational models that have the potential to monitor and evaluate changes in kinematic and kinetic properties during telerehabilitation using biometric sensors such as electromyography and other wearable and noncontact sensors based on force and speed. And finally, the article discusses how virtual reality environments can be facilitated in telerehabilitation., Competing Interests: Disclosure No commercial or financial conflicts of interest is reported by any authors of this article. Some of the work reported in this article did receive outside support., (Published by Elsevier Inc.)

Abstract: Lumbar spinal stenosis is one of the most commonly diagnosed spinal disorders worldwide and remains a major cause for surgery in older adults. Lumbar spinal stenosis is clinically defined as a progressive degenerative disorder with low back pain and associated neurogenic intermittent claudication. Conservative and surgical management of lumbar spinal stenosis has been shown to be minimally effective on its symptoms. A treatment option that has not been investigated in the United States is the utilization of prostaglandin E1 analogs, which have been used primarily in Japan for the treatment of lumbar spinal stenosis since the 1980s. The vasodilatory and antiplatelet aggregation effects of prostaglandin E1 presumably improve symptoms of lumbar spinal stenosis by increasing blood flow to the spinal nerve roots. This brief report examines the potential vascular pathology of lumbar spinal stenosis, reviews evidence on the use of prostaglandin E1 analog limaprost in Japan for lumbar spinal stenosis, and briefly discusses misoprostol as a possible alternative in the United States. The studies summarized in this report suggest that prostaglandin E1 analogs may provide benefit as a conservative treatment option for patients with lumbar spinal stenosis. However, higher-quality studies conducted in the United States and comparison with other currently used conservative treatments are required before it can be recommended for routine clinical use., Competing Interests: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: While obstructive sleep apnea (OSA) is associated with several chronic health conditions such as hypertension, obesity, and chronic hypoxia, there is limited information on its association with neuromuscular and spinal pathologies that may be of interest to a musculoskeletal (MSK) medicine or pain management clinician. The objective of this study was to perform a systematic literature review to examine the association between OSA and cervical spine pathologies, postural changes, and pain., Design: We systematically reviewed PubMed and Embase databases up to 4/15/2019. We included studies that explored associations between OSA and a) pain, b) postural characteristics or changes, or c) cervical spine morphology. Systematic reviews, meta-analysis, randomized control trials, cohort studies, and case-control studies were included. Case reports, narrative reviews or expert opinion papers were excluded. From the articles that met selection criteria, information regarding type, direction and magnitude of such associations was extracted. The OSA-pain association studies were further divided into 3 subgroups: neuropathic, temporomandibular, and chronic pain., Results: 21 articles that met our study criteria were selected for this review. Two studies were on cervical spine pathologies, eight on postural changes, and eleven on pain associated with OSA. Exploring the association between OSA and cervical spine pathologies, postural changes, and pain in this systematic review we found: (1) Cervical spine lesions, fusions, and abnormalities that reduce retropharyngeal space are associated with OSA, likely by way of worsening posture and decreasing range of motion. (2) Head extension and anteriorization are associated with OSA likely as a compensatory mechanism. Extension may improve airway function, while anteriorization helps to maintain visual sense. (3) Head-of-bed-elevation may improve OSA symptoms and can possibly supplement other conservative treatment measures. (4) Neuropathic pain is associated with OSA, likely by way of inflammatory pathways. (5) Oral appliance use (eg mandibular advancement/protruding device) in OSA likely contributes to transient temporomandibular pain. (6) There is little association between OSA and chronic pain prevalence. (7) Increased pain intensity and decreased pain tolerance are somewhat associated with OSA, likely by way of hypoxemia and sleep fragmentation., Conclusions: Clinicians in MSK and pain medicine need to consider these associations and consider obtaining imaging studies and/or making referrals for management of their OSA to better provide appropriate care to these patients., (Published by Elsevier B.V.)

Persons with back, neck, and limb symptoms constitute a major referral population to specialists in electrodiagnostic (EDX) medicine. The evaluation of these patients involves consideration of both the common and less common disorders. The EDX examination with needle electromyography (EMG) is the most important means of testing for radiculopathy. This test has modest sensitivity but high specificity and well complements imaging of the spine. Needle EMG in combination with nerve conduction testing is valuable in excluding entrapment neuropathies and polyneuropathy-conditions that frequently mimic radicular symptoms. In this first of a two-part review, the optimal EDX evaluation of persons with suspected radiculopathy is presented. In part two, the implications of EDX findings for diagnosis and clinical management of persons with radiculopathy are reviewed., (© 2020 by the American Association of Neuromuscular & Electrodiagnostic Medicine, Inc. All rights reserved.)

The COVID-19 pandemic has forced a rapid adoption of telemedicine over traditional in-person visits due to social restrictions. While telemedicine improves access and reduces barriers to healthcare access for many, several barriers and challenges remain for persons with disabilities, and novel challenges have been exposed, many of which may persist long-term. The challenges and barriers that need to be systematically addressed include: Infrastructure and access barriers, operational challenges, regulatory barriers, communication barriers and legislative barriers. Persons with disabilities are a vulnerable population and little attention has been placed on their healthcare access during the pandemic. Access and communication during a healthcare encounter are important mediators of outcomes for persons with disabilities. Significant, long-term changes in technological, regulatory, and legislative infrastructure and custom solutions to unique patient and health system needs are required to address these barriers going forward in order to improve healthcare access and outcomes for persons with disabilities., (Published by Elsevier Inc.)

Background: Epidural steroid injections (ESIs) may be beneficial for lumbar spinal stenosis (LSS) symptoms. Past studies found interferon-gamma, fibronectin-aggrecan complex, and electromyography (EMG) to predict patients' response to ESIs for other spinal pathologies, but no similar studies have been done for LSS., Objective: To explore the ability of biomarkers and EMG to help predict outcome after ESI in LSS., Design: Prospective observational cohort., Setting: The physical medicine & rehabilitation spine clinic at a tertiary care center., Participants: Eleven patients with LSS were recruited from the spine clinic at a Veterans Affairs Medical Center., Interventions: Participants underwent one interlaminar ESI. Before ESI, the following data were collected: pain intensity on visual analog scale (VAS), disability via the Pain Disability Questionnaire (PDQ) and LSS symptoms via the Swiss Spinal Stenosis Questionnaire (SSSQ), serum high-sensitivity C-reactive protein level, standard diagnostic EMG, assay of epidural lavasate (epidural saline lavage performed immediately prior to ESI) and serum cytokine biomarkers indicative of inflammation., Outcome Measures: Leg pain intensity (VAS), disability (PDQ), LSS symptoms (SSSQ) and satisfaction (SSSQ satisfaction subscale) were assessed at 1 and 2 months following ESI. Pearson correlational coefficients were calculated between independent variables and outcome measures., Results: Serum monocyte chemoattractant protein-1 (MCP-1) level positively correlated with improvement on 2-month satisfaction. Abnormal EMG finding of radiculopathy positively correlated with improvement in PDQ score at 1 month. Epidural cytokine levels were not detectable in most samples, except for scattered marginally elevated levels in a few cytokines such as MCP-1, RANTES (Regulated on Activation, Normal T Cell Expressed and Secreted) and interleukin-1b., Conclusions: This exploratory pilot study revealed that some biomarkers and EMG findings indicative of inflammation and nerve root injury may be predictive of improvement following ESI in patients with LSS. The results of this study will be used to inform a fully powered study to further evaluate these relationships in LSS patients., (© 2019 American Academy of Physical Medicine and Rehabilitation. This article has been contributed to by US Government employees and their work is in the public domain in the USA.)

Background Context: The North American Spine Society's (NASS) Evidence Based Clinical Guideline for the Diagnosis and Treatment of Low Back Pain features evidence-based recommendations for diagnosing and treating adult patients with nonspecific low back pain. The guideline is intended to reflect contemporary treatment concepts for nonspecific low back pain as reflected in the highest quality clinical literature available on this subject as of February 2016., Purpose: The purpose of the guideline is to provide an evidence-based educational tool to assist spine specialists when making clinical decisions for adult patients with nonspecific low back pain. This article provides a brief summary of the evidence-based guideline recommendations for diagnosing and treating patients with this condition., Study Design: This is a guideline summary review., Methods: This guideline is the product of the Low Back Pain Work Group of NASS' Evidence-Based Clinical Guideline Development Committee. The methods used to develop this guideline are detailed in the complete guideline and technical report available on the NASS website. In brief, a multidisciplinary work group of spine care specialists convened to identify clinical questions to address in the guideline. The literature search strategy was developed in consultation with medical librarians. Upon completion of the systematic literature search, evidence relevant to the clinical questions posed in the guideline was reviewed. Work group members utilized NASS evidentiary table templates to summarize study conclusions, identify study strengths and weaknesses, and assign levels of evidence. Work group members participated in webcasts and in-person recommendation meetings to update and formulate evidence-based recommendations and incorporate expert opinion when necessary. The draft guideline was submitted to an internal and external peer review process and ultimately approved by the NASS Board of Directors., Results: Eighty-two clinical questions were addressed, and the answers are summarized in this article. The respective recommendations were graded according to the levels of evidence of the supporting literature., Conclusions: The evidence-based clinical guideline has been created using techniques of evidence-based medicine and best available evidence to aid practitioners in the diagnosis and treatment of adult patients with nonspecific low back pain. The entire guideline document, including the evidentiary tables, literature search parameters, literature attrition flowchart, suggestions for future research, and all of the references, is available electronically on the NASS website at https://www.spine.org/ResearchClinicalCare/QualityImprovement/ClinicalGuidelines.aspx., (Copyright © 2020. Published by Elsevier Inc.)

Objective: The aim of the study was to compare hyaluronate with triamcinolone injections in treating chronic low back pain suggestive of lumbar zygopophyseal joint arthropathy., Design: This was a prospective, double-blind, randomized controlled trial. Thirty subjects were randomly assigned to receive bilateral L3-S1 lumbar zygopophyseal joint injections with triamcinolone (KA) or Synvisc-One (HA). Pain (visual analog scale) and Pain Disability Questionnaire scores at 1, 3, and 6 mos were evaluated., Results: No significant intergroup differences (P > 0.05) in outcomes were noted in the 30 recruited subjects. For KA/HA (baseline; 1 mo; 3 mos; 6 mos), visual analog scale scores were the following: 70 (15)/74 (10); 58 (29)/45 (25); 58 (29)/56 (25); and 59 (28)/63 (24), respectively. Pain Disability Questionnaire scores were the following: 100 (23)/102 (28); 77 (30)/74 (34); 87 (26)/74 (36); and 96 (25)/79 (25). Overall percent improvement at 6 mos for KA was 51 (35) and for HA was 42 (33) (P = 0.51). Synvisc-One group visual analog scale scores improved significantly (70 [20]-45 [25] at 1 mo, P = 0.008). Pain Disability Questionnaire scores improved at 1 mo (100 [23]-77 [30], P = 0.009) in the KA group and at all time points in the HA group (102 [28]-74 [34] at 1 mo, P = 0.002; 74 [36] at 3 mos, P = 0.037; 79 at 6 mos [median = 52-99.5], P < 0.001). Medians and quartiles were used in statistical analysis when data did not pass normality., Conclusions: Patients with chronic low back pain suggestive of lumbar lumbar zygopophyseal joint arthropathy responded similarly to triamcinolone or hyaluronate injections. Synvisc-One group showed significant short- and long-term functional improvement and short-term pain improvement; KA group showed only significant short-term functional benefit and no significant short- or long-term pain improvement.

We report a patient with a previously undiagnosed spinal dural arteriovenous fistula (SDAVF) who became acutely paraplegic following a lumbar epidural steroid injection for lumbar spinal stenosis. Magnetic resonance imaging showed multiple flow voids and serpentine vessels on the cord surface with cord edema extending from T3 through the conus. Spinal angiography confirmed an SDAVF fed by the left lateral sacral artery, which was subsequently endovascularly embolized, and the patient had a partial return of function. Presence of an undiagnosed SDAVF should be considered in patients presenting with lower-extremity weakness without pain and considered a contraindication to lumbar epidural steroid injection.

Background: Minimal longitudinal data exist regarding the role of lumbar musculature in predicting back pain and function. In cross-sectional study designs, there is often atrophy of the segmental multifidus muscle in subjects with low back pain compared with matched controls. However, the cross-sectional design of these studies prevents drawing conclusions regarding whether lumbar muscle characteristics predict or modify future back pain or function., Objective: The primary objective of this study is to determine whether the cross-sectional area (CSA) of lumbar muscles predict functional status or back pain at 6- or 12-month follow-up in older adults with spinal degeneration. The secondary objective is to evaluate whether these muscle characteristics improve outcome prediction above and beyond the prognostic information conferred by demographic and psychosocial variables., Design: Secondary analysis of a randomized controlled trial., Participants: A total of 209 adults aged 50 years and older with clinical and radiographic spinal stenosis from the Lumbar Epidural steroid injection for Spinal Stenosis (LESS) trial., Methods: Using baseline magnetic resonance images, we calculated CSAs of the lumbar multifidus, psoas, and quadratus lumborum muscles using a standardized protocol by manually tracing the borders of each of the muscles. The relationship between lumbar muscle CSAs and baseline measures was assessed with Pearson or Spearman correlation coefficients. The relationship between lumbar muscle characteristics and 6- and 12-month Roland Morris Disability Questionnaire (RDQ) and back pain Numeric Rating Scale (NRS) responses was further evaluated with multivariate linear regression. A hierarchical approach to the regression was performed: a basic model with factors of conceptual importance including age, gender, BMI, and baseline RDQ score formed the first step. The second and third steps evaluated whether psychosocial variables or muscle measures conferred additional prognostic information to the basic model., Main Outcome Measures: Function as measured by the RDQ and back pain as measured by the NRS at 6- and 12-month follow-up., Results: Lumbar muscle CSA was not a significant predictor of 6- or 12-month RDQ or pain score in multivariate analyses., Conclusions: Cross-sectional areas of lumbar muscles do not predict function or pain at medium- and long-term follow-up in adults with lumbar spinal stenosis., Level of Evidence: III., (Copyright © 2017 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

Background Context: The North American Spine Society's (NASS) Evidence-Based Clinical Guideline for the Diagnosis and Treatment of Degenerative Lumbar Spondylolisthesis features evidence-based recommendations for diagnosing and treating degenerative lumbar spondylolisthesis. The guideline updates the 2008 guideline on this topic and is intended to reflect contemporary treatment concepts for symptomatic degenerative lumbar spondylolisthesis as reflected in the highest quality clinical literature available on this subject as of May 2013. The NASS guideline on this topic is the only guideline on degenerative lumbar spondylolisthesis included in the Agency for Healthcare Research and Quality's National Guideline Clearinghouse (NGC)., Purpose: The purpose of this guideline is to provide an evidence-based educational tool to assist spine specialists when making clinical decisions for patients with degenerative lumbar spondylolisthesis. This article provides a brief summary of the evidence-based guideline recommendations for diagnosing and treating patients with this condition., Study Design: A systematic review of clinical studies relevant to degenerative spondylolisthesis was carried out., Methods: This NASS spondyolisthesis guideline is the product of the Degenerative Lumbar Spondylolisthesis Work Group of NASS' Evidence-Based Guideline Development Committee. The methods used to develop this guideline are detailed in the complete guideline and technical report available on the NASS website. In brief, a multidisciplinary work group of spine care specialists convened to identify clinical questions to address in the guideline. The literature search strategy was developed in consultation with medical librarians. Upon completion of the systematic literature search, evidence relevant to the clinical questions posed in the guideline was reviewed. Work group members used the NASS evidentiary table templates to summarize study conclusions, identify study strengths and weaknesses, and assign levels of evidence. Work group members participated in webcasts and in-person recommendation meetings to update and formulate evidence-based recommendations and incorporate expert opinion when necessary. The draft guidelines were submitted to an internal peer review process and ultimately approved by the NASS Board of Directors. Upon publication, the Degenerative Lumbar Spondylolisthesis guideline was accepted into the NGC and will be updated approximately every 5 years., Results: Twenty-seven clinical questions were addressed in this guideline update, including 15 clinical questions from the original guideline and 12 new clinical questions. The respective recommendations were graded by strength of the supporting literature, which was stratified by levels of evidence. Twenty-one new or updated recommendations or consensus statements were issued and 13 recommendations or consensus statements were maintained from the original guideline., Conclusions: The clinical guideline was created using the techniques of evidence-based medicine and best available evidence to aid practitioners in the care of patients with degenerative lumbar spondylolisthesis. The entire guideline document, including the evidentiary tables, literature search parameters, literature attrition flow chart, suggestions for future research, and all of the references, is available electronically on the NASS website at https://www.spine.org/Pages/ResearchClinicalCare/QualityImprovement/ClinicalGuidelines.aspx and will remain updated on a timely schedule., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Study Design: Secondary analysis of data from a double-blind randomized controlled trial., Objective: To identify mediators of the effect of lumbar epidural injections of corticosteroid plus lidocaine on patient satisfaction at 6 weeks postinjection in patients with lumbar spinal stenosis. We hypothesized that short-term (≤3 wk) change in leg pain would be a significant mediator of satisfaction., Summary of Background Data: No prior studies have identified mediators of effects of epidural injections on patient satisfaction with treatment of lumbar spinal stenosis., Methods: We used mediation analysis methods to examine selected intermediate variables (adverse events and change in leg pain, back pain, disability, depression, and fatigue at 3 wk) as potential mediators of the effect of lumbar epidural injections of corticosteroid plus lidocaine on patient satisfaction with treatment. We used the overall satisfaction item from the Swiss Spinal Stenosis Questionnaire as our primary outcome to measure patient satisfaction with the injection procedure at 6 weeks., Results: Among 400 patients randomized to receive epidural injections with corticosteroid plus lidocaine or with lidocaine alone, 369 had complete data for the satisfaction outcome and potential mediators and served as the analysis sample. Contrary to our expectations, 3-week change in leg pain intensity did not have significant mediation effects on patient satisfaction. Three-week change in disability as measured by the Roland-Morris Disability Questionnaire was a significant mediator of the effects of lumbar epidural corticosteroid injections on patient satisfaction at 6 weeks, explaining 48% to 60% of the treatment effect on satisfaction. Changes in pain intensity in the leg and back together explained very little of the treatment effect on satisfaction beyond the information contributed by disability change alone. We did not find other intermediate variables to be mediators of patient satisfaction., Conclusion: These findings support the current approach of examining disability as a primary patient-reported outcome in comparative effectiveness studies of lumbar spinal stenosis., Level of Evidence: 2.

Background: Evidence supports peroneal nerve functional electrical stimulation (FES) as an effective alternative to ankle-foot orthoses (AFO) for treatment of foot drop poststroke, but few randomized controlled comparisons exist., Objective: To compare changes in gait and quality of life (QoL) between FES and an AFO in individuals with foot drop poststroke., Methods: In a multicenter randomized controlled trial (ClinicalTrials.gov #NCT01087957) with unblinded outcome assessments, 495 Medicare-eligible individuals at least 6 months poststroke wore FES or an AFO for 6 months. Primary endpoints: 10-Meter Walk Test (10MWT), a composite of the Mobility, Activities of Daily Living/Instrumental Activities of Daily Living, and Social Participation subscores on the Stroke Impact Scale (SIS), and device-related serious adverse event rate. Secondary endpoints: 6-Minute Walk Test, GaitRite Functional Ambulation Profile (FAP), Modified Emory Functional Ambulation Profile (mEFAP), Berg Balance Scale (BBS), Timed Up and Go, individual SIS domains, and Stroke-Specific Quality of Life measures. Multiply imputed intention-to-treat analyses were used with primary endpoints tested for noninferiority and secondary endpoints tested for superiority., Results: A total of 399 subjects completed the study. FES proved noninferior to the AFO for all primary endpoints. Both the FES and AFO groups improved significantly on the 10MWT. Within the FES group, significant improvements were found for SIS composite score, total mFEAP score, individual Floor and Obstacle course time scores of the mEFAP, FAP, and BBS, but again, no between-group differences were found., Conclusions: Use of FES is equivalent to the AFO. Further studies should examine whether FES enables better performance in tasks involving functional mobility, activities of daily living, and balance., (© The Author(s) 2014.)

Background: Degenerative processes can cause chronic low back pain that occasionally creates impingement of the lumbar dorsal rami, resulting in a clinical syndrome previously described as lumbar dorsal ramus syndrome (LDRS)., Objectives: To evaluate the clinical basis of LDRS by comparing pain, disability, and objective measures of pathophysiology in 3 groups of subjects defined by needle electromyography examination (NEE) findings., Design: Prospective group cohort study with retrospective chart review., Setting: Veterans Affairs medical center outpatient clinic., Patients: Subjects who had undergone lower limb NEE and lumbar magnetic resonance imaging., Methods: A total of 71 subjects' records that met the study criteria were retrospectively reviewed for interventional spine procedures performed and to measure the lumbosacral paraspinal cross-sectional area (PSP CSA); 28 of the 71 subjects underwent further clinical assessment. One-way analysis of variance was performed to evaluate group differences., Main Outcome Measurements: In the retrospective arm: (1) PSP CSAs measured at 4 lower lumbar disk levels (average of 3 consecutive slices/level) bilaterally and overall left and right lumbar average PSP CSA and (2) the frequency and type of interventional spine procedures performed. In the prospective arm: (1) temporal changes of NEE abnormalities, (2) pain measured using the Visual Analog Scale, (3) Pain Disability Questionnaire responses, and (4) Short Form-36 scores., Results: The right L5 CSA was significantly greater in the group with mechanical low back pain compared with the group with lumbar radicular syndrome (F = 3.3; P < .05). No significant group differences were noted in the number of spine procedures performed. No significant differences in pain or disability scores were found among the groups. NEE findings improved over time predominantly in the LDRS group., Conclusions: LDRS is a diagnosis with identifiable NEE (lumbar multifidus denervation) findings and magnetic resonance imaging findings that may include lower lumbar paraspinal atrophy. NEE (paraspinal denervation) findings in persons with LDRS may change over time, and the clinical relevance of LDRS to pain, functional disability, and treatment response is unclear., (Copyright © 2013 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)