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Maple syrup production can provide significant value to rural economies and contribute to the long-term sustainability of forest ecosystems. Producers’ experiences vary based on their type of sugaring operation, so foresters, Extension educators, and equipment suppliers can more effectively support the expansion of maple syrup production if they tailor their outreach to the needs of each type of producer. Drawing on a survey of Wisconsin maple syrup producers (n = 657), this study compares the motivations, confidence in forest management knowledge, interests in learning, interests in new behaviors, desire to expand, and barriers to expansion among three groups of maple syrup producers: non-commercial, small commercial, and large commercial producers. Most producers were motivated by spending time in nature, and as might be expected, commercial producers were more motivated by finances than non-commercial producers. All three groups expressed interest in forest health management. The producers most interested in expansion were those who already sell for income, who are motivated by finances, who have fewer seasons of experience, and are newer woodland owners. Key barriers to expansion included efficient sap collection and a lack of time for non-commercial and small commercial producers, while workforce availability and a lack of capital were key barriers to expansion for both groups of commercial producers. Based on these results, we provide recommendations for audience segmentation strategies to support maple syrup producers through education, marketing, and research.

Psychological distress is associated with disability and quality of life for patients with shoulder pain. However, uncertainty around heterogeneity of psychological distress has limited the adoption of shoulder care models that address psychological characteristics. In a cohort of patients with shoulder pain, our study sought to (1) describe the prevalence of various subtypes of psychological distress; (2) evaluate associations between psychological distress and self-reported shoulder pain, disability, and function; and (3) determine differences in psychological distress profiles between patients receiving nonoperative vs. operative treatment.The sample included 277 patients who were evaluated in clinic by a shoulder surgeon and completed the Optimal Screening for Prediction of Referral and Outcome Yellow Flag Assessment Tool (OSPRO-YF) from 2019 to 2021. This tool categorizes maladaptive and adaptive psychological traits, and the number of yellow flags (YFs) ranges from 0 to 11, with higher YF counts indicating higher pain-related psychological distress. Operative and nonoperative cohorts were compared using χTwo hundred fifty-one patients (91%) had at least 1 YF on the OSPRO-YF tool, with a mean number of 6 ± 3.5 YFs. YFs in unhelpful coping (85%) and helpful coping domains (78%) were most prevalent. The number of YFs was significantly associated with baseline shoulder pain (P.001), Single Assessment Numeric Evaluation (P.001), and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (P.001) scores. Comparing operative and nonoperative cohorts, the operative cohort had a significantly higher mean number of YFs (6.5 vs. 5.6, P = .035), presence of any YF (94.3% vs. 85.7%, P = .015), and presence of YFs within the unhelpful coping domain (91.8% vs. 75.6%, P.001). Three phenotypes were described, corresponding to low, moderate, and severe psychological distress (P.001), with females (P = .037) and smokers (P = .018) associated with higher psychological distress phenotypes.YFs, particularly within the unhelpful coping and helpful coping domains, were highly prevalent in a cohort of patients presenting to a shoulder surgeon's clinic. Additionally, operative patients were found to have a significantly higher rate of YFs across multiple dimensions of psychological distress. These findings stress the importance of routine attentiveness to multiple dimensions of pain-related psychological distress in shoulder populations, which can provide an opportunity to reinforce healthy interpretation of pain while minimizing distress in appropriately identified patients.

10-15% of individuals who sustain a concussion develop persistent post-concussion symptoms (PPCS). Presently, there is no consensus regarding the pathophysiology of PPCS. Preliminary evidence sugge...

„Dämonisierung“ nennt der amerikanische Physiotherapeut und Professor Dr. Chad E. Cook die in den letzten Jahren lauter werdende Kritik an der Manuellen Therapie. Acht dieser „Dämonisierungen“ greift er auf und bewertet diese sorgfältig anhand der aktuellen Literatur. Seine Ziele mit dem Artikel sind: Diskussionen anstoßen, falsche Annahmen abbauen und Patienten eine evidenzbasierte Therapie ermöglichen.

Low back pain (LBP) is the leading cause of disability worldwide among all musculoskeletal disorders despite an intense focus in research efforts. Researchers and decision makers have produced multiple clinical practice guidelines for the rehabilitation of LBP, which contain specific recommendations for clinicians. Adherence to these recommendations may have several benefits, such as improving the quality of care for patients living with LBP, by ensuring that the best evidence-based care is being delivered. However, clinicians' adherence to recommendations from these guidelines is low and numerous implementation barriers and challenges, such as complexity of information and sheer volume of guidelines have been documented. In a previous paper, we performed a systematic review of the literature to identify high-quality clinical practice guidelines on the management of LBP, and developed a concise yet comprehensive infographic that summarizes the recommendations from these guidelines. Considering the wealth of scientific evidence, passive dissemination alone of this research knowledge is likely to have limitations to help clinicians implement these recommendations into routine practice. Thus, an active and engaging dissemination strategy, aimed at improving the implementation and integration of specific recommendations into practice is warranted. In this paper, we argue that a conceptual framework, such as the theoretical domains framework, could facilitate the implementation of these recommendations into clinical practice. Specifically, we present a systematic approach that could serve to guide the development of a theory-informed knowledge translation intervention as a means to overcome implementation challenges in rehabilitation of LBP.

Background Despite the emergence of multiple clinical practice guidelines (CPGs) for the rehabilitation of low back pain (LBP) over the last decade, self-reported levels of disability in this population have not improved. This may be explained by the numerous implementation barriers, such as the complexity of information and sheer volumes of CPGs. Objectives The purpose of this study was to summarize the evidence and recommendations from the most recent and high-quality CPGs on the rehabilitation management of LBP by developing an infographic summarizing the recommendations to facilitate dissemination into clinical practice. Methods We performed a systematic review of high-quality CPGs with an emphasis on rehabilitation approaches. We searched major health-related research databases (e.g., PubMed, CINAHL, and PEDro). We performed quality assessment via the AGREE-II instrument. Contents of the CPGs were synthesized by extracting recommendations, which were then compared to one another to identify consistencies based on an iterative evaluation process. Results We identified and assessed 5 recent high-quality CPGs. We synthesized 13 recommendations on the rehabilitation management of LBP (2 for screening procedures, 3 for assessment procedures, and 8 involving treatment approaches) and 2 underlying principles were highlighted. These results were then synthetized and illustrated in a concise infographic that serves as a conceptual roadmap that identifies the specific behavior changes (i.e., adoption of CPGs' recommendations) rehabilitation professionals should adopt in order to integrate an evidenced-based approach for the management of LBP. Conclusions We systematically reviewed the literature for CPGs' recommendations for the physical rehabilitation management of LBP and synthesized the information through an infographic.

Introduction: Employment status plays an essential role as a social determinant of health. Unemployed are more likely to have a longer length of hospital stay and a nearly twofold greater rate of 30 day readmission than those who were well employed at the time of back surgery. This study aimed to investigate whether employment status influenced post-surgery outcomes and if so, the differences were clinically meaningful among groups. Methods: This retrospective observational study used data from the Quality Outcomes Database Lumbar Registry. Data refinement was used to isolate individuals 18 to 64 who received primary spine surgeries and had a designation of employed, unemployed, or disabled. Outcomes included 12 and 24 month back and leg pain, disability, patient satisfaction, and quality of life. Differences in descriptive variables, comorbidities, and outcomes measures (at 12 and 24 months) were analyzed using chi-square and linear mixed-effects modeling. When differences were present among groups, we evaluated whether they were clinically significant or not. Results: Differences (between employed, unemployed, and disabled) among baseline characteristics and comorbidities were present in nearly every category (p

BACKGROUND: Burnout and professional satisfaction is an often an overlooked component for healthcare outcomes; the COVID-19 pandemic represents an unprecedented stressor that could contribute to higher levels of burnout. OBJECTIVES: Our primary objective was to evaluate the association of a battery of fulfillment, job satisfaction change, COVID-19 concerns, and coping measures. Our secondary objective was to determine whether the fulfillment and coping measures differed by gender and by experience levels among a battery of physician specialties. METHODS: The study was a purposive sample of convenience. Study participants included all trainees and attending orthopedic surgeons from our academic institution; all participants were invited to complete a survey built around a validated measure of professional fulfillment aimed at assessing response to acute change and stressors. We performed univariate statistics and a matrix correlational analysis to correlate different survey domains with variables of interest. RESULTS: The survey was sent electronically to 138 individuals; 63 surveys were completed (response rate = 45.7%). Twenty-seven (42.8%) individuals met the threshold criteria for fulfillment whereas 10 (15.9%) met the threshold for burnout. We found that surgeon perspectives on COVID-19 were not associated with burnout or professional fulfillment. Burnout was inversely associated with professional fulfillment (R = –0.35). Support seeking was noted to be correlated with professional fulfillment (R = 0.37). CONCLUSIONS: Stressors related to COVID-19 pandemic were not correlated with physician burnout and fulfillment. This held true even when stratifying by gender and by attending vs. trainee. Continued efforts should be implemented to protect against physician burnout and ensure professional fulfillment for Orthopedic surgeons.

Background and purpose Physical activity (PA) promotion delivered by physical therapists is effective. However, little is known about how much PA promotion is integrated into outpatient US physical therapist practice. The purpose of this study was to determine the current PA promotion practices and factors that influence those practices among outpatient US physical therapists. Methods A sample of outpatient US physical therapists from the Academy of Orthopaedic Physical Therapy and American Physical Therapy Association (APTA) Geriatrics completed an adaptive online survey that included questions related to PA promotion practices and factors that influence those practices. We dichotomized levels of PA promotion as regular and irregular. Multivariable logistic regression was used to determine what factors predicted regular PA promotion. Results and discussion A total of 522 individuals participated and 393 surveys were included in the analyses (75.3%). Most participants (58.5%) irregularly promoted PA and few reported always screening for patients' PA levels (12.7%). The strongest predictor of regularly promoting PA was screening for baseline PA (odds ratio = 5.07, 95% confidence interval = 2.23, 11.57). Physical therapists' own PA levels compared favorably to the US adult population and other health professionals and predicted PA promotion. Other factors related to capability, opportunity, and environment were predictors of PA promotion. Perceived lack of financial support from insurance companies, lack of support from clinical employers, and a perception of competing priorities were barriers to PA promotion. Despite being a public health priority, the majority of physical therapists surveyed infrequently screen for baseline PA and irregularly promote PA. Perceived financial barriers, lack of organizational support, and prioritizing other patient problems hinder PA promotion in the outpatient setting. Conclusion Despite guidance from national and international governing bodies, US outpatient physical therapists do not regularly promote PA to patients and perceive financial constraints and competing priorities as key barriers. Professional and patient stakeholders should be involved in designing pathways to improve PA promotion practices among outpatient US physical therapists.

Background Coordinated efforts between the National Institutes of Health, the Department of Defense, and the Department of Veterans Affairs have built the capacity for large-scale clinical research investigating the effectiveness of nonpharmacologic pain treatments. This is an encouraging development; however, what constitutes best practice for nonpharmacologic management of low back pain (LBP) is largely unknown. Design The Improving Veteran Access to Integrated Management of Back Pain (AIM-Back) trial is an embedded pragmatic cluster-randomized trial that will examine the effectiveness of two different care pathways for LBP. Sixteen primary care clinics will be randomized 1:1 to receive training in delivery of 1) an integrated sequenced-care pathway or 2) a coordinated pain navigator pathway. Primary outcomes are pain interference and physical function (Patient-Reported Outcomes Measurement Information System Short Form [PROMIS-SF]) collected in the electronic health record at 3 months (n=1,680). A subset of veteran participants (n=848) have consented to complete additional surveys at baseline and at 3, 6, and 12 months for supplementary pain and other measures. Summary AIM-Back care pathways will be tested for effectiveness, and treatment heterogeneity will be investigated to identify which veterans may respond best to a given pathway. Health care utilization patterns (including opioid use) will also be compared between care pathways. Therefore, the AIM-Back trial will provide important information that can inform the future delivery of nonpharmacologic treatment of LBP.

Hinter der Manuellen Therapie stehen seit jeher zahlreiche philosophische Ansätze. Heute nimmt man an, dass sie insbesondere bei schmerzadaptiven Patienten wirkt, die das eigene Schmerzempfinden selbst modulieren können. Der Artikel erörtert die Evidenz in Bezug auf Manuelle Therapie und liefert theoretische Begründungen für die Veränderungen, die man im klinischen Umfeld bei Patienten beobachtet.

STUDY DESIGN This is an observational study on the measurement properties of the Oswestry Disability Index (ODI) version 1.0. OBJECTIVES To (1) determine the construct validity of the tool, specifically structural validity; (2) analyze the criterion validity of the tool, specifically concurrent validity against proxy measures of pain, function, and quality of life and predictive validity of each item to proxy measures of disability; and (3) reliability of the tool, specifically internal consistency. SUMMARY OF BACKGROUND DATA We endeavored to investigate the measurement properties of the ODI on a spine surgery population to test the assumption that a more disabled population may influence the properties of the tool. METHODS Data were pulled from the Quality Outcomes Database (QOD) Spine Registry. A total of 57,199 participants who underwent primary or revision lumbar spine surgeries were included. Structural validity was assessed by exploratory and confirmatory factor analysis, concurrent validity, predictive validity by odds ratios, and internal consistency by Cronbach alpha. The Visual Analog Scale for back pain, two standard open questions, and the EuroQol 5 Dimension/Visual Analogue Scale were included as proxy measures of pain, function, and quality of life, respectively. Hospital readmission, return to operating room for treatment and revision surgery (all within 30 days) were included as proxy measures of disability to assess the predictive validity of each ODI item. RESULTS The ODI demonstrated a two-factor structural solution, which explained 54.9% of the total variance. Fair internal consistency (0.74-0.77), and fair criterion validity (concurrent) and significant findings with predictive validity (P

Prior opioid use can influence outcomes for patients with musculoskeletal disorders. The purpose of this study was to compare downstream medical utilization-based outcomes (costs, visits, recurrent episodes) after an initial diagnosis of patellofemoral pain based on pre-injury utilization of opioids. A total of 85,7880 consecutive patients were followed for a full 12 months before and 24 months after an initial diagnosis of patellofemoral pain (January 2009 to December 2013). Data were sourced from the Military Health System Data Repository, a single-payer closed government system. Opioid prescription fills were identified, and medical visits and costs were calculated for all knee-related medical care, to include recurrence rates in the 2-year surveillance period. A relatively small number of individuals filled an opioid prescription in the year prior (n = 1746; 2.0%); however, these individuals had almost twice the mean costs of knee-related medical care ($1557 versus %802) and medical visits (8.4 versus 4.0). Patients with prior opioid use were more likely to have at least 1 recurrent episode of knee pain (relative risk 1.58, 95% CI 1.51, 1.65) with a higher mean number of episodes of knee pain (1.5 vs 1.8). The use of opioids with higher risk of misuse or dependency (Schedule II or III) resulted in greater medical costs (for any reason) and recurrent episodes of knee pain compared to the use of opioids in a lower risk category (Schedule IV). Prior opioid utilization was associated with a greater number of recurrent episodes of knee pain and higher downstream medical costs compared with individuals without prior opioid use. For individuals with prior opioid utilization, opioids with higher risk of misuse or dependency (Schedule II or III) resulted in greater medical costs (for any reason) and recurrent episodes compared to the use of lower-risk opioids (Schedule IV).

Objectives: The purpose of this study was to identify the key constructs associated with symptom description and behavior, natural history of complaints, and previous medical history of cervical arterial dysfunction (CAD) according to a panel of physical therapist (PT) educators. Methods: An electronic survey was conducted of licensed PT educators currently involved in musculoskeletal physical therapy education within a credentialed program. Survey prompts queried educators to list the subjective and objective items associated with CAD, in open-text format. Responses were coded to identify unique themes (constructs). Principal axis factor analysis with Varimax rotation was performed to identify underlying constructs associated with CAD according to the panel of educators. Results: Seventy-two educators completed the survey (24.2% response rate) resulting in 50 identified unique items through thematic coding. Factor analysis (Kaiser-Meyer-Olkin measure of sampling adequacy = .679, Bartlett’s test of sphericity (x(2)(351) = 1129.06. p

Background Differential diagnosis is a systematic process used to identify the proper diagnosis from a set of possible competing diagnoses. Methods The goal of this masterclass is to discuss the higher order thinking components of differential diagnosis. Conclusions For healthcare providers, diagnosis is one of many necessary components during the clinical decision making process and it is hallmarked by differentiation of competing structures for a definitive understanding of the underlying condition. The diagnostic process involves identifying or determining the etiology of a disease or condition through evaluation of patient history, physical examination, and review of laboratory data or diagnostic imaging; and the subsequent descriptive title of that finding. Whereas differential diagnosis is a varied skill set among all healthcare providers, the concept of a diagnosis is equally germane, regardless of one's background. In theory, a diagnosis improves the use of classification tools, improves clarity and communication, provides a trajectory of treatment, improves understanding of a person's prognosis, and in some cases, may be useful for preventative treatments. To achieve these improvements, one must have an understanding of relation of the clinical utility of tests and measures with diagnosis, and how to best implement these findings in clinical practice. This requires a deeper understanding (higher order thinking) of the role of diagnosis in the management of patients.

While advances in assessment and management of musculoskeletal conditions have improved care for many people, there have been other, less beneficial developments in the provision of care for people with musculoskeletal pain conditions, one of which is the worrying tendency to provide too much medicine. Too much medicine occurs when the provision of either investigation or intervention (or both) is unjustifiably excessive. Another concern in musculoskeletal health care is medicalizing normality-when a normal human function or condition is labeled as abnormal. In this Viewpoint, the authors argue that medicalizing normality creates health concerns where none exist, while too much medicine involves provision of care where benefits do not outweigh harms, and wastes precious health care resources. The authors (1) list 2 common examples of too much medicine, and 2 examples of medicalizing normality, relevant to physical therapy practice; (2) outline the drivers of too much medicine and medicalizing normality; and (3) make suggestions for change. J Orthop Sports Phys Ther 2020;50(1):1-4. doi:10.2519/jospt.2020.0601.

Background Given the ongoing battle with opioid abuse and overuse in the United States, new strategies are consistently being implemented to reduce opioid utilization and overprescribing. Objectives The purpose of this study was to determine if a more regulated explicit pain management instruction plan could reduce the number of opioids taken. Methods Blinded randomized prospective study comparing a total of 110 (Group A = 55, Group B = 55) women who underwent elective outpatient bilateral breast reduction surgery by 2 different plastic surgeons. Patients were randomly divided into either Group A (control) that received general pain management instructions or Group B (experimental) that received explicit pain management instructions from the surgeons and nurses. Participants were asked to record the number of times they treated their pain with each separate modality. They were also asked to record their average daily pain scale for the days that they were treating their pain. Results Patients in Group B took on average 1.5 oxycodone (5 mg) and patients in Group A took on average 5.7 oxycodone (5 mg) (P Conclusions Based on these results, it appears that standardizing how patients are instructed to treat their pain postoperatively may reduce the number of narcotics needed, thus reducing the number of narcotics prescribed without compromising pain control. Level of Evidence: 2

Purpose: Orthopedic manual therapy (OMT) education demonstrates significant variability between philosophies and while literature has offered a more comprehensive understanding of the contextual, patient specific, and technique factors which interact to influence outcome, most OMT training paradigms continue to emphasize the mechanical basis for OMT application. The purpose of this study was to establish consensus on modifications & adaptions to training paradigms which need to occur within OMT education to align with current evidence.Methods: A 3-round Delphi survey instrument designed to identify foundational knowledge to include and omit from OMT education was completed by 28 educators working within high level manual therapy education programs internationally. Round 1 consisted of open-ended questions to identify content in each area. Round 2 and Round 3 allowed participants to rank the themes identified in Round 1.Results: Consensus was reached on 25 content areas to include within OMT education, 1 content area to omit from OMT education, and 34 knowledge components which should be present in those providing OMT. Support was seen for education promoting understanding the complex psychological, neurophysiological, and biomechanical systems as they relate to both evaluation and treatment effect. While some concepts were more consistently supported there was significant variability in responses which is largely expected to be related to previous training.Conclusion: The results of this study indicate manual therapy educators understanding of evidence-based practice as support for all 3 tiers of evidence were represented. The results of this study should guide OMT training program development and modification.

OBJECTIVE To investigate the influence of time taken to begin musculoskeletal rehabilitation on injury recurrence and ankle-related medical care use at 1 year after ankle sprain. DESIGN Retrospective cohort study of all beneficiaries of the US Military Health System seeking care for an ankle sprain over a 4-year period. METHODS Individuals were classified according to whether they did or did not receive physical rehabilitation. For those who received rehabilitation (n = 6150), linear relationships (with appropriate covariate controls) were analyzed with generalized linear models and generalized additive models to measure the effects of rehabilitation timing on injury recurrence and injury-related medical care use (costs and visits) at 1 year after injury. The nonlinear effect of rehabilitation timing on the probability of recurrence was assessed. RESULTS Approximately 1 in 4 people received rehabilitation. The probability of ankle sprain recurrence increased for each day that rehabilitation was not provided during the first week. The probability of ankle sprain recurrence plateaued until about 2 months after initial injury, then increased again, with 2 times greater odds of recurrence compared to those who received physical rehabilitation within the first month. When rehabilitation care was delayed, recurrence (odds ratio [OR] = 1.28), number of foot/ankle-related visits (OR = 1.22), and foot/ankle-related costs increased (OR = 1.13; up to $1400 per episode). CONCLUSION The earlier musculoskeletal rehabilitation care started after an ankle sprain, the lower the likelihood of recurrence and the downstream ankle-related medical costs incurred. J Orthop Sports Phys Ther 2021;51(12):619-627. doi:10.2519/jospt.2021.10730.

Patient-reported outcome measures (PROMs) are reported by the patient and designed to capture patients' unique perspectives of their symptoms, quality of life, function, disability, and overall health status. Despite their important role in the health care landscape, it is important to recognize that PROMs have numerous shortcomings. These include weaknesses in the development of tools and interpretation of scale values, which can lead to variable patient reporting and dissimilarities in study results, potentially influencing the effectiveness of findings. This Viewpoint makes recommendations for how to interpret and best use PROMs, in spite of their shortcomings.

This study aims to determine whether surgery for cruciate ligament (anterior or posterior) or meniscus injury increased risks of subsequent comorbidities in beneficiaries of the Military Health System. The study was a retrospective case-control design in which individuals with cruciate or meniscus injuries were divided into two groups (surgery or none). Data were pulled 12 months prior and 24 months following each respective event and presence of comorbidities were compared between the two groups. Bivariate analyses and logistic regression were used to determine if surgery increased the odds of comorbidities. Participants included 1,686 with a cruciate ligament injury (30.1% treated surgically) and 13,146 with a meniscus injury (44.4% treated surgically). Bivariate comparisons of surgery versus nonsurgical treatment found multiple significant differences. After adjusting for covariates, a significant (p

Background Whereas ankle-foot injuries are ubiquitous and affect ~16% of military service-members, granularity of information pertaining to ankle sprain subgroups and associated variables is lacking. The purpose of this study was to characterize and contextualize the burden of ankle sprain injuries in the U.S. Military Health System. Methods This was a retrospective cohort study of beneficiaries seeking care for ankle sprains, utilizing data from the Military Health System Data Repository from 2009 to 2013. Diagnosis and procedural codes were used to identify and categorize ankle sprains as isolated lateral, isolated medial, concomitant medial/lateral, unspecified, or concomitant ankle sprain with a malleolar or fibular fracture. Patient characteristics, frequency of recurrence, operative cases, and injury-related healthcare costs were analyzed. Results Of 30,910 patients included, 68.4% were diagnosed with unspecified ankle sprains, 22.8% with concomitant fractures, (6.9%) with isolated lateral sprains, (1.7%) with isolated medial sprains and 0.3% with combined medial/lateral sprains. Pertaining to recurrence, 44.2% had at least one recurrence. Sprains with fractures were ~2-4 times more likely to have surgery within one year following injury (36.2% with fractures; 9.7% with unspecified sprains) and had the highest ankle-related downstream costs. Conclusion Fractures were a common comorbidity of ankle sprain (one in five injuries), and operative care occurred in 16.4% of cases. Recurrence in this cohort approximates the 40% previously reported in individuals with first-time ankle sprain who progress to chronic ankle instability. Future epidemiological studies should consider reporting on subcategories of ankle sprain injuries to provide a more granular assessment of the distribution of severity. Level of evidence 3b

Lumbar surgery is a commonly prescribed intervention for low back pain but poses higher risks and worse outcomes for older adults. Identifying clinical phenotypes based on biopsychosocial factors may help identify older adults who are at greatest risk for poor postoperative recovery. This study aimed to (a) classify older adults who underwent lumbar surgery based on preoperative biopsychosocial factors, and (b) quantify the association between preoperative biopsychosocial classifications and 3 and 12 months postoperative improvement outcomes. Latent class analysis was used to identify biopsychosocial classifications in 10,283 individuals aged ≥60 from the Quality Outcomes Database (the United States, 2021-2018). Logistic regression models measured the association between biopsychosocial classifications and 3 and 12 months postoperative outcomes (back/leg pain intensity, disability and quality of life), adjusting for covariates. Three classes were identified based on 19 a priori biopsychosocial factors and were characterised as 'high-risk' (15%), 'physical-/social health-risk' (44%) and 'low-risk' (41%). The high-risk class demonstrated increased odds of failing to recover post-operatively compared to the other classes. Similarly, the physical-/social-risk class demonstrated increased odds of failing to recover in all outcomes and time points compared to the low-risk class. Biopsychosocial factors with higher prevalence in the high versus low-risk class were depression (92.5% vs. 10.6%), multiple morbidities (55.3% vs. 25.7%) and obesity (59.5% vs. 37.2%). This study introduces novel non-recovery phenotypes for older adults undergoing lumbar surgery and may lead to the development of tailored interventions to improve clinical care and outcomes for this population.

In health care, clinical decision making is typically based on diagnostic findings. Rehabilitation clinicians commonly rely on pathoanatomical diagnoses to guide treatment and define prognosis. Targeting prognostic factors is a promising way for rehabilitation clinicians to enhance treatment decision-making processes, personalize rehabilitation approaches, and ultimately improve patient outcomes. This can be achieved by using prognostic tools that provide accurate estimates of the probability of future outcomes for a patient in clinical practice. Most literature reviews of prognostic tools in rehabilitation have focused on prescriptive clinical prediction rules. These studies highlight notable methodological issues and conclude that these tools are neither valid nor useful for clinical practice. This has raised the need to open the scope of research to understand what makes a quality prognostic tool that can be used in clinical practice. Methodological guidance in prognosis research has emerged in the last decade, encompassing exploratory studies on the development of prognosis and prognostic models. Methodological rigor is essential to develop prognostic tools, because only prognostic models developed and validated through a rigorous methodological process should guide clinical decision making. This Perspective argues that rehabilitation clinicians need to master the identification and use of prognostic tools to enhance their capacity to provide personalized rehabilitation. It is time for prognosis research to look for prognostic models that were developed and validated following a comprehensive process before being simplified into suitable tools for clinical practice. New models, or rigorous validation of current models, are needed. The approach discussed in this Perspective offers a promising way to overcome the limitations of most models and provide clinicians with quality tools for personalized rehabilitation approaches. Impact Prognostic research can be applied to clinical rehabilitation; this Perspective proposes solutions to develop high-quality prognostic models to optimize patient outcomes.

Objectives:(1) To identify baseline variables associated with patients that sought no additional care during the 12 months following a single self-management education session for low back pain (LBP), and (2) in those who sought care, to determine whether the same variables were associated with low versus high downstream LBP-related healthcare utilization.Design:An observational cohort.Setting:Single large military hospital.Participants:A total of 733 patients with LBP.Intervention:Single self-management education session.Main outcomes:Eleven variables were explored in two distinct logistic regression models: (1) no additional care versus additional care, and (2) low versus high number of additional visits in the additional care group.Results:In the first model, not being on active duty service (odds ratio (OR) = 1.98, 95% confidence interval (CI) = 1.37–2.86), low baseline disability (OR = 1.02, 95% CI = 1.00–1.04), low baseline fear-avoidance related to work (OR = 1.02, 95% CI = 1.00–1.03), and, in the last year, no opioid prescriptions (OR = 1.44, 95% CI = 1.00–2.07), physical therapy (OR = 1.63, 95% CI = 1.00–2.65), or sleep disorder diagnosis (OR = 1.62, 95% CI = 1.05–2.51) significantly increased the odds that patients would not seek any additional care. In the second model, not being on active duty service (OR = 2.18, 95% CI = 1.38–3.46), low baseline disability (OR = 1.04, 95% CI = 1.02–1.06), and no opioid prescriptions in the prior year (OR = 2.19, 95% CI = 1.42–3.37) increased the odds that patients would have less visits (⩽2 visits).Conclusion:Our study found several variables that helped determine whether patients would seek little or no additional care during the 12 months following a self-management education class for LBP.

Background: There is a relationship between sleep, pain, and chronic opioid utilization. This has been poorly explored in general, and especially in patients undergoing orthopaedic surgery. Fewer studies have investigated this relationship based on a sleep diagnosis present both before and after surgery. Objectives: To identify the association between insomnia and sleep apnea and downstream opioid use and medical utilization (visits and cost) in the 2 years following arthroscopic hip surgery. Study Design: A retrospective cohort. Setting: The US Military Health System. Methods: This was a consecutive cohort of individuals undergoing hip arthroscopy in the Military Health System (MHS). Medical utilization data were abstracted from the MHS Data Repository between 2003 and 2015, representing 1 year prior and 2 years after surgery for every individual. Sleep disorder diagnoses (insomnia and sleep apnea) were identified using International Classification of Disease codes, and opioid utilization was determined from pharmacy data based on American Hospital Formulary Service codes 280808 and 280812. Sleep disorders present before surgery were used as predictors in multivariate logistic regression, and sleep disorders present after surgery were examined for associations with the outcomes using the Chi-square tests. The dependent variables in both cases were downstream medical utilization (costs, visits, and opioid use). Results: Of 1870 eligible patients (mean age 32.3 years; 44.5% women), 165 (8.8%) had a diagnosis of insomnia before surgery and 333 (17.8%) after surgery; whereas 93 (5.0%) had a diagnosis of apnea before surgery and 268 (14.3%) after surgery. A diagnosis of insomnia before surgery predicted having at least 3+ opioids prescriptions after surgery (adjusted odds ratio, 1.97 [95% confidence interval, 1.39, 2.79]) and greater downstream total medical visits and costs in the 2 years after surgery. However, the number of individuals with a diagnosis of insomnia or apnea after surgery more than doubled, and was significantly associated with chronic opioid use, all-cause medical and all hip-related medical downstream visits and costs in the 2 years after surgery. Limitations: The use of observational data and claims data are only as good as how it was entered. Conclusions: Sleep disorders prior to surgery predicted chronic opioid use and medical utilization after surgery. However, a much higher rate of individuals had sleep apnea and insomnia present after surgery, which were significantly associated with chronic opioid use and greater total and hip-related medical utilization (visits and costs). Screening for sleep disorders prior to surgery may be important, but an even higher rate of sleep disorders may be developed after surgery, and continued screening after surgery may have greater clinical merit. Assessing quality of sleep during perioperative management may provide a unique opportunity to decrease pain and chronic opioid use after surgery. Key words: Pain, opioid use, insomnia, sleep apnea, orthopaedic surgery, military medicine, health care utilization Pain Physician 2019

The Lumbar Spine Instability Questionnaire (LSIQ) is a self-report measure of 15 items. Previous studies have used the LSIQ as a measure of clinical instability; however, a comprehensive evaluation of its clinimetric properties has not been conducted.The aim of this study was to evaluate the clinimetric properties of the LSIQ in patients with chronic nonspecific low back pain (LBP).In this clinical measurement study, the authors included patients with nonspecific LBP presenting to primary care clinicians in Australia. Rasch analysis was conducted to assess item hierarchy, targeting, unidimensionality, person fit, internal consistency, and differential item functioning. The researchers assessed test-retest reliability of total scores and individual item scores, as well as convergent and divergent validity.A total of 107 participants with LBP (60 men and 47 women) were recruited. The results were variable. The LSIQ appeared to constitute a unidimensional measure, targeted the sample well, and showed adequate test-retest reliability. However, the scale had poor internal consistency, did not appear to function as an interval-level measure, and had unclear construct validity. Although no items appeared to be redundant, several items were biased by factors other than the proposed construct of the measure.The LSIQ does not seem to be ready to be implemented in clinical practice and may require theoretical reconsideration. Although the LSIQ provided satisfactory estimates for some clinimetric features, the authors do not consider the instrument to be useful as an interval-level measure but rather as an index. Future studies are needed to investigate whether the LSIQ could measure clinical instability or some other construct. J Orthop Sports Phys Ther 2018;48(12):915-922. Epub 22 Jun 2018. doi:10.2519/jospt.2018.7866.

OBJECTIVE For individuals with severe disability requiring spine surgery, appropriate discharge destination is a challenging and complex decision. Past studies have found associations between discharge destination and postoperative outcomes but were limited by biases in sampling characteristics. The purpose of this study was to explore whether there is an association between discharge destination and odds of worse postoperative outcomes in high-risk individuals with severe/crippling/bedbound disability who received lumbar spine surgery. METHODS This was an observational study using the Quality Outcomes Database Spine Registry. Subjects were limited to age ≥18 years, primary lumbar spine surgery, and severe disability at baseline (Oswestry Disability Index [ODI] ≥50%). Discharge destination was dichotomized to home or healthcare institution. RESULTS Of the 13,050 patients, 11,859 patients (90.9%) were discharged home and 1191 (9.1%) patients were discharged to a healthcare institution. Individuals who were discharged to a healthcare institution were older (68.6 vs 56.9 p

Background Upper limb neurodynamic tests (ULNT) are used to diagnose neuropathic conditions such as cervical radiculopathy (CR). Within the literature, a positive ULNT is defined in markedly variable ways, which is likely why the diagnostic accuracy of these tests lacks consistency across studies. Objectives To determine the diagnostic accuracy of single and combined upper limb neurodynamic tests ((ULNT)1,2a, 2b and 3) for cervical radiculopathy using test findings that are similar to those used in practice. Design Diagnostic accuracy study (prospective) design following the updated STARD 2015 reporting guideline. Method From 109 consecutively enrolled individuals with suspected CR. Of the 85 participants included, 27 (31.7%) were diagnosed with CR (mean age, 43.9years; Neck Disability Index 38,16%). ULNTs test were performed by a blind examiner to a CR reference standard of clinical diagnosis and magnetic resonance imaging verification provided by a neurosurgeon. Results In general, the single tests were better at ruling in CR versus ruling out. Of the single ULNT, the ULNT3 demonstrated the strongest post-test probability change with a positive finding (73.28%). Three of four test combinations demonstrated the highest clinical utility for changing the post-test probability with a positive finding at 83.29% and with LR+ = 12.89 (95%CI: 3.10–53.62). Having none of the test's positive was able to rule out CR with LR- = 0.08 (95%CI: 0.01–0.56). Conclusion ULNTs fail to significantly alter post-test probability when used singularly for diagnosis of CR. However, combinations of ULNT (3 out of 4 positive) can rule in CR, and rule out CR when all ULNT are negative.

Objective Limited research has investigated the use of manual therapy to treat the preadolescent (0–12 years of age) population with musculoskeletal and neurological impairments. The purpose of this study was to identify the following among physical therapists holding advanced credentials in pediatrics, neurodevelopmental treatment, or manual therapy: (1) consensus regarding effective techniques in the preadolescent population, (2) differences in opinion, and (3) perceived decision-making barriers and factors regarding use of manual therapy techniques. Methods Credentialed physical therapists in the United States were recruited for a 3-round Delphi investigation. An electronic survey in Round 1 identified musculoskeletal and neurological impairments and the manual techniques considered effective to treat such conditions, in addition to factors and barriers. Responses were used to create the second round, during which a 4-point Likert scale was used to score each survey item. A third round of scoring established consensus. Descriptive statistics and composite scores were calculated for each manual technique by impairment. Between-group differences were calculated using the Mann-Whitney U test with Bonferroni correction. Results Consensus was determined for several concepts. First, neuromuscular techniques were considered effective across all impairments, and joint mobilizations (grades I–IV) were believed to be effective to treat joint and muscle and myofascial impairments. Second, visceral manipulation and craniosacral therapy were considered ineffective in treating most impairments. There was lack of consensus and clear differences of opinion regarding the use of grade V mobilizations and dry needling. Significant barriers to use of manual therapy were: lack of knowledge, lack of evidence, and fear of litigation and harming patients. Conclusion This study is an initial step for developing manual therapy guidelines, research, and educational opportunities regarding manual therapy in pediatric physical therapy.

Purpose: There is a potential link between the clinical education phase of a physical therapist’s education and increased incidence of student mental health challenges. The Director of Clinical Education (DCE) has a complex role in supporting students and clinical sites during clinical education experiences (CEEs.) The purposes of this study were to explore DCE’s experiences and perceptions with supporting students with mental health challenges during CEEs. Methods: Two-hundred-twenty DCEs from accredited Doctor of Physical Therapy programs were invited to participate in an electronic survey. Survey questions included demographics, institutional and curricular characteristics, and current perceptions/experiences with student mental health challenges. DCEs (n = 106; 48.2%) responded and were included in the analyses. Analyses included descriptive statistics, simple frequencies, and binary logistic regression. Incident coding processes analyzed responses of open-ended questions. Results: Seventy-four percent of respondents indicated awareness of a student(s) experiencing a mental health concern during a full-time clinical experience in the past 3 years. Regression analyses showed that length of terminal clinical experience, out-of-state placement, cohort size, and availability of online/video counseling were related to prevalence of DCE’s experience. Forty-six percent of DCEs indicated feeling prepared to deal with these issues, while 35% were ‘unsure’. DCEs indicated experience, training, and workload support as contributors to successfully supporting students. Conclusion: Results contribute to the emerging understanding of the prevalence of student mental health challenges in physical therapist education from the DCE’s perspective. Our findings suggest that institutional and curricular characteristics are potential contributors to the prevalence of this issue. We recommend training and institutional support for the DCE in these situations.

Background Postpartum runners report musculoskeletal pain with running. Because of inadequate research, little is known about the origin and pain-related classification. Through expert consensus, this study is the first attempt to understand the musculoskeletal impairments that these runners present with. The objective of this survey was to gather expert consensus on characteristics of reported impairments in postpartum runners that have musculoskeletal pain. Methods A web-based Delphi survey was conducted and was composed of five categories: strength, range of motion, alignment and flexibility impairments, as well as risk factors for pain in postpartum runners. Results A total of 117 experts were invited. Forty-five experts completed round I and forty-one completed rounds II and III. The strength impairments that reached consensus were abdominal, hip and pelvic floor muscle weakness. The range of motion impairments that reached consensus were hip extension restriction, anterior pelvic tilt and general hypermobility. The alignment impairments that reached consensus were a Trendelenburg sign, dynamic knee valgus, lumbar lordosis, over-pronation and thoracic kyphosis. The flexibility impairments that reached consensus were abdominal wall laxity, and tightness in hip flexors, lumbar extensors, iliotibial band and hamstrings. The risk factors for pain in postpartum runners were muscular imbalance, poor lumbopelvic control, too much too soon, life stressors, pain during pregnancy and pelvic floor trauma. Conclusion This study presents a framework for clinicians to understand pain in postpartum runners and that can be investigated in future cohort studies. Level of evidence 5

Background: Previous studies have shown that the rates of complications associated with revision spine surgery are higher than those of primary spine surgery. However, there is a lack of research exploring the difference in magnitude of risk of poor outcomes between primary and revision lumbar spine surgeries. Purposes: We sought to compare the risks of poor outcomes for primary and revision lumbar spine surgeries and to analyze different measures of risk to better understand the true differences between the 2 forms of surgery. Methods: This retrospective observational study used data from the Quality Outcomes Database Lumbar Spine Surgical Registry from 2012 to 2018. We included individuals who received primary or revision surgery due to degenerative lumbar disorders. Outcome variables collected were complications within 30 days of surgery and 3 destination variables, specifically, (1) 30-day hospital readmission, (2) 30-day return to operating room, and (3) revision surgery within 3 months. Measures of risk considered were odds ratio (OR), relative risk (RR), relative risk increase (RRI), and absolute risk increase (ARI). Results: There were 31,843 individuals who received primary surgery and 7889 who received revision surgery. After controlling for baseline descriptive variables and comorbidities, revision surgery increased the odds of 4 complications and all 3 destination variables. Risk ratios reflected smaller magnitudes but similar findings as the statistically significant ORs. Conclusion: Revision surgery is related to higher overall risks than primary surgery, but the true magnitudes of these risks are very small. RRI and ARI should be included when reporting ORs to better clarify the significance.

Objectives This overview of reviews aimed to identify (1) aspects of the patient experience when seeking care for musculoskeletal disorders from healthcare providers and the healthcare system, and (2) which mechanisms are used to measure aspects of the patient experience. Data sources Four databases were searched from inception to December 20th, 2019. Review methods Systematic or scoping reviews examining patient experience in seeking care for musculoskeletal from healthcare providers and the healthcare system were included. Independent authors screened and selected studies, extracted data, and assessed the methodological quality of the reviews. Patient experience concepts were compiled into five themes from a perspective of a) relational and b) functional aspects. A list of mechanisms used to capture the patient experience was also collected. Results Thirty reviews were included (18 systematic and 12 scoping reviews). Relational aspects were reported in 29 reviews and functional aspects in 25 reviews. For relational aspects, the most prevalent themes were “information needs” (education and explanation on diseases, symptoms, and self-management strategies) and “understanding patient expectations” (respect and empathy). For functional aspects, the most prevalent themes were patient’s “physical and environmental needs,” (cleanliness, safety, and accessibility of clinics), and “trusted expertise,” (healthcare providers’ competence and clinical skills to provide holistic care). Interviews were the most frequent mechanism identified to collect patient experience. Conclusions Measuring patient experience provides direct insights about the patient’s perspectives and may help to promote better patient-centered health services and increase the quality of care. Areas of improvement identified were interpersonal skills of healthcare providers and logistics of health delivery, which may lead to a more desirable patient-perceived experience and thus better overall healthcare outcomes. Trial registration Systematic review registration: PROSPERO (CRD42019136500).