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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.

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

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.

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

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.

Background In 2019, a majority of runners participating in running events were female and 49% were of childbearing age. Studies have reported that women are initiating or returning to running after childbirth with up to 35% reporting pain. There are no studies exploring running-related pain or risk factors for this pain after childbirth in runners. Postpartum runners have a variety of biomechanical, musculoskeletal, and physiologic impairments from which to recover from when returning to high impact sports like running, which could influence initiating or returning to running. Therefore, the purpose of this study was to identify risk factors associated with running-related pain in postpartum runners with and without pain. This study also aimed to understand the compounding effects of multiple associative risk factors by developing a clinical decision tool to identify postpartum runners at higher risk for pain. Methods Postpartum runners with at least one child ≤36 months who ran once a week and postpartum runners unable to run because of pain, but identified as runners, were surveyed. Running variables (mileage, time to first postpartum run), postpartum variables (delivery type, breastfeeding, incontinence, sleep, fatigue, depression), and demographic information were collected. Risk factors for running-related pain were analyzed in bivariate regression models. Variables meeting criteria (P Results Analyses included 538 postpartum runners; 176 (32.7%) reporting running-related pain. Eleven variables were included in the multivariate model with six retained in the clinical decision tool: runner type-novice (OR 3.51; 95% CI 1.65, 7.48), postpartum accumulated fatigue score of >19 (OR 2.48; 95% CI 1.44, 4.28), previous running injury (OR 1.95; 95% CI 1.31, 2.91), vaginal delivery (OR 1.63; 95% CI 1.06, 2.50), incontinence (OR 1.95; 95% CI 1.31, 2.84) and Conclusion The results of this study provide a deeper understanding of the risk factors for running-related pain in postpartum runners. With this information, clinicians can monitor and educate postpartum runners initiating or returning to running. Education could include details of risk factors, combinations of factors for pain and strategies to mitigate risks. Coaches can adapt running workload accounting for fatigue and sleep fluctuations to optimize recovery and performance. Future longitudinal studies that follow asymptomatic postpartum women returning to running after childbirth over time should be performed to validate these findings.

The purpose of this study was to investigate the association between positive change in depression or anxiety within three months post-operation and clinically meaningful changes in long-term clinical outcomes after lumbar spine surgery.This study included adults with preoperative diagnosis of depression or anxiety who underwent lumbar spine surgery in the Quality Outcomes Database (QOD) from 2012 to 2018 with either a 12- or 24-month follow-up. Positive change in depression and anxiety was assessed three months after surgery. Clinical outcomes measured included Numeric Rating Scale (NRS) score for back pain (BP) and leg pain (LP), Oswestry Disability Index score (ODI) for disability, EuroQol Visual Analog Scale score (EQ-VAS) for health-related quality of life (HRQOL), and North American Spine Surgery (NASS) index score for patient satiaction measured at 12- and 24 months after surgery.Of the 9,656 and 1,393 patients who were included in the 12- and 24-month cohort, respectively, 7,277 patients (75.4 %) and 1,089 (78.2 %) experienced a positive change in depression or anxiety within three months after surgery. At both 12- and 24-month follow-up, patients who had positive change in depression or anxiety were more likely to achieve minimal clinically important changes in NRS-BP/LP, ODI, EQ-VAS, and NASS (all p 0.01) compared to those who did not experience improvement in depression or anxiety.Depression and anxiety are important comorbidities to consider in patients undergoing lumbar spine surgery. Positive change in depression and anxiety are associated with improvements in pain, disability, satisfaction, and overall functioning.

Objectives This study aimed to report compliance with stepped care management of patellofemoral pain and determine whether adherence to stepped care results in decreased recurrence and lower health care utilization. Methods A total of 60,730 participants were included, using data from the Military Health System Data Repository, a large single-payer government health system. Outcomes included total knee-related care visits and costs, knee surgeries, opioid prescriptions, and 2-year recurrence. Stepped care was based on interventions delivered within the appropriate timing and in the appropriate order (low risk/cost before high risk/cost). Results A total of 54,460 (89.7%) participants received adherent Step 1 care, 10,964 (18.1%) received step 2, and 4168 (6.9%) received step 3. A total of 32.0% and 50.8%, respectively, of all patients in Step 2 and Step 3 care were adherent. Of the 2385 participants (3.9% of cohort) that received both Step 2 and Step 3 care, 24.8% of participants received adherent care. For participants receiving both Step 2 and Step 3 care, adherence resulted in cost savings (mean difference [MD] $1708; 95% confidence interval [CI]: $1241, 2175), fewer knee-related visits (MD 3.4; 95% CI 2.2, 4.7), fewer episodes of knee pain (MD 0.7; 95% CI 0.5, 0.8), fewer knee surgeries (adjusted odds ratio 0.4; 95% CI 0.3, 0.5), and fewer opioid prescriptions (adjusted odds ratio 0.6; 95% CI 0.5, 0.8). Conclusion These findings demonstrate the value of following stepped care guidelines for pain management in patients with patellofemoral pain.

The influence of prior patterns of health care utilization on future health care utilization has had minimal investigation in populations with musculoskeletal disorders.The purpose of this study was to explore the relationship between presurgical health care utilization and postsurgical health care utilization in a population of patients undergoing hip surgery in the US Military Health System.In this observational cohort study, person-level data were collected for patients undergoing hip arthroscopy in the Military Health System from 2003 to 2015, capturing all encounters 12 months before and 24 months after surgery for every individual. Cluster analysis was used to categorize individuals with high and low health care utilization, based on preoperative health care visits. Unadjusted and adjusted Poisson and generalized linear models were generated. Health care utilization outcomes were targeted, including costs, visits, and medication use.There were 1850 individuals in the final cohort (mean age, 32.18 years; 55.4% male). The high health care utilization group averaged 57.69 ± 25.87 visits, compared to 20.43 ± 8.36 visits in the low utilization group. There were significant differences between groups for total health care visits (58.17; 95% confidence interval [CI]: 57.39, 58.58), total health care costs ($11 539.71; 95% CI: $10 557.26, $12 595.04), hip-related visits (12.77; 95% CI: 12.59, 12.96), hip-related costs ($3325.07; 95% CI: $2886.43, $3804.51), days' supply of pain medications (752.67; 95% CI: 751.24, 754.11), opioid prescriptions (48.83; 95% CI: 48.47, 49.21), and cost of pain medications ($1074.80; 95% CI: $1011.91, $1137.68).Presurgical patterns of health care utilization were associated with postsurgical patterns of health care utilization, indicating that those patients who used more care before surgery also used more care after surgery. Clinicians should consider prior patterns of health care utilization, including utilization unrelated to the index condition, when determining care plans and prognosis. J Orthop Sports Phys Ther 2018;48(11):878-886. Epub22 Jul 2018. doi:10.2519/jospt.2018.8259.

Objectives The purpose of this study was to identify descriptive factors in individuals with a primary complaint of low back pain (LBP) associated with improved pain and function after receiving physical therapy for LBP with or without manual therapy and exercise directed at the femoroacetabular joints. Methods Participants were enrolled in a randomized clinical trial investigating physical therapy interventions for their LBP, with or without interventions directed at the femoroacetabular joints (hips). A participant was deemed recovered if all of the following were met: Numeric Pain Rating Scale (NPRS) score of ≤2 points, ≤10% on the modified Oswestry Disability Index at discharge, and a global rating of change score of +4 at both 2 weeks and discharge. Logistic regression modelling determined descriptor variables that best predicted treatment recovery. Results Data from 90 participants were included in the analysis, with 44% (n = 40) achieving recovery by discharge from physical therapy (average 7.95 [±4.68]) visits. The variables of concurrent hip problems, lower body mass index ≤25.4, an irritable condition, and a baseline NPRS score of 4 points or less were retained in the final model (R 2 = .384). Having a concurrent hip problem had the highest odds of achieving recovery in the model (odds ratio: 5.34, 95 % confidence interval: 1.31-21.8). Conclusions The findings for the patients in this study suggest that those with a concurrent hip problem, a lower body mass index, irritable symptoms, and a baseline NPRS score of 4 points or less were associated with greater odds of achieving recovery with multimodal physical therapy interventions. Further research should continue to investigate the interplay between the lumbar spine and hip joints.

Background As defined by Medicare (United States), post-acute rehabilitation services include care provided in inpatient rehabilitation units and facilities, skilled nursing facilities, long-term acute hospitals, and by home health services. Methods We retrospectively evaluated the use of rehabilitation-based post-acute services among Medicare beneficiaries who were hospitalized for lumbar spinal fusion (ICD-9-CM procedure codes 81.04–81.08) in 2012–2014, examined the case-mix for those discharged to rehabilitation- and non-rehabilitation based services, and determined the association between these categories of discharge disposition and 30-day rehospitalization. The independent effect of rehabilitation-based discharge destination on 30-day readmissions was examined with a generalized linear mixed model, first adjusting for patient characteristics and then stratified by clusters that delineated more homogenous clinical profiles. Results Among 261,558 Medicare beneficiaries with lumbar spinal fusion surgery, 50.8% were discharged to a rehabilitation-based post-acute services. Patients discharged to rehabilitation-based services were older and had more comorbidities, and had longer hospital lengths of stays. After adjusting for patient and hospital characteristics, patients discharged to rehabilitation-based post-acute care had increased odds of 30-day rehospitalization than those without discharge to other destinations (OR 1.36; 95%CI = 1.31, 1.40). Analysis of patients by clinical profile clusters found similar results. Conclusions Clinical profiles of Medicare beneficiaries who had lumbar spinal fusion surgery and were discharged to rehabilitation-based post-acute services included more comorbidities than those discharged to non-rehabilitation based settings. Controlling for these differences did not mediate the negative association between use of rehabilitation-based post-acute services and 30-day readmission.

The purpose of this study was to determine: 1) the test-retest reliability of Fear-Avoidance Beliefs Questionnaire (FABQ) Work (FABQW) subscale, FABQ Physical Activity (FABQPA) subscale, Shoulder Pain and Disability Index (SPADI) Pain subscale, SPADI Disability subscale, and Numeric Pain Rating scale (NPRS); and 2) the relationship between the FABQPA, FABQW, SPADI pain, SPADI disability, and NPRS after 4 weeks of pragmatically applied physical therapy (PT) in patients with shoulder pain.Prospective, single-group observational design.Data were collected at initial evaluation, the first follow-up visit prior to the initiation of treatment, and after 4 weeks of treatment.Statistically significant Intraclass Correlation Coefficient (ICCSince a meaningful relationship between the FABQ, SPADI, and NPRS did not exist, it suggests that the FABQPA may be measuring a metric other than pain.This study suggests that the FABQW may not be sensitive to change over time.

Neck pain affects 15.1% of the United States' general population every 3 months, and ranks fourth in global disability. Because of the tendency for neck pain to become a chronic issue, it is important to identify risk factors that could encourage prevention and early diagnosis. The purpose of this systematic review was to identify risk factors for a first episode of neck pain. Three databases were searched with key words such as "neck pain" and "first incidence." Risk factors from the resulting articles were reported as either a physical or psychosocial risk factor and ranked by the strength of their odds/risk/hazard ratio

Study Design Retrospective study. Background Alternative models of care that allow patients to choose direct access to physical therapy have shown promise in terms of cost reduction for neck and back pain. However, real-world exploration within the US health care system is notably limited. Objectives To compare total claims paid and patient outcomes for patients with neck and back pain who received physical therapy intervention via direct access versus medical referral. Methods Data were accessed for patients seeking care for neck or back pain (n = 603) between 2012 and 2014, who chose to begin care either through traditional medical referral or direct access to a physical therapy- led spine management program. All patients received a standardized, pragmatic physical therapy approach, with patient-reported measures of pain and disability assessed before and after treatment. Patient demographics and outcomes data were obtained from the medical center patient registry and combined with total claims paid calculated for the year after the index claim. Linear mixed-effects modeling was used to analyze group differences in pain and disability, visits/time, and annualized costs. Results Patients who chose to enter care via the direct-access physical therapy-led spine management program displayed significantly lower total costs (mean difference, $1543; 95% confidence interval: $51, $3028; P = .04) than those who chose traditional medical referral. Patients in both groups showed clinically important improvements in pain and disability, which were similar between groups (P>.05). Conclusion The initial patient choice to begin care with a physical therapist for back or neck pain resulted in lower cost of care over the next year, while resulting in similar improvements in patient outcomes at discharge from physical therapy. These findings add to the emerging literature suggesting that patients' choice to access physical therapy through direct access may be associated with lower health care expenditures for patients with neck and back pain. Level of Evidence Economic and decision analyses, level 4. J Orthop Sports Phys Ther 2018;48(2):63-71. Epub 26 Oct 2017. doi:10.2519/jospt.2018.7423.

Posterior shoulder tightness (PST) is a postoperative complication leading to pain, impaired mobility, and reduced function. Despite the potential morbidity associated with PST, no studies have investigated the efficacy of shoulder-stretching methods in the postsurgical population. The purpose of this study was to determine the short-term efficacy of two stretches designed to reduce PST.The study enrolled 63 patients [mean age 51 (12) years, height 173.7 (3.6) cm, body mass 88.2 (17.9) kg]. The study was a single-blinded randomized control trial in which patients who had arthroscopic shoulder surgery were assigned to one of three groups: [(horizontal adduction stretch (n = 21), supine sleeper (n = 21), or control (n = 21)]. Dependent variables included measurements of internal rotation mobility, sidelying PST, pain, and the QuickDASH. Following the physical therapy (PT) initial evaluation, subjects were instructed to perform the allocated intervention twice daily until their first follow-up appointment 48-72 h following the initial PT visit.Between group analyses of dependent variables revealed significant differences within PST measurements (p = 0.005) (eta squared = 0.14) taken at baseline and follow-up (48-72 h) favoring horizontal adduction stretching. Post-hoc testing demonstrated superiority of horizontal adduction stretching over both the supine sleeper group (p = 0.01) and control (p = 0.002).The horizontal adduction stretch is more effective at reducing acute PST in the postoperative shoulder population when compared to the supine sleeper stretch and no stretch at all. Knowledge of efficacious stretching methods may serve to reduce the potential morbidity associated with postoperative stiffness.

Background: This study describes a low‐cost and time‐efficient clinical sensory test (CST) battery and evaluates its concurrent validity as a screening tool to detect somatosensory dysfunction as determined using quantitative sensory testing (QST). Method: Three patient cohorts with carpal tunnel syndrome (CTS, n = 76), non‐specific neck and arm pain (NSNAP, n = 40) and lumbar radicular pain/radiculopathy (LR, n = 26) were included. The CST consisted of 13 tests, each corresponding to a QST parameter and evaluating a broad spectrum of sensory functions using thermal (coins, ice cube, hot test tube) and mechanical (cotton wool, von Frey hairs, tuning fork, toothpicks, thumb and eraser pressure) detection and pain thresholds testing both loss and gain of function. Agreement rate, statistical significance and strength of correlation (phi coefficient) between CST and QST parameters were calculated. Results: Several CST parameters (cold, warm and mechanical detection thresholds as well as cold and pressure pain thresholds) were significantly correlated with QST, with a majority demonstrating >60% agreement rates and moderate to relatively strong correlations. However, agreement varied among cohorts. Gain of function parameters showed stronger agreement in the CTS and LR cohorts, whereas loss of function parameters had better agreement in the NSNAP cohort. Other CST parameters (16 mN von Frey tests, vibration detection, heat and mechanical pain thresholds, wind‐up ratio) did not significantly correlate with QST. Conclusion: Some of the tests in the CST could help detect somatosensory dysfunction as determined with QST. Parts of the CST could therefore be used as a low‐cost screening tool in a clinical setting. Significance: Quantitative sensory testing, albeit considered the gold standard to evaluate somatosensory dysfunction, requires expensive equipment, specialized examiner training and substantial time commitment which challenges its use in a clinical setting. Our study describes a CST as a low‐cost and time‐efficient alternative. Some of the CST tools (cold, warm, mechanical detection thresholds; pressure pain thresholds) significantly correlated with the respective QST parameters, suggesting that they may be useful in a clinical setting to detect sensory dysfunction.

Objective: The objective was to explore for universal prognostic variables, or predictors, across three different outcome measures in patients with chronic low back pain (LBP). We hypothesized that selected prognostic variables would be ‘universal’ prognostic variables, regardless of the outcome measures used. Methods: This study was a secondary analysis of data from a previous randomized controlled trial comparing the McKenzie treatment approach with placebo in patients with chronic LBP. Ten baseline prognostic variables were explored in predictive models for three outcomes: pain intensity, disability, and global perceived effect, at 6 and 12 months. Predictive models were created using backward stepwise logistic and linear multivariate regression analyses. Results: Several predictors were present including age, expectancy of improvement, global perceived effect; however, we only identified baseline disability as a universal predictor of outcomes at 6 months. The second most represented universal predictor was baseline pain intensity for outcomes at 12 months. Discussion: Only two predictors demonstrated an association with more than one outcome measure. High baseline disability predicts multidimensional outcome measures at 6 months in patients with chronic LBP while baseline pain intensity can best predict the outcome at 12 months. Nevertheless, other predictors seem to be unique to the outcome used. Level of evidence: 2c.

Background Direct access physical therapy (DAPT) may result in improved patient outcomes and reduced healthcare costs. Prognostic factors associated with spine-related outcomes and insurance claims with DAPT are needed. Objective To identify factors that predict variations in outcomes for spine pain and insurance claims using DAPT. Methods Individuals (N = 250) with spine pain were analyzed. Outcomes were classified into High, Low, or Did Not Meet minimal clinically important difference (MCID) scores. Claims were categorized into low, medium, or high tertiles. Prognostic variables were identified from patient information. Results Females were more likely to meet High MCID (odds ratio [OR] 2.84 (95% CI = 1.32, 6.11) and Low MCID (OR 2.86, 95% CI = 1.34, 6.10). Higher initial ODI/NDI scores were associated with High MCID (OR 1.04, 95% CI = 1.07, 1.22) and Low MCID (OR 0.91, 95% CI = 0.77, 1.07). Odds of a high claim were lowered by the absence of imaging (OR 0.04, 95% CI = 0.02, 0.09) and an active versus passive treatment (OR 0.38, 95% CI = 0.18, 0.80). Conclusion Females and higher initial disability predicted favorable outcomes. The novel introduction of claims into the prognostic modeling supports that active interventions and avoiding imaging may reduce claims.

Key Points Question Is early physical therapy associated with long-term opioid use by patients with musculoskeletal pain? Findings In this cross-sectional analysis of 88 985 patients with shoulder, neck, knee, or low back pain, early physical therapy was associated with an approximately 10% statistically significant reduction in subsequent opioid use. Meaning By serving as an alternative or adjunct to short-term opioid use for patients with musculoskeletal pain, early physical therapy may play a role in reducing the risk of long-term opioid use., Importance Nonpharmacologic methods of reducing the risk of new chronic opioid use among patients with musculoskeletal pain are important given the burden of the opioid epidemic in the United States. Objective To determine the association between early physical therapy and subsequent opioid use in patients with new musculoskeletal pain diagnosis. Design, Setting, and Participants This cross-sectional analysis of health care insurance claims data between January 1, 2007, and December 31, 2015, included privately insured patients who presented with musculoskeletal pain to an outpatient physician office or an emergency department at various US facilities from January 1, 2008, to December 31, 2014. The sample comprised 88 985 opioid-naive patients aged 18 to 64 years with a new diagnosis of musculoskeletal shoulder, neck, knee, or low back pain. The data set (obtained from the IBM MarketScan Commercial database) included person-level International Classification of Diseases, Ninth Revision or Tenth Revision diagnosis codes, Current Procedural Terminology codes, and date of service as well as pharmaceutical information (National Drug Code, generic name, dose, and number of days supplied). Early physical therapy was defined as at least 1 session received within 90 days of the index date, the earliest date a relevant diagnosis was provided. Data analysis was conducted from March 1, 2018, to May 18, 2018. Main Outcomes and Measures Opioid use between 91 and 365 days after the index date. Results Of the 88 985 patients included, 51 351 (57.7%) were male and 37 634 (42.3%) were female with a mean (SD) age of 46 (11.0) years. Among these patients, 26 096 (29.3%) received early physical therapy. After adjusting for potential confounders, early physical therapy was associated with a statistically significant reduction in the incidence of any opioid use between 91 and 365 days after the index date for patients with shoulder pain (odds ratio [OR], 0.85; 95% CI, 0.77-0.95; P = .003), neck pain (OR, 0.92; 95% CI, 0.85-0.99; P = .03), knee pain (OR, 0.84; 95% CI, 0.77-0.91; P, This cross-sectional study examines the association between early physical therapy and subsequent opioid use among opioid-naive adults with a new diagnosis of musculoskeletal shoulder, neck, knee, or low back pain.

Introduction Self-reported levels of disability in individuals with low back pain (LBP) have not improved in the last decade. A broader perspective and a more comprehensive management framework may improve disability outcomes. We recently developed and validated the Low Back Pain and Disability Drivers Management (PDDM) model, which aims to identify the domains driving pain and disability to guide clinical decisions. The objectives of this study were to determine the applicability of the PDDM model to a LBP population and the feasibility of conducting a pragmatic trial, as well as to explore clinicians’ perceived acceptability of the PDDM model’s use in clinical settings. Methods This study was an one-arm prospective feasibility trial. Participants included physiotherapists working with a population suffering from LBP and their patients aged 18 years or older presenting with a primary complaint of LBP that sought a new referral and deemed fit for rehabilitation from private and public clinical settings. Clinicians participated in a one-day workshop on the integration of the PDDM model into their clinical practice, and were asked to report various LBP-related outcomes via self-reported questionnaires (i.e., impact of pain on physical function, nervous system dysfunctions, cognitive-emotional factors, work disabilities) at baseline and at six-week follow-up. Physiotherapists’ acceptability of the use of the PDDM model and appreciation of the training were assessed via semi-structured phone interviews. Analyses focused on a description of the model’s applicability to a LBP population, feasibility outcomes and acceptability measures. Results Applicablity of the PDDM model was confirmed since it successfully established the profile of patients according to the elements of each categories, and each of the 5 domains of the model was represented among the study sample. Trial was deemed feasible contingent upon few modifications as our predefined success criteria for the feasibility outcomes were met but feasibility issues pertaining to data collection were highlighted. Twenty-four (24) clinicians and 61 patients were recruited within the study’s timeframe. Patient’s attrition rate (29%) and clinicians’ compliance to the study protocol were adequate. Clinicians’ perceived acceptability of the use of the model in clinical settings and their appreciation of the training and online resources were both positive. Recommendations to improve the model’s integration in clinical practice, content of the workshop and feasibility of data collection methods were identified for future studies. A positive effect for all patients’ reported outcome measures were also observed. All outcome measures except for the PainDetect questionnaire showed a statistically significant reduction post-intervention (p Conclusion These findings provide preliminary evidence of the potential of the PDDM model to optimize LBP management as well as conducting a future larger-scale pragmatic trial to determine its effectiveness. Trial registration Clinicaltrial.gov: NCT03949179.

Background Several factors potentially influence outcomes of surgery, including perioperative complications. Complications may take many forms and the Clavien–Dindo (CD) classification is designed to categorize them by degree of severity. The aim of this study was to evaluate the influence of perioperative complications by severity categorization on the 1-and 2-year pain and disability outcomes for patients who received low back surgery. Materials and methods Data used for the study involved a purposive sample (N = 477; 8.1%) from a spine outcomes registry of 5876 patients who received spine surgery and encountered complications. All complications were categorized using the CD classification and were collapsed according to distribution frequencies, i.e., Grade I–II and Grade III–V. Adjusted and unadjusted regression analyses were used to determine the association between CD classification and 1- and 2-year outcomes. Results The majority of surgical complications were Grade III−V (N = 358; 75.1%), with two incidences in which death occurred. For the unadjusted models, there were no significant associations between CD classification categorizations for 1-year outcomes; however, 2-year outcomes were significantly worse (P

BACKGROUND: People with neck pain often present with weakness in the scapulothoracic muscles. Few studies have examined lower trapezius (LT), middle trapezius (MT) and serratus anterior (SA) muscle strength in individuals with neck pain, nor compared strength to asymptomatic individuals. OBJECTIVES: The aim of this study was to examine LT, MT and SA muscle strength in individuals with chronic neck pain. METHODS:Descriptive cross sectional design. Twenty two individuals with chronic neck pain and 17 asymptomatic individuals were included. Participants were asked to complete a screening questionnaire, Neck Disability Index, and underwent manual muscle testing for the LT, MT, and SA muscles bilaterally. Data analyses included paired and comparative independent t-tests. RESULTS:For individuals with neck pain, significant within subject differences in strength between sides for the LT ( P< 0.01) and MT ( P< 0.01) were present. In contrast, no within subject difference between sides for the asymptomatic group was found for any muscle. Individuals with neck pain were significantly weaker than asymptomatic individuals for the LT (p = 0.02), MT (p = 0.03), and SA (p = 0.01) on their side of neck pain, but not on their non-painful side. CONCLUSIONS: Significant within subject differences were found between sides for the LT and MT while significant between group differences were identified for all three muscles tested.

Rationale, aims and objectives Musculoskeletal shoulder pain is commonly treated in physical therapy. There is inconsistency in the literature regarding patient characteristics related to prognosis. Having prognostic information could be useful for improving clinical efficiency and decreasing the cost of associated care. The objective of this study was to identify predictive characteristics related to patients with shoulder pain who have a high-risk of a bad prognosis (lowest functional recovery compared with visit utilization) as well as those who are at low-risk of a bad prognosis (highest functional recovery compared with visit utilization). Methods We completed a secondary analysis of a retrospective cohort using data obtained from an existing commercial outcomes database. Data from 5214 patients with shoulder pain were analysed to determine predictive characteristics that identify patients who either have a low-risk or a high-risk of a bad prognosis to physical therapy care. Multinomial regression was used to identify significant patient characteristics predictive of treatment response. Results Statistically significant predictors of high-risk categorization included older age, no surgical history, insurance designated as worker's compensation, litigation or automotive and three or more co-morbidities. Predictors of low risk categorization were younger age, shorter duration of symptoms, no surgical history and payer type. Conclusion Selected variables were associated with both poor and good recovery. Further research on prognosis, efficacy of physical therapy care and cost appear warranted for patients with shoulder pain.

Introduction Scapulothoracic muscle weakness has been associated with neck pain (NP). Little evidence exists regarding lower trapezius (LT), middle trapezius (MT) and serratus anterior (SA) strength in this population. LT strength changes have been observed following thoracic manipulation in healthy subjects. The purpose of the present study was to examine scapulothoracic strength changes following cervical manipulation in subjects with NP. Methods Twenty-two subjects with NP and 17 asymptomatic control (AC) subjects underwent strength testing of the LT, MT and SA using a hand-held dynamometer. Subjects with NP were treated with passive intervertebral neck manipulation and neck range of motion exercises. The AC group received no intervention. Strength testing was repeated after manipulation, then 48 and 96 hours later. Change scores were calculated for strength over time. Paired t-tests were done for strength change between painful and non-painful sides in the NP group. Independent t-tests were done for strength change between the NP group and AC group. Results There was no significant difference between groups for age, gender, hand dominance or body mass index. Mean (standard deviation) symptom duration for subjects in the NP group was 43.27 (62.71) months. There was no significant difference in strength change over time between painful and non-painful sides in the NP group for any muscle; however, there was a significant difference in strength change over time between those in the NP group and AC group for the LT (p

Objectives Our objective was to analyze the collective effect of social determinants of health (SDoH) on lumbar spine surgery outcomes utilizing two different statistical methods of combining variables. Methods This observational study analyzed data from the Quality Outcomes Database, a nationwide United States spine registry. Race/ethnicity, educational attainment, employment status, insurance payer, and gender were predictors of interest. We built two models to assess the collective influence of SDoH on outcomes following lumbar spine surgery—a stepwise model using each number of SDoH conditions present (0 of 5, 1 of 5, 2 of 5, etc) and a clustered subgroup model. Logistic regression analyses adjusted for age, multimorbidity, surgical indication, type of lumbar spine surgery, and surgical approach were performed to identify the odds of failing to demonstrate clinically meaningful improvements in disability, back pain, leg pain, quality of life, and patient satisfaction at 3- and 12-months following lumbar spine surgery. Results Stepwise modeling outperformed individual SDoH when 4 of 5 SDoH were present. Cluster modeling revealed 4 distinct subgroups. Disparities between the younger, minority, lower socioeconomic status and the younger, white, higher socioeconomic status subgroups were substantially wider compared to individual SDoH. Discussion Collective and cluster modeling of SDoH better predicted failure to demonstrate clinically meaningful improvements than individual SDoH in this cohort. Viewing social factors in aggregate rather than individually may offer more precise estimates of the impact of SDoH on outcomes.

ObjectivesWe aimed to identify the rate of seven comorbidities (mental health disorders, chronic pain, substance abuse disorders, cardiovascular disorders, metabolic syndrome, systemic arthropathy and sleep disorders) that occurred within 2 years after hip arthroscopy.MethodsData from individuals (ages 18–50 years) undergoing arthroscopic hip surgery between 2004 and 2013 were collected from the Military Health System (MHS) Data Repository (MDR). The MDR captures all healthcare encounters in all settings and locations for individuals within the MHS. Person-level data over 36 months were pulled and aggregated. Seven comorbidities related to poor outcomes from musculoskeletal disorders (mental health disorders, chronic pain, substance abuse disorders, cardiovascular disorders, metabolic syndrome, systemic arthropathy and sleep disorders) were examined 12 months prior and 24 months after surgery. Changes in frequencies were calculated as were differences in proportions between presurgery and postsurgery.Results1870 subjects were identified (mean age 32.24 years; 55.5% men) and analysed. There were statistically significant increases (pConclusionsMajor (potentially ‘hidden’) clinical comorbidities increased substantially after elective arthroscopic hip surgery when compared with preoperative status. These comorbidities appear to have been overlooked in major studies evaluating the benefits and risks of arthroscopic hip surgery.Level of evidencePrognostic, level III.

Introduction As patient-reported outcome measures (PROMs) continue to evolve as vital measures of patient status, it may be useful to identify efficiently, Single Assessment Numeric Evaluation (SANE) scores that are valid and related to the patient's specific functional needs. Objective To evaluate the concurrent validity between SANE scores and commonly used body region-specific functional PROMs, functional percentage change scores, and total visits in patients with musculoskeletal (MSK) disorders. Methods 479 patients completed the SANE and one of the following PROMs at physical therapy discharge: Modified Low Back Pain Disability Questionnaire [MDQ], Neck Disability Index [NDI], Penn Shoulder Score [PSS], International Knee Documentation Committee [IKDC], Lower Extremity Functional Scale [LEFS]. Pearson correlation coefficients were used to assess the relationship between SANE and the aforementioned outcomes and total visits. Results The SANE was moderately negatively correlated with the MDQ and NDI at discharge. There were high positive correlations between SANE and PSS and IKDC and moderate positive correlation between SANE and LEFS. The SANE and MDQ and IKDQ demonstrated low positive correlation for functional percentage change scores, and the SANE and NDI demonstrated moderate positive correlation for functional percentage change scores. For total visits outcome, there was a negligible negative correlation between SANE and MDQ and NDI at discharge. Conclusion The SANE exhibits acceptable concurrent validity across all investigated PROMs at physical therapy discharge. However, inconsistent relationships across body regions for functional percentage change and total visits suggest differences in these values as compared to raw discharge scores.

BACKGROUND: Recent clinical practice guidelines have suggested conservative treatment approaches, including physical therapy, are indicated as first-line treatment for patients with low back pain (LBP); however, LBP continues to be managed with opioids, despite decreases in function, morbidity, and insignificant improvements in pain. OBJECTIVE: The primary purpose was to compare characteristics and downstream medication use between patients with LBP with prior opioid exposure vs. those who were opioid-naïve. The secondary purpose was to explore the role of prior opioid use by LBP disability. METHODS: Seven hundred and nine participants in a LBP self-management class were evaluated utilizing self-report data at baseline and longitudinal claims data from the Military Health System Data Repository. Participants were dichotomized into opioid-naïve and prior opioid use groups and then further divided into low and high disability groups based on Oswestry Disability Index (ODI) scores. Patient characteristics, comorbidities, and medication use were compared between groups. RESULTS: Prior opioid users had significantly higher baseline ODI and Fear Avoidance Beliefs Questionnaire physical activity subscale and work subscale scores as well as pre-index instances of mental health disorders, chronic pain, and insomnia than opioid-naïve individuals. Prior opioid users filled significantly more pain medication prescriptions in the year after the index date than did opioid-naïve individuals. Prior opioid users were significantly more likely to be taking opioids at 1 year after the index date, regardless of disability level. CONCLUSION: In patients presenting with LBP, prior opioid exposure appears to be related to increased analgesic use (opioid and non-opioid) and longitudinal analgesic utilization at 1 year after the index date.

Background The global burden of low back pain is growing rapidly, accompanied by increasing rates of associated healthcare utilization. Health seeking behavior (HSB) has been suggested as a mediator of healthcare utilization. The aims of this study were to: 1) develop a proxy HSB measure based on healthcare consumption patterns prior to initial consultation for spinal pain, and 2) examine associations between the proxy HSB measure and future healthcare utilization in a population of patients with spine disorders. Methods A cohort of 1,691 patients seeking care for spinal pain at a single military hospital were included. Cluster analyses were performed for the identification of a proxy HSB measure. Logistic regression was used to identify the predictive capacity of HSB on eight different general and spine-related high healthcare utilization (upper 25%) outcomes variables. Results The strongest proxy measure of HSB was prior primary care provider visits. In unadjusted models, HSB predicted healthcare utilization across all eight general and spine-related outcome variables. After adjusting for covariates, HSB still predicted general and spine-related healthcare utilization for most variables including total medical visits (OR = 2.48, 95%CI 1.09,3.11), total medical costs (OR = 2.72, 95%CI 2.16,3.41), and low back pain-specific costs (OR = 1.31, 95%CI 1.00,1.70). Conclusion Health seeking behavior prior to initial consultation for spine pain was related to healthcare utilization after consultation for spine pain. HSB may be an important variable to consider when developing an individualized care plan and considering the prognosis of a patient.

Aims To explore the ability of a physiotherapist, using a standardised musculoskeletal physiotherapy assessment protocol, to accurately identify the structures potentially responsible for shoulder symptoms against a standardised arthroscopic shoulder diagnostic assessment, and to determine the physiotherapists' ability to influence post-test diagnostic accuracy. Study design Consecutive case-based cohort study. Subject selection All participants were selected by two orthopaedic surgeons for arthroscopic investigation during a 6-month period. Setting Private orthopaedic clinic. Method All consenting participants selected for arthroscopic investigation were examined by the physiotherapist prior to arthroscopy. Presence and priority of impairments/diagnoses were recorded on a standardised form. Inter and intra-rater reliability and diagnostic accuracy were tabulated. Statistical analysis Proportional agreement on diagnostic incidence (broad) and priority (strict) using 2×2 contingency tables for sensitivity, specificity, positive and negative predictive value and positive and negative likelihood ratios were calculated. Post-test probabilities were analysed to determine the influence of a positive or a negative finding. Results 211 participants, aged 14-79 years were included. Overall prevalence of subacromial pathology was (77%) and, disorders of the passive restraints (29%). For both negative and positive findings, post-test probabilities were not notably altered; although positive findings yielded greater value in the decision-making modelling. The physiotherapist's ability to identify individual pathology (eg, tendon rupture vs tendinopathy, capsular vs labral) was lower than recognition of pathology within the broader diagnostic category. Conclusions The physiotherapist's ability to diagnose individual pathologies was inconsistent. Indirectly, this raises the issue of whether signs and symptoms identified under arthroscopic surgery are reflective of a lesion/pathology reflective of a specific tissue.' Refereed/Peer-reviewed

Objective To review the quality of literature and measurement properties of physical performance tests (PPTs) of the lower extremity in athletes. Methods Using the PICOS method we established our research question as to whether individual PPTs of the lower extremity have any relationship to injury in competitive athletes ages 12 years to adult (no limit). A search strategy was constructed by combining the terms ‘lower extremity’ and synonyms for ‘performance test’ and names of performance tests with variants of the term ‘athlete’. After examining the knee in part 1 of this 2 part series, the current report focuses on findings in the rest of the lower extremity. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed and the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) checklist was used to critique the methodological quality of each paper. A second measure was used to analyse the quality of the measurement properties of each test. Results Thirty-one articles examined the measurement properties of 14 PPTs pertaining to the lower extremity. The terminology used to name and describe the tests and methodology by which the tests were conducted was inconsistent. The star excursion balance test performed in three directions (anterior, posteromedial, and posterolateral) appears to be the only test to be associated with increased injury risk. There is moderate evidence that the one leg hop for distance and the hexagon hop can distinguish between normal and unstable ankles. There is also moderate evidence that the medial hop can distinguish between painful and normal hips in dancers. Conclusions Currently, there is relatively limited research-backed information on PPTs of the lower extremity in athletes. We would suggest convening an international consortium comprised of experts in sports to standardise the descriptions and methodologies, and to set forth a research agenda to establish definitively the measurement properties of the most common PPTs.

Background Dizziness is commonly reported after concussion. With the forces experienced at the time of the injury, several anatomical locations may have been altered, causing dizziness. Objective Describe an objective examination and the types of impairment/dysfunction implicated by the results of clinical examination tests in subjects with dizziness after a concussion. Design Cross-Sectional. Methods Athletes between ages 10–23 were enrolled with a diagnosis of concussion. An examination was completed to identify areas potentially contributing to dizziness, including tests of oculomotor control, the vestibular system, neuromotor control, and musculoskeletal components of the cervical spine. Descriptive analyses were completed to define the anatomical areas/types of dysfunction identified by positive findings of the examination tests. Results All (n = 41; 100%) subjects had examination findings consistent with central dysfunction. Of these, 36 (97.8%) had oculomotor control deficits; 29 (70.7%) demonstrated motion sensitivity; and 6 (15%) had central vestibular deficits. Nineteen (46.3%) had peripheral dysfunction, including 18 (43.9%) with unilateral hypofunction, and 2 (4.9%) with Benign Paroxysmal Positional Vertigo. Thirty-four (82.9%) had cervical dysfunction, with 11 (26.8%) presenting with cervicogenic dizziness, and 31 (75.6%) with altered neuromotor control. Conclusions Functional injury to centrally-mediated pathways, specifically oculomotor control, and afferent and efferent pathways in the cervical spine are commonly identified through clinical examination tests in individuals with a complaint of dizziness post-concussion. According to results presented here, a high majority (90%) of the participants demonstrated dizziness that appeared to be multifactorial in nature and was not attributable to one main type of dysfunction. The common pathways between the systems make it difficult to isolate only one anatomical area as a contributor to dizziness.

Background Physical therapy and opioid prescriptions are common after hip surgery, but are sometimes delayed or not used. Objective The objective of this study was to compare downstream health care utilization and opioid use following hip surgery for different patterns of physical therapy and prescription opioids. Design The design of this study was an observational cohort. Methods Health care utilization was abstracted from the Military Health System Data Repository for patients who were 18 to 50 years old and were undergoing arthroscopic hip surgery between 2004 and 2013. Patients were grouped into those receiving an isolated treatment (only opioids or only physical therapy) and those receiving both treatments on the basis of timing (opioid first or physical therapy first). Outcomes included overall health care visits and costs, hip-related visits and costs, additional surgeries, and opioid prescriptions. Results Of 1870 total patients, 82.7% (n = 1546) received physical therapy only, 71.6% (n = 1339) received prescription opioids, and 1073 (56.1%) received both physical therapy and opioids. Because 24 patients received both opioids and physical therapy on the same day, they were eventually removed the final timing-of-care analysis. Adjusted hip–related mean costs were the same in both groups receiving isolated treatments (${\$}$11,628 vs ${\$}$11,579), but the group receiving only physical therapy had significantly lower overall total health care mean costs (${\$}$18,185 vs ${\$}$23,842) and fewer patients requiring another hip surgery. For patients receiving both treatments, mean hip-related downstream costs were significantly higher in the group receiving opioids first than in the group receiving physical therapy first (${\$}$18,806 vs ${\$}$16,955) and resulted in greater opioid use (7.83 vs 4.14 prescriptions), greater total days’ supply of opioids (90.17 vs 44.30 days), and a higher percentage of patients with chronic opioid use (69.5% vs 53.2%). Limitations Claims data were limited by the accuracy of coding, and observational data limit inferences of causality. Conclusions Physical therapy first was associated with lower hip-related downstream costs and lower opioid use than opioids first; physical therapy instead of opioids was associated with less total downstream health care utilization. These results need to be validated in prospective controlled trials.

Background context Great effort has been made toward limiting low back pain (LBP). Recent focus has included factors involved with secondary and tertiary prevention, with less attention given to primary prevention. Purpose This review provided a current estimate of the incidence of LBP and risk factors associated with either first-time LBP or transition to LBP from a baseline of a pain-free state. Study design A systematic review and meta-analyses were performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Patient sample Studies included subjects aged 18 years or older, from longitudinal, observational, cohort designs that included baseline risk factors to an outcome of either first-time LBP or transition to LBP from a baseline of a pain-free state. Outcome measures Risk factors and incidence rates were reported using descriptive analysis and the PRISMA guidelines. Methods Electronic search strategies in PubMed, CINAHL/SPORTDiscus, and Cochrane Central Register of Controlled Trials were combined with a hand search to identify articles for inclusion. Studies were classified based on the population studied (community vs. occupational based) and type of LBP outcome (first ever vs. transition from a baseline pain-free state). Results A total of 41 studies were included for review. Meta-analytical incidence rates for first-time LBP and transition to pain from a pain-free state were similar (∼25%), regardless of community or occupational populations. Risk factors for first-time LBP or transition to LBP from a baseline of a pain-free state were psychosocial and physically related. No consistent risk factor emerged as predictive of first-time LBP, although prior LBP was a consistent predictor of future incident LBP. Significant heterogeneity was found across studies in most models, which limits these findings. Conclusions The results of this study suggest that incidence of LBP is similar in community and occupational settings regardless of LBP definition. There were multiple diverse physical and psychosocial risk factors for first-time LBP. A history of LBP was the most consistent risk factor for transition to LBP from a baseline of a pain-free state.

Background Numerous clinical practice guidelines (CPGs) have been developed to assist clinicians in care options for low back pain (LBP). Knowledge of CPGs has been marginal across health-related professions. Objective The aims of this study were: (1) to measure US-based physical therapists' knowledge of care recommendations associated with multidisciplinary LBP CPGs and (2) to determine which characteristics were associated with more correct responses. Design A cross-sectional survey was conducted. Methods Consenting participants attending manual therapy education seminars read a clinical vignette describing a patient with LBP and were asked clinical decision-making questions regarding care, education, and potential referral. Descriptive statistics illustrating response accuracy and binary logistic regression determined adjusted associations between predictor variables and appropriate decisions. Results A total of 1,144 of 3,932 surveys were eligible for analysis. Correct responses were 55.9% for imaging, 54.7% for appropriate medication, 62.0% for advice to stay active, 92.7% for appropriate referral with failed care, and 16.6% for correctly answering all 4 questions. After adjustment, practicing in an outpatient facility was significantly associated with a correct decision on imaging. Female participants were more likely than male participants to correctly select proper medications, refer the patient to another health care professional when appropriate, and answer all 4 questions correctly. Participants reporting caseloads of greater than 50% of patients with LBP were more likely to select proper medications, give advice to stay active, and answer all 4 questions correctly. Participants attending more continuing education were more likely to give advice to stay active and older, and more experienced participants were more likely to appropriately refer after failed care. Limitations There was potential selection bias, which limits generalizability. Conclusions The survey identified varied understanding of CPGs when making decisions that were similar in recommendation to the CPGs. No single predictor for correct responses for LBP CPGs was found.

Shoulder impingement syndrome (SIS) is a complex, multi-factorial problem that is treated with a variety of different conservative options. One conservative option that has shown effectiveness is manual therapy to the thoracic spine. Another option, manual therapy to the cervical spine, has been studied only once with good results, evaluating short-term outcomes, in a small sample size. The purpose of this study was to investigate the benefit of neck manual therapy for patients with SIS. The study was a randomised, single blinded, clinical trial where both groups received pragmatic, evidence-based treatment to the shoulder and one group received neck manual therapy. Subjects with neck pain were excluded from the study. Comparative pain, disability, rate of recovery and patient acceptable symptom state (PASS) measures were analyzed on the 68 subjects seen over an average of 56.1 days (standard deviation (SD) = 55.4). Eighty-six percent of the sample reported an acceptable change on the PASS at discharge. There were no between-groups differences in those who did or did not receive neck manual therapy; however, both groups demonstrated significant within-groups improvements. On average both groups improved 59.7% (SD = 25.1) for pain and 53.5% (SD = 40.2) for the Quick Disabilities of the Shoulder and Hand Questionnaire (QuickDASH) from baseline. This study found no value when neck manual therapy was added to the treatment of SIS. Reasons may include the lack of therapeutic dosage provided for the manual therapy approach or the lack of benefit to treating the neck in subjects with SIS who do not have concomitant neck problems.

Determine which examination findings are key clinical descriptors of femoroacetabular impingement syndrome (FAIS) through use of an international, multi-disciplinary expert panel. A three-round Delphi survey utilizing an international, multi-disciplinary expert panel operationally defined from international publications and presentations was utilized. All six domains (subjective examination, patient-reported outcome measures, physical examination, special tests, physical performance measures, and diagnostic imaging) had at least one descriptor with 75% consensus agreement for diagnosis and assessment of FAIS. Diagnostic imaging was the domain with the highest level of agreement. Domains such as patient-reported outcome measures (PRO’s) and physical examination were identified as non-diagnostic measures (rather as assessments of disease impact). Although it also had the greatest level of variability in description of examination domains, diagnostic imaging continues to be the preeminent diagnostic measure for FAIS. No single domain should be utilized as the sole diagnostic or assessment parameter for FAIS. While not all investigated domains provide diagnostic capability for FAIS, those that do not are able to serve purpose as a measure of disease impact (e.g., impairments and activity limitations). The clinical relevance of this Delphi survey is the understanding that a comprehensive assessment measuring both diagnostic capability and disease impact most accurately reflects the patient with FAIS. V.

Physical therapist program level successes have been associated with cognitive and noncognitive predictors. To our knowledge, no studies in physical therapy have explored predictive criteria for positive professional performance (PPP) in one's career beyond an educational program. The two-fold purpose of this study was to analyze what traits were key indicators of PPP beyond one's academic preparation, with secondary goal to determine whether traits related to PPP could be mediated by academic preparation.A three-round Delphi survey targeted expert academicians with a specialization in programmatic performance and student success.Twenty-one Delphi respondents completed all survey rounds; identifying and determining consensus on traits associated with PPP. Respondents determined whether the traits could be influenced by programmatic training. The majority of traits identified with PPP were noncognitive and over half were considered modifiable through academic training. Traits such as critical thinking, promoting and engaging in an active learning process, ethical practice, good communication skills, conveying professionalism, and responsibility for one's own actions scored the highest in the survey.Findings may serve to benefit curricular designs of academic health professional programs to improve both programmatic and post-academic success.

To determine patient acceptable symptom state (PASS) estimates in outcome measures commonly used in hip osteoarthritis (OA). Identification of cut-points on commonly used outcome measures associated with patient satisfaction with their current state of health. As part of a randomized controlled trial, 70 patients with a clinical diagnosis of hip OA undergoing a 9-session physiotherapy treatment program completed four physical performance measures and three self-report measures at 9 weeks and 1 year. Upon completion of treatment, patients assessed their current health status according to the PASS question. Cut-points were estimated using receiver operating characteristic curves (anchor-based method), based on the patient's response to the PASS question. At 9 weeks and 1 year, identified cut-points were, respectively, ≤10 and ≤11 for the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain subscale; ≤35 and ≤40 on the WOMAC physical function subscale; ≥+5 and ≥+6 on the global rating of change score; ≤6.05 and ≤5.30 s for the timed-up-and-go; ≤28.3 and ≤24.9 for the 40-m self-paced walk test; ≥11 and ≥12 repetitions for the 30-s chair stand test; and ≥46 repetitions for the 20-cm step test. Initial target cut-points signaling patient satisfaction with their current symptom state following physiotherapy in patients with hip osteoarthritis were determined for seven outcome measures over 1 year.

The purpose of the study was to compare the effects of thrust manipulation (TM) and non-TM (NTM) on a sample of older subjects with low back pain.This is a secondary data analysis of a randomized control trial. Forty-nine subjects aged 55 to 88 years participated in the trial, who received either a TM or NTM on at least 2 occasions during the course of care, and were extracted from the larger data set. The treatment program included a standardized home exercise program for the first 2 sessions, which could be modified by the therapist after those 2 sessions. Numeric pain rating scale and Oswestry Disability Index (ODI) were the outcomes for this study.Multivariate analysis revealed no significant between-group differences for treatment group (P=.99) without group×time interaction (P=.90). Significant within-group changes were observed for both groups for ODI and numeric pain rating scale (P.001); the average self-report of recovery was 78.0% (SD, 19.8%). Age stratification of the older subset revealed between-group differences in ODI change scores for the oldest subjects (70 years) compared with 60 to 69 years (P=.02).This study showed that outcomes for both TM and NTM improved in older adults with low back pain.

Rationale The benefits of providing manual therapy and exercise targeting the hips in individuals with mechanical low-back pain (LBP) are not well established. Objectives The objective in this study is to determine whether a formal prescriptive treatment protocol for the hips improves outcomes in patients with a primary complaint of mechanical LBP. Methods Eighty-four (84) subjects (50 males, 46.1 ± 16.2 years) were randomized to 1 of 2 groups: pragmatic treatment of the lumbar spine only (LBP) (n = 39) or pragmatic treatment of the lumbar spine and prescriptive treatment of bilateral hips (LBP + HIP) (n = 45). Pragmatic treatment of the lumbar spine was based upon published clinical guidelines. Prescriptive treatment of the hips involved the use of 3 hip exercises targeting the gluteal musculature and 3 mobilization techniques targeting the hips. Subjects were assessed at baseline, 2 weeks, and at discharge with the following measures: Modified Oswestry Disability Index, Numeric Pain Rating Scale, a global rating of change (GRoC) score, the patient acceptable symptom state (PASS), and patient satisfaction. Results At 2 weeks, significant differences between groups differences were found in GRoC and patient satisfaction (P

STUDY DESIGN: Retrospective cohort study using data from the Nationwide Inpatient Sample administrative data from 1988 through 2003. OBJECTIVE: To examine perioperative morbidity and mortality for patients with and without diabetes mellitus following lumbar spinal fusion. SUMMARY OF BACKGROUND DATA: Diabetes has been associated with worse outcomes in a variety of orthopedic procedures including spinal surgery. There is limited evidence that diabetic patients have more complications following lumbar fusion with little published data to support this conclusion. METHODS: Data from 197,461 patients who underwent lumbar fusion were included. Over 11,000 patients (5.6%) with a postoperative diagnosis of diabetes mellitus were identified. Selected variables were used for comparison of patients with and without diabetes. Bivariate statistical analyses compared postoperative complication rates while multivariate statistics were used to determine likelihood of complications with diabetes. RESULTS: Bivariate analysis demonstrated that diabetes was significantly associated with postoperative infection, need for transfusion, pneumonia, in-hospital mortality, and nonroutine discharge (P

Randomized controlled trial.Several studies that have investigated the effects of a therapist-selected versus a randomly assigned segmental approach have looked at immediate effects only for pain-related outcomes.To examine differences in outcomes following a therapist-selected nonthrust manipulation versus a prescriptively selected nonthrust manipulation in subjects with low back pain.Subjects with mechanically producible low back pain were randomly treated with nonthrust manipulation in a therapist-selected approach or a prescriptively selected approach. All subjects received a standardized home exercise program. Outcome measures included pain, disability, global rating of change, and patient acceptable symptom state. Analyses of covariance, chi-square tests, and Mann-Whitney U tests were used to determine differences between groups.Sixty-three subjects were tracked for 6 months, during which subjects in both groups significantly improved. There were no differences between groups in pain, disability, or patient acceptable symptom state scores at 6 months. There was a significant difference in global rating of change scores favoring the therapist-selected manipulation group at 6 months.This study measured long-term differences between a prescriptively selected nonthrust manipulation and a therapist-selected approach to nonthrust manipulation. In pain, disability, and patient acceptable symptom state there were no differences in outcomes, findings similar to studies of immediate effects. After 6 months, perceived well-being was significantly higher for those in the therapist-selected treatment group. The study was registered at ClinicalTrials.gov (NCT01940744).Therapy, level 1b.

The purposes of the study were to determine whether the combined occurrence of within/between-session changes were significantly associated with functional outcomes, pain, and self-report of recovery in patients at discharge who were treated with manual therapy for low back pain. A secondary purpose was to determine the extent of change needed for the within/between-session change with association to function. The study involved 100 subjects who were part of a randomized controlled trial that examined manual therapy techniques who demonstrated a positive response to manual therapy during the initial assessment. Within- and between-session findings (within/between session) were defined as a change in pain report from baseline to after the second physiotherapy visit. Within/between-session changes were analyzed for associations between pain change scores at discharge, rate of recovery, and a 50% reduction of the Oswestry disability index (ODI) by discharge. The results suggest there is a significant association between a within/between-session change after the second physiotherapy visit and discharge outcomes for pain and ODI in this sample of patients who received a manual therapy intervention. A 2-point change or greater on an 11-point scale is associated with functional recovery at discharge and accurately described the outcome in 67% of the cases. This is the first study that has shown an association of within/between-session changes with disability scores at discharge and is the first to define the extent of change necessary for prognosis of an outcome. A within/between-session change should be considered as a complimentary artifact along with other examination findings during clinical decision making.

Background The purpose of this study was to prospectively evaluate the accuracy of three different approaches used for glenohumeral injections. In addition, the accuracy of the injection was compared to the experience and confidence of the provider. Methods One-hundred six consecutive patients with shoulder pain underwent attempted intra-articular injection either posteriorly, supraclavicularly, or anteriorly. Each approach was performed by an experienced and inexperienced provider. A musculoskeletal radiologist blinded to technique used and provider interpreted fluroscopic images to determine accuracy. Providers were blinded to these results. Results The accuracy of the anterior approach regardless of experience was 64.7%, the posterior approach was 45.7%, and the supraclavicular approach was 45.5%. With each approach, experience did not provide an advantage. For the anterior approach, the experienced provider was 50% accurate compared to 85.7%. For the posterior approach, the experienced provider had a 42.1% accuracy rate compared to 50%. The experienced provider was accurate 50% of the time in the supraclavicular approach compared to 38.5%. The providers were not able to predict their accuracy regardless of experience. The experienced providers, when compared to those who were less experienced, were more likely to be overconfident, particularly with the anterior and supraclavicular approaches. Conclusion There was no statistically significant difference between the 3 approaches. The anterior approach was the most accurate, independent of the experience level of the provider. The posterior approach produced the lowest level of confidence regardless of experience. The experienced providers were not able to accurately predict the results of their injections, and were more likely to be overconfident with the anterior and supraclavicular approaches.

Background Few studies have investigated or identified common clinical tests and measures as being associated with progression of hip osteoarthritis (OA); fewer still are longitudinal studies exploring prognostic variables associated with long-term outcome following physical therapy treatment. Objective The purpose of this study was to determine a set of prognostic factors that maximize the accuracy of identifying patients with hip osteoarthritis (OA) likely to demonstrate a favorable response to physical therapy intervention. Design This was a prognostic study. Methods Ninety-one patients with a clinical diagnosis of hip OA were analyzed to determine which clinical measures, when clustered together, were most predictive of a favorable response to physical therapy intervention. Responders were determined based on OMERACT-OARSI response criteria, which included percent and absolute changes in pain, function, and global rating of change over 1 year. These data served as the reference standard for determining the predictive validity of baseline clinical examination variables. Using multivariate regression analyses and calculations for sensitivity, specificity, and positive and negative likelihood ratios, a cluster was identified. Results Five baseline variables (unilateral hip pain, age of ≤58 years, pain of ≥6/10 on a numeric pain rating scale, 40-m self-paced walk test time of ≤25.9 seconds, and duration of symptoms of ≤1 year) were retained in the final model. Failure to exhibit a condition of 1 of the 5 predictor variables decreased the posttest probability of responding favorably to physical therapy intervention from 32% to

To compare femoral cross-pin guidewire insertion at differing angles to identify "safe zones" relative to saphenous nerve, popliteus tendon, fibular collateral ligament, peroneal nerve, and femoral artery/vein locations between transtibial and medial-portal femoral tunnel drilling methods.Five paired cadaveric knees were randomly assigned to a transtibial or medial-portal femoral (anatomic) tunnel drilling group. Guidewires were inserted at differing frontal plane angles (+10°, 0°, -10°, and -20°). Distances between the guidewire and the anatomic structure of interest were measured with an electronic caliper.Two-way analysis of variance showed that guidewire angle, not tunnel drilling method, created significant differences between guidewire-saphenous nerve (P.001) and guidewire-femoral artery/vein (P.001) distances. The +10° angle showed a shorter guidewire-saphenous nerve distance than the 0°, -10°, and -20° angles. The +10° angle also showed a shorter guidewire-femoral artery/vein distance than the -10° and -20° angles, and the 0° insertion angle created a shorter guidewire-femoral artery/vein distance than the -10° and -20° angles. Fisher exact tests showed that guidewires inserted at a +10° angle showed a greater incidence of safe-zone violations for the saphenous nerve (P = .04) and femoral artery/vein (P.0001).Insertion angle, not tunnel drilling method, influenced saphenous nerve and femoral artery/vein injury risk. At the +10° angle, the saphenous nerve and femoral artery/vein are at greater risk for surgically induced injury. Guidewire insertion at -10° or -20° angles should increase concerns about potential popliteus tendon and fibular collateral ligament injury.Insertion angle, not tunnel drilling method, influenced saphenous nerve and femoral artery/vein injury risk.

Objective To analyze the dimensionality of 2 self-report outcome measures (Foot/Ankle Disability Index [FADI] and Short-Form [SF]-36), 3 biomechanical measures (stance and step symmetry measures, gait speed, and step width), 2 physical-performance measures (timed get-up and go [TUG] and 4-square step test [4SST]), and 1 clinician-report outcome measure (American Orthopaedic Foot and Ankle Society [AOFAS] Hindfoot Scale) in a patient population with unilateral ankle arthritis. These measures captured the following functions: mobility and speed, pain and its relationship to function, social integration, and symmetry and efficiency of gait. Design Case series design. Setting Biomechanical research laboratory adjacent to a busy orthopedic clinical practice. Patients Seventy-nine consecutive patients with unilateral traumatic arthritis who were candidates for a total ankle replacement. Methods An exploratory factor analysis with oblimin rotation was performed to determine the dimensions of the physical performance, biomechanical, self-report, and clinician-report measures. Main Outcome Measurements Outcomes measures included the SF-36 and pertinent subscales, gait speed, the 4SST, the TUG, the FADI, the AOFAS Hindfoot Scale, and biomechanical measures of step width, step symmetry, and stance symmetry. Results Four distinct dimensions were captured during factor analysis. Factor 1 included the TUG, gait speed, the 4SST, and step width; factor 2 included the FADI, the SF-36 bodily pain score, and the SF-36 physical function score; factor 3 included the biomechanical scores of stance symmetry ratio and the step symmetry ratio; and factor 4 included SF-36 social functioning and the AOFAS Hindfoot Scale. Conclusions Findings suggest that various outcome measures for the ankle capture different dimensions and should be considered when evaluating the presence of disability or long-term change in outcome.

Wright AA, Cook CE, Baxter GD, Garcia J, Abbott JH. Relationship between the Western Ontario and McMaster Universities Osteoarthritis Index Physical Function Subscale and physical performance measures in patients with hip osteoarthritis. Objective To examine the convergent and factor validity of the Western Ontario and McMaster Universities Osteoarthritis Index physical function subscale (WOMAC-PF) using a battery of physical performance measures (PPMs) in patients with non–end-stage hip osteoarthritis (OA). Design Cross-sectional data. Setting A university physiotherapy research center. Participants Patients with a clinical diagnosis of hip OA (N=93) referred for participation in research. Interventions Not applicable. Main Outcome Measures Factor validity of the WOMAC-PF was evaluated by using confirmatory factor analysis (CFA). Exploratory factor analysis (EFA) was run to determine whether WOMAC-PF and PPMs were capturing separate aspects of physical function. Covariates including pain, depression, Pain Beliefs Screening Instrument, body mass index, hip flexion, use of an assistive device, and lower-extremity strength were included in the EFA as independent variables. Results CFA of the WOMAC-PF yielded a 1-factor solution accounting for 84% of the variance in the data (eigenvalue=11). EFA yielded a 2-factor solution accounting for 68% of the variance in the data. The PPMs and the WOMAC-PF loaded on separate factors. Conclusions We were unable to confirm a 4-factor solution model of the WOMAC-PF as previously reported. This suggests that the WOMAC-PF shows sufficient factor validity in capturing perceived physical function in patients with non–end-stage hip OA but captures a different construct than that of PPMs, confirming the need for both when evaluating functional outcome. Furthermore, we suggest a new standardized battery of physical performance measures to serve as the criterion standard against which self-report measures could be compared.