Search

Objective: The aim of this study was to explore associations between the utilization of active, passive, and manual therapy interventions for low back pain (LBP) with 1-year escalation-of-care events, including opioid prescriptions, spinal injections, specialty care visits, and hospitalizations., Methods: This was a retrospective cohort study of 4827 patients identified via the Military Health System Data Repository who received physical therapist care for LBP in 4 outpatient clinics between January 1, 2015 and January 1, 2018. One-year escalation-of-care events were evaluated based on type of physical therapist interventions (ie, active, passive, or manual therapy) received using adjusted odds ratios., Results: Most patients (89.9%) received active interventions. Patients with 10% higher proportion of visits that included at least 1 passive intervention had a 3% to 6% higher likelihood of 1-year escalation-of-care events. Similarly, with 10% higher proportion of passive to active interventions used during the course of care, there was a 5% to 11% higher likelihood of 1-year escalation-of-care events. When compared to patients who received active interventions only, the likelihood of incurring 1-year escalation-of-care events was 50% to 220% higher for those who received mechanical traction and 2 or more different passive interventions, but lower by 50% for patients who received manual therapy., Conclusion: Greater use of passive interventions for LBP was associated with elevated odds of 1-year escalation-of-care events. In addition, the use of specific passive interventions such as mechanical traction in conjunction with active interventions resulted in suboptimal escalation-of-care events, while the use of manual therapy was associated with more favorable downstream health care outcomes., Impact: Physical therapists should be judicious in the use of passive interventions for the management of LBP as they are associated with greater likelihood of receiving opioid prescriptions, spinal injections, and specialty care visits., (© The Author(s) 2023. Published by Oxford University Press on behalf of the American Physical Therapy Association. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Purpose: Primary care physicians (PCPs) often face a complex intersection of patient expectations, evidence, and policy that influences their care recommendations for acute low back pain (aLBP). The purpose of this study was to elucidate patterns of PCP orders for patients with aLBP, identify the most common patterns, and describe patient clinical and demographic characteristics associated with patterns of aLBP care., Methods: This prospective cohort study included 9574 aLBP patients presenting to 1 of 77 primary care practices in 4 geographic locations in the United States. We performed a cluster analysis of PCP orders extracted from electronic health records within the first 21 days of an initial visit for aLBP., Results: 1401 (15%) patients did not receive a PCP order related to back pain within the first 21 days of their initial visit. These patients predominantly had aLBP without leg pain, less back-related disability, and were at low-risk for persistent disability. Of the remaining 8146 patients, we found 4 distinct order patterns: combined nonpharmacologic and first-line medication (44%); second-line medication (39%); imaging (10%); and specialty referral (7%). Among all patients, 29% received solely 1 order from their PCP. PCPs more often combined different guideline concordant and discordant orders. Patients with higher self-reported disability and psychological distress were more likely to receive guideline discordant care., Conclusion: Guideline discordant orders such as steroids and NSAIDS are often combined with guideline recommended orders such as physical therapy. Further defining patient, clinician, and health care setting characteristics associated with discordant care would inform targeted efforts for deimplementation initiatives., Competing Interests: Conflict of interest: The authors have no conflicts of interest to declare., (© Copyright by the American Board of Family Medicine.)

Objective: Costs associated with low back pain (LBP) continue to rise. Despite numerous clinical practice guidelines, the evaluation and treatments for LBP are variable and largely depend on the individual provider. As yet, little attention has been given to the first choice of provider. Early research indicates that the choice of first provider and the timing of interventions for LBP appear to influence utilization. We sought to examine the association between the first provider seen and health care utilization., Methods: Using 2015-2018 data from a large insurer, this retrospective analysis focused on patients (29,806) seeking care for a new episode of LBP. The study identified the first provider chosen and examined the following year of medical utilization. Cox proportional hazards models were calculated using inverse probability weighting on propensity scores to evaluate the time to event and the relationship to the first choice of provider., Results: The primary outcome was the timing and use of health care resources. Total health care use was lowest in those who first sought care with chiropractic care or physical therapy. Highest health care use was seen in those patients who chose the emergency department., Conclusion: Overall, there appears to be an association between the first choice of provider and future health care use. Chiropractic care and physical therapy provide nonpharmacologic and nonsurgical, guideline-based interventions. The use of physical therapists and chiropractors as entry points into the health system appears related to a decrease in immediate and long-term use of health resources. This study expands the existing body of literature and provides a compelling case for the influence of the first provider on an acute episode of LBP., Impact: The first provider seen for an acute episode of LBP influences immediate treatment decisions, the trajectory of a specific patient episode, and future health care choices in the management of LBP., (© The Author(s) 2023. Published by Oxford University Press on behalf of the American Physical Therapy Association. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

As a member of the Back Pain Consortium (BACPAC), the University of Pittsburgh Mechanistic Research Center's research goal is to phenotype chronic low back pain using biological, biomechanical, and behavioral domains using a prospective, observational cohort study. Data will be collected from 1,000 participants with chronic low back pain according to BACPAC-wide harmonized and study-specific protocols. Participation lasts 12 months with one required in person baseline visit, an optional second in person visit for advanced biomechanical assessment, and electronic follow ups at months 1, 2, 3, 4, 5, 6, 9, and 12 to assess low back pain status and response to prescribed treatments. Behavioral data analysis includes a battery of patient-reported outcomes, social determinants of health, quantitative sensory testing, and physical activity. Biological data analysis includes omics generated from blood, saliva, and spine tissue. Biomechanical data analysis includes a physical examination, lumbopelvic kinematics, and intervertebral kinematics. The statistical analysis includes traditional unsupervised machine learning approaches to categorize participants into groups and determine the variables that differentiate patients. Additional analysis includes the creation of a series of decision rules based on baseline measures and treatment pathways as inputs to predict clinical outcomes. The characteristics identified will contribute to future studies to assist clinicians in designing a personalized, optimal treatment approach for each patient., (© The Author(s) 2023. Published by Oxford University Press on behalf of the American Academy of Pain Medicine.)

Objective: We assessed whether race or ethnicity was associated with the incidence of high-impact chronic low back pain (cLBP) among adults consulting a primary care provider for acute low back pain (aLBP)., Methods: In this secondary analysis of a prospective cohort study, patients with aLBP were identified through screening at seventy-seven primary care practices from four geographic regions. Incidence of high-impact cLBP was defined as the subset of patients with cLBP and at least moderate disability on Oswestry Disability Index [ODI >30]) at 6 months. General linear mixed models provided adjusted estimates of association between race/ethnicity and high-impact cLBP., Results: We identified 9,088 patients with aLBP (81.3% White; 14.3% Black; 4.4% Hispanic). Black/Hispanic patients compared to White patients, were younger and more likely to be female, obese, have Medicaid insurance, worse disability on ODI, and were at higher risk of persistent disability on STarT Back Tool (all P < .0001). At 6 months, more Black and Hispanic patients reported high-impact cLBP (30% and 25%, respectively) compared to White patients (15%, P < .0001, n = 5,035). After adjusting for measured differences in socioeconomic and back-related risk factors, compared to White patients, the increased odds of high-impact cLBP remained statistically significant for Black but not Hispanic patients (adjusted odds ration [aOR] = 1.40, 95% confidence interval [CI]: 1.05-1.87 and aOR = 1.25, 95%CI: 0.83-1.90, respectively)., Conclusions: We observed an increased incidence of high-impact cLBP among Black and Hispanic patients compared to White patients. This disparity was partly explained by racial/ethnic differences in socioeconomic and back-related risk factors. Interventions that target these factors to reduce pain-related disparities should be evaluated., Clinicaltrials.gov Identifier: NCT02647658., (© The Author(s) 2022. Published by Oxford University Press on behalf of the American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Chronic low back pain (cLBP) is widespread, costly, and burdensome to patients and health systems. Little is known about non-pharmacological treatments for the secondary prevention of cLBP. There is some evidence that treatments addressing psychosocial factors in higher risk patients are more effective than usual care. However, most clinical trials on acute and subacute LBP have evaluated interventions irrespective of prognosis., Methods: We have designed a phase 3 randomized trial with a 2 × 2 factorial design. The study is also a Hybrid type 1 trial with focus on intervention effectiveness while simultaneously considering plausible implementation strategies. Adults (n = 1000) with acute/subacute LBP at moderate to high risk of chronicity based on the STarT Back screening tool will be randomized in to 1 of 4 interventions lasting up to 8 weeks: supported self-management (SSM), spinal manipulation therapy (SMT), both SSM and SMT, or medical care. The primary objective is to assess intervention effectiveness; the secondary objective is to assess barriers and facilitators impacting future implementation. Primary effectiveness outcome measures are: (1) average pain intensity over 12 months post-randomization (pain, numerical rating scale); (2) average low back disability over 12 months post-randomization (Roland-Morris Disability Questionnaire); (3) prevention of cLBP that is impactful at 10-12 months follow-up (LBP impact from the PROMIS-29 Profile v2.0). Secondary outcomes include: recovery, PROMIS-29 Profile v2.0 measures to assess pain interference, physical function, anxiety, depression, fatigue, sleep disturbance, and ability to participate in social roles and activities. Other patient-reported measures include LBP frequency, medication use, healthcare utilization, productivity loss, STarT Back screening tool status, patient satisfaction, prevention of chronicity, adverse events, and dissemination measures. Objective measures include the Quebec Task Force Classification, Timed Up & Go Test, the Sit to Stand Test, and the Sock Test assessed by clinicians blinded to the patients' intervention assignment., Discussion: By targeting those subjects at higher risk this trial aims to fill an important gap in the scientific literature regarding the effectiveness of promising non-pharmacological treatments compared to medical care for the management of patients with an acute episode of LBP and the prevention of progression to a severe chronic back problem., Trial Registration: ClinicalTrials.gov Identifier: NCT03581123., (© 2023. The Author(s).)

Abstract: Treatment effect modifiers identify patient characteristics associated with treatment responses. The purpose of this secondary analysis was to identify potential treatment effect modifiers for disability from the TARGET trial that compared usual care (control) with usual care + psychologically informed physical therapy (PIPT). The sample consisted of a STarT Back tool identified high-risk patients with acute low back pain that completed Oswestry Disability Index (ODI) data at index visit and 6 months later (n = 1250). Candidate treatment effect modifiers were identified a priori and informed by the literature. Linear mixed models tested for treatment effect modification through tests of statistical interaction. All statistical interactions ( P ≤ 0.20) were stratified by modifier to inspect for specific effects ( P ≤ 0.05). Smoking was identified as a potential effect modifier (treatment * smoking interaction, P = 0.08). In participants who were smokers, the effect of PIPT was (ODI = 5.5; 95% CI: 0.6-10.4; P = 0.03) compared with usual care. In participants who were nonsmokers, the effect of PIPT was (ODI = 1.5; 95% CI: -1.4 to 4.4; P = 0.31) compared with usual care. Pain medication was also identified as a potential effect modifier (treatment × pain medication interaction, P = 0.10). In participants prescribed ≥3 pain medications, the effect of PIPT was (ODI = 7.1; 95% CI: -0.1 to 14.2; P = 0.05) compared with usual care. The PIPT effect for participants prescribed no pain medication was (ODI = 3.5; 95% CI: -0.4 to 7.4; P = 0.08) and for participants prescribed 1 to 2 pain medications was (ODI = 0.6; 95% CI: -2.5 to 3.7; P = 0.70) when compared with usual care. These findings may be used for generating hypotheses and planning future clinical trials investigating the effectiveness of tailored application of PIPT., (Copyright © 2022 International Association for the Study of Pain.)

Background Context: Psychological comorbidities are important prognostic factors for low back pain (LBP). To develop improved treatment paradigms, it is first necessary to characterize and determine current patterns of treatment in this population., Purpose: Identify how comorbid depression or anxiety in patients with LBP is related to use of healthcare resources., Study Design/setting: Retrospective cohort study using electronic health records from outpatient offices at a large multisite academic medical center., Patient Sample: Data from 513,088 unique patients seen between January 2010 and July 2020 (58.0% female, 52.6±19.5 years) with a diagnosis of LBP, indicated by predetermined ICD-9 and ICD-10 codes., Outcome Measures: Average self-reported pain scores, absolute differences and unadjusted risk ratios to compare opioid use, emergency department visits, hospitalizations, advanced imaging orders, spinal injections, and back surgeries between cohorts., Methods: Clinical characteristics and data regarding use of healthcare resources were extracted from the electronic health record. Clinical features and patterns in healthcare utilization were determined for patients with depression or anxiety compared to those without., Results: Depression or anxiety was coded for 21.4% of patients at first LBP visit. Those with depression or anxiety were more likely to be on opioids (unadjusted risk ratio: 1.22, CI: [1.22,1.23]), go to the emergency department (1.31 [1.30-1.33]), be hospitalized (1.15 [1.13, 1.17]), receive advanced imaging (1.09 [1.08, 1.11]), receive an epidural steroid injection (1.16 [1.15, 1.18]), and less likely to have back surgery (0.74 [0.72, 0.77]). Differences in pain scores for those with depression/anxiety compared to those without were not clinically significant., Conclusions: Depression/anxiety is associated with increased use of healthcare resources, and is not associated with clinically meaningful elevated pain scores. Limitations come from use of an aggregate data set and reliance on administrative coding., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Purpose: To identify baseline characteristics of adults with chronic low back pain (cLBP) that predict response (i.e., a clinically important improvement) and/or modify treatment effect across three nonpharmacologic interventions., Design: Secondary analysis of a randomized controlled trial., Setting: Academic safety net hospital and seven federally qualified community health centers., Subjects: Adults with cLBP (N = 299)., Methods: We report patient characteristics that were predictors of response and/or modified treatment effect across three 12-week treatments: yoga, physical therapy [PT], and a self-care book. Using preselected characteristics, we used logistic regression to identify predictors of "response," defined as a ≥30% improvement in the Roland Morris Disability Questionnaire. Then, using "response" as our outcome, we identified baseline characteristics that were treatment effect modifiers by testing for statistical interaction (P < 0.05) across two comparisons: 1) yoga-or-PT vs self-care and 2) yoga vs PT., Results: Overall, 39% (116/299) of participants were responders, with more responders in the yoga-or-PT group (42%) than the self-care (23%) group. There was no difference in proportion responding to yoga (48%) vs PT (37%, odds ratio [OR] = 1.5, 95% confidence interval = 0.88 - 2.6). Predictors of response included having more than a high school education, a higher income, employment, few depressive symptoms, lower perceived stress, few work-related fear avoidance beliefs, high pain self-efficacy, and being a nonsmoker. Effect modifiers included use of pain medication and fear avoidance beliefs related to physical activity (both P = 0.02 for interaction). When comparing yoga or PT with self-care, a greater proportion were responders among those using pain meds (OR = 5.3), which differed from those not taking pain meds (OR = 0.94) at baseline. We also found greater treatment response among those with lower (OR = 7.0), but not high (OR = 1.3), fear avoidance beliefs around physical activity., Conclusions: Our findings revealed important subgroups for whom referral to yoga or PT may improve cLBP outcomes., (© The Author(s) 2020. Published by Oxford University Press on behalf of the American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Importance: Acute low back pain (LBP) is highly prevalent, with a presumed favorable prognosis; however, once chronic, LBP becomes a disabling and expensive condition. Acute to chronic LBP transition rates vary widely owing to absence of standardized operational definitions, and it is unknown whether a standardized prognostic tool (ie, Subgroups for Targeted Treatment Back tool [SBT]) can estimate this transition or whether early non-guideline concordant treatment is associated with the transition to chronic LBP., Objective: To assess the associations between the transition from acute to chronic LBP with SBT risk strata; demographic, clinical, and practice characteristics; and guideline nonconcordant processes of care., Design, Setting, and Participants: This inception cohort study was conducted alongside a multisite, pragmatic cluster randomized trial. Adult patients with acute LBP stratified by SBT risk were enrolled in 77 primary care practices in 4 regions across the United States between May 2016 and June 2018 and followed up for 6 months, with final follow-up completed by March 2019. Data analysis was conducted from January to March 2020., Exposures: SBT risk strata and early LBP guideline nonconcordant processes of care (eg, receipt of opioids, imaging, and subspecialty referral)., Main Outcomes and Measures: Transition from acute to chronic LBP at 6 months using the National Institutes of Health Task Force on Research Standards consensus definition of chronic LBP. Patient demographic characteristics, clinical factors, and LBP process of care were obtained via electronic medical records., Results: Overall, 5233 patients with acute LBP (3029 [58%] women; 4353 [83%] White individuals; mean [SD] age 50.6 [16.9] years; 1788 [34%] low risk; 2152 [41%] medium risk; and 1293 [25%] high risk) were included. Overall transition rate to chronic LBP at six months was 32% (1666 patients). In a multivariable model, SBT risk stratum was positively associated with transition to chronic LBP (eg, high-risk vs low-risk groups: adjusted odds ratio [aOR], 2.45; 95% CI, 2.00-2.98; P < .001). Patient and clinical characteristics associated with transition to chronic LBP included obesity (aOR, 1.52; 95% CI, 1.28-1.80; P < .001); smoking (aOR, 1.56; 95% CI, 1.29-1.89; P < .001); severe and very severe baseline disability (aOR, 1.82; 95% CI, 1.48-2.24; P < .001 and aOR, 2.08; 95% CI, 1.60-2.68; P < .001, respectively) and diagnosed depression/anxiety (aOR, 1.66; 95% CI, 1.28-2.15; P < .001). After controlling for all other variables, patients exposed to 1, 2, or 3 nonconcordant processes of care within the first 21 days were 1.39 (95% CI, 1.21-2.32), 1.88 (95% CI, 1.53-2.32), and 2.16 (95% CI, 1.10-4.25) times more likely to develop chronic LBP compared with those with no exposure (P < .001)., Conclusions and Relevance: In this cohort study, the transition rate to chronic LBP was substantial and increased correspondingly with SBT stratum and early exposure to guideline nonconcordant care.

Background: Physical therapy (PT) is frequently used for the management of low back pain (LBP) within the US Departments of Defense (DOD) and Veterans Affairs (VA). However, variations in PT practice patterns and use of ineffective interventions lower the quality and increase the cost of care. Although adherence to the clinical practice guidelines (CPGs) can improve the outcomes and cost-effectiveness of LBP care, PT CPG adherence remains below 50%. The Resolving the Burden of Low Back Pain in Military Service Members and Veterans (RESOLVE) trial will evaluate the effectiveness of an active PT CPG implementation strategy using an education, audit, and feedback model for reducing pain, disability, medication use, and cost of LBP care within the DOD and VA health care systems., Design: The RESOLVE trial will include 3,300 to 7,260 patients with LBP across three DOD and two VA medical facilities using a stepped-wedge study design. An education, audit, and feedback model will be used to encourage physical therapists to better adhere to the PT CPG recommendations. The Oswestry Disability Index and the Defense and Veterans Pain Rating Scale will be used as primary outcomes. Secondary outcomes will include the LBP-related medication use, medical resource utilization, and biopsychosocial predictors of outcomes. Statistical analyses will be based on the intention-to-treat principle and will use linear mixed models to compare treatment conditions and examine the interactions between treatment and subgrouping status (e.g., limb loss)., Summary: The RESOLVE trial will provide a pragmatic approach to evaluate whether better adherence to PT CPGs can reduce pain, disability, medication use, and LBP care cost within the DOD and VA health care systems., (Published by Oxford University Press on behalf of the American Academy of Pain Medicine 2020.This work is written by US Government employees and is in the public domain in the US.)

Background: Although risk-stratifying patients with acute lower back pain is a promising approach for improving long-term outcomes, efforts to implement stratified care in the US healthcare system have had limited success. The objectives of this process evaluation were to 1) examine variation in two essential processes, risk stratification of patients with low back pain and referral of high-risk patients to psychologically informed physical therapy and 2) identify barriers and facilitators related to the risk stratification and referral processes., Methods: We used a sequential mixed methods study design to evaluate implementation of stratified care at 33 primary care clinics (17 intervention, 16 control) participating in a larger pragmatic trial. We used electronic health record data to calculate: 1) clinic-level risk stratification rates (proportion of patients with back pain seen in the clinic over the study period who completed risk stratification questionnaires), 2) rates of risk stratification across different points in the clinical workflow (front desk, rooming, and time with clinician), and 3) rates of referral of high-risk patients to psychologically informed physical therapy among intervention clinics. We purposively sampled 13 clinics for onsite observations, which occurred in month 24 of the 26-month study., Results: The overall risk stratification rate across the 33 clinics was 37.8% (range: 14.7-64.7%). Rates were highest when patients were identified as having back pain by front desk staff (overall: 91.9%, range: 80.6-100%). Rates decreased as the patient moved further into the visit (rooming, 29.3% [range: 0-83.3%]; and time with clinician, 11.3% [range: 0-49.3%]. The overall rate of referrals of high-risk patients to psychologically informed physical therapy across the 17 intervention clinics was 42.1% (range: 8.3-70.8%). Barriers included staffs' knowledge and beliefs about the intervention, patients' needs, technology issues, lack of physician engagement, and lack of time. Adaptability of the processes was a facilitator., Conclusions: Adherence to key stratified care processes varied across primary care clinics and across points in the workflow. The observed variation suggests room for improvement. Future research is needed to build on this work and more rigorously test strategies for implementing stratified care for patients with low back pain in the US healthcare system., Trial Registration: Trial registration: ClinicalTrials.gov ( NCT02647658 ). Registered January 6, 2016.

Background: One proposed mechanism of chronic low back pain might be paraspinal muscle impairment. Commonly, this impairment is treated with stabilization exercises. However, the effect size of stabilization exercises has been previously reported to be small., Design: Randomized controlled trial., Objective: To investigate the clinical benefit of using neuromuscular electrical stimulation as a supplement to stabilization exercises in patients with chronic low back pain., Methods: Thirty participants with chronic low back pain were randomized into a stabilization exercise only group (n=15) or a stabilization exercise plus neuromuscular electrical stimulation group (n=15). The stabilization exercises included abdominal, side support, and quadruped exercises. The neuromuscular electrical stimulation was applied to the lumbar paraspinal muscles for 20min each session. Both groups received their respective interventions twice a week for 6 weeks. Participant eligibility for inclusion was age between 18 and 60 years, body mass index ≤34, chronic low back pain ≥3 months, Numeric Pain Rating Scale ≥3, Modified Oswestry Disability Questionnaire score ≥20 and ability to understand English. Outcome measurements were self-reported neuromuscular electrical stimulation tolerability scale, Modified Oswestry Disability Questionnaire, Numeric Pain Rating Scale, Fear-Avoidance Beliefs Questionnaire and paraspinal muscle strength., Results: The neuromuscular electrical stimulation was reported to be tolerable. There were no significant between-group differences on any of the outcome measures (p>0.05)., Conclusions: The application of neuromuscular electrical stimulation on the paraspinal muscles was reported to be tolerable. Supplementing stabilization exercises with neuromuscular electrical stimulation did not offer any additional clinical benefit for the chronic low back pain patients., (Copyright © 2018 Associação Brasileira de Pesquisa e Pós-Graduação em Fisioterapia. Publicado por Elsevier Editora Ltda. All rights reserved.)

Background: Low back pain (LBP) is one of the most prevalent and potentially disabling conditions for which people seek health care. Patients, providers, and payers agree that greater effort is needed to prevent acute LBP from transitioning to chronic LBP., Methods and Study Design: The TARGET (Targeted Interventions to Prevent Chronic Low Back Pain in High-Risk Patients) Trial is a primary care-based, multisite, cluster randomized, pragmatic trial comparing guideline-based care (GBC) to GBC + referral to Psychologically Informed Physical Therapy (PIPT) for patients presenting with acute LBP and identified as high risk for persistent disabling symptoms. Study sites include primary care clinics within each of five geographical regions in the United States, with clinics randomized to either GBC or GBC + PIPT. Acute LBP patients at all clinics are risk stratified (high, medium, low) using the STarT Back Tool. The primary outcomes are the presence of chronic LBP and LBP-related functional disability determined by the Oswestry Disability Index at 6 months. Secondary outcomes are LBP-related processes of health care and utilization of services over 12 months, determined through electronic medical records. Study enrollment began in May 2016 and concluded in June 2018. The trial was powered to include at least 1860 high-risk patients in the randomized controlled trial cohort. A prospective observational cohort of approximately 6900 low and medium-risk acute LBP patients was enrolled concurrently., Discussion: The TARGET pragmatic trial aims to establish the effectiveness of the stratified approach to acute LBP intervention targeting high-risk patients with GBC and PIPT., Trial Registration: ClinicalTrials.govNCT02647658 Registered Jan. 6, 2016., (Copyright © 2019. Published by Elsevier Inc.)

Background: Low back pain (LBP) is a public health concern because it is highly prevalent and the leading cause of disability worldwide. Psychologically informed physical therapy (PIPT) is a secondary prevention approach that first aims to identify individuals at high risk for transitioning to chronicity and then provides tailored treatment to reduce that risk. Training models that are feasible to implement with acceptable training quality are needed to improve scalability for widespread implementation of PIPT. This manuscript describes the PIPT training program that was developed for training physical therapists providing PIPT in the TARGET trial., Methods: The PIPT training program was developed, tested, and modified using an iterative process. Content development consisted of stakeholder engagement, beta testing, modification of training, and confirmation of final course objectives. Methods of delivery consisted of a website that included brief online educational modules followed by a live 8-h workshop that included video-based mock case scenarios and case-based role playing. Attitudes, beliefs, and confidence in implementing PIPT principles were assessed before and immediately after training to measure training quality and impact., Results: Early stakeholder engagement and beta testing indicated the need for increased emphasis on experiential learning opportunities and patient-centered communication training. Booster training varied extensively across TARGET sites with involvement of 'clinician champions' providing brief follow-up sessions identified as best practice. Favorable post-training changes in physical therapist attitudes and beliefs toward biopsychosocial treatment orientation and increased confidence in implementing PIPT principles were observed., Conclusions: PIPT training for provider participation in the TARGET trial was feasible to deliver. Course content was acceptable to physical therapists and resulted in improved beliefs and confidence in applying PIPT skills during clinical practice. Ongoing consultation and site-based continuing education were methods by which specific TARGET sites maintained or augmented PIPT skill training; however, implementing ongoing training was challenging in general. Due to the pragmatic nature of the TARGET trial, it was not possible to directly measure the effect of PIPT training on treatment fidelity, which was a limitation of our approach., Trial Registration: ClinicalTrials.gov, NCT02647658 . Registered on 6 January 2016.

Objective: The Stand Back study evaluated the feasibility and effects of a multicomponent intervention targeting reduced prolonged sitting and pain self-management in desk workers with chronic low back pain (LBP)., Methods: This randomised controlled trial recruited 27 individuals with chronic LBP, Oswestry Disability Index (ODI) >10% and desk jobs (sitting ≥20 hours/week). Participants were randomised within strata of ODI (>10%-<20%, ≥20%) to receive bimonthly behavioural counselling (in-person and telephone), a sit-stand desk attachment, a wrist-worn activity-prompting device and cognitive behavioural therapy for LBP self-management or control. Self-reported work sitting time, visual analogue scales (VAS) for LBP and the ODI were assessed by monthly, online questionnaires and compared across intervention groups using linear mixed models., Results: Baseline mean (SD) age was 52 (11) years, 78% were women, and ODI was 24.1 (10.5)%. Across the 6-month follow-up in models adjusted for baseline value, work sitting time was 1.5 hour/day (P<0.001) lower comparing intervention to controls. Also across follow-up, ODI was on average 8 points lower in intervention versus control (P=0.001). At 6 months, the relative decrease in ODI from baseline was 50% in intervention and 14% in control (P=0.042). LBP from VAS was not significantly reduced in intervention versus control, though small-to-moderate effect sizes favouring the intervention were observed (Cohen's d ranged from 0.22 to 0.42)., Conclusion: An intervention coupling behavioural counselling targeting reduced sedentary behaviour and pain self-management is a translatable treatment strategy that shows promise for treating chronic LBP in desk-bound employees., Trial Registration Number: NCT0224687; Pre-results., Competing Interests: Competing interests: BBG reports being a Principal Investigator on studies funded by the National Institutes of Health, and the American Heart Association, and the Tomayko Foundation, and a Co-Investigator on studies funded by the Agency for Healthcare and Quality Research and the National Institutes of Health. BBG was also the Principal Investigator of a separate, investigator-initiated study funded by the Humanscale company; Humanscale had no role and provided no funding or supplies to this research. JMJ reports being one the Scientific Advisory Board for Weight Watchers International, a Co-Investigator on a study funded by Weight Watchers International awarded to the University of Pittsburgh, a Co-Investigator on a study funded by Humanscale awarded to the University of Pittsburgh, and a Principal and Co-Investigator on studies funded by the National Institutes of Health awarded to the University of Pittsburgh. JMJ was also a Co-Investigator of a separate, investigator-initiated study funded by the Humanscale company; Humanscale had no role and provided no funding or supplies to this research., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

We present the movement control approach as part of the treatment-based classification system. This approach proposes a movement control schema that clarifies that movement control is a product of the interplay among multiple biopsychosocial components. The schema illustrates that for movement to occur in a dynamically controlled fashion, the lumbar spine requires both local mobility and global stability. Local mobility means that the lumbar spine and its adjacent regions possess adequate nerve and joint(s) mobility and soft tissue compliance (ie, the malleability of tissue to undergo elastic deformation). Global stability means that the muscles of the lumbar spine and its adjacent regions can generate activation that is coordinated with various joint movements and incorporated into activities of daily living. Local mobility and global stability are housed within the bio-behavioral and socio-occupational factors that should be addressed during movement rehabilitation. This schema is converted into a practical physical examination to help the rehabilitation provider to construct a clinical rationale as to why the movement impairment(s) exist. The examination findings are used to guide treatment. We suggest a treatment prioritization that aims to consecutively address neural sensitivity, joint(s) and soft tissue mobility, motor control, and endurance. This prioritization enables rehabilitation providers to better plan the intervention according to each patient's needs. We emphasize that treatment for patients with low back pain is not a static process. Rather, the treatment is a fluid process that changes as the clinical status of the patient changes. This movement control approach is based on clinical experience and indirect evidence; further research is needed to support its clinical utility.

Background: Yoga is effective for mild to moderate chronic low back pain (cLBP), but its comparative effectiveness with physical therapy (PT) is unknown. Moreover, little is known about yoga's effectiveness in underserved patients with more severe functional disability and pain., Objective: To determine whether yoga is noninferior to PT for cLBP., Design: 12-week, single-blind, 3-group randomized noninferiority trial and subsequent 40-week maintenance phase. (ClinicalTrials.gov: NCT01343927)., Setting: Academic safety-net hospital and 7 affiliated community health centers., Participants: 320 predominantly low-income, racially diverse adults with nonspecific cLBP., Intervention: Participants received 12 weekly yoga classes, 15 PT visits, or an educational book and newsletters. The maintenance phase compared yoga drop-in classes versus home practice and PT booster sessions versus home practice., Measurements: Primary outcomes were back-related function, measured by the Roland Morris Disability Questionnaire (RMDQ), and pain, measured by an 11-point scale, at 12 weeks. Prespecified noninferiority margins were 1.5 (RMDQ) and 1.0 (pain). Secondary outcomes included pain medication use, global improvement, satisfaction with intervention, and health-related quality of life., Results: One-sided 95% lower confidence limits were 0.83 (RMDQ) and 0.97 (pain), demonstrating noninferiority of yoga to PT. However, yoga was not superior to education for either outcome. Yoga and PT were similar for most secondary outcomes. Yoga and PT participants were 21 and 22 percentage points less likely, respectively, than education participants to use pain medication at 12 weeks. Improvements in yoga and PT groups were maintained at 1 year with no differences between maintenance strategies. Frequency of adverse events, mostly mild self-limited joint and back pain, did not differ between the yoga and PT groups., Limitations: Participants were not blinded to treatment assignment. The PT group had disproportionate loss to follow-up., Conclusion: A manualized yoga program for nonspecific cLBP was noninferior to PT for function and pain., Primary Funding Source: National Center for Complementary and Integrative Health of the National Institutes of Health.

The treatment-based classification (TBC) system for the treatment of patients with low back pain (LBP) has been in use by clinicians since 1995. This perspective article describes how the TBC was updated by maintaining its strengths, addressing its limitations, and incorporating recent research developments. The current update of the TBC has 2 levels of triage: (1) the level of the first-contact health care provider and (2) the level of the rehabilitation provider. At the level of first-contact health care provider, the purpose of the triage is to determine whether the patient is an appropriate candidate for rehabilitation, either by ruling out serious pathologies and serious comorbidities or by determining whether the patient is appropriate for self-care management. At the level of the rehabilitation provider, the purpose of the triage is to determine the most appropriate rehabilitation approach given the patient's clinical presentation. Three rehabilitation approaches are described. A symptom modulation approach is described for patients with a recent-new or recurrent-LBP episode that has caused significant symptomatic features. A movement control approach is described for patients with moderate pain and disability status. A function optimization approach is described for patients with low pain and disability status. This perspective article emphasizes that psychological and comorbid status should be assessed and addressed in each patient. This updated TBC is linked to the American Physical Therapy Association's clinical practice guidelines for low back pain., (© 2016 American Physical Therapy Association.)

Background and Purpose: Our nation's suboptimal health care quality and unsustainable costs can be linked to the failure to implement evidence-based interventions. Implementation is the bridge between the decision to adopt a strategy and its sustained use in practice. The purpose of this case report is threefold: (1) to outline the historical implementation of an evidence-based quality improvement project, (2) to describe the program's future direction using a systems perspective to identify implementation barriers, and (3) to provide implications for the profession as it works toward closing the evidence-to-practice gap., Case Description: The University of Pittsburgh Medical Center (UPMC) Centers for Rehab Services is a large, multicenter physical therapy organization. In 2005, they implemented a Low Back Initiative utilizing evidence-based protocols to guide clinical decision making., Outcomes: The initial implementation strategy used a multifaceted approach. Formative evaluations were used repeatedly to identify barriers to implementation. Barriers may exist outside the organization, they can be created internally, they may result from personnel, or they may be a direct function of the research evidence. Since the program launch, 3 distinct improvement cycles have been utilized to address identified implementation barriers., Discussion: Implementation is an iterative process requiring evaluation, measurement, and refinement. During this period, behavior change is actualized as clinicians become increasingly proficient and committed to their use of new evidence. Successfully incorporating evidence into routine practice requires a systems perspective to account for the complexity of the clinical setting. The value the profession provides can be enhanced by improving the implementation of evidence-based strategies. Achieving this outcome will require a concerted effort in all areas of the profession. New skills will be needed by leaders, researchers, managers, and clinicians., (© 2015 American Physical Therapy Association.)

Unlabelled: Despite rapidly increasing intervention, functional disability due to chronic low back pain (cLBP) has increased in recent decades. We often cannot identify mechanisms to explain the major negative impact cLBP has on patients' lives. Such cLBP is often termed non-specific and may be due to multiple biologic and behavioral etiologies. Researchers use varied inclusion criteria, definitions, baseline assessments, and outcome measures, which impede comparisons and consensus. Therefore, NIH Pain Consortium charged a Research Task Force (RTF) to draft standards for research on cLBP. The resulting multidisciplinary panel recommended using 2 questions to define cLBP; classifying cLBP by its impact (defined by pain intensity, pain interference, and physical function); use of a minimum dataset to describe research participants (drawing heavily on the PROMIS methodology); reporting "responder analyses" in addition to mean outcome scores; and suggestions for future research and dissemination. The Pain Consortium has approved the recommendations, which investigators should incorporate into NIH grant proposals. The RTF believes that these recommendations will advance the field, help to resolve controversies, and facilitate future research addressing the genomic, neurologic, and other mechanistic substrates of chronic low back pain. We expect that the RTF recommendations will become a dynamic document and undergo continual improvement., Perspective: A task force was convened by the NIH Pain Consortium with the goal of developing research standards for chronic low back pain. The results included recommendations for definitions, a minimum dataset, reporting outcomes, and future research. Greater consistency in reporting should facilitate comparisons among studies and the development of phenotypes., (© 2014 by the American Pain Society. Reprinted from: Deyo RA, Dworkin SF, Amtmann D, et al. Report of the NIH task force on research standards for chronic low back pain. J Pain. 2014;15(6):569-585, with permission from Elsevier Inc/American Pain Society.)

Unlabelled: Despite rapidly increasing intervention, functional disability due to chronic low back pain (cLBP) has increased in recent decades. We often cannot identify mechanisms to explain the major negative impact cLBP has on patients' lives. Such cLBP is often termed non-specific and may be due to multiple biologic and behavioral etiologies. Researchers use varied inclusion criteria, definitions, baseline assessments, and outcome measures, which impede comparisons and consensus. Therefore, NIH Pain Consortium charged a Research Task Force (RTF) to draft standards for research on cLBP. The resulting multidisciplinary panel recommended using 2 questions to define cLBP; classifying cLBP by its impact (defined by pain intensity, pain interference, and physical function); use of a minimum dataset to describe research participants (drawing heavily on the PROMIS methodology); reporting "responder analyses" in addition to mean outcome scores; and suggestions for future research and dissemination. The Pain Consortium has approved the recommendations, which investigators should incorporate into NIH grant proposals. The RTF believes that these recommendations will advance the field, help to resolve controversies, and facilitate future research addressing the genomic, neurologic, and other mechanistic substrates of chronic low back pain. We expect that the RTF recommendations will become a dynamic document and undergo continual improvement., Perspective: A task force was convened by the NIH Pain Consortium with the goal of developing research standards for chronic low back pain. The results included recommendations for definitions, a minimum dataset, reporting outcomes, and future research. Greater consistency in reporting should facilitate comparisons among studies and the development of phenotypes.

Objectives: Despite rapidly increasing intervention, functional disability due to chronic low back pain (cLBP) has increased in recent decades. We often cannot identify mechanisms to explain the major negative impact cLBP has on patients' lives. Such cLBP is often termed nonspecific and may be due to multiple biologic and behavioral etiologies. Researchers use varied inclusion criteria, definitions, baseline assessments, and outcome measures, which impede comparisons and consensus. The purpose of this article is to disseminate the report of the National Institutes of Health (NIH) task force on research standards for cLBP., Methods: The NIH Pain Consortium charged a research task force (RTF) to draft standards for research on cLBP. The resulting multidisciplinary panel developed a 3-stage process, each with a 2-day meeting., Results: The panel recommended using 2 questions to define cLBP; classifying cLBP by its impact (defined by pain intensity, pain interference, and physical function); use of a minimal data set to describe research subjects (drawing heavily on the Patient Reported Outcomes Measurement Information System methodology); reporting "responder analyses" in addition to mean outcome scores; and suggestions for future research and dissemination. The Pain Consortium has approved these recommendations, which investigators should incorporate into NIH grant proposals., Conclusions: The RTF believes that these recommendations will advance the field, help to resolve controversies, and facilitate future research addressing the genomic, neurologic, and other mechanistic substrates of cLBP. Greater consistency in reporting should facilitate comparisons among studies and the development of phenotypes. We expect the RTF recommendations will become a dynamic document and undergo continual improvement., (Copyright © 2014 National University of Health Sciences. Published by Elsevier Inc. All rights reserved.)

Unlabelled: Despite rapidly increasing intervention, functional disability due to chronic low back pain (cLBP) has increased in recent decades. We often cannot identify mechanisms to explain the major negative impact cLBP has on patients' lives. Such cLBP is often termed non-specific and may be due to multiple biologic and behavioral etiologies. Researchers use varied inclusion criteria, definitions, baseline assessments, and outcome measures, which impede comparisons and consensus. Therefore, NIH Pain Consortium charged a Research Task Force (RTF) to draft standards for research on cLBP. The resulting multidisciplinary panel recommended using 2 questions to define cLBP; classifying cLBP by its impact (defined by pain intensity, pain interference, and physical function); use of a minimum dataset to describe research participants (drawing heavily on the PROMIS methodology); reporting "responder analyses" in addition to mean outcome scores; and suggestions for future research and dissemination. The Pain Consortium has approved the recommendations, which investigators should incorporate into NIH grant proposals. The RTF believes that these recommendations will advance the field, help to resolve controversies, and facilitate future research addressing the genomic, neurologic, and other mechanistic substrates of chronic low back pain. We expect that the RTF recommendations will become a dynamic document and undergo continual improvement., Perspective: A task force was convened by the NIH Pain Consortium with the goal of developing research standards for chronic low back pain. The results included recommendations for definitions, a minimum dataset, reporting outcomes, and future research. Greater consistency in reporting should facilitate comparisons among studies and the development of phenotypes., (Copyright © 2014 American Pain Society. Published by Elsevier Inc. All rights reserved.)

Background: Chronic low back pain causes substantial morbidity and cost to society while disproportionately impacting low-income and minority adults. Several randomized controlled trials show yoga is an effective treatment. However, the comparative effectiveness of yoga and physical therapy, a common mainstream treatment for chronic low back pain, is unknown., Methods/design: This is a randomized controlled trial for 320 predominantly low-income minority adults with chronic low back pain, comparing yoga, physical therapy, and education. Inclusion criteria are adults 18-64 years old with non-specific low back pain lasting ≥ 12 weeks and a self-reported average pain intensity of ≥ 4 on a 0-10 scale. Recruitment takes place at Boston Medical Center, an urban academic safety-net hospital and seven federally qualified community health centers located in diverse neighborhoods. The 52-week study has an initial 12-week Treatment Phase where participants are randomized in a 2:2:1 ratio into i) a standardized weekly hatha yoga class supplemented by home practice; ii) a standardized evidence-based exercise therapy protocol adapted from the Treatment Based Classification method, individually delivered by a physical therapist and supplemented by home practice; and iii) education delivered through a self-care book. Co-primary outcome measures are 12-week pain intensity measured on an 11-point numerical rating scale and back-specific function measured using the modified Roland Morris Disability Questionnaire. In the subsequent 40-week Maintenance Phase, yoga participants are re-randomized in a 1:1 ratio to either structured maintenance yoga classes or home practice only. Physical therapy participants are similarly re-randomized to either five booster sessions or home practice only. Education participants continue to follow recommendations of educational materials. We will also assess cost effectiveness from the perspectives of the individual, insurers, and society using claims databases, electronic medical records, self-report cost data, and study records. Qualitative data from interviews will add subjective detail to complement quantitative data., Trial Registration: This trial is registered in ClinicalTrials.gov, with the ID number: NCT01343927.

Objectives: To evaluate the feasibility of an RCT of a pedometer-driven walking program and education/advice to remain active compared with education/advice only for treatment of chronic low back pain (CLBP)., Methods: Fifty-seven participants with CLBP recruited from primary care were randomly allocated to either: (1) education/advice (E, n=17) or (2) education/advice plus an 8-week pedometer-driven walking program (EWP, n=40). Step targets, actual daily step counts, and adverse events were recorded in a walking diary over the 8 weeks of intervention for the EWP group only. All other outcomes (eg, functional disability using the Oswestry Disability Questionnaire (ODQ), pain scores, physical activity (PA) measurement etc.) were recorded at baseline, week 9 (immediately post-intervention), and 6 months in both groups., Results: The recruitment rate was 22% and the dropout rate was lower than anticipated (13% to 18% at 6 mo). Adherence with the EWP was high, 93% (n=37/40) walked for ≥ 6 weeks, and increased their steps/day (mean absolute increase in steps/d, 2776, 95% confidence interval [CI], 1996-3557) by 59% (95% CI, 40.73%-76.25%) from baseline. Mean percentage adherence with weekly step targets was 70% (95% CI, 62%-77%). Eight (20%) minor-related adverse events were observed in 13% (5/40) of the participants. The EWP group participants demonstrated an 8.2% point improvement (95% CI, -13 to -3.4) on the ODQ at 6 months compared with 1.6% points (95% CI, -9.3 to 6.1) for the E group (between group d=0.44). There was also a larger mean improvement in pain (d=0.4) and a larger increase in PA (d=0.59) at 6 months in EWP., Discussion: This preliminary study demonstrated that a main RCT is feasible. EWP was safe and produced a real increase in walking; CLBP function and pain improved, and participants perceived a greater improvement in their PA levels. These improvements require confirmation in a fully powered RCT.

The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization’s International Classification of Functioning, Disability, and Health (ICF). The purpose of these low back pain clinical practice guidelines, in particular, is to describe the peer-reviewed literature and make recommendations related to (1) treatment matched to low back pain subgroup responder categories, (2) treatments that have evidence to prevent recurrence of low back pain, and (3) treatments that have evidence to influence the progression from acute to chronic low back pain and disability.

As the biopsychosocial model of health has become increasingly understood, it has become clear that there are complex, interdependent relationships between the physical and biomedical features of low back pain and the psychological and social factors that present concomitantly. Epidemiological studies have not only highlighted that psychological and social factors are associated with back pain and disability but also have shed light on the way in which these factors serve as prognostic indicators, or obstacles to recovery, predicting which patients will have a poor prognosis. Integrating the assessment of these obstacles to recovery into physical therapist practice and using this information to guide clinical decision making have the potential to improve the quality of care offered by physical therapists by improving the targeting of treatments to individuals and enhancing the therapist-patient relationship and adherence to management advice and treatment programs. In turn, such approaches may improve both patients' clinical outcomes and the efficiency and effectiveness of service provision, helping direct interventions to those who need them. This article summarizes the key challenges to embedding psychosocial perspectives within physical therapist practice for patients with low back pain and the opportunities that could be realized by doing so, and it highlights new developments in research, clinical practice, and education that are shaping future directions in this field.

Objective: To develop a clinical prediction rule (CPR) for identifying postpartum women with low back pain (LBP) and/or pelvic girdle pain (PGP) whose functional disability scores improve with a high-velocity thrust technique (HVTT) conducted by a physical therapist., Design: Prospective cohort., Setting: Outpatient physical therapy departments., Participants: Sixty-nine postpartum women referred to physical therapy with the complaint of LBP and/or PGP., Methods: Subjects underwent a physical examination and a HVTT to the lumbopelvic region., Main Outcome Measures: Success with treatment was determined by the use of percent changes in disability scores and served as the reference standard for determining accuracy of the examination variables. Variables with univariate prediction of success and nonsuccess were combined into multivariate CPRs., Results: Fifty-five subjects (80%) had success with the HVTT. A CPR for success with 4 criteria was identified. The presence of 2 of 4 criteria (positive likelihood ratio=3.05) increased the probability of success from 80% to 92%. A CPR for treatment failure with 3 criteria was identified. The presence of 2 of 3 criteria (positive likelihood ratio=11.79) increased the probability of treatment failure from 20% to 75%., Conclusions: The pretest probability of success (80%) is sufficient to reassure the clinician about the decision to use a HVTT to the lumbopelvic region in postpartum women with LBP and/or PGP. If 2 of 3 criteria for treatment failure are met in the CPR, an alternative approach is warranted. An intervention such as the HVTT is compelling, given the need to minimize pharmaceutical remedies in women who are potentially breast-feeding post partum., (Copyright © 2010 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

Background: Current evidence supports the use of exercise-based treatment for chronic low back pain that encourages the patient to assume an active role in their recovery. Walking has been shown it to be an acceptable type of exercise with a low risk of injury. However, it is not known whether structured physical activity programmes are any more effective than giving advice to remain active., Methods/design: The proposed study will test the feasibility of using a pedometer-driven walking programme, as an adjunct to a standard education and advice session in participants with chronic low back pain. Fifty adult participants will be recruited via a number of different sources. Baseline outcome measures including self reported function; objective physical activity levels; fear-avoidance beliefs and health-related quality of life will be recorded. Eligible participants will be randomly allocated under strict, double blind conditions to one of two treatments groups. Participants in group A will receive a single education and advice session with a physiotherapist based on the content of the 'Back Book'. Participants in group B will receive the same education and advice session. In addition, they will also receive a graded pedometer-driven walking programme prescribed by the physiotherapist. Follow up outcomes will be recorded by the same researcher, who will remain blinded to group allocation, at eight weeks and six months post randomisation. A qualitative exploration of participants' perception of walking will also be examined by use of focus groups at the end of the intervention. As a feasibility study, treatment effects will be represented by point estimates and confidence intervals. The assessment of participant satisfaction will be tabulated, as will adherence levels and any recorded difficulties or adverse events experienced by the participants or therapists. This information will be used to modify the planned interventions to be used in a larger randomised controlled trial., Discussion: This paper describes the rationale and design of a study which will test the feasibility of using a structured, pedometer-driven walking programme in participants with chronic low back pain., Trial Registration: [ISRCTN67030896].

Objective: This is an observational prospective cohort study to explore the treatment effect of mechanical vs manual manipulation for acute low back pain., Methods: Ninety-two patients with a history of acute low back pain were recruited from 3 private chiropractic offices, 2 of which used manual lumbar manipulation and 1 used mechanical instrument manipulation (Activator) as their primary modes of treatment. The chiropractors used their "treatment-as-usual" protocols for a maximum of 8 visits or 4 weeks, whichever occurred first. Primary outcome measures were changes in Numeric Pain Rating Scale (NPRS) and Oswestry Disability Index (ODI) scores from baseline to 4 weeks. The linear regression models were adjusted for baseline NPRS and ODI scores, age, and treatment expectancy., Results: Comparison of baseline characteristics did not show any significant differences between the groups except for age (38.4 vs 49.7 years, P < .001) and treatment expectancy (5.7 vs 6.3, P = .003). Linear regression revealed significantly lower NPRS scores in the manual manipulation group at 4 weeks (beta = -1.2; 95% confidence interval, -2.1 to -.28) but no significant difference in ODI scores between the 2 groups at 4 weeks (beta = 1.5; 95% confidence interval, -8.3 to 2.4). Treatment expectancy, but not age, was found to have a significant main effect on both NPRS and ODI scores at 4 weeks. Exploratory analysis of the clinical patterns of care between the clinicians revealed significant differences in treatment frequency, duration, modality, and radiograph use between the 2 cohorts., Conclusions: This study highlights the challenges inherent with conducting research that allows for "treatment as usual." The data and experience derived from this investigational study will be used to design a future randomized clinical trial in which tighter controls will be imposed on the treatment protocol., (Copyright 2010 National University of Health Sciences. Published by Mosby, Inc. All rights reserved.)

Chronic low back pain (CLBP) in older adults may be disabling and therapeutically challenging, largely because of the inefficacy and/or morbidity associated with traditional pain treatment. We conducted a randomized controlled trial in 200 men and women > or = age 65 with CLBP to evaluate the efficacy of percutaneous electrical nerve stimulation (PENS) with and without general conditioning and aerobic exercise (GCAE), for reducing pain and improving physical function. Participants were randomized to receive (1) PENS, (2) control-PENS (brief electrical stimulation to control for treatment expectancy), (3) PENS+GCAE, or (4) control-PENS+GCAE, twice a week for 6 weeks. All four groups experienced significantly reduced pain (range -2.3 to -4.1 on the McGill Pain Questionnaire short form), improved self-reported disability (range -2.1 to -3.0 on Roland scale) and improved gait velocity (0.04-0.07 m/s), sustained at 6 months. The GCAE groups experienced significantly fewer fear avoidance beliefs immediately post-intervention and at 6 months than non-GCAE groups. There were no significant side effects. Since brief electrical stimulation (i.e., control-PENS) facilitated comparably reduced pain and improved function at 6 months as compared with PENS, the exact dose of electrical stimulation required for analgesia cannot be determined. GCAE was more effective than PENS alone in reducing fear avoidance beliefs, but not in reducing pain or in improving physical function.

Background: Evidence supports the use of exercise for chronic low back pain (CLBP); however, adherence is often poor due to ongoing pain. Auricular acupuncture is a form of pain relief involving the stimulation of points on the outer ear corresponding with specific body parts. It may be a useful adjunct to exercise in managing CLBP; however, there is only limited evidence to support its use with this patient group., Methods/design: This study was designed to test the feasibility of an assessor-blind randomised controlled trial which assess the effects on clinical outcomes and exercise adherence of adding manual auricular acupuncture to a personalised and supervised exercise programme (PEP) for CLBP. No sample size calculation has been carried out as this study aims to identify CLBP referral rates within the catchment area of the study site. The researchers aim to recruit four cohorts of n = 20 participants to facilitate a power analysis for a future randomised controlled trial. A computer generated random allocation sequence will be prepared centrally and used to allocate participants by cohort to one of the following interventions: 1) six weeks of PEP plus manual auricular acupuncture; 2) six weeks of PEP alone. Both groups will also complete a further six weeks of self-paced exercise with telephone follow-up support. In addition to a baseline and exit questionnaire at the beginning and end of the study, the following outcomes will be collected at baseline, and after 7, 13 and 25 weeks: pain frequency and bothersomeness, back-specific function, objective assessment and recall of physical activity, use of analgesia, perceived self-efficacy, fear avoidance beliefs, and beliefs about the consequences of back pain. Since this is a feasibility study, significance tests will not be presented, and treatment effects will be represented by point estimates and confidence intervals. For each outcome variable, analysis of covariance will be performed on the data, conditioning on the baseline value., Discussion: The results of this study investigating the adjuvant effects of auricular acupuncture to exercise in managing CLBP will be used to inform the design of a future multi-centre randomised controlled trial., Trial Registration: Current Controlled Trials ISRCTN94142364.

Background and Purpose: People with acute low back injury and fear-avoidance beliefs are at risk for remaining off work for an extended period of time. However, the effectiveness of intervention strategies for improving return-to-work status in people with acute low back pain and fear-avoidance beliefs has not been reported. The objective of this study was to determine whether education and counseling on pain management, physical activity, and exercise could significantly decrease the number of days that people with low back injury are off work., Subjects: Thirty-four people who were unable to return to work following a work-related episode of low back pain and who exhibited fear-avoidance beliefs participated in this study., Methods: Participants who scored 50 points or higher on the Fear-Avoidance Beliefs Questionnaire were alternately assigned to an education group or a comparison group. Both groups received conventional physical therapy intervention. Participants in the education group were given education and counseling on pain management tactics and the value of physical activity and exercise. The effectiveness of the interventions was measured by the number of days before people returned to work without restrictions., Results: All participants in the education group returned to regular work duties within 45 days. One third of the participants in the comparison group remained off work at 45 days. There was a statistically significant difference between the groups with regard to the number of days before returning to work., Discussion and Conclusion: Education and counseling regarding pain management, physical activity, and exercise can reduce the number of days off work in people with fear-avoidance beliefs and acute low back pain.

Study Design: Randomized clinical trial., Objective: Compare outcomes of patients with low back pain receiving treatments matched or unmatched to their subgrouping based on initial clinical presentation., Summary of Background Data: Patients with "nonspecific" low back pain are often viewed as a homogeneous group, equally likely to respond to any particular intervention. Others have proposed methods for subgrouping patients as a means for determining the treatment most likely to benefit patients with particular characteristics., Methods: Patients with low back pain of less than 90 days' duration referred to physical therapy were examined before treatment and classified into one of three subgroups based on the type of treatment believed most likely to benefit the patient (manipulation, stabilization exercise, or specific exercise). Patients were randomly assigned to receive manipulation, stabilization exercises, or specific exercise treatment during a 4-week treatment period. Disability was assessed in the short-term (4 weeks) and long-term (1 year) using the Oswestry. Comparisons were made between patients receiving treatment matched to their subgroup, versus those receiving unmatched treatment., Results: A total of 123 patients participated (mean age, 37.7 +/- 10.7 years; 45% female). Patients receiving matched treatments experienced greater short- and long-term reductions in disability than those receiving unmatched treatments. After 4 weeks, the difference favoring the matched treatment group was 6.6 Oswestry points (95% CI, 0.70-12.5), and at long-term follow-up the difference was 8.3 points (95% CI, 2.5-14.1). Compliers-only analysis of long-term outcomes yielded a similar result., Conclusions: Nonspecific low back pain should not be viewed as a homogenous condition. Outcomes can be improved when subgrouping is used to guide treatment decision-making.

Objective: To develop a clinical prediction rule to predict treatment response to a stabilization exercise program for patients with low back pain (LBP)., Design: A prospective, cohort study of patients with nonradicular LBP referred to physical therapy (PT)., Setting: Outpatient PT clinics., Participants: Fifty-four patients with nonradicular LBP., Intervention: A standardized stabilization exercise program., Main Outcome Measure: Treatment response (success or failure) was categorized based on changes in the Oswestry Disability Questionnaire scores after 8 weeks., Results: Eighteen subjects were categorized as treatment successes, 15 as treatment failures, and 21 as somewhat improved. After using regression analyses to determine the association between standardized examination variables and treatment response status, preliminary clinical prediction rules were developed for predicting success (positive likelihood ratio [LR], 4.0) and failure (negative LR, .18). The most important variables were age, straight-leg raise, prone instability test, aberrant motions, lumbar hypermobility, and fear-avoidance beliefs., Conclusions: It appears that the response to a stabilization exercise program in patients with LBP can be predicted from variables collected from the clinical examination. The prediction rules could be used to determine whether patients with LBP are likely to benefit from stabilization exercises.

Background and Purpose: Treatment-based classification (TBC) provides matched interventions for patients with acute low back pain (LBP) through key history and clinical findings. This study investigated the discriminant validity of TBC by determining whether commonly used clinical examination variables discriminated among TBC groups., Subjects: The mean age of the 131 participants was 37.7 years (SD=10.1), 66 participants (50.4%) were female, mean duration of LBP was 16.5 days (SD=16.1), and 60 participants (45.8%) had a prior history of LBP. Fifty-one study participants (38.9%) were classified for specific exercise, 42 (32.1%) for mobilization, 28 (21.4%) for immobilization, and 10 (7.6%) for traction., Methods: One-way analyses of variance and Kruskal-Wallis tests were used to investigate differences in clinical variables by TBC group. Then, discriminant function analysis (DFA) predicted TBC group membership., Results: The TBC groups differed on present pain intensity, duration of LBP, and history of LBP. Present pain intensity, duration of LBP, total lumbar flexion, presence of leg pain, and history of LBP produced 2 statistically significant discriminant functions that predicted TBC group membership. These functions correctly classified (cross-validation value in parentheses) 65% (65%) for specific exercise, 45% (40%) for mobilization, and 32% (32%) for immobilization., Discussion and Conclusion: This study provided evidence supporting the discriminant validity of TBC. Additional diagnostic information related to TBC groups was generated.

Background: Conflicting evidence exists about the effectiveness of spinal manipulation., Objective: To validate a manipulation clinical prediction rule., Design: Multicenter randomized, controlled trial., Setting: Physical therapy clinics., Patients: 131 consecutive patients with low back pain, 18 to 60 years of age, who were referred to physical therapy., Intervention: Patients were randomly assigned to receive manipulation plus exercise or exercise alone by a physical therapist for 4 weeks., Measurements: Patients were examined according to the clinical prediction rule criteria (symptom duration, symptom location, fear-avoidance beliefs, lumbar mobility, and hip rotation range of motion). Disability and pain at 1 and 4 weeks and 6 months were assessed., Results: Outcome from spinal manipulation depends on a patient's status on the prediction rule. Treatment effects are greatest for the subgroup of patients who were positive on the rule (at least 4 of 5 criteria met); health care utilization among this subgroup was decreased at 6 months. Compared with patients who were negative on the rule and received exercise, the odds of a successful outcome among patients who were positive on the rule and received manipulation were 60.8 (95% CI, 5.2 to 704.7). The odds were 2.4 (CI, 0.83 to 6.9) among patients who were negative on the rule and received manipulation and 1.0 (CI, 0.28 to 3.6) among patients who were positive on the rule and received exercise. A patient who was positive on the rule and received manipulation has a 92% chance of a successful outcome, with an associated number needed to treat for benefit at 4 weeks of 1.9 (CI, 1.4 to 3.5)., Limitations: The response rate for the 6-month follow-up resulted in inadequate power to detect statistically significant differences for some comparisons., Conclusions: The spinal manipulation clinical prediction rule can be used to improve decision making for patients with low back pain.

Study Design: A randomized clinical trial was conducted., Objective: To compare the effectiveness of classification-based physical therapy with that of therapy based on clinical practice guidelines for patients with acute, work-related low back pain., Summary of Background Data: Clinical practice guidelines recommend minimal intervention during the first few weeks after acute low back injury. However, studies supporting this recommendation have not attempted to identify which patients are likely to respond to particular interventions., Methods: For this study, 78 subjects with work-related low back pain of less than 3 weeks duration were randomized to receive therapy based on a classification system that attempts to match patients to specific interventions or therapy based on the Agency for Health Care Policy and Research guidelines. The subjects were followed for 1 year. Outcomes included the impairment index, Oswestry scale, SF-36 component scores, satisfaction, medical costs, and return to work status., Results: After adjustment for baseline factors, subjects receiving classification-based therapy showed greater change on the Oswestry (P = 0.023) and the SF-36 physical component (P = 0.029) after 4 weeks. Patient satisfaction was greater (P = 0.006) and return to full-duty work status more likely (P = 0.017) after 4 weeks in the classification-based group. After 1 year, there was a trend toward reduced Oswestry scores in the classification-based group (P = 0.063). Median total medical costs for 1 year after injury were 1003.68 dollars for the guideline-based group and 774.00 dollars for the classification-based group (P = 0.13)., Conclusions: For patients with acute, work-related low back pain, the use of a classification-based approach resulted in improved disability and return to work status after 4 weeks, as compared with therapy based on clinical practice guidelines. Further research is needed on the optimal timing and methods of intervention for patients with acute low back pain.

The evaluation of an athlete with LBP using the classification system proposed by Delitto et al has been outlined. For outpatient orthopaedic practice, evidence in the literature is available documenting the reliability and the effectiveness of treatment guided by TBC. This classification system provides framework for the clinician to evaluate athletes with LBP because it investigates the presence of serious pathology, considers the severity of the disease process, and provides matched treatment based on the athlete's clinical presentation. When treating athletes with episodes of acute LBP, pain modulation and return to daily function are the primary treatment goals. When treating athletes with episodes of chronic LBP, return to sport and prevention of recurrence are the primary treatment goals.

Fear-avoidance beliefs have been identified as an important psychosocial variable in patients with chronic disability doe to low back pain. The importance of fear-avoidance beliefs for individuals with acute low back pain has not been explored. Seventy-eight subjects with work-related low back pain of less than 3 weeks'duration were studied. Measurements of pain intensity, physical impairment, disability, nonorganic signs and symptoms, and depression were taken at the initial evaluation. Fear-avoidance beliefs were measured with the work and physical activity subscales of the Fear-avoidance Beliefs Questionnaire. Disability and work status were re-assessed after 4 weeks of physical therapy. Patterns of correlation between fear-avoidance beliefs and other concurrently-measured variables were similar to those reported in patients with chronic low back pain. Fear-avoidance beliefs did not explain a significant amount of the variability in initial disability levels after controlling for pain intensity and physical impairment. Fear-avoidance beliefs about work were significant predictors of 4-week disability and work status even after controlling for initial levels of pain intensity, physical impairment, and disability, and the type of therapy received. Fear-avoidance beliefs are present in patients with acute low back pain, and may be an important factor in explaining the transition from acute to chronic conditions. Screening for fear-avoidance beliefs may be useful for identifying patients at risk of prolonged disability and work absence.

Objective: To determine the interrater reliability of judgments of status change, including the centralization phenomenon during examination of the lumbar spine, and to determine the effects of training and experience on reliability., Design: A videotape study of judgments by physical therapists and physical therapy students of the results of movement testing during the examination of patients with low back pain., Setting: Outpatient physical therapy clinic., Patients: Patients receiving physical therapy treatment for low back pain., Intervention: Patients with low back pain were videotaped while performing a variety of movement tests including single, repeated, and sustained movements. Forty licensed physical therapists and 40 physical therapy students were provided with operational definitions of the three potential judgments of status change with movement testing; centralization, peripheralization, status quo. All therapists and students viewed the videotape and made a judgment regarding the patient's status change in response to the test., Main Outcome Measure: Percentage agreement and kappa coefficient values for agreement., Results: Interrater reliability was excellent for the total sample of examiners (kappa = .793), for the licensed physical therapists (kappa = .823), and for the students (kappa = .763)., Conclusions: Judgments of status change are reliable when operational definitions are provided. Clinical experience does not appear to substantially improve reliability.

This study assesses the ability of a two-stage treadmill test to distinguish stenotic from nonstenotic subjects by capitalizing on the postural dependency of stenotic symptoms. Forty-five subjects (26 stenotic, 19 nonstenotic) participated. An earlier onset of symptoms with level walking (p = 0.0009), increased total walking time on an inclined treadmill (p = 0.014), and prolonged recovery time after level walking (p = 0.001) were significantly associated with stenosis. Only one of four self-reported postural variables were significantly associated with stenosis. Linear discriminant analysis performed using the treadmill variables resulted in the correct classification of 76.9 and 94.7% of stenotic and nonstenotic subjects, respectively. Likelihood ratios for all treadmill variables were > 2.50, and < 2.00 for all self-report variables. A two-stage treadmill test may be useful in the differential diagnosis of lumbar stenosis, and clinical measurement of the postural nature of symptoms seems to be superior to subjects' self-reports.

Study Design: This study evaluated performance differences between patients with chronic low back pain and a control group during their performance of a novel functional capacity task., Objective: To 1) evaluated strength and endurance differences between patients and control subjects, 2) test for movement pattern differences between these groups, and 3) evaluate how these patterns changed with repetitive performance of the wheel-turning task., Summary of Background Data: Despite increased emphasis on quantifying functional capacities, few well-controlled studies comparing the performances of patients with low back pain with those of control subjects have appeared in the literature, particularly for movement patterns., Methods: Forty patients with low back pain and 40 control subjects performed a sustained isodynamic wheel turning task. This task was selected because it simultaneously combined several common pain-related movements. A set of kinematic measures to characterize the basic movement patterns during this task were developed., Results: Control subjects produced significantly higher levels of static torque and completed significantly more wheel-turning repetitions. Patients with low back pain exhibited significantly less upper torso and pelvic motion, upper torso rotation, and lateral trunk flexion than those in the control group., Conclusion: The dissimilar movement strategies found between the patient and control groups suggests that factors beyond more global physical explanations (e.g., deconditioning) may be important in accounting for the large discrepancy between these groups regarding the amount of work performed. These findings, along with the basic kinematic patterns developed in this study, may have important implications for determining the efficacy of instruction in body mechanics and treatment outcome for patients with chronic low back pain.

We present a treatment-based classification approach to the conservative management of low back syndrome. The approach has three levels of classification based on historical information, behavior of symptoms, and clinical signs. We first distinguish patients whose conservative care can be managed predominantly and independently by physical therapists versus patients who require consultation with other services (eg, psychology) or who require referral because of possible serious nonmusculoskeletal pathology. Once patients who can be managed by physical therapists are identified, the next level of classification is to stage their condition with regard to severity. We propose three stages: stage I for patients in the acute phase where the therapeutic goal is symptom relief, stage II for patients in a subacute phase where symptom relief and quick return to normal function are encouraged, and stage III for selected patients who must return to activities requiring high physical demands and who demonstrate a lack of physical conditioning necessary to perform the desired activities safely. The remainder of the article focuses on a third level of classification for stage I only in which patients are classified into distinct categories that are treatment-based and that specifically guide conservative management. The entire approach is diagnosis based, with specific algorithms and decision rules as well as examples presented.

Background and Purpose: The relative effectiveness of an extension program and a manipulation program with flexion and extension exercises was examined in patients with low back syndrome., Subjects: Forty-nine patients with less than a 3-month history of low back pain were seen at physical therapy clinics in western Pennsylvania, southern Mississippi, and eastern Missouri during a 6-month period. Twenty-seven of the 49 patients were classified a priori into a treatment-oriented category of extension/mobilization and were then randomly assigned to participate in an extension program or a program of manipulation followed by hand-heel rocks (flexion and extension). Two patients dropped out of the study (1 patient returned to work, and the other patient was unable to comply with the treatment schedule), and 1 patient was eliminated from the study because of magnified illness behavior. The remaining 24 patients (15 male, 9 female; mean age = 44 years, SD = 15, range = 14-73) were assigned randomly and equally to the two groups. Eight physical therapists participated in the study., Methods: A randomized clinical trial comparing the two regimens was conducted for a 1-week period. Outcome was assessed using an Oswestry Low Back Pain Questionnaire initially (before treatment) and at 3 and 5 days posttreatment, and data were analyzed using a 2 x 3 (group x time) analysis of variance., Results: A significant interaction of the group and time variables was demonstrated, indicating that the rate of positive response was greater in the manipulation/hand-heel rock group than in the extension group., Conclusion and Discussion: In this category of patients with low back pain, the use of manipulation as an adjunct to an ongoing exercise program appears to be warranted.

Currently, disablement due to low back syndrome (LBS) inflicts an extremely high cost to society, with yearly direct and indirect costs estimated in the billions of dollars. Patients with LBS often present a challenge for physical therapists trained in the evaluation of the physical nature of LBS. The psychosocial nature of a patient's complaint and the use of measures obtained from evaluation to guide patient management sometimes require interaction in a multidisciplinary environment. In this article, LBS will be discussed within the frameworks of Nagi's disablement pathway and an illness model described by Waddell. Both models suggest that to adequately treat LBS requires evaluation of the impairment, functional limitations, and disability using tools with adequate measurement characteristics. This article will focus on impairments and patient self-reports of quality of life and will discuss the relationship between impairments, functional limitations, and disability in LBS. Standardized quality of life measures are easily administered in everyday clinical settings and capture the patient's perceptions of the functional limitations and disability seen with LBS. Common self-reports are reviewed, and potential barriers to their use are discussed. Lacking an identifiable disease process in the majority of cases of LBS leaves most clinicians to deal with the impairments, functional limitations, and resultant disability. Physical therapists should, therefore, measure and gauge changes in all of these dimensions. To accomplish this, physical therapists must be willing to evaluate the dimensions of functional limitations and disabilities using tools that allow adherence to the same measurement standards (eg, reliability and validity) as those used to evaluate physical impairments.

Background and Purpose: The prescriptive validity of a treatment-oriented extension-mobilization category for patients with low back syndrome (LBS) was examined., Subjects: Of a total of 39 patients with LBS referred for physical therapy, 24 patients (14 male, 10 female), aged 14 to 50 years (means = 31.3, SD = 11.6), were classified as having signs and symptoms indicating treatment with an extension-mobilization approach. The remaining subjects were dismissed from the study. Patients in the extension-mobilization category were randomly assigned to either an experimental (treatment) group (n = 14) or a comparison group (n = 10)., Methods: The experimental and comparison group subjects were treated with either mobilization and extension (a treatment matched to the category) or a flexion exercise regimen (an unmatched treatment). Outcome was assessed with a modified Oswestry Low Back Pain Questionnaire administered initially and at 3 and 5 days after initiation of treatment. Data were analyzed with a 2 x 3 (treatment group x treatment period) analysis of variance., Results: The subjects' rate of improvement, as indicated by the Oswestry questionnaire scores, was dependent on the treatment group to which they were assigned. Subjects treated with extension and mobilization positively responded at a faster rate than did those treated with a flexion-oriented program., Conclusion and Discussion: This study illustrates that a priori classification of selected patients with LBS into a treatment category of extension and mobilization and subsequently treating the patients accordingly with specified interventions can be an effective approach to conservative management of selected patients.