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A generalized radar scattering model based on wave theory is described. The model predicts polarimetric radar backscattering coefficients for structurally complex vegetation comprised of multiple species and layers. Compared to conventional two-layer crown-trunk models, modeling of actual forests has been improved substantially, allowing better understanding of microwave interaction with vegetation. The model generalizes an existing single-species discrete scatterer model and, by including scattering and propagation effects through judiciously defined vegetation layers, enables its application to an arbitrary number of species types. The scatterers within each layer are modeled as finite cylinders or disks having arbitrary size, density, and orientation, as in the predecessor model. The distorted Born approximation is used to represent the propagation through each layer, while scattering from each is modeled as a linear superposition of scattering from its respective random collection of scatterers. Interactions of waves within and between each layer and direct scattering from the ground are accounted for. Validation of the model is presented based on its application to 23 wooded savanna sites located in Queensland, Australia, and comparison with Advanced Land Observing Satellite (ALOS) Phased Arrayed L-band Synthetic Aperture Radar (PALSAR) and National Aeronautics and Space Administration (NASA) Jet Propulsion Laboratory (JPL) Airborne Synthetic Aperture Radar (AIRSAR) data. Results indicate good agreement between simulated and actual backscattering coefficients, particularly at HH and VV polarizations. More discrepancies are found at HV polarizations and can be explained by uncertainties in the knowledge of input parameters, such as inaccuracies in the surface model, surface roughness parameterization, and soil moisture. [ABSTRACT FROM PUBLISHER]

Introduction: Neck pain is a common musculoskeletal disorder, with a prevalence rate (age-standardized) of 27.0 per 1000 in 2019. Approximately 50-85% of individuals with acute neck pain do not experience complete resolution of symptoms, experiencing chronic pain. Manual therapy is a widely employed treatment approach for nonspecific neck pain (NSNP), cervical radiculopathy (CR) and cervicogenic headaches (CGH). This umbrella review synthesized systematic reviews examining manual physical therapy for individuals with cervical disorders., Methods: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed with Prospero registration (CRD42022327434). Four databases were searched from January 2016 to May 2023 for systematic reviews with or without meta-analysis examining manual therapy for individuals with neck pain of any stage. Interventions included any manual physical therapy of the cervical or thoracic spine as well as neuromobilization of the upper quarter. Primary outcomes included pain and disability. Two reviewers screened for eligibility and completed data extraction. Methodological quality was assessed using the Assessment of Multiple Systematic Reviews (AMSTAR 2) tool., Results: A total of 35 SRs were included: 15 NSNP, 7 cervical radiculopathy, 9 CGH and 4 samples with combined diagnoses. AMSTAR 2 ratings of the SRs support high confidence in results for 10 reviews, moderate confidence in 12 reviews and low to critically low confidence in 13 reviews. For NSNP, there was high confidence in the results showing manual therapy combined with exercise was superior to either treatment in isolation. In cervical radiculopathy, neural mobilization, distraction, soft tissue treatment and mobilization/manipulation to cervical and thoracic spine were supported with moderate confidence in results. For CGH, there was high confidence in the results supporting the use of cervical spine mobilization/manipulation, soft tissue mobilization, and manual therapy combined with exercise. Original authors of SRs reported varying quality of primary studies with lack of consistent high quality/low risk of bias designs., Conclusion: Manual therapy plus exercise, cervical or thoracic mobilization and manipulation, neuromobilization, and other types of manual therapy were supported as effective interventions in the management of pain and disability for individuals with NSNP, CGH, or CR in the short-term.

Objective: Perform a systematic critical appraisal of current clinical practice guidelines (CPGs) for frozen shoulder., Literature Survey: Systematic review of CPGs (PROSPERO number CRD42022368775). Inclusion criteria- CPGs written in English providing guidance on the evaluation and or treatment for frozen shoulder, traumatic injury and neurologic CPGs were excluded.Relevant studies were assessed for inclusion and selected studies were identified from PubMed, EMBASE, Scopus and CINAHL databases. The search strategy was developed by a biomedical librarian, performed on October 9, 2024., Methodology: Data were extracted from the selected CPGs and underwent quality assessment using the Appraisal of Guidelines for Research and Evaluation (AGREE) II., Synthesis: The search resulted in 38,428 studies and 2 CPGs were retained for appraisal. The mean overall AGREE II score was 75% (SD = 5.7). Lowest mean scores were found in the applicability (27% SD = 24.0) and editorial independence (48% SD = 14.1) domains. The highest domain scores were found in scope and purpose (92% SD = 7.8) and clarity and presentation (79% SD = 9.9). One CPG was rated as low quality based on a priori criteria and ultimately one higher quality CPG was recommended., Conclusion: Given the advances in research that have developed over the last decade pertaining to the evaluation and treatment of frozen shoulder there is a critical need for an up to date, evidence informed, high quality CPG in order to identify gaps in our knowledge that the global research community should address.

Objective: The aim of this study was to establish international consensus regarding the use of spinal manipulation and mobilisation among infants, children, and adolescents among expert international physiotherapists., Methods: Twenty-six international expert physiotherapists in manual therapy and paediatrics voluntarily participated in a 3-Round Delphi survey to reach a consensus via direct electronic mail solicitation using Qualtrics®. Consensus was defined a-priori as ≥75% agreement on all items with the same ranking of agreement or disagreement. Round 1 identified impairments and conditions where spinal mobilisation and manipulation might be utilised. In Rounds 2 and 3, panelists agreed or disagreed using a 4-point Likert scale., Results: Eleven physiotherapists from seven countries representing five continents completed all three Delphi rounds. Consensus regarding spinal mobilisation or manipulation included:Manipulation is not recommended : (1) for infants across all conditions, impairments, and spinal levels; and (2) for children and adolescents across most conditions and spinal levels.Manipulation may be recommended for adolescents to treat spinal region-specific joint hypomobility (thoracic, lumbar), and pain (thoracic).Mobilisation may be recommended for children and adolescents with hypomobility, joint pain, muscle/myofascial pain, or stiffness at all spinal levels., Conclusion: Consensus revealed spinal manipulation should not be performed on infants regardless of condition, impairment, or spinal level. Additionally, the panel agreed that manipulation may be recommended only for adolescents to treat joint pain and joint hypomobility (limited to thoracic and/or lumbar levels). Spinal mobilisation may be recommended for joint hypomobility, joint pain, muscle/myofascial pain, and muscle/myofascial stiffness at all spinal levels among children and adolescents.

Objective: To identify factors and barriers, which affect the utilisation of spinal manipulation and mobilisation among infants, children, and adolescents., Methods: Twenty-six international expert physiotherapists in manual therapy and paediatrics were invited to participate in a Delphi investigation using Qualtrics Ⓡ . In Round-1 physiotherapists selected from a list of factors and barriers affecting their decision to use spinal manipulation and mobilisation in the paediatric population and had opportunity to add to the list. Round-2 asked respondents to select as many factors and barriers that they agreed with, resulting in a frequency count. The subset of responses to questions around barriers and facilitators are the focus of this study., Results: Twelve physiotherapists completed both rounds of the survey. Medical diagnosis, mechanism of injury, patient presentation, tolerance to handling, and therapist's knowledge of techniques were the dominant deciding factors to use spinal manipulation and mobilisation among infants, children, and adolescents across spinal levels. More than 90% of the respondents selected manipulation as inappropriate among infants as their top barrier. Additional dominant barriers to using spinal manipulation among infants and children identified by ≥ 75% of the respondents included fear of injuring the patient, fear of litigation, lack of communication, lack of evidence, lack of guardian consent, and precision of the examination to inform clinical reasoning., Conclusion: This international survey provides much needed insight regarding the factors and barriers physiotherapists should consider when contemplating the utilisation of spinal mobilisation and manipulation in the paediatric population.

Introduction: An international taskforce of clinician-scientists was formed by specialty groups of World Physiotherapy - International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) & International Organisation of Physiotherapists in Paediatrics (IOPTP) - to develop evidence-based practice position statements directing physiotherapists clinical reasoning for the safe and effective use of spinal manipulation and mobilisation for paediatric populations (<18 years) with varied musculoskeletal or non-musculoskeletal conditions., Method: A three-stage guideline process using validated methodology was completed: 1. Literature review stage (one scoping review, two reviews exploring psychometric properties); 2. Delphi stage (one 3-Round expert Delphi survey); and 3. Refinement stage (evidence-to-decision summative analysis, position statement development, evidence gap map analyses, and multilayer review processes)., Results: Evidence-based practice position statements were developed to guide the appropriate use of spinal manipulation and mobilisation for paediatric populations. All were predicated on clinicians using biopsychosocial clinical reasoning to determine when the intervention is appropriate.1. It is not recommended to perform:• Spinal manipulation and mobilisation on infants.• Cervical and lumbar spine manipulation on children.•Spinal manipulation and mobilisation on infants, children, and adolescents for non-musculoskeletal paediatric conditions including asthma, attention deficit hyperactivity disorder, autism spectrum disorder, breastfeeding difficulties, cerebral palsy, infantile colic, nocturnal enuresis, and otitis media.2. It may be appropriate to treat musculoskeletal conditions including spinal mobility impairments associated with neck-back pain and neck pain with headache utilising:• Spinal mobilisation and manipulation on adolescents;• Spinal mobilisation on children; or• Thoracic manipulation on children for neck-back pain only.3. No high certainty evidence to recommend these interventions was available.Reports of mild to severe harms exist; however, risk rates could not be determined., Conclusion: Specific directives to guide physiotherapists' clinical reasoning on the appropriate use of spinal manipulation or mobilisation were identified. Future research should focus on trials for priority conditions (neck-back pain) in children and adolescents, psychometric properties of key outcome measures, knowledge translation, and harms.

Purpose: Systematically evaluate the comparative effectiveness of dry needling (DN) or local acupuncture to various types of wet needling (WN) for musculoskeletal pain disorders (MPD)., Methods: Seven databases (PubMed, PEDro, SPORTDiscus, CINAHL, Scopus, Embase, and Cochrane Central Register of Controlled Trials) were searched following PROSPERO registration. Randomized clinical trials were included if they compared DN or local acupuncture with WN for MPD. Primary outcomes were pain and/or disability. The Revised Cochrane Collaboration tool (RoB 2.0) assessed the risk of bias., Results: Twenty-six studies were selected. Wet Needling types included cortisone (CSI) ( N  = 5), platelet-rich plasma (PRP) ( N  = 6), Botox (BoT) ( N  = 3), and local anesthetic injection (LAI) ( N  = 12). Evidence was rated as low to moderate quality. Results indicate DN produces similar effects to CSI in the short-medium term and superior outcomes in the long term. In addition, DN produces similar outcomes compared to PRP in the short and long term and similar outcomes as BoT in the short and medium term; however, LAI produces better pain outcomes in the short term., Conclusion: Evidence suggests the effectiveness of DN to WN injections is variable depending on the injection type, outcome time frame, and diagnosis. In addition, adverse event data were similar but inconsistently reported. PROSPERO Registration: 2019 CRD42019131826Implications for rehabilitationDry needling produces similar effects for pain and disability in the short and medium term compared to cortisone, Botox, and platelet-rich plasma injections. Local anesthetic injection may be more effective at reducing short-term pain.Long-term effects on pain and disability are similar between dry needling and platelet-rich plasma injections, but dry needling may produce better long-term outcomes than cortisone injections.The available adverse event data is similar between dry and wet needling.The conclusions from this study may be beneficial for patients and clinicians for considering risk and cost benefit analyses.

Background: Typically treated medically, chronic rhinosinusitis (CRS) is a prevalent condition characterized by multiple craniofacial symptoms, some of which may respond favorably to dry needling intervention., Objective: To describe the outcomes of a patient presenting with craniofacial pain and symptoms consistent with a diagnosis of CRS who was treated with dry needling. Case Description : A 41-year-old male, self-referred to physical therapy with a diagnosis of CRS, with a 20-year history of signs and symptoms associated with CRS, including craniofacial pain and headaches. The patient had been treated with multiple medication regimens over this time, including antihistamines, anti-inflammatories, decongestants, leukotriene inhibitors, and antibiotics; all of which provided only short-term relief. On initial examination, the patient was tender to palpation in multiple muscles of the head, neck, and face. Intervention consisted of dry needling to these muscular tender points once or twice weekly over 2 months., Outcomes: After 2 months of dry needling, the patient demonstrated clinically meaningful improvements in pain and quality of life, which included a decrease in both medication usage and the frequency of sinus infections., Conclusion: Although CRS is generally managed medically, we observed areas of muscular tenderness in this case, which were effectively managed with dry needling. Rehabilitative providers may consider screening CRS patients for muscular impairments that may be modifiable with dry needling. Further research should be performed to determine whether dry needling has a role in the management of CRS.

Purpose: Burnout is identified as a workplace problem rather than a worker problem. However, it remains unclear what job stressors are associated with burnout among outpatient physical therapists. Thus, the primary objective of this study was to understand the burnout experiences of outpatient physical therapists. The secondary aim was to identify the relationship between physical therapist burnout and the work setting., Methods: One-on-one interviews based on hermeneutics were used for qualitative analysis. Quantitative data was collected using the Maslach Burnout Inventory-Health Services Survey (MBI-HSS) and the Areas of Worklife Survey (AWS)., Results: Qualitative analysis found participants interpreted an increased workload with no increase in wages, loss of control, and a mismatch between organizational culture and values as the main drivers of organizational stress. Professional issues such as high debt burden, low salaries, and declining reimbursement emerged as stressors. Participants showed moderate to high emotional exhaustion per the MBI-HSS. There was a statistically significant association between emotional exhaustion and workload and control (p < 0.001). For every one-point increase in workload, emotional exhaustion increased by 6.49 while for every one-point increase in control, emotional exhaustion decreased by 4.17., Conclusion: Outpatient physical therapists in this study felt that increased workload with a lack of incentives and inequity, coupled with a loss of control, and a mismatch between personal and organizational values were significant job stressors. Creating awareness of outpatient physical therapist's perceived stressors may play an important role in developing strategies to diminish or prevent burnout., (© 2023 John Wiley & Sons Ltd.)

A globally relevant and standardized taxonomy and framework for consistently describing land cover change based on evidence is presented, which makes use of structured land cover taxonomies and is underpinned by the Driver-Pressure-State-Impact-Response (DPSIR) framework. The Global Change Taxonomy currently lists 246 classes based on the notation 'impact (pressure)', with this encompassing the consequence of observed change and associated reason(s), and uses scale-independent terms that factor in time. Evidence for different impacts is gathered through temporal comparison (e.g., days, decades apart) of land cover classes constructed and described from Environmental Descriptors (EDs; state indicators) with pre-defined measurement units (e.g., m, %) or categories (e.g., species type). Evidence for pressures, whether abiotic, biotic or human-influenced, is similarly accumulated, but EDs often differ from those used to determine impacts. Each impact and pressure term is defined separately, allowing flexible combination into 'impact (pressure)' categories, and all are listed in an openly accessible glossary to ensure consistent use and common understanding. The taxonomy and framework are globally relevant and can reference EDs quantified on the ground, retrieved/classified remotely (from ground-based, airborne or spaceborne sensors) or predicted through modelling. By providing capacity to more consistently describe change processes-including land degradation, desertification and ecosystem restoration-the overall framework addresses a wide and diverse range of local to international needs including those relevant to policy, socioeconomics and land management. Actions in response to impacts and pressures and monitoring towards targets are also supported to assist future planning, including impact mitigation actions., (© 2022 The Authors. Global Change Biology published by John Wiley & Sons Ltd.)

Global shipping accounts for 13% of global emissions of SO 2 , which, once oxidized to sulfate aerosol, acts to cool the planet both directly by scattering sunlight and indirectly by increasing the albedo of clouds. This cooling due to sulfate aerosol offsets some of the warming effect of greenhouse gasses and is the largest uncertainty in determining the change in the Earth's radiative balance by human activity. Ship tracks-the visible manifestation of the indirect of effect of ship emissions on clouds as quasi-linear features-have long provided an opportunity to quantify these effects. However, they have been arduous to catalog and typically studied only in particular regions for short periods of time. Using a machine-learning algorithm to automate their detection we catalog more than 1 million ship tracks to provide a global climatology. We use this to investigate the effect of stringent fuel regulations introduced by the International Maritime Organization in 2020 on their global prevalence since then, while accounting for the disruption in global commerce caused by COVID-19. We find a marked, but clearly nonlinear, decline in ship tracks globally: An 80% reduction in SO[Formula: see text] emissions causes only a 25% reduction in the number of tracks detected.

Background: Physical therapy for neck and low back pain is highly variable despite the availability of clinical practice guidelines (CPG). This review aimed to determine the impact of CPG implementation on patient-level outcomes for spinal pain. Implementation strategies were also examined to determine prevalence and potential impact., Methods: Multiple databases were searched through April 2021 for studies assessing CPG implementation in physical therapy for neck and low back pain. Articles were screened for eligibility. The Modified Downs and Black checklist was utilized to determine study quality. Due to the heterogeneity between studies, a meta-analysis was not performed., Results: Twenty-one studies were included in this review. Implementation strategies were significantly varied between studies. Outcomes pertaining to healthcare utilization, pain, and physical functioning were assessed in relation to the implementation of CPGs. Multiple implementation strategies were identified, with Managing Quality as the most frequently utilized key implementation process. Findings indicate CPG implementation decreased healthcare utilization, but inconsistent results were found with physical functioning and pain outcomes., Conclusions: CPG implementation appears to have a beneficial effect on healthcare utilization outcomes, but may not impact pain and physical functioning outcomes. Effective CPG implementation strategies remain unknown, though utilizing implementation framework may improve outcomes. More research is needed to determine the most effective implementation strategies and effects on pain and physical function outcomes., (© 2022. The Author(s).)

Objective: The purpose of this systematic review is to identify and summarise the social determinants of health (SDH) cited in the literature and evaluate their association with individuals using physical therapy services., Design: A systematic review using qualitatively synthesised information to describe the association between SDH and physical therapy use., Data Sources: The electronic databases Medline, Embase and Scopus were searched from inception to February 2021, identifying observational and qualitative studies., Eligibility Criteria: Published studies included all adults, aged 18 or older, who independently sought to use physical therapy, in all practice settings from all geographical locations., Results: Of the 9248 studies screened, 36 met the inclusion criteria for the review. The participants represented 8 countries and totaled 2 699 437. The majority of the papers reported moderate strength of association for each SDH. Female gender, non-Hispanic white race/ethnicity, increased education attainment, urban environment, access to transportation, employment, high socioeconomic status and private insurance were associated with higher likelihood of physical therapy use., Conclusion: This systematic review identifies predisposing and enabling factors impacting physical therapy usage among adults in different countries and across physical therapy settings. The results of this study have implications for policy and future research regarding populations that have been shown to be using physical therapy services less, such as those with lower levels of education, those in a rural area, or those in a low socioeconomic class., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To determine the relationship between health care use and the magnitude of change in patient-reported outcomes in individuals who received treatment for subacromial pain syndrome. The secondary objective was to determine the value of care, as measured by change in pain and disability per dollar spent., Design: Secondary analysis of a randomized clinical trial that investigated the effects of nonsurgical care for subacromial pain syndrome., Methods: Two groups of treatment responders were created, based on 1-year change in Shoulder Pain and Disability Index (SPADI) score (high, 46.83 points; low, 8.21 points). Regression analysis was performed to determine the association between health care use and 1-year change in SPADI score. Baseline SPADI score was used as a covariate in the regression analysis. Value was measured by comparing health care visits and costs expended per SPADI 1-point change between responder groups., Results: Ninety-eight patients were included; 38 were classified as high responders (mean 1-year SPADI change score, 46.83 points) and 60 were classified as low responders (1-year SPADI change score, 8.21 points). Neither unadjusted medical visits (5.89; 95% confidence interval [CI]: 4.35, 7.44 versus 6.30; 95% CI: 5.14, 7.46) nor medical costs ($1404.86; 95% CI: $1109.34, $1779.09 versus $1679.26; 95% CI: $1391.54, $2026.48) were significantly different between high and low responders, respectively., Conclusion: Neither the number of visits nor the financial cost of nonsurgical shoulder- related care was associated with improvement in shoulder pain and disability at 1 year. J Orthop Sports Phys Ther 2020;50(11):642-648. doi:10.2519/jospt.2020.9440 .

Objective: To systematically determine the specific impact of therapeutic alliance (TA) on chronic musculoskeletal pain, identify factors influencing TA between physical therapists and patients with chronic musculoskeletal pain, and determine the working definition of TA across studies. Data Sources : Databases, including PubMed, CINHAL, and Embase, were searched from inception to January 2017. Study Selection : The initial search resulted in 451 papers. After screening, seven studies were identified that examined the role of TA on chronic pain (> 12 weeks) management in physical therapy settings. Data Extraction : Authors extracted data into tables. Risk of bias was assessed using Cochrane Collaboration methodology. Data Synthesis : Three studies examined the influence of a strong TA coupled with physical therapy on pain outcomes. Four studies identified factors that positively and negatively influenced TA. The working definition of TA was identified in each study. Conclusions : Emerging evidence suggests that for individuals participating in physical therapy for chronic musculoskeletal pain, a strong TA may improve pain outcomes. In order to facilitate a strong TA, physical therapists must understand factors that positively and negatively influence the relationship. Studies demonstrate that the definition of TA remains consistent as it transitions to the physical therapy setting.

Background: The effectiveness of blood flow restriction training (BFRT) as compared with other forms of training, such as resistance training, has been evaluated in the literature in clinical and nonclinical populations. However, the safety of this intervention has been summarized only in healthy populations and not in clinical populations with musculoskeletal disorders., Purpose: To evaluate the safety and adverse events associated with BFRT in patients with musculoskeletal disorders., Study Design: Systematic review., Methods: A literature search was conducted with 3 online databases (MEDLINE, CINAHL, and Embase). Eligibility criteria for selecting studies were as follows: (1) BFRT was used as a clinical intervention, (2) study participants had a disorder of the musculoskeletal system, (3) authors addressed adverse events, (4) studies were published in English, and (5) the intervention was performed with human participants., Results: Nineteen studies met eligibility criteria, with a pooled sample size of 322. Diagnoses included various knee-related disorders, inclusion body myositis, polymyositis or dermatomyositis, thoracic outlet syndrome, Achilles tendon rupture, and bony fractures. Nine studies reported no adverse events, while 3 reported rare adverse events, including an upper extremity deep vein thrombosis and rhabdomyolysis. Three case studies reported common adverse events, including acute muscle pain and acute muscle fatigue. In the randomized controlled trials, individuals exposed to BFRT were not more likely to have an adverse event than individuals exposed to exercise alone. Of the 19 studies, the adverse events were as follows: overall, 14 of 322; rare overall, 3 of 322; rare BFRT, 3 of 168; rare control, 0 of 154; any adverse BFRT, 10 of 168; any adverse control, 4 of 154. A majority of studies were excluded because they did not address safety., Conclusion: BFRT appears to be a safe strengthening approach for knee-related musculoskeletal disorders, but further research is needed to make definitive conclusions and to evaluate the safety in other musculoskeletal conditions. Improved definitions of adverse events related to BFRT are needed to include clear criteria for differentiating among common, uncommon, and rare adverse events. Finally, further research is needed to effectively screen who might be at risk for rare adverse events.

Satellites collecting optical data offer a unique perspective from which to observe the problem of plastic litter in the marine environment, but few studies have successfully demonstrated their use for this purpose. For the first time, we show that patches of floating macroplastics are detectable in optical data acquired by the European Space Agency (ESA) Sentinel-2 satellites and, furthermore, are distinguishable from naturally occurring materials such as seaweed. We present case studies from four countries where suspected macroplastics were detected in Sentinel-2 Earth Observation data. Patches of materials on the ocean surface were highlighted using a novel Floating Debris Index (FDI) developed for the Sentinel-2 Multi-Spectral Instrument (MSI). In all cases, floating aggregations were detectable on sub-pixel scales, and appeared to be composed of a mix of seaweed, sea foam, and macroplastics. Building first steps toward a future monitoring system, we leveraged spectral shape to identify macroplastics, and a Naïve Bayes algorithm to classify mixed materials. Suspected plastics were successfully classified as plastics with an accuracy of 86%.

Objective: To synthesize literature about the effect of early physical therapy (PT) for acute low back pain (LBP) on subsequent health services utilization (HSU), compared to delayed PT or usual care., Data Sources: Electronic databases (MEDLINE, CINAHL, Embase) were searched from their inception to May 2018., Study Selection: Study selection included randomized control trials and prospective and retrospective cohort studies that investigated the association between early PT and HSU compared to delayed PT or usual care. Two independent authors screened titles, abstracts, and full-text articles for inclusion based on eligibility criteria, and a third author resolved discrepancies. Eleven out of 1146 articles were included., Data Extraction: Two independent reviewers extracted data on participants, timing of PT, comparisons to delayed PT or usual care, and downstream HSU, and a third reviewer assessed the information to ensure accuracy and reach consensus. Risk of bias was assessed with the Downs and Black checklist using the same method., Data Synthesis: Eleven studies met eligibility criteria. Early PT is within 30 days of the index visit for acute LBP. Five out of 6 studies that compared early PT to delayed PT found that early PT reduces future HSU. Random effects meta-analysis indicated a significant reduction in opioid use, spine injection, and spine surgery. Five studies compared early PT to usual care and reported mixed results., Conclusions: Early PT for acute LBP may reduce HSU, cost, and opioid use, and improve health care efficiency. This review may assist patients, health care providers, health care systems, and third-party payers in making decisions for the treatment of acute LBP., (Copyright © 2019 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

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

Background: The global burden of low back pain is growing rapidly, accompanied by increasing rates of associated healthcare utilization. Health seeking behavior (HSB) has been suggested as a mediator of healthcare utilization. The aims of this study were to: 1) develop a proxy HSB measure based on healthcare consumption patterns prior to initial consultation for spinal pain, and 2) examine associations between the proxy HSB measure and future healthcare utilization in a population of patients with spine disorders., Methods: A cohort of 1,691 patients seeking care for spinal pain at a single military hospital were included. Cluster analyses were performed for the identification of a proxy HSB measure. Logistic regression was used to identify the predictive capacity of HSB on eight different general and spine-related high healthcare utilization (upper 25%) outcomes variables., Results: The strongest proxy measure of HSB was prior primary care provider visits. In unadjusted models, HSB predicted healthcare utilization across all eight general and spine-related outcome variables. After adjusting for covariates, HSB still predicted general and spine-related healthcare utilization for most variables including total medical visits (OR = 2.48, 95%CI 1.09,3.11), total medical costs (OR = 2.72, 95%CI 2.16,3.41), and low back pain-specific costs (OR = 1.31, 95%CI 1.00,1.70)., Conclusion: Health seeking behavior prior to initial consultation for spine pain was related to healthcare utilization after consultation for spine pain. HSB may be an important variable to consider when developing an individualized care plan and considering the prognosis of a patient., Competing Interests: The authors have declared that no competing interests exist.

Background: Physical therapists' familiarity, perceptions, and beliefs about health services utilization and health seeking behaviour have not been previously assessed., Objectives: The purposes of this study were to identify physical therapists' characteristics related to familiarity of health services utilization and health seeking behaviour, and to assess what health seeking behaviour factors providers felt were related to health services utilization., Methods: We administered a survey based on the Andersen behavioural model of health services utilization to physical therapists using social media campaigns and email between March and June of 2017. In addition to descriptive statistics, we performed binomial logistic regression analysis. We asked respondents to rate familiarity with health services utilization and health seeking behaviour and collected additional characteristic variables., Results: Physical therapists are more familiar with health services utilization than health seeking behaviour. Those who are familiar with either construct tend to be those who assess for health services utilization, use health services utilization for a prognosis, and believe that health seeking behaviour is measurable. Physical therapists rated need and enabling factors as having more influence on health services utilization than predisposing and health belief factors., Conclusion: Physical therapists are generally familiar with health services utilization and health seeking behaviour; however, there appears to be a disconnect between what is familiar, what is perceived to be important, and what can be assessed for both health services utilization and health seeking behaviour., (Copyright © 2018 Associação Brasileira de Pesquisa e Pós-Graduação em Fisioterapia. All rights reserved.)

Background: Large healthcare databases, with their ability to collect many variables from daily medical practice, greatly enable health services research. These longitudinal databases provide large cohorts and longitudinal time frames, allowing for highly pragmatic assessment of healthcare delivery. The purpose of this paper is to discuss the methodology related to the use of the United States Military Health System Data Repository (MDR) for longitudinal assessment of musculoskeletal clinical outcomes, as well as address challenges of using this data for outcomes research., Methods: The Military Health System manages care for approximately 10 million beneficiaries worldwide. Multiple data sources pour into the MDR from multiple levels of care (inpatient, outpatient, military or civilian facility, combat theater, etc.) at the individual patient level. To provide meaningful and descriptive coding for longitudinal analysis, specific coding for timing and type of care, procedures, medications, and provider type must be performed. Assumptions often made in clinical trials do not apply to these cohorts, requiring additional steps in data preparation to reduce risk of bias. The MDR has a robust system in place to validate the quality and accuracy of its data, reducing risk of analytic error. Details for making this data suitable for analysis of longitudinal orthopaedic outcomes are provided., Results: Although some limitations exist, proper preparation and understanding of the data can limit bias, and allow for robust and meaningful analyses. There is the potential for strong precision, as well as the ability to collect a wide range of variables in very large groups of patients otherwise not captured in traditional clinical trials. This approach contributes to the improved understanding of the accessibility, quality, and cost of care for those with orthopaedic conditions., Conclusion: The MDR provides a robust pool of longitudinal healthcare data at the person-level. The benefits of using the MDR database appear to outweigh the limitations.

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 revised clinical practice guidelines is to review recent peer-reviewed literature and make recommendations related to neck pain. J Orthop Sports Phys Ther. 2017;47(7):A1-A83. doi:10.2519/jospt.2017.0302.

Background : Shared Decision-Making (SDM) is a dynamic process by which the health care professional and the patient influence each other in making health-related choices or decisions. SDM is strongly embedded in today's health care approaches, and is advocated as an ideal model since it renders individuals more control towards the health care they choose to receive, and has been shown to improve patient outcomes. Objectives : The goal of this systematic review was to investigate the added-value of SDM on clinical health-related outcomes in patients with a variety of musculoskeletal conditions. Data sources : PubMed and CINAHL. Study selection : PRISMA guidelines were followed for this review. To be considered for review, the study had to meet all the following criteria: (1) prospective studies that involved treatment decision-making; (2) randomized controlled trial design; (3) involving patients faced with having to make a treatment decision; (4) comparing SDM with a control intervention and (5) including one or more of the following outcome measures: well-being, costs, health-related pain or disability measures, or quality of life. Study appraisal : A priori, we determined to perform methodological quality assessment using the Cochrane Risk of Bias tool for randomized controlled trials. Results : We did not find a single study that looked at the true effect of SDM on patient reported outcomes in a population with musculoskeletal pain. Conclusion : For the management of painful musculoskeletal conditions, in the light of the current evidence (none), we estimate that it would be wise to explore the effectiveness of SDM before forcing its large-scale implementation in rehabilitation.

Study Design Case report. Background Abnormal sensation, such as numbness or tingling, is traditionally thought to originate from neural compression. There is limited evidence to support reports of abnormal sensation arising from a trigger point. Case Description The patient was a 60-year-old woman with a primary complaint of right shoulder pain and secondary complaints of neck pain and right upper extremity numbness. Cervical spine neurological examination was unremarkable, and manual examination did not reproduce the patient's arm numbness or tingling symptoms. Compression of a trigger point in the infraspinatus and teres minor reproduced the patient's primary complaint of shoulder pain. The initial intervention included dry needling, which reproduced her upper extremity numbness. Subsequent treatment included manual therapy and exercise. Outcomes The patient was seen for a total of 3 visits, including the evaluation. Dry needling was utilized in 2 of her 3 visits. At discharge, she reported complete resolution of pain and altered sensation. Additionally, her scores on the Neck Disability Index, numeric pain-rating scale, and global rating of change exceeded the minimal clinically important difference. These outcomes were maintained at 2- and 12-month follow-up phone calls. Discussion This case report described the examination and use of dry needling in a case where the diagnosis was unclear. Clinicians may consider trigger point referral when examining patients with reports of abnormal sensation, especially when a more common cause cannot be identified. Level of Evidence Therapy, level 5. J Orthop Sports Phys Ther 2017;47(4):287-292. Epub 3 Mar 2017. doi:10.2519/jospt.2017.7055.

Midsubstance Achilles tendinopathy is one of the most common lower leg conditions. Most patients can recover with nonsurgical treatment that focuses on tendon loading exercises and, when necessary, symptom modulating treatments such as topical, oral, or injected medication, ice, shoe inserts, manual therapy, stretching, taping, or low-level laser. If unresponsive to initial management, a small percentage of patients may consider shockwave or sclerosing treatment and possibly surgery., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Study Design: Case report., Background: Prognosis for adhesive capsulitis has been described as self-limiting and can persist for 1 to 3 years. Conservative treatment that includes physical therapy is commonly advised., Case Description: The patient was a 54-year-old woman with primary symptoms of shoulder pain and loss of motion consistent with adhesive capsulitis. Manual physical therapy intervention initially consisted of joint mobilizations of the shoulder region and thrust manipulation of the cervicothoracic region. Although manual techniques seemed to result in some early functional improvement, continued progression was limited by pain. Subsequent examination identified trigger points in the upper trapezius, levator scapula, deltoid, and infraspinatus muscles, which were treated with dry needling to decrease pain and allow for higher grades of manual intervention., Outcomes: The patient was treated for a total of 13 visits over a 6-week period. After trigger point dry needling was introduced on the third visit, improvements in pain-free shoulder range of motion and functional outcome measures, assessed with the Shoulder Pain and Disability Index and the shortened form of the Disabilities of the Arm, Shoulder and Hand questionnaire, exceeded the minimal clinically important difference after 2 treatment sessions. At discharge, the patient had achieved significant improvements in shoulder range of motion in all planes, and outcome measures were significantly improved., Discussion: This case report describes the clinical reasoning behind the use of trigger point dry needling in the treatment of a patient with adhesive capsulitis. The rapid improvement seen in this patient following the initiation of dry needling to the upper trapezius, levator scapula, deltoid, and infraspinatus muscles suggests that surrounding muscles may be a significant source of pain in this condition.