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Objective. The purpose of this study was to describe the referrals and use of a hybrid care model for low back pain that includes on-site care by physical therapists, physical activity training, and psychologically informed practice (PiP) delivered by telehealth in the Improving Veteran Access to Integrated Management of Low Back Pain (AIM-Back) trial. Methods. Data were collected from November 2020 through February 2023 from 5 Veteran Health Administration clinics participating in AIM-Back, a multisite, cluster-randomized embedded pragmatic trial. The authors extracted data from the Veteran Health Administration Corporate Data Warehouse to describe referral and enrollment metrics, telehealth use (eg, distribution of physical activity and PiP calls), and treatments used by physical therapists and telehealth providers. Results. Seven hundred one veterans were referred to the AIM-Back trial with 422 enrolling in the program (consult-to-enrollment rate = 60.2%). After travel restrictions were lifted, site visits resulted in a significant increase in referrals and a number of new referring providers. At initial evaluation by on-site physical therapists, 92.2% of veterans received pain modulation (eg, transcutaneous electrical nerve stimulation, manual therapy). Over 81% of enrollees completed at least 1 telehealth physical activity call, with a mean of 2.8 (SD = 2.0) calls out of 6. Of the 167 veterans who screened as medium to high risk of persistent disability, 74.9% completed at least 1 PiP call, with a mean of 2.5 (SD = 2.0) calls out of 6. Of those who completed at least 1 PiP call (n = 125), 100% received communication strategies, 97.6% received pain coping skills training, 89.6% received activity-based treatments, and 99.2% received education in a home program. Conclusion. In implementing a hybrid care pathway for low back pain, the authors observed consistency in the delivery of core components (ie, pain modulation, use of physical activity training, and risk stratification to PiP), notable variability in telehealth calls, high use of PiP components, and increased referrals with tailored provider engagement. Impact. These findings describe variability occurring within a hybrid care pathway and can inform future implementation efforts. Keywords: Behavior Therapy, Chronic Pain, Guideline Adherence, Low Back Pain, Models, Musculoskeletal Pain, Organizational, Pain Management, Patient Care Management, Primary Health Care, Telemedicine, Background Embedded pragmatic clinical trials (ePCTs) present a unique opportunity to study the effectiveness and implementation of health care treatments in real-world clinical settings. (1,2) These trial designs use existing [...]

Introduction Theoretically, the movement system is the integration of body systems that generate and maintain all movements contributing to individual function. (1) Movement diagnoses are diagnostic labels ascribed to movements [...]

Psychologically Informed Practice: Let's Not Throw the Baby Out With the Bath Water Nicholls (1) offers an interesting lens on psychologically informed practice (PiP) and back pain using cardiac disease [...]

The Academy of Orthopedic Physical Therapy Pain Education Manual supports the advancement of modern pain content, and the National Institutes of Health Federal Pain Research Strategy has called for new models for pain management. This Perspective proposes the Pain Recovery and Integrative Systems Model (PRISM) as a new model that addresses the multidimensional nature of pain. PRISM is a salutogenic, integrative, process-based cognitive-behavioral model designed for physical therapist education and practice. PRISM aligns with national and international initiatives to better understand and manage pain, thereby mitigating the global opioid crisis. PRISM aims to address the multidimensional nature of pain while building resilience, nurturing growth, and facilitating pain recovery. Impact. PRISM is a salutogenic, integrative, process-based cognitive-behavioral model to guide physical therapists in managing the multidimensional nature of pain. Keywords: Pain Education, Pain Science, Education: Competency-Based, Chronic Pain, Mental Health, Musculoskeletal Pain, Whole Health, Cognitive Behavioral Therapy, Pain Management, Integrative Pain Management, Process-Based Therapy, Introduction/Background Pain is an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage. (1) Nociception and pain are different phenomena. Nociception is [...]

Psychologically informed practice (PiP) includes a special focus on psychosocial obstacles to recovery, but research trials have revealed significant difficulties in implementing PiP outside of research environments. Qualitative studies have identified problems of both competence and confidence in tackling the psychosocial aspects of care, with a tendency to prefer dealing with the more mechanical aspects of care. In PiP, the distinction between assessment and management is not clear-cut. Analysis of the problem is part of the intervention, and guided self-management begins with the initial detective work by the patient, who is encouraged to develop successful and relevant behavior change. This requires a different style and focus of communication that some clinicians find difficult to enact. In this Perspective, the PiP Consultation Roadmap is offered as a guide for clinical implementation to establish a therapeutic relationship, develop patient-centered communication, and guide effective pain self-management. These strategies are illustrated through the metaphor of the patient learning to drive, with the therapist as a driving instructor and the patient as a student driver. For convenience, the Roadmap is depicted in 7 stages. Each stage represents aspects of the clinical consultation in a recommended order, although the Roadmap should be viewed as a general guide with a degree of flexibility to accommodate individual differences and optimize PiP interventions. It is anticipated that the experienced PiP clinician will find it progressively easier to implement the Roadmap as the building blocks and style of consultation become more familiar. Keywords: Psychologically Informed Practice, Pain, Communication, Introduction A detailed description of psychologically informed practice (PiP) and its origins (1) is presented in the accompanying paper in this issue. (2) In brief, PiP's most distinctive features are [...]

There has been increasing interest in the secondary prevention of chronic pain and pain-associated disability over the past 3 decades. In 2011, psychologically informed practice (PiP) was suggested as a framework for managing persistent and recurrent pain, and, since then, it has underpinned the development of stratified care linking risk identification (screening). Although PiP research trials have demonstrated clinical and economic advantage over usual care, pragmatic studies have been less successful, and qualitative studies have identified implementation difficulties in both system delivery and individual clinical management. Effort has been put into the development of screening tools, the development of training, and the assessment of outcomes; however, the nature of the consultation has remained relatively unexplored. In this Perspective, a review of the nature of clinical consultations and the clinician--patient relationship is followed by reflections on the nature of communication and the outcome of training courses. Consideration is given to the optimization of communication, including the use of standardized patient-reported measures and the role of the therapist in facilitating adaptive behavior change. Several challenges in implementing a PiP approach in day-to-day practice are then considered. Following brief consideration of the impact of recent developments in health care, the Perspective concludes with a brief introduction to the PiP Consultation Roadmap (the subject of a companion paper), the use of which is suggested as a way of structuring the consultation with the flexibility required for a patient-centered approach to guided self-management of chronic pain conditions. Keywords: Psychologically Informed Practice, Pain, Communication, Introduction This Perspective is centered on the nature of the clinical consultation in Psychologically Informed Practice (PiP) and focuses on how the use of communication skills can be used to [...]

I have enjoyed recent Physical Therapy (PTJ) contributions to the dialog on the continued inability of research to meaningfully influence clinical practice. These contributions include the Point of View by [...]

Thank you to Dr Sahrmann for considering our Point of View and sharing her thoughts. (1) We welcome this important discussion and respond to her areas of concern below. Lack [...]

"PTJ gives priority to... articles that address important questions that will have an impact on physical therapy and rehabilitation..." (1). Like many peer-reviewed scientific journals, PTJ: Physical Therapy & Rehabilitation [...]

Objective. The STarT Back Tool (SBT) predicts risk for persistent low back pain (LBP)-related disability based on psychological distress levels. Other non-psychological factors associated with LBP, such as pain sensitivity and physical performance, may further characterize SBT-risk subgroups. The purpose of this study was to determine whether a low-risk SBT subgroup demonstrated lower pain sensitivity and/or higher physical performance compared with a medium-/high-risk SBT subgroup. Methods. In this cross-sectional, secondary analysis, adults with LBP (N = 76) completed SBT and demographics (age, sex, race, chronicity) questionnaires. Participants underwent pain sensitivity (local and remote pressure pain thresholds, temporal summation, conditioned pain modulation) and physical performance (Back Performance Scale, walking speed, obstacle negotiation, Timed "Up & Go" [TUG], TUG Cognitive) testing. Independent samples t tests determined low- versus medium-/high-risk SBT subgroup differences. A follow-up discriminant function analysis was also conducted. Results. The medium-/high-risk subgroup demonstrated a lower proportion of participants with acute pain. The lowrisk subgroup demonstrated lower pain sensitivity (higher local pressure pain thresholds and higher conditioned pain modulation) and higher physical performance (superior Back Performance Scale scores, faster walking speeds, faster obstacle approach and crossing speeds, and faster TUG completion). Discriminant function analysis results supported the 2-subgroup classification and indicated strong to moderate relationships with obstacle crossing speed, chronicity, and conditioned pain modulation. Conclusion. Lower pain sensitivity and higher physical performance characterized the low-risk SBT subgroup and may represent additional LBP prognostic factors associated with persistent disability. Longitudinal studies are needed to confirm whether these factors can enhance SBT prediction accuracy and further direct treatment priorities. Impact. Sensory and physical factors contribute to SBT risk classification, suggesting additional, non-psychological factors are indicative of favorable LBP outcomes. Findings highlight the need for assessment of multiple factors to improve LBP clinical prediction. Lay Summary. People at low risk for back pain disability have less sensitivity to pain and better physical performance. By measuring these factors, physical therapists could guide treatment and improve outcomes for people with back pain. Keywords: Low Back Pain, Musculoskeletal Pain, Subgrouping, Walking Function, Introduction Low back pain (LBP) is a common musculoskeletal pain condition. In 2017,the global LBP point prevalence was 7.5%, or 577 million. (1) LBP is also the leading cause of [...]

Objective. The purpose of this study was to develop screening measures using item response theory (IRT) for 2 factors highly relevant to fear of movement (FoM): fear avoidance and negative pain coping. Methods. A total of 431 patients with neck (n = 93), shoulder (n = 108), low back (n=119), or knee (n = 111) conditions seeking physical therapy completed 8 validated psychological questionnaires measuring fear avoidance and negative pain coping, resulting in 97 candidate items for IRT analysis. Unidimensionality and local independence were assessed using exploratory factor analyses followed by confirmatory factor analyses. Items were assessed for model fit to the graded response model for ordinal items. Using the final item bank, a computer adaptive test (CAT) administration mode was constructed, and reduced item sets were selected to create short forms (SFs), including items with highest information (reliability) at the different levels of the trait being measured while also considering clinical content. Results. The results supported a 28-item bank for fear avoidance and 16-item bank for negative pain coping. A 10-item and 8-item SF were developed for fear avoidance and negative pain coping, respectively. Additionally, 4-item form versions were created to provide options with lower administrative burden. CAT administration used a mean (median) of 7.7 (8) and 7.0 (7) items for fear avoidance and negative pain coping, respectively. All factors demonstrated construct validity by discriminating patient groups in expected clinical patterns. Conclusion. These newly derived SFs and CAT administration modes provide reliable, valid, and efficient options to screen for fear avoidance and negative pain coping in populations with musculoskeletal pain. Impact. These tools, collectively referred to as the Screening for Pain Vulnerability and Resilience tools, address a critical need for standard FoM screening processes that aid in clinical decision-making to identify who might benefit from psychologically informed approaches. Keywords: Musculoskeletal Pain, Psychological, Rehabilitation, Screening, Introduction Musculoskeletal pain is a prevalent and costly health condition with significant public health impacts, including chronic pain, disability, and opioid-related addiction. (1-3) Fear of movement (FoM), a key element [...]

Objective. Chronic low back pain (CLBP) is a disabling and costly condition for older adults that is difficult to properly classify and treat. In a cohort study, a subgroup of older adults with CLBP who had elevated hip pain and hip muscle weakness was identified; this subgroup differentiated itself by being at higher risk for future mobility decline. The primary purpose of this clinical trial is to evaluate whether a hip-focused low back pain (LBP) treatment provides better disability and physical performance outcomes for this at-risk group compared with a spine-focused LBP treatment. Methods. This study is a multisite, single-blinded, randomized controlled, parallel arm, Phase II trial conducted across 3 clinical research sites. A total of 180 people aged between 60 and 85 years with CLBP and hip pain are being recruited. Participants undergo a comprehensive baseline assessment and are randomized into 1 of 2 intervention arms: hip-focused or spine-focused. They are treated twice weekly by a licensed physical therapist for 8 weeks and undergo follow-up assessments at 8 weeks and 6 months after randomization. Primary outcome measures include the Quebec Low Back Disability Scale and the 10-Meter Walk Test, which are measures of self-report and performance-based physical function, respectively. Impact. This multicenter, randomized clinical trial will determine whether a hip-focused or spine-focused physical therapist intervention results in improved disability and physical performance for a subgroup of older adults with CLBP and hip pain who are at increased risk of mobility decline. This trial will help further the development of effective interventions for this subgroup of older adults with CLBP. Keywords: Hip Pain, Low Back Pain, Older Adults, Osteoarthritis, Physical Function, Introduction Chronic low back pain (CLBP) is a prevalent, costly, and disabling problem in the older adult population; the rising prevalence suggests that current treatment approaches are not effective. (1-8) [...]