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Farrokhi S, Bechard L, Gorczynski S, Patterson C, Kakyomya J, Hendershot BD, Condon R, Perkins LTCM, Rhon DI, Delitto A, Schneider M, Dearth CL. The Influence of Active, Passive, and Manual Therapy Interventions for Low Back Pain on Opioid Prescription and Health Care Utilization. Phys Ther 2024; 104:pzad173. [PMID: 38112119 DOI: 10.1093/ptj/pzad173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 08/10/2023] [Accepted: 10/19/2023] [Indexed: 12/20/2023]
Abstract
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.
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Affiliation(s)
- Shawn Farrokhi
- Extremity Trauma and Amputation Center of Excellence, Defense Health Agency, Falls Church, Virginia, USA
- Department of Physical and Occupational Therapy, Naval Medical Center San Diego, San Diego, California, USA
- Department of Rehabilitation Medicine, Uniformed Services University of Health Sciences, Bethesda, Maryland, USA
| | - Laura Bechard
- Extremity Trauma and Amputation Center of Excellence, Defense Health Agency, Falls Church, Virginia, USA
- Department of Physical and Occupational Therapy, Naval Medical Center San Diego, San Diego, California, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine Inc, Bethesda, Maryland, USA
| | - Sara Gorczynski
- Extremity Trauma and Amputation Center of Excellence, Defense Health Agency, Falls Church, Virginia, USA
- Department of Physical and Occupational Therapy, Naval Medical Center San Diego, San Diego, California, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine Inc, Bethesda, Maryland, USA
| | - Charity Patterson
- Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Joseph Kakyomya
- Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Brad D Hendershot
- Extremity Trauma and Amputation Center of Excellence, Defense Health Agency, Falls Church, Virginia, USA
- Department of Rehabilitation Medicine, Uniformed Services University of Health Sciences, Bethesda, Maryland, USA
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Rachel Condon
- Army-Baylor Doctoral Program in Physical Therapy, Fort Sam Houston, Texas, USA
| | - L T C Matthew Perkins
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Daniel I Rhon
- Department of Rehabilitation Medicine, Uniformed Services University of Health Sciences, Bethesda, Maryland, USA
| | - Anthony Delitto
- Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Michael Schneider
- Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Christopher L Dearth
- Extremity Trauma and Amputation Center of Excellence, Defense Health Agency, Falls Church, Virginia, USA
- Department of Rehabilitation Medicine, Uniformed Services University of Health Sciences, Bethesda, Maryland, USA
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
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Tesfa A, Petrosyan H, Fahmy M, Sexton T, Arvanian V. Spinal magnetic stimulation to treat chronic back pain: a feasibility study in veterans. Pain Manag 2024; 14:75-85. [PMID: 38314568 DOI: 10.2217/pmt-2023-0004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2024] Open
Abstract
Aim: Chronic low back pain represents a significant societal problem leading to increased healthcare costs and quality of life. This study was designed to evaluate the feasibility and effectiveness of non-invasive spinal electromagnetic simulation (SEMS) to treat nonspecific chronic low back pain (CLBP). Methods: A single-site prospective study was conducted to evaluate SEMS in reducing pain and improving disability. A total of 17 patients received SEMS two to three sessions a week. The Numeric Rating Scale and the Modified Oswestry Disability Questionnaire were used to assess pain and disability. Results: Participants receiving SEMS exhibited statistically significant reductions in pain and disability. Conclusion: Current results suggest that non-invasive SEMS can be an effective treatment in reducing pain and improving disability associated with CLBP.
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Affiliation(s)
- Asrat Tesfa
- Research & Development Service, Department of Veterans Affairs Medical Center, Northport, 11768, NY, USA
| | - Hayk Petrosyan
- Department of Physical Medicine & Rehabilitation, Hackensack Meridian, JFK Johnson Rehabilitation Institute, Edison, 08820, NJ, USA
| | - Magda Fahmy
- Physical Medicine & Rehabilitation Service, Department of Veterans Affairs Medical Center, Northport, 11768, NY, USA
| | - Thomas Sexton
- College of Business, Stony Brook University, Stony Brook, 11790, NY, USA
| | - Victor Arvanian
- Research & Development Service, Department of Veterans Affairs Medical Center, Northport, 11768, NY, USA
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Kerns RD, Davis AF, Fritz JM, Keefe FJ, Peduzzi P, Rhon DI, Taylor SL, Vining R, Yu Q, Zeliadt SB, George SZ. Intervention Fidelity in Pain Pragmatic Trials for Nonpharmacologic Pain Management: Nuanced Considerations for Determining PRECIS-2 Flexibility in Delivery and Adherence. THE JOURNAL OF PAIN 2023; 24:568-574. [PMID: 36574858 PMCID: PMC10079571 DOI: 10.1016/j.jpain.2022.12.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 12/05/2022] [Accepted: 12/18/2022] [Indexed: 12/25/2022]
Abstract
Nonpharmacological treatments are considered first-line pain management strategies, but they remain clinically underused. For years, pain-focused pragmatic clinical trials (PCTs) have generated evidence for the enhanced use of nonpharmacological interventions in routine clinical settings to help overcome implementation barriers. The Pragmatic Explanatory Continuum Indicator Summary (PRECIS-2) framework describes the degree of pragmatism across 9 key domains. Among these, "flexibility in delivery" and "flexibility in adherence," address a key goal of pragmatic research by tailoring approaches to settings in which people receive routine care. However, to maintain scientific and ethical rigor, PCTs must ensure that flexibility features do not compromise delivery of interventions as designed, such that the results are ethically and scientifically sound. Key principles of achieving this balance include clear definitions of intervention core components, intervention monitoring and documentation that is sufficient but not overly burdensome, provider training that meets the demands of delivering an intervention in real-world settings, and use of an ethical lens to recognize and avoid potential trial futility when necessary and appropriate. PERSPECTIVE: This article presents nuances to be considered when applying the PRECIS-2 framework to describe pragmatic clinical trials. Trials must ensure that patient-centered treatment flexibility does not compromise delivery of interventions as designed, such that measurement and analysis of treatment effects is reliable.
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Affiliation(s)
- Robert D Kerns
- Departments of Psychiatry, Neurology, and Psychology, Yale University, New Haven, Connecticut, Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center of Innovation, VA Connecticut Healthcare System, West Haven, Connecticut.
| | - Alison F Davis
- Pain Management Collaboratory, Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut
| | - Julie M Fritz
- Department of Physical Therapy & Athletic Training, College of Health, The University of Utah, Salt Lake City, Utah
| | - Francis J Keefe
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Peter Peduzzi
- Department of Biostatistics, Yale Center for Analytical Sciences, Yale School of Public Health, , New Haven, Connecticut
| | - Daniel I Rhon
- Department of Rehabilitation Medicine, School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Stephanie L Taylor
- Center for the Study of Healthcare Innovation, Implementation and Policy, Veterans Health Administration, Greater Los Angeles VA Health Care System, Los Angeles, California; Department of Medicine and Department of Health Policy and Management, UCLA, Los Angeles, California
| | - Robert Vining
- Palmer Center for Chiropractic Research, Palmer College of Chiropractic, Davenport, Iowa
| | - Qilu Yu
- Office of Clinical and Regulatory Affairs, National Institutes of Health, National Center for Complementary and Integrative Health, Bethesda, Maryland
| | - Steven B Zeliadt
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington; Department of Health Services, School of Public Health, University of Washington, Seattle, Washington
| | - Steven Z George
- Laszlo Ormandy Distinguished Professor, Department of Orthopaedic Surgery and Duke Clinical Research Institute, Duke University, Durham North Carolina
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