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Grenier JP, Rothmund M. A critical review of the role of manual therapy in the treatment of individuals with low back pain. J Man Manip Ther 2024; 32:464-477. [PMID: 38381584 PMCID: PMC11421166 DOI: 10.1080/10669817.2024.2316393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 02/04/2024] [Indexed: 02/23/2024] Open
Abstract
The number of low back pain (LBP) cases is projected to increase to more than 800 million by 2050. To address the substantial burden of disease associated with this rise in prevalence, effective treatments are needed. While clinical practice guidelines (CPG) consistently recommend non-pharmacological therapies as first-line treatments, recommendations regarding manual therapy (MT) in treating low back pain vary. The goal of this narrative review was to critically summarize the available evidence for MT behind these recommendations, to scrutinize its mechanisms of action, and propose some actionable steps for clinicians on how this knowledge can be integrated into a person-centered approach. Despite disparate recommendations from CPG, MT is as effective as other available treatments and may be offered to patients with LBP, especially as part of a treatment package with exercise and education. Most of the effects of MT are not specific to the technique. MT and other interventions share several mechanisms of action that mediate treatment success. These mechanisms can encompass patients' expectations, prior experiences, beliefs and convictions, epistemic trust, and nonspecific contextual effects. Although MT is safer than opioids for patients with LBP, this alone is insufficient. Our goal is to encourage clinicians to shift away from outdated and refuted ideas in MT and embrace a person-centered approach rooted in a comprehensive biopsychosocial framework while incorporating patients' beliefs, addressing illness behaviors, and seeking to understand each patient's journey.
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Affiliation(s)
- Jean-Pascal Grenier
- Department of Physiotherapy, Health University of Applied Sciences Tyrol, Innsbruck, Austria
- Department of Internal Medicine II, University Clinic Innsbruck, Innsbruck, Austria
| | - Maria Rothmund
- Department of Psychiatry, Psychotherapy, Psychosomatics, and Medical Psychology, University Clinic for Psychiatry II, Medical University Innsbruck, Innsbruck, Austria
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Paris Ferrer T, Masaracchio M, Kirker K, Madi Dewan B, Manthripragada M, Ojha H. Outcomes of direct access telehealth physical therapy for patients with musculoskeletal pain: a single cohort observational retrospective study. Physiother Theory Pract 2024; 40:2233-2240. [PMID: 37585711 DOI: 10.1080/09593985.2023.2245032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 08/02/2023] [Accepted: 08/02/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND Telehealth direct access physical therapy is becoming more prevalent in the management of outpatient musculoskeletal pain. This innovative model affords more opportunity to reach potential patients who otherwise would not be able to access services due to geographical isolation, travel barriers, and timely access to quality care. OBJECTIVE The purpose of the study was to investigate if pain, function, and ability to perform jobs improved after direct access telehealth physical therapy in patients with musculoskeletal pain. METHODS A single cohort retrospective design was implemented to offer telehealth physical therapy to patients with musculoskeletal pain from March to November 2021. Eligible patients were at least 18 years old, located in California, and had a history of peripartum pelvic dysfunction, muscle pain, joint pain, or neural symptoms. Paired-samples t-tests and the Wilcoxon signed-rank test were used to analyze normally distributed and non-parametric data (α = 0.05), respectively, to compare pretest and post scores. RESULTS Based on 89 participants, paired-samples t-tests showed statistically significant differences in function [t(87) = 20.71, p < .0001] and pain [t(82) = -8.15, p < .0001]. Wilcoxon's signed-rank test showed statistically significant differences in ability to perform job (Z = -7.345, p < .0001). CONCLUSION This study demonstrated that in a cohort of individuals with multiregional musculoskeletal pain, there was a decrease in pain and improvements in function and ability to perform job after direct access telehealth physical therapy.
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Affiliation(s)
- Tiffany Paris Ferrer
- Department of Physical Therapy, Malcom Randall VA Medical Center, Gainesville, FL, USA
| | | | - Kaitlin Kirker
- Department of Physical Therapy, Long Island University, Brooklyn, NY, USA
| | | | | | - Heidi Ojha
- Department of Physical Therapy, Aware Health, Lafayette, CA, USA
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Pérez-de la Cruz S. Influence and Relationship of Pain on Lumbar Biomechanics in a Young Adult Population with Non-Specific Low Back Pain. Sports (Basel) 2024; 12:190. [PMID: 39058081 PMCID: PMC11281180 DOI: 10.3390/sports12070190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Revised: 06/24/2024] [Accepted: 07/09/2024] [Indexed: 07/28/2024] Open
Abstract
The therapeutic actions indicated for low back pain, in addition to physiotherapy, include mobilization of the affected segment, as it is assumed that a loss of mobility may contribute to a patient's pain. The aim of this study was to investigate the influence of back pain on the degrees of spinal mobility in young adults. Eighty-six volunteers participated in the study. Fingertip-to-floor distance, Schöber's test, the fingertip-to-floor lateral flexion test, GHQ-12, the Fear-Avoidance Beliefs Questionnaire and the STarT Back Screening Tool were used. There were statistically significant differences between the two groups (pain and no pain) in degrees of spinal flexion (Schöber's test and side flexion) showing greater mobility in the group with pain. However, the group with low back pain showed less rotational mobility. The presence or absence of back pain had an impact on the individual's sporting practice and perception of pain, and they were able to carry out their sporting activities normally. Young adults with idiopathic low back pain showed some statistically significant differences in relation to the mobility of the spine in the different planes of movement (flexion and side flexion), conditioning their quality of life and sports practice.
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Duarte ST, Moniz A, Costa D, Donato H, Heleno B, Aguiar P, Cruz EB. Low back pain management in primary healthcare: findings from a scoping review on models of care. BMJ Open 2024; 14:e079276. [PMID: 38754873 PMCID: PMC11097853 DOI: 10.1136/bmjopen-2023-079276] [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: 08/31/2023] [Accepted: 04/11/2024] [Indexed: 05/18/2024] Open
Abstract
INTRODUCTION Models of care (MoCs) describe evidence-informed healthcare that should be delivered to patients. Several MoCs have been implemented for low back pain (LBP) to reduce evidence-to-practice gaps and increase the effectiveness and sustainability of healthcare services. OBJECTIVE To synthesise research evidence regarding core characteristics and key common elements of MoCs implemented in primary healthcare for the management of LBP. DESIGN Scoping review. DATA SOURCES Searches on MEDLINE (PubMed), EMBASE, Cochrane Central Register of Controlled Trials, PEDro, Scopus, Web of Science and grey literature databases were conducted. ELIGIBILITY CRITERIA Eligible records included MoCs implemented for adult LBP patients in primary healthcare settings. DATA EXTRACTION AND SYNTHESIS Data extraction was carried out independently by two researchers and included a summary of the studies, the identification of the MoCs and respective key elements, concerning levels of care, settings, health professionals involved, type of care delivered and core components of the interventions. Findings were investigated through a descriptive qualitative content analysis using a deductive approach. RESULTS 29 studies reporting 11 MoCs were included. All MoCs were implemented in high-income countries and had clear objectives. Ten MoCs included a stratified care approach. The assessment of LBP patients typically occurred in primary healthcare while care delivery usually took place in community-based settings or outpatient clinics. Care provided by general practitioners and physiotherapists was reported in all MoCs. Education (n=10) and exercise (n=9) were the most common health interventions. However, intervention content, follow-ups and discharge criteria were not fully reported. CONCLUSIONS This study examines the features of MoCs for LBP, highlighting that research is in its early stages and stressing the need for better reporting to fill gaps in care delivery and implementation. This knowledge is crucial for researchers, clinicians and decision-makers in assessing the applicability and transferability of MoCs to primary healthcare settings.
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Affiliation(s)
- Susana Tinoco Duarte
- Comprehensive Health Research Centre, NOVA National School of Public Health - NOVA University Lisbon, Lisboa, Portugal
- Department of Physiotherapy, Polytechnic Institute of Setúbal - School of Health Care, Setúbal, Portugal
| | - Alexandre Moniz
- Department of Physiotherapy, Polytechnic Institute of Setúbal - School of Health Care, Setúbal, Portugal
- Comprehensive Health Research Centre, NOVA Medical School | Faculdade de Ciências Médicas, NMS | FCM - NOVA University Lisbon, Lisboa, Portugal
| | - Daniela Costa
- Department of Physiotherapy, Polytechnic Institute of Setúbal - School of Health Care, Setúbal, Portugal
- Department of Physiotherapy, Escola Superior de Saúde do Alcoitão, Alcabideche, Portugal
| | - Helena Donato
- Documentation and Scientific Information Service, Centro Hospitalar e Universitario de Coimbra EPE, Coimbra, Portugal
- University of Coimbra Faculty of Medicine, Coimbra, Portugal
| | - Bruno Heleno
- Comprehensive Health Research Centre, NOVA Medical School | Faculdade de Ciências Médicas, NMS | FCM - NOVA University Lisbon, Lisboa, Portugal
| | - Pedro Aguiar
- Comprehensive Health Research Centre, NOVA National School of Public Health - NOVA University Lisbon, Lisboa, Portugal
| | - Eduardo B Cruz
- Department of Physiotherapy, Polytechnic Institute of Setúbal - School of Health Care, Setúbal, Portugal
- Comprehensive Health Research Centre, NOVA University Lisbon, Lisboa, Portugal
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Hubeishy MH, Rossen CB, Dannapfel P, Thomas K, Jensen TS, Maribo T, Rolving N. Developing a low back pain guideline implementation programme in collaboration with physiotherapists and chiropractors using the Behaviour Change Wheel: a theory-driven design study. Implement Sci Commun 2024; 5:33. [PMID: 38570830 PMCID: PMC10993475 DOI: 10.1186/s43058-024-00568-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 03/09/2024] [Indexed: 04/05/2024] Open
Abstract
BACKGROUND Low back pain is still the leading cause of disability and societal burden, with 619 million prevalent cases worldwide in 2020. Most countries produce clinical guidelines to support healthcare professionals in evidence-based care regarding low back pain. However, several studies have identified relatively poor uptake of guidelines. Tailored strategies to facilitate the implementation of guidelines have been argued to increase uptake. This study aimed to develop a contextually tailored implementation programme to enhance evidence-based low back pain care among Danish physiotherapists and chiropractors in primary care. METHODS A theory-driven implementation programme development study was conducted using the Behaviour Change Wheel, with high healthcare professional involvement. Data collection included four workshops with seven physiotherapists and six chiropractors from primary care clinics. The development process consisted of [1] establishing a theoretical frame, [2] involving participants, [3] understanding the behaviour, [4] designing the implementation programme, and [5] final implementation programme. RESULTS The target behaviours selected (guideline recommendations) for the implementation programme were (i) screening of psychosocial risk factors and (ii) offering patient education. The barriers and facilitators for the selected behaviours were described and linked to intervention functions and behavioural techniques. Finally, the implementation programme comprised five strategies: webinars, e-learning videos, communication exercises, peer learning, and group dialogue meetings. In addition, the programme consisted of implementation support: champions, a physical material folder, a weekly email reminder, a specially designed website and a visit from an implementation consultant. An essential element of the overall programme was that it was designed as a step-by-step implementation process consisting of 16 h of education and training distributed over 16 weeks. CONCLUSIONS A programme for implementing low back pain guideline recommendations was developed based on behaviour change theory and four co-design workshops involving healthcare professionals to overcome the contextually identified barriers. A theory-driven approach involving healthcare professionals was useful in identifying relevant target behaviours and tailoring the programme to consider contextual barriers and facilitators for implementation. The effectiveness of the final implementation programme will be evaluated in the project's next phase. TRIAL REGISTRATION Central Denmark Region, Registered November 11, 2021, act no. 1-16-02-93-19.
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Affiliation(s)
- Maja Husted Hubeishy
- Interdisciplinary Research Unit, Elective Surgery Centre, Silkeborg Regional Hospital, Hospital in Central Denmark Region, Falkevej 1-3, 8600, Silkeborg, Denmark.
- Department of Public Health, Aarhus University, Aarhus, Denmark.
- Department of Physiotherapy and Occupational Therapy, Aarhus University Hospital, Aarhus, Denmark.
| | - Camilla Blach Rossen
- Interdisciplinary Research Unit, Elective Surgery Centre, Silkeborg Regional Hospital, Hospital in Central Denmark Region, Falkevej 1-3, 8600, Silkeborg, Denmark
| | - Petra Dannapfel
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Kristin Thomas
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Tue Secher Jensen
- Diagnostic Centre - Imaging Section, Silkeborg Regional Hospital, Silkeborg, Denmark
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Thomas Maribo
- Department of Public Health, Aarhus University, Aarhus, Denmark
- DEFACTUM, Central Region Denmark, Aarhus, Denmark
| | - Nanna Rolving
- Department of Public Health, Aarhus University, Aarhus, Denmark
- Department of Physiotherapy and Occupational Therapy, Aarhus University Hospital, Aarhus, Denmark
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Bauer MR, Richard P, Ritter G, Yoon J, Larson MJ. Clinician approaches to new spine pain cases in primary care: Balance of opioid prescribing and early linkage to exercise therapy and spinal manipulation. J Eval Clin Pract 2024; 30:355-366. [PMID: 38062882 PMCID: PMC11023770 DOI: 10.1111/jep.13944] [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: 06/06/2023] [Revised: 09/29/2023] [Accepted: 10/26/2023] [Indexed: 02/28/2024]
Abstract
RATIONALE, AIMS AND OBJECTIVES Spine pain (SP) is common and often disabling. Clinical practice guidelines discourage opioid treatment and outline the value of varied nonpharmacologic therapies (NPTs). This study elucidates the amount of variability in primary-care clinicians' (PCPs') prescribing of opioids and in their cases' receipt of the two most common NPTs (exercise therapy and spinal manipulation). METHOD The design was a retrospective cohort study examining variation in the treatment of PCPs' new SP cases, classified by receipt of (a) prescription of an opioid at the initial visit; (b) exercise therapy and/or spinal manipulation within 30 days of initial visit. The study was set in the primary care clinics at military treatment facilities of the US Military Health System in the period between October 2011 and September 2016. RESULTS The majority of cases did not receive a study treatment (66.3%); 19.6% of cases received only NPT within 30 days of initial visit; 11.5% were prescribed only an opioid at the initial visit with receipt of both NPT and opioid during early treatment rare (2.6%). Exercise therapy within 30 days exhibited more than a twofold difference in interquartile percentile rates (IQR) (median provision 15.8%, IQR 9.8%-22.1%). The other treatments exhibited even greater variation; specifically, spinal manipulation (median 8.5%, IQR 3.3%-15.8%), and opioid at initial visit (median 10.3%, IQR 4.4%-18.2%). The availability of physical therapists and doctors of chiropractic had significant association with several clinical provision rates. CONCLUSION Among providers of spine care for a sample of Army soldiers, there was substantial variation in the early provision of exercise therapy, spinal manipulation, and opioid prescriptions. The magnitude of the case-mix adjusted variation and its association with facility availability of providers suggests that quality of care initiatives may help reduce this variation.
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Affiliation(s)
- Mark R. Bauer
- Heller School for Social Policy and Management, Brandeis University, Waltham MA
| | - Patrick Richard
- Preventive Medicine & Biostatistics, Uniformed Services University, Bethesda MD
| | - Grant Ritter
- Heller School for Social Policy and Management, Brandeis University, Waltham MA
| | - Jangho Yoon
- Preventive Medicine & Biostatistics, Uniformed Services University, Bethesda MD
| | - Mary Jo Larson
- Heller School for Social Policy and Management, Brandeis University, Waltham MA
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Kosakowski H, Rone-Adams S, Boissonnault WG, Harmon-Matthews L, Kuczynski J, Martin M, Briggs MS. Financial impact associated with implementation of the low back pain clinical practice guideline in outpatient physical therapist practice at a large academic medical center. Physiother Theory Pract 2024; 40:746-754. [PMID: 36567617 PMCID: PMC10290726 DOI: 10.1080/09593985.2022.2160940] [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] [Received: 04/04/2022] [Revised: 12/12/2022] [Accepted: 12/14/2022] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Low back pain (LBP) is the top health condition requiring rehabilitation in the United States. The financial burden of managing LBP is also amongst the highest in the United States. Clinical practice guidelines (CPGs) provide management recommendations and have the potential to lower health costs. Limited evidence exists on the impact of CPG implementation on downstream medical costs. OBJECTIVE To examine the impact of CPG implementation in physical therapist (PT) practice on direct and downstream costs for patients with LBP. METHODS A retrospective observational study examined billing data from 270 patients with LBP who were treated at multiple sites within one large academic medical center by PTs who participated in a multifaceted CPG implementation program. Costs were analyzed for direct PT services, downstream medical services, and PT utilization from September 2017 to March 2018 (pre-implementation group) and compared with costs from June 2018 to December 2018 (post-implementation group). RESULTS Direct PT costs were significantly lower post-implementation than pre-implementation mean: $2,863 USD (SD: $1,968) vs. $3,459 USD (SD: $2,838), p = .05, 95% CI [11, 1182]. All downstream costs were lower post-implementation with statistically significant lower costs found in downstream imaging: p = .04, 95% CI [32, 1,905]; pharmacy: p = .03, 95% CI [70, 1,217]; surgery: p = .03, 95% CI [446, 9,152], and "other": p = .02, 95% CI [627, 7,920]. CONCLUSION Implementing the LBP CPG in outpatient PT practice can have a positive impact on lowering downstream costs and the potential to increase the value of PT services.
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Affiliation(s)
- Heidi Kosakowski
- World Physiotherapy, Unit 17 Empire Square, London, SE1 4NA United Kingdom
| | - Shari Rone-Adams
- Nova Southeastern University, 3200 S. University Drive, Fort Lauderdale, FL 33328
| | - William G. Boissonnault
- University of Wisconsin-Madison, Department of Orthopedics, 1300 University Avenue, Madison, WI 53706
| | - Lindsay Harmon-Matthews
- Jameson Crane Sports Medicine Institute, Ohio State University, Wexner Medical Center, 2835 Fred Taylor Drive, Columbus, OH, 43202
| | - J.J. Kuczynski
- James Cancer Hospital and Solove Research Institute, Ohio State University Wexner Medical Center, 410 W. 10 Avenue, Columbus, OH 43210
| | - Michael Martin
- Richard M. Ross Heart Hospital, Ohio State University Wexner Medical Center, 452 W 10 Avenue, Suite 1255, Columbus, OH 43210
| | - Matthew S. Briggs
- Jameson Crane Sports Medicine Institute, Ohio State University, Wexner Medical Center, 2835 Fred Taylor Drive, Columbus, OH, 43202
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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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9
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Hubeishy MH, Rolving N, Poulsen AG, Jensen TS, Rossen CB. Barriers to the use of clinical practice guidelines: a qualitative study of Danish physiotherapists and chiropractors. Disabil Rehabil 2024; 46:105-114. [PMID: 36537245 DOI: 10.1080/09638288.2022.2157501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 12/06/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE Low back pain (LBP) is the leading cause of disability worldwide. Providing evidence-based practice (EBP) for patients with LBP is more cost-effective compared with non-EBP. To help health care professionals provide EBP, several clinical practice guidelines have been published. However, a relatively poor uptake of the guidelines has been identified across various countries. To enhance future implementation of EBP, the aim of this study was to explore barriers to using LBP guidelines in clinical practice. MATERIALS AND METHODS A qualitative constructivist grounded theory design was employed in order to gain an in-depth understanding of the barriers. Semi-structured interviews (+/- observations) of nine physiotherapists and nine chiropractors from primary care in the Central Denmark Region were conducted. RESULTS Two key barriers were found to using guidelines in practice: (1) a scepticism due to doubts about validity and applicability of the guidelines, which emerged particularly among physiotherapists; and (2) a deep biomechanical professional identity, due to perceived role, interest, lack of skills, and patient preferences, which emerged particularly among chiropractors. CONCLUSIONS For guidelines to be better implemented in practice, these key barriers must be addressed in a tailored strategy. Furthermore, this study showed a difference in barriers between the two professions.
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Affiliation(s)
- Maja Husted Hubeishy
- Interdisciplinary Research Unit, Elective Surgery Centre, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Nanna Rolving
- Department of Physiotherapy and Occupational Therapy, Aarhus University Hospital, Aarhus, Denmark
- Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Anne Grøndahl Poulsen
- DEFACTUM, Public Health and Rehabilitation Research, Central Region Denmark, Aarhus, Denmark
| | - Tue Secher Jensen
- Diagnostic Center - Imaging Section, Silkeborg Regional Hospital, Silkeborg, Denmark
- Department of Sport Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Camilla Blach Rossen
- Interdisciplinary Research Unit, Elective Surgery Centre, Silkeborg Regional Hospital, Silkeborg, Denmark
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D Delgado A, Salazar SI, Rozaieski K, Putrino D, Tabacof L. Engagement in an mHealth-Guided Exercise Therapy Program Is Associated With Reductions in Chronic Musculoskeletal Pain. Am J Phys Med Rehabil 2023; 102:984-989. [PMID: 37026894 DOI: 10.1097/phm.0000000000002257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
Abstract
CONTEXT Chronic musculoskeletal pain costs the US $980 billion annually. Conservative treatments are the criterion standard, but scalable methods of treatment remain to be evaluated. OBJECTIVE The aim of the study is to determine the effects of pain reduction and the perceived benefits of an mHealth exercise therapy program. DESIGN This is a retrospective observational study on data from 3109 people (18-98, 49% female) with musculoskeletal pain in an mHealth exercise program. Presession pain was measured via 11-point numeric rating scale and nonstandardized single-item questions for work and quality of life; all were analyzed using mixed-effects models. RESULTS By 11 sessions, there was an estimated a 2.09-point decrease in average numeric rating scale pain levels. There was an average percent increase of approximately 0.7 points for work life and quality of life ( tdf =6,632 = 12.06, P < 0.001). User engagement was high; 46% of participants were performing more than one session per day, and 88% were engaging within a week, indicating the feasibility of the deployment of an mHealth exercise app. CONCLUSIONS An mHealth exercise program was associated with significant decrease in pain and increased perceived benefits in a large population. These findings serve as preliminary findings of the feasibility for mHealth exercise interventions as scalable tools to improve chronic musculoskeletal pain outcomes.
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Affiliation(s)
- Andrew D Delgado
- From the Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York City, New York (ADD, SIS, DP, LT); and Cape May Veterans Affairs Community Based Outpatient Clinic, Wilmington VAMC, Wilmington, Delaware (KR)
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Bourassa M, Kolb WH, Barrett D, Wassinger C. Guideline adherent screening and referral: do third year Doctor of Physical Therapy students identify red and yellow flags within descriptive patient cases? a United States based survey study. J Man Manip Ther 2023; 31:253-260. [PMID: 36740949 PMCID: PMC10324444 DOI: 10.1080/10669817.2023.2170743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 01/16/2023] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION The need for early detection and appropriate management of flags in physical therapy has been established. The lack of early detection has been shown to lead to poor outcomes such as serious pathology, increased disability, prolonged symptoms, and increased healthcare utilization. OBJECTIVE The main purpose of this survey study was to assess third-year Doctor of Physical Therapy (DPT) students' adherence to clinical practice guidelines specifically in the identification and management of red and yellow flags through a case-based approach. METHODS A survey including three different flag case scenarios was sent to DPT students in 15 geographically diverse physical therapy programs. Previously published case scenarios measuring adherence to practice guidelines were used. Correlational analyses were performed to link student demographic details and guideline adherent management. RESULTS The survey was completed by 64 students. Guideline adherent management was greater for red flags (85%) than yellow flag cases (25% and 42%). No significant relationship was noted between the student details and guideline adherent management. CONCLUSION DPT students may need additional educational content related to yellow flag screening. Educators may consider utilizing published red and yellow flag cases to guide decision-making and highlight best screening practices.
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Affiliation(s)
- Michael Bourassa
- Department of Rehabilitative Sciences, East Tennessee State University, Johnson City, Tennessee, United States
- Doctor of Physical Therapy Program, East Tennessee State University, Johnson City, Tennessee
| | - William H. Kolb
- Department of Physical Therapy, Waldron College of Health Sciences, Radford University Carilion, Roanoke, VA, United States
| | - Dustin Barrett
- Doctor of Physical Therapy Program, School of Health Sciences, Emory & Henry College, Marion, Virginia, United States
| | - Craig Wassinger
- Director of Research and Faculty Development, Doctor of Physical Therapy Program, Tufts University School of Medicine, Boston, MA, United States
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Olivier TJ, Konda C, Pham T, Baltich Nelson B, Patel A, Sharma GS, Trivedi K, Annaswamy TM. Clinical practice guidelines on interventional management of low back pain: A synthesis of recommendations. PM R 2023; 15:1052-1063. [PMID: 36507598 DOI: 10.1002/pmrj.12930] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 11/14/2022] [Accepted: 11/14/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To summarize the recommendations on the interventional management of subacute and chronic nonradicular low back pain (LBP) from the 21 quality-appraised clinical practice guidelines (CPGs) identified in a previously published paper: "Quality of Clinical Practice Guidelines on Interventional Management of Low Back Pain: A Systematic Review." By disseminating this information, we aimed to facilitate the implementation of these recommendations into clinical practice. TYPE: Systematic Review LITERATURE SURVEY: Electronic bibliographic databases, guideline databases, and gray literature were searched from January 2016 to January 2020 to identify CPGs that met study criteria. METHODOLOGY A total of 21 CPGs were quality appraised and interventional management recommendations were extracted and organized into several treatment categories including epidural steroid injections, radiofrequency procedures (RF), facet injections, sacroiliac injections, and prolotherapy. Within each treatment category, the recommendations were organized based on two factors: quality of CPG and strength of recommendation. SYNTHESIS Overall, there was no consistency in recommendations for or against any interventional procedure, even when accounting for the quality of the CPG. In all of the CPGs reviewed, the most common strength of recommendation was weakly for. The second, third, and fourth most common strength of recommendations were inconclusive, weakly against, and strongly against, respectively, and the least common was strongly for. The treatment categories with the greatest number of recommendations were RF procedures (most common strength of recommendation was weakly for) and facet procedures. Among the high-quality CPGs, the most common strength of recommendation was inconclusive. CONCLUSIONS Most of the interventional management recommendations for management of nonradicular LBP in the 21 CPGs appraised in this review were either weakly for, weakly against, or inconclusive, with several recommendations within each treatment category contradicting each other. Appraisal of Guidelines for Research & Evaluation Instrument quality appraisals of CPGs on interventional management of LBP were of unclear utility in guiding clinical implementation.
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Affiliation(s)
- Timothy J Olivier
- Department of Physical Medicine & Rehabilitation, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Chaitanya Konda
- Department of Physical Medicine & Rehabilitation, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Tri Pham
- University of Texas Southwestern Medical School, Dallas, Texas, USA
| | - Becky Baltich Nelson
- Clinical Library, University of Massachusetts Medical Center, Worcester, Massachusetts, USA
| | - Ankit Patel
- Department of Physical Medicine & Rehabilitation, UT Southwestern Medical Center, Dallas, Texas, USA
| | - G Sunny Sharma
- Department of Physical Medicine & Rehabilitation, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Kavita Trivedi
- Department of Physical Medicine & Rehabilitation, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Thiru M Annaswamy
- Department of Physical Medicine & Rehabilitation, UT Southwestern Medical Center, Dallas, Texas, USA
- Physical Medicine & Rehabilitation Service, VA North Texas Health Care System, Dallas, Texas, USA
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13
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Reiter NL, Rosen D, Erhart M, Vogel B. Barriers, facilitators and implementation strategies for guideline-adherence in physiotherapy: a scoping review protocol. BMJ Open 2023; 13:e074640. [PMID: 37451730 PMCID: PMC10351290 DOI: 10.1136/bmjopen-2023-074640] [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: 04/24/2023] [Accepted: 07/03/2023] [Indexed: 07/18/2023] Open
Abstract
INTRODUCTION Guideline-adherent physiotherapy can improve patient outcomes and reduce costs in the healthcare system. However, although there are numerous guidelines for physiotherapy practice, services are not consistently based on clinical practice guidelines. While various systematic and scoping reviews have highlighted barriers, facilitators and implementation strategies for guideline-adherent practice in other health professions, this scoping review aims to explore the barriers and facilitators for guideline-adherent physiotherapy and summarises the strategies used to implement such practice. METHODS AND ANALYSIS This scoping review will be based on Arksey and O'Malley's scoping review methodology and the methodological guidance for conducting scoping reviews published by Joanna Briggs Institute. Relevant publications will be first searched from the beginning of June 2023 on the MEDLINE and CINAHL databases before we expand the search to other databases such as EMBASE, the Cochrane Library and PEDro at the end of June 2023. Two reviewers will independently screen the titles and abstracts of all retrieved citations for inclusion against the eligibility criteria before conducting an independent full-text screening. The criteria will be tested on a sample of abstracts before beginning the abstract review to ensure that they are robust enough to capture any articles that may relate. The extracted data will finally be collated and charted to summarise key findings regarding our research question. ETHICS AND DISSEMINATION This scoping review will provide an extensive overview of the barriers, facilitators and implementation strategies for guideline-adherent physiotherapy. As scoping reviews are a form of secondary data analysis, ethical review is not required. Results will be disseminated through a peer-reviewed publication and stakeholder meetings. TRIAL REGISTRATION NUMBER This scoping review has been registered on 3 April 2023 on the Open Science Framework under https://doi.org/10.17605/OSF.IO/SEUW6.
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Affiliation(s)
- Nils L Reiter
- Department of Health, Alice Salomon University of Applied Sciences, Berlin, Germany
- PhsioBib GbR, Berlin, Germany
| | - Diane Rosen
- Department of Health, Alice Salomon University of Applied Sciences, Berlin, Germany
- Berlin School of Public Health, Berlin, Germany
- JBI Affiliated Group EBB, Brandenburg Medical School Theodor Fontane, Brandenburg an der Havel, Germany
| | - Michael Erhart
- Department of Health, Alice Salomon University of Applied Sciences, Berlin, Germany
- Apollon University of Applied Sciences, Bremen, Germany
| | - Barbara Vogel
- Department of Orthopedics and Sports Orthopedics, Physical Therapy, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
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Ganesh GS, Khan AR, Khan A. A survey of Indian physiotherapists' clinical practice patterns and adherence to clinical guidelines in the management of patients with acute low back pain. Musculoskeletal Care 2023; 21:478-490. [PMID: 36444875 DOI: 10.1002/msc.1720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 11/17/2022] [Accepted: 11/19/2022] [Indexed: 06/16/2023]
Abstract
INTRODUCTION Clinical practice guidelines (CPG) exist for the management of non-specific low back pain (LBP). The objective of this study is to evaluate if Indian physiotherapists' follow CPGs when treating patients with acute LBP. METHODS A cross-sectional survey using an online questionnaire was used to collect demographic information, views, and opinion about acute LBP and CPGs, and management strategies of a clinical vignette presenting a patient with acute LBP. RESULTS Responses from 328 physiotherapists were included in this study. Eighty-one percent of respondents indicated familiarity with CPGs for LBP and 75.3% (n = 328) respondents indicated that their intervention choices aligned with guidelines to at least some extent. Participants with post-graduate and doctoral degrees were more accustomed to CPGs than those with bachelor's degrees (p < 0.01). There were significant differences in clinical practice (p < 0.01) between therapists who expressed familiarity with guidelines and those who were not, as well as those with and without post-graduate and doctoral degrees. CONCLUSION In general, the study showed adherence to guidelines; however, there were areas that did not align with established evidence, especially referral for radiology and use of electrical modalities.
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Affiliation(s)
- G Shankar Ganesh
- Composite Regional Centre for Skill Development, Rehabilitation, and Empowerment of Persons with Disabilities, Lucknow, Uttar Pradesh, India
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15
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Peurois M, Bertin M, Fouquet N, Adjeroud N, Roquelaure Y, Ramond-Roquin A. Factors associated with referral to physiotherapists for adult patients consulting for musculoskeletal disorders in primary care; an ancillary study to ECOGEN. BMC PRIMARY CARE 2023; 24:13. [PMID: 36641488 PMCID: PMC9840270 DOI: 10.1186/s12875-023-01970-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 01/04/2023] [Indexed: 01/15/2023]
Abstract
BACKGROUND Musculoskeletal disorders (MSD) are multifactorial requiring multidisciplinary treatment including physiotherapy. General practitioners (GP) have a central role in managing MSDs and mostly solicit physiotherapists accounting for 76.1% of physiotherapy referrals in France. Patient, physician, and contextual factors, including healthcare accessibility, can influence physiotherapy referral rates. OBJECTIVE To identify patient, physician, and contextual factors associated with physiotherapy referral in adult patients with MSDs in general practice. METHODS This study is based on the 2011/2012 French cross-sectional ECOGEN study. Analyses included working-age patients consulting their GP for any MSD. Physiotherapy referral was assessed initially, then adjusted multilevel logistic model analysis of patient, physician, geographical area-related factors associated with these referrals was performed. RESULTS Among the 2305 patients included, 456 (19.8%) were referred to a physiotherapist. Following multilevel multivariate analyses, physiotherapist referral was more frequent for female patients (OR 1.28; 95% CI [1.03, 1.59]) with spinal (OR 1.47; 95% CI [1.18, 1.83]) and upper limb disorders (OR 1.66; 95% CI [1.20, 2.29]), and less frequent for patients ≥ 50 years (OR 0.69; 95% CI [0.52, 0.91]), living in deprived geographical areas (OR 0.60; 95% CI [0.40, 0.90]). GPs referred to a physiotherapist less frequently if they were ≥ 50 years (OR 0.50; 95% CI [0.39, 0.63]), had a high number of annual consultations, or were practicing in semi-urban area in a multidisciplinary team. CONCLUSION This multilevel analysis identifies factors associated with physiotherapy referral for patients with MSDs, including living in deprived geographical areas. This constitutes an original contribution towards addressing healthcare disparities.
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Affiliation(s)
- M. Peurois
- grid.7252.20000 0001 2248 3363Univ Angers, Univ Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail) - UMR_S 1085, SFR ICAT, F-49000 Angers, France ,grid.7252.20000 0001 2248 3363Univ Angers, Département de médecine générale, F-49000 Angers, France
| | - M. Bertin
- grid.7252.20000 0001 2248 3363Univ Angers, Univ Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail) - UMR_S 1085, SFR ICAT, F-49000 Angers, France
| | - N. Fouquet
- grid.493975.50000 0004 5948 8741Santé publique France, Saint‑Maurice, France
| | - N. Adjeroud
- grid.7252.20000 0001 2248 3363Univ Angers, Département de médecine générale, F-49000 Angers, France
| | - Y. Roquelaure
- grid.411147.60000 0004 0472 0283Univ Angers, CHU Angers, Univ Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail) - UMR_S 1085, SFR ICAT, F-49000 Angers, France
| | - A. Ramond-Roquin
- grid.7252.20000 0001 2248 3363Univ Angers, Univ Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail) - UMR_S 1085, SFR ICAT, F-49000 Angers, France ,grid.7252.20000 0001 2248 3363Univ Angers, Département de médecine générale, F-49000 Angers, France ,grid.86715.3d0000 0000 9064 6198Département de Médecine de Famille Et de Médecine d’urgence, Université de Sherbrooke, Québec, Canada
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Lemmers GPG, Bier JD, van Lankveld W, Westert GP, Staal JB, van der Wees PJ. Guideline adherence of physiotherapists in the treatment of patients with low back pain: A qualitative study. J Eval Clin Pract 2022; 28:1147-1156. [PMID: 35615965 PMCID: PMC9796459 DOI: 10.1111/jep.13703] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 04/28/2022] [Accepted: 05/04/2022] [Indexed: 01/01/2023]
Abstract
RATIONALE Adherence rates to guidelines show room for improvement, and increase in adherence to guidelines may potentially lead to better outcomes and reduced costs of treatment. To improve adherence, it is essential to understand the considerations of physiotherapists regarding the assessment and management of low back pain (LBP). The purpose of this study is to gain insight in the considerations of Dutch physiotherapists on adherence to the national physiotherapy guideline in the treatment of patients with LBP. METHODS This is a qualitative study, using an interpretive approach of semi-structured interviews with 14 physiotherapists who regularly treat patients with LBP. Thematic analysis was conducted with open coding using an existing framework. This framework distinguishes five components to adherence based on patient factors, provider factors, guideline characteristics, institutional factors and the implementation process. RESULTS Participating physiotherapists mentioned that the guideline should provide more information about psychosocial prognostic factors and psychosocial treatment options. The participants experienced difficulties in addressing patient expectations that conflict with guideline recommendations. The implementation process of the guideline was considered insufficient. Physiotherapists might rely too much on their experience, and knowledge of evidence-based treatment might be improved. In general, the interviewed physiotherapists thought they were mainly non-adherent to the guidelines. However, when comparing their considerations with the actual guideline recommendations they were mainly adherent. CONCLUSION To improve adherence, the guideline should provide more information about addressing psychosocial prognostic factors, and Dutch physiotherapists might be trained in communication skills to better address patient expectations. A more extensive implementation process is warranted for the next guideline to increase the physiotherapists' knowledge of evidence-based treatment.
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Affiliation(s)
- Gijs Petrus Gerardus Lemmers
- Department of IQ HealthcareRadboud University Medical Center, Radboud Institute for Health SciencesNijmegenThe Netherlands
- Department of Research & DevelopmentFysius Back ExpertsNijverdalThe Netherlands
- School for Allied Health, Musculoskeletal Rehabilitation Research GroupHAN University of Applied SciencesNijmegenThe Netherlands
| | - Jasper Daniël Bier
- Department of General PracticeErasmus MCRotterdamThe Netherlands
- Department of PhysiotherapyFS FysioCapelle aan den IJsselThe Netherlands
| | - Wim van Lankveld
- School for Allied Health, Musculoskeletal Rehabilitation Research GroupHAN University of Applied SciencesNijmegenThe Netherlands
| | - Gerard Pieter Westert
- Department of IQ HealthcareRadboud University Medical Center, Radboud Institute for Health SciencesNijmegenThe Netherlands
| | - Jacobus Bart Staal
- Department of IQ HealthcareRadboud University Medical Center, Radboud Institute for Health SciencesNijmegenThe Netherlands
- School for Allied Health, Musculoskeletal Rehabilitation Research GroupHAN University of Applied SciencesNijmegenThe Netherlands
| | - Philip Jan van der Wees
- Department of IQ HealthcareRadboud University Medical Center, Radboud Institute for Health SciencesNijmegenThe Netherlands
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Fillipo R, Pruka K, Carvalho M, Horn ME, Moore J, Ramger B, Clewley D. Does the implementation of clinical practice guidelines for low back and neck pain by physical therapists improve patient outcomes? A systematic review. Implement Sci Commun 2022; 3:57. [PMID: 35659117 PMCID: PMC9164354 DOI: 10.1186/s43058-022-00305-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 05/04/2022] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Rebecca Fillipo
- Department of Physical Therapy and Occupational Therapy, Duke University Health System, Durham, North Carolina, USA.
| | - Katie Pruka
- Department of Outpatient Rehabilitation, Duke University Health System, Durham, North Carolina, USA
| | - Marissa Carvalho
- Department of Physical Therapy and Occupational Therapy, Duke University Health System, Durham, North Carolina, USA
| | - Maggie E Horn
- Division of Doctor of Physical Therapy, Department of Orthopaedic Surgery, School of Medicine, Duke University, Durham, North Carolina, USA.,Department of Population Health Sciences, School of Medicine, Duke University, Durham, North Carolina, USA
| | - Jordan Moore
- Department of Physical Therapy and Occupational Therapy, Duke University Health System, Durham, North Carolina, USA
| | - Benjamin Ramger
- Department of Outpatient Rehabilitation, Duke University Health System, Durham, North Carolina, USA
| | - Derek Clewley
- Division of Doctor of Physical Therapy, Department of Orthopaedic Surgery, School of Medicine, Duke University, Durham, North Carolina, USA
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Willy RW, Hoglund L, Glaviano NR, Bolgla LA, Bazett-Jones DM. Survey of confidence and knowledge to manage patellofemoral pain in readers versus NonReaders of the physical therapy clinical practice guideline. Phys Ther Sport 2022; 55:218-228. [DOI: 10.1016/j.ptsp.2022.04.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 04/12/2022] [Accepted: 04/13/2022] [Indexed: 12/21/2022]
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Peurois M, Bouton C, Bègue C, Fouquet N, Adjeroud N, Raber C, Ramond-Roquin A. Influence of low back pain characteristics on the healthcare procedures prescribed by general practitioners for adult patients: ancillary analysis of the French ECOGEN study. Rev Epidemiol Sante Publique 2022; 70:133-139. [PMID: 35410701 DOI: 10.1016/j.respe.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 03/07/2022] [Accepted: 03/08/2022] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Non-specific low back pain is a frequent reason for consultation, yet little is known about how general practitioners manage it in France. OBJECTIVES To describe the healthcare procedures general practitioners prescribe for low back pain in France. MATERIALS AND METHODS This is an ancillary analysis of an observational, cross-sectional study (ECOGEN) conducted between November 2011 and April 2012 among 128 general practitioners. Adults younger than 65 years consulting for low back pain were included. Patient and general practitioner characteristics, consultation results (diagnosis) and healthcare procedures were collected and coded using the International Classification in Primary Care. Analyses focused on the initial or follow-up consultation, adjusting on age, gender, and socio-occupational category. RESULTS AND DISCUSSION Out of 11510 consultations, 845 (7.3%) were for low back pain. Of these, 776 (79.5%) resulted in a clinical examination, 634 (73.4%) in medication prescription, and 203 (23.9%) were prescribed sick leave, but imaging and specialist referral were rare. Imaging was more frequent with radiating pain (adjusted odds ratio (aOR) = 1.61; 95% CI [1.07, 2.42]), as were specialist referrals (OR = 2.92; 95% CI [1.40, 6.09]) and sick leave prescription (aOR = 1.52; 95% CI [1.10, 2.09]), but physiotherapist referral was less frequent (aOR = 0.55; 95% CI [0.38, 0.82]). Clinical examinations (aOR = 2.75; 95% CI [1.98, 3.80]), imaging (aOR = 1.61; 95% CI [1.02, 2.31]) and medication prescriptions (aOR = 2.34; 95% CI [1.65, 3.30]) were more common in initial consultations, but specialist referral (aOR = 0.16; 95% CI [0.05, 0.47]) or sick leave prescription (aOR = 0.68; 95% CI [0.48, 0.97]) were rarer. CONCLUSION Low back pain characteristics could influence healthcare procedures more markedly than patient or general practitioner characteristics.
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Affiliation(s)
- Matthieu Peurois
- Université Angers, Université Rennes, Inserm, EHESP (Ecole des Hautes Etudes en santé Publique), IRSET (Institut de Recherche en Santé, Environnement et Travail) - UMR_S 1085, F-49000 Angers, France; Université Angers, Département de médecine générale, F-49000 Angers, France.
| | - Céline Bouton
- Université Nantes, Département de médecine générale, 44035 Nantes, France
| | - Cyril Bègue
- Université Angers, Université Rennes, Inserm, EHESP (Ecole des Hautes Etudes en santé Publique), IRSET (Institut de Recherche en Santé, Environnement et Travail) - UMR_S 1085, F-49000 Angers, France; Université Angers, Département de médecine générale, F-49000 Angers, France
| | | | - Najia Adjeroud
- Université Angers, Département de médecine générale, F-49000 Angers, France
| | - Cécile Raber
- Université Angers, Département de médecine générale, F-49000 Angers, France
| | - Aline Ramond-Roquin
- Université Angers, Université Rennes, Inserm, EHESP (Ecole des Hautes Etudes en santé Publique), IRSET (Institut de Recherche en Santé, Environnement et Travail) - UMR_S 1085, F-49000 Angers, France; Université Angers, Département de médecine générale, F-49000 Angers, France; Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, Québec, Canada
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Halfpap J, Riebel L, Tognoni A, Coller M, Sheu RG, Rosenthal MD. Improving Access and Decreasing Healthcare Utilization for Patients With Acute Spine Pain: Five-Year Results of a Direct Access Clinic. Mil Med 2022; 188:usac064. [PMID: 35284938 DOI: 10.1093/milmed/usac064] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 01/21/2022] [Accepted: 02/24/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Spine pain is one of the largest and costliest burdens to our healthcare systems. While evidence-based guidelines for spine pain have been established, and continue to evolve, the actual management of this condition continues to burden the healthcare system. This has led to increased costs due to inefficient entry to healthcare, utilization of treatments unsupported by clinical guidelines, and patient navigation through our healthcare systems. The purpose of this study was to assess the healthcare utilization and related outcomes for Active Duty Service Members (ADSM) receiving healthcare services in a novel acute spine pain clinic (ASPC) during the first 5 years of operation at a large Military Treatment Facility. MATERIALS AND METHODS In 2014 the Physical Medicine and Rehabilitation and Physical Therapy (PT) services designed a novel acute spine clinic intended to directly receive ADSM with acute spine symptoms for an initial evaluation by a Physical Therapist. The inclusion criteria into the ASPC were: ADSM, pain less than or equal to 7 days, no more than three prior episodes of acute spine pain in the past 3 years, and not currently receiving care from Chiropractic, Pain Management, or PT services. The exclusion criteria were: significant and/or progressive neurological deficits, bowel or bladder dysfunction, unstable vital signs or fever, hematuria or extensive trauma. RESULTS A total of 1,215 patients presented to the ASPC for evaluation between 2014 and 2019. The most common chief complaint was acute pain in the lumbar spine (73%), followed by cervical spine pain (15%), and thoracic spine pain (12%) represented the fewest. The average number of PT visits per patient was 3.5 (range 1-13) with 61.1% utilizing three or fewer visits. Over 95% of cases returned to work the same day as their initial evaluation. Sixty-six percent returned to work without restriction the same day as their initial evaluation. Light duty recommendations were provided to 412 (33.9%) patients ranging from one to 30 days, with greater than 85% of the light duty being less than 14 days. Recommendations to not return to work (sick-in-quarters) were issued to 56 (4.6%) patients. The sick-in-quarters recommendations were for a 24-hour period in 48 cases, 48 hours for seven cases, and 72 hours for one case. All encounters in which the patient first sought care at the ASPC for low back pain met the Healthcare Effectiveness Data Set standard for low back pain care of having no imaging within 28 days of the first encounter for nonspecific low back pain. A medical record review of 100 randomly selected patients within 12 months of the initial evaluation demonstrated decreased utilization of medication, imaging, and referral to surgical services. CONCLUSIONS This innovative approach demonstrates the potential benefits of rapid access to treatment and education for patients with acute spine pain by a Physical Therapist. Modeling this approach at Military Treatment Facilities may lead to decreased utilization of medications, radiology services, specialty care referrals, and reduced cost of care provided to individuals with acute spine pain.
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Affiliation(s)
- Josh Halfpap
- Bowling Green State University, College of Health and Human Services, Doctor of Physical Therapy Program, Bowling Green, OH, USA
- Department of Physical and Occupational Therapy, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - Laura Riebel
- Sports Medicine and Rehabilitation Team, Naval Medical Readiness and Training Command Great Lakes, North Chicago, IL 60064, USA
| | - Angela Tognoni
- Department of Physical Therapy, Scripps Mercy Hospital San Diego, San Diego, CA 92103, USA
| | - Michael Coller
- Bowling Green State University, College of Health and Human Services, Doctor of Physical Therapy Program, Bowling Green, OH, USA
- Department of Physical and Occupational Therapy, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - Robert G Sheu
- Department of Physical Medicine and Rehabilitation, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - Michael D Rosenthal
- Doctor of Physical Therapy Program, College of Allied Health Professions, University of Nebraska Medical Center, Omaha, NE 68198, USA
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Bolton R, Ritter G, Highland K, Larson MJ. The relationship between capacity and utilization of nonpharmacologic therapies in the US Military Health System. BMC Health Serv Res 2022; 22:312. [PMID: 35255912 PMCID: PMC8900315 DOI: 10.1186/s12913-022-07700-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 02/24/2022] [Indexed: 11/17/2022] Open
Abstract
Background Nonpharmacologic therapies (NPTs) are recommended as first-line treatments for pain, however the impact of expanding professional capacity to deliver these therapies on use has not been extensively studied. We sought to examine whether an effort by the US Military Health System (MHS) to improve access to NPTs by expanding professional capacity increased NPT utilization in a cohort at higher risk for pain – Army soldiers returning from deployment. Methods Our study involved secondary analysis of MHS workforce data derived from the Defense Medical Human Resources System Internet (DMHRSi), and healthcare utilization data obtained from two ambulatory record systems of the Military Health System (MHS) for a sample of 863,855 Army soldiers previously deployed to Iraq or Afghanistan over a 10-year period (2008–2017). We measured clinical provider capacity in three occupational groups responsible for pain management at 130 military treatment facilities (MTFs): physical therapy, chiropractic, and behavioral health, measured annually as full-time equivalence per 100,000 patients served at each MTF. Utilization in both direct and purchased care settings was measured as annual mean NPT users per 1000 sample members and mean encounters per NPT user. Generalized estimating equation models estimated the associations of facility-level occupational capacity measures and facility-level utilization NPT measures. Results In 2008, nearly all MTFs had some physical therapist and behavioral health provider capacity, but less than half had any chiropractor capacity. The largest increase in capacity from 2008 to 2017 was for chiropractors (89%) followed by behavioral health providers (77%) and physical therapists (37%). Models indicated that increased capacity of physical therapists and chiropractors were associated with significantly increased utilization of six out of seven NPTs. Acupuncture initiation was associated with capacity increases in each occupation. Increased professional capacity in MTFs was associated with limited but positive effects on NPT utilization in purchased care. Conclusions Increasing occupational capacity in three professions responsible for delivering NPTs at MTFs were associated with growing utilization of seven NPTs in this Army sample. Despite increasing capacity in MTFs, some positive associations between MTF capacity and purchased care utilization suggest an unmet need for NPTs. Future research should examine if these changes lead to greater receipt of guideline-concordant pain management. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07700-4.
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Affiliation(s)
- Rendelle Bolton
- The Heller School for Social Policy and Management, Brandeis University, 415 South Street, MA, 02453, Waltham, USA. .,US Department of Veterans Affairs, VA Bedford Healthcare System, Center for Healthcare Organization and Implementation Research, 200 Springs Road, Bedford, MA, 01730, USA.
| | - Grant Ritter
- The Heller School for Social Policy and Management, Brandeis University, 415 South Street, MA, 02453, Waltham, USA
| | - Krista Highland
- Department of Anesthesiology, Defense and Veterans Center for Integrative Pain Management, Uniformed Services University, 11300 Rockville Pike, Suite 709, Rockville, MD, 20852, USA.,Henry M. Jackson Foundation, 11300 Rockville Pike, Suite 709, Rockville, MD, 20852, USA
| | - Mary Jo Larson
- The Heller School for Social Policy and Management, Brandeis University, 415 South Street, MA, 02453, Waltham, USA
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22
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Schröder K, Öberg B, Enthoven P, Hedevik H, Abbott A. Improved adherence to clinical guidelines for low back pain after implementation of the BetterBack model of care: A stepped cluster randomized controlled trial within a hybrid type 2 trial. Physiother Theory Pract 2022:1-15. [PMID: 35230212 DOI: 10.1080/09593985.2022.2040669] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND The BetterBack model of care (MoC) for low back pain (LBP) was recently developed in Swedish physiotherapy (PT) primary care. OBJECTIVE To evaluate if PTs' adherence to LBP clinical practice guidelines (CPGs) improves after implementation of the BetterBack MoC (intervention). METHODS This was a stepped, single-blinded cluster randomized controlled trial. Patients nested in the three clusters were allocated to routine care (n = 222) or intervention (n = 278). The primary outcome was referral to specialist consultation. This was among five best practice recommendations divided into an assessment quality index (no referral to specialist consultation and no medical imaging) and a treatment quality index (use of educational interventions; use of exercise interventions; no use of non-evidence-based physiotherapy). For overall adherence, patients had to be treated with all five recommendations fulfilled. Logistic regression was used for between-group comparisons. RESULTS The proportion of patients receiving referral to specialist consultation during the PT treatment period was low in both groups with no between-group differences. However, patients in the intervention group showed significantly higher assessment quality index, treatment quality index and overall adherence compared to routine care. Adherence to the separate recommendations showed improved stratified number of visits, use of exercise was maintained high, patient educational intervention increased and use of non-evidence-based physiotherapy decreased. A reduction of medical imaging during the physiotherapy treatment period was also observed. CONCLUSIONS The adoption of CPGs could be substantially improved by introducing a MoC through PT training and supportive materials.
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Affiliation(s)
- Karin Schröder
- Unit of Physiotherapy, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Birgitta Öberg
- Unit of Physiotherapy, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Paul Enthoven
- Unit of Physiotherapy, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Henrik Hedevik
- Unit of Physiotherapy, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Allan Abbott
- Unit of Physiotherapy, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
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23
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American Physical Therapy Association Clinical Practice Guideline Implementation for Neck and Low Back Pain in Outpatient Physical Therapy: A Nonrandomized, Cross-sectional Stepped-Wedge Pilot Study. J Orthop Sports Phys Ther 2022; 52:113-123. [PMID: 35100820 DOI: 10.2519/jospt.2022.10545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To determine whether a multifaceted implementation strategy for American Physical Therapy Association neck and low back pain clinical practice guidelines (CPGs) was associated with changes in clinician and patient outcomes. DESIGN Cross-sectional stepped-wedge pilot study. METHODS Physical therapy clinics (n = 9) were allocated to 1 of 4 clusters that varied by CPG implementation timing. Clinics crossed over from usual care (control) to CPG implementation (intervention) every 8 weeks and ended with a 24-week follow-up period. Implementation outcomes were measured at the clinician (perspectives and behaviors) and patient (pain and disability outcomes) levels. Descriptive statistics were used to summarize clinician perspectives and behaviors. Generalized linear mixed models were used to analyze patient-level outcomes data (pain and disability) and total number of physical therapy visits. RESULTS Improvements in several clinician perspectives about CPGs were observed 8 weeks after training and sustained at 16 weeks (P<.05), although it is unclear whether these changes were meaningful. Training on CPGs was relevant to physical therapists and more acceptable at 16 weeks (P<.05). In a random sample (n = 764/1994, 38.3%), the overall rate of CPG classification was 65.0% (n = 497/764), and CPG intervention concordance was 71.2% (n = 354/497). Implementation of a CPG was not associated with final pain and disability scores (P>.05) but was associated with an approximate increase of 8% in total visits. CONCLUSION Our multifaceted implementation strategy was associated with statistical changes in clinician perspectives and behaviors, but not in patient outcomes. J Orthop Sports Phys Ther 2022;52(2):113-123. doi:10.2519/jospt.2022.10545.
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24
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The Lived Experience of Managing HIV and Chronic Pain: Qualitative Interviews with Patients and Healthcare Providers. AIDS Behav 2022; 26:496-511. [PMID: 34350531 PMCID: PMC8827137 DOI: 10.1007/s10461-021-03406-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2021] [Indexed: 02/03/2023]
Abstract
People living with HIV (PLWH) experience higher rates of comorbid chronic pain conditions compared to the general population. Managing HIV and chronic pain, two stigmatized health conditions, can exacerbate physical and psychological suffering. The current qualitative study was designed to increase our understanding of the experience of living with HIV and chronic pain. Twenty participants were recruited from a hospital-based immunology center to participate in individual in-depth qualitative interviews. The interviews focused on the experience of living with (or managing) chronic pain for PLWH. All interviews were audio recorded, transcribed and double-coded. Several themes emerged from our applied thematic analysis of the transcripts. The primary theme was that pain remained poorly managed among PLWH. Patients engaged in a variety of pain management strategies and described benefits from both traditional pain management interventions (e.g., pharmacology, physical therapy) as well as non-traditional approaches (e.g., medical marijuana, cannabidiol products, and spirituality). Other themes that emerged included barriers related to health insurance and the need to validate the patient pain experience. PLWH and chronic pain described compounding effects of managing two chronic health conditions, including perceived immune system over-activation, heightened awareness of illness, and negative mindset. More research is needed to improve care for those managing these often co-occurring health conditions.
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25
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Liu W, Huang L, Zhang C, Liu Z. Effect of Nerve Training Technology on Apoptosis of Cartilage and Osteoblasts and Expression of Aggrecan Protein in Osteoporotic Arthritis. J BIOMATER TISS ENG 2022. [DOI: 10.1166/jbt.2022.2880] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Arthritis and osteoporosis are two common disorders in the world, especially for the elder, but the current treatments have limited efficacy. Herein, we aimed to determine whether the novel technique, neurological training can alleviate osteoporosis complicated with arthritis in rat
model. Thirty rats were assigned into normal group, model group, and treatment group (treated with forsythin and neurological training) (n = 10) followed by assessment of chondrocytes and osteoblasts using Mankin score, apoptosis by TUNEL and flow cytometry, and IL-1β, TNF-α,
and Aggrecan levels. Apoptotic chondrocytes of treatment group (27.43±1.34) was lower than model group (p < 0.05), whereas amount of osteoblast was increased upon forsythin and neurological training, with lower Mankin’s score (6.38±0.76). Besides, the content
of IL-1β and TNF-α of treatment group was significantly lower but Aggrecan mRNA and protein expression was significantly higher. In conclusion, neurological training could protect and alleviate osteoporosis complicated with arthritis.
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Affiliation(s)
- Wei Liu
- Department of Orthopedics, Yongchuan Hospital Affiliated to Chongqing Medical University, Chongqing, 402100, China
| | - Lili Huang
- Department of Infections, Yongchuan Hospital Affiliated to Chongqing Medical University, Chongqing, 402100, China
| | - Cuiying Zhang
- Department of Gynaecology and Obstetrics, Yongchuan Hospital Affiliated to Chongqing Medical University, Chongqing, 402100, China
| | - Zuozhong Liu
- Department of Orthopedics, Yongchuan Hospital Affiliated to Chongqing Medical University, Chongqing, 402100, China
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26
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Tolchin B, Baslet G, Carson A, Dworetzky BA, Goldstein LH, LaFrance WC, Martino S, Perez DL, Reuber M, Stone J, Szaflarski JP. The role of evidence-based guidelines in the diagnosis and treatment of functional neurological disorder. Epilepsy Behav Rep 2021; 16:100494. [PMID: 34877515 PMCID: PMC8627961 DOI: 10.1016/j.ebr.2021.100494] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 10/05/2021] [Accepted: 10/13/2021] [Indexed: 11/19/2022] Open
Abstract
Evidence-based guidelines use systematic reviews to support clinical recommendations. Adherence to evidence-based guidelines improves healthcare costs and patient outcomes. Recent randomized trials make guidelines for functional neurological disorders possible.
Evidence-based clinical practice guidelines, based on systematic reviews of existing evidence, play an important role in improving and standardizing the quality of patient care in many medical and psychiatric disorders, and could play an important role in the diagnosis and treatment of functional seizures and other functional neurological disorder (FND) subtypes. There are several reasons to think that evidence-based guidelines might be especially beneficial for the management of FND. In particular, the interdisciplinary and multidisciplinary teamwork necessary for the care of people with FND, the current lack of formal clinical training in FND, and the rapidly expanding body of evidence relating to FND all make guidelines based on systematic literature reviews especially valuable. In this perspective piece, we review clinical practice guidelines, their advantages and limitations, the reasons why evidence-based guidelines might be especially beneficial in the diagnosis and treatment of FND, and the steps that must be taken to create such guidelines for FND. We propose that professional organizations such as the American Academy of Neurology and the American Psychiatric Association undertake guideline development, ideally to create a co-authored or jointly endorsed set of guidelines that can set standards for interdisciplinary care for neurologists and mental health clinicians alike.
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Affiliation(s)
- Benjamin Tolchin
- Yale Comprehensive Epilepsy Center, Department of Neurology, Yale School of Medicine, New Haven, CT, USA
- Yale New Haven Health System Center for Clinical Ethics, New Haven, CT, USA
- Corresponding author at: Yale Comprehensive Epilepsy Center, Department of Neurology, Yale School of Medicine, 15 York Street, New Haven, CT 06510, USA.
| | - Gaston Baslet
- Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Alan Carson
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Barbara A. Dworetzky
- Department of Neurology, The Edward B. Bromfield Epilepsy Center, Brigham and Women’s Hospital, Harvard Medical School., Boston, MA, USA
| | - Laura H. Goldstein
- King’s College London, Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - W. Curt LaFrance
- Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, RI, USA
| | - Steve Martino
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
- Department of Psychology, VA Connecticut Health Care System, West Haven, CT, USA
| | - David L. Perez
- Functional Neurological Disorder Unit, Departments of Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Markus Reuber
- Academic Neurology Unit, University of Sheffield, Sheffield, UK
| | - Jon Stone
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Jerzy P. Szaflarski
- UAB Epilepsy Center, Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
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Abstract
The use of manual therapy as an intervention has garnered intense debate, one that is often mired in a straw-man argument that manual therapy is a purely passive intervention. When passive interventions are equated with low-value care, it is easy to deride manual therapy as low-value care. However, manual therapy describes a wide variety of treatments, some with passive components and some that are primarily passive in certain scenarios. But manual therapy can be an integral part of highly active treatment strategies. We implore investigators to describe manual therapy interventions in sufficient detail so that they can be reproduced and thereby help the end users of research (including clinicians) to better assess the value of such interventions. This Viewpoint challenges the assumption that manual therapy is always a passive treatment of low value. J Orthop Sports Phys Ther 2021;51(10):474-477. Epub 1 Jul 2021. doi:10.2519/jospt.2021.10330.
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28
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Itaya T, Shimizu S, Hara T, Matsuoka Y, Fukuhara S, Yamamoto Y. Association between facility-level adherence to phosphorus management guidelines and mortality in haemodialysis patients: a prospective cohort study. BMJ Open 2021; 11:e051002. [PMID: 34531214 PMCID: PMC8449959 DOI: 10.1136/bmjopen-2021-051002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 08/19/2021] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES To examine the association between facility-level adherence to phosphorus management guidelines and mortality among patients with haemodialysis, and to explore the facility-related factors associated with facility-level guideline adherence. DESIGN Prospective cohort study. SETTING The Dialysis Outcomes and Practice Pattern Study, which included 57 representative dialysis facilities in Japan between 2012 and 2015. PARTICIPANTS A total of 2054 adult patients who received maintenance haemodialysis were included. We defined exposure according to the following four categories, depending on whether facility-level target ranges of serum phosphorus concentration adhered to the Japanese clinical practice guidelines: adherence group (lower limit ≥3.5 mg/dL and upper limit ≤6.0 mg/dL), low-target group (lower limit <3.5 and upper limit ≤6.0), wide-target group (lower limit <3.5 and upper limit >6.0) and high-target group (lower limit ≥3.5 and upper limit >6.0). PRIMARY OUTCOME MEASURE The primary outcome was the patient all-cause mortality rate. RESULTS The mortality rate among the patients was 7.3 per 100 person-years; 27 facilities (47%) set targets according to the guidelines. HRs for mortality with reference to the adherence group were 1.04 (95% CI 0.76 to 1.43) in the low-target group, 1.11 (95% CI 0.68 to 1.81) in the wide-target group and 1.95 (95% CI 1.12 to 3.38) in the high-target group. Involvement of dieticians in dialysis treatment was associated with facility-level guideline adherence (OR 4.51; 95% CI 1.15 to 17.7). CONCLUSIONS A higher facility-level target range for phosphorus was associated with increased patient mortality. Among facilities that set the target according to the guidelines, dieticians tended to be involved in dialysis care. These findings suggest the importance of reviewing facilities' treatment policies in relation to updated guidelines and the need to work with relevant professionals.
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Affiliation(s)
- Takahiro Itaya
- Department of Healthcare Epidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
| | - Sayaka Shimizu
- Section of Clinical Epidemiology, Department of Community Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
- Institute for Health Outcomes and Process Evaluation Research (iHope International), Kyoto, Japan
| | - Takashi Hara
- Department of Healthcare Epidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
| | - Yoshinori Matsuoka
- Department of Healthcare Epidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
- Department of Emergency Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Shunichi Fukuhara
- Section of Clinical Epidemiology, Department of Community Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
- Center for Innovative Research for Communities and Clinical Excellence (CiRCLE), Fukushima Medical University, Fukushima, Japan
- Shirakawa STAR for General Medicine, Fukushima Medical University, Fukushima, Japan
| | - Yosuke Yamamoto
- Department of Healthcare Epidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
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29
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Castillo S, Joodi R, Williams LE, Pezeshk P, Chhabra A. Sacrum magnetic resonance imaging for low back and tail bone pain: A quality initiative to evaluate and improve imaging utility. World J Methodol 2021; 11:110-115. [PMID: 34322363 PMCID: PMC8299904 DOI: 10.5662/wjm.v11.i4.110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 12/20/2020] [Accepted: 05/20/2021] [Indexed: 02/06/2023] Open
Abstract
As quality and cost effectiveness become essential in clinical practice, an evidence-based evaluation of the utility of imaging orders becomes an important consideration for radiology’s value in patient care. We report an institutional quality improvement project including a retrospective review of utility of sacrum magnetic resonance (MR) imaging for low back pain at our institution over a four-year period and follow-up results after physician education intervention. Sacral MR imaging for low back pain and tailbone pain were only positive for major findings in 2/98 (2%) cases, and no major changes in patient management related to imaging findings occurred over this period, resulting in almost $500000 cost without significant patient benefit. We distributed these results to the Family Medicine department and clinics that frequently placed this order. An approximately 83% drop in ordering rate occurred over the ensuing 3 mo follow-up period. Sacrum MR imaging for low back pain and tail bone pain has not been a cost-effective diagnostic tool at our institution. Physician education was a useful tool in reducing overutilization of this study, with a remarkable drop in such studies after sharing these findings with primary care physicians at the institution. In conclusion, sacrum MR imaging rarely elucidates the cause of low back/tail pain diagnosed in a primary care setting and is even less likely to result in major changes in management. The practice can be adopted in other institutions for the benefit of their patients and improve cost efficiency.
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Affiliation(s)
- Samantha Castillo
- Department of Radiology, UT Southwestern, Dallas, TX 75390, United States
| | - Robert Joodi
- Department of Radiology, UT Southwestern, Dallas, TX 75390, United States
| | | | - Parham Pezeshk
- Department of Radiology, UT Southwestern, Dallas, TX 75390, United States
| | - Avneesh Chhabra
- Department of Radiology, UT Southwestern, Dallas, TX 75390, United States
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30
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Bahns C, Happe L, Thiel C, Kopkow C. Physical therapy for patients with low back pain in Germany: a survey of current practice. BMC Musculoskelet Disord 2021; 22:563. [PMID: 34147077 PMCID: PMC8214788 DOI: 10.1186/s12891-021-04422-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 06/01/2021] [Indexed: 11/25/2022] Open
Abstract
Background Low back pain (LBP) is one of the most common musculoskeletal disorders worldwide. The National Disease Management Guideline (NVL) “Non-specific LBP” is a practical decision-making aid for both physicians and non-medical professionals in Germany to improve quality of health care. Although LBP is the most frequent diagnosis resulting in physical therapy treatment, information on the current management of patients with LBP and guideline adherence is limited. The objective of this study was to evaluate the current physical therapy management of patients with LBP in Germany, and to explore guideline adherence to the NVL “Non-specific LBP” recommendations. Methods An online survey among physical therapists working in Germany was conducted based on the recommendations given in the NVL “Non-specific LBP”. Participants were recruited using a snowball sampling approach and invited to complete the questionnaire. Guideline adherence was evaluated by comparing the survey findings with the recommendations of the NVL. Results In total, 1361 physical therapists (41 years of age (SD 11); 839 female, 514 male; 16 years of clinical experience (SD 10)) completed the survey. Fifty percent (n = 675) of our respondents adhered to the recommendations of the NVL on the therapeutic diagnostic process, and 72% (n = 973) to the recommendations concerning treatment. The guideline adherence across the entire management process (i.e., both diagnosis and treatment) of LBP was 38% (n = 513). German physical therapists predominantly provide active interventions, e.g., exercise therapy, but also use interventions with low or conflicting evidence, respectively. Massage and Kinesio Taping were frequently used despite being not recommended. Less than one third of study participants (n = 400, 29%) answered to know the NVL or had dealt with its recommendations. Conclusions In the management of LBP, overall guideline adherence among German physical therapists was 38% with higher adherence in the treatment section than in the physical therapeutic diagnostic process. Widespread employment of implementation strategies and removal of existing barriers against the application of evidence-based guidelines could facilitate the transfer of scientific evidence into clinical practice and contribute to optimize the quality of health care. Trial registration German Clinical Trials Register (DRKS00012607). Registered 04 October 2017. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-021-04422-2.
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Affiliation(s)
- Carolin Bahns
- Department of Therapy Science I, Brandenburg Technical University Cottbus - Senftenberg, Universitätsplatz 1, 01968, Senftenberg, Germany. .,Department of Applied Health Sciences, Division of Physiotherapy, University of Applied Sciences, Bochum, Germany.
| | - Lisa Happe
- Department of Applied Health Sciences, Division of Physiotherapy, University of Applied Sciences, Bochum, Germany.,Department for Health Services Research, Assistance Systems and Medical Devices, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Christian Thiel
- Department of Applied Health Sciences, Division of Physiotherapy, University of Applied Sciences, Bochum, Germany.,Faculty of Sports Science, Training and Exercise Science, Ruhr-University Bochum, Bochum, Germany
| | - Christian Kopkow
- Department of Therapy Science I, Brandenburg Technical University Cottbus - Senftenberg, Universitätsplatz 1, 01968, Senftenberg, Germany.,Department of Applied Health Sciences, Division of Physiotherapy, University of Applied Sciences, Bochum, Germany
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31
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Folgen Physiotherapeutinnen und Physiotherapeuten bei der Behandlung muskuloskelettaler Erkrankungen den Empfehlungen evidenzbasierter Leitlinien? Systematische Übersichtsarbeit. PHYSIOSCIENCE 2021. [DOI: 10.1055/a-1404-9693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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32
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Longtin C, Décary S, Cook CE, Tousignant-Laflamme Y. What does it take to facilitate the integration of clinical practice guidelines for the management of low back pain into practice? Part 2: A strategic plan to activate dissemination. Pain Pract 2021; 22:107-112. [PMID: 33998767 DOI: 10.1111/papr.13032] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 05/04/2021] [Accepted: 05/08/2021] [Indexed: 02/06/2023]
Abstract
Low back pain (LBP) is the leading cause of disability worldwide among all musculoskeletal disorders despite an intense focus in research efforts. Researchers and decision makers have produced multiple clinical practice guidelines for the rehabilitation of LBP, which contain specific recommendations for clinicians. Adherence to these recommendations may have several benefits, such as improving the quality of care for patients living with LBP, by ensuring that the best evidence-based care is being delivered. However, clinicians' adherence to recommendations from these guidelines is low and numerous implementation barriers and challenges, such as complexity of information and sheer volume of guidelines have been documented. In a previous paper, we performed a systematic review of the literature to identify high-quality clinical practice guidelines on the management of LBP, and developed a concise yet comprehensive infographic that summarizes the recommendations from these guidelines. Considering the wealth of scientific evidence, passive dissemination alone of this research knowledge is likely to have limitations to help clinicians implement these recommendations into routine practice. Thus, an active and engaging dissemination strategy, aimed at improving the implementation and integration of specific recommendations into practice is warranted. In this paper, we argue that a conceptual framework, such as the theoretical domains framework, could facilitate the implementation of these recommendations into clinical practice. Specifically, we present a systematic approach that could serve to guide the development of a theory-informed knowledge translation intervention as a means to overcome implementation challenges in rehabilitation of LBP.
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Affiliation(s)
- Christian Longtin
- School of Rehabilitation, University of Shebrooke, Sherbrooke, Quebec, Canada
| | - Simon Décary
- School of Rehabilitation, University of Shebrooke, Sherbrooke, Quebec, Canada.,Research Centre of the CHUS, CIUSSS de l'Estrie-CHUS, Sherbrooke, Quebec, Canada
| | - Chad E Cook
- Department of Orthopedics, Duke University, Durham, North Carolina, USA
| | - Yannick Tousignant-Laflamme
- School of Rehabilitation, University of Shebrooke, Sherbrooke, Quebec, Canada.,Research Centre of the CHUS, CIUSSS de l'Estrie-CHUS, Sherbrooke, Quebec, Canada
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33
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Longtin C, Décary S, Cook CE, Tousignant-Laflamme Y. What does it take to facilitate the integration of clinical practice guidelines for the management of low back pain into practice? Part 1: A synthesis of recommendation. Pain Pract 2021; 21:943-954. [PMID: 33998769 DOI: 10.1111/papr.13033] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 02/18/2021] [Accepted: 03/23/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Despite the emergence of multiple clinical practice guidelines (CPGs) for the rehabilitation of low back pain (LBP) over the last decade, self-reported levels of disability in this population have not improved. This may be explained by the numerous implementation barriers, such as the complexity of information and sheer volumes of CPGs. OBJECTIVES The purpose of this study was to summarize the evidence and recommendations from the most recent and high-quality CPGs on the rehabilitation management of LBP by developing an infographic summarizing the recommendations to facilitate dissemination into clinical practice. METHODS We performed a systematic review of high-quality CPGs with an emphasis on rehabilitation approaches. We searched major health-related research databases (e.g., PubMed, CINAHL, and PEDro). We performed quality assessment via the AGREE-II instrument. Contents of the CPGs were synthesized by extracting recommendations, which were then compared to one another to identify consistencies based on an iterative evaluation process. RESULTS We identified and assessed 5 recent high-quality CPGs. We synthesized 13 recommendations on the rehabilitation management of LBP (2 for screening procedures, 3 for assessment procedures, and 8 involving treatment approaches) and 2 underlying principles were highlighted. These results were then synthetized and illustrated in a concise infographic that serves as a conceptual roadmap that identifies the specific behavior changes (i.e., adoption of CPGs' recommendations) rehabilitation professionals should adopt in order to integrate an evidenced-based approach for the management of LBP. CONCLUSIONS We systematically reviewed the literature for CPGs' recommendations for the physical rehabilitation management of LBP and synthesized the information through an infographic.
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Affiliation(s)
- Christian Longtin
- School of Rehabilitation, University of Shebrooke, Sherbrooke, Quebec, Canada
| | - Simon Décary
- School of Rehabilitation, University of Shebrooke, Sherbrooke, Quebec, Canada.,Research Centre of the CHUS, CIUSSS de l'Estrie-CHUS, Sherbrooke, Quebec, Canada
| | - Chad E Cook
- Department of Orthopaedics, Duke University, Durham, North Carolina, USA
| | - Yannick Tousignant-Laflamme
- School of Rehabilitation, University of Shebrooke, Sherbrooke, Quebec, Canada.,Research Centre of the CHUS, CIUSSS de l'Estrie-CHUS, Sherbrooke, Quebec, Canada
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Effectiveness and Quality of Implementing a Best Practice Model of Care for Low Back Pain (BetterBack) Compared with Routine Care in Physiotherapy: A Hybrid Type 2 Trial. J Clin Med 2021; 10:jcm10061230. [PMID: 33809640 PMCID: PMC8002355 DOI: 10.3390/jcm10061230] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 03/12/2021] [Accepted: 03/12/2021] [Indexed: 12/12/2022] Open
Abstract
Low back pain (LBP) occurs in all ages and first-line treatment by physiotherapists is common. The main aim of the current study was to evaluate the effectiveness of implementing a best practice model of care for LBP (intervention group—BetterBack☺ MoC) compared to routine physiotherapy care (control group) regarding longitudinal patient reported outcomes. The BetterBack☺ MoC contains clinical guideline recommendations and support tools to facilitate clinician adherence to guidelines. A secondary exploratory aim was to compare patient outcomes based on the fidelity of fulfilling a clinical practice quality index regarding physiotherapist care. A stepped cluster randomized design nested patients with LBP in the three clusters which were allocated to control (n = 203) or intervention (n = 264). Patient reported measures were collected at baseline, 3, 6 and 12 months and analyzed with mixed model regression. The primary outcome was between-group changes from baseline to 3 months for pain intensity and disability. Implementation of the BetterBack☺ MoC did not show any between-group differences in the primary outcomes compared with routine care. However, the intervention group showed significantly higher satisfaction at 3 months and clinically meaningful greater improvement in LBP illness perception at 3 months and quality of life at 3 and 6 months but not in patient enablement and global impression of change compared with the control group. Physiotherapists’ care that adhered to all clinical practice quality indices resulted in an improvement of most patient reported outcomes with a clinically meaningful greater improved LBP illness perception at 3 months and quality of life at 3 and 6 months, significantly greater improvement in LBP illness perception, pain and satisfaction at 3 and 6 months and significantly better enablement at all time points as well as better global improvement outcomes at 3 months compared with non-adherent care. This highlights the importance of clinical guideline based primary care for improving patient reported LBP outcomes.
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Research Roundup - HIV and Chronic Pain: The Emerging Role of Physical Therapy. REHABILITATION ONCOLOGY 2021; 38:E41-E42. [PMID: 33447471 DOI: 10.1097/01.reo.0000000000000212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Hon S, Ritter R, Allen DD. Cost-Effectiveness and Outcomes of Direct Access to Physical Therapy for Musculoskeletal Disorders Compared to Physician-First Access in the United States: Systematic Review and Meta-Analysis. Phys Ther 2021; 101:5999910. [PMID: 33245117 DOI: 10.1093/ptj/pzaa201] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 03/09/2020] [Accepted: 10/08/2020] [Indexed: 11/14/2022]
Abstract
OBJECTIVE Direct access to physical therapy provides an alternative to physician-first systems for patients who need physical therapy for musculoskeletal disorders (MSDs). Direct access across multiple countries and the United States (US) military services has produced improved functional outcomes and/or cost-effectiveness at clinical and health care system levels; however, data remain scarce from civilian health care systems within the United States. The purpose of this study was to compare evidence regarding costs and clinical outcomes between direct access and physician-first systems in US civilian health services. METHODS A database search of PubMed, CINAHL, Cochrane Reviews, and PEDro was conducted through May 2019. Studies were selected if they specified civilian US, physical therapy for MSDs, direct access or physician-first, and extractable outcomes for cost, function, or number of physical therapy visits. Studies were excluded if interventions utilized early or delayed physical therapy access compared with physician-first. Five retrospective studies met the criteria. Means and standard deviations for functional outcomes, cost, and number of visits were extracted, converted to effect sizes (d) and 95% CI, and combined into grand effect sizes using fixed-effect or random-effects models depending on significance of the Q heterogeneity statistic. RESULTS Direct access to physical therapy showed reduced physical therapy costs (d = -0.23; 95% CI = -0.35 to -0.11), total health care costs (d = -0.19; 95% CI = -0.32 to -0.07), and number of physical therapy visits (d = -0.17; 95% CI = -0.29 to -0.05) compared to physician-first systems. Disability decreased in both direct access (d = -1.78; 95% CI = -2.28 to -1.29) and physician-first (d = -0.89; 95% CI = -0.92 to -0.85) groups; functional outcome improved significantly more with direct access (z score = 0.89; 95% CI = 0.40 to 1.39). CONCLUSIONS Direct access to physical therapy is more cost-effective, resulting in fewer visits than physician-first access in the United States, with greater functional improvement. IMPACT These findings within civilian US health care services support a cost-effective health care access alternative for spine-related MSDs and can inform health care policy makers.
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Affiliation(s)
- Sandra Hon
- Graduate Program in Physical Therapy, University California, San Francisco/San Francisco State University, San Francisco, California, USA
| | - Richard Ritter
- Graduate Program in Physical Therapy, University California, San Francisco/San Francisco State University, San Francisco, California, USA
| | - Diane D Allen
- Graduate Program in Physical Therapy, University California, San Francisco/San Francisco State University, San Francisco, California, USA
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Scoglio AAJ, Kraus SW, Saczynski J, Jooma S, Molnar BE. Systematic Review of Risk and Protective Factors for Revictimization After Child Sexual Abuse. TRAUMA, VIOLENCE & ABUSE 2021; 22:41-53. [PMID: 30669947 DOI: 10.1177/1524838018823274] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Child sexual abuse (CSA) is a widespread public health problem in the United States. It has been associated with multiple long-term deleterious outcomes including revictimization in adulthood. This systematic review of 25 studies synthesizes research examining possible risk and protective factors that might explain the established link between CSA and future victimizations. Specific risk factors identified included co-occurring maltreatment in the home, risky sexual behavior (particularly in adolescence), post-traumatic stress disorder, emotion dysregulation, and other maladaptive coping strategies. Only one protective factor was identified: perceived parental care. The review also revealed considerable variability in definitions and measurement of both CSA and adult victimization, particularly in terms of how researchers conceptualized age. Many of the studies were limited in generalizability by including only college-age women. These findings have clinical and research implications. Public health interventions working to prevent revictimization among CSA survivors can utilize these findings when designing programs. For researchers, the results highlight the need for standardized definitions of both CSA and revictimization, for well-validated and consistent measurement, and for inclusion of additional population groups in future research.
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Affiliation(s)
- Arielle A J Scoglio
- Institute of Health Equity & Social Justice Research, Northeastern University, Boston, MA, USA
- Social & Community Reintegration Research Program, ENRM VA, Bedford, MA, USA
| | - Shane W Kraus
- VISN 1 New England MIRECC, ENRM VA, Bedford, MA, USA
- University of Massachusetts Medical School, Worcester, MA, USA
| | - Jane Saczynski
- Bouvé College of Health Sciences, Northeastern University, Boston, MA, USA
| | - Shehzad Jooma
- Mental Health Service Line, ENRM VA, Bedford, MA, USA
| | - Beth E Molnar
- Institute of Health Equity & Social Justice Research, Northeastern University, Boston, MA, USA
- Department of Health Sciences, Northeastern University, Boston, MA, USA
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Farrokhi S, Russell Esposito E, McPherson D, Mazzone B, Condon R, Patterson CG, Schneider M, Greco CM, Delitto A, Highsmith MJ, Hendershot BD, Maikos J, Dearth CL. Resolving the Burden of Low Back Pain in Military Service Members and Veterans (RESOLVE): Protocol for a Multisite Pragmatic Clinical Trial. PAIN MEDICINE 2020; 21:S45-S52. [PMID: 33313735 DOI: 10.1093/pm/pnaa367] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
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.
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Affiliation(s)
- Shawn Farrokhi
- DOD-VA Extremity Trauma and Amputation Center of Excellence, Falls Church, Virginia.,Naval Medical Center San Diego, San Diego, California
| | - Elizabeth Russell Esposito
- DOD-VA Extremity Trauma and Amputation Center of Excellence, Falls Church, Virginia.,Veterans Affairs Puget Sound Health Care System, Seattle, Washington.,Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Danielle McPherson
- Naval Medical Center San Diego, San Diego, California.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland
| | - Brittney Mazzone
- DOD-VA Extremity Trauma and Amputation Center of Excellence, Falls Church, Virginia.,Naval Medical Center San Diego, San Diego, California
| | - Rachel Condon
- Naval Medical Center San Diego, San Diego, California
| | | | | | | | | | - M Jason Highsmith
- US Department of Veterans Affairs, Tampa, Florida.,University of South Florida, Tampa, Florida
| | - Brad D Hendershot
- DOD-VA Extremity Trauma and Amputation Center of Excellence, Falls Church, Virginia.,Walter Reed National Military Medical Center, Bethesda, Maryland.,Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Jason Maikos
- US Department of Veterans Affairs New York Harbor Healthcare System, New York, New York, USA
| | - Christopher L Dearth
- DOD-VA Extremity Trauma and Amputation Center of Excellence, Falls Church, Virginia.,Walter Reed National Military Medical Center, Bethesda, Maryland.,Uniformed Services University of the Health Sciences, Bethesda, Maryland
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Benny E, Evans C. Ontario Musculoskeletal Physiotherapists' Attitudes toward and Beliefs about Managing Chronic Low Back Pain. Physiother Can 2020; 72:355-363. [PMID: 35110808 PMCID: PMC8781503 DOI: 10.3138/ptc-2019-0026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/30/2023]
Abstract
Purpose: The purpose of this study was to explore Ontario musculoskeletal physiotherapists' attitudes toward and beliefs about managing chronic low back pain (CLBP), and their biomedical (BM) and bio-psychosocial (BPS) treatment orientation. Method: Through a link in the Ontario Physiotherapy Association newsletter, we administered an electronic survey to registered physiotherapists via SurveyMonkey. We used a modified three-step Dillman approach to encourage participation. The questionnaire included the Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT) measure, and demographic-practice items. Results: A total of 99 physiotherapists met the eligibility criteria and completed the PABS-PT (72.7% women; mean 17 years of experience). Respondents scored a mean of 26.98 (SD 7.69) on the BM sub-scale and 34.43 (SD 4.84) on the BPS sub-scale. Physiotherapists in public practice had a stronger BPS orientation (mean 36.52) than those in private practice (33.80; p = 0.01). Less experienced physiotherapists (<10 y) had a higher BM sub-scale score (mean 29.33) than more experienced physiotherapists (25.24, p = 0.013), and 78.8% of physiotherapists reported an awareness of clinical practice guidelines. Conclusions: Our preliminary findings suggest that Ontario physiotherapists' attitudes and beliefs align with a BPS orientation. Future studies should explore the impact of education that promotes a BPS approach to the management of CLBP.
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Affiliation(s)
| | - Cathy Evans
- Department of Physical Therapy, University of Toronto, Toronto
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Allaire C, Long AJ, Bedaiwy MA, Yong PJ. Interdisciplinary Teams in Endometriosis Care. Semin Reprod Med 2020; 38:227-234. [PMID: 33080631 DOI: 10.1055/s-0040-1718943] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Endometriosis-associated chronic pelvic pain can at times be a complex problem that is resistant to standard medical and surgical therapies. Multiple comorbidities and central sensitization may be at play and must be recognized with the help of a thorough history and physical examination. If a complex pain problem is identified, most endometriosis expert reviews and guidelines recommend multidisciplinary care. However, there are no specific recommendations about what should be the components of this approach and how that type of team care should be delivered. There is evidence showing the effectiveness of specific interventions such as pain education, physical therapy, psychological therapies, and pharmacotherapies for the treatment of chronic pain. Interdisciplinary team models have been well studied and validated in other chronic pain conditions such as low back pain. The published evidence in support of interdisciplinary teams for endometriosis-associated chronic pain is more limited but appears promising. Based on the available evidence, a model for an interdisciplinary team approach for endometriosis care is outlined.
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Affiliation(s)
- Catherine Allaire
- Department of Obstetrics and Gynecology, The University of British Columbia, Vancouver, Canada.,BC Women's Centre for Pelvic Pain and Endometriosis, Vancouver, Canada
| | - Alicia Jean Long
- Department of Obstetrics and Gynecology, The University of British Columbia, Vancouver, Canada.,BC Women's Centre for Pelvic Pain and Endometriosis, Vancouver, Canada
| | - Mohamed A Bedaiwy
- Department of Obstetrics and Gynecology, The University of British Columbia, Vancouver, Canada.,BC Women's Centre for Pelvic Pain and Endometriosis, Vancouver, Canada
| | - Paul J Yong
- Department of Obstetrics and Gynecology, The University of British Columbia, Vancouver, Canada.,BC Women's Centre for Pelvic Pain and Endometriosis, Vancouver, Canada
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Karmali RN, Skinner AC, Trogdon JG, Weinberger M, George SZ, Hassmiller Lich K. The association between the supply of select nonpharmacologic providers for pain and use of nonpharmacologic pain management services and initial opioid prescribing patterns for Medicare beneficiaries with persistent musculoskeletal pain. Health Serv Res 2020; 56:275-288. [PMID: 33006158 DOI: 10.1111/1475-6773.13561] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To test the relationship between the supply of select nonpharmacologic providers (physical therapy (PT) and mental health (MH)) and use of nonpharmacologic services among older adults with a persistent musculoskeletal pain (MSP) episode. DATA SOURCES/STUDY SETTING Claims data from a 5 percent random sample of Medicare beneficiaries enrolled fee-for-service (2007-2014) and the Area Health Resource File (AHRF). STUDY DESIGN This retrospective study used generalized estimating equations to estimate the association between the county nonpharmacologic provider supply and individual service use with opioid prescriptions filled during Phase 1 (first three months of an episode) and Phase 2 (three months following Phase 1). DATA COLLECTION/EXTRACTION METHODS We identified beneficiaries (>65 years) with ≥2 MSP diagnoses ≥90 days apart and no opioid prescription six months before the first pain diagnosis (N = 69 456). Beneficiaries' county characteristics were assigned using the AHRF. PRINCIPAL FINDINGS About 13.9 percent of beneficiaries used PT, 1.8 percent used MH services, and 10.7 percent had an opioid prescription during the first three months of a persistent MSP episode. An additional MH provider/10 000 people/county [aOR: 0.97, 95% CI: 0.96-0.98] and PT/10 000 people/county [aOR: 0.98, 95% CI: 0.97-1.00] was associated with lower odds of filling an opioid prescription in Phase 1. An additional MH provider/10 000 people/county [aOR: 0.97, 95% CI: 0.96-0.98] and PT use in Phase 1 [aOR: 0.62, 95% CI: 0.58-0.67] were associated with lower odds of filling an opioid prescription in Phase 2. The associations between the supply of providers and nonpharmacologic service use in Phase 1 and Phase 1 opioid prescriptions significantly differed by metropolitan and rural counties (P-value: .019). CONCLUSIONS Limited access to nonpharmacologic services is associated with opioid prescriptions at the onset of a persistent MSP episode. Initiating PT at the onset of an episode may reduce future opioid use. Strategies for engaging beneficiaries in nonpharmacologic services should be tailored for metropolitan and rural counties.
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Affiliation(s)
- Ruchir N Karmali
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina-Chapel Hill, Oakland, California, USA.,Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA.,Department of Population Health Sciences, School of Medicine, Duke University, Durham, North Carolina, USA.,Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Asheley C Skinner
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA.,Department of Population Health Sciences, School of Medicine, Duke University, Durham, North Carolina, USA
| | - Justin G Trogdon
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina-Chapel Hill, Oakland, California, USA
| | - Morris Weinberger
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina-Chapel Hill, Oakland, California, USA
| | - Steven Z George
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA.,Department of Orthopedic Surgery, School of Medicine, Duke University, Durham, North Carolina, USA
| | - Kristen Hassmiller Lich
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina-Chapel Hill, Oakland, California, USA
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Husted M, Rossen CB, Jensen TS, Mikkelsen LR, Rolving N. Adherence to key domains in low back pain guidelines: A cross-sectional study of Danish physiotherapists. PHYSIOTHERAPY RESEARCH INTERNATIONAL 2020; 25:e1858. [PMID: 32537859 PMCID: PMC7583478 DOI: 10.1002/pri.1858] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 03/25/2020] [Accepted: 05/23/2020] [Indexed: 12/29/2022]
Abstract
OBJECTIVE The aim of the study was threefold: Firstly, to investigate the adherence to clinical practice guidelines for low back pain (LBP) among Danish physiotherapists with regard to three key domains: (a) activity, (b) work and (c) psychosocial risk factors. Secondly, to investigate whether adherence differed between physiotherapists working in private clinics (private physiotherapists) and physiotherapists working at public healthcare centres (public physiotherapists). Thirdly, to describe the physiotherapists' treatment modalities for patients with LBP. METHODS A cross-sectional online survey was conducted with 817 physiotherapists working in the Central Denmark Region. Adherence to the guideline domains was assessed using two vignettes. The difference in adherence between the groups was assessed using the Chi-squared test. Treatment modalities were reported using descriptive statistics. RESULTS A total of 234 physiotherapists responded, hereof 163 private physiotherapists and 71 public physiotherapists (response rate 29%). The proportions of physiotherapists managing the patients strictly in line with the guideline domains were 32% (activity), 16% (work) and 82% (psychosocial risk factors) for Vignette 1 and 6% (activity), 53% (work) and 60% (psychosocial risk factors) for Vignette 2. Public physiotherapists were more likely to manage patients strictly in line with guidelines for assessing the psychosocial risk factors compared to private physiotherapist (Vignette 1: 92% vs. 77% p = .030; Vignette 2:70% vs. 55% p = .035). Regarding the other two domains, there was no significant difference between the two groups in terms of adherence (p > .05). Concerning treatment modalities, the majority of physiotherapists instructed the patients in adopting an exercise program or informed the patients about the benign nature and prognosis of LBP. CONCLUSION Overall, the participating Danish physiotherapists strictly adhered to only one out of three key domains. This underlines the importance of bringing focus on implementing the current guidelines' recommendations in clinical practice.
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Affiliation(s)
- Maja Husted
- Interdisciplinary Research Unit, Elective Surgery CentreSilkeborg Regional HospitalSilkeborgDenmark
| | - Camilla B. Rossen
- Interdisciplinary Research Unit, Elective Surgery CentreSilkeborg Regional HospitalSilkeborgDenmark
| | - Tue S. Jensen
- Diagnostic Centre, University Research Clinic for Innovative Patient PathwaysSilkeborg Regional HospitalSilkeborgDenmark
- Department of Sports Science and Clinical BiomechanicsSDUOdenseDenmark
| | - Lone R. Mikkelsen
- Interdisciplinary Research Unit, Elective Surgery CentreSilkeborg Regional HospitalSilkeborgDenmark
- Department of Clinical MedicineAarhus UniversityAarhusDenmark
| | - Nanna Rolving
- Diagnostic Centre, University Research Clinic for Innovative Patient PathwaysSilkeborg Regional HospitalSilkeborgDenmark
- Public Health & Rehabilitation Research DEFACTUMAarhusDenmark
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Matheson LN, Verna J, Saunders-Enright D, Gherscovici E, Kemp B, Mayer J. Development and validation of a method to screen for co-morbid depression by non-behavioral health practitioners treating musculoskeletal pain. Work 2020; 67:55-65. [PMID: 32955474 PMCID: PMC7683063 DOI: 10.3233/wor-203252] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND: Although diagnosis and treatment of depressive illness is outside the scope of practice for non-behavioral health practitioners such as occupational therapists, physical therapists, kinesiotherapists, and chiropractors, it frequently is comorbid with painful musculoskeletal disorders such as low back pain and it negatively affects outcomes, including return to work. As psychologically-informed practice becomes more widely implemented without the immediate availability of behavioral health practitioners, safe and effective methods to screen for and appropriately triage depressive illness by nonbehavioral health practitioners are necessary. OBJECTIVES: To demonstrate the efficacy and validity of a method employed by non-behavioral health practitioners to screen for and appropriately triage musculoskeletal pain patients who also are experiencing depressive illness. METHODS: As part of a previously-published psychometric research study conducted in a community-based musculoskeletal pain rehabilitation program, a method was developed for nonbehavioral health practitioners to screen for and appropriately triage patients for co-morbid depressive illness, thus providing the current opportunity to examine the effects of depressive illness on work outcomes. The first step in the two-step process involves a 22-item questionnaire, providing scores used in the second step to triage for outside consultation with behavioral health practitioners. This paper describes the screening method and its application in an observational study of the impact of depressive illness on work outcomes. RESULTS: Among 156 consecutive patients who were presenting with musculoskeletal pain disorders to an outpatient rehabilitation program, 22.3% also were identified to have co-morbid clinical depression. The screening process allowed all patients to continue in the rehabilitation program. Those who were already receiving behavioral health care were encouraged to inform care providers of their participation in the program. Those who were not receiving behavioral health care were successfully triaged to care outside of the clinic. Depressive illness was found to affect success in the program, confirming the validity of the screening process for outpatient rehabilitation program participants experiencing chronic pain. CONCLUSIONS: A simple and effective depression screening process that triages patients without interruption of musculoskeletal treatment can be employed by nonbehavioral health practitioners. Because return to work outcomes were found to be negatively affected by depressive illness, this approach has the potential to improve overall program efficacy.
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Affiliation(s)
- Leonard N Matheson
- The Vert Mooney Research Foundation, San Diego, CA, USA.,Epic Neurorehabilitation & Psychology Services, Chico, CA, USA
| | - Joe Verna
- The Vert Mooney Research Foundation, San Diego, CA, USA.,Spine & Sport, San Diego, CA, USA
| | | | | | - Bryan Kemp
- Rancho Los Amigos National Rehabilitation Center, Downey, CA, USA
| | - John Mayer
- The Vert Mooney Research Foundation, San Diego, CA, USA
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Pullen SD, Acker C, Kim H, Mullins M, Sims P, Strasbaugh H, Zimmerman S, del Rio C, Marconi VC. Physical Therapy for Chronic Pain Mitigation and Opioid Use Reduction Among People Living with Human Immunodeficiency Virus in Atlanta, GA: A Descriptive Case Series. AIDS Res Hum Retroviruses 2020; 36:670-675. [PMID: 32390457 DOI: 10.1089/aid.2020.0028] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
People living with HIV (PLH) may be at increased risk of experiencing both chronic pain and opioid dependence. Physical therapy (PT) has been shown to be effective as a nonpharmacological strategy for mitigating chronic pain in the general population, however, there is gap in research investigating PT to reduce chronic pain and opioid use among PLH. This case series describes the feasibility of an innovative PT intervention to decrease chronic pain and opioid use at a multidisciplinary human immunodeficiency virus (HIV) clinic. Participants (n = 4) were evaluated and given an individualized PT "package" consisting of manual therapy, exercise prescription, Transcutaneous Electrical Nerve Stimulation, and pain coping strategies. Pre- and postintervention outcomes were measured for pain reports, opioid use, and quality-of-life measures. After the intervention, all participants reported decrease or total elimination of both pain measured on the 0-10 numerical rating scale and opioid use measured in morphine milligram equivalents (MME). A paired t-test showed a significant difference (<.05) in the preintervention and postintervention pain scores and MME values. Results of this case series suggest in this sample that the described PT intervention is a feasible approach to mitigating chronic pain and opioid use among PLH and should be implemented on a larger scale for maximal effect.
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Affiliation(s)
- Sara D. Pullen
- Division of Physical Therapy, Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Christi Acker
- Division of Physical Therapy, Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Haemi Kim
- Division of Physical Therapy, Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Morgan Mullins
- Division of Physical Therapy, Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Payton Sims
- Division of Physical Therapy, Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Holly Strasbaugh
- Division of Physical Therapy, Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Samantha Zimmerman
- Division of Physical Therapy, Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Carlos del Rio
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Vincent C. Marconi
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
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Increasing Physical Therapy Visits as a Marker for Time Lost From Work and High Workers' Compensation Claim Costs. J Occup Environ Med 2020; 62:e328-e333. [PMID: 32730036 DOI: 10.1097/jom.0000000000001891] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To quantify the association between physical therapy (PT) visits and workers' compensation costs and lost time. METHOD A total of 40,203 lost-time claims (1998 to 2018) were analyzed. RESULTS The odds ratio of total paid claim costs more than or equal to $100,000 increased with the number of PT visits from 1.91 with 1 to 3 PT visits (95% confidence interval [CI]: 1.62 to 2.26) to 5.56 (95% CI: 4.86 to 6.37) for workers with a surgical procedure and more than or equal to 50 PT visits versus those without PT visits, when controlling for confounding factors. The risk of remaining at an off work status is greatest among claims involving surgery, escalating among claims with 15 or more PT visits (hazard ratio more than or equal to 3.76). CONCLUSIONS PT visits may be used as a marker for high workers' compensation cost and delayed return-to-work.
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The Association Between the Supply of Nonpharmacologic Providers, Use of Nonpharmacologic Pain Treatments, and High-risk Opioid Prescription Patterns Among Medicare Beneficiaries With Persistent Musculoskeletal Pain. Med Care 2020; 58:433-444. [PMID: 32028525 DOI: 10.1097/mlr.0000000000001299] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Opioids are prescribed more frequently than nonpharmacologic treatments for persistent musculoskeletal pain (MSP). We estimate the association between the supply of physical therapy (PT) and mental health (MH) providers and early nonpharmacologic service use with high-risk opioid prescriptions among Medicare beneficiaries with persistent MSP. RESEARCH DESIGN We retrospectively studied Medicare beneficiaries (>65 y) enrolled in Fee-for-Service and Part D (2007-2014) with a new persistent MSP episode and no opioid prescription during the prior 6 months. Independent variables were nonpharmacologic provider supply per capita and early nonpharmacologic service use (any use during first 3 mo). One year outcomes were long-term opioid use (LTOU) (≥90 days' supply) and high daily dose (HDD) (≥50 mg morphine equivalent). We used multinomial regression and generalized estimating equations and present adjusted odds ratios (aORs). RESULTS About 2.4% of beneficiaries had LTOU; 11.9% had HDD. The supply of MH providers was not associated with LTOU and HDD. Each additional PT/10,000 people/county was associated with greater odds of LTOU [aOR: 1.06; 95% confidence interval (CI), 1.01-1.11). Early MH use was associated with lower odds of a low-risk opioid use (aOR: 0.81; 95% CI, 0.68-0.96), but greater odds of LTOU (aOR: 1.93; 95% CI, 1.28-2.90). Among beneficiaries with an opioid prescription, early PT was associated with lower odds of LTOU (aOR: 0.75; 95% CI, 0.64-0.89), but greater odds of HDD (aOR: 1.25; 95% CI, 1.15-1.36). CONCLUSIONS The benefits of nonpharmacologic services on opioid use may be limited. Research on effective delivery of nonpharmacologic services to reduce high-risk opioid use for older adults with MSP is needed.
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Stander J, Grimmer K, Brink Y. A user-friendly clinical practice guideline summary for managing low back pain in South Africa. SOUTH AFRICAN JOURNAL OF PHYSIOTHERAPY 2020; 76:1366. [PMID: 32161826 PMCID: PMC7059441 DOI: 10.4102/sajp.v76i1.1366] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 10/02/2019] [Indexed: 12/29/2022] Open
Abstract
Background Clinical practice guidelines (CPGs) provide conveniently packaged evidence-based recommendations to inform clinical decisions. However, intended end-users often do not know how to source, appraise, interpret or choose among CPGs. Moreover, it can be confusing when recommendations on the same topic differ among CPGs, in wording, intent and underpinning evidence. Objectives This article reports on the processes of: (1) identifying current CPGs for acute and subacute low back pain (LBP) to fit the needs of South African physiotherapists, (2) collating and summarising CPG recommendations to produce a user-friendly end-user product and (3) testing the utility of the summary CPG document on South African physiotherapy clinicians to efficiently determine acceptability, appropriateness and feasibility to inform clinical decision-making. Method An adapted approach was followed by systematically searching online CPG repositories and online databases for LBP CPGs; screening and critically appraising identified CPGs; summarising recommendations from relevant CPGs and organising them into clinical practice activities. Feedback on utility was obtained from 11 physiotherapists. Results Three high-quality, international CPGs provided 25 recommendations on the assessment and management of acute and subacute LBP relevant to South African physiotherapy practice. They were organised into 10 headings. Physiotherapy user feedback suggested that this document would assist in clinical decision-making. Conclusion Organised recommendations extracted from multiple, relevant CPGs provide an end-user-friendly resource for physiotherapists treating LBP. Clinical implications Collated and organised CPG recommendations may effectively assist South African physiotherapists’ clinical decision-making in assessing and managing patients with acute and subacute LBP.
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Affiliation(s)
- Jessica Stander
- Division of Physiotherapy, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Karen Grimmer
- Division of Physiotherapy, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Yolandi Brink
- Division of Physiotherapy, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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Angelo M, Vass R, Flores Vazquez I, Pierre D, Del Vecchio T, Souder E. Association Between Outpatient Rehabilitation Therapy and Total Cost of Care for a Frail Elderly Population in a Medicare Accountable Care Organization. Popul Health Manag 2020; 24:110-115. [PMID: 32069183 DOI: 10.1089/pop.2019.0223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Frailty is a debilitating and increasingly costly condition in an elderly population equating to nearly $7.6 billion in Medicare spending in 2016. Understanding the burden of frailty and how to manage this population efficiently is of key importance in an accountable care organization. Using an operational, claims-derived definition of frailty, the authors set out to explore the association between therapy and total cost of care for the frail elderly population. Claims data were reviewed for nearly 94,000 beneficiaries to identify the burden of frailty in that population along with the association with therapy utilization. Nearly 10% of patients in the study populations were found to meet the operational definition of frailty. When the frail population is segmented into those who receive outpatient rehabilitation therapy and those who do not, outpatient rehabilitation therapy is associated with decreased cost at 13-32 therapy units delivered. Outside of this dose range, outpatient rehabilitation therapy was not associated with statistically significant improvements in total cost of care for this population. Results suggest that from the standpoint of population health management, utilization of outpatient rehabilitation services may be helpful to decrease costs in several domains. When that cost reduction is compared to therapy units delivered, it is demonstrated that outpatient rehabilitation therapy is associated with lower costs at a certain quantity of therapy. This study has implications for population health management of a frail elderly cohort as well as for managing preferred partnerships with therapy providers, given the wide array of therapy patterns delivered.
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Affiliation(s)
- Mark Angelo
- Delaware Valley Accountable Care Organization, Thomas Jefferson University, Radnor, Pennsylvania, USA
| | - Ryan Vass
- Delaware Valley Accountable Care Organization, Thomas Jefferson University, Radnor, Pennsylvania, USA
| | - Imelda Flores Vazquez
- Delaware Valley Accountable Care Organization, Thomas Jefferson University, Radnor, Pennsylvania, USA
| | - Daniella Pierre
- Delaware Valley Accountable Care Organization, Thomas Jefferson University, Radnor, Pennsylvania, USA
| | | | - Elizabeth Souder
- Delaware Valley Accountable Care Organization, Thomas Jefferson University, Radnor, Pennsylvania, USA
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Walston Z, McLester C, McLester J. Effect of Low Back Pain Chronicity on Patient Outcomes Treated in Outpatient Physical Therapy: A Retrospective Observational Study. Arch Phys Med Rehabil 2019; 101:861-869. [PMID: 31874155 DOI: 10.1016/j.apmr.2019.11.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 11/14/2019] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To examine the potential relationship between physical therapy (PT) treatment outcomes and chronicity of low back pain (LBP) in the outpatient setting. DESIGN Retrospective observational study. SETTING Outpatient PT clinics across 11 states. PARTICIPANTS A total of 11,941 patients with LBP provided with PT services and discharged from care between January 1, 2017, and December 31, 2018. MAIN OUTCOME MEASURES Focus on Therapeutic Outcome Low Back Functional Status (FS) Patient-Reported Outcome Measure (PROM) was the primary outcomes measure used. It assesses the patients' perceived physical abilities for patients experiencing LBP impairments. It determined a functional score on a linear metric ranging from 0 (low functioning) to 100 (high functioning). The difference in score between the intake FS and final FS score produced the FS change, which represented the overall improvement of the episode of care. RESULTS The mean FS change was 16.997 (n=11,945). Patients with chronic symptoms (>90-d duration) had an FS change of 15.920 (n=7264) across 14.63 visits. Patients with subacute symptoms (15-90d) had an FS change of 21.66 (n=3631) across 14.05. Patients with acute symptoms (0-14d) had an FS change of 29.32 (n=1050) across 13.66 visits. Stepwise regression analysis revealed a significant â for chronicity (-4.155) with all models. CONCLUSIONS Overall, this study shows patients experiencing shorter duration of LBP symptoms before starting a PT episode of care experience significantly better outcomes than patients who waited. Furthermore, the number of treatment session and duration of care was similar between groups, indicating potential ineffective or insufficient care was provided for patients with chronic pain.
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Affiliation(s)
- Zachary Walston
- PT Solutions Physical Therapy, Atlanta, Georgia, United States.
| | | | - John McLester
- Kennesaw State University, Kennesaw, Georgia, United States
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Khodadad B, Letafatkar A, Hadadnezhad M, Shojaedin S. Comparing the Effectiveness of Cognitive Functional Treatment and Lumbar Stabilization Treatment on Pain and Movement Control in Patients With Low Back Pain. Sports Health 2019; 12:289-295. [PMID: 31841078 DOI: 10.1177/1941738119886854] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND The treatment of chronic low back pain (LBP) should target both behavioral variables and physical performance factors. HYPOTHESIS Cognitive functional treatment (CFT) and lumbar stabilization treatment (LST) will result in positive changes in pain and lumbar movement control (LMC) in patients with LBP. STUDY DESIGN Pretest-posttest intervention. LEVEL OF EVIDENCE Level 3. METHODS After screening, 52 participants (mean age, 44.3 ± 2.46 years) with chronic LBP were allocated into CFT (n = 17), LST (n = 17), or control (n = 18) groups. Pain and LMC were evaluated before and after 8 weeks of intervention with visual analog scale (VAS) and Luomajoki LMC battery tests, respectively. RESULTS Compared with baseline, pain and LMC were reduced and improved significantly in both groups after 8 weeks. However, the changes in both variables were not significantly different between groups. Percent change for pain between pretest and posttest values in the LST group was a decrease of 45% (P = 0.003), compared with a decrease of 40% (P = 0.003) in the CFT group. Change in LMC in the LST group was a decrease of 100% (P = 0.026), compared with a decrease of 200% (P = 0.018) in the CFT group. There as no change for both variables in the control group. CONCLUSION Both CFT and LST groups improved LMC scores and reduced pain intensity. However, there was no difference between the 2 experimental groups on pain and LMC test results. CLINICAL RELEVANCE In this study, intended to construct an intervention for people with chronic LBP, the primary aims were to help individuals "make sense of their pain," develop effective pain control strategies via body relaxation and extinction of safety behaviors, and adopt healthy lifestyle behaviors to affect cognitive factors known to affect pain sensitivity and disability. These primary aims were achieved through an emphasis on factors such as development of positive beliefs, reduced fear, increased awareness, enhanced understanding and control of pain, adaptive coping, enhanced self-efficacy, confidence, and improved mood through the class-based intervention.
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Affiliation(s)
- Behrouz Khodadad
- Faculty of Physical Education and Sport Sciences, Department of Biomechanics and Sport Injuries, Kharazmi University, Tehran, Republic of Iran
| | - Amir Letafatkar
- Faculty of Physical Education and Sport Sciences, Department of Biomechanics and Sport Injuries, Kharazmi University, Tehran, Republic of Iran
| | - Malihe Hadadnezhad
- Faculty of Physical Education and Sport Sciences, Department of Biomechanics and Sport Injuries, Kharazmi University, Tehran, Republic of Iran
| | - Sadredin Shojaedin
- Faculty of Physical Education and Sport Sciences, Department of Biomechanics and Sport Injuries, Kharazmi University, Tehran, Republic of Iran
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