Physical Therapy Referral From Primary Care for Acute Back Pain With Sciatica : A Randomized Controlled Trial.

BACKGROUND: Few studies have examined primary care management for acute sciatica, including referral to physical therapy. OBJECTIVE: To evaluate whether early referral to physical therapy reduced disability more than usual care (UC) alone for patients with acute sciatica. DESIGN: Randomized controlled clinical trial. (ClinicalTrials.gov: NCT02391350). SETTING: 2 health care systems in Salt Lake City, Utah. PATIENTS: 220 adults aged 18 to 60 years with sciatica of less than 90 days' duration who were making an initial primary care consultation. INTERVENTION: All participants received imaging and medication at the discretion of the primary care provider before enrollment. A total of 110 participants randomly assigned to UC were provided 1 session of education, and 110 participants randomly assigned to early physical therapy (EPT) were provided 1 education session and then referred for 4 weeks of physical therapy, including exercise and manual therapy. MEASUREMENTS: The primary outcome was the Oswestry Disability Index (OSW) score after 6 months. Secondary outcomes were pain intensity, patient-reported treatment success, health care use, and missed workdays. RESULTS: Participants in the EPT group had greater improvement from baseline to 6 months for the primary outcome (relative difference, -5.4 points [95% CI, -9.4 to -1.3 points]; P = 0.009). The OSW and several secondary outcomes favored EPT after 4 weeks. After 1 year, between-group differences favored EPT for the OSW (relative difference, -4.8 points [CI, -8.9 to -0.7 points]) and back pain intensity (relative difference, -1.0 points [CI, -1.6 to -0.4 points]). The EPT group was more likely to self-report treatment success after 1 year (45.2%) than the UC group (27.6%) (relative risk, 1.6 [CI, 1.1 to 2.4]). There were no significant differences in health care use or missed workdays. LIMITATION: The patients and providers were unblinded, and specific physical therapy interventions responsible for effects could not be determined. CONCLUSION: Referral from primary care to physical therapy for recent-onset sciatica improved disability and other outcomes compared with UC. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.

Implementation of an Alternative Pathway for Patients Seeking Care for Low Back Pain: A Prospective Observational Cohort Study.

Background: In the United States, low back pain (LBP) is among the most common symptoms prompting a health care visit. Patients can receive escalated care, such as advanced imaging or invasive procedures, before guideline-recommended options offered by physical therapists. A guideline-concordant alternative care pathway (RapidAccess) that emphasized early physical therapy for patients with LBP before they consulted a physiatrist was implemented. Evaluating the implementation of care pathways, such as RapidAccess using the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework, provides a broader understanding of the barriers to implementation. Objective: The purpose of this study was to evaluate the implementation of a guideline-concordant care pathway for patients with LBP using a RE-AIM framework. Design: This study used a prospective observational cohort design. Methods: Patients with a chief complaint of LBP who were scheduling a new appointment with physiatry were eligible. Eligible patients chose whether or not to participate in RapidAccess before a consultation with a physiatrist. Implementation outcomes were evaluated using the RE-AIM framework. Results: During the study period, 1556 patients with LBP called to schedule a new visit with a physiatrist. Of these, 400 (25.7%) were eligible for RapidAccess, and 124 (31% of those eligible) participated in the program (reach). Of the 400 eligible patients, 225 (56.3%) were offered RapidAccess (adoption). Compared with patients who were managed in physical therapy following a consultation with a physiatrist, RapidAccess participants demonstrated improvement in physical function with physical therapist management (effectiveness); 58.9% cancelled their physiatrist visit (implementation), and rates of imaging and injections were lower (effectiveness). Reach and adoption (maintenance) trended downward beyond the first 6 months of the project. Limitations: The results are from a single health system and might not be broadly generalizable. Conclusions: The RE-AIM framework was useful in evaluating the implementation of RapidAccess. Factors influencing reach and adoption must be further examined.

Early Physical Therapy vs Usual Care in Patients With Recent-Onset Low Back Pain: A Randomized Clinical Trial.

IMPORTANCE: Low back pain (LBP) is common in primary care. Guidelines recommend delaying referrals for physical therapy. OBJECTIVE: To evaluate whether early physical therapy (manipulation and exercise) is more effective than usual care in improving disability for patients with LBP fitting a decision rule. DESIGN, SETTING, AND PARTICIPANTS: Randomized clinical trial with 220 participants recruited between March 2011 and November 2013. Participants with no LBP treatment in the past 6 months, aged 18 through 60 years (mean age, 37.4 years [SD, 10.3]), an Oswestry Disability Index (ODI) score of 20 or higher, symptom duration less than 16 days, and no symptoms distal to the knee in the past 72 hours were enrolled following a primary care visit. INTERVENTIONS: All participants received education. Early physical therapy (n = 108) consisted of 4 physical therapy sessions. Usual care (n = 112) involved no additional interventions during the first 4 weeks. MAIN OUTCOMES AND MEASURES: Primary outcome was change in the ODI score (range: 0-100; higher scores indicate greater disability; minimum clinically important difference, 6 points) at 3 months. Secondary outcomes included changes in the ODI score at 4-week and 1-year follow-up, and change in pain intensity, Pain Catastrophizing Scale (PCS) score, fear-avoidance beliefs, quality of life, patient-reported success, and health care utilization at 4-week, 3-month, and 1-year follow-up. RESULTS: One-year follow-up was completed by 207 participants (94.1%). Using analysis of covariance, early physical therapy showed improvement relative to usual care in disability after 3 months (mean ODI score: early physical therapy group, 41.3 [95% CI, 38.7 to 44.0] at baseline to 6.6 [95% CI, 4.7 to 8.5] at 3 months; usual care group, 40.9 [95% CI, 38.6 to 43.1] at baseline to 9.8 [95% CI, 7.9 to 11.7] at 3 months; between-group difference, -3.2 [95% CI, -5.9 to -0.47], P = .02). A significant difference was found between groups for the ODI score after 4 weeks (between-group difference, -3.5 [95% CI, -6.8 to -0.08], P = .045]), but not at 1-year follow-up (between-group difference, -2.0 [95% CI, -5.0 to 1.0], P = .19). There was no improvement in pain intensity at 4-week, 3-month, or 1-year follow-up (between-group difference, -0.42 [95% CI, -0.90 to 0.02] at 4-week follow-up; -0.38 [95% CI, -0.84 to 0.09] at 3-month follow-up; and -0.17 [95% CI, -0.62 to 0.27] at 1-year follow-up). The PCS scores improved at 4 weeks and 3 months but not at 1-year follow-up (between-group difference, -2.7 [95% CI, -4.6 to -0.85] at 4-week follow-up; -2.2 [95% CI, -3.9 to -0.49] at 3-month follow-up; and -0.92 [95% CI, -2.7 to 0.61] at 1-year follow-up). There were no differences in health care utilization at any point. CONCLUSIONS AND RELEVANCE: Among adults with recent-onset LBP, early physical therapy resulted in statistically significant improvement in disability, but the improvement was modest and did not achieve the minimum clinically important difference compared with usual care. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01726803.

An Eccentrically Biased Rehabilitation Program Early after TKA Surgery.

Rehabilitation services are less-studied aspects of the management following total knee arthroplasty (TKA) despite long-term suboptimal physical functioning and chronic deficits in muscle function. This paper describes the preliminary findings of a six-week (12 session) eccentrically-biased rehabilitation program targeted at deficits in physical function and muscle function, initiated one month following surgery. A quasiexperimental, one group, pretest-posttest study with thirteen individuals (6 female, 7 male; mean age 57 ± 7 years) examined the effectiveness of an eccentrically-biased rehabilitation program. The program resulted in improvements in the primary physical function endpoints (SF-36 physical component summary and the six-minute walk test) with increases of 59% and 47%, respectively. Muscle function endpoints (knee extension strength and power) also increased 107% and 93%, respectively. Eccentrically-biased exercise used as an addition to rehabilitation may help amplify and accelerate physical function following TKA surgery.

The long-term contribution of muscle activation and muscle size to quadriceps weakness following total knee arthroplasty.

PURPOSE: Many older individuals have persistent quadriceps strength impairments after a total knee arthroplasty (TKA). A combination of muscle atrophy and neuromuscular activation deficits apparently contributes to residual strength impairments. The purpose of this short report is to describe the contribution of quadriceps muscle activation and muscle volume to impaired muscle strength in older individuals an average of 21 months following a TKA. METHODS: Seventeen individuals (males: 3, females: 14; mean age: 68 yrs +/- 8.7; BMI: 33 +/- 4.8 kg/m2; number of TKA: 24; average postoperative months: 21 +/- 11.3) recruited from an orthopaedic surgeon's practice provided their written consent and participated in this study. Quadriceps strength (MVIC) and voluntary quadriceps muscle activation (QA) were measured with use of a burst-superimposition technique in which a supramaximal burst of electrical stimulation is superimposed on an MVIC. Quadriceps volume (QV) was assessed from magnetic resonance images of the quadriceps. RESULTS: The mean quadriceps strength was 107.3 Nm +/- 36.4 (range: 43.22 - 205.2). The mean QA (as described with a central activation ratio) was 0.97 +/- 0.04 (range: 0.83 - 1.00). The mean QV was 1093 cm3 +/- 311.80 (range: 653.66 - 1706.56). QA and QV explain 85% of the variance in quadriceps strength (R2 = .85, p < 0.001), with QV having the greatest contribution to strength (R2 = .77, p < 0.001). CONCLUSIONS: QV is a much stronger predictor of quadriceps strength than QA in individuals more than 1 year following TKA. Activation levels contributed little to strength one year following TKA, compared to its profound contribution in the first few postoperative months. Physical therapy interventions focused on improving muscle size in this population should be considered more relevant than countermeasures addressing neuromuscular activation.

Chitosan-coated silica as a solid phase for RNA purification in a microfluidic device.

Chitosan-coated silica particles and chitosan-coated microchannels have been explored as an alternative to a standard silica phase for DNA extraction in a microdevice (Cao, W.; Easley, C. J.; Ferrance, J. P.; Landers, J. P. Anal. Chem. 2006, 78 (20), 7222-7228). A method that exploits the use of aqueous buffers for nucleic acid binding to and release from a solid phase is advantageous, avoiding the reagents used for conventional extraction (isopropanol and guanadinium hydrochloride), which are potent PCR inhibitors. The pH-controlled approach, which promotes nucleic acid binding to and release to the chitosan phase based on a change in buffer pH, is exploited here for RNA purification in a microfluidic device. The chitosan phase reproducibly allowed for higher RNA extraction efficiencies under aqueous conditions (71%) compared to that with a silica phase under chaotropic conditions (53%). The effectiveness of the chitosan phase was demonstrated with the successful purification of RNA from the alveolar rhabdomyosarcoma (ARMS) cancer cell line, with 3.5-fold greater extraction efficiencies than obtained when the same sample was purified using a silica phase: the resulting RNA was found to be amplifiable in reverse-transcription PCR. Low-molecular weight chitosan is also a proven inhibitor of RNases, further demonstrating the advantages of chitosan as a solid phase for RNA purification compared to silica. The chitosan phase is, therefore, a superior choice for extraction and purification of RNA in a microfluidic device and is compatible with biological samples found in a clinical or forensic setting.

Reversing muscle and mobility deficits 1 to 4 years after TKA: a pilot study.

UNLABELLED: Muscle and mobility deficits can persist for years after a total knee arthroplasty (TKA). The purposes of this study were (1) to determine if 12 weeks of rehabilitation with resistance exercise induces increases in muscle size, strength, and mobility in individuals 1 to 4 years after a TKA; and (2) to compare the muscle and mobility outcomes of a traditional resistance exercise rehabilitation program with a rehabilitation program focused on eccentric resistance exercise. Seventeen individuals (13 women, four men; mean age, 68 years; age range, 55-80 years) with either a unilateral or bilateral TKA (total of 24 knees) were included in this matched and randomized repeated-measures rehabilitation pilot trial. Increases in quadriceps muscle volume and knee extension strength followed 12 weeks of eccentric exercise. Improvements were also noted in four mobility tests. Similar improvements were noted in the traditional group in two mobility tests. An increase in muscle size and strength and an improvement in levels of mobility can occur after 12 weeks of resistance exercise in older individuals 1 to 4 years after TKA. When the exercise mode focuses on eccentric resistance, the muscle growth response is greater as is the improvement in important mobility tasks. LEVEL OF EVIDENCE: Level II, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Total knee arthroplasty: muscle impairments, functional limitations, and recommended rehabilitation approaches.

UNLABELLED: The number of total knee arthroplasty (TKA) surgeries performed each year is predicted to steadily increase. Following TKA surgery, self-reported pain and function improve, though individuals are often plagued with quadriceps muscle impairments and functional limitations. Postoperative rehabilitation approaches either are not incorporated or incompletely address the muscular and functional deficits that persist following surgery. While the reason for quadriceps weakness is not well understood in this patient population, it has been suggested that a combination of muscle atrophy and neuromuscular activation deficits contribute to residual strength impairments. Failure to adequately address the chronic muscle impairments has the potential to limit the long-term functional gains that may be possible following TKA. Postoperative rehabilitation addressing quadriceps strength should mitigate these impairments and ultimately result in improved functional outcomes. The purpose of this paper is to describe these quadriceps muscle impairments and discuss how these impairments can contribute to the related functional limitations following TKA. We will also describe the current concepts in TKA rehabilitation and provide recommendations and clinical guidelines based on the current available evidence. LEVEL OF EVIDENCE: Therapy, level 5.