Ultrasound assessment of deep cervical extensors morphology and quality in populations with whiplash associated disorders: An intra- and inter-examiner reliability study.

BACKGROUND: Ultrasound imaging (US) has shown to be a reliable and valid tool for assessing muscle morphology and quality. However, most studies have focused on asymptomatic populations. OBJECTIVE: To investigate intra- and inter-rater reliability estimates of muscle morphology and quality of cervical multifidus (CM) and short rotators (SR) in patients with whiplash associated disorders (WAD). DESIGN: An intra- and inter-examiner reliability study. METHODS: US images were acquired in a blinded fashion in 34 patients (35% males) by two experienced and two novice examiners. Cross-sectional area (CSA), perimeter, mean echo-intensity (EI) and the percentage of fatty infiltration were assessed twice, one-week apart, in a randomized order. Reliability estimates (i.e., intra-class correlation coefficients -ICC-, standard error of measurement -SEM-, minimal detectable change, mean of measurements, absolute and percent errors) were calculated. RESULTS: Intra-examiner reliability for experienced assessors ranged from good to excellent for CM and SR (ICC3,1 = 0.888-0.975 and 0.810-0.964 respectively) and from moderate-to-good for novices (ICC3,1 = 0.708-0.790 and 0.655-0.796 respectively). The agreement between the experienced examiners was moderate to good (ICC3,2 = 0.737-0.899 and 0.728-0.899 CM and SR respectively); between novice and experienced examiners was moderate to good (ICC3,2 = 0.617-0.873 and 0.657-0.766 CM and SR respectively); and between novice examiners was moderate-to-good for CM (ICC3,2 = 0.610-0.777) and moderate for SR (ICC3,2 = 0.600-0.730). CONCLUSION: CM and SR intra-examiner reliability was good-to-excellent for novice and experienced examiners. However, inter-examiner reliability was clinically acceptable just for experienced examiners at the C4/C5 level in WAD populations.

Timing of physical therapy for individuals with patellofemoral pain and the influence on healthcare use, costs and recurrence rates: an observational study.

BACKGROUND: Early physical therapy has been shown to decrease downstream healthcare use, costs and recurrence rates in some musculoskeletal conditions, but it has not been investigated in individuals with patellofemoral pain. The purpose was to evaluate how the use and timing of physical therapy influenced downstream healthcare use, costs, and recurrence rates. METHODS: Seventy-four thousand four hundred eight individuals aged 18 to 50 diagnosed with patellofemoral pain between 2010 and 2011 in the Military Health System were categorized based on use and timing of physical therapy (first, early, or delayed). Healthcare use, costs, and recurrence rates were compared between the groups using descriptive statistics and a binary logit regression. RESULTS: The odds for receiving downstream healthcare use (i.e. imaging, prescription medications, and injections) were lowest in those who saw a physical therapist as the initial contact provider (physical therapy first), and highest in those who had delayed physical therapy (31-90 days after patellofemoral pain diagnosis). Knee-related costs for those receiving physical therapy were lowest in the physical therapy first group ($1,136, 95% CI $1,056, $1,217) and highest in the delayed physical therapy group ($2,283, 95% CI $2,192, $2,374). Recurrence rates were lowest in the physical therapy first group (AOR = 0.55, 95% CI 0.37, 0.79) and highest in the delayed physical therapy group (AOR = 1.78, 95% CI 1.36, 2.33). CONCLUSIONS: For individuals with patellofemoral pain using physical therapy, timing is likely to influence outcomes. Healthcare use and costs and the odds of having a recurrence of knee pain were lower for patients who had physical therapy first or early compared to having delayed physical therapy.

DUAL-TASK ASSESSMENT IMPLICATIONS FOR ANTERIOR CRUCIATE LIGAMENT INJURY: A SYSTEMATIC REVIEW.

BACKGROUND: Several systematic reviews have evaluated the role of dual-task assessment in individuals with concussion. However, no systematic reviews to date have investigated dual-task protocols with implications for individuals with anterior cruciate ligament (ACL) injury or ACL reconstruction (ACLR). PURPOSE: To systematically review the evidence on dual-task assessment practices applicable to those with ACL deficiency/ACLR, specifically with the aim to identify motor-cognitive performance costs. STUDY DESIGN: Systematic review. METHODS: A systematic literature review was undertaken on those with ACL-deficient or ACL-reconstructed knees performing dual-task activities. The following databases were searched from inception to June 8, 2018 including CINAHL, PsychInfo, PubMed, SPORTDiscus, Web of Science, and gray literature. Three primary search categories (knee, cognition, and motor task) were included. Only one reviewer independently performed the database search, data extraction, and scored each article for quality. All studies were assessed for quality and pertinent data were extracted, examined and synthesized. RESULTS: Ten studies were included for analysis, all of which were published within the prior ten years. Performance deficits were identified in those with either ACL deficiency or ACLR while dual-tasking, such as prioritization of postural control at the expense of cognitive performance, impaired postural control in single limb stance, greater number of cognitive errors, and increased step width coefficient of variation while walking. No studies examined those with prior ACL injury or ACLR during tasks that mimicked ACL injury mechanisms such as jump-landing or single-leg cutting. CONCLUSION: The results of the current systematic review suggests that postural control, gait, and/or cognitive deficits exist when evaluated under a dual-task paradigm in those with ACL deficiency or ACLR. This systematic review highlights the need for future research on dual-task assessment for individuals who have sustained an ACL injury or undergone ACLR, specifically utilizing more difficult athletic movements. LEVEL OF EVIDENCE: Level 3a.

Four Examples of Potential Competing Interests Affecting How Clinicians Read and Use Research: Financial, Academic, Idealistic, and Personal.

The integrity of published scientific literature relies on transparency. There are processes in place to promote transparency and enhance the trustworthiness of study results. Journals, including the Journal of Orthopaedic & Sports Physical Therapy (JOSPT), require full disclosure of competing interests when authors submit manuscripts for publication. A competing interest is "a financial or intellectual relationship that may impact an individual's ability to approach a scientific question with an open mind." The purpose of this editorial is to discuss the types of competing interests that may influence the work of authors. J Orthop Sports Phys Ther 2020;50(3):116-117. doi:10.2519/jospt.2020.0103.

Cost-Effectiveness Evaluation of Manual Physical Therapy Versus Surgery for Carpal Tunnel Syndrome: Evidence From a Randomized Clinical Trial.

BACKGROUND: Carpal tunnel syndrome (CTS) results in substantial societal costs and can be treated either by nonsurgical or surgical approaches. OBJECTIVE: To evaluate differences in cost-effectiveness of manual physical therapy versus surgery in women with CTS. METHODS: In this randomized clinical trial, 120 women with a clinical and an electromyographic diagnosis of CTS were randomized through concealed allocation to either manual physical therapy or surgery. Interventions consisted of 3 sessions of manual physical therapy, including desensitization maneuvers of the central nervous system, or decompression/release of the carpal tunnel. Societal costs and health-related quality of life (estimated by the European Quality of Life-5 Dimensions [EQ-5D] scale) over 1 year were used to generate incremental cost per quality-adjusted life year ratios for each treatment. RESULTS: The analysis was possible for 118 patients (98%). Incremental quality-adjusted life years showed greater cost-effectiveness in favor of manual physical therapy (difference, 0.135; 95% confidence interval: 0.134, 0.136). Manual therapy was significantly less costly than surgery (mean difference in cost per patient, €2576; P<.001). Patients in the surgical group received a greater number of other treatments and made more visits to medical doctors than those receiving manual physical therapy (P = .02). Absenteeism from paid work was significantly higher in the surgery group (P<.001). The major contributors to societal costs were the treatment protocol (surgery versus manual therapy mean difference, €106 980) and absenteeism from paid work (surgery versus manual physical therapy mean difference, €42 224). CONCLUSION: Manual physical therapy, including desensitization maneuvers of the central nervous system, has been found to be equally effective but less costly (ie, more cost-effective) than surgery for women with CTS. From a cost-benefit perspective, the proposed CTS manual physical therapy intervention can be considered. LEVEL OF EVIDENCE: Economic and decision analyses, level 1b. J Orthop Sports Phys Ther 2019;49(2):55-63. Epub 30 Nov 2018. doi:10.2519/jospt.2019.8483.

Relationships between Cornell Musculoskeletal Discomfort Questionnaire and Online Rapid Office Strain Assessment Questionnaire.

BACKGROUND: The Rapid Office Strain Assessment (ROSA) is a tool employed online to screen office workstations, which may require modification to decrease musculoskeletal discomfort of workers. This study aimed to examine if the ROSA is able to evaluate pain severity in the lower back, shoulder and neck of office workers accurately. METHODS: Overall, 142 participants (height: 1.80 ± 0.15 m, BMI: 26.08± 6.70, age: 35±15 yr) with at least a year of working experience completed both questionnaires, the online ROSA and the Cornell musculoskeletal discomfort, in 2016 in Malaysia. RESULTS: Relationship between the total scores of both questionnaires for lower back, shoulder and neck pain were significant but exhibited a weak to moderate relationship (range of r values from 0.012 (CI 95%, -0.153-0.176) to 0.503 (CI 95%, 0.369-0.616). CONCLUSION: The online ROSA does not appear to be a reasonable tool for evaluating the severity of lower back, shoulder and neck pain among office workers as the correlations were low. We suggest continued use of the musculoskeletal discomfort questionnaire. Additional studies are required to further examine the ROSA for other anatomical regions.

Comparison of Downstream Health Care Utilization, Costs, and Long-Term Opioid Use: Physical Therapist Management Versus Opioid Therapy Management After Arthroscopic Hip Surgery.

Background: Physical therapy and opioid prescriptions are common after hip surgery, but are sometimes delayed or not used. Objective: The objective of this study was to compare downstream health care utilization and opioid use following hip surgery for different patterns of physical therapy and prescription opioids. Design: The design of this study was an observational cohort. Methods: Health care utilization was abstracted from the Military Health System Data Repository for patients who were 18 to 50 years old and were undergoing arthroscopic hip surgery between 2004 and 2013. Patients were grouped into those receiving an isolated treatment (only opioids or only physical therapy) and those receiving both treatments on the basis of timing (opioid first or physical therapy first). Outcomes included overall health care visits and costs, hip-related visits and costs, additional surgeries, and opioid prescriptions. Results: Of 1870 total patients, 76.8% (n = 1437) received physical therapy, 71.6% (n = 1339) received prescription opioids, and 1073 (56.1%) received both physical therapy and opioids. Because 24 patients received both opioids and physical therapy on the same day, they were eventually removed the final timing-of-care analysis. Adjusted hip-related mean costs were the same in both groups receiving isolated treatments (${\$}$11,628 vs ${\$}$11,579), but the group receiving only physical therapy had significantly lower overall total health care mean costs (${\$}$18,185 vs ${\$}$23,842) and fewer patients requiring another hip surgery. For patients receiving both treatments, mean hip-related downstream costs were significantly higher in the group receiving opioids first than in the group receiving physical therapy first (${\$}$18,806 vs ${\$}$16,955) and resulted in greater opioid use (7.83 vs 4.14 prescriptions), greater total days' supply of opioids (90.17 vs 44.30 days), and a higher percentage of patients with chronic opioid use (69.5% vs 53.2%). Limitations: Claims data were limited by the accuracy of coding, and observational data limit inferences of causality. Conclusions: Physical therapy first was associated with lower hip-related downstream costs and lower opioid use than opioids first; physical therapy instead of opioids was associated with less total downstream health care utilization. These results need to be validated in prospective controlled trials.

Risk stratification of patients with shoulder pain seen in physical therapy practice.

RATIONALE, AIMS AND OBJECTIVES: Musculoskeletal shoulder pain is commonly treated in physical therapy. There is inconsistency in the literature regarding patient characteristics related to prognosis. Having prognostic information could be useful for improving clinical efficiency and decreasing the cost of associated care. The objective of this study was to identify predictive characteristics related to patients with shoulder pain who have a high-risk of a bad prognosis (lowest functional recovery compared with visit utilization) as well as those who are at low-risk of a bad prognosis (highest functional recovery compared with visit utilization). METHODS: We completed a secondary analysis of a retrospective cohort using data obtained from an existing commercial outcomes database. Data from 5214 patients with shoulder pain were analysed to determine predictive characteristics that identify patients who either have a low-risk or a high-risk of a bad prognosis to physical therapy care. Multinomial regression was used to identify significant patient characteristics predictive of treatment response. RESULTS: Statistically significant predictors of high-risk categorization included older age, no surgical history, insurance designated as worker's compensation, litigation or automotive and three or more co-morbidities. Predictors of low risk categorization were younger age, shorter duration of symptoms, no surgical history and payer type. CONCLUSION: Selected variables were associated with both poor and good recovery. Further research on prognosis, efficacy of physical therapy care and cost appear warranted for patients with shoulder pain.

Validity and everyday clinical applicability of lumbar muscle fatigue assessment methods in patients with chronic non-specific low back pain: a systematic review.

PURPOSE: This systematic literature review aimed at examining the validity and applicability in everyday clinical rehabilitation practise of methods for the assessment of back muscle fatiguability in patients with chronic non-specific low back pain (CNSLBP). METHODS: Extensive research was performed in MEDLINE, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Embase, Physiotherapy Evidence Database (PEDro) and Cochrane Central Register of Controlled Trials (CENTRAL) databases from their inception to September 2014. Potentially relevant articles were also manually looked for in the reference lists of the identified publications. Studies examining lumbar muscle fatigue in people with CNSLBP were selected. Two reviewers independently selected the articles, carried out the study quality assessment and extracted the results. A modified Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) scale was used to evaluate the scientific rigour of the selected works. RESULTS: Twenty-four studies fulfilled the selection criteria and were included in the systematic review. We found conflicting data regarding the validity of methods used to examine back muscle fatigue. The Biering-Sorensen test, performed in conjunction with surface electromyography spectral analysis, turned out to be the most widely used and comparatively, the most optimal modality currently available to assess objective back muscle fatigue in daily clinical practise, even though critical limitations are discussed. CONCLUSIONS: Future research should address the identification of an advanced method for lower back fatigue assessment in patients with CNSLBP which, eventually, might provide physical therapists with an objective and reliable test usable in everyday clinical practise. Implications for Rehabilitation Despite its limitations, the Biering-Sorensen test is currently the most used, convenient and easily available fatiguing test for lumbar muscles. To increase validity and reliability of the Biering-Sorensen test, concomitant activation of synergistic muscles should be taken into account. Pooled mean frequency and half-width of the spectrum are currently the most valid electromyographic parameters to assess fatigue in chronic non-specific low back pain. Body mass index, grading of pain and level of disability of the study population should be reported to enhance research quality.

The impact of physical therapy residency or fellowship education on clinical outcomes for patients with musculoskeletal conditions.

STUDY DESIGN: A retrospective cohort design was conducted using data from an electronic survey and an existing commercial outcomes database. OBJECTIVE: To compare the clinical outcomes of patients with musculoskeletal conditions treated by physical therapists who had completed residency or fellowship programs versus those who had not. BACKGROUND: There is an increasing focus on specialization through postprofessional education in physical therapy residency and fellowship programs. Scant evidence exists that evaluates the influence of postprofessional clinical education on actual patient outcomes. METHODS: Physical therapists using a national outcomes database were surveyed to determine their level of postprofessional education. Survey responders were categorized into 1 of 3 groups that included no residency or fellowship training, residency trained, or fellowship trained. Outcomes for 25 843 patients with musculoskeletal conditions treated by 363 therapists from June 2012 to June 2013 were extracted from the database. These data were analyzed to identify any differences in functional status change and efficiency achieved between the 3 groups. Potentially confounding variables were controlled for statistically. RESULTS: The fellowship-trained group of physical therapists achieved functional status changes and efficiency that were greater than those of the other groups. No difference in functional status change was observed between the residency group and the therapists without residency or fellowship training. The group without residency or fellowship training was more efficient than the residency-trained group. Fellowship-trained therapists were more likely to achieve greater treatment effect sizes than therapists without residency or fellowship training. Residency-trained therapists were less likely to achieve greater treatment effect sizes than the therapists without residency or fellowship training. CONCLUSION: These data demonstrate that fellowship training may contribute to statistically greater patient outcomes. Residency training did not appear to contribute to improved patient functional status change or efficiency. It is unknown whether the statistical differences observed would be clinically meaningful for patients.

Methods for the assessment of neuromotor capacity in non-specific low back pain: Validity and applicability in everyday clinical practice.

BACKGROUND: Physiotherapists and clinicians require methods that can be used in everyday practice for measuring proprioception of the trunk in individuals with non-specific low back pain (NSLBP). OBJECTIVE: Our objective was to conduct a systematic literature review of methods used for assessment of proprioception of the trunk in individuals with non-specific low back pain. METHOD: Data were obtained from MEDLINE, CINAHL, Embase, PEDro and CENTRAL databases from their inception to December 2011. Reference lists of the selected reviews were hand searched for other potentially relevant studies. Randomized and nonrandomized controlled studies proprioception of the trunk in individuals with low back pain were selected. Thirty-six studies satisfied the selection criteria and were included in this review. RESULTS: Two reviewers independently selected the studies, conducted the quality assessment, and extracted data from each study. The Strobe scale was used to evaluate the scientific rigor of each selected study. CONCLUSIONS: This systematic review covered all the relevant literature, but none of the included studies offered a valid, reliable and feasible method to assess neuromotor capacity in everyday physiotherapy clinical practice.

Psychometric properties of the Outpatient Physical Therapy Improvement in Movement Assessment Log (OPTIMAL) in patients with musculoskeletal disorders: a replication study with additional findings.

BACKGROUND: The Outpatient Physical Therapy Improvement in Movement Assessment Log (OPTIMAL) is a recently developed self-report outcome instrument designed to measure the extent of activity limitation as defined by the World Health Organization. OBJECTIVE: The purposes of the study were to replicate some aspects of the original study of the OPTIMAL Difficulty and Confidence scales and to conduct additional psychometric tests. DESIGN: A cross-sectional design was used in the study. METHODS: Of a total of 1,150 patients who received treatment at 4 outpatient centers over the study period, 1,030 patients were recruited for this study and completed the OPTIMAL instrument and previously validated region-specific functional status measures. A variety of analytic methods were used to examine the extent of redundancy between the OPTIMAL Difficulty and Confidence scales, as well as the internal consistency reliability, standard error of measurement, known-groups validity, and convergent validity of OPTIMAL Difficulty Scale scores. RESULTS: The OPTIMAL Difficulty and Confidence scale scores were found in a factor analysis to be load-based on anatomical region rather than on difficulty and confidence concepts. Internal consistency reliability for the subscales of the Confidence Scale varied and was .80 or higher for the lower-extremity subscale but .50 or less for the trunk and upper-extremity subscales. LIMITATIONS: Only cross-sectional relationships were examined, and another pure measure of activity limitation was not used for comparison. CONCLUSIONS: The findings generally did not support the psychometric properties of the OPTIMAL instrument. Although not conclusive, the data suggested that the OPTIMAL Difficulty and Confidence scales demonstrate substantial overlap. Reliability was generally low, with the exception of the lower-extremity subscale. Scores for the subscales of the Difficulty Scale differentiated among patients with lower-extremity versus trunk or upper-extremity diagnoses, but associations with previously validated region-specific measures were generally weak or absent. Clinicians treating outpatients with musculoskeletal disorders should consider alternative measures when attempting to quantify the extent of activity limitations.

Does continuing education improve physical therapists' effectiveness in treating neck pain? A randomized clinical trial.

BACKGROUND AND PURPOSE: Physical therapists often attend continuing education (CE) courses to improve their overall clinical performance and patient outcomes. However, evidence suggests that CE courses may not improve the outcomes for patients receiving physical therapy for the management of neck pain. The purpose of this study was to investigate the effectiveness of an ongoing educational intervention for improving the outcomes for patients with neck pain. PARTICIPANTS: The study participants were 19 physical therapists who attended a 2-day CE course focusing on the management of neck pain. All patients treated by the therapists in this study completed the Neck Disability Index (NDI) and a pain rating scale at the initial examination and at their final visit. METHODS: Therapists from 11 clinics were invited to attend a 2-day CE course on the management of neck pain. After the CE course, the therapists were randomly assigned to receive either ongoing education consisting of small group sessions and an educational outreach session or no further education. Clinical outcomes achieved by therapists who received ongoing education and therapists who did not were compared for both pretraining and posttraining periods. The effects of receiving ongoing education were examined by use of linear mixed-model analyses with time period and group as fixed factors; improvements in disability and pain as dependent variables; and age, sex, and the patient's initial NDI and pain rating scores as covariates. RESULTS: Patients treated by therapists who received ongoing education experienced significantly greater reductions in disability during the study period (pretraining to posttraining) than those treated by therapists who did not receive ongoing training (mean difference=4.2 points; 95% confidence interval [CI]=0.69, 7.7). Changes in pain did not differ for patients treated by the 2 groups of therapists during the study period (mean difference=0.47 point; 95% CI=-0.11, 1.0). Therapists in the ongoing education group also used fewer visits during the posttraining period (mean difference=1.5 visits; 95% CI=0.81, 2.3). DISCUSSION AND CONCLUSION: The results of this study demonstrated that ongoing education for the management of neck pain was beneficial in reducing disability for patients with neck pain while reducing the number of physical therapy visits. However, changes in pain did not differ for patients treated by the 2 groups of therapists. Although it appears that a typical CE course does not improve the overall outcomes for patients treated by therapists attending that course, more research is needed to evaluate other educational strategies to determine the most clinically effective and cost-effective interventions.

Physical therapy for acute low back pain: associations with subsequent healthcare costs.

STUDY DESIGN: Case-control. OBJECTIVE: To examine the association between adherence to the evidence-based recommendation for active physical therapy care and clinical outcomes along with subsequent healthcare utilization and charges for 1 year after completion of physical therapy. SUMMARY OF BACKGROUND DATA: Low back pain (LBP) is a common condition associated with high costs. Many patients with acute LBP receive physical therapy. The type of physical therapy care provided may impact subsequent healthcare costs. METHODS: A retrospective review was undertaken of patients age 18-60 with acute (<90 days) LBP receiving physical therapy covered by 1 insurance provider. Adherence to the recommendation for active care was determined from billing records. Disability (Oswestry) and pain (numerical pain rating) were assessed at the beginning and completion of physical therapy. Subsequent healthcare utilization for LBP and charges were recorded from insurer's databases. RESULTS: Four hundred and seventy-one patients were included (mean age 41.2 years [SD = 11.0], 54% female), 28.0% received adherent care. Patients receiving adherent care had fewer physical therapy visits (mean difference 1.3 visits, P < 0.05) with lower charges (nontransformed mean difference $167, P < 0.05), greater improvement in pain (mean difference 12.3%, 95% confidence interval [CI]: 3.2-21.3) and disability (mean difference 17.6%, 95% CI: 11.1-24.1). During the year after discharge, receiving adherent care was associated with a lower likelihood of receiving prescription medication (46.2% vs. 57.2%, P < 0.05), magnetic resonance imaging (MRI) (8.3% vs. 15.9%, P < 0.05), or epidural injections (5.3% vs. 12.1%, P < 0.05). CONCLUSION: Adherence to the recommendation for active care was associated with better clinical outcomes and decreased subsequent use of prescription medication, MRI, and injections. Improving adherence to this recommendation may present an opportunity to improve the cost-effectiveness of care for acute LBP.

Predictive validity of initial fear avoidance beliefs in patients with low back pain receiving physical therapy: is the FABQ a useful screening tool for identifying patients at risk for a poor recovery?

Several prospective studies examining patients receiving physical therapy support the predictive validity of FABQ subscale scores. This has lead to the proposition that the FABQ would be a useful screening tool, permitting early identification of patients at risk for a poor outcome with an opportunity to modify the treatment accordingly. However, the predictive validity of the FABQ within physical therapy practice has yet to be examined. Predictive validity was analyzed between the FABQ-PA, FABQ-W using both disability and pain as the dependent variables using Pearson correlation coefficients and stepwise hierarchical linear regression modeling controlling for baseline variables. Separate analyses were run for patients with private health insurance and those receiving workers' compensation. Further analysis of predictive validity was performed by dichotomizing the outcome of physical therapy. Patients were coded as having a poor outcome if they failed to achieve a minimum clinically important change in disability over the course of treatment. The accuracy of previously reported cut-off scales for both the FABQ-W and FABQ-PA were examined for both payor types. Results of the hierarchical linear regression analyses for patients with private insurance showed neither the FABQ-PA nor the FABQ-W score significantly improved the explained variance in change in pain or disability. For patients receiving workers' compensation, only the FABQ-W subscale score significantly contributed to the model after controlling for the other baseline variables for both changes in disability and pain. Only the FABQ-W subscale was predictive of poor outcome and this was only identified in the worker's compensation group. The results suggest that the work subscale of the FABQ might be an appropriate screening tool to identify patients with work-related LBP who are at risk for a poor outcome with routine physical therapy. Neither FABQ subscale was predictive of outcome for patients with private insurance, and the use of the FABQ, as a screening tool for patients with non-work-related LBP was not supported.

Does adherence to the guideline recommendation for active treatments improve the quality of care for patients with acute low back pain delivered by physical therapists?

BACKGROUND: Numerous practice guidelines have been developed for patients with low back pain in an attempt to reduce inappropriate variations and improve the cost-effectiveness of care. Guideline implementation has received more research attention than the impact of adherence to guideline recommendations on outcomes and costs of care. OBJECTIVE: Examine the association between adherence to the guideline recommendation to use active versus passive treatments with clinical outcomes and costs for patients with acute low back pain receiving physical therapy. RESEARCH DESIGN: Retrospective review of patients with acute low back pain receiving physical therapy in 2004-2005. Adherence to the recommendation for active treatment was determined from billing records. Clinical and financial outcomes were compared between patients receiving adherent or nonadherent care. SUBJECTS: A total of 1190 patients age 18-60 years old with low back pain of less than 90 days duration in 10 clinics in 1 geographic region. MEASURES: Clinical outcomes included the numeric pain rating and Oswestry disability questionnaire taken initially and at the completion of treatment. Financial outcomes included the number of sessions and charges for physical therapy care. RESULTS: Adherence rate was 40.4%. Adherence was greater for patients receiving workers' compensation (P < 0.05). Patients receiving adherent care had fewer visits and lower charges (P < 0.05), and showed more improvement in disability [adjusted mean difference for percentage improvement 25.8%, 95% confidence interval (CI): 21.3-30.4, P < 0.001] and pain (adjusted mean difference for percentage improvement 22.4%, 95% CI: 17.5-27.3, P < 0.001). Patients receiving adherent care were more likely to have a successful physical therapy outcome (64.7% vs. 36.5%, P < 0.001). CONCLUSIONS: Adherence to the guideline recommendation for active care was associated with better clinical outcomes and reduced cost.