Sling Exercise in the Management of Chronic Low Back Pain: A Systematic Review and Meta-Analysis.

ABSTRACT: Drummond, C, Lebedeva, V, Kirker, K, and Masaracchio, M. Sling exercise in the management of chronic low back pain: A systematic review and meta-analysis. J Strength Cond Res XX(X): 000-000, 2021-The purpose of this systematic review is to assess the effectiveness of sling exercise therapy (SET) in individuals with chronic low back pain (LBP). Eligible studies were randomized clinical trials or prospective cohort studies published in the English language that assessed SET on measures of pain, disability, or muscle attributes in chronic LBP. The search identified 1,204 studies, with 12 studies meeting the inclusion criteria. The average score was 7.3 on the Cochrane Risk of Bias Criteria. Meta-analysis comparing SET with general exercise revealed a nonsignificant effect for pain (mean difference [MD] 0.14; 95% confidence interval [CI]: -0.58, 0.87). Meta-analysis comparing SET with motor control training/lumbar stabilization revealed a significant effect favoring SET for pain (MD -4.13; 95% CI: -7.82 to -0.45) and disability (MD -3.19; 95% CI: -4.63 to -1.76). Meta-analysis comparing SET with no treatment revealed a significant effect favoring SET for pain (MD -1.05; 95% CI: -2.82 to -0.71). Meta-analysis comparing SET plus modalities with modalities revealed a significant effect favoring the SET plus modalities group for pain (MD -1.19; 95% CI: -1.48 to -0.89) and a nonsignificant effect for disability (MD -6.67; 95% CI: -17.25 to 3.92). Sling exercise therapy was more effective than all comparisons for various muscle attributes. The overall level of evidence ranged from very low to moderate. Sling exercise therapy is effective in reducing pain, disability, and improving core muscle activation, strength, thickness, and onset in patients with chronic LBP. Because SET demonstrated comparable outcomes with common active interventions, it provides an opportunity to implement pain-free exercises based on the patient's initial functional level early in the plan of care.

Examination and Management of a 4-Year-Old Following a Femoral Aneurysmal Bone Cyst: A Case Report.

PURPOSE: The literature lacks recommendations for postoperative rehabilitation following removal of aneurysmal bone cysts (ABCs). This case report describes the rehabilitation with return to age-appropriate functional activities for a 4-year-old following surgical fixation of a femoral ABC, with emphasis on clinical decision-making in the absence of definitive treatment algorithms. SUMMARY OF KEY POINTS: The child improved in range of motion, strength, balance, transfers, gait, stair negotiation, and percentile rank on the Test of Gross Motor Development 2. CONCLUSION: This case is successful outcomes of a 4-year-old girl (GP) following surgical fixation for an ABC. RECOMMENDATIONS FOR CLINICAL PRACTICE: This case fills a current void in the literature emphasizing clinical decision-making and attainment of GP-specific functional goals. A goal-driven approach incorporating key elements of the International Classification of Function model resulted in successful return to age-appropriate activity following surgical fixation of a femoral fracture due to an ABC.

Shoulder Joint and Muscle Characteristics Among Weight-Training Participants With and Without Impingement Syndrome.

Kolber, MJ, Hanney, WJ, Cheatham, SW, Salamh, PA, Masaracchio, M, and Liu, X. Shoulder joint and muscle characteristics among weight-training participants with and without impingement syndrome. J Strength Cond Res 31(4): 1024-1032, 2017-Subacromial impingement syndrome (SIS) has been reported as an etiological source of shoulder pain among weight-training (WT) participants; however, a paucity of evidence exists to describe intrinsic risk factors. The purpose of this study was to investigate specific risk-related joint and muscle adaptations among WT participants identified as having SIS based on a previously validated clinical testing cluster. Fifty-five men (mean age 27.3 years) who participated in recreational WT a minimum of 2 d·wk were recruited, including 24 individuals with SIS and 31 without SIS serving as controls. Active range of motion (AROM), bodyweight-adjusted strength values, and strength ratios were compared between groups. Significant differences were present as WT participants with SIS had decreased internal and external rotation AROM (p ≤ 0.016) and decreased bodyweight-adjusted strength values of the external rotator and lower trapezius musculature (p ≤ 0.02) when compared with WT participants without SIS. Select strength ratios were greater in the SIS group (p ≤ 0.004) implying agonist to antagonist muscle imbalances. The impaired joint and muscle characteristics identified among WT participants with SIS are not without consequence, as they are associated with shoulder disorders in both general and athletic populations. Practical applications for these findings may reside in exercise prescription that addresses internal rotation mobility, mitigates training bias, and favors muscles responsible for stabilization, such as the external rotators and lower trapezius. Strength and conditioning professionals should consider risk-related adaptations associated with WT when prescribing upper-extremity exercises.

Management of an Anterior Cruciate Ligament Tear in a 5 Year-Old Boy.

PURPOSE: The purpose of this retrospective case report was to describe clinical decision making during the examination and treatment of a 5-year-old boy with an anterior cruciate ligament (ACL) tear. KEY POINTS: A paucity of research exists for the management of ACL tears in children. A combination of manual therapy interventions initially, followed by a unique and comprehensive therapeutic exercise program, was implemented during the course of a 3-month treatment period. Improvements in range of motion, quadriceps strength, single-leg stance time, and the Knee Injury and Osteoarthritis Outcome Score were noted. At discharge, the patient safely returned to unrestricted home and school activities. CONCLUSION: This case demonstrates successful management of a child after an ACL injury. CLINICAL IMPLICATIONS: Clinicians are encouraged to implement sound clinical reasoning in the absence of well-established evidence when treating similar patients in their clinical practice.

The effectiveness of strain counterstrain in the treatment of patients with chronic ankle instability: A randomized clinical trial.

STUDY DESIGN: Randomized clinical trial. OBJECTIVE: To determine the effect of strain counterstrain (SCS) on dynamic balance and subjective sense of instability in individuals with chronic ankle instability (CAI). Although many studies have been published on CAI, the cause for this common clinical dysfunction remains inconclusive. No studies have assessed the effectiveness of SCS on CAI. METHODS: At baseline all participants completed a demographic questionnaire, the star excursion balance test (SEBT), and the foot and ankle ability measure (FAAM). Following the baseline evaluation, participants were randomized into the SCS experimental group (EG) (n = 13) or the sham SCS group (SG) (n = 14). All participants received the assigned treatment once a week for 4 weeks and participated in a prescribed exercise program. At week 4, all participants repeated the outcome measures and completed a global rating of change (GROC) form. The primary aim was examined with a two-way analysis of variance (ANOVA). RESULTS: A significant group-by-time interaction was found for seven directions in the SEBT (P<0.031). For subjective measures, no significant group-by-time interaction was found for the FAAM (P>0.548), but the GROC revealed a significant difference (P = 0.014) in the mean score for the EG (3.92±1.66) when compared to the SG (2.43±1.66). DISCUSSION: Although SCS may not have an effect on subjective ankle function in individuals with CAI, preliminary evidence suggests that SCS may lead to an improvement in dynamic ankle stability and the subjective sense of ankle instability. LEVEL OF EVIDENCE: Therapy, Level 1b.

Management of lumbar spinal stenosis: a systematic review and meta-analysis of rehabilitation, surgical, injection, and medication interventions.

BACKGROUND: Lumbar spinal stenosis (LSS) has a substantial impact on mobility, autonomy, and quality of life. Previous reviews have demonstrated inconsistent results and/or have not delineated between specific nonsurgical interventions. OBJECTIVE: The purpose of this systematic review is to assess the effectiveness of interventions in the management of LSS. METHODS: Eligible studies were randomized controlled trials (RCTs) or prospective studies, included patients with LSS, assessed the effectiveness of any interventions (rehabilitation, surgical, injection, medication), included at least two intervention groups, and included at least one measure of pain, disability, ambulation assessment, or LSS-specific symptoms. Eighty-five articles met inclusion criteria. Meta-analyses were conducted across outcomes. Effect sizes were calculated using Hedge's g and reported descriptively. Formal grading of evidence was conducted. RESULTS: Meta-analysis comparing rehabilitation to no treatment/placebo demonstrated significant effects on pain favoring rehabilitation (mean difference, MD -1.63; 95% CI: -2.68, -0.57; I2 = 71%; p = .002). All other comparisons to no treatment/placebo revealed nonsignificant findings. The level of evidence ranged from very low to high for rehabilitation and medication versus no treatment/placebo for pain, disability, ambulation ability, and LSS symptoms. CONCLUSIONS: Although the findings of this review are inconclusive regarding superiority of interventions, this accentuates the value of multimodal patient-centered care in the management of patients with LSS.

Manual therapy and exercise for adhesive capsulitis: a systematic review with meta-analysis.

BACKGROUND: Adhesive capsulitis (AC) affects approximately 1% of the general population. Current research lacks clear guidance on the dosage of manual therapy and exercise interventions. OBJECTIVE: The purpose of this systematic review was to assess the effectiveness of manual therapy and exercise in the management of AC, with a secondary aim of describing the available literature present on the dosage of interventions. METHODS: Eligible studies were randomized clinical/quasi-experimental trials with complete data analysis and no limits on date of publication, published in English, recruited participants >18 years of age with primary adhesive capsulitis, that had at least two groups with one group receiving manual therapy (MT) alone, exercise alone, or MT and exercise, that included at least one outcome measure of pain, disability, or external rotation range of motion, and that had dosage of visits clearly defined. An electronic search was conducted using PubMed, Embase, Cochrane, Pedro, and clinicaltrials.gov. Risk of bias was assessed using the Cochrane Collaboration Risk of Bias 2 Tool. The Grading of Recommendations Assessment, Development, and Evaluation was used to provide an overall assessment of the quality of evidence. Meta-analyses were conducted when possible, and dosage was discussed in narrative form. RESULTS: Sixteen studies were included. All meta-analyses revealed non-significant effects of pain, disability, and external rotation range of motion at short- and long-term follow-up, with an overall level of evidence ranging from very low to low. CONCLUSION: Non-significant findings with low-to-very-low-quality of evidence were found across meta-analyses, preventing seamless transition of research evidence to clinical practice. Lack of consistency in study designs, manual therapy techniques, dosing parameters, and duration of care impedes the ability to make strong recommendations regarding optimal dosage of physical therapy for individuals with AC.

Outcomes of direct access telehealth physical therapy for patients with musculoskeletal pain: a single cohort observational retrospective study.

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.

The Prevalence of Tibiofemoral Knee Osteoarthritis Following Arthroscopic Partial Meniscectomy Is Variably Reported in General, and Over Time: A Systematic Review With a Minimum of 5-Year Follow-Up.

Purpose: To assess the prevalence of tibiofemoral (TF) osteoarthritis (OA) following arthroscopic partial meniscectomy (APM) with a minimum follow-up of 5 years, to explore the prevalence of symptomatic TF OA, and to identify potential risk factors for the development of TF OA following APM. Methods: An electronic search was conducted using PubMed, CINAHL, Pedro, AMED, Embase, the Cochrane Library, and clinicaltrials.gov. Prospective/retrospective studies including participants with a mean age ≥18 years old, undergoing isolated APM, reported radiographic assessment of knee OA as an outcome, had at least 5-year follow-up, and were written in English were included. Two authors extracted relevant data. Four authors assessed methodologic quality using the Center of Reviews and Dissemination and the Downs and Black checklist. The prevalence of TF OA after APM was reported for each study, with the range provided across studies for each time period (5 years to <10 years, 10 years to <15 years, ≥15 years). Results: Twenty-two studies were included. Radiologic TF OA prevalence following APM ranged from 35% to 90%, 23% to 100%, and 52% to 57.7% at an average follow-up of 5 years to <10 years, 10 years to <15 years, and ≥15 years, respectively. Prevalence of symptomatic TF OA ranged from 24.1% to 67% according to individual operational definitions, with 2 studies reporting correlations between function and radiological findings. Conclusions: APM results in a prevalence of radiographic TF OA ranging from 23% to 100% across follow-up periods of 5 or more years with the lowest prevalence reported between 5 and <10 years and the highest prevalence reported between 10 and <15 years follow-up. Considerably less data was available to assess symptomatic TF OA or risk factors associated with TF OA. Level of Evidence: Level III, systematic review of Level II and III studies.

Minimal physical therapy utilization compared with higher physical therapy utilization for patients with low back pain: a systematic review.

Aim: Currently there is a large and perhaps unwarranted variation regarding physical therapy utilization for individuals with low back pain (LBP).  The purpose of this systematic review was to compare the effects of minimal physical therapy utilization/education (two visits or less) versus typical physical therapy utilization (three visits or more) on patient-important outcomes for patients with LBP. Methods: Two independent reviewers searched Cochrane, Medline, CINAHL, Web of Science, and PEDro from database inception until March 2017. Eligible studies used a randomized design, included subjects with LBP, and compared minimal versus higher utilization. The GRADE approach was used to provide an overall level of evidence regarding utilization. Eight articles (1153 individual subjects) met the inclusion criteria. Effect sizes for each outcome measure were calculated using Hedge's g and were adjusted for baseline values at each time period. Findings: When compared with minimal utilization, higher utilization demonstrated no significant differences on pain, disability, or quality of life at the 1-year follow-up. However, two of the three studies that analyzed cost-effectiveness found higher utilization to be more cost-effective at 1-year follow-up. Moreover, there was insufficient evidence available to investigate patient subgroups (acuity, risk for chronicity), multiple levels of utilization dosage (low, typical, and high), or intervention type. Conclusions: This review identifies the need for further research on the dosage of physical therapy among various subgroups of patients with LBP. While higher utilization may not result in significant improvements in patient-important outcomes, it may be more cost-effective for patients with chronic or complex LBP conditions when compared to minimal utilization.

Exploration of Graduate Health Care Student Writing Skills Using a Transformational Learning Approach to a Literacy Enrichment Program.

BACKGROUND: Health care educators are obligated to ensure that student writing skills are current, appropriate, and integrated into their role as future practitioners. The purpose of this study was to examine the impact and satisfaction of a transformational learning approach in a literacy-enriched health professions program on student's writing skills. METHODS: Two different cohorts of occupational therapy students enrolled in a literacy program embedded in the first year of the professional phase of the occupational therapy program curriculum. The literacy-enriched program was based on transformative learning theories and was delivered by program faculty and writing tutors from the university writing center. Effectiveness was assessed using the ASSET writing test and a student satisfaction survey. Paired t-tests compared pre- and post-curriculum implementation scores on the ASSET. The association between student satisfaction post-program and pre- and post-writing scores were analyzed using Pearson correlations. RESULTS: Significant differences were found in the pre- and-post ASSET scores. Additionally, many students reported satisfaction with the writing program regarding their ability to revise, edit, proofread, and paraphrase content. CONCLUSION: This study demonstrated continuity of improved writing skill development across three different years of students using a transformational learning approach in a literacy-enriched curriculum, suggesting a potential positive outcome of the program.

Thoracic spine manipulation for the management of mechanical neck pain: A systematic review and meta-analysis.

OBJECTIVE: To investigate the role of thoracic spine manipulation (TSM) on pain and disability in the management of mechanical neck pain (MNP). DATA SOURCES: Electronic databases PubMed, CINAHL, Pedro, Embase, AMED, the Cochrane Library, and clinicaltrials.gov were searched in January 2018. STUDY SELECTION: Eligible studies were completed RCTs, written in English, had at least 2 groups with one group receiving TSM, had at least one measure of pain or disability, and included patients with MNP of any duration. The search identified 1717 potential articles, with 14 studies meeting inclusion criteria. STUDY APPRAISAL AND SYNTHESIS METHODS: Methodological quality was evaluated independently by two authors using the guidelines published by the Cochrane Collaboration. Pooled analyses were analyzed using a random-effects model with inverse variance methods to calculate mean differences (MD) and 95% confidence intervals for pain (VAS 0-100mm, NPRS 0-10pts; 0 = no pain) and disability (NDI and NPQ 0-100%; 0 = no disability). RESULTS: Across the included studies, there was increased risk of bias for inadequate provider and participant blinding. The GRADE approach demonstrated an overall level of evidence ranging from very low to moderate. Meta-analysis that compared TSM to thoracic or cervical mobilization revealed a significant effect favoring the TSM group for pain (MD -13.63; 95% CI: -21.79, -5.46) and disability (MD -9.93; 95% CI: -14.38, -5.48). Meta-analysis that compared TSM to standard care revealed a significant effect favoring the TSM group for pain (MD -13.21; 95% CI: -21.87, -4.55) and disability (MD -11.36; 95% CI: -18.93, -3.78) at short-term follow-up, and a significant effect for disability (MD -4.75; 95% CI: -6.54, -2.95) at long-term follow-up. Meta-analysis that compared TSM to cervical spine manipulation revealed a non-significant effect (MD 3.43; 95% CI: -7.26, 14.11) for pain without a distinction between immediate and short-term follow-up. LIMITATIONS: The greatest limitation in this systematic review was the heterogeneity among the studies making it difficult to assess the true clinical benefit, as well as the overall level of quality of evidence. CONCLUSIONS: TSM has been shown to be more beneficial than thoracic mobilization, cervical mobilization, and standard care in the short-term, but no better than cervical manipulation or placebo thoracic spine manipulation to improve pain and disability. TRIAL REGISTRATION: PROSPERO CRD42017068287.

The Influence of an Active Treatment Approach in Patients With Low Back Pain: A Systematic Review.

Introduction. Low back pain (LBP) is one of the most common medical conditions in the United States. Clinical practice guidelines recommend active treatment approaches; however, there continues to be a significant disparity in how patients with LBP are treated. Therefore, the purpose of this systematic review is to evaluate the reported efficacy of active treatment approaches as recommended by clinical practice guidelines on LBP treatment on patient outcomes. Methods. Between the months of June and August 2015, a comprehensive search of the PubMed, Medline (EBSCO Host), and CINAHL (EBSCO Host) databases was performed. The search was restricted to articles that were published in a peer-reviewed journal, published in the English language, examined patient outcomes with a determined scale, determined the usage of an established clinical practice guideline for LBP treatment, reported at least one outcome measure, and specified either nonspecific or acute LBP. Results. Fifty-three articles were initially identified, with 4 articles ultimately meeting the criteria after screening. Articles scored between 17 and 20 points based on a maximum total score of 26 on the modified Downs and Black checklist. Conclusion. Studies identified in this review indicate that adherence to an active treatment approach as recommended by clinical practice guidelines may result in improved patient outcomes.

Immediate Physical Therapy Initiation in Patients With Acute Low Back Pain Is Associated With a Reduction in Downstream Health Care Utilization and Costs.

Background: Physical therapy is an important treatment option for patients with low back pain (LBP). However, whether to refer patients for physical therapy and the timing of initiation remain controversial. Objective: The objective of this study was to evaluate the impact of receiving physical therapy and the timing of physical therapy initiation on downstream health care utilization and costs among patients with acute LBP. Design: The design was a retrospective cohort study. Methods: Patients who had a new onset of LBP between January 1, 2009, and December 31, 2013, in New York State were identified and grouped into different cohorts on the basis of whether they received physical therapy and the timing of physical therapy initiation. The probability of service use and LBP-related health care costs over a 1-year period were analyzed. Results: Among 46,914 patients with acute LBP, 40,246 patients did not receive physical therapy and 6668 patients received physical therapy initiated at different times. After controlling for patient characteristics and adjusting for treatment selection bias, health care utilization and cost measures over the 1-year period were the lowest among patients not receiving physical therapy, followed by patients with immediate physical therapy initiation (within 3 days), with some exceptions. Among patients receiving physical therapy, those receiving physical therapy within 3 days were consistently associated with the lowest health care utilization and cost measures. Limitations: This study was based on commercial insurance claims data from 1 state. Conclusions: When referral for physical therapy is warranted for patients with acute LBP, immediate referral and initiation (within 3 days) may lead to lower health care utilization and LBP-related costs.

Timing of rehabilitation on length of stay and cost in patients with hip or knee joint arthroplasty: A systematic review with meta-analysis.

OBJECTIVE: To investigate the role of early initiation of rehabilitation on length of stay (LOS) and cost following total hip arthroplasty, total knee arthroplasty, or unicompartmental knee arthroplasty. DATA SOURCES: Electronic databases PubMed, CINAHL, Pedro, Embase, AMED, and the Cochrane Library were searched in July 2016. Five additional trials were identified through reference list scanning. STUDY SELECTION: Eligible studies were published in English language peer-reviewed journals; included participants that had undergone total hip arthroplasty, total knee arthroplasty, or unicompartmental knee arthroplasty reported clearly defined timing of rehabilitation onset for at least two groups; and reported at least one measure of LOS or cost. Inclusion criteria were applied by 2 independent authors, with disagreements being determined by a third author. Searching identified 1,029 potential articles, of which 17 studies with 26,614 participants met the inclusion criteria. DATA EXTRACTION: Data was extracted independently by 2 authors, with disagreements being determined by a third author. Methodological quality of each study was evaluated independently by 2 authors using the Downs and Black checklist. Pooled analyses were analyzed using a random-effects model with inverse variance methods to calculate standardized mean differences (SMD) and 95% confidence intervals for LOS. DATA SYNTHESIS: When compared with standard care, early initiation of physical therapy demonstrated a decrease in length of stay for the 4 randomized clinical trials (SMD = -1.90; 95% CI -2.76 to -1.05; I2 = 93%) and for the quasi-experimental and 5 prospective studies (SMD = -1.47; 95% CI -1.85 to -1.10; I2 = 88%). CONCLUSION: Early initiation of rehabilitation following total hip arthroplasty, total knee arthroplasty, or unicompartmental knee arthroplasty is associated with a shorter LOS, a lower overall cost, with no evidence of an increased number of adverse reactions. Additional high quality studies with standardized methodology are needed to further examine the impact of early initiation of physical therapy among patients with joint replacement procedures.

The effects of a standardized belly dance program on perceived pain, disability, and function in women with chronic low back pain.

BACKGROUND: An alternative approach to facilitate movement and control through the trunk and pelvis is belly dancing. Investigations of belly dancing mechanics indicate similar muscular activation patterns of those known to influence chronic low back pain (cLBP). However, no documented studies have examined its effectiveness as a treatment for cLBP. OBJECTIVE: The purpose of this study was to investigate the influence of a standardized belly dance program in women with cLBP. METHODS: A single subject design was used to evaluate weekly outcomes during a three-week baseline period, six-week belly dance program, and again at a two-month follow-up. Outcome measures for pain, disability, function, and fear-avoidance beliefs were utilized. RESULTS: Two subjects completed the program. No significant differences were noted during the baseline assessment period. At two months, subject one demonstrated change scores of -1.12, -1%, and 2.2 for pain, disability, and function respectively while subject two demonstrated change scores of 5.4, 5%, and 1.1 for pain, disability, and function, respectively. Subject one showed a clinically significant change score for both fear avoidance of work and physical activity, with score changes of 4 and 3.3, respectively. CONCLUSION: The results of this study suggest a standardized belly dance program may positively influence pain and function in women with cLBP.

The Influence of Physical Therapy Guideline Adherence on Healthcare Utilization and Costs among Patients with Low Back Pain: A Systematic Review of the Literature.

BACKGROUND: Low back pain (LBP) is common and associated healthcare costs are significant. While clinical practice guidelines have been established in an attempt to reduce costs and healthcare utilization, it is unclear if adherence to physical therapy guidelines for those with LBP is efficacious. Therefore, the purpose of this study was to assess current evidence and evaluate the impact of physical therapy guideline adherence on subsequent healthcare costs and utilization for patients with LBP. METHODS: An electronic search was conducted in PubMed, CINAHL (EBSCO Host), AMED (Ovid), and PEDro. Studies included in this review were published in peer reviewed journals and the primary mode of treatment was administered by a physical therapist. Also, the definition of adherence was clearly defined based on claims data and at least one measure of cost or utilization reported. Quality assessment was evaluated via a modified Downs and Black checklist. Due to the conceptual heterogeneity in variable measurements, data were qualitatively synthesized and stratified by reported utilization and cost measures. RESULTS: A total of 256 results were identified and after omitting duplicates, 4 articles were retained, which were all retrospective in nature. Quality scores ranged between 19 and 21 points out of a possible 26 on the modified Downs and Black checklist. All identified studies used the same definition of guideline adherence, which focused on billing active codes and minimizing use of passive codes. The results demonstrated trends that, with a few exceptions, suggested those patients with LBP that were treated with an adherent guideline program demonstrated decreased healthcare utilization and an overall healthcare savings. CONCLUSION: Preliminary evidence suggests that adherence to established clinical practice guidelines may assist with decreasing healthcare utilization and costs. Additional research based on prospective randomized controlled trials are needed to provide high quality evidence regarding the impact of guideline adherence among patients with LBP.

AN INTERVENTION-BASED CLINICAL REASONING FRAMEWORK TO GUIDE THE MANAGEMENT OF THORACIC PAIN IN A DANCER: A CASE REPORT.

BACKGROUND AND PURPOSE: As a result of the anatomical proximity of the thoracic spine to the cervical, lumbar, and shoulder regions, dysfunction in the thoracic spine can influence pain, mobility, and stability across these areas. Currently, a paucity of evidence exists addressing treatment of individuals with primary thoracic pain, especially in young, athletic patients. Furthermore, current research discussing clinical reasoning frameworks focus on the differential diagnostic process. The purpose of this case report was to present a framework that describes the clinical reasoning process for the implementation and sequencing of procedural interventions for the management of a dancer with thoracic pain. CASE DESCRIPTION: A 21-year-old female dancer presented to physical therapy with a medical diagnosis of thoracic pain. The patient reported exacerbation of left thoracic pain with prolonged sitting, twisting/arching her back during dance, and lifting >15 lbs overhead. Examination revealed hypomobility with positive pain provocation during mobility testing of T1-T3 and the sternocostal junction of ribs 2-4, with associated muscle guarding palpated in the left iliocostalis thoracis and levator scapulae. OUTCOMES: Following 10 visits, the patient had no pain, no functional deficits, and a Global Rating of Change (GROC) of + 6. She returned to full competition, and a 3-month follow-up revealed continued success with dancing and a GROC of +7. DISCUSSION: This case report described the successful management of a dancer with primary thoracic pain using a clinical reasoning framework for the sequencing of procedural interventions, while incorporating Olson's impairment-based classification system. A combination of manual therapy techniques and neuromuscular control exercises were incorporated to address mobility, stability, mobility on stability, and skill level impairments, which allowed the patient to return to dance activities safely. Future studies should consider the development of further treatment-based clinical reasoning frameworks that illustrate the importance of the sequencing within a session and across the episode of care. LEVEL OF EVIDENCE: 4.