The Influence of Active, Passive, and Manual Therapy Interventions for Low Back Pain on Opioid Prescription and Health Care Utilization.

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.

Pleiotropic actions of Vitamin D in composite musculoskeletal trauma.

Composite tissue injuries are the result of high energy impacts caused by motor vehicle accidents, gunshot wounds or blasts. These are highly traumatic injuries characterized by wide-spread, penetrating wounds affecting the entire musculoskeletal system, and are generally defined by frank volumetric muscle loss with concomitant segmental bone defects. At the tissue level, the breadth of damage to multiple tissue systems, and potential for infection from penetration, have been shown to lead to an exaggerated, often chronic inflammatory response with subsequent dysregulation of normal musculoskeletal healing mechanisms. Aside from the direct effects of inflammation on myogenesis and osteogenesis, frank muscle loss has been shown to directly impair fracture union and ultimately contribute to failed wound regeneration. Care for these injuries requires extensive surgical intervention and acute care strategies. However, often these interventions do not adequately mitigate inflammation or promote proper musculoskeletal injury repair and force amputation of the limb. Therefore, identification of factors that can promote tissue regeneration and mitigate inflammation could be key to restoring wound healing after composite tissue injury. One such factor that may directly affect both inflammation and tissue regeneration in response to these multi-tissue injuries may be Vitamin D. Beyond traditional roles, the pleiotropic and localized actions of Vitamin D are increasingly being recognized in most aspects of wound healing in complex tissue injuries - e.g., regulation of inflammation, myogenesis, fracture callus mineralization and remodeling. Conversely, pre-existing Vitamin D deficiency leads to musculoskeletal dysfunction, increased fracture risk or fracture non-unions, decreased strength/function and reduced capacity to heal wounds through increased inflammation. This Vitamin D deficient state requires acute supplementation in order to quickly restore circulating levels to an optimal level, thereby facilitating a robust wound healing response. Herein, the purpose of this review is to address the roles and critical functions of Vitamin D throughout the wound healing process. Findings from this review suggest that careful monitoring and/or supplementation of Vitamin D may be critical for wound regeneration in composite tissue injuries.