Effectiveness of Physical Therapy Combined With Epidural Steroid Injection for Individuals With Lumbar Spinal Stenosis: A Randomized Parallel-Group Trial.

OBJECTIVE: To examine the effectiveness of epidural steroid injection (ESI) and back education with and without physical therapy (PT) in individuals with lumbar spinal stenosis (LSS). DESIGN: Randomized clinical trial. SETTING: Orthopedic spine clinics. PARTICIPANTS: A total of 390 individuals were screened with 60 eligible and randomly selected to receive ESI and education with or without PT (N=54). INTERVENTIONS: A total of 54 individuals received 1-3 injections and education in a 10-week intervention period, with 31 receiving injections and education only (ESI) and 23 additionally receiving 8-10 sessions of multimodal PT (ESI+PT). MAIN OUTCOME MEASURES: Disability, pain, quality of life, and global rating of change were collected at 10 weeks, 6 months, and 1 year and analyzed using linear mixed model analysis. RESULTS: No significant difference was found between ESI and ESI+PT in the Oswestry Disability Index at any time point, although the sample had significant improvements at 10 weeks (P<.001; 95% confidence interval [CI], -18.01 to -5.51) and 1 year (P=.01; 95% CI, -14.57 to -2.03) above minimal clinically important difference. Significant differences in the RAND 36-Item Short Form Health Survey 1.0 were found for ESI+PT at 10 weeks with higher emotional role function (P=.03; 95% CI, -49.05 to -8.01), emotional well-being (P=.02; 95% CI, -19.52 to -2.99), and general health perception (P=.05; 95% CI, -17.20 to -.78). CONCLUSIONS: Epidural steroid injection plus PT was not superior to ESI alone for reducing disability in individuals with LSS. Significant benefit was found for the addition of PT related to quality of life factors of emotional function, emotional well-being, and perception of general health.

Implications of early and guideline adherent physical therapy for low back pain on utilization and costs.

BACKGROUND: Initial management decisions following a new episode of low back pain (LBP) are thought to have profound implications for health care utilization and costs. The purpose of this study was to evaluate the impact of early and guideline adherent physical therapy for low back pain on utilization and costs within the Military Health System (MHS). METHODS: Patients presenting to a primary care setting with a new complaint of LBP from January 1, 2007 to December 31, 2009 were identified from the MHS Management Analysis and Reporting Tool. Descriptive statistics, utilization, and costs were examined on the basis of timing of referral to physical therapy and adherence to practice guidelines over a 2-year period. Utilization outcomes (advanced imaging, lumbar injections or surgery, and opioid use) were compared using adjusted odds ratios with 99% confidence intervals. Total LBP-related health care costs over the 2-year follow-up were compared using linear regression models. RESULTS: 753,450 eligible patients with a primary care visit for LBP between 18-60 years of age were considered. Physical therapy was utilized by 16.3% (n = 122,723) of patients, with 24.0% (n = 17,175) of those receiving early physical therapy that was adherent to recommendations for active treatment. Early referral to guideline adherent physical therapy was associated with significantly lower utilization for all outcomes and 60% lower total LBP-related costs. CONCLUSIONS: The potential for cost savings in the MHS from early guideline adherent physical therapy may be substantial. These results also extend the findings from similar studies in civilian settings by demonstrating an association between early guideline adherent care and utilization and costs in a single payer health system. Future research is necessary to examine which patients with LBP benefit early physical therapy and determine strategies for providing early guideline adherent care.

Effect of Risk-Stratified Care on Disability Among Adults With Low Back Pain Treated in the Military Health System: A Randomized Clinical Trial.

Importance: Tailored treatments for low back pain (LBP) based on stratifying risk for poor prognosis have emerged as a promising approach to improve quality of care, but they have not been validated in trials at the level of individual randomization in US health systems. Objective: To assess the clinical effectiveness of risk-stratified vs usual care on disability at 1 year among patients with LBP. Design, Setting, and Participants: This parallel-group randomized clinical trial enrolled adults (ages 18-50 years) seeking care for LBP with any duration in primary care clinics within the Military Health System from April 2017 to February 2020. Data analysis was conducted from January to December 2022. Interventions: Risk-stratified care, in which participants received physiotherapy treatment tailored for their risk category (low, medium, or high), or usual care, in which care was determined by participants' general practitioners and may have included a referral to physiotherapy. Main Outcomes and Measures: The primary outcome was the Roland Morris Disability Questionnaire (RMDQ) score at 1 year, with planned secondary outcomes of Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference (PI) and Physical Function (PF) scores. Raw downstream health care utilization was also reported within each group. Results: Analysis included 270 participants (99 [34.1%] female participants; mean [SD] age, 34.1 [8.5] years). Only 21 patients (7.2%) were classified as high risk. Neither group was superior on the RMDQ (least squares [LS] mean ratio of risk-stratified vs usual care: 1.00; 95% CI, 0.80 to 1.26), the PROMIS PI (LS mean difference, -0.75 points; 95% CI -2.61 to 1.11 points), or the PROMIS PF (LS mean difference, 0.05 points; 95% CI, -1.66 to 1.76 points). Conclusions and Relevance: In this randomized clinical trial, using risk stratification to categorize and provide tailored treatment for patients with LBP did not result in better outcomes at 1 year compared with usual care. Trial Registration: ClinicalTrials.gov Identifier: NCT03127826.

Abdominal and lumbar multifidus muscle size and symmetry at rest and during contracted States. Normative reference ranges.

OBJECTIVES: The purpose of this study was to establish reference values for abdominal and lumbar multifidus muscles at rest and while contracted in a sample of active healthy adults. METHODS: Three hundred forty participants (mean age ± SD, 21.8 ± 3.9 years; 96 females and 244 males) completed the study. Ultrasound imaging was used to assess the thickness of the transversus abdominis, internal and external oblique, rectus abdominis, and lumbar multifidus muscles. Additionally, the cross-sectional area of the rectus abdominis was assessed. RESULTS: Although males had significantly thicker muscles than females (P < .05), the relative change in thickness during specified tasks was equivalent. Overall, relative muscle thickness and symmetry were similar to previous studies using smaller sample sizes. CONCLUSIONS: These findings provide a robust data set of muscle thickness values measured by ultrasound imaging and can be used for comparison to those with pain, abnormal function, and pathologic conditions.

Brief psychosocial education, not core stabilization, reduced incidence of low back pain: results from the Prevention of Low Back Pain in the Military (POLM) cluster randomized trial.

BACKGROUND: Effective strategies for the primary prevention of low back pain (LBP) remain elusive with few large-scale clinical trials investigating exercise and education approaches. The purpose of this trial was to determine whether core stabilization alone or in combination with psychosocial education prevented incidence of low back pain in comparison to traditional lumbar exercise. METHODS: The Prevention of Low Back Pain in the Military study was a cluster randomized clinical study with four intervention arms and a two-year follow-up. Participants were recruited from a military training setting from 2007 to 2008. Soldiers in 20 consecutive companies were considered for eligibility (n = 7,616). Of those, 1,741 were ineligible and 1,550 were eligible but refused participation. For the 4,325 Soldiers enrolled with no previous history of LBP average age was 22.0 years (SD = 4.2) and there were 3,082 males (71.3%). Companies were randomly assigned to receive traditional lumbar exercise, traditional lumbar exercise with psychosocial education, core stabilization exercise, or core stabilization with psychosocial education, The psychosocial education session occurred during one session and the exercise programs were done daily for 5 minutes over 12 weeks. The primary outcome for this trial was incidence of low back pain resulting in the seeking of health care. RESULTS: There were no adverse events reported. Evaluable patient analysis (4,147/4,325 provided data) indicated no differences in low back incidence resulting in the seeking of health care between those receiving the traditional exercise and core stabilization exercise programs. However, brief psychosocial education prevented low back pain episodes regardless of the assigned exercise approach, resulting in a 3.3% (95% CI: 1.1 to 5.5%) decrease over two years (numbers needed to treat (NNT) = 30.3, 95% CI = 18.2 to 90.9). CONCLUSIONS: Core stabilization has been advocated as preventative, but offered no such benefit when compared to traditional lumbar exercise in this trial. Instead, a brief psychosocial education program that reduced fear and threat of low back pain decreased incidence of low back pain resulting in the seeking of health care. Since this trial was conducted in a military setting, future studies are necessary to determine if these findings can be translated into civilian populations. TRIAL REGISTRATION: NCT00373009 at ClinicalTrials.gov - http://clinicaltrials.gov/

Inter-rater reliability of ultrasound imaging of the trunk musculature among novice raters.

OBJECTIVE: The purpose of this study was to determine the inter-rater reliability of ultrasound imaging for assessing trunk muscle morphologic characteristics at rest and while contracted among different pairs of novice raters. The secondary purpose was to compare 3 different measurement techniques for assessing lateral abdominal muscle thickness. METHODS: A single-group repeated measures reliability study was conducted on 21 healthy participants (mean ± SD, 21.5 ± 4.4 years; 5 female and 16 male) without low back pain. Ultrasound images of the transversus abdominis, internal oblique, rectus abdominis, and lumbar multifidus muscles were obtained by different pairs of novice raters in a counterbalanced order. All raters received a standardized training program before obtaining measurements. RESULTS: The intraclass correlation coefficient (1, 3) point estimates ranged from 0.86 to 0.94; the standard error of the measurement ranged from 0.04 to 0.16 cm for the thickness values and 0.67 cm(2) for the cross-sectional area of the rectus abdominis muscle. There was no meaningful difference between the different measurement techniques used to analyze the lateral abdominal muscles. CONCLUSIONS: Good to excellent reliability was obtained for all measures by novice raters. Minimal differences in reliability were noted between the different measurement techniques to assess lateral abdominal muscle thickness.

Predictors of web-based follow-up response in the Prevention Of Low Back Pain In The Military Trial (POLM).

BACKGROUND: Achieving adequate follow-up in clinical trials is essential to establish the validity of the findings. Achieving adequate response rates reduces bias and increases probability that the findings can be generalized to the population of interest. Therefore, the purpose of this study was to determine the influence of attention, demographic, psychological, and health status factors on web-based response rates in the ongoing Prevention of Low Back Pain in the Military (POLM) trial. METHODS: Twenty companies of Soldiers (n = 4,325) were cluster randomized to complete a traditional exercise program including sit-ups (TEP) with or without a psychosocial educational program (PSEP) or a core stabilization exercise program (CSEP) with or without PSEP. A subgroup of Soldiers (n = 371) was randomized to receive an additional physical and ultrasound imaging (USI) examination of key trunk musculature. As part of the surveillance program, all Soldiers were encouraged to complete monthly surveys via email during the first year. Descriptive statistics of the predictor variables were obtained and compared between responders and non-responders using two sample t-tests or chi-square test, as appropriate. Generalized linear mixed models were subsequently fitted for the dichotomous outcomes to estimate the effects of the predictor variables. The significance level was set at .05 a priori. RESULTS: The overall response rate was 18.9% (811 subjects) for the first year. Responders were more likely to be older, Caucasian, have higher levels of education and income, reservist military status, non smoker, lower BMI, and have received individualized attention via the physical/USI examination (p < .05). Age, race/ethnicity, education, military status, smoking history, BMI, and whether a Soldier received the physical/USI examination remained statistically significant (p < .05) when considered in a full multivariate model. CONCLUSION: The overall web based response rate during the first year of the POLM trial was consistent with studies that used similar methodology, but lower when compared to rates expected for standard clinical trials. One year response rate was significantly associated with demographic characteristics, health status, and individualized attention via additional testing. These data may assist for planning of future trials that use web based response systems. TRIAL REGISTRATION: This study has been registered at reports at http://clinicaltrials.gov (NCT00373009).

A randomized clinical trial of the effectiveness of mechanical traction for sub-groups of patients with low back pain: study methods and rationale.

BACKGROUND: Patients with signs of nerve root irritation represent a sub-group of those with low back pain who are at increased risk of persistent symptoms and progression to costly and invasive management strategies including surgery. A period of non-surgical management is recommended for most patients, but there is little evidence to guide non-surgical decision-making. We conducted a preliminary study examining the effectiveness of a treatment protocol of mechanical traction with extension-oriented activities for patients with low back pain and signs of nerve root irritation. The results suggested this approach may be effective, particularly in a more specific sub-group of patients. The aim of this study will be to examine the effectiveness of treatment that includes traction for patients with low back pain and signs of nerve root irritation, and within the pre-defined sub-group. METHODS/DESIGN: The study will recruit 120 patients with low back pain and signs of nerve root irritation. Patients will be randomized to receive an extension-oriented treatment approach, with or without the addition of mechanical traction. Randomization will be stratified based on the presence of the pre-defined sub-grouping criteria. All patients will receive 12 physical therapy treatment sessions over 6 weeks. Follow-up assessments will occur after 6 weeks, 6 months, and 1 year. The primary outcome will be disability measured with a modified Oswestry questionnaire. Secondary outcomes will include self-reports of low back and leg pain intensity, quality of life, global rating of improvement, additional healthcare utilization, and work absence. Statistical analysis will be based on intention to treat principles and will use linear mixed model analysis to compare treatment groups, and examine the interaction between treatment and sub-grouping status. DISCUSSION: This trial will provide a methodologically rigorous evaluation of the effectiveness of using traction for patients with low back pain and signs of nerve root irritation, and will examine the validity of a pre-defined sub-grouping hypothesis. The results will provide evidence to inform non-surgical decision-making for these patients. TRIAL REGISTRATION: This trial has been registered with http://ClinicalTrials.gov: NCT00942227.

Awareness and compliance with recommended running shoe guidelines among U.S. Army soldiers.

The purpose of this study was to determine awareness and compliance with recommended running shoe selection, sizing, and replacement guidelines among U.S. Army soldiers. Soldiers (n = 524) attending training at Fort Sam Houston, Texas completed self-report questionnaires and a foot assessment, which included measurement of foot size and arch height index. Researchers examined each soldier's running shoes for type, wear pattern, and general condition. Thirty-five percent of the soldiers wore shoes that were inappropriately sized; 56.5% wore shoes that were inappropriate for their foot type. Thirty-five percent of the soldiers had excessively worn shoes and 63% did not know recommended shoe replacement guidelines. Further efforts may be necessary to ensure that soldiers are aware of and compliant with recommended running shoe selection, sizing, and replacement guidelines. Future research is needed to determine whether adherence to these guidelines has a favorable effect on reducing risk of overuse injury.

Associates of physical function and pain in patients with patellofemoral pain syndrome.

OBJECTIVES: To explore whether impairment of muscle strength, soft tissue length, movement control, postural and biomechanic alterations, and psychologic factors are associated with physical function and pain in patients with patellofemoral pain syndrome (PFPS). DESIGN: Cross-sectional study. SETTING: Rehabilitation outpatient. PARTICIPANTS: Seventy-four patients diagnosed with PFPS. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Measurements were self-reported function and pain; strength of quadriceps, hip abduction, and hip external rotation; length of hamstrings, quadriceps, plantar flexors, iliotibial band/tensor fasciae latae complex, and lateral retinaculum; foot pronation; Q-angle; tibial torsion; visual observation of quality of movement during a lateral step-down task; anxiety; and fear-avoidance beliefs. RESULTS: After controlling for age and sex, anxiety and fear-avoidance beliefs about work and physical activity were associated with function, while only fear-avoidance beliefs about work and physical activity were associated with pain. CONCLUSIONS: Psychologic factors were the only associates of function and pain in patients with PFPS. Factors related to physical impairments did not associate to function or pain. Our results should be validated in other samples of patients with PFPS. Further studies should determine the role of other psychologic factors, and how they relate to anxiety and fear-avoidance beliefs in these patients.

Ultrasound characteristics of the deep abdominal muscles during the active straight leg raise test.

OBJECTIVE: To determine whether changes in the transversus abdominis (TrA) and internal oblique (IO) muscles, as seen on ultrasound imaging, during the active straight leg raise (ASLR) test differ between subjects with and without unilateral lumbopelvic pain. DESIGN: Cross-sectional, case-control study. SETTING: Clinical laboratory. PARTICIPANTS: Subjects (n=15) with unilateral symptoms in the lumbopelvic region and age-matched and sex-matched control subjects (n=15). INTERVENTIONS: Bilateral measurements of the deep abdominal muscles (TrA and IO) were obtained simultaneously using ultrasound imaging to compare the percent change in muscle thickness from rest with (1) immediately on raising, (2) after a 10-second hold, and (3) within 5 seconds after returning the lower extremity to the plinth. MAIN OUTCOME MEASURE: Percent change in muscle thickness of both muscles from rest to the other 3 time intervals during the ASLR test. RESULTS: The 3-way group x side measured x time and 2-way side measured x time interactions were not significant for either the TrA (P> or =.34) or the IO (P> or =.14) muscles. The 2-way interaction group x time was significant for both the TrA (P=.003) and the IO (P=.02) muscles. On lifting the lower extremity, the control group demonstrated a 23.7% and 11.2% increase in TrA and IO muscle thickness, respectively, while those with lumbopelvic pain demonstrated a 6.4% and 5.7% increase in TrA and IO muscle thickness, respectively. CONCLUSIONS: Although subjects with unilateral lumbopelvic pain demonstrated a smaller increase in muscle thickness, during the ASLR test there appears to be a symmetrical response in both of the deep abdominal muscles regardless of which lower extremity is lifted during the ASLR test or the unilateral nature of the symptoms. This study attests to the potential construct validity of using the ASLR test to assess different motor control strategies of the TrA and IO muscles in subjects with unilateral lumbopelvic pain.

Psychosocial education improves low back pain beliefs: results from a cluster randomized clinical trial (NCT00373009) in a primary prevention setting.

The general population has a pessimistic view of low back pain (LBP), and evidence-based information has been used to positively influence LBP beliefs in previously reported mass media studies. However, there is a lack of randomized trials investigating whether LBP beliefs can be modified in primary prevention settings. This cluster randomized clinical trial investigated the effect of an evidence-based psychosocial educational program (PSEP) on LBP beliefs for soldiers completing military training. A military setting was selected for this clinical trial, because LBP is a common cause of soldier disability. Companies of soldiers (n = 3,792) were recruited, and cluster randomized to receive a PSEP or no education (control group, CG). The PSEP consisted of an interactive seminar, and soldiers were issued the Back Book for reference material. The primary outcome measure was the back beliefs questionnaire (BBQ), which assesses inevitable consequences of and ability to cope with LBP. The BBQ was administered before randomization and 12 weeks later. A linear mixed model was fitted for the BBQ at the 12-week follow-up, and a generalized linear mixed model was fitted for the dichotomous outcomes on BBQ change of greater than two points. Sensitivity analyses were performed to account for drop out. BBQ scores (potential range: 9-45) improved significantly from baseline of 25.6 +/- 5.7 (mean +/- SD) to 26.9 +/- 6.2 for those receiving the PSEP, while there was a significant decline from 26.1 +/- 5.7 to 25.6 +/- 6.0 for those in the CG. The adjusted mean BBQ score at follow-up for those receiving the PSEP was 1.49 points higher than those in the CG (P < 0.0001). The adjusted odds ratio of BBQ improvement of greater than two points for those receiving the PSEP was 1.51 (95% CI = 1.22-1.86) times that of those in the CG. BBQ improvement was also mildly associated with race and college education. Sensitivity analyses suggested minimal influence of drop out. In conclusion, soldiers that received the PSEP had an improvement in their beliefs related to the inevitable consequences of and ability to cope with LBP. This is the first randomized trial to show positive influence on LBP beliefs in a primary prevention setting, and these findings have potentially important public health implications for prevention of LBP.

Development of a clinical prediction rule to identify patients with neck pain likely to benefit from cervical traction and exercise.

The objective of the study was to develop a clinical prediction rule (CPR) to identify patients with neck pain likely to improve with cervical traction. The study design included prospective cohort of patients with neck pain referred to physical therapy. Development of a CPR will assist clinicians in classifying patients with neck pain likely to benefit from cervical traction. Eighty patients with neck pain received a standardized examination and then completed six sessions of intermittent cervical traction and cervical strengthening exercises twice weekly for 3 weeks. Patient outcome was classified at the end of treatment, based on perceived recovery according to the global rating of change. Patients who achieved a change > or =+6 ("A great deal better" or "A very great deal better") were classified as having a successful outcome. Univariate analyses (t tests and chi-square) were conducted on historical and physical examination items to determine potential predictors of successful outcome. Variables with a significance level of P < or = 0.15 were retained as potential prediction variables. Sensitivity, specificity and positive and negative likelihood ratios (LRs) were then calculated for all variables with a significant relationship with the reference criterion of successful outcome. Potential predictor variables were entered into a step-wise logistic regression model to determine the most accurate set of clinical examination items for prediction of treatment success. Sixty-eight patients (38 female) were included in data analysis of which 30 had a successful outcome. A CPR with five variables was identified: (1) patient reported peripheralization with lower cervical spine (C4-7) mobility testing; (2) positive shoulder abduction test; (3) age > or =55; (4) positive upper limb tension test A; and (5) positive neck distraction test. Having at least three out of five predictors present resulted in a +LR equal to 4.81 (95% CI = 2.17-11.4), increasing the likelihood of success with cervical traction from 44 to 79.2%. If at least four out of five variables were present, the +LR was equal to 23.1 (2.5-227.9), increasing the post-test probability of having improvement with cervical traction to 94.8%. This preliminary CPR provides the ability to a priori identify patients with neck pain likely to experience a dramatic response with cervical traction and exercise. Before the rule can be implemented in routine clinical practice, future studies are necessary to validate the rule. The CPR developed in this study may improve clinical decision-making by assisting clinicians in identifying patients with neck pain likely to benefit from cervical traction and exercise.

Patella fracture during rehabilitation after bone-patellar tendon-bone anterior cruciate ligament reconstruction: 2 case reports.

STUDY DESIGN: Case report. BACKGROUND: Patellar fracture is a rare but significant complication following anterior cruciate ligament (ACL) reconstruction when using a bone-patellar tendon-bone (BPTB) autograft. The purpose of these case reports is to describe 2 cases in which patellar fracture occurred during rehabilitation after ACL reconstruction using a BPTB. CASE DESCRIPTION: Both patients were 23-year-old males referred for rehabilitation after ACL reconstruction using a BPTB autograft. They were both progressing satisfactorily in rehabilitation until sustaining a fracture of the patella. One fracture occurred during the performance of the eccentric phase of a knee extension exercise during the sixth week of rehabilitation (7 weeks postsurgery), whereas the other fracture occurred during testing of the patient is quadriceps maximum voluntary isometric contraction in the ninth week of rehabilitation (10 weeks postsurgery). Both patients were subsequently treated with open reduction and internal fixation of the patella. DISCUSSION: During rehabilitation following ACL reconstruction using BPTB autograft, clinicians should consider the need to balance the sometimes-competing goals of improving quadriceps strength while providing protection to the healing graft, minimization of patellofemoral pain, and protection of the patellar donor site.

Changes in lateral abdominal muscle thickness during the abdominal drawing-in maneuver in those with lumbopelvic pain.

STUDY DESIGN: Controlled laboratory study. OBJECTIVES: To determine if changes in transversus abdominis (TrA) and internal oblique (IO) muscle thickness and side-to-side symmetry differ in individuals with and without unilateral lumbopelvic pain while at rest and during the abdominal drawing-in maneuver (ADIM). BACKGROUND: Although the ADIM has been found to produce a symmetrical change in TrA and IO muscle thickness in healthy subjects, how these muscles are activated in those with unilateral lumbopelvic pain during the ADIM remains unknown. METHODS: Fifteen subjects with lumbopelvic pain and 15 age- and gender-matched control subjects were recruited. To investigate a similar subgroup of patients with lumbopelvic pain that has been used in previous research, subjects were required to have unilateral symptoms, a positive sacroiliac provocation test, and a positive active straight-leg raise test. Ultrasound images were obtained bilaterally at 2 different points during each trial of the ADIM: (1) at rest and (2) while maintaining the ADIM. Average percent change in thickness of the TrA and IO muscles was obtained over 3 trials. RESULTS: The percent change in thickness of the TrA was 20.9% less in those with lumbopelvic pain compared to the control group (P = .035), while the percent change in IO thickness was equivalent between groups (P = .522). No differences were observed for the TrA or IO muscles between the symptomatic and asymptomatic sides in those with (TrA, P = .263; IO, P = .172) or without (TrA, P = .780; IO, P = .635) lumbopelvic pain during the ADIM. Changes in TrA muscle thickness were greater than the IO muscle during the ADIM for both groups (P<.001). Specifically, the increases in TrA muscle thickness in those with and without lumbopelvic dysfunction were 32.7% and 47.3% greater, respectively, compared to changes in the IO muscle. CONCLUSIONS: Individuals with unilateral lumbopelvic pain demonstrated a smaller increase in thickness of the TrA muscle during the ADIM. This finding provides an element of construct validity for the use of the ADIM for assessing TrA muscle thickness in those with unilateral lumbopelvic pain. However, both groups demonstrated a symmetrical side-to-side change in TrA and IO muscle thickness despite the symptomatic group having unilateral symptoms. Further, we detected a preferential change in TrA muscle thickness during the ADIM in both groups.

Mental health symptoms in combat medic training: a longitudinal examination.

Mental health symptoms in military populations are rising and constitute a significant health concern. This study examined the prevalence of depression, anxiety, and suicidal ideation in soldiers (N = 3,792) undergoing combat medic training. At the start of training, 10.4%, 15.5%, and 4.1% of soldiers had clinically significant depression, anxiety, or suicidal ideation, respectfully. These percentages increased to 12.2%, 20.3%, and 5.7% at completion of training, respectfully. Worsening of depression, anxiety, and suicidal ideation occurred for 7.7%, 11.4%, and 4% of soldiers. Higher percentages of symptoms were associated with females, lower education, and lower income. Active duty personnel were more likely to worsen following training with respect to suicidal ideation (OR = 1.9, 95% CI = 1.2-2.9) compared to reservists. The identification of these significant predictors of mental health status may serve to identify individuals at risk. Additional work to examine the relative contribution of anticipatory (impending deployment) factors vs. training-related factors is warranted.

Comparison of short-term response to two spinal manipulation techniques for patients with low back pain in a military beneficiary population.

OBJECTIVE: To determine whether military health care beneficiaries with low back pain (LBP) who are likely to respond successfully to spinal manipulation experience a difference in short-term clinical outcomes based on the manipulation technique that is used. METHODS: Sixty patients with LBP identified as likely responders to manipulation underwent a standardized clinical examination and were randomized to receive a lumbopelvic (LP) or lumbar neutral gap (NG) manipulation technique. Outcome measures were a numeric pain rating scale and the modified Oswestry Disability Questionnaire. RESULTS: Both the LP and NG groups experienced statistically significant reductions in pain and disability at 48 hours postmanipulation. The improvements seen in each group were small because of the short follow-up. There were no statistically significant or clinically meaningful differences in pain or disability between the two groups. CONCLUSION: The two manipulation techniques used in this study were equally effective at reducing pain and disability when compared at 48 hours posttreatment. Clinicians may employ either technique for the treatment of LBP and can expect similar outcomes in those who satisfy the clinical prediction rule (CPR). Further research is required to determine whether differences exist at longer-term follow-up periods, after multiple treatment sessions, or in different clinical populations.

Normative parameters and anthropometric variability of lumbar muscle stiffness using ultrasound shear-wave elastography.

BACKGROUND: Quantifying stiffness of the lumbar spine musculature using shear-wave elastography (SWE) maybe beneficial in the diagnosis and treatment of non-specific low back pain (LBP). The primary purpose of this study was to establish normative parameter and variance estimates of lumbar spine muscle stiffness at rest and during submaximal contraction levels using SWE in healthy individuals. A second aim was to determine the relationship between lumbar spine muscle stiffness and a variety of demographic, anthropometric, and medical history variables. METHODS: This cross-sectional study included stiffness measurements of the lumbar musculature in 120 asymptomatic individuals using ultrasound SWE. The lumbar erector spinae muscle was measured during rest only and lumbar multifidus muscle was measured during rest and during submaximal contraction using a prone contralateral arm lift. Statistical comparisons of shear modulus were made between sex (male vs. female) and muscle condition (erector spinae rest, lumbar multifidus rest, lumbar multifidus contracted) using 2 × 3 repeated measures analysis of variance (ANOVA). Univariate associations between shear modulus and age, sex, BMI, activity level, and history of back pain were assessed using correlation analysis. FINDINGS: Shear modulus at rest was approximately 4 kPa for the erector spinae muscles and approximately 6 kPa for the lumbar multifidus muscles. Shear modulus substantially increased during contraction, and varied by sex, BMI, and self-reported activity level, with men and more active individuals generally having stiffer muscles. INTERPRETATION: Variability in shear modulus of the lumbar musculature may be mediated through a combination of muscle size and contractile state, which is consistent with our findings of higher stiffness in the more postural lumbar multifidi muscles, during contraction, and in larger and more active individuals. These findings should inform and be accounted for in future comparative clinical studies.

Psychometric properties of the Neck Disability Index and Numeric Pain Rating Scale in patients with mechanical neck pain.

OBJECTIVE: To examine the psychometric properties including test-retest reliability, construct validity, and minimum levels of detectable and clinically important change for the Neck Disability Index (NDI) and the numeric rating scale (NRS) for pain in a cohort of patients with neck pain. DESIGN: Single-group repeated-measures design. SETTING: Outpatient physical therapy (PT) clinics. PARTICIPANTS: Patients (N=137) presenting to PT with a primary report of neck pain. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: All patients completed the NDI and the NRS at the baseline examination and at a follow-up. At the time of the follow-up, all patients also completed the global rating of change, which was used to dichotomize patients as improved or stable. Baseline and follow-up scores were used to determine the test-retest reliability, construct validity, and minimal levels of detectable and clinically important change for both the NDI and NRS. RESULTS: Test-retest reliability was calculated using an intraclass correlation coefficient (ICC) (NDI ICC=.50; 95% confidence interval [CI], .25-.67; NRS ICC=.76; 95% CI, .51-.87). The area under the curve was .83 (95% CI, .75-.90) for the NDI score and .85 (95% CI, .78-.93) for the NRS score for determining between stable and improved patients. Thresholds for the minimum clinically important difference (MCID) for the NDI were 19-percentage points and 1.3 for the NRS. CONCLUSIONS: Both the NDI and NRS exhibit fair to moderate test-retest reliability in patients with mechanical neck pain. Both instruments also showed adequate responsiveness in this patient population. However, the MCID required to be certain that the change in scores has surpassed a level that could be contributed to measurement error for the NDI was twice that which has previously been reported. Therefore the ongoing analyses of the properties of the NDI in a patient population with neck pain are warranted.