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.

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.

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.

Effect of Lumbar Progressive Resistance Exercise on Lumbar Muscular Strength and Core Muscular Endurance in Soldiers.

OBJECTIVES: Low back pain is common, costly, and disabling for active duty military personnel and veterans. The evidence is unclear on which management approaches are most effective. The purpose of this study was to assess the effectiveness of lumbar extensor high-intensity progressive resistance exercise (HIPRE) training versus control on improving lumbar extension muscular strength and core muscular endurance in soldiers. METHODS: A randomized controlled trial was conducted with active duty U.S. Army Soldiers (n = 582) in combat medic training at Fort Sam Houston, Texas. Soldiers were randomized by platoon to receive the experimental intervention (lumbar extensor HIPRE training, n = 298) or control intervention (core stabilization exercise training, n = 284) at one set, one time per week, for 11 weeks. Lumbar extension muscular strength and core muscular endurance were assessed before and after the intervention period. RESULTS: At 11-week follow-up, lumbar extension muscular strength was 9.7% greater (p = 0.001) for HIPRE compared with control. No improvements in core muscular endurance were observed for HIPRE or control. CONCLUSIONS: Lumbar extensor HIPRE training is effective to improve isometric lumbar extension muscular strength in U.S. Army Soldiers. Research is needed to explore the clinical relevance of these gains.

The Effectiveness of Mechanical Traction Among Subgroups of Patients With Low Back Pain and Leg Pain: A Randomized Trial.

STUDY DESIGN: Randomized clinical trial. Background The recommended initial management strategy for patients with low back pain and signs of nerve root compression is conservative treatment, but there is little evidence to guide the most appropriate management strategy. Preliminary research suggests that a treatment protocol of mechanical traction and extension-oriented exercises may be effective, particularly in a specific subgroup of patients. OBJECTIVE: To examine the effectiveness of mechanical traction in patients with lumbar nerve root compression and within a predefined subgroup. METHODS: One hundred twenty patients with low back pain with nerve root compression were recruited from physical therapy clinics. Using predefined subgrouping criteria, patients were stratified at baseline and randomized to receive an extension-oriented treatment approach with or without the addition of mechanical traction. During a 6-week period, patients received up to 12 treatment visits. Primary outcomes of pain and disability were collected at 6 weeks, 6 months, and 1 year by assessors blinded to group allocation. Outcomes were examined using linear mixed-model analyses examining change over time by treatment and the interaction between treatment and subgrouping status. RESULTS: The mean ± SD age of participants was 41.1 ± 11.3 years, median duration of symptoms was 62 days, and 57% were male. No significant differences in disability or pain outcomes were noted between treatment groups at any time point, nor was any interaction found between subgroup status and treatment. CONCLUSION: Patients with lumbar nerve root compression presenting for physical therapy can expect significant changes in disability and pain over a 6-week treatment period. There is no evidence that mechanical lumbar traction in combination with an extension-oriented treatment is superior to extension-oriented exercises alone in the management of these patients or within a predefined subgroup of patients. The study protocol was registered with ClinicalTrials.gov (NCT00942227). Level of Evidence Therapy, level 2b.

Incremental Effects of Telephone Call Center and Healthcare Utilization Database Use to Improve Follow-up Rate in the Prevention of Low Back Pain in the Military Trial.

BACKGROUND: Studies that have relied exclusively on web-based surveys to secure follow-up have yielded inadequate follow-up rates, resulting in the need to explore whether supplementing with other methods results in incremental improvements. The primary purpose of this study was to determine the effectiveness of each follow up strategy that was used to collect the follow up data in our ongoing Prevention of Low Back Pain in the Military (POLM) trial. METHODS: This study represents a secondary analysis of the POLM trial. Twenty companies of Soldiers (N=4,325) were cluster randomized to complete one of four exercise programs. Since web-based response rates were lower than anticipated, a telephone call center was established to contact Soldiers who had not responded to the web-based survey. A military healthcare utilization database (M2) was also used to capture additional follow-up. Descriptive statistics and pairwise comparisons were performed to determine the incremental benefits of supplementing the primary web-based follow-up strategy in our ongoing POLM trial and determine whether differences existed in demographic characteristics, pain intensity, and low back pain incidence based on follow-up strategy. RESULTS: Of the 4,325 Soldiers who were enrolled, 632 (14.6%) subjects completed the monthly web-based survey only; 571 (13.2%) responded only to the telephone call; and 233 (5.4%) responded to both the web-based and telephone survey. Adding the telephone call center contributed 804 unique contributions to follow-up, increasing the overall follow-up to 33.2% (n=1,436) and resulting in a net 18.6% increase in follow-up rate. Querying the M2 database yielded follow-up data for an additional 2,788 Soldiers, increasing the follow-up rate by 64.5%. This rate, combined with the web-based and telephone strategies, resulted in an overall follow-up rate of 97.7%. Compared to the web-based survey, those who responded to the telephone call center tended to be younger, white, have a lower income, more likely to smoke, more likely to exercise regularly, and less likely to have low back pain (all with P<.05). CONCLUSIONS: The results of this study can inform the design of future clinical trials by establishing the benefit of supplementing a web-based survey with a telephone call center to secure additional follow-up.

The Incremental Effects of Manual Therapy or Booster Sessions in Addition to Exercise Therapy for Knee Osteoarthritis: A Randomized Clinical Trial.

STUDY DESIGN: A factorial randomized controlled trial. OBJECTIVES: To investigate the addition of manual therapy to exercise therapy for the reduction of pain and increase of physical function in people with knee osteoarthritis (OA), and whether "booster sessions" compared to consecutive sessions may improve outcomes. BACKGROUND: The benefits of providing manual therapy in addition to exercise therapy, or of distributing treatment sessions over time using periodic booster sessions, in people with knee OA are not well established. METHODS: All participants had knee OA and were provided 12 sessions of multimodal exercise therapy supervised by a physical therapist. Participants were randomly allocated to 1 of 4 groups: exercise therapy in consecutive sessions, exercise therapy distributed over a year using booster sessions, exercise therapy plus manual therapy without booster sessions, and exercise therapy plus manual therapy with booster sessions. The primary outcome measure was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC score; 0-240 scale) at 1-year follow-up. Secondary outcome measures were the numeric pain-rating scale and physical performance tests. RESULTS: Of 75 participants recruited, 66 (88%) were retained at 1-year follow-up. Factorial analysis of covariance of the main effects showed significant benefit from booster sessions (P = .009) and manual therapy (P = .023) over exercise therapy alone. Group analysis showed that exercise therapy with booster sessions (WOMAC score, -46.0 points; 95% confidence interval [CI]: -80.0, -12.0) and exercise therapy plus manual therapy (WOMAC score, -37.5 points; 95% CI: -69.7, -5.5) had superior effects compared with exercise therapy alone. The combined strategy of exercise therapy plus manual therapy with booster sessions was not superior to exercise therapy alone. CONCLUSION: Distributing 12 sessions of exercise therapy over a year in the form of booster sessions was more effective than providing 12 consecutive exercise therapy sessions. Providing manual therapy in addition to exercise therapy improved treatment effectiveness compared to providing 12 consecutive exercise therapy sessions alone. Trial registered with the Australian New Zealand Clinical Trials Registry (ACTRN12612000460808).

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.

Implications of practice setting on clinical outcomes and efficiency of care in the delivery of physical therapy services.

STUDY DESIGN: Retrospective analysis of episodes of care. OBJECTIVE: To assess the implications of practice setting (hospital outpatient settings versus private practice) on clinical outcomes and efficiency of care in the delivery of physical therapy services. BACKGROUND: Many patients with musculoskeletal conditions benefit from care provided by physical therapists. The majority of physical therapists deliver services in either a private practice setting or in a hospital outpatient setting. There have not been any recent studies comparing whether clinical outcomes or efficiency of care differ based on practice setting. METHODS: Practices that use the Focus On Therapeutic Outcomes, Inc system were surveyed to determine the specific type of setting in which outcomes were collected in patients with musculoskeletal impairments. Patient outcome data over 12 months (2011-2012) were extracted from the database and analyzed to identify differences in the functional status achieved and the efficiency of the care delivery process between private practices and hospital outpatient settings. RESULTS: The data suggest that patients experience more efficient care when receiving physical therapy in hospital outpatient settings compared to private practice settings, as demonstrated by 3.1 points of greater improvement in functional status over 2.9 fewer physical therapy visits. However, the difference in improvement between settings is less than the minimum clinically important difference of 9 points in functional status outcome score. CONCLUSION: In this cohort, our data suggest that more efficient care was delivered in the hospital outpatient setting compared to the private practice setting. However, we cannot conclude that care delivered in the hospital setting is more cost-effective, because it is possible that any difference in efficiency of care favoring the hospital outpatient setting is more than offset by higher costs of care.

Criterion validity of manual assessment of spinal stiffness.

Assessment of spinal stiffness is widely used by manual therapy practitioners as a part of clinical diagnosis and treatment selection. Although studies have commonly found poor reliability of such procedures, conflicting evidence suggests that assessment of spinal stiffness may help predict response to specific treatments. The current study evaluated the criterion validity of manual assessments of spinal stiffness by comparing them to indentation measurements in patients with low back pain (LBP). As part of a standard examination, an experienced clinician assessed passive accessory spinal stiffness of the L3 vertebrae using posterior to anterior (PA) force on the spinous process of L3 in 50 subjects (54% female, mean (SD) age = 33.0 (12.8) years, BMI = 27.0 (6.0) kg/m(2)) with LBP. A criterion measure of spinal stiffness was performed using mechanized indentation by a blinded second examiner. Results indicated that manual assessments were uncorrelated to criterion measures of stiffness (spearman rho = 0.06, p = 0.67). Similarly, sensitivity and specificity estimates of judgments of hypomobility were low (0.20-0.45) and likelihood ratios were generally not statistically significant. Sensitivity and specificity of judgments of hypermobility were not calculated due to limited prevalence. Additional analysis found that BMI explained 32% of the variance in the criterion measure of stiffness, yet failed to improve the relationship between assessments. Additional studies should investigate whether manual assessment of stiffness relates to other clinical and biomechanical constructs, such as symptom reproduction, angular rotation, quality of motion, or end feel.

Impact of an innovative clinical internship model in the US Army-Baylor Doctoral Program in physical therapy.

STUDY DESIGN: Retrospective case-control. BACKGROUND AND PURPOSE: Physical therapy education has been characterized by positive reform including the transition to doctoral level education and the emergence of evidence-based practice as a standard part of the curricula. However, clinical education remains largely unaffected by these advancements and continues as a highly fragmented and ill-equipped model marked by an inefficient 1:1 student to faculty ratio. Current clinical educational models provide highly variable and suboptimal learning experiences for many students, which contribute to disjointed and noncollaborative learning. The purpose of this study is to examine the implications of a one-year collaborative internship model in the US Army-Baylor University Doctoral Program in Physical Therapy in which interns train in groups rather than 1:1 on productivity and efficiency of care. CASE DESCRIPTION: The Army-Baylor program culminates in a 12-month clinical internship conducted at 4 locations within south central Texas (3 military academic medical centers and one multisite outpatient privately-owned physical therapy practice). Each site can accommodate up to 8 (range=4 to 8) students who complete a standardized internship curricula across the full continuum of learning experiences. In this retrospective case-control design, productivity and staffing metrics were extracted for the 3 military sites using the Department of Defense M2 database during the period from 2006-2010. A separate analysis was conducted for each site with descriptive statistics used to assess clinic productivity and efficiency. OUTCOMES: Data from all 3 sites indicate the presence of interns resulted in little variability in clinic productivity and efficiency. Decreased productivity and/or efficiency would bring into question the long term viability and sustainability of the collaborative internship model. Additionally, this model maximized the opportunity for highly engaged mentorship, individual attention, and quality instruction. COMMENT: The findings suggest clinics can accommodate multiple interns and provide high quality education in a collaborative model without a decline in productivity or efficiency. In addition to the standardized curricula across sites, this model facilitates a highly collaborative and peer learning environment in which the intern class supports, challenges, and holds one another accountable to a more standardized and higher level of practice. Each site contributes 1-2 clinical faculty who no longer engage their own patient schedule but rather are able to serve in a full time clinical mentorship role with the interns. In return, the clinical site receives 3-4 full time equivalents of productivity delivered by closely supervised interns who are afforded sufficient time to conduct their examinations and treatments in collaboration with the clinical faculty. Finally, the collaborative internship model supports the mission of each internship site, providing them a critical mass of labor via economies of scale in exchange for an enriched investment into their clinical education.

Physical therapist vs. family practitioner knowledge of simple low back pain management in the U.S. Air Force.

The purpose of this study was to compare knowledge in managing low back pain (LBP) between physical therapists and family practice physicians. Fifty-four physical therapists and 130 family practice physicians currently serving in the U.S. Air Force completed standardized examinations assessing knowledge, attitudes, the usefulness of clinical practice guidelines, and management strategies for patients with LBP. Beliefs of physical therapists and family practice physicians about LBP were compared using relative risks and independent t tests. Scores related to knowledge, attitudes, and the usefulness of clinical practice guidelines were generally similar between the groups. However, physical therapists were more likely to recommend the correct drug treatments for patients with acute LBP compared to family practice physicians (85.2% vs. 68.5%; relative risk: 1.24 [95% confidence interval: 1.06-1.46]) and believe that patient encouragement and explanation is important (75.9% vs. 56.2%; relative risk: 1.35 [95% confidence interval: 1.09-1.67]). In addition, physical therapists showed significantly greater knowledge regarding optimal management strategies for patients with LBP compared to family practice physicians. The results of this study may have implications for health policy decisions regarding the utilization of physical therapists to provide care for patients with LBP without a referral.

Exercise only, exercise with mechanical traction, or exercise with over-door traction for patients with cervical radiculopathy, with or without consideration of status on a previously described subgrouping rule: a randomized clinical trial.

STUDY DESIGN: Randomized clinical trial. OBJECTIVES: To examine the effectiveness of cervical traction in addition to exercise for specific subgroups of patients with neck pain. BACKGROUND: Cervical traction is frequently used, but its effectiveness has not been adequately examined. Existing studies have failed to target patients most likely to respond. Traction is typically recommended for patients with cervical radiculopathy. A prediction rule has been described to identify a narrower subgroup of patients likely to respond to cervical traction. METHODS: Patients with neck pain and signs of radiculopathy were randomized to 4 weeks of treatment with exercise, exercise with mechanical traction, or exercise with over-door traction. Baseline assessment included subgrouping-rule status. The primary outcome measure (Neck Disability Index, scored 0-100) and secondary outcome measure (neck and arm pain intensity) were assessed at 4 weeks, 6 months, and 12 months after enrollment. The primary analyses examined 2-way treatment-by-time interactions. Secondary analyses examined validity of the subgrouping rule by adding 3-way interactions. RESULTS: Eighty-six patients (53.5% female; mean age, 46.9 years) were enrolled in the study. Intention-to-treat analysis found lower Neck Disability Index scores at 6 months in the mechanical traction group compared to the exercise group (mean difference between groups, 13.3; 95% confidence interval: 5.6, 21.0) and over-door traction group (mean difference between groups, 8.1; 95% confidence interval: 0.8, 15.3), and at 12 months in the mechanical traction group compared to the exercise group (mean difference between groups, 9.8; 95% confidence interval: 0.2, 19.4). Secondary outcomes favored mechanical traction at several time points. The validity of the subgrouping rule was supported on the Neck Disability Index at the 6-month time point only. CONCLUSION: Adding mechanical traction to exercise for patients with cervical radiculopathy resulted in lower disability and pain, particularly at long-term follow-ups. The study protocol was registered at http://clinicaltrials.gov (NCT00979108).

Prevention of low back pain in the military cluster randomized trial: effects of brief psychosocial education on total and low back pain-related health care costs.

BACKGROUND CONTEXT: Effective strategies for preventing low back pain (LBP) have remained elusive, despite annual direct health care costs exceeding $85 billion dollars annually. In our recently completed Prevention of Low Back Pain in the Military (POLM) trial, a brief psychosocial education program (PSEP) that reduced fear and threat of LBP reduced the incidence of health care-seeking for LBP. PURPOSE: The purpose of this cost analysis was to determine if soldiers who received psychosocial education experienced lower health care costs compared with soldiers who did not receive psychosocial education. STUDY DESIGN/SETTING: The POLM trial was a cluster randomized trial with four intervention arms and a 2-year follow-up. Consecutive subjects (n=4,295) entering a 16-week training program at Fort Sam Houston, TX, to become a combat medic in the U.S. Army were considered for participation. METHODS: In addition to an assigned exercise program, soldiers were cluster randomized to receive or not receive a brief psychosocial education program delivered in a group setting. The Military Health System Management Analysis and Reporting Tool was used to extract total and LBP-related health care costs associated with LBP incidence over a 2-year follow-up period. RESULTS: After adjusting for postrandomization differences between the groups, the median total LBP-related health care costs for soldiers who received PSEP and incurred LBP-related costs during the 2-year follow-up period were $26 per soldier lower than for those who did not receive PSEP ($60 vs. $86, respectively, p=.034). The adjusted median total health care costs for soldiers who received PSEP and incurred at least some health care costs during the 2-year follow-up period were estimated at $2 per soldier lower than for those who did not receive PSEP ($2,439 vs. $2,441, respectively, p=.242). The results from this analysis demonstrate that a brief psychosocial education program was only marginally effective in reducing LBP-related health care costs and was not effective in reducing total health care costs. Had the 1,995 soldiers in the PSEP group not received PSEP, we would estimate that 16.7% of them would incur an adjusted median LBP-related health care cost of $517 compared with the current 15.0% soldiers incurring an adjusted median cost of $399, which translates into an actual LBP-related health care cost savings of $52,846 during the POLM trial. However, it is likely that the unaccounted for direct and indirect costs might erase even these small cost savings. CONCLUSION: The results of this study will help to inform policy- and decision-making regarding the feasibility of implementing psychosocial education in military training environments across the services. It would be interesting to explore in future research whether cost savings from psychosocial education could be enhanced given a more individualized delivery method tailored to an individual's specific psychosocial risk factors.

Y-balance test: a reliability study involving multiple raters.

The Y-balance test (YBT) is one of the few field expedient tests that have shown predictive validity for injury risk in an athletic population. However, analysis of the YBT in a heterogeneous population of active adults (e.g., military, specific occupations) involving multiple raters with limited experience in a mass screening setting is lacking. The primary purpose of this study was to determine interrater test-retest reliability of the YBT in a military setting using multiple raters. Sixty-four service members (53 males, 11 females) actively conducting military training volunteered to participate. Interrater test-retest reliability of the maximal reach had intraclass correlation coefficients (2,1) of 0.80 to 0.85 with a standard error of measurement ranging from 3.1 to 4.2 cm for the 3 reach directions (anterior, posteromedial, and posterolateral). Interrater test-retest reliability of the average reach of 3 trails had an intraclass correlation coefficients (2,3) range of 0.85 to 0.93 with an associated standard error of measurement ranging from 2.0 to 3.5cm. The YBT showed good interrater test-retest reliability with an acceptable level of measurement error among multiple raters screening active duty service members. In addition, 31.3% (n = 20 of 64) of participants exhibited an anterior reach asymmetry of >4cm, suggesting impaired balance symmetry and potentially increased risk for injury.