Interrater reliability of quantitative ultrasound measures of muscle in critically ill patients.

BACKGROUND: Quantitative neuromuscular ultrasound is increasingly used to study muscle pathology and changes in muscle mass during critical illness. Advantages of ultrasound are high axial resolution, low procedural risks, no ionizing radiation, and ease of use early in the course of disease. However, ultrasound is known to be an operator dependent imaging modality and the intensive care unit setting poses additional challenges to obtaining reliable measurements. There is limited evidence validating the feasibility and reliability of its application in this setting. OBJECTIVE: To conduct a standardized protocol for measuring muscle linear depth and cross-sectional area in critically ill populations with a high degree of interrater agreement and feasibility. DESIGN: Prospective observational cohort study of interrater reliability. SETTING: Medical intensive care unit at an academic medical center and a level one trauma and burn center. PATIENTS: Fifteen critically ill patients were evaluated using a standardized ultrasound protocol measuring total elbow flexor, knee extensor, and tibialis anterior depth, as well as rectus femoris cross-sectional area. Each site was independently scanned by two investigators. Reliability of measurements between observers was determined by calculating intraclass correlation coefficients (ICCs) using a two-way random effects model and absolute agreement. An ICC > 0.75 was considered good and >0.90 was considered excellent. RESULTS: In critically ill patients, interrater reliability of linear depth measured at elbow flexor, knee extensor, tibialis anterior, and cross-sectional area of rectus femoris sites was good to excellent with ICC between 0.87 (0.54-0.97) and 0.99 (0.97-1.00). Interrater reliability was improved by creating a summary index of measures resulting in an ICC of 0.99 (0.98-1.00). Feasibility, as definite by the percentage of each measure that was obtainable, ranged from 75%-100%. CONCLUSIONS: Using a standardized protocol, ultrasound measures obtained in critically ill patients demonstrated high levels of interrater agreement with good to excellent feasibility.

Feasibility and impact of a musculoskeletal health for musicians (MHM) program for musician students: A randomized controlled pilot study.

BACKGROUND: There is a high incidence of performance-related musculoskeletal disorders in musicians that may be reduced via education programs. However, the efficacy of formalized injury prevention programs has not been rigorously studied. PURPOSE: To assess the feasibility and effect of a formalized injury prevention education workshop on incidence and severity of musculoskeletal pain in a cohort of musician-students attending an intensive summer music festival compared to controls. STUDY DESIGN: Randomized-controlled-pilot trial. METHODS: Musicians at an 8-week long intensive summer festival were randomized to an intervention (workshop) or control group. Workshop attendees participated in a 90-minute session of injury prevention strategies. Musculoskeletal outcome data were collected at the start and end of the festival. Outcomes included presence of musculoskeletal pain, adherence level, and sub-scales of the Musculoskeletal Pain Intensity and Interference Questionnaire for Musicians. RESULTS: A total of 57 musician-students (ages 17-30, 23 females) participated in the study, and 48(84%) completed the study. Seventy-five percent of workshop participants reported adherence over 8 weeks. At baseline, 84% of participants reported a history of playing-related pain, and 47% recent or current pain. Participants played a range of instruments (50% string, 34% piano, 16% woodwind/brass). At baseline, average weekly reported playing time was 39 hours (±11). At follow-up, reported pain decreased by 32% in the intervention group and increased by 8% in controls (P < .01). Pain interference scores were lower (Post - Pre = -4.58, 95% CI -9.26 to 0.11, P = .055). There was no statistically significant difference between groups for pain intensity. CONCLUSIONS: The high compliance and willingness to participate suggests that injury prevention education implementation is feasible. Our preliminary findings suggest a positive effect on pain incidence and pain interference in the intervention group. Future studies will examine the relationship between adherence levels and injury rates in a larger cohort and identify obstacles to implementation.

Post-Procedure Protocols Following Platelet-Rich Plasma Injections for Tendinopathy: A Systematic Review.

OBJECTIVE: Platelet-rich plasma (PRP) has been increasingly studied as a treatment for tendinopathy. Many factors may influence outcomes after PRP, including different protocols following administration. It was hypothesized that there would be heterogeneity in post-PRP protocols. LITERATURE SURVEY: A systematized review of the literature on post-PRP protocols for tendinopathy was conducted using an electronic search of MEDLINE and Embase databases through September 2018. METHODOLOGY: After duplicates were removed, English language articles involving adult patients who received PRP for tendinopathy were reviewed. Exclusion criteria included studies with fewer than 10 patients, PRP used to treat pathology other than tendinopathy, multiple protocols in one study, and surgical settings. Protocol specifics were extracted including nonsteroidal anti-inflammatory drugs (NSAID) restrictions before and after injection, postinjection restrictions on movement and weight bearing, use of orthoses, activity modifications, and postinjection rehabilitation protocols. Given limitations in the data, a meta-analysis was not performed. SYNTHESIS: Eighty-four studies met inclusion criteria. Following PRP injection, weight-bearing restrictions were mentioned rarely (12% of protocols). Orthosis use was uncommon overall (18%) but more common in Achilles tendinopathy protocols (53%). The majority of protocols instituted a period of stretching (51%) and strengthening (54%). Stretching programs generally began 2-7 days following injection, and strengthening programs began within 2-3 weeks. Preinjection NSAID restriction was reported rarely (20%), whereas postinjection NSAID restriction was more common (56%), with a typical restriction of greater than 2 weeks (38%). Return to play or full activity was reported in 42% of protocols, most commonly at 4-6 weeks following injection. CONCLUSION: Although the clinical effectiveness of PRP remains controversial, even less is known about the effect of post-PRP protocols, which may affect the outcomes attributed to PRP itself. No studies directly compare post-PRP protocols, and the protocols studied demonstrate substantial heterogeneity. Some consensus regarding post-PRP protocols exists, although the rationale for these recommendations is limited.

The Effectiveness of Autologous Platelet-Rich Plasma for Osteoarthritis of the Hip: A Retrospective Analysis.

BACKGROUND: Platelet-rich plasma (PRP) is a minimally invasive treatment option to reduce pain and promote tissue healing. At the time this study was performed, there was limited published literature analyzing outcomes for patients treated with PRP for hip osteoarthritis. METHODS: Thirty-six patients aged 49-85 (66.0 ± 12.1) years with chronic hip pain who met inclusion criteria underwent image-guided intra-articular hip PRP injection. Outcomes were measured at baseline, two weeks, three months, and up to six months using the visual analog scale (VAS) for pain and the Hip Disability and Osteoarthritis Outcome Score (HOOS). The proportion of responders, as defined by a ≥50% reduction in VAS pain score, was assessed at three and six months. RESULTS: At two weeks, there was a significant improvement (P < 0.05) of function in two HOOS subscales: Symptoms and Activities of Daily Living. There was a significant improvement in all HOOS categories at six months. A significant improvement in VAS was observed at six months (baseline VAS = 6.9 ± 0.7 &→ 4.3 ± 1.8, 95% confidence interval = 2.0 to 3.2, P < 0.05). Sixty-seven percent (24/36) of the patients reported a ≥50% improvement in pain at three months; 58% (21/36) reported a ≥50% improvement in pain at six months. Stratification by Kellgren-Lawrence grades revealed that 86% and 82% of the KL grades 1 and 2 were responders at six months, respectively. CONCLUSIONS: In patients with mild/moderate hip osteoarthritis, PRP may provide pain relief and functional improvement for up to six months.

Platelet-Rich Plasma Use in Musculoskeletal Disorders: Are the Factors Important in Standardization Well Understood?

Platelet-rich plasma (PRP) is a novel therapeutic treatment option for joint and tendon disease, but preparation methods are varied. This article summarizes research on uses of PRP, compares classification systems to standardize various PRP compositions, and discusses the most common methodologies to produce PRP. Even with advances in understanding PRP, there are unknowns about the factors and processes that may have an impact on treatment efficacy for musculoskeletal conditions. PRP studies should pursue determining optimal PRP preparation, setting a standard to evaluate PRP mixtures and preparation methods, assessing efficacy of PRP for various musculoskeletal conditions, and managing and reducing costs.

Ultrasound measures of muscle thickness may be superior to strength testing in adults with knee osteoarthritis: a cross-sectional study.

BACKGROUND: Evaluation of muscle strength as performed routinely with a dynamometer may be limited by important factors such as pain during muscle contraction. Few studies have compared formal strength testing with ultrasound to measure muscle bulk in adults with knee osteoarthritis (OA). METHODS: We investigated the muscle bulk of lower limb muscles in adults with knee OA using quantitative ultrasound. We analyzed the relationship between patient reported function and the muscle bulk of hip adductors, hip abductors, knee extensors and ankle plantarflexors. We further correlated muscle bulk measures with joint torques calculated with a hand held dynamometer. We hypothesized that ultrasound muscle bulk would have high levels of interrater reliability and correlate more strongly with pain and function than strength measured by a dynamometer. 23 subjects with unilateral symptomatic knee OA completed baseline questionnaires including the Western Ontario and McMaster Universities Arthritis Index (WOMAC) and Lower Extremity Activity Scale. Joint torque was measured with a dynamometer and muscle bulk was assessed with ultrasound. RESULTS: Higher ultrasound measured muscle bulk was correlated with less pain in all muscle groups. When comparing muscle bulk and torque measures, ultrasound-measured muscle bulk of the quadriceps was more strongly correlated with measures of pain and function than quadriceps isometric strength measured with a dynamometer. CONCLUSIONS: Ultrasound is a feasible method to assess muscle bulk of lower limb muscles in adults with knee OA, with high levels of interrater reliability, and correlates negatively with patient reported function. Compared with use of a hand held dynamometer to measure muscle function, ultrasound may be a superior modality.

Trajectories of Quality of Life and Associated Risk Factors in Patients With Knee Osteoarthritis: Findings From the Osteoarthritis Initiative.

OBJECTIVE: Knee osteoarthritis (OA) has a significant impact on quality of life (QOL). Although QOL is generally thought to diminish over time, it is unknown whether different patient groups demonstrate unique patterns of change in QOL. We sought to identify and characterize QOL trajectories in knee OA. DESIGN: This prospective cohort study included 1013 individuals with symptomatic knee OA from the osteoarthritis initiative. We used group-based trajectory modeling to identify distinct temporal patterns of change in the Knee Injury and Osteoarthritis Outcome Score QOL subscale for 8 yrs. Baseline covariates included age, sex, ethnicity, education, co-morbidities, body mass index, substance use, depression, knee pain, and functional tests. RESULTS: Group-based trajectory modeling revealed the following three distinct QOL trajectories: a high QOL trajectory (32% of the cohort) experiencing improvement for 8 yrs as well as moderate (49%) and low QOL (20%) trajectories maintaining similar levels over time. Low QOL trajectory membership was significantly associated with younger age (P < 0.001), nonwhite race (P < 0.001), less education (P < 0.001), more co-morbidities (P < 0.001), higher body mass index (P < 0.001), and more depressive symptoms (P < 0.001). Higher QOL trajectory members were less likely to undergo knee replacement surgery (P < 0.001). CONCLUSIONS: Distinct QOL trajectories exist in knee OA and are associated with modifiable factors, with a subset of patients showing potential to improve their QOL over time.

The Use of Dehydrated Human Amnion/Chorion Membrane Allograft Injection for the Treatment of Tendinopathy or Arthritis: A Case Series Involving 40 Patients.

BACKGROUND: Degenerative joint and tendon injuries remain difficult to treat, with few effective conservative treatment options available. Regenerative approaches aim to promote the inherent healing capacity of injured tissues. Micronized dehydrated human amnion/chorion membrane (dHACM) injection is an emerging regenerative option with promising preclinical results. OBJECTIVE: To test the clinical effectiveness of dHACM injection in patients with chronic tendinopathy and arthropathy. DESIGN: Case series. SETTING: Academic medical center outpatient sports medicine clinic. PATIENTS: A total of 40 patients with chronic tendinosis or arthropathy who received dHACM over a period of 9 months. METHODS: A structured interview was administered to patients by telephone to supplement the clinical information available in the medical chart. All patients received an ultrasound-guided injection of dHACM. MAIN OUTCOME MEASURES: The primary outcome was change in pain level, and the secondary outcome was change in activities of daily living (ADLs) and sports/recreation function. More than 30% improvement in average pain and function was considered a successful outcome. RESULTS: Patient pain and function were measured at 1, 2, and 3 months after the procedure. Patient-reported average pain scores decreased from a baseline value of 6.4 (95% confidence interval [CI] = 5.7-7.0) to 2.7 (95% CI = 2.1-3.3; P < .001) at 1 month, 1.7 (95% CI = 1.1-2.2; P < .001) at 2 months, and 1.4 (95% CI = 0.9-1.9; P < .001) at 3 months. The percentage of patients achieving clinical success, defined as 30% or greater improvement in pain levels, was 68% at 1 month, 82% at 2 months, and 91% at 3 months. Patient-reported functional impairment in ADLs decreased from 6.8 (95% CI = 6.0-7.5) to 2.0 (95% CI = 1.4-2.7) (P < .001); impairment in sports/recreation decreased from 8.5 (95% CI = 7.9-9.1) to 3.2 (95% CI = 2.6-3.9) (P < .001). Frequency of pain medication use decreased from 29 of 40 patients (72.5%) before the procedure to 9 of 40 patients (22.5%) at final follow up (P < .001). Localized pain at the injection site was common, but no other adverse events or side effects were reported. CONCLUSION: In the setting of tendinosis or arthropathy, dHACM injection was clinically effective in reducing pain and improving function in a majority of adults. LEVEL OF EVIDENCE: IV.

Lumbar Muscle Cross-Sectional Areas Do Not Predict Clinical Outcomes in Adults With Spinal Stenosis: A Longitudinal Study.

BACKGROUND: Minimal longitudinal data exist regarding the role of lumbar musculature in predicting back pain and function. In cross-sectional study designs, there is often atrophy of the segmental multifidus muscle in subjects with low back pain compared with matched controls. However, the cross-sectional design of these studies prevents drawing conclusions regarding whether lumbar muscle characteristics predict or modify future back pain or function. OBJECTIVE: The primary objective of this study is to determine whether the cross-sectional area (CSA) of lumbar muscles predict functional status or back pain at 6- or 12-month follow-up in older adults with spinal degeneration. The secondary objective is to evaluate whether these muscle characteristics improve outcome prediction above and beyond the prognostic information conferred by demographic and psychosocial variables. DESIGN: Secondary analysis of a randomized controlled trial. PARTICIPANTS: A total of 209 adults aged 50 years and older with clinical and radiographic spinal stenosis from the Lumbar Epidural steroid injection for Spinal Stenosis (LESS) trial. METHODS: Using baseline magnetic resonance images, we calculated CSAs of the lumbar multifidus, psoas, and quadratus lumborum muscles using a standardized protocol by manually tracing the borders of each of the muscles. The relationship between lumbar muscle CSAs and baseline measures was assessed with Pearson or Spearman correlation coefficients. The relationship between lumbar muscle characteristics and 6- and 12-month Roland Morris Disability Questionnaire (RDQ) and back pain Numeric Rating Scale (NRS) responses was further evaluated with multivariate linear regression. A hierarchical approach to the regression was performed: a basic model with factors of conceptual importance including age, gender, BMI, and baseline RDQ score formed the first step. The second and third steps evaluated whether psychosocial variables or muscle measures conferred additional prognostic information to the basic model. MAIN OUTCOME MEASURES: Function as measured by the RDQ and back pain as measured by the NRS at 6- and 12-month follow-up. RESULTS: Lumbar muscle CSA was not a significant predictor of 6- or 12-month RDQ or pain score in multivariate analyses. CONCLUSIONS: Cross-sectional areas of lumbar muscles do not predict function or pain at medium- and long-term follow-up in adults with lumbar spinal stenosis. LEVEL OF EVIDENCE: III.

Subsequent health-care utilization associated with early physical therapy for new episodes of low back pain in older adults.

BACKGROUND: The association between early physical therapy (PT) and subsequent health-care utilization following a new visit for low back pain is not clear, particularly in the setting of acute low back pain. PURPOSE: This study aimed to estimate the association between initiating early PT following a new visit for an episode of low back pain and subsequent back pain-specific health-care utilization in older adults. DESIGN/SETTING: This is a prospective cohort study. Data were collected at three integrated health-care systems in the United States through the Back Pain Outcomes using Longitudinal Data (BOLD) registry. PATIENT SAMPLE: We recruited 4,723 adults, aged 65 and older, presenting to a primary care setting with a new episode of low back pain. OUTCOME MEASURES: Primary outcome was total back pain-specific relative value units (RVUs), from days 29 to 365. Secondary outcomes included overall RVUs for all health care and use of specific health-care services including imaging (x-ray and magnetic resonance imaging [MRI] or computed tomography [CT]), emergency department visits, physician visits, PT, spinal injections, spinal surgeries, and opioid use. METHODS: We compared patients who had early PT (initiated within 28 days of the index visit) with those not initiating early PT using appropriate, generalized linear models to adjust for potential confounding variables. RESULTS: Adjusted analysis found no statistically significant difference in total spine RVUs between the two groups (ratio of means 1.19, 95% CI of 0.72-1.96, p=.49). For secondary outcomes, only the difference between total spine imaging RVUs and total PT RVUs was statistically significant. The early PT group had greater PT RVUs; the ratio of means was 2.56 (95% CI of 2.17-3.03, p<.001). The early PT group had greater imaging RVUs; the ratio of means was 1.37 (95% CI of 1.09-1.71, p=.01.) CONCLUSIONS: We found that in a group of older adults presenting for a new episode of low back pain, the use of early PT is not associated with any statistically significant difference in subsequent back pain-specific health-care utilization compared with patients not receiving early PT.

Soleus Muscle Herniation With Magnetic Resonance Imaging and Ultrasound Correlation in a Female Long-Distance Runner: A Case Report.

This is a case of a 40-year-old female endurance athlete with right leg pain while running. A comprehensive workup revealed a fascial defect with soleus muscle herniation. Although historically in many practice settings magnetic resonance imaging is the diagnostic imaging modality of choice for suspected muscle herniation through the fascia, the use of ultrasound is increasing because of lower cost, ease of access, and dynamic evaluation. To the authors' knowledge, there has not been a direct comparison between the accuracy of magnetic resonance imaging versus ultrasound in determining the size or location of a soleus muscle herniation. LEVEL OF EVIDENCE: Not applicable.

The Healing Cascade: Facilitating and Optimizing the System.

Healing is a complex process of orchestrated reactions and interactions with the goal of restoring structure and physical properties to damaged tissues. The musculoskeletal system is composed of different types of connective tissues. When healthy, each has a unique structure, function, and remodeling process. When damaged, they demonstrate unique healing processes. However, similarities in the process exist. Understanding these properties of healing is critical in the development and application of regenerative therapeutics. This article describes the common phases of healing, differences between healing in musculoskeletal tissues, factors that affect healing, and strategies to facilitate and optimize healing.

Timing of Physical Therapy Initiation for Nonsurgical Management of Musculoskeletal Disorders and Effects on Patient Outcomes: A Systematic Review.

STUDY DESIGN: Systematic review. BACKGROUND: Current US practice guidelines suggest an initial "wait-and-see" approach following onset of musculoskeletal pain, particularly for spinal pain. Several studies suggest that early, compared with delayed, initiation of physical therapy for musculoskeletal conditions may decrease health costs and improve outcomes. OBJECTIVE: To compare early and delayed initiation of physical therapy for individuals with musculoskeletal conditions and to assess effects on patient-important outcomes and cost. METHODS: MEDLINE (Ovid), CINAHL (EBSCO), Web of Science, and PEDro were the data sources. We included studies that compared early and delayed initiation of physical therapy for patients with musculoskeletal disorders. Studies in which early and delayed interventions differed were excluded. Two independent reviewers extracted study characteristics and outcomes, and determined eligibility and quality through consensus with a third reviewer. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used in summary conclusions. Standardized effect sizes (d) and odds ratios were calculated to assess the effect strength of early versus delayed physical therapy for each included study. RESULTS: Of the 3855 articles initially screened, 14 studies were included. The majority of articles studied low back pain (only 2 articles studied cervical pain). For spinal pain, there was low-quality evidence that early versus delayed physical therapy was associated with decreased cost and decreased frequency of opioid prescriptions, advanced imaging, and surgeries without compromising patient-important outcomes. One subgroup analyzed showed improved function/disability with early physical therapy in an occupational health setting. CONCLUSION: Although there were consistent results across studies favoring early physical therapy for decreased cost and medical utilization, quality was limited. Preliminary evidence suggests that early physical therapy may decrease cost without compromising outcomes. The primary limitation of the current research on this topic is in study design. Additional high-quality research involving prospective randomized designs and economic impact analyses is required to further investigate the outcomes associated with early initiation of physical therapy. LEVEL OF EVIDENCE: Therapy, level 1a.

Intense focused ultrasound stimulation of the rotator cuff: evaluation of the source of pain in rotator cuff tears and tendinopathy.

The objective of this preliminary study was to evaluate the ability of individual 0.1-s long pulses of intense focused ultrasound (iFU) emitted with a carrier frequency of 2 MHz to evoke diagnostic sensations when applied to patients whose shoulders have rotator cuff tears or tendinopathy. Patients were adults with painful shoulders and clinical and imaging findings consistent with rotator cuff disease. iFU stimulation of the shoulder was performed using B-mode ultrasound coupled with a focused ultrasound transducer that allowed image-guided delivery of precisely localized pulses of energy to different anatomic areas around the rotator cuff. The main outcome measure was iFU spatial average-temporal average intensity (I_SATA), and location required to elicit sensation. In control patients, iFU produced no sensation throughout the range of stimulation intensities (≤2000 W/cm(2) I_SATA). In patients with rotator cuff disease, iFU was able to induce sensation in the tendons of the rotator cuff, the subacromial bursa, and the subchondral bone in patients with chronic shoulder pain and rotator cuff disease, with an average ± standard deviation intensity equaling 680 ± 281 W/cm(2) I_SATA. This result suggests a primary role for these tissues in the pathogenesis of shoulder pain related to rotator cuff tendinopathy.

Do Muscle Characteristics on Lumbar Spine Magnetic Resonance Imaging or Computed Tomography Predict Future Low Back Pain, Physical Function, or Performance? A Systematic Review.

OBJECTIVE: To determine whether lumbar muscle characteristics on magnetic resonance imaging (MRI) or computed tomography (CT) can inform clinicians as to the course of future low back pain (LBP), functional limitations, or physical performance, in adults with or without LBP. TYPE: Systematic review. LITERATURE REVIEW: We searched PubMed, Embase, and CINAHL through October 2014 for articles published in English in which authors assessed lumbar muscle characteristics on conventional MRI/CT as predictors of future LBP, functional limitations, or physical performance in adults. Studies with only postsurgical subjects were excluded. Our search identified 3554 articles, of which 6 observational cohort studies were included in the final review. METHODOLOGY: We used the Newcastle Ottawa Scale to evaluate potential bias. Data were extracted on study design, study population, sample size, participant characteristics, details of MRI/CT assessments, interventions, study outcomes, analysis methods, and study results. Because of heterogeneity between studies, we conducted a qualitative evidence synthesis. SYNTHESIS: Among high-quality studies, there was limited evidence that, for individuals with or without LBP, greater MRI-detected multifidus cross-sectional area at L5-S1 predicted greater LBP intensity at 1-year follow-up, lesser erector spinae fat infiltration (FI) at L5-S1 predicted greater LBP intensity at 15-year follow-up, and greater erector spinae side-to-side FI asymmetry at L3-L4 predicted lower LBP frequency at 15-year follow-up; however, there was also limited evidence that all other MRI-detected paraspinal muscle characteristics examined were not predictive of LBP incidence, prevalence, frequency, or intensity at follow-up durations ranging from 1 to 15 years. There was limited evidence that greater CT-detected trunk muscle FI predicted worse physical performance in older adults at 3-year follow-up, but that trunk muscle cross-sectional area did not. CONCLUSION: Few lumbar muscle characteristics have limited evidence for an association with future LBP and physical performance outcomes, and the vast majority have limited evidence for having no association with such outcomes.

Clinical outcomes of early and later physical therapist services for older adults with back pain.

BACKGROUND CONTEXT: The timing of physical therapy (PT) services and its association with later function and pain are not clear, especially in older adults. PURPOSE: The purpose of this study was to compare clinical outcomes of patients receiving early or later PT services with those not receiving PT among older adults presenting to primary care for a new visit for back pain. STUDY DESIGN/SETTING: Prospective cohort study using the Back Pain Outcomes Using Longitudinal Data registry. PATIENT SAMPLE: A total of 3,705 adults 65 years and older with a new visit for back pain were included. OUTCOME MEASURES: The outcome measures were Roland-Morris Disability Questionnaire (RMDQ), Pain Numerical Rating Scales, and EuroQol-5D. METHODS: We studied two phases of PT utilization: early (0-28 days) and later (3-6 months). At baseline, we selected the participants with complete 12 months of patient-reported outcomes and electronic medical record data. Early PT was defined as initiating PT less than or equal to 28 days from the index visit for back pain. The no early PT group consisted of patients with no PT, no injections, no surgery, and no chiropractic within 28 days. We restricted the later phase analysis to patients with pain greater than 2 of 10 and an RMDQ score greater than 4 to create a subsample of patients with continuing clinically important back pain. We defined later PT as initiating PT between 3 and 6 months after the index visit. The no later PT group consisted of patients without any PT during this time. We used propensity score matching followed by multiple linear regression to estimate the mean difference in outcome. Sensitivity analysis examined clinically important change and dose of PT use among the early PT group. RESULTS: The early PT group had better functional status with an adjusted mean RMDQ of 1.1 points less than the no early PT group (95% confidence interval: -2.2, -0.1) and less back pain of -0.5 (-0.9, -0.1) at 12 months. There was no difference between early PT groups at 3 and 6 months. The odds of a 30% improvement in function or pain were not different between these matched groups at 12 months, but the early PT group had increased odds of a 50% improvement in function at 12 months (odds ratio: 1.58, 95% confidence interval: 1.04, 2.40). There was no difference between later groups at 12 months. Greater dose of PT use within the early PT group was associated with better functional status (p= .01). CONCLUSIONS: We found that among older adults presenting to their primary care providers for a new episode of back pain, early referral to PT resulted in no or minimal differences in pain, function, or health-related quality at 3, 6, or 12 months compared with a matched group that did not receive early PT. Secondary analysis show that patients initiating early PT may be somewhat more likely to experience 50% improvement in function at 12 months.

Inter-rater, intra-rater, and inter-machine reliability of quantitative ultrasound measurements of the patellar tendon.

The use of ultrasound (US) to perform quantitative measurements of musculoskeletal tissues requires accurate and reliable measurements between investigators and ultrasound machines. The objective of this study was to evaluate inter-rater and intra-rater reliability of patellar tendon measurements between providers with different levels of US experience and inter-machine reliability of US machines. Sixteen subjects without a history of knee pain were evaluated with US examinations of the patellar tendon. Each tendon was scanned independently by two investigators using two different ultrasound machines. Tendon length and cross-sectional area (CSA) were obtained, and examiners were blinded to each other's results. Tendon length was measured using a validated system involving surface markers and calipers, and CSA was measured using each machine's measuring software. Intra-class correlation coefficients (ICCs) were used to determine reliability of measurements between observers, where ICC > 0.75 was considered good and ICC > 0.9 was considered excellent. Inter-rater reliability between sonographers was excellent and revealed an ICC of 0.90 to 0.92 for patellar tendon CSA and an ICC of 0.96 for tendon length. ICC for intra-rater reliability of tendon CSA was also generally excellent, with ICC between 0.87 and 0.96. Inter-machine reliability was excellent, with ICC of 0.91-0.98 for tendon CSA and 0.96-0.98 for tendon length. Bland-Altman plots were constructed to measure validity and demonstrated a mean difference between sonographers of 0.03 mm(2) for CSA measurements and 0.2 mm for tendon length. Using well-defined scanning protocols, a novice and an experienced musculoskeletal sonographer attained high levels of inter-rater agreement, with similarly excellent results for intra-rater and inter-machine reliability. To our knowledge, this study is the first to report inter-machine reliability in the setting of quantitative musculoskeletal ultrasound.

Osteoarthritis of the spine: the facet joints.

Osteoarthritis (OA) of the spine involves the facet joints, which are located in the posterior aspect of the vertebral column and, in humans, are the only true synovial joints between adjacent spinal levels. Facet joint osteoarthritis (FJ OA) is widely prevalent in older adults, and is thought to be a common cause of back and neck pain. The prevalence of facet-mediated pain in clinical populations increases with increasing age, suggesting that FJ OA might have a particularly important role in older adults with spinal pain. Nevertheless, to date FJ OA has received far less study than other important OA phenotypes such as knee OA, and other features of spine pathoanatomy such as degenerative disc disease. This Review presents the current state of knowledge of FJ OA, including relevant anatomy, biomechanics, epidemiology, and clinical manifestations. We present the view that the modern concept of FJ OA is consonant with the concept of OA as a failure of the whole joint, and not simply of facet joint cartilage.