Lack of standardization in dry needling dosage and adverse event documentation limits outcome and safety reports: a scoping review of randomized clinical trials.

OBJECTIVES: Examine: (1) whether variability in dry needling (DN) dosage affects pain outcomes, (2) if effect sizes are clinically important, and (3) how adverse events (AE) were documented and whether DN safety was determined. METHODS: Nine databases were searched for randomized controlled trials (RCTs) investigating DN in symptomatic musculoskeletal disorders. Methodological quality was assessed using the Physiotherapy Evidence Database (PEDro) scale. Included RCTs met PEDro criteria #1 and scored > 7/10. Data extraction included DN dosage, pain outcome measures, dichotomous AE reporting (yes/no), and AE categorization. Clinically meaningful differences were determined using the minimum clinically important difference (MCID) for pain outcomes . RESULTS: Out of 22 identified RCTs, 11 demonstrated significant between-group differences exceeding the MCID, suggesting a clinically meaningful change in pain outcomes. Nine documented whether AE occurred. Only five provided AEs details and four cited a standard means to report AE. DISCUSSION: There was inconsistency in reporting DN dosing parameters and AE. We could not determine if DN dosing affects outcomes, whether DN consistently produces clinically meaningful changes, or establish optimal dosage. Without more detailed reporting, replication of methods in future investigations is severely limited. A standardized method is lacking to report, classify, and provide context to AE from DN. Without more detailed AE reporting in clinical trials investigating DN efficacy, a more thorough appraisal of relative risk, severity, and frequency was not possible. Based on these inconsistencies, adopting a standardized checklist for reporting DN dosage and AE may improve internal and external validity and the generalizability of results.

The clinical impact of pain neuroscience continuing education on physical therapy outcomes for patients with low back and neck pain.

OBJECTIVES: Research suggests that attendance by physical therapists at continuing education (CE) targeting the management of low back pain (LBP) and neck pain does not result in positive impacts on clinical outcomes. The aim of this study was to determine if therapists attending a self-paced 3-hour online Pain Neuroscience Education (PNE) program was associated with any observed changes to patient outcomes and also clinical practice. METHODS: Participants were 25 different physical therapists who treated 3,705 patients with low back pain (LBP) or neck pain before and after they had completed an online PNE CE course. Change in outcomes measures of pain and disability at discharge were compared for the patients treated before and after the therapist training. Clinical practice patterns of the therapists, including total treatment visits, duration of care, total units billed, average units billed per visit, percentage of 'active' billing units and percentage of 'active and manual' billing units, were also compared for the patient care episodes before and after the therapist training. RESULTS: There was no significant difference for change in pain scores at discharge for patients treated after therapist CE training compared to those treated before regardless of the condition (LBP or neck pain). However, patients with LBP who were treated after therapist CE training did report greater improvement in their disability scores. Also after CE training, for each episode of care, therapists tended to use less total visits, billed fewer units per visit, and billed a greater percentage of more 'active' and 'active and manual' billing units. DISCUSSION: Attending an online 3-hour CE course on PNE resulted in improved disability scores for patients with LBP, but not for those with neck pain. Changes in clinical behavior by the therapists included using less visits, billing fewer total units, and shifting to more active and manual therapy interventions. Further prospective studies with control groups should investigate the effect of therapist CE on patient outcomes and clinical practice.

A comparison of treatment signatures of high and low performing physical therapists for patients with lower back pain: analysis of spine care from a physical therapy outcomes registry.

INTRODUCTION: Lower back pain (LBP) is the most common orthopedic complaint in the United States. Physical therapy is recommended as a conservative, non-pharmacological intervention for LBP. While it is thought that skill level and effectiveness of physical therapists differ, there is little understanding regarding characteristics that distinguish high and low performing physical therapists. The purpose of this study was to compare differences in care delivery, termed treatment signatures, between high and low performing physical therapists previously differentiated by a risk-adjusted performance measure. METHODS: Using previously published methodology, 1,240 physical therapists were classified as "outperforming", "meeting expectations", or "underperforming" relative to predicted change in Modified Low Back Pain Disability Questionnaire (MDQ) across patients receiving care for LBP. Patients were divided into quartiles of baseline disability per initial MDQ. Two-way analyses of variance were used to compare billed (1) active, exercise-based units per visit (UPV), (2) manual therapy UPV, (3) modality UPV, and (4) the combination of active and manual therapy UPV (broadly termed skilled UPV) by performance cohort and baseline patient disability quartile among physical therapists deemed "outperforming" and "underperforming". Tukey's post hoc tests established mean differences with 95% confidence intervals. RESULTS: Physical therapists that "outperformed" (n=120; 17,404 patients) used more active UPV (mean difference (diff) = 0.1, p<.001), manual therapy UPV (mean diff = 0.2, p<.001), and skilled UPV (mean diff = 0.3, p<.001), and less modality UPV (mean diff = 0.1, P < 0.001) than those that "underperformed" (n=139; 21,800 patients). Tukey's post hoc tests showed that while differences in care were negligible in patients with low baseline disability, the highest performing PT cohort delivered skilled (0.4 UPV), active (0.2 UPV), and manual therapy (0.2 UPV) UPV at a significantly higher mean rate in patients with the highest baseline disability. CONCLUSIONS: Clinically effective physical therapists incorporated a treatment signature that included a consistent blend of skilled active and manual therapy interventions that was distinct from lower performing physical therapists. While group mean differences were relatively small, a consistent pattern emerged in which high performing physical therapists maintained a high level of skilled, one-on-one interventions across their entire caseload-while their lower performing counterparts significantly decreased use of the same interventions as baseline disability increased. These differences highlighted a treatment signature that was associated with clinically important improvements for patients with greater baseline disability. Future guideline recommendations should consider the importance of baseline disability and the consistent application of skilled active and manual therapy interventions.

Preoperative screening in patients having elective shoulder surgery reveals a high rate of fall risk.

INTRODUCTION: Fall risk is an acknowledged but relatively understudied concern for older patients undergoing shoulder surgery. The cause is multifactorial, and it includes advanced age, impaired upper extremity function, use of shoulder abduction braces, and postoperative use of opioid medications. No previous study has examined preoperative fall risk in patients undergoing elective shoulder surgery. Previous literature looking at fall risk in elective orthopedic procedures has predominantly focused on falls occurring in the hospital setting, although falls have also been shown to occur in the outpatient setting. Gait speed and Timed Up and Go (TUG) are well-researched functional measures in the aging population with established cutoff scores indicating increased fall risk. The purpose of this study was to quantify gait speed and TUG scores in a series of patients who were scheduled to undergo either rotator cuff repair (RCR) or total shoulder arthroplasty (TSA) in order to assess overall risk of fall in these populations. METHODS: A total of 198 patients scheduled for TSA or RCR surgery were evaluated preoperatively from multiple outpatient physical therapy clinics within Greenville, South Carolina. The TUG score (>14 seconds considered high fall risk) and 10 Meter Walk test (<0.7 m/s considered high risk for falls) were recorded for each patient. Patient-reported outcomes were also collected, including Veteran's Rand 12 Physical Component and Mental Component Scores, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form score, and the Single Assessment Numeric Evaluation. RESULTS: Patients undergoing TSA (n = 80; 65.4 ± 11.4 years) were older than those undergoing RCR (n = 118; 59.0 ± 14.2 years). Fifty-nine percent of all patients were classified as being a high risk for falls based on gait speed <0.7 m/s. Patients in the TSA group were more likely to display preoperative fall risk compared to patients in the RCR group (62% vs. 38%; χ2 = 8.9, P = .03). There were no significant differences in ambulatory status, Veteran's Rand 12 Physical Component and Mental Component Scores, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, or Single Assessment Numeric Evaluation scores between groups (P = .11). DISCUSSION: Both patient groups demonstrated a high rate of fall risk in preoperative evaluation. Patients undergoing TSA more often displayed fall risk compared with patients undergoing RCR. Although patients in the TSA group were older, there was no association between age or ambulatory status and fall risk. CONCLUSION: Our results suggest that fall risk screening may be important for patients undergoing TSA and RCR surgeries. The higher fall risk in the TSA group may be an important consideration as this procedure shifts toward outpatient status.

Providing value-based care as a physiotherapist.

BACKGROUND: Despite millions spent in research funding, studies, and guidelines, outcomes involving musculoskeletal care continue to decline. The purpose of this Viewpoint is to describe value-based care and to suggest measures for its adoption by physiotherapists who manage individuals with musculoskeletal related pain disorders. DISCUSSION: The provision of value-based care is best defined as care that includes: 1) patient centeredness, 2) guideline-oriented, integrated strategies, 3) measurement of patient outcomes and experiences, and 4) cost effectiveness. Physiotherapists are well positioned to be leaders in the application of value-based care by assuring they address each of the four strategies during the daily patient encounter. This Viewpoint discusses strategies for application to clinical practice. CONCLUSION: By implementing value-based care principals, physiotherapists could assure that patients with musculoskeletal related pain disorders receive the right care at the right time, by the right provider.

Short-term Response to Treatment Targeting the Thoracolumbar Junction in Patients With Hip Pain: A Case Series.

BACKGROUND: In patients presenting with hip and groin symptoms, evaluation and treatment of the thoracolumbar junction (TLJ) may be underutilized. The TLJ is less recognized as a source of pain referral in these regions. The purpose of this case series was to describe the management of 3 patients with primary hip and groin pain who were treated with interventions targeting the TLJ. DIAGNOSIS: The 3 patients in this case series presented with subacute or chronic complaints of hip and groin pain that had failed to resolve with typical treatments. They had undergone several inconclusive clinical testing procedures. Each patient underwent a detailed physical therapy evaluation and was found to have pain and mobility deficits at the TLJ. Once the therapist had determined that the patients' symptoms were likely of musculoskeletal origin, treatment commenced. Joint mobilization and exercise directed at the TLJ were used in each case. Marked improvements in pain, thoracic range of motion, and functional deficits were observed within 3 to 4 weeks, after an average of 6 treatment sessions. All patients returned to prior activity levels. Patients in cases 1 and 3 had improvements in hip mobility and strength without direct treatment to the hip. DISCUSSION: This case series describes the management of 3 patients with hip and groin symptoms who were successfully treated with interventions targeting the TLJ. In patients reporting primary hip or groin pain, physical therapists should consider the TLJ as a potential source of symptoms and include treatment strategies directed at the TLJ, as warranted, after a careful examination and clinical-reasoning process. LEVEL OF EVIDENCE: Differential diagnosis, level 4. J Orthop Sports Phys Ther 2019;49(8):611-619. doi:10.2519/jospt.2019.8309.

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.

Physical Therapy Management of Patients With Chronic Low Back Pain and Hip Abductor Weakness.

BACKGROUND AND PURPOSE: Hip abductor dysfunction is common in individuals with chronic low back pain (CLBP). Previous research investigating abductor strengthening in the heterogeneous CLBP population is sparse and has failed to target those patients most likely to benefit. The aim of the current case series was to describe the physical therapy management and outcomes of 3 patients with CLBP matching a previously identified subgroup characterized by substantial hip abductor weakness. CASE DESCRIPTION: Three nonconsecutive patients with CLBP-a 77-year-old man, a 78-year-old woman, and an 85-year-old woman-were treated in an outpatient physical therapy clinic. All 3 patients matched a previously identified CLBP subgroup characterized by substantial hip abductor weakness. INTERVENTION: Patients were treated using a targeted exercise approach consisting mostly of hip abductor strengthening for 11 to 17 visits over 8 to 10 weeks. Patients received additional treatments including heel lift and pain neuroscience education when indicated. OUTCOMES: By discharge, all patients had made clinically important improvements in pain (3- to 7-point reduction on the Numeric Pain Rating Scale), function (10- to 16-point change on the Modified Oswestry Disability Index), and perceived improvement (6-7 on Global Rating of Change Scale). Lumbar range of motion was painless, and hip abductor strength was improved from 2+/5 to 3+/5 in all 3 patients. These gains were maintained at 3-month follow-up. DISCUSSION: The current case series describes the use of a targeted exercise approach consisting mostly of hip abductor strengthening in a group of patients with CLBP and hip abductor weakness. The results indicated that this approach may be effective in reducing pain and improving function, particularly for older patients.

The Influence of Patient Choice of First Provider on Costs and Outcomes: Analysis From a Physical Therapy Patient Registry.

Study Design Retrospective study. Background Alternative models of care that allow patients to choose direct access to physical therapy have shown promise in terms of cost reduction for neck and back pain. However, real-world exploration within the US health care system is notably limited. Objectives To compare total claims paid and patient outcomes for patients with neck and back pain who received physical therapy intervention via direct access versus medical referral. Methods Data were accessed for patients seeking care for neck or back pain (n = 603) between 2012 and 2014, who chose to begin care either through traditional medical referral or direct access to a physical therapy- led spine management program. All patients received a standardized, pragmatic physical therapy approach, with patient-reported measures of pain and disability assessed before and after treatment. Patient demographics and outcomes data were obtained from the medical center patient registry and combined with total claims paid calculated for the year after the index claim. Linear mixed-effects modeling was used to analyze group differences in pain and disability, visits/time, and annualized costs. Results Patients who chose to enter care via the direct-access physical therapy-led spine management program displayed significantly lower total costs (mean difference, $1543; 95% confidence interval: $51, $3028; P = .04) than those who chose traditional medical referral. Patients in both groups showed clinically important improvements in pain and disability, which were similar between groups (P>.05). Conclusion The initial patient choice to begin care with a physical therapist for back or neck pain resulted in lower cost of care over the next year, while resulting in similar improvements in patient outcomes at discharge from physical therapy. These findings add to the emerging literature suggesting that patients' choice to access physical therapy through direct access may be associated with lower health care expenditures for patients with neck and back pain. Level of Evidence Economic and decision analyses, level 4. J Orthop Sports Phys Ther 2018;48(2):63-71. Epub 26 Oct 2017. doi:10.2519/jospt.2018.7423.

Physical Therapist Clinical Reasoning and Action for Individuals With Undiagnosed Lower Extremity Tumors: A Report of 3 Cases.

Study Design Resident's case problem. Background Although rare in the general population, bone and soft tissue tumors may be more frequently encountered in patients seeking physical therapy because of the propensity of their initial symptoms to mimic those of commonly treated musculoskeletal disorders. Screening for tumors requires the physical therapist to be attentive to unexpected findings. The purpose of this paper was to describe the clinical-reasoning and screening processes of physical therapists who facilitated the timely recognition of bone and soft tissue tumors in 3 patients referred through medical channels. Diagnosis The referral diagnoses were lumbar spinal stenosis, calcaneal bursitis, and postexcisional quadriceps weakness. When comprehensively examined, each of the patients had either atypical examination findings or failed to respond to physical therapy treatment. After the physical therapists alerted the appropriate medical providers of the examination findings, diagnoses of high-grade osteosarcoma of the pelvis, chondroma of the knee, and liposarcoma of the thigh followed. Discussion Tumors of the lower extremity can initially mimic common musculoskeletal pathology. Physical therapists must remain alert for red flags, atypical signs and symptoms, and poor responses to treatment, even when patients are referred through medical channels. Particular attention is necessary in the case of unusual symptoms in the lower extremity, where over half of primary malignant tumors occur. Level of Evidence Differential diagnosis, level 5. J Orthop Sports Phys Ther 2017;47(5):359-366. Epub 29 Mar 2017. doi:10.2519/jospt.2017.7037.

Abdominal pain in physical therapy practice: 3 patient cases.

STUDY DESIGN: Resident's case problem. BACKGROUND: Abdominal pain is a common symptom, but not a common diagnosis, of patients referred to physical therapists for examination and intervention. For patients with primary symptoms of abdominal pain, a thorough evaluation must be performed to determine if symptoms are musculoskeletal in nature or of a nonmusculoskeletal origin that would warrant a referral to a different healthcare provider. This report describes the management of 3 adults with primary complaints of abdominal pain who were referred for physical therapy evaluation and treatment. DIAGNOSIS: Two of the patients had secondary symptoms of hip and/or low back pain and had previously undergone extensive medical testing for their chronic abdominal pain, without a definitive diagnosis having been determined. A physical therapy evaluation was conducted, and treatment, including manual physical therapy and exercise, was administered to address all relative impairments, once the physical therapist had determined that the patients' symptoms were of musculoskeletal origin. The third patient included in this series was referred to a physical therapist with a diagnosis of greater trochanteric versus iliopsoas bursitis. However, the patient had abdominal pain that was more acute in nature and a history and physical examination findings that were concerning for abdominal pain of nonmusculoskeletal origin. Both patients with abdominal pain of musculoskeletal origin showed marked improvement in pain and disability after 7 treatment sessions. The third patient was referred to her primary care physician, and ultrasound examination of the abdomen revealed several intrauterine masses that were consistent with uterine fibroids. Following uterine fibroid embolization, the patient was symptom free. DISCUSSION: Although not routinely managed by physical therapists, abdominal pain is a relatively common patient symptom that can have several causes, both musculoskeletal and nonmusculoskeletal. This paper emphasizes the importance of physical therapists having the necessary differential diagnostic skills to determine if patients with primary symptoms of abdominal pain require physician referral or physical therapist intervention.

Low back pain.

The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). The purpose of these low back pain clinical practice guidelines, in particular, is to describe the peer-reviewed literature and make recommendations related to (1) treatment matched to low back pain subgroup responder categories, (2) treatments that have evidence to prevent recurrence of low back pain, and (3) treatments that have evidence to influence the progression from acute to chronic low back pain and disability.