Publications by authors named "Stephen J Hunter"

20 Publications

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Predicting Clinical Improvement for Patients with Low Back Pain: Keeping it Simple for Patients Seeking Physical Therapy Care.

Phys Ther 2021 Jul 28. Epub 2021 Jul 28.

Rehabilitation Services, Intermountain Healthcare, Salt Lake City, Utah.

Objective: Develop and validate an original prediction formula that estimated the probability of success for patients with LBP to achieve a minimal clinical important difference (MCID) on the Modified Low Back Disability Questionnaire (MDQ).

Methods: Patients were 10 to 90 years old in this retrospective cohort study. Data was extracted from Intermountain Healthcare's registry, Rehabilitation Outcomes Management System (ROMS): 62,858 patients admitted to physical therapy from 2002 to 2013 formed the training dataset and 15,128, patients admitted 2015 to 2016 formed the verification dataset. Predicted probability to achieve MCID was compared to actual percentage who succeeded. Two models were developed: 6-point improvement and 30% improvement. MDQ assessed disability, numeric pain score assessed pain intensity. Predictive models used restricted cubic splines on age, initial pain and disability scores for non-linear effects. Sex, symptom duration, and payer type were included as indicator variables. Predicted chance of success was compared to the actual percentage of patients that succeeded. Relative change in R-squared was calculated to assess variable importance in predicting success. Odds ratios for duration of injury and payer were calculated.

Results: A positive trend was observed in both models between predicted and actual success achieved. Both "verification" models appear accurate and closely approximate the "training dataset". Baseline MDQ score was most important factor to predict a 6-point improvement. Payer type and injury duration were important factors to predict 30% improvement. Best odds to achieve an MCID was having a Workers Compensation insurance payer and seeking care within 14 days.

Conclusion: The two models demonstrated an accurate visualization of the chance of patients' achieving significant improvement compared to the usual representation of the average rate of improvement for all patients.

Impact: Enhancing physical therapists' understanding of the probability of a patient achieving significant clinical improvement can enhance decision-making processes and help physical therapists manage a patient's care more effectively.
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July 2021

Stratified care to prevent chronic low back pain in high-risk patients: The TARGET trial. A multi-site pragmatic cluster randomized trial.

EClinicalMedicine 2021 Apr 30;34:100795. Epub 2021 Mar 30.

Department of Family Medicine, Boston Medical Center, 1 Boston Medical Center Place, Dowling 5 South, Boston, MA 02118 USA.

Background: Many patients with acute low back pain (LBP) first seek care from primary care physicians. Evidence is lacking for interventions to prevent transition to chronic LBP in this setting. We aimed to test if implementation of a risk-stratified approach to care would result in lower rates of chronic LBP and improved self-reported disability.

Methods: We conducted a pragmatic, cluster randomized trial using 77 primary care clinics in four health care systems across the United States. Practices were randomly assigned to a stratified approach to care (intervention) or usual care (control). Using the STarTBack screening tool, adults with acute LBP were screened low, medium, and high-risk. Patients screened as high-risk were eligible. The intervention included electronic best practice alerts triggering referrals for psychologically informed physical therapy (PIPT). PIPT education was targeted to community clinics geographically close to intervention primary care clinics. Primary outcomes were transition to chronic LBP and self-reported disability at six months. Trial Registry: NCT02647658.

Findings: Between May 2016 and June 2018, 1207 patients from 38 intervention and 1093 from 37 control practices were followed. In the intervention arm, around 50% of patients were referred for physical therapy (36% for PIPT) compared to 30% in the control. At 6 months, 47% of patients reported transition to chronic LBP in the intervention arm (38 practices,  = 658) versus 51% of patients in the control arm (35 practices,  = 635; OR=0.83 95% CI 0.64, 1.09;  = 0.18). No differences in disability were detected (difference -2·1, 95% CI -4.9-0.6;  = 0.12). Opioids and imaging were prescribed in 22%-25% and 23%-26% of initial visits, for intervention and control, respectively. Twelve-month LBP utilization was similar in the two groups.

Interpretation: There were no differences detected in transition to chronic LBP among patients presenting with acute LBP using a stratified approach to care. Opioid and imaging prescribing rates were non-concordant with clinical guidelines.

Funding: Patient-Centered Outcomes Research Institute (PCORI) contract # PCS-1402-10867.
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April 2021

Risk Factors Associated With Transition From Acute to Chronic Low Back Pain in US Patients Seeking Primary Care.

JAMA Netw Open 2021 02 1;4(2):e2037371. Epub 2021 Feb 1.

Department of Family Medicine, Boston Medical Center, Boston, Massachusetts.

Importance: Acute low back pain (LBP) is highly prevalent, with a presumed favorable prognosis; however, once chronic, LBP becomes a disabling and expensive condition. Acute to chronic LBP transition rates vary widely owing to absence of standardized operational definitions, and it is unknown whether a standardized prognostic tool (ie, Subgroups for Targeted Treatment Back tool [SBT]) can estimate this transition or whether early non-guideline concordant treatment is associated with the transition to chronic LBP.

Objective: To assess the associations between the transition from acute to chronic LBP with SBT risk strata; demographic, clinical, and practice characteristics; and guideline nonconcordant processes of care.

Design, Setting, And Participants: This inception cohort study was conducted alongside a multisite, pragmatic cluster randomized trial. Adult patients with acute LBP stratified by SBT risk were enrolled in 77 primary care practices in 4 regions across the United States between May 2016 and June 2018 and followed up for 6 months, with final follow-up completed by March 2019. Data analysis was conducted from January to March 2020.

Exposures: SBT risk strata and early LBP guideline nonconcordant processes of care (eg, receipt of opioids, imaging, and subspecialty referral).

Main Outcomes And Measures: Transition from acute to chronic LBP at 6 months using the National Institutes of Health Task Force on Research Standards consensus definition of chronic LBP. Patient demographic characteristics, clinical factors, and LBP process of care were obtained via electronic medical records.

Results: Overall, 5233 patients with acute LBP (3029 [58%] women; 4353 [83%] White individuals; mean [SD] age 50.6 [16.9] years; 1788 [34%] low risk; 2152 [41%] medium risk; and 1293 [25%] high risk) were included. Overall transition rate to chronic LBP at six months was 32% (1666 patients). In a multivariable model, SBT risk stratum was positively associated with transition to chronic LBP (eg, high-risk vs low-risk groups: adjusted odds ratio [aOR], 2.45; 95% CI, 2.00-2.98; P < .001). Patient and clinical characteristics associated with transition to chronic LBP included obesity (aOR, 1.52; 95% CI, 1.28-1.80; P < .001); smoking (aOR, 1.56; 95% CI, 1.29-1.89; P < .001); severe and very severe baseline disability (aOR, 1.82; 95% CI, 1.48-2.24; P < .001 and aOR, 2.08; 95% CI, 1.60-2.68; P < .001, respectively) and diagnosed depression/anxiety (aOR, 1.66; 95% CI, 1.28-2.15; P < .001). After controlling for all other variables, patients exposed to 1, 2, or 3 nonconcordant processes of care within the first 21 days were 1.39 (95% CI, 1.21-2.32), 1.88 (95% CI, 1.53-2.32), and 2.16 (95% CI, 1.10-4.25) times more likely to develop chronic LBP compared with those with no exposure (P < .001).

Conclusions And Relevance: In this cohort study, the transition rate to chronic LBP was substantial and increased correspondingly with SBT stratum and early exposure to guideline nonconcordant care.
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February 2021

Overcoming Research Challenges to Improve Clinical Practice Guideline Development.

Phys Ther 2020 10;100(11):1889-1890

A.M. Jette, PT, PhD, FAPTA, is editor in chief of PTJ and is based in Boston, Massachusetts.

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October 2020

Polar amplification of Pliocene climate by elevated trace gas radiative forcing.

Proc Natl Acad Sci U S A 2020 09 4;117(38):23401-23407. Epub 2020 Sep 4.

Bristol Research Initiative for the Dynamic Global Environment, School of Geographical Sciences, University of Bristol, Bristol BS8 1SS, United Kingdom.

Warm periods in Earth's history offer opportunities to understand the dynamics of the Earth system under conditions that are similar to those expected in the near future. The Middle Pliocene warm period (MPWP), from 3.3 to 3.0 My B.P, is the most recent time when atmospheric CO levels were as high as today. However, climate model simulations of the Pliocene underestimate high-latitude warming that has been reconstructed from fossil pollen samples and other geological archives. One possible reason for this is that enhanced non-CO trace gas radiative forcing during the Pliocene, including from methane (CH), has not been included in modeling. We use a suite of terrestrial biogeochemistry models forced with MPWP climate model simulations from four different climate models to produce a comprehensive reconstruction of the MPWP CH cycle, including uncertainty. We simulate an atmospheric CH mixing ratio of 1,000 to 1,200 ppbv, which in combination with estimates of radiative forcing from NO and O, contributes a non-CO radiative forcing of 0.9 [Formula: see text] (range 0.6 to 1.1), which is 43% (range 36 to 56%) of the CO radiative forcing used in MPWP climate simulations. This additional forcing would cause a global surface temperature increase of 0.6 to 1.0 °C, with amplified changes at high latitudes, improving agreement with geological evidence of Middle Pliocene climate. We conclude that natural trace gas feedbacks are critical for interpreting climate warmth during the Pliocene and potentially many other warm phases of the Cenezoic. These results also imply that using Pliocene CO and temperature reconstructions alone may lead to overestimates of the fast or Charney climate sensitivity.
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September 2020

Drier tropical and subtropical Southern Hemisphere in the mid-Pliocene Warm Period.

Sci Rep 2020 08 10;10(1):13458. Epub 2020 Aug 10.

Key Laboratory of Cenozoic Geology and Environment, Institute of Geology and Geophysics, Chinese Academy of Sciences, Beijing, China.

Thermodynamic arguments imply that global mean rainfall increases in a warmer atmosphere; however, dynamical effects may result in more significant diversity of regional precipitation change. Here we investigate rainfall changes in the mid-Pliocene Warm Period (~ 3 Ma), a time when temperatures were 2-3ºC warmer than the pre-industrial era, using output from the Pliocene Model Intercomparison Projects phases 1 and 2 and sensitivity climate model experiments. In the Mid-Pliocene simulations, the higher rates of warming in the northern hemisphere create an interhemispheric temperature gradient that enhances the southward cross-equatorial energy flux by up to 48%. This intensified energy flux reorganizes the atmospheric circulation leading to a northward shift of the Inter-Tropical Convergence Zone and a weakened and poleward displaced Southern Hemisphere Subtropical Convergences Zones. These changes result in drier-than-normal Southern Hemisphere tropics and subtropics. The evaluation of the mid-Pliocene adds a constraint to possible future warmer scenarios associated with differing rates of warming between hemispheres.
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August 2020

Physical Therapist Management of Total Knee Arthroplasty.

Phys Ther 2020 08;100(9):1603-1631

Department of Physical Therapy, University of Delaware, Newark, Delaware.

A clinical practice guideline on total knee arthroplasty was developed by an American Physical Therapy (APTA) volunteer guideline development group that consisted of physical therapists, an orthopedic surgeon, a nurse, and a consumer. The guideline was based on systematic reviews of current scientific and clinical information and accepted approaches to management of total knee arthroplasty.
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August 2020

Study protocol for targeted interventions to prevent chronic low back pain in high-risk patients: A multi-site pragmatic cluster randomized controlled trial (TARGET Trial).

Contemp Clin Trials 2019 07 25;82:66-76. Epub 2019 May 25.

Boston Medical Center, 1 Boston Medical Center Place, Dowling 5 South, Boston, MA 02118, USA.

Background: Low back pain (LBP) is one of the most prevalent and potentially disabling conditions for which people seek health care. Patients, providers, and payers agree that greater effort is needed to prevent acute LBP from transitioning to chronic LBP.

Methods And Study Design: The TARGET (Targeted Interventions to Prevent Chronic Low Back Pain in High-Risk Patients) Trial is a primary care-based, multisite, cluster randomized, pragmatic trial comparing guideline-based care (GBC) to GBC + referral to Psychologically Informed Physical Therapy (PIPT) for patients presenting with acute LBP and identified as high risk for persistent disabling symptoms. Study sites include primary care clinics within each of five geographical regions in the United States, with clinics randomized to either GBC or GBC + PIPT. Acute LBP patients at all clinics are risk stratified (high, medium, low) using the STarT Back Tool. The primary outcomes are the presence of chronic LBP and LBP-related functional disability determined by the Oswestry Disability Index at 6 months. Secondary outcomes are LBP-related processes of health care and utilization of services over 12 months, determined through electronic medical records. Study enrollment began in May 2016 and concluded in June 2018. The trial was powered to include at least 1860 high-risk patients in the randomized controlled trial cohort. A prospective observational cohort of approximately 6900 low and medium-risk acute LBP patients was enrolled concurrently.

Discussion: The TARGET pragmatic trial aims to establish the effectiveness of the stratified approach to acute LBP intervention targeting high-risk patients with GBC and PIPT.

Trial Registration: ClinicalTrials.govNCT02647658 Registered Jan. 6, 2016.
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July 2019

Responsiveness to Change of Functional Limitation Reporting: Cross-sectional Study Using the Intermountain ROMS Scale in Outpatient Rehabilitation.

Phys Ther 2017 Dec;97(12):1182-1189

K.I. Minick, PT, DPT, Rehabilitation Services, Intermountain Healthcare.

Background: The Centers for Medicare and Medicaid Services (CMS) require physical therapists document patients' functional limitations. The process is not standardized. 
A systematic approach to determine a patient's functional limitations and responsiveness to change is needed.

Objective: The purpose of this study is to compare patient-reported outcomes (PROs) responsiveness to change using 7-level severity/complexity modifier scale proposed by Medicare to a derived scale implemented by Intermountain Healthcare's Rehabilitation Outcomes Management System (ROMS).

Design: This was a retrospective, observational cohort design.

Methods: 165,183 PROs prior to July 1, 2013, were compared to 46,334 records from July 1, 2013, to December 31, 2015. Histograms and ribbon plots illustrate distribution and change of patients' scores. ROMS raw score ranges were calculated and compared to CMS' severity/complexity levels based on score percentage. Distribution of the population was compared based on the 2 methods. Sensitivity and specificity were compared for responsiveness to change based on minimal clinically important difference (MCID).

Results: Histograms demonstrated few patient scores placed in CMS scale levels at the extremes, whereas the majority of scores placed in 2 middle levels (CJ, CK). ROMS distributed scores more evenly across levels. Ribbon plots illustrated advantage of ROMS' using narrower score ranges. Greater chance for patients to change levels was observed with ROMS when an MCID was achieved. ROMS narrower scale levels resulted in greater sensitivity and good specificity.

Limitations: Geographic representation for the United States was limited. Without patients' global rating of change, a reference standard to gauge validation of improvement could not be provided.

Conclusions: ROMS provides a standard approach to identify accurately functional limitation modifier levels and to detect improvement more accurately than a straight across transposition using the CMS scale.
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December 2017

Rothstein Roundtable Podcast-"Putting All of Our Eggs in One Basket: Human Movement System".

Phys Ther 2015 Nov;95(11):1466

A. Delitto, PT, PhD, FAPTA, Professor and Interim Dean, School of Health and Rehabilitation Sciences; Professor, Department of Physical Therapy; Associate Dean for Research, School of Health and Rehabilitation Sciences; and Vice President of Education and Research, Centers for Rehab Services, University of Pittsburgh, Pittsburgh, Pennsylvania.

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November 2015

Physical Therapy or Advanced Imaging as First Management Strategy Following a New Consultation for Low Back Pain in Primary Care: Associations with Future Health Care Utilization and Charges.

Health Serv Res 2015 Dec 16;50(6):1927-40. Epub 2015 Mar 16.

Intermountain Physical Therapy, Intermountain Healthcare, Salt Lake City, UT.

Objective: Compare health care utilization and charges for low-back-pain (LBP) patients receiving advanced imaging or physical therapy as a first management strategy following a new primary care consultation.

Data Source: Electronic medical record (EMR) and insurance claims data.

Study Design: Retrospective analysis of propensity-matched groups.

Data Collection/extraction: Claims and EMR data were used. Utilization and LBP-related charges over a 1-year period were extracted from claims data.

Principal Findings: In the propensity-matched sample (n = 406), advanced imaging recipients had higher odds of all utilization outcomes. Charges were higher with advanced imaging by an average $4,793 (95 percent CI: $3,676, $5,910).

Conclusions: For patients with LBP whom newly consulted primary care referred for additional management, advanced imaging as a first management was associated with higher health care utilization and charges than physical therapy.
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December 2015

Outpatient rehabilitation care process factors and clinical outcomes among patients discharged home following unilateral total knee arthroplasty.

J Arthroplasty 2015 May 13;30(5):885-90. Epub 2014 Dec 13.

Intermountain Healthcare Physical Therapy, Salt Lake City, Utah.

Research examining care process variables and their relationship to clinical outcomes after total knee arthroplasty has focused primarily on inpatient variables. Care process factors related to outpatient rehabilitation have not been adequately examined. We conducted a retrospective review of 321 patients evaluating outpatient care process variables including use of continuous passive motion, home health physical therapy, number of days from inpatient discharge to beginning outpatient physical therapy, and aspects of outpatient physical therapy (number of visits, length of stay) as possible predictors of pain and disability outcomes of outpatient physical therapy. Only the number of days between inpatient discharge and outpatient physical therapy predicted better outcomes, suggesting that this may be a target for improving outcomes after total knee arthroplasty for patients discharged directly home.
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May 2015

On the identification of a Pliocene time slice for data-model comparison.

Philos Trans A Math Phys Eng Sci 2013 Oct 16;371(2001):20120515. Epub 2013 Sep 16.

School of Earth and Environment, University of Leeds, , Woodhouse Lane, Leeds LS2 9JT, UK.

The characteristics of the mid-Pliocene warm period (mPWP: 3.264-3.025 Ma BP) have been examined using geological proxies and climate models. While there is agreement between models and data, details of regional climate differ. Uncertainties in prescribed forcings and in proxy data limit the utility of the interval to understand the dynamics of a warmer than present climate or evaluate models. This uncertainty comes, in part, from the reconstruction of a time slab rather than a time slice, where forcings required by climate models can be more adequately constrained. Here, we describe the rationale and approach for identifying a time slice(s) for Pliocene environmental reconstruction. A time slice centred on 3.205 Ma BP (3.204-3.207 Ma BP) has been identified as a priority for investigation. It is a warm interval characterized by a negative benthic oxygen isotope excursion (0.21-0.23‰) centred on marine isotope stage KM5c (KM5.3). It occurred during a period of orbital forcing that was very similar to present day. Climate model simulations indicate that proxy temperature estimates are unlikely to be significantly affected by orbital forcing for at least a precession cycle centred on the time slice, with the North Atlantic potentially being an important exception.
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October 2013

Initial management decisions after a new consultation for low back pain: implications of the usage of physical therapy for subsequent health care costs and utilization.

Arch Phys Med Rehabil 2013 May 18;94(5):808-16. Epub 2013 Jan 18.

Department of Physical Therapy, University of Utah, Salt Lake City, UT, USA.

Objectives: To describe the utilization of physical therapy following a new primary care consultation for low back pain (LBP) and to examine the relations between physical therapy utilization and other variables with health care utilization and costs in the year after consultation.

Design: Retrospective cohort obtained from electronic medical records and insurance claims data.

Setting: Single health care delivery system.

Participants: Individuals (N=2184) older than 18 years with a new consultation for LBP from 2004 to 2008.

Interventions: Patients were categorized as receiving initial physical therapy management if care occurred within 14 days after consultation.

Main Outcome Measures: Total health care costs for all LBP-related care received in the year after consultation were calculated from claims data. Predictors of utilization of emergency care, advanced imaging, epidural injections, specialist visits, and surgery were identified using multivariate logistic regression. The generalized linear model was used to compare LBP-related costs based on physical therapy utilization and identify other cost determinants.

Results: Initial physical therapy was received by 286 of the 2184 patients (13.1%), and was not a determinant of LBP-related health care costs or utilization of specific services in the year after consultation. Older age, mental health, or neck pain comorbidity and initial management with opioids were determinants of cost and several utilization outcomes.

Conclusions: Initial physical therapy management was not associated with increased health care costs or utilization of specific services following a new primary care LBP consultation. Additional research is needed to examine the cost consequences of initial management decisions made following a new consultation for LBP.
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May 2013

Utilization and clinical outcomes of outpatient physical therapy for medicare beneficiaries with musculoskeletal conditions.

Phys Ther 2011 Mar 13;91(3):330-45. Epub 2011 Jan 13.

Department of Physical Therapy, University of Utah, 520 Wakara Way, Salt Lake City, UT 84108, USA.

Background: Medicare beneficiaries frequently receive physical therapy for musculoskeletal conditions. Little information is available about this care.

Objective: The purposes of this study were: (1) to describe characteristics, clinical outcomes, and utilization for Medicare beneficiaries receiving physical therapy in outpatient clinics within one integrated health care system; (2) to compare characteristics, outcomes, and utilization based on the body region affected; and (3) to examine factors predictive of outcomes and utilization.

Design: This was a prospective, longitudinal study.

Methods: Medicare beneficiaries aged 65 years or older (n=1,840 episodes of care) participated in the study. Descriptive statistics were calculated for patient characteristics and outcomes. Comparisons were made based on body region. Regression models evaluated factors associated with change in pain, improved outcome, and utilization.

Results: The patients' mean age was 74.2 years (SD=6.3), and 65.3% were female. The most common body regions were the lumbar spine, shoulder, and knee, collectively accounting for 71.3% of the episodes of care. Patients attended a mean of 6.8 visits (SD=4.7), and 63.9% experienced an improved outcome. Episodes of care for lumbar spine conditions had less reduction in pain, whereas shoulder conditions and foot/ankle conditions showed the greatest improvement. Care for hip conditions was least likely to result in an improved outcome. Knee conditions were most likely to have an improved outcome. Care for shoulder and knee conditions had the highest number of visits. Factors associated with greater reduction in pain and improved outcomes included greater initial pain or disability and attending more visits. Factors associated with greater utilization included a postsurgical condition and higher initial pain rating. Limitations The study was performed in one geographic region within a single health care delivery system.

Conclusion: The results provide information on outcomes of physical therapy for Medicare beneficiaries in one health care system. Further research is needed to examine optimal utilization and care for these patients.
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March 2011

Physical therapy for acute low back pain: associations with subsequent healthcare costs.

Spine (Phila Pa 1976) 2008 Jul;33(16):1800-5

Rehabilitation Agency, Intermountain Healthcare, University of Utah, Salt Lake City, Utah, USA.

Study Design: Case-control.

Objective: To examine the association between adherence to the evidence-based recommendation for active physical therapy care and clinical outcomes along with subsequent healthcare utilization and charges for 1 year after completion of physical therapy.

Summary Of Background Data: Low back pain (LBP) is a common condition associated with high costs. Many patients with acute LBP receive physical therapy. The type of physical therapy care provided may impact subsequent healthcare costs.

Methods: A retrospective review was undertaken of patients age 18-60 with acute (<90 days) LBP receiving physical therapy covered by 1 insurance provider. Adherence to the recommendation for active care was determined from billing records. Disability (Oswestry) and pain (numerical pain rating) were assessed at the beginning and completion of physical therapy. Subsequent healthcare utilization for LBP and charges were recorded from insurer's databases.

Results: Four hundred and seventy-one patients were included (mean age 41.2 years [SD = 11.0], 54% female), 28.0% received adherent care. Patients receiving adherent care had fewer physical therapy visits (mean difference 1.3 visits, P < 0.05) with lower charges (nontransformed mean difference $167, P < 0.05), greater improvement in pain (mean difference 12.3%, 95% confidence interval [CI]: 3.2-21.3) and disability (mean difference 17.6%, 95% CI: 11.1-24.1). During the year after discharge, receiving adherent care was associated with a lower likelihood of receiving prescription medication (46.2% vs. 57.2%, P < 0.05), magnetic resonance imaging (MRI) (8.3% vs. 15.9%, P < 0.05), or epidural injections (5.3% vs. 12.1%, P < 0.05).

Conclusion: Adherence to the recommendation for active care was associated with better clinical outcomes and decreased subsequent use of prescription medication, MRI, and injections. Improving adherence to this recommendation may present an opportunity to improve the cost-effectiveness of care for acute LBP.
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July 2008

Is there a subgroup of patients with low back pain likely to benefit from mechanical traction? Results of a randomized clinical trial and subgrouping analysis.

Spine (Phila Pa 1976) 2007 Dec;32(26):E793-800

Intermountain Healthcare, Salt Lake City, UT, USA.

Study Design: Randomized Clinical Trial.

Objective: To identify a subgroup of patients with low back pain who are likely to respond favorably to an intervention including mechanical traction.

Summary Of Background Data: Previous research has failed to find evidence supporting traction for patients with low back pain. Previous studies have used heterogeneous samples, although clinical experts tend to recommend traction for a more limited subgroup of patients with low back pain.

Methods: Sixty-four subjects (mean age 41.1 year, 56.3% female) with low back and leg pain and signs of nerve root compression were randomized to receive a 6-week extension-oriented intervention with or without mechanical traction during the first 2 weeks. Between-group comparisons were conducted for changes in pain, disability, and fear-avoidance beliefs. Baseline variables were explored for potential as subgrouping criteria defining a subgroup of subjects likely to benefit from traction.

Results: The group receiving traction showed greater improvements in disability (adjusted mean difference in Oswestry change 7.2 points) and fear-avoidance beliefs (adjusted mean difference in FABQPA change 2.6 points) after 2 weeks. There were no between-group differences after 6 weeks. Two baseline variables were associated with greater improvements with traction treatment; peripheralization with extension movements and a crossed straight leg raise.

Conclusion: A subgroup of patients likely to benefit from mechanical traction may exist. The results of this study suggest this subgroup is characterized by the presence of leg symptoms, signs of nerve root compression, and either peripheralization with extension movements or a crossed straight leg raise. Further research is needed to validate this finding.
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December 2007

Impact of continuing education interventions on clinical outcomes of patients with neck pain who received physical therapy.

Phys Ther 2006 Sep;86(9):1251-62

Rehabilitation Agency, Intermountain Health Care, Salt Lake City, Utah 84108, USA.

Background And Purpose: Physical therapists frequently attend continuing education courses with the goal of providing better care, yet the effectiveness of continuing education for improving outcomes has not been examined.

Subjects: Data were obtained for all eligible patients (n=1,365; mean age=42.1 years, SD=14.0 years; 69.9% female) with a chief complaint of neck pain who were treated in 13 physical therapy clinics over a 24-month period. Disability data (Neck Disability Index scores) from the initial and final therapy sessions were recorded from clinical databases.

Methods: Thirty-four of 57 physical therapists employed within the 13 clinics attended a 2-day continuing education course. Eleven of the 34 attendees also participated in an ongoing clinical improvement project for patients with neck pain. Clinical outcomes were compared in the pre- and post-course periods for therapists attending or not attending the course, and for therapists participating or not participating in the ongoing project.

Results: There were no differences in clinical outcomes based on attendance at the continuing education course. There was an interaction between time and participation in the ongoing project, such that participants achieved greater change in disability after the course. The percentage of patients achieving at least the minimum detectable amount of change in disability with treatment increased significantly for participants after the course.

Discussion And Conclusion: Attendance at a 2-day continuing education course was not associated with improvement in clinical outcomes, but participation in an ongoing improvement project did result in greater clinical improvement for patients with neck pain. Further investigation of educational methods to improve clinical outcomes is needed. These results suggest that traditional continuing education formats may not be effective for improving patient care.
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September 2006

Identifying subgroups of patients with acute/subacute "nonspecific" low back pain: results of a randomized clinical trial.

Spine (Phila Pa 1976) 2006 Mar;31(6):623-31

Rehab Agency Intermountain Health Care, Salt Lake City, UT, USA.

Study Design: Randomized clinical trial.

Objective: Compare outcomes of patients with low back pain receiving treatments matched or unmatched to their subgrouping based on initial clinical presentation.

Summary Of Background Data: Patients with "nonspecific" low back pain are often viewed as a homogeneous group, equally likely to respond to any particular intervention. Others have proposed methods for subgrouping patients as a means for determining the treatment most likely to benefit patients with particular characteristics.

Methods: Patients with low back pain of less than 90 days' duration referred to physical therapy were examined before treatment and classified into one of three subgroups based on the type of treatment believed most likely to benefit the patient (manipulation, stabilization exercise, or specific exercise). Patients were randomly assigned to receive manipulation, stabilization exercises, or specific exercise treatment during a 4-week treatment period. Disability was assessed in the short-term (4 weeks) and long-term (1 year) using the Oswestry. Comparisons were made between patients receiving treatment matched to their subgroup, versus those receiving unmatched treatment.

Results: A total of 123 patients participated (mean age, 37.7 +/- 10.7 years; 45% female). Patients receiving matched treatments experienced greater short- and long-term reductions in disability than those receiving unmatched treatments. After 4 weeks, the difference favoring the matched treatment group was 6.6 Oswestry points (95% CI, 0.70-12.5), and at long-term follow-up the difference was 8.3 points (95% CI, 2.5-14.1). Compliers-only analysis of long-term outcomes yielded a similar result.

Conclusions: Nonspecific low back pain should not be viewed as a homogenous condition. Outcomes can be improved when subgrouping is used to guide treatment decision-making.
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March 2006

An examination of the reliability of a classification algorithm for subgrouping patients with low back pain.

Spine (Phila Pa 1976) 2006 Jan;31(1):77-82

Division of Physical Therapy, University of Utah, Intermountain Health Care, Salt Lake City, USA.

Study Design: Test-retest design to examine interrater reliability.

Objective: Examine the interrater reliability of individual examination items and a classification decision-making algorithm using physical therapists with varying levels of experience.

Summary Of Background Data: Classifying patients based on clusters of examination findings has shown promise for improving outcomes. Examining the reliability of examination items and the classification decision-making algorithm may improve the reproducibility of classification methods.

Methods: Patients with low back pain less than 90 days in duration participating in a randomized trial were examined on separate days by different examiners. Interrater reliability of individual examination items important for classification was examined in clinically stable patients using kappa coefficients and intraclass correlation coefficients. The findings from the first examination were used to classify each patient using the decision-making algorithm by clinicians with varying amounts of experience. The reliability of the classification algorithm was examined with kappa coefficients.

Results: A total of 123 patients participated (mean age 37.7 [+/-10.7] years, 44% female), 60 (49%) remained stable between examinations. Reliability of range of motion, centralization/peripheralization judgments with flexion and extension, and the instability test were moderate to excellent. Reliability of centralization/peripheralization judgments with repeated or sustained extension or aberrant movement judgments were fair to poor. Overall agreement on classification decisions was 76% (kappa = 0.60, 95% confidence interval 0.56, 0.64), with no significant differences based on level of experience.

Conclusion: Reliability of the classification algorithm was good. Further research is needed to identify sources of disagreements and improve reproducibility.
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January 2006