A Cluster Analysis of Initial Primary Care Orders for Patients with Acute Low Back Pain.

PURPOSE: Primary care physicians (PCPs) often face a complex intersection of patient expectations, evidence, and policy that influences their care recommendations for acute low back pain (aLBP). The purpose of this study was to elucidate patterns of PCP orders for patients with aLBP, identify the most common patterns, and describe patient clinical and demographic characteristics associated with patterns of aLBP care. METHODS: This prospective cohort study included 9574 aLBP patients presenting to 1 of 77 primary care practices in 4 geographic locations in the United States. We performed a cluster analysis of PCP orders extracted from electronic health records within the first 21 days of an initial visit for aLBP. RESULTS: 1401 (15%) patients did not receive a PCP order related to back pain within the first 21 days of their initial visit. These patients predominantly had aLBP without leg pain, less back-related disability, and were at low-risk for persistent disability. Of the remaining 8146 patients, we found 4 distinct order patterns: combined nonpharmacologic and first-line medication (44%); second-line medication (39%); imaging (10%); and specialty referral (7%). Among all patients, 29% received solely 1 order from their PCP. PCPs more often combined different guideline concordant and discordant orders. Patients with higher self-reported disability and psychological distress were more likely to receive guideline discordant care. CONCLUSION: Guideline discordant orders such as steroids and NSAIDS are often combined with guideline recommended orders such as physical therapy. Further defining patient, clinician, and health care setting characteristics associated with discordant care would inform targeted efforts for deimplementation initiatives.

Significant Clinical Improvement Was Predicted in a Cohort of Patients With Low Back Pain Early in the Care Process.

OBJECTIVE: The purpose of this study was to determine the proportion of patients with low back pain who achieved clinical improvement in disability within 3 or 6 physical therapy visits, identify factors that predicted improvement, and predict the probability of improvement by the third and sixth visits. METHODS: This retrospective, observational study looked at patients (N = 6523) who completed a numeric pain scale and Modified Low Back Disability Questionnaire (MDQ) at every visit. Four prediction models were developed: 30% improvement by visit 3 and by visit 6 and 50% improvement by visit 3 and by visit 6. A logistic regression model was fit to predict patients' improvement in disability using the MDQ. Predictive models used age, disability scores, sex, symptom duration, and payer type as factors. Receiver operating characteristic curves and area under the curve were computed for the models. Nomograms illustrate the relative impacts of the predictor variables. RESULTS: Disability improved 30% in 42.7% of patients by visit 3 and 49% by visit 6. Disability improved 50% in 26% of patients by visit 3 and 32.9% by visit 6. First visit score (MDQ1) was strongest factor to predict 30% improvement by visit 3. The visit 3 score (MDQ3) was strongest factor to predict a 30% or 50% improvement by visit 6. The combination of MDQ1 and MDQ3 scores was strongest overall predictive factor for visit 6. The area under the curve values for models using only the MDQ1 and MDQ3 scores to predict 30% or 50% improvement by the sixth visit were 0.84 and 0.85, respectively, representing excellent overall diagnostic accuracy of the prediction models. CONCLUSION: Excellent discrimination to predict patients' significant clinical improvement by visit 6 using 2 outcome scores was demonstrated. Gathering outcomes routinely enhances assessment of prognosis and clinical decision making. IMPACT: Understanding prognosis of clinical improvement supports physical therapists' contribution to value-based care.

Beyond the pain: A qualitative study exploring the physical therapy experience in patients with chronic low back pain.

BACKGROUND: Chronic low back pain (cLBP) is a complex condition that is physically and psychologically debilitating, with vulnerable populations experiencing more severe outcomes. Physical therapy (PT) includes evidence-based treatments that can reduce disability, however the experience of PT can vary amongst different populations. Empirical evidence is largely based on majority samples that are predominantly white with high educational attainment. Little is known regarding how people from vulnerable groups (e.g. low income and racial minority) experience physical therapy treatment for low back pain. OBJECTIVE: To describe the experience of physical therapy in a predominantly low-income and minority population with cLBP. METHODS: This qualitative study was embedded within a randomized controlled trial for patients with cLBP in urban, underserved communities. We used a convenience sample to interview 12 participants from the 102 who participated in the PT arm of the trial and then performed thematic analysis to describe their experience. RESULTS: Three major themes emerged: 1) Empowerment through education and exercise; 2) Interconnectedness to providers and other patients; and 3) Improvements in pain, body mechanics, and mood. Divergent cases were few however centered around a lack of improvement in pain or an absence of connection with the therapist. Within the first theme a prevailing sub-theme emerged that aligned with Bandura's theory of self-efficacy: 1) Mastery of experience; 2) Verbal persuasion; 3) Vicarious experience; and 4) Physiological state. CONCLUSIONS: Our participants' insight highlighted the value of cognitive-emotional and interpersonal dimensions of PT. These may be particularly important components of PT in populations that have experienced systemic distrust in providers and disparities in services. Future work could use Bandura's model of self-efficacy to build a PT intervention comprised of fear-based movement exercises, interconnectedness, a strong therapeutic alliance, and mindfulness techniques.

Racial and Ethnic Disparities in the Incidence of High-Impact Chronic Pain Among Primary Care Patients with Acute Low Back Pain: A Cohort Study.

OBJECTIVE: We assessed whether race or ethnicity was associated with the incidence of high-impact chronic low back pain (cLBP) among adults consulting a primary care provider for acute low back pain (aLBP). METHODS: In this secondary analysis of a prospective cohort study, patients with aLBP were identified through screening at seventy-seven primary care practices from four geographic regions. Incidence of high-impact cLBP was defined as the subset of patients with cLBP and at least moderate disability on Oswestry Disability Index [ODI >30]) at 6 months. General linear mixed models provided adjusted estimates of association between race/ethnicity and high-impact cLBP. RESULTS: We identified 9,088 patients with aLBP (81.3% White; 14.3% Black; 4.4% Hispanic). Black/Hispanic patients compared to White patients, were younger and more likely to be female, obese, have Medicaid insurance, worse disability on ODI, and were at higher risk of persistent disability on STarT Back Tool (all P < .0001). At 6 months, more Black and Hispanic patients reported high-impact cLBP (30% and 25%, respectively) compared to White patients (15%, P < .0001, n = 5,035). After adjusting for measured differences in socioeconomic and back-related risk factors, compared to White patients, the increased odds of high-impact cLBP remained statistically significant for Black but not Hispanic patients (adjusted odds ration [aOR] = 1.40, 95% confidence interval [CI]: 1.05-1.87 and aOR = 1.25, 95%CI: 0.83-1.90, respectively). CONCLUSIONS: We observed an increased incidence of high-impact cLBP among Black and Hispanic patients compared to White patients. This disparity was partly explained by racial/ethnic differences in socioeconomic and back-related risk factors. Interventions that target these factors to reduce pain-related disparities should be evaluated. CLINICALTRIALS.GOV IDENTIFIER: NCT02647658.

Development of a rehabilitation researcher survey of knowledge and interest in learning health systems research.

Introduction: LeaRRn, an NIH-funded rehabilitation resource center, is dedicated to developing learning health systems (LHS) research competencies within the rehabilitation community. To appropriately target resources and training opportunities for rehabilitation researchers, we developed and pilot tested a survey based on AHRQ LHS research core competencies to assess the training needs of rehabilitation researchers interested in LHS research. Methods: Survey items were developed by the investigative team and iteratively refined with the assistance of an expert panel using two rounds of content validation. Survey items addressed knowledge of, ability to apply, and interest in LHS research competencies. The survey was pre-pilot tested with six rehabilitation professionals, refined again, and then pilot tested. Time to complete the survey was measured. Spearman correlations examined relationships between knowledge and ability. Results: A 78-item survey was pilot tested. Forty-five individuals completed the pilot survey in full (71% female, 84% white, and 93% non-Hispanic). Due to concerns about response burden (mean 15 minutes to complete) and strong correlation between "knowledge" and "ability" ratings (all rho >0.57), "ability" was dropped, resulting in a 55-item survey assessing "knowledge" and "interest" in LHS research competencies. Conclusions: We developed a survey of knowledge and interest in LHS research competencies for rehabilitation researchers. The resulting survey may be used to assess training needs and guide LHS research content development by educators, programs directors, and other initiatives within the rehabilitation research community.

The primary spine practitioner as a new role in healthcare systems in North America.

BACKGROUND: In an article published in 2011, we discussed the need for a new role in health care systems, referred to as the Primary Spine Practitioner (PSP). The PSP model was proposed to help bring order to the chaotic nature of spine care. Over the past decade, several efforts have applied the concepts presented in that article. The purpose of the present article is to discuss the ongoing need for the PSP role in health care systems, present persistent barriers, report several examples of the model in action, and propose future strategies. MAIN BODY: The management of spine related disorders, defined here as various disorders related to the spine that produce axial pain, radiculopathy and other related symptoms, has received significant international attention due to the high costs and relatively poor outcomes in spine care. The PSP model seeks to bring increased efficiency, effectiveness and value. The barriers to the implementation of this model have been significant, and responses to these barriers are discussed. Several examples of PSP integration are presented, including clinic systems in primary care and hospital environments, underserved areas around the world and a program designed to reduce surgical waiting lists. Future strategies are proposed for overcoming the continuing barriers to PSP implementation in health care systems more broadly. CONCLUSION: Significant progress has been made toward integrating the PSP role into health care systems over the past 10 years. However, much work remains. This requires substantial effort on the part of those involved in the development and implementation of the PSP model, in addition to support from various stakeholders who will benefit from the proposed improvements in spine care.

Evaluation of United States chiropractic professional subgroups: a survey of randomly sampled chiropractors.

BACKGROUND: Professional subgroups are common and may play a role in aiding professional maturity or impeding professional legitimization. The chiropractic profession in the United States has a long history of diverse intra-professional subgroups with varying ideologies and practice styles. To our knowledge, large-scale quantification of chiropractic professional subgroups in the United States has not been conducted. The purpose of this study was to quantify and describe the clinical practice beliefs and behaviors associated with United States chiropractic subgroups. METHODS: A 10% random sample of United States licensed chiropractors (n = 8975) was selected from all 50 state regulatory board lists and invited to participate in a survey. The survey consisted of a 7-item questionnaire; 6 items were associated with chiropractic ideological and practice characteristics and 1 item was related to the self-identified role of chiropractic in the healthcare system which was utilized as the dependent variable to identify chiropractic subgroups. Multinomial logistic regression with predictive margins was used to analyze which responses to the 6 ideology and practice characteristic items were predictive of chiropractic subgroups. RESULTS: A total of 3538 responses were collected (39.4% response rate). Respondents self-identified into three distinct subgroups based on the perceived role of the chiropractic profession in the greater healthcare system: 56.8% were spine/neuromusculoskeletal focused; 22.0% were primary care focused; and 21.2% were vertebral subluxation focused. Patterns of responses to the 6 ideologies and practice characteristic items were substantially different across the three professional subgroups. CONCLUSIONS: Respondents self-identified into one of three distinct intra-professional subgroups. These subgroups can be differentiated along themes related to clinical practice beliefs and behaviors.

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

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: ClinicalTrials.gov 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, n = 658) versus 51% of patients in the control arm (35 practices, n = 635; OR=0.83 95% CI 0.64, 1.09; p = 0.18). No differences in disability were detected (difference -2·1, 95% CI -4.9-0.6; p = 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.

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

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.

Implementing stratified care for acute low back pain in primary care using the STarT Back instrument: a process evaluation within the context of a large pragmatic cluster randomized trial.

BACKGROUND: Although risk-stratifying patients with acute lower back pain is a promising approach for improving long-term outcomes, efforts to implement stratified care in the US healthcare system have had limited success. The objectives of this process evaluation were to 1) examine variation in two essential processes, risk stratification of patients with low back pain and referral of high-risk patients to psychologically informed physical therapy and 2) identify barriers and facilitators related to the risk stratification and referral processes. METHODS: We used a sequential mixed methods study design to evaluate implementation of stratified care at 33 primary care clinics (17 intervention, 16 control) participating in a larger pragmatic trial. We used electronic health record data to calculate: 1) clinic-level risk stratification rates (proportion of patients with back pain seen in the clinic over the study period who completed risk stratification questionnaires), 2) rates of risk stratification across different points in the clinical workflow (front desk, rooming, and time with clinician), and 3) rates of referral of high-risk patients to psychologically informed physical therapy among intervention clinics. We purposively sampled 13 clinics for onsite observations, which occurred in month 24 of the 26-month study. RESULTS: The overall risk stratification rate across the 33 clinics was 37.8% (range: 14.7-64.7%). Rates were highest when patients were identified as having back pain by front desk staff (overall: 91.9%, range: 80.6-100%). Rates decreased as the patient moved further into the visit (rooming, 29.3% [range: 0-83.3%]; and time with clinician, 11.3% [range: 0-49.3%]. The overall rate of referrals of high-risk patients to psychologically informed physical therapy across the 17 intervention clinics was 42.1% (range: 8.3-70.8%). Barriers included staffs' knowledge and beliefs about the intervention, patients' needs, technology issues, lack of physician engagement, and lack of time. Adaptability of the processes was a facilitator. CONCLUSIONS: Adherence to key stratified care processes varied across primary care clinics and across points in the workflow. The observed variation suggests room for improvement. Future research is needed to build on this work and more rigorously test strategies for implementing stratified care for patients with low back pain in the US healthcare system. TRIAL REGISTRATION: Trial registration: ClinicalTrials.gov ( NCT02647658 ). Registered January 6, 2016.

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).

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.

Improving Physical Therapy Pain Care, Quality, and Cost Through Effectiveness-Implementation Research.

The variability and delay in utilizing evidence in clinical practice are barriers to improving care, quality, and cost in health care, as charged by the "triple aim" framework. Scientific research provides an avenue not only to further the field of pain research, but also to study and change the patterns and processes that drive systemic and individual clinical practices. Implementation science is an emerging field that can be integrated with more traditional effectiveness research to accomplish a combination of aims within the same study. This type of concurrent study of effectiveness and implementation is known as a hybrid design and can be used to improve behavioral or operational practice patterns as well as to collect evidence of clinical effectiveness. Recently, the National Pain Strategy put forth recommendations to improve the care of patients with pain through research and practice. Hybrid designs align well with recent efforts that emphasize value-based, patient-centered health care evolving and described in the National Pain Strategy. The purposes of this perspective are to describe implementation science and hybrid studies and to put forth opportunities to utilize this research to advance the care of patients with pain in the United States.

What Types of Treatment Are Provided for Patients With Carpal Tunnel Syndrome? A Retrospective Analysis of Commercial Insurance.

BACKGROUND: Treatment of carpal tunnel syndrome (CTS) in commercially insured patients across the spectrum of provider types rarely has been described. OBJECTIVE: To describe patterns of types of treatment for patients with CTS using a large commercial insurance database. DESIGN: Retrospective cohort descriptive study. SETTING: Administrative health data from the Clinformatics Data Mart (OptumInsight, Eden Prairie, MN). PATIENTS: Adults with a primary diagnosis of CTS seen from between January 2010 to December 2012 who had a total of 48 months of continuous data (12 months before diagnosis and 36 months after diagnosis) (n = 24,931). OUTCOMES: Frequency of types of treatment (heat, manual therapy, positioning, steroids, stretching, surgery) by number of treatments, number of visits, provider type, and characteristics. RESULTS: Fifty-four percent of patients received no reported treatment, and 50.4% had no additional visits. Surgery (42.5%) and positioning (39.8%) were the most frequent single treatments. Patients who were seen by orthopedist for their first visit more frequently received some treatment (75.1%) and at least 1 additional visit (74.1%) compared with those seen by general practitioners (59.5%, 57.5%, respectively) or other providers (65.4%, 68.4, respectively). Orthopedists more frequently prescribed positioning devices (26.8%) and surgery (36.8%) than general practitioners (18.8%, 14.1%, respectively) or other providers (15.7%, 19.7%, respectively). Older adults more frequently had CTS surgery, as did people who lived in the Midwest. Overall, only 24% of patients with CTS had surgery. CONCLUSIONS: For more than one-half of patients with CTS no treatment was provided after an initial visit. Surgery rates were much lower than what has previously been reported in the literature. Generally, patients with CTS receive treatments that are supported by current treatment guidelines. LEVEL OF EVIDENCE: NA.

Association of Early Outpatient Rehabilitation With Health Service Utilization in Managing Medicare Beneficiaries With Nontraumatic Knee Pain: Retrospective Cohort Study.

BACKGROUND: Nontraumatic knee pain (NTKP) is highly prevalent in adults 65 years of age and older. Evidence-based guidelines recommend early use of rehabilitation; however, there is limited information comparing differences in health care utilization when rehabilitation is included in the management of NTKP. OBJECTIVES: To describe the overall health care utilization associated with the management of NTKP; estimate the proportion of people who receive outpatient rehabilitation services; and evaluate the timing of outpatient rehabilitation and its association with other health care utilization. DESIGN: Rretrospective cohort study was conducted using a random 10% sample of 2009-2010 Medicare claims. The sample included 52,504 beneficiaries presenting within the ambulatory setting for management of NTKP. METHODS: Exposure to outpatient rehabilitative services following the NTKP index ambulatory visit was defined as 1) no rehabilitation; 2) early rehabilitation (1-15 days); 3) intermediate rehabilitation (16-120 days); and 4) late rehabilitation (>120 days). Logistic regression models were fit to analyze the association of rehabilitation timing with narcotic analgesic use, utilization of nonsurgical invasive procedure, and knee surgery during a 12-month follow-up period. RESULTS: Only 11.1% of beneficiaries were exposed to outpatient rehabilitation services. The likelihood of using narcotics, nonsurgical invasive procedures, or surgery was significantly less (adjusted odds ratios; 0.67, 0.50, 0.58, respectively) for those who received early rehabilitation when compared to no rehabilitation. The exposure-outcome relationships were reversed in the intermediate and late rehabilitation cohorts. LIMITATIONS: This was an observational study, and residual confounding could affect the observed relationships. Therefore, definitive conclusions regarding the causal effect of rehabilitation exposure and reduced utilization of more aggressive interventions cannot be determined at this time. CONCLUSIONS: Early referral for outpatient rehabilitation may reduce the utilization of health services that carry greater risks or costs in those with NTKP.

Yoga, Physical Therapy, or Education for Chronic Low Back Pain: A Randomized Noninferiority Trial.

BACKGROUND: Yoga is effective for mild to moderate chronic low back pain (cLBP), but its comparative effectiveness with physical therapy (PT) is unknown. Moreover, little is known about yoga's effectiveness in underserved patients with more severe functional disability and pain. OBJECTIVE: To determine whether yoga is noninferior to PT for cLBP. DESIGN: 12-week, single-blind, 3-group randomized noninferiority trial and subsequent 40-week maintenance phase. (ClinicalTrials.gov: NCT01343927). SETTING: Academic safety-net hospital and 7 affiliated community health centers. PARTICIPANTS: 320 predominantly low-income, racially diverse adults with nonspecific cLBP. INTERVENTION: Participants received 12 weekly yoga classes, 15 PT visits, or an educational book and newsletters. The maintenance phase compared yoga drop-in classes versus home practice and PT booster sessions versus home practice. MEASUREMENTS: Primary outcomes were back-related function, measured by the Roland Morris Disability Questionnaire (RMDQ), and pain, measured by an 11-point scale, at 12 weeks. Prespecified noninferiority margins were 1.5 (RMDQ) and 1.0 (pain). Secondary outcomes included pain medication use, global improvement, satisfaction with intervention, and health-related quality of life. RESULTS: One-sided 95% lower confidence limits were 0.83 (RMDQ) and 0.97 (pain), demonstrating noninferiority of yoga to PT. However, yoga was not superior to education for either outcome. Yoga and PT were similar for most secondary outcomes. Yoga and PT participants were 21 and 22 percentage points less likely, respectively, than education participants to use pain medication at 12 weeks. Improvements in yoga and PT groups were maintained at 1 year with no differences between maintenance strategies. Frequency of adverse events, mostly mild self-limited joint and back pain, did not differ between the yoga and PT groups. LIMITATIONS: Participants were not blinded to treatment assignment. The PT group had disproportionate loss to follow-up. CONCLUSION: A manualized yoga program for nonspecific cLBP was noninferior to PT for function and pain. PRIMARY FUNDING SOURCE: National Center for Complementary and Integrative Health of the National Institutes of Health.

Treatment-based Classification System for Patients With Low Back Pain: The Movement Control Approach.

We present the movement control approach as part of the treatment-based classification system. This approach proposes a movement control schema that clarifies that movement control is a product of the interplay among multiple biopsychosocial components. The schema illustrates that for movement to occur in a dynamically controlled fashion, the lumbar spine requires both local mobility and global stability. Local mobility means that the lumbar spine and its adjacent regions possess adequate nerve and joint(s) mobility and soft tissue compliance (ie, the malleability of tissue to undergo elastic deformation). Global stability means that the muscles of the lumbar spine and its adjacent regions can generate activation that is coordinated with various joint movements and incorporated into activities of daily living. Local mobility and global stability are housed within the bio-behavioral and socio-occupational factors that should be addressed during movement rehabilitation. This schema is converted into a practical physical examination to help the rehabilitation provider to construct a clinical rationale as to why the movement impairment(s) exist. The examination findings are used to guide treatment. We suggest a treatment prioritization that aims to consecutively address neural sensitivity, joint(s) and soft tissue mobility, motor control, and endurance. This prioritization enables rehabilitation providers to better plan the intervention according to each patient's needs. We emphasize that treatment for patients with low back pain is not a static process. Rather, the treatment is a fluid process that changes as the clinical status of the patient changes. This movement control approach is based on clinical experience and indirect evidence; further research is needed to support its clinical utility.

Perceived performance and impact of a non-physician-led interprofessional team in a trauma clinic setting.

Faced with the challenge of meeting the wide degree of post-discharge needs in their trauma population, the University of Pittsburgh Medical Center (UPMC) developed a non-physician-led interprofessional team to provide follow-up care at its UPMC Falk Trauma Clinic. We assessed this model of care using a survey to gauge team member perceptions of this model, and used clinic visit documentation to apply a novel approach to assessing how this model improves the care received by clinic patients. The high level of perceived team performance and cohesion suggests that this model has been successful thus far from a provider perspective. Patients are seen most frequently by audiologists, while approximately half of physical therapy and speech language therapy consults generate a new therapy referral, which is interpreted as a potential change in the patient's care trajectory. The broader message of this analysis is that a collaborative, non-hierarchical team model incorporating rehabilitative specialists, who often operate independently of one another, can be successful in this setting, where patients appear to have a strong and previously under-attended need for rehabilitative intervention.

Variations in Patterns of Utilization and Charges for the Care of Headache in North Carolina, 2000-2009: A Statewide Claims' Data Analysis.

OBJECTIVES: The purpose of the study was to compare patterns of utilization and charges generated by medical doctors (MDs), doctors of chiropractic (DCs), and physical therapists (PTs) for the treatment of headache in North Carolina. METHODS: Retrospective analysis of claims data from the North Carolina State Health Plan for Teachers and State Employees from 2000 to 2009. Data were extracted from Blue Cross Blue Shield of North Carolina for the North Carolina State Health Plan using International Classification of Diseases, Ninth Revision, diagnostic codes for headache. The claims were separated by individual provider type, combination of provider types, and referral patterns. RESULTS: The majority of patients and claims were in the MD-only or MD plus referral patterns. Chiropractic patterns represented less than 10% of patients. Care patterns with single-provider types and no referrals incurred the least charges on average for headache. When care did not include referral providers or services, MD with DC care was generally less expensive than MD care with PT. However, when combined with referral care, MD care with PT was generally less expensive. Compared with MD-only care, risk-adjusted charges (available 2006-2009) for patients in the middle risk quintile were significantly less for DC-only care. CONCLUSIONS: Utilization and expenditures for headache treatment increased from 2000 to 2009 across all provider groups. MD care represented the majority of total allowed charges in this study. MD care and DC care, alone or in combination, were overall the least expensive patterns of headache care. Risk-adjusted charges were significantly less for DC-only care.

Variations in Patterns of Utilization and Charges for the Care of Neck Pain in North Carolina, 2000 to 2009: A Statewide Claims' Data Analysis.

OBJECTIVES: The purpose of the study was to compare utilization and charges generated by medical doctors (MD), doctors of chiropractic (DC) and physical therapists (PT) by provider patterns of care for the treatment of neck pain in North Carolina. METHODS: This was an analysis of neck-pain-related closed claim data from the North Carolina State Health Plan for Teachers and State Employees (NCSHP) from 2000 to 2009. Data were extracted from Blue Cross Blue Shield of North Carolina for the NCSHP using ICD-9 diagnostic codes for uncomplicated neck pain (UNP) and complicated neck pain (CNP). RESULTS: Care patterns with single-provider types and no referrals incurred the least average charges for both UNP and CNP. When care did not include referral providers or services, for either UNP or CNP, MD care with PT was generally less expensive than MD care with DC care. However, when care involved referral providers or services, MD and PT care was on average more expensive than MD and DC care for either UNP or CNP. Risk-adjusted charges for patients in the middle quintile of risk (available 2006-2009) were lower for chiropractic patients with or without medical care or referral care to other providers. CONCLUSIONS: Chiropractic care alone or DC with MD care incurred appreciably fewer charges for UNP or CNP compared to MD care with or without PT care, when care included referral providers or services. This finding was reversed when care did not include referral providers or services. Risk-adjusted charges for UNP and CNP patients were lower for DC care patterns.

Variations in Patterns of Utilization and Charges for the Care of Low Back Pain in North Carolina, 2000 to 2009: A Statewide Claims' Data Analysis.

OBJECTIVES: The purpose of the study was to compare utilization and charges generated by medical doctors (MD), doctors of chiropractic (DC) and physical therapists (PT) by patterns of care for the treatment of low back pain in North Carolina. METHODS: This was an analysis of low-back-pain-related closed claim data from the North Carolina State Health Plan for Teachers and State Employees from 2000 to 2009. Data were extracted from Blue Cross Blue Shield of North Carolina for the North Carolina State Health Plan using International Classification of Diseases, 9th Revision diagnostic codes for uncomplicated low back pain (ULBP) and complicated low back pain (CLBP). RESULTS: Care patterns with single-provider types and no referrals incurred the least charges on average for both ULBP and CLBP. When care did not include referral providers or services, for ULBP, MD and DC care was on average $465 less than MD and PT care. For CLBP, MD and DC care averaged $965 more than MD and PT care. However, when care involved referral providers or services, MD and DC care was on average $1600 less when compared to MD and PT care for ULBP and $1885 less for CLBP. Risk-adjusted charges (available 2006-2009) for patients in the middle quintile of risk were significantly less for DC care patterns. CONCLUSIONS: Chiropractic care alone or DC with MD care incurred appreciably fewer charges for ULBP than MD care with or without PT care. This finding was reversed for CLBP. Adjusted charges for both ULBP and CLBP patients were significantly lower for DC patients.