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.

The immediate effect of atlanto-axial high velocity thrust techniques on blood flow in the vertebral artery: A randomized controlled trial.

BACKGROUND: High velocity thrust (HVT) cervical techniques have been associated with serious vertebral artery (VA) trauma. Despite numerous studies, the nature of this association is uncertain. Previous studies have failed to demonstrate haemodynamic effects on the VA in simulated pre-thrust positions. No study has investigated haemodynamic affects during or immediately following HVT, nor sufficiently controlled for the influence of the thrust. OBJECTIVES: To investigate the immediate effects of HVT of the atlanto-axial joint upon haemodynamics in the sub-occipital portion of the vertebral artery (VA3). DESIGN: Randomized Controlled Trial. METHOD: Twenty-three healthy participants (14 women, 9 men; mean age 40, range 27-69 years of age) were randomly assigned to two groups: an intervention group (MANIP, n = 11) received HVT to the atlanto-axial segment whilst a control group (CG, n = 12) was held in the pre-manipulative hold position. Colour-flow Doppler ultrasound was used to measure VA3 haemodynamics. Primary outcome measures were peak systolic (PSV) and end diastolic velocities (EDV) of three cardiac cycles measured at neutral (N1), pre-HVT (PreMH), post-HVT (PostMH), post-HVT-neutral (N2) positions. RESULTS: Test-retest reliability for the Doppler measures demonstrated intra-class correlation coefficient (ICC) of 0.99 (95% CI 0.98-1.0) for PSV and 0.91 (95% CI 0.84-0.96) for EDV. Visually, EDV were lower in the MANIP group than in the CONTROL group across the four measurements. However, there were no significantly different changes (at p ≤ 0.01) between the MANIP and CONTROL groups for any measurement variable. CONCLUSIONS: HVT to the atlanto-axial joint segment does not affect the haemodynamics of the sub-occipital portion of the vertebral artery during or immediately following HVT in healthy subjects.