Joel M. Stevans

Comparison of spinal manipulation methods and usual medical care for acute and subacute low back pain: a randomized clinical trial.

Study Design. Randomized controlled trial with follow-up to 6 months. Objective. This was a comparative effectiveness trial of manual-thrust manipulation (MTM) versus mechanical-assisted manipulation (MAM); and manipulation versus usual medical care (UMC). Summary of Background Data. Low back pain (LBP) is one of the most common conditions seen in primary care and physical medicine practice. MTM is a common treatment for LBP. Claims that MAM is an effective alternative to MTM have yet to be substantiated. There is also question about the effectiveness of manipulation in acute and subacute LBP compared with UMC. Methods. A total of 107 adults with onset of LBP within the past 12 weeks were randomized to 1 of 3 treatment groups: MTM, MAM, or UMC. Outcome measures included the Oswestry LBP Disability Index (0–100 scale) and numeric pain rating (0–10 scale). Participants in the manipulation groups were treated twice weekly during 4 weeks; subjects in UMC were seen for 3 visits during this time. Outcome measures were captured at baseline, 4 weeks, 3 months, and 6 months. Results. Linear regression showed a statistically significant advantage of MTM at 4 weeks compared with MAM (disability = −8.1, P = 0.009; pain = −1.4, P = 0.002) and UMC (disability = −6.5, P = 0.032; pain = −1.7, P < 0.001). Responder analysis, defined as 30% and 50% reductions in Oswestry LBP Disability Index scores revealed a significantly greater proportion of responders at 4 weeks in MTM (76%; 50%) compared with MAM (50%; 16%) and UMC (48%; 39%). Similar between-group results were found for pain: MTM (94%; 76%); MAM (69%; 47%); and UMC (56%; 41%). No statistically significant group differences were found between MAM and UMC, and for any comparison at 3 or 6 months. Conclusion. MTM provides greater short-term reductions in self-reported disability and pain scores compared with UMC or MAM. Level of Evidence: 2

The 2008 prevalence of chiropractic use in the US adult population.

OBJECTIVE The purpose of this study was to produce prevalence estimates and identify determinants of variability in chiropractic use in the US adult population. METHODS The Medical Expenditure Panel Survey was used to estimate prevalence for the adult population and subpopulations according to several sociodemographic, geographic, and health characteristics. Multivariable logistic regression model was used to explore the effects of the independent predictors on chiropractic use. RESULTS The 2008 chiropractic prevalence of use was estimated to be 5.2% (95% confidence interval, 4.7-5.6). The adjusted odds of using chiropractic services were approximately 46% less for Asians, 63% less for Hispanics, and 73% less for blacks compared with whites; 21% less for men than women; and 68% higher for those with arthritis compared with those without. Persons from high-income families have greater odds of using chiropractic services compared with those from middle-income (42%) and low-income (67%) families. There was a significant interaction between Census region and urban-rural location. The results showed the prevalence of chiropractic use to be highest in small metro areas in the Midwest (10.5%) and Northeast (10.4%) as well as micropolitan/noncore areas in the West (10.8%) and Midwest (10.1%). CONCLUSIONS This study validates previous findings showing the prevalence of use is higher for whites, women, and persons with higher family income or reported arthritis. The results of this study also indicate that chiropractic use varies across the urban-rural landscape depending on the region of the country, suggesting that the effect of geographic location may be more complex than previously reported.

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 yogas 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 Low Back Pain: Revision and Update

The treatment-based classification (TBC) system for the treatment of patients with low back pain (LBP) has been in use by clinicians since 1995. This perspective article describes how the TBC was updated by maintaining its strengths, addressing its limitations, and incorporating recent research developments. The current update of the TBC has 2 levels of triage: (1) the level of the first-contact health care provider and (2) the level of the rehabilitation provider. At the level of first-contact health care provider, the purpose of the triage is to determine whether the patient is an appropriate candidate for rehabilitation, either by ruling out serious pathologies and serious comorbidities or by determining whether the patient is appropriate for self-care management. At the level of the rehabilitation provider, the purpose of the triage is to determine the most appropriate rehabilitation approach given the patients clinical presentation. Three rehabilitation approaches are described. A symptom modulation approach is described for patients with a recent—new or recurrent—LBP episode that has caused significant symptomatic features. A movement control approach is described for patients with moderate pain and disability status. A function optimization approach is described for patients with low pain and disability status. This perspective article emphasizes that psychological and comorbid status should be assessed and addressed in each patient. This updated TBC is linked to the American Physical Therapy Associations clinical practice guidelines for low back pain.

Evidence-Based Practice Implementation: Case Report of the Evolution of a Quality Improvement Program in a Multicenter Physical Therapy Organization

Background and Purpose Our nations suboptimal health care quality and unsustainable costs can be linked to the failure to implement evidence-based interventions. Implementation is the bridge between the decision to adopt a strategy and its sustained use in practice. The purpose of this case report is threefold: (1) to outline the historical implementation of an evidence-based quality improvement project, (2) to describe the programs future direction using a systems perspective to identify implementation barriers, and (3) to provide implications for the profession as it works toward closing the evidence-to-practice gap. Case Description The University of Pittsburgh Medical Center (UPMC) Centers for Rehab Services is a large, multicenter physical therapy organization. In 2005, they implemented a Low Back Initiative utilizing evidence-based protocols to guide clinical decision making. Outcomes The initial implementation strategy used a multifaceted approach. Formative evaluations were used repeatedly to identify barriers to implementation. Barriers may exist outside the organization, they can be created internally, they may result from personnel, or they may be a direct function of the research evidence. Since the program launch, 3 distinct improvement cycles have been utilized to address identified implementation barriers. Discussion Implementation is an iterative process requiring evaluation, measurement, and refinement. During this period, behavior change is actualized as clinicians become increasingly proficient and committed to their use of new evidence. Successfully incorporating evidence into routine practice requires a systems perspective to account for the complexity of the clinical setting. The value the profession provides can be enhanced by improving the implementation of evidence-based strategies. Achieving this outcome will require a concerted effort in all areas of the profession. New skills will be needed by leaders, researchers, managers, and clinicians.

Clinical, demographic, and geographic determinants of variation in chiropractic episodes of care for adults using the 2005-2008 Medical Expenditure Panel Survey.

OBJECTIVE The primary aim of this study was to report nationally representative estimates of the visit utilization, per visit expenditures, and total expenditures for chiropractic episodes of care in the US adult population. The secondary aim was to identify clinical, demographic, geographic, and payment factors associated with variation in the levels of utilization and expenditures. METHODS Data from the 2005-2008 Medical Expenditure Panel Survey were used to construct complete episodes of chiropractic care (n = 1639) for the civilian, noninstitutionalized adult population. Bivariate descriptive statistics were calculated for visit utilization, per visit expenditures, and total expenditures per episode of care by several clinical, demographic, geographic, and payment variables. Multivariable regression models were used to evaluate the effects of the independent variables on each of the 3 dependent variables. RESULTS The unadjusted mean number of visits per episode was 5.8 (95% confidence interval [CI], 5.3-6.4] and varied significantly by race/ethnicity, perceived mental health, urban-rural location, and source of payment. The mean total expenditures per visit per episode were estimated to be

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

69 (95% CI,

Innovative approaches to interprofessional care at the University of Pittsburgh Medical Center.

65-

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

73). There was variation associated with the census region, urban-rural location, and source of payment variables. Total expenditures for an episode of care were estimated to be

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

424 (95% CI,