Establishing appropriate and realistic goals and expected outcomes for patients with a declining functional status can be challenging – knowing that the ultimate trajectory of function is expected to be downward. A new APTA podcast series addresses the challenges of and suggests solutions for managing the care of these patients, who may have conditions such as Parkinson disease, muscular sclerosis, cystic fibrosis, or late-stage congestive heart failure.

The first podcast begins with general functional status and safety examples. In upcoming podcasts physical therapists will share their experiences in applying these principles to specific patients with conditions that are characterized by a declining functional status.

Self-management interventions are widely recommended for patients with low back pain (LBP), but a meta-analysis by Australian researchers suggests that its effects on pain and disability are likely to be small and are supported by only moderate-quality evidence, says a Medscape Medical News article.

The researchers included randomized controlled trials evaluating self-management for nonspecific LBP and assessing pain and disability in their review. They pooled data when studies were similar enough and divided analyses into short-term (less than 6 months after randomization) and long-term (at least 12 months after randomization) outcomes.

They found 13 original trials that met inclusion criteria. Efficacy of self-management (including shared responsibility for a plan of care, self-monitoring, and management of signs and symptoms) was compared with efficacy of minimal intervention and with other interventions such as massage, acupuncture, yoga, and exercise.

"The improvement [in pain and disability] was less than what is generally considered worthwhile by patients," said lead author Vincinius C. Oliveira. Specifically, the short-term improvement was -3.2 points on a 100-point scale for pain and -2.3 points for disability. According to the authors, effect sizes of 20% to 30% are needed for patients to consider interventions worthwhile.

Dawn Carnes, DO, director of the National Council for Osteopathic Research and senior research fellow at the London School of Medicine and Dentistry in the United Kingdom, told Medscape that she was surprised by the strength of the authors' conclusion because small changes in large populations (such as LBP) do make a difference at a population level. 

Carnes also voiced concerned about the review's inclusion criteria. She said, "[The authors] included all types of [LBP], including chronic. Why would you expect pain to improve in a chronic pain population, where drugs don't even work for these people? Similarly, disability is unlikely to change in chronic patients, especially those with permanent bony or physiological change."

The researchers told Medscape that they "were surprised by lack of definition criteria for self-management. The study raised questions that our group is currently working on such as consensus on what self-management for [LBP] is among experts, including clinicians and researchers."

In comparing self-management with minimal intervention, the authors found "moderate-quality evidence that self-management interventions have small but statistically significant effects, compared to minimal interventions, on pain and disability for LBP."

In addition, they found only low-quality evidence that self-management is not better than massage, acupuncture, yoga, and exercise in reducing pain or disability in LBP.

The study was published online October 27 and in the November print issue of Arthritis Care & Research.

Physical activity, including walking on a treadmill and stretching and resistance exercise, appears to improve gait speed, muscle strength, and fitness for patients with Parkinson disease, say researchers at the University of Maryland. Their article is published online in Archives of Neurology.

The researchers compared 67 people with Parkinson disease who were randomly assigned to 1 of 3 exercise groups: walking on a treadmill at low intensity for 50 minutes, higher-intensity treadmill training to improve cardiovascular fitness for 30 minutes, and using weights (leg presses, extensions and curls) and stretching exercises to improve muscle strength and range of motion. Participants exercised 3 times a week for 3 months under the supervision of exercise physiologists at the Baltimore VA Medical Center.

The investigators found improved cardiovascular fitness in both the higher- and lower-intensity treadmill exercise groups. However, only the stretching and resistance exercises improved muscle strength (16% increase) during the study.

One key measurement was distance covered during a 6-minute walk, where all 3 types of exercisers showed improvement compared with their baseline measurement: lower-intensity treadmill exercise (12% increase), stretching and resistance exercises (9% increase), and higher-intensity treadmill exercises (6% increase).

"We are encouraged to see that the lower-intensity treadmill exercise, which is feasible for most Parkinson patients, proved to have the greatest benefit for mobility while also improving cardiovascular fitness," said Lisa Shulman, MD, the study's principle investigator.

E. Ray Dorsey, MD, coauthor of an accompanying journal editorial, told HealthDay News, "I hope this study adds to the evidence that exercise should be the standard of care."

In order to continue to provide states that are pursuing state-based exchanges with appropriate technical support, the Department of Health and Human Services (HHS) is extending the deadline for blueprint applications to Friday, December 14. Originally states had to provide federal regulators a blueprint by November 16, as outlined in HHS' final rule. The deadline for a declaration letter for a state-based exchange remains Friday, November 16, 2012. In a November 9 letter sent to governors, HHS says it will approve or conditionally approve the state-based exchanges for 2014 by the statutory deadline of January 1, 2013.

HHS will accept declaration letters and blueprint applications for states that are pursuing state partnership exchanges and make approval determinations on a rolling basis. The final deadline for both the declaration letter and blueprint that would be effective for 2014 has been extended to Friday, February 15, 2013, says the letter. States will be able to apply to run these exchanges in subsequent years.

Most qualified health plans offered in exchanges must include the 10 categories of essential health benefits (EHB) mandated by the Affordable Care Act, which include rehabilitative and habilitative services. HHS is expected to release the final rule on EHB in the near future.

A new study reveals that black Americans display lower levels of vitamin D and greater pain sensitivity than do white Americans. A Vitamin D deficiency may be a risk factor for increased knee osteoarthritic pain in black Americans, the authors conclude. 

Clinical practice guidelines state that vitamin D levels less than 20 ng/mL represent deficiency, and levels between 21 and 29 ng/mL represent insufficiency. Given that low levels of vitamin D are linked to chronic pain and other health conditions, especially in black Americans, the research team set out to investigate if variations in vitamin D levels contribute to racial differences in patients with knee pain caused by osteoarthritis (OA).

Researchers at the University of Florida and the University of Alabama at Birmingham recruited 94 participants—45 black and 49 white patients with symptomatic knee OA—to complete questionnaires regarding their symptoms. The study group was 75% female and an average 56 years old.

In addition, study participants underwent testing that included sensitivity to heat and mechanical pain on the affected knee and the forearm. Researchers measured heat pain threshold as the point when patients indicate the sensation "first becomes painful" and pain tolerance when patients "no longer feel able to tolerate the pain." Mechanical pain measures were determined by the patients' response to pressure in the knee and forearm.

Findings indicate that despite living in a southern sunny climate, 84% of black participants had vitamin D levels less than 30 ng/mL compared with 51% of white subjects. Furthermore, the average vitamin D level for black Americans was 19.9 ng/mL (deficiency), compared with white Americans who averaged 28.2 ng/mL (insufficiency). Black participants reported greater overall knee osteoarthritis pain, and those with lower vitamin D levels displayed greater sensitivity to heat and mechanical pain (experimental pain).

"Our data demonstrate that differences in experimental pain sensitivity between the 2 races are mediated at least in part by variations in vitamin D levels," said lead author Toni Glover, MSN, ARNP. "However, further studies are needed to fully understand the link between low vitamin D levels and racial disparities in pain."

Healthcare 411, a new podcast series produced by the Agency for Healthcare Research and Quality (AHRQ), shares news and information about current research on important health care topics to help consumers with health care decision making.

Content provided by the Healthcare 411 Web site includes interviews that range from 60 seconds to 15 minutes on a variety of health topics. Programs remain available and searchable on the Healthcare 411 site. The site also hosts audio and video public service announcements produced by AHRQ and provides links to related consumer publications and other studies and guides funded by AHRQ.