• Tuesday, November 24, 2015RSS Feed

    Patients, PTs Generally Agree on LBP Triggers

    While patient education can be an important part of treatment for low back pain (LBP), physical therapists (PTs) and physical therapist assistants (PTAs) may not have as much educating to do when it comes to triggers for the condition. According to a new study from Australia, patients' understanding of what causes sudden-onset acute LBP is fairly consistent with PTs' views.

    For the study, e-published ahead of print in Spine (abstract only available for free), researchers surveyed 102 PTs and 999 patients with sudden onset acute LBP to find out perceptions around common triggers. The groups were asked slightly different questions: patients were asked what they thought caused their own LBP episode, while the PTs were asked to list "the 5 most likely factors involving short-term exposure that are triggers for a sudden episode of LBP."

    Though the questions were different, the answers showed "remarkably similar" perceptions among both groups, according to the study's authors.

    In terms of broad categories—"individual," "biomechanical," "psychological/psychosocial," "genetic," and "other"—biomechanical was the clear winner, with 87.7% of patients and 89.4% of PTs citing that broad area as the most important risk factor. When it came to kinds of biomechanical events that are triggers, PTs and patients further agreed in citing lifting, bending, and prolonged sitting the most important triggers (lifting was most common).

    Though agreement was significant, patients and PTs did part ways with a few trigger subcategories, with patients more often pointing to awkward posture (31.4% of patients vs 1.2% of PTs) and sports injury (15.9% of patients vs 4.7% of PTs) as a trigger. PTs, on the other hand, more often cited physical trauma (9.2% of PTs vs 3.4% of patients) and unaccustomed activity (7.3% of PTs vs 2.3% of patients) as triggers.

    Other findings from the study:

    • Even though psychological and psychosocial factors have been linked to increased risk for LBP, neither group in this study cited these triggers in significant numbers. Authors described this discrepency as something that "warrants further investigation."
    • Authors noted that while prolonged sitting was one of the most-frequently cited triggers, "there is little to no evidence that prolonged sitting is an independent risk factor for LBP."
    • Researchers believe that some of the differences between the groups may be related to how the question itself was read and understood. For example, they assert, patients may interpret a "sports injury" as any injury that occurs while playing a sport, while PTs are more likely to pinpoint the biomechanical cause of the injury.

    Ultimately, the findings produced a kind of "no news is good news" result for researchers, who were particularly interested in defining the scope of triggers perceived by the groups and uncovering any "novel triggers" that may be overlooked by PTs or patients. According to the study's authors, high levels of agreement around a particular condition contribute to greater patient satisfaction and compliance with treatment.

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Friday, November 20, 2015RSS Feed

    Study: Increased Leg Power Associated With Slower Cognitive Aging in Women

    Women who want to protect themselves against cognitive decline as they age could get a leg up through legwork, according to a new study that found "a striking protective relationship" between aging women's leg power and cognitive changes over 12 years.

    Researchers in England reached this conclusion after analyzing leg muscle power and cognitive performance among 324 healthy female twins at baseline (average age, 55; range 43-73) and then 12 years later. After controlling for health and demographic variables, they found that the women who had increased leg power at baseline scored better on tests of brain processing speed and visual memory 12 years later than the women with lower leg power at baseline. Overall differences were modest but consistent, with a 40-watt leg explosive power (LEP) increase correlated with an average 3.3 years' lower cognitive age.

    Authors of the study assert that the use of twins further strengthens their conclusions, because they were able to compare 10-year differences among "discordant" twins—twins with similar genetic traits and childhood environmental influences, but whose leg power was different at baseline. As with entire group comparisons, researchers found that the twin with the greater leg power tended to demonstrate slower cognitive decline than her sister. The strongest differences were noted in dizygotic (fraternal) twins; less so in monozygotic (identical) twins.

    The differences weren't just revealed in test scores—magnetic resonance imaging of the brains of a subset of participants revealed larger gray matter volume at 12 years after the baseline leg power assessment. Results were published online in the November 10 issue of Gerontology.

    Researchers chose LEP as a measurement of physical fitness because they felt that it was "sensitive to low-intensity [physical activity], " and that it is associated with functional ability "and declines with age earlier, and more dramatically, than physical strength." The baseline LEP scores were measured using the Leg Extensor Power Rig designed by the Nottingham University Medical School.

    Authors of the study write that their work stands out in at least 2 ways: it's the first study "linking a power of large leg muscular response to brain changes," and it's one of a very few studies that have tracked the effects of fitness on cognition and brain function over more than 10 years.

    While they acknowledge that the study does not itself prove causality between physical fitness and brain aging, authors argue that like earlier research, their work "support[s] the probability of a causal relationship."

    Exactly what that relationship might be is a matter for further research, however.

    Authors of the Gerontology study offer a couple of possible explanations. One option, they write, is that LEP itself could be related to cognitive aging "through a shared mechanism which is independent of genetic and many development factors and specific to lower limb and/or speed and coordination of muscle function, which affects lower limb power before cognition." If that's the case, they write, research should focus on "non-genetic mechanisms" such as cellular changes in brain and muscle tissue in response to the environment.

    But the simpler—and hence more likely—possibility is that leg power is a good marker of physical activity levels, which are correlated with slower brain aging.

    "The principle of parsimony would favor this latter explanation," they write. "If so, interventional trials aimed at improving leg power over the long term may be fruitful in the search for strategies to improve cognitive aging in the healthy population."

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.  

    Friday, November 13, 2015RSS Feed

    Study: For Best LBP Results, Take a PT's Advice – Plus Customized Physical Therapy

    The role of education and advice in the treatment of low back pain (LBP) may be important, but it's probably not as effective as coupling that advice with physical therapy that's been "individualized" to the particular kind of LBP a patient is experiencing, according to a new study from Australia.

    Researchers focused on 300 patients, aged 18-65 (average age, 44.2) who had experienced LBP for between 6 weeks and 6 months. They split participants into 2 groups: 1 group received 2 30-minute education and advice sessions provided by a physical therapist (PT), plus 10 30-minute physical therapy sessions over 10 weeks; the other group received the education and advice sessions only. Results were e-published ahead of print in the British Journal of Sports Medicine (abstract only available for free).

    Previous research has taken a similar approach, but what makes the latest study different is that the physical therapy participants were further subdivided into 5 groups based on the nature of their LBP: disc herniation with associated radiculopathy, reducible discogenic pain, nonreducible discogenic pain, zygapophysical joint pain, and multifactorial persistent pain. Each group received an "individualized" treatment protocol during the 10 sessions. Those treatments were:

    Reducible discogenic pain—home exercise and postural reeducation program "based on mechanical loading strategies"

    Zygapophysical joint pain—targeted manual therapy

    Disc herniation with associated radiculopathy and nonreducible discogenic pain (2 groups)—motor control training leading to a functional exercise program

    Multifactoral persistent pain—physical therapy "focusing on psychosocial and neurophysiological rather than pathoanatomical mechanisms"

    In every subgroup, participants receiving physical therapy reported better function outcomes than their advice-only counterparts at 10, 26, and 52 weeks after treatment, as well as better back and leg pain outcomes at 5, 10, and 26 weeks. Researchers estimated that the participants receiving physical therapy had a 1.8 times greater chance of improving back pain by 50% or more compared with the advice group. The chance of a 50%-or-more improvement in leg pain was estimated at 1.6 times that of the advice group.

    While all groups registered improvements that met standards for minimally clinically important difference (MCID), the difference between the physical therapy and advice-only groups did not meet the MCID threshold for primary outcomes. Authors of the study characterize the differences as "statistically significant," and argue that "the MCID was developed for use on individuals, and application to mean between-group differences may not be appropriate."

    "Given the population sampled were [6 weeks or more] postinjury where spontaneous recovery is limited, it is likely that both treatments were effective, with [individualized physical therapy] conferring additional benefits over and above advice," authors write.

    The newest study is 1 of several recently published studies that have looked at the relationship between physical therapy and LBP. Another study, published in October, looked at 1-year outcomes for individuals with LBP who received education and early physical therapy, and compared those with outcomes for individuals who received only PT-led education. In that study, researchers found few differences in outcomes between the 2 groups.

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Tuesday, October 27, 2015RSS Feed

    Physical Therapy Achieves Faster Outcomes Than Surgery for Common Type of Shoulder Dislocation

    Acromio-clavicular (AC) joint dislocations—even moderate-to-severe cases—may be better-treated through nonsurgical approaches, according to a new study from Canada that found better short-term outcomes, faster return-to-work rates, and fewer complications among individuals who received physical therapy only.

    The study aimed to compare outcomes among patients who received hook plate fixation surgery—a common surgical technique—with patients who received nonoperative care including using a sling for 4 weeks and then participating in a "standard physiotherapy regimen" of active and passive exercise followed by resistance and strengthening exercises for 6 weeks after injury. Progress in several areas was measured at discharge, 6 weeks, 3 months, 6 months, 1 year, and 2 years.

    When researchers analyzed results from 83 patients treated between 2008 and 2010, they found that the 43 participants who received the nonoperative care averaged scores on the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire that were significantly better than the surgery group at 6 weeks and 2 months. After that, DASH scores were similar, with both groups reporting improvements. Results were published in the November Journal of Orthopaedic Trauma (abstract only available for free).

    The nonoperative group also experienced faster return-to-work rates, with 75% of those patients returning to work in 3 months, compared with 43% of the surgery patients. Another plus for the nonoperative group: complications were less prevalent, with only 2 patients reporting problems. Among the surgery group, 14 complications were recorded, including plate loosenings, clavicular fracture, and a deep wound infection.

    The only areas that seemed to favor surgery had to do with imaging and aesthetics. Because the hook plate is designed to return the joint to its preinjury position, radiographs of the joints of the surgery group were better than the nonsurgical group in terms of coraco-clavicular distance. Similarly, because all individuals in the nonsurgical group had a displaced distal clavicle, participants in the physical therapy-only approach tended to be less satisfied with the look of their shoulder after 1 year.

    Principal investigator Michael McKee, MD, believes that surgery's ability to create a shoulder that "appears more symmetrical and pleasing to the eye" is just about the only thing that would make going under the knife a preferable option.

    "While satisfaction with the appearance of the shoulder should be a consideration, I believe surgeons should think twice before recommending surgery for an AC joint dislocation—regardless of the severity," McKee said in a press release. "Patients who forgo surgery return to work sooner, experience less disability during the first months after injury, and have fewer complications."

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Monday, October 26, 2015RSS Feed

    'Choosing Wisely' Campaign Registers Mixed Results in Study of 7 Low-Value Services

    The "Choosing Wisely" campaign aimed at reducing the use of unnecessary medical procedures, treatments, and tests may have received plenty of media attention since its beginnings in 2012, but new research has concluded that so far, the initiative hasn't made a significant dent in the problem—though there are signs that it may be having an effect in some areas. Authors of a new study on the campaign see those mixed results as a call for more focused efforts to more closely link "Choosing Wisely" with actual practice.

    Researchers wanted to find out if 7 specific "Choosing Wisely" recommendations, included since the list's early days, were being used less frequently after being identified as unnecessary in most patient circumstances. To do this, they reviewed insurance claims data from 25 million members of Anthem-affiliated Blue Cross and Blue Shield programs for at least 10 quarters between 2010 and 2013 to compare usage rates pre- and post-“Choosing Wisely.”

    The 7 treatments studied were: imaging tests for headache with uncomplicated conditions; cardiac imaging for members without a history of cardiac conditions; preoperative chest x-rays with unremarkable history and physical examination results; low back pain imaging for members without red flag conditions; human papillomavirus (HPV) testing for women under age 30; antibiotics for acute sinusitis; and prescription nonsteroidal anti-inflammatory drugs (NSAIDs) for members with hypertension, heart failure, or chronic kidney disease.

    What researchers found was that only 2 services—imaging for headaches and cardiac imaging—showed declines in use, while the use of NSAIDs and HPV testing of women under 30 actually increased slightly. The other 3 services "remained high with no statistically significant changes," authors write. Results were published in the October 12 online edition of JAMA Internal Medicine (abstract only available for free).

    "Choosing Wisely" is a project developed by the American Board of Internal Medicine Foundation in partnership with Consumer Reports, and now includes recommendations from over 70 societies. APTA became 1 of the first non-physician groups to be included in the campaign with the 2014 publication of its list of "5 Things Physical Therapists and Patients Should Question." Since its debut, the APTA list has been featured on National Public Radio, US News and World Report, and other media outlets.

    Authors of the JAMA study point out that there is broad consensus around the idea that the services they studied are in fact low-value practices that should not be used frequently. In this regard, their study "underscores the view that simple publication of recommendations—such as the 'Choosing Wisely' lists—is insufficient to produce major changes to practice," they write.

    While authors acknowledge that usage of the services "could be affected by changes in the nature and size of the target population over time, or in criteria used for clinical diagnoses," they believe that these changes were not countered by a sufficiently strong campaign to decrease usage.

    The bottom line, they believe, is that more needs to be done to support the “Choosing Wisely” campaign.

    "Our mixed results highlight the need for interventions beyond the current level of promotion, such as data feedback, physician communication training, systems interventions … , clinical scorecards, patient-focused strategies, and financial incentives," they write.

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Friday, October 23, 2015RSS Feed

    Study: For Some, TKA With Nonsurgical Treatment Better Than Nonsurgical Treatment Alone

    According to a new study, patients with moderate-to-severe knee osteoarthritis (OA) who receive knee replacement surgery (TKA) and conservative treatment that includes physical therapy tend to fare better after 12 months than those who receive only the conservative treatment, though both groups see significant improvement. Researchers believe the findings—which also reported higher rates of serious adverse events for the surgery group—underscore the need for considering patients' "preferences and values" before deciding on a course of treatment.

    The study analyzed data from 95 patients who presented with moderate-to-severe knee OA and were determined to be eligible for TKA, with roughly half receiving TKA followed by 12 weeks of multidisciplinary rehabilitation, and the other half receiving only the rehabilitation treatment. Using the Knee Injury and Osteoarthritis Outcome Score (KOOS) as the primary outcome measure, researchers found that 1 year later, the surgery group recorded KOOS scores that were, on average, 16.5 points above the nonsurgical group on the 100-point KOOS scale (researchers used 10 points as the threshold for a minimal clinically important difference). Secondary outcome measures, including the Timed Up-and-Go test and averages of 20-meter walk tests, were also more favorable for the surgery group.

    The nonsurgical treatment administered to both groups comprised 5 interventions that included exercise, education, dietary advice, the use of special insoles, and pain medication when determined necessary for participation by an orthopedic surgeon (acetaminophen, ibuprofen, and pantoprazole). The exercise sessions were conducted in weekly 1-hour group sessions held over the course of 12 weeks and emphasized "neutral, dynamic alignment," according to authors of the study. Researchers assessed outcomes at 3, 6, and 12 months after the startup of the nonsurgical treatment. Results were published in the New England Journal of Medicine.

    Researchers pointed out that while the surgical group reported a bigger change, "both groups in our study had substantial improvement with respect to most outcomes," and they noted that among the nonsurgical group, only 13 of the nonsurgical patients (26%) wound up having TKA before the 12-month follow-up. Further tempering the results as a conclusive finding in favor of one approach over the other, researchers found that serious adverse events—deep venous thrombosis, stiffness requiring manipulation, musculoskeletal problems in areas other than the index knee, and other conditions—occurred at a higher rate in the surgery group.

    A story on the research published in The New York Times described TKA-plus-rehabilitation as relieving pain and improving function "much more effectively than nonsurgical therapy alone" but noted that the findings don't necessarily mean that TKA is the best course of treatment in every case of moderate-to-severe knee OA.

    "Most surgeons have assumed that total knee replacement provides superior results," the NYT reports. "But experts said this new trial suggested that patients with severe osteoarthritis and difficulty walking should not always go under the knife."

    A recent WebMD article on the research reached a similar conclusion, saying that physical therapy "is often effective and should be viewed as a viable option."

    Authors of the study conclude that for the population studied, TKA and nonsurgical treatment is "superior" to nonsurgical treatment alone, although they acknowledge the effect exercise can have on outcomes, and advocate for approaches to treatment that are patient-centered.

    "Even for patients progressing to surgery, participation in supervised exercise before surgery has been associated with a faster postoperative recovery," authors write. "The benefits and harms of the respective treatments underscore the importance of considering patients' preferences and values during shared decision-making about treatment for moderate-to-severe knee osteoarthritis."

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Thursday, October 22, 2015RSS Feed

    Small Study Finds Varied Walking Speed Burns More Calories Than Steady Pace

    The value of interval training and changing up routines has been substantiated for more demanding exercise programs, so why couldn't the concept also apply to simply walking? It does, say researchers, who also found that an individual's naturally "preferred" walking speed varies depending on how far he or she has to walk.

    According to a small-scale study published in the September issue of Biology Letters(pdf), walking at varying speeds requires a 6% to 20% higher metabolic cost than walking at a constant rate, and the acts of starting and stopping alone could account for between 4% and 8% of the caloric costs of a walking episode. They assert that those starts, stops, and fluctuations aren't always considered when calculating the caloric burn associated with walking.

    The findings are based on research involving 16 healthy young adults (average age—23) who were asked to walk on a treadmill set to a constant speed, and then instructed to increase or decrease their pace—to walk toward the front or allow themselves to slow to the back of the treadmill—at varying intervals. Researchers used 2 models to evaluate energy consumption—one based on kinetic energy fluctuations and the other the inverted pendulum model—and were able to identify metabolic rate increases through both.

    In a second part of their investigation, researchers instructed 10 participants to each walk 10 distances—.5, 1, 2, 4, 6, 8, 10, 12, 14, and 89 meters—at a "comfortable" speed to find out if an individual's preferred rate varied depending on the walking distance required. The answer: it does, with participants tending to walk more slowly over shorter distances, and speeding things up when tasked with a longer walk.

    Researchers believe that the results of the study may help inform rehabilitation professionals as they assess patients and clients.

    "Rehabilitation walking speeds are used to quantify mobility and rehabilitation, so bout distances should be chosen to avoid artificially lowering speeds," authors write. As for the findings related to metabolic cost, they write that "using the cost of changing speeds may improve daily activity tracking, energy balance estimates for obesity, and metabolic estimates during sports."

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Tuesday, October 20, 2015RSS Feed

    Foundation Funding Opportunities Available

    The Foundation for Physical Therapy (Foundation) is now accepting applications for 2 major funding programs.

    Eligibility and application information for the postprofessional 2016 Promotion of Doctoral Studies (PODS) Scholarship and the New Investigator Fellowship Training Initiative (NIFTI) is now posted on the Foundation website. The deadline to apply is January 20, 2016, by 12:00 pm, ET.

    Applicants are encouraged to start the submission process early to allow for potential questions to be answered. Award recipients will be notified in June.

    Contact Rachael Crockett for more information, or call 800/875-1378, ext 3385.

    Important tip: thoroughly read through all instructions and funding mechanism deadlines before beginning your application. Want to stay on top of what's available? Sign up for the F4PT Alert and be first to know about Foundation funding opportunities.

    Monday, October 19, 2015RSS Feed

    Keeping PTs in the Workforce May Be Key to Reducing Anticipated Shortage

    No matter how you slice the data, there will likely be a growing shortage of physical therapists (PTs) in the coming years. And while there are several moving parts that could affect just how big the shortage will be, authors of a new study believe that keeping PTs from leaving the workforce could have a major impact on reducing those supply gaps.

    For the study, e-published ahead of print in APTA's journal Physical Therapy (PTJ), researchers compared methodologies they used in calculating workforce projections in 2010/2011, 2012, and 2013. Authors describe how changes to elements such as a rise in PT graduates, a decline in the number of PTs failing the National Physical Therapist Exam (NPTE) for licensure, and the increase in the number of insured Americans under the Affordable Care Act (ACA) have an effect on just how significant the shortage of PTs will be through 2020.

    But it turns out that the biggest variable may be 1 of the hardest to pin down—exactly how many PTs will be lost to attrition over the next 5 years.

    Because no definitive research has been conducted on PT attrition, researchers looked at similar work in other professions to get an idea of the range of anticipated rates. What they found was that these rates varied fairly widely; so, instead of agreeing on a single attrition rate for physical therapy, authors of the current study analyzed data using 3 models of annual attrition: 1.5%, 2.5%, and 3.5%.

    Plugging in those rates, the 2013 model anticipated that there will be a shortage of 27,822 PTs by 2020 if attrition occurs at a 3.5% rate. That shortage drops to 13,368 should the attrition rate occur at 2.5%, and further declines to 1,530 at the 1.5% rate.

    Estimates developed in 2014—available at the APTA website but not included in this report—adjust that gap slightly, to 26,969, 14,167, and 606 at the 3.5%, 2.5%, and 1.5% attrition rates, respectively.

    "The proposed model for projecting [PT] workforce indicates that the US supply of PTs appears to be headed toward a shortfall, and this shortfall is projected to persist with or without increased demand related to the ACA," authors write, elsewhere stating that "the models assume attrition is a significant factor.” Based on the results, the authors believe that striking a balance between future supply and demand is linked to managing and reducing attrition rates.

    As in earlier models, the 2013 approach establishes a "supply side" by using data that include a 4% growth rate in PT graduates, a 2% NPTE failure rate, an annual addition of 535 internationally trained PTs entering the workforce, and a constant rate of 85% of PTs being employed full time, with the remaining 15% being employed part time at an average of 24 hours a week.

    On the demand side, researchers factored in general population projections from the US Census Bureau and projected increases in the insured population, mostly due to the ACA, that the Congressional Budget Office estimates will add between 14 million and 25 million Americans to the insurance rolls between now and 2020.

    The ACA is no small player in the anticipated workforce shortfall, according to the authors, who estimate, that if all other factors hold constant and the insurance predictions hold true, "the gap between supply and demand for PTs will almost double" by 2020.

    Given these predictions, researchers identified attrition rates as a variable that could be controlled in order to decrease the magnitude of the coming shortage. Authors also identify an increase in the number and size of PT education programs as something that might help but is largely beyond the control of society or the profession itself. Similarly, they note that upping the number of internationally educated PTs may help but add that licensure requirements may have an effect on just how significantly this number might rise.

    Which leaves attrition as the potentially controllable factor that could, as authors write, "'bend the curve' in terms of human resources."

    "Implementation of new policies within the physical therapy profession that affect workforce retention are equally as important as strategies that increase the number of providers," authors write. "In the aggregate, it is far less costly to retain a provider than it is to produce or educate a replacement provider."

    The researchers also call for more extensive data collection, so that future projections can focus on geographic regions, population density, or areas of need.

    "It would … be helpful into the future to be able to apply the model to particular types of practice, as previous work has shown that surpluses or shortages may vary by practice type," authors write. "Moreover, future models will be required to grasp the eventual outcomes related to the existing and potentially expanding role of physical therapist assistants (PTAs) in delivering care."

    Authors of the study include Michel Landry, BScPT, PhD, Laurita Hack, PT, DPT, MBA, PhD, FAPTA, Elizabeth Coulson, PT, MBA, Janet Freburger, PT, PhD, Michael Johnson, PT, PhD, OCS, Richard Katz, PT, DPT, MA, Joanne Kerwin, PT, PhD, MMHS, Henry "Bud" Wessman, PT, JD, LNHA, Diana Venskus, PT, PhD, and Patricia Sinnott, PT, PhD, MPH. APTA staff Megan Smith and former staff Marc Goldstein also are contributing authors.

    PT supply and demand projections are among several resources available at APTA's Physical Therapy Workforce webpage. Also available: median salary information, demographic data, and turnover rates in various settings.

    Wednesday, October 14, 2015RSS Feed

    Activity, Education, and Time May Play Biggest Role in Recovery From LBP

    According to a new randomized clinical trial, early physical therapy may be related to minor short-term improvements in disability for individuals with low back pain (LBP), but the changes aren't really much different than what patients experience when they receive no treatment—provided those patients have been well-educated on the importance of staying as physically active as possible, that is.

    The study analyzed data from 207 participants with recent-onset LBP who were divided into 2 groups—1 receiving an education on LBP followed by 4 sessions of physical therapy, and the other group receiving no further care after the education session. To assess improvement, authors of the study looked at patient-reported scores on the Oswestry Disability Index (ODI) at baseline, 4 weeks, 3 months, and 1 year after enrollment, as well as a few other measures, including the Pain Catastrophizing Scale (PCS) and Fear Avoidance Belief Questionnaires for physical activity and work. The study was published in JAMA, the journal of the American Medical Association (abstract only available for free).

    All participants began by participating in what authors describe as an educational approach "likely beyond what typically occurs," with a session that educated them "about the favorable prognosis of LBP" and "advised [them] to remain as active as possible." Participants also received a book about back care and reviewed its contents with the researcher.

    After that, the participant groups went their separate ways.

    The physical therapy groups received sessions that began within 72 hours of enrollment in the trial, and were scheduled over 3 weeks, with 2 sessions in week 1, and a session each in weeks 2 and 3. The first session began with an assessment, followed by spinal manipulation, and instruction on spinal range-of-motion exercises to be performed at home. The second session included manipulation, review of exercises from the previous session, and instruction on trunk-strengthening exercises to be performed at home. The third and fourth sessions included exercise review and progression.

    The "usual care" group receive no further intervention.

    After 3 months—the primary outcome target of the researchers—the patients in the physical therapy group showed significant improvement in ODI scores (a 0-100 scale, with lower scores indicating less disability), with a drop in average scores from 41.3 to 6.6. This drop was better than the change recorded by the usual-care group, whose average score dropped from 40.9 to 9.8, but did not exceed the 6 point difference that researchers believe would have constituted a medically clinically important difference (MCID). Currently there is no single agreed-upon MCID score for the ODI.

    Similar significant changes were seen at 4 weeks, and again, while these changes happened for both groups, the physical therapy group's change was more significant, albeit with a relatively modest between-group difference. By the end of 1 year, no between-group differences were found.

    Secondary measures were a mixed bag, with some statistically significant outcomes favoring the physical therapy group slightly at 3 months (primarily in PCS scores and fear avoidance beliefs for work), but most others showing no between-group differences.

    The study has received attention from media outlets including National Public Radio, which quoted lead author Julie Fritz, PT, PhD, FAPTA, as saying that "The average amount of improvement over 100 patients was small, but within that group, there were certainly patients that experienced large improvement and then others who didn't receive much benefit at all."

    In its report on the study, HealthDay News notes that "the new study results aren't an indictment of physical therapy," adding that physical therapy "can be useful for someone who needs assistance starting to exercise or staying active while recovering from back pain." In that article, Fritz is quoted as saying that while most people can recover from LBP on their own, "physical therapy can help accelerate the process a little bit."

    Other physical therapist authors of the study include John Magel, PT, PhD, DSc, FAAOMPT, OCS, Anne Thackeray, PT, PhD, Whitney Meier, PT, DPT,COMT, OCS, and Gerard Brennan, PT, PhD. More information on the research is available at the National Institutes of Health clinical trials website.

    The association's PTNow evidence-based practice resource offers a clinical practice guideline on LBP developed by the association's Orthopaedic Section.

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.