• Thursday, April 30, 2015RSS Feed

    If Supervised Exercise Is Better Than Unsupervised Exercise for Intermittent Claudication, Why Are Quality of Life Indicators Similar?

    A new study on intermittent claudication (IC) says that when it comes to improvements in walking distances and time before the onset of pain, supervised exercise (SE) is more effective than unsupervised exercise (UE). When it comes to quality of life and increased community-based walking, however, those differences aren't as clear—and teasing out exactly why isn't easy.

    Researchers conducted a meta-analysis of 27 studies (24 randomized controlled trials and 4 observational studies) of 2,074 patients that compared SE and UE approaches for participants with IC, a condition associated with peripheral artery disease that causes cramping and early fatigue after walking even short distances. What they found is likely not surprising to physical therapists (PTs) and physical therapist assistants (PTAs): SE resulted in a "moderate to large" improvement in maximal walking distance (MWD) and a "moderate" improvement in claudication onset time (COT) compared with unsupervised exercise.

    The findings are important, authors write, because even though SE is widely recognized as the preferred approach for treatment of IC, "given the lack of Medicare reimbursement, lack of physician and patient awareness of the role of [SE], and patient transportation and time barriers, [SE] is underused." The study was published in the American Heart Journal (abstract only available for free).

    Less definitive were differences in quality of life (QOL) and community-based walking as measured by the walking impairment questionnaire (WIQ). Here, researchers found little difference between the SE and UE groups—a result that seems to run counter to the assumption that if individuals with IC are able to walk longer with a slower onset of IC thanks to SE, they'll report improvements in life quality and more time spent walking at home.

    Authors argue that part of the reason for the similarities may have to do with the effects of treadmill walking versus overground walking on the 6-minute walk test used in some QOL assessments. "In contrast to treadmill walking, 6-minute walk tests have been shown to correlate better with physical activity in daily life," authors write. "In addition, the biomechanics of treadmill walking differ substantially from overground walking … providing for a potential physiologic basis for the discrepancy between treadmill gains and QOL."

    When it comes to similarities in community-based walking assessed through WIQ, authors urge caution about drawing conclusions due to the fact that only a small number of studies included this kind of analysis.

    The study's authors offer still another explanation for the QOL similarities: the lack of disease-specific QOL assessments used in some of the studies. More generic QOL assessments, they write, "typically do not address the emotional and psychosocial impact of disease-specific physical limitations and thus may not adequately assess therapy-related improvements in QOL."

    And while the authors found SE "superior" to UE for improvement in maximal treadmill walking and COT, they write that in the end, it could be this lack of solid disease-specific evidence on QOL improvements that will hold up any significant changes in utilization.

    "Given the current lack of evidence that [SE] improves QOL or community walking over [UE]," they write, "further evidence may be needed before reimbursement policies for supervised exercise will be reconsidered."

    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.

    Wednesday, April 29, 2015RSS Feed

    Survey of Individuals With PD Shows Strong Appreciation for Exercise, Role of PT

    A recently released survey of 1,500 individuals with Parkinson Disease (PD) reveals a high level of appreciation for the importance of exercise among this population, and a fairly strong understanding—both by people with PD and physicians—of the benefits of physical therapy in treatment.

    The survey was aimed at getting the patient's perspective on exercise (.pdf) by asking a series of questions that included not only how much and how often participants exercise, but their perceptions of the benefits, views on perceived barriers to exercise, and general life satisfaction. Results are presented in aggregate and by a variety of demographic factors, as well as according to the number of years since the individual was diagnosed with PD.

    The study was created and conducted by DBS4PD, an affiliate of the Parkinson Alliance that supports the use of deep-brain stimulation (DBS). No differences in exercise data were found between DBS and non-DBS groups.

    Among the findings:

    • Among all respondents, nearly 92% reported that they participated in some form of exercise, with 59% indicating they had engaged in exercise on a "fairly regular or regular basis" throughout their adulthood.
    • Eighty-four percent of participants reported that their physician had recommended exercise.
    • When it came to physical therapy, 66% of respondents indicated that their physician had recommended seeing a physical therapist, and 62% reported that they had participated in physical therapy for treatment.
    • Nearly 9 out of 10 (87%) of participants said that exercise was "quite a bit" to "extremely" important, with nearly that number (86%) believing that an individual with PD should exercise 3 times a week or more—although they were divided as to whether each exercise session should last for 30 minutes (46%) or 45 minutes or more (40%).
    • Walking was cited as the most common form of exercise (65%), followed by strength training (33%).
    • Approximately 90% of participants reported remaining sedentary for more than 2 hours a day, with 45% to 57% reporting being sedentary for more than 5 hours a day, depending on age and PD duration.
    • Barriers to exercise included feeling too tired (61%-74%), health problems related to PD (46%-67%), and health problems not related to PD (50%-60%). Specific to PD-related motor problems, respondents reported balance problems, walking difficulties, and stiffness as major barriers.

    In its summary of the findings, DBS4PD urges individuals with PD to consult with a physical therapist.

    "Asking the doctor for a referral to a physical therapist can help people with PD get started on an effective exercise program," survey authors write. "A physical therapist can help design or modify exercises to facilitate successful participation."

    APTA offers several resources on the role physical therapy can play in the treatment of PD, including a PT's Guide to Parkinson Disease and evidence-based practice research that can be accessed through PTNow. Looking for continuing education on the role of the PT in PD? Check out a 4-module series APTA produced in partnership with the Parkinson Disease Foundation (module 1, module 2, module 3, module 4).

    Wednesday, April 29, 2015RSS Feed

    Ortho Section's Plantar Fasciitis Guidelines Get Attention

    When does an APTA clinical guideline on heel pain merit a hefty 2,500-word story? When the reporting outlet is Lower Extremity Review (LER), and experts have a thing or 2 to say about the guideline's assertion of stronger evidence for nonsurgical treatments such as manual therapy and therapeutic taping.

    The latest issue of LERfeatures an extensive report on the Orthopaedic Section’s plantar fasciitis guidelines. Updated in 2014 and featured on APTA’s PTNow.org, the guidelines received high ratings from PTNow’s CPG+ appraisal team. LER reporter Hank Black uses the guidelines as the jumping-off place for a detailed exploration of how treatment opinions differ among providers.

    Both Rob Roy Martin, PT, PhD, one of the guideline authors, and Michael Gross, PT, PhD, FAPTA, were quoted in the LER article, and both provide insight into the recommendations, while foot and ankle surgeons discuss approaches that include corticosteroid injections, extracorporeal shock wave therapy, and surgery. The article also touches on the use of dry needling and foot orthoses.

    "Basically, patients should receive some type of manual therapy in the form of joint and soft tissue mobilizations, as well as some form of taping," Martin says in the story. "And hopefully, the physical therapist will pay attention as evidence-based research is developed, and make it part of their routine practice."

    In addition to clinical guidelines, APTA also offers consumer-focused resources on plantar fasciitis as part of MoveForward.com.

    Wednesday, April 22, 2015RSS Feed

    What's Not to Like? Study Says Hospital Facebook Ratings Higher When Readmission Rates Are Low

    In what may be a prime example of absence making the heart grow fonder, recently published research claims that the lower a hospital's readmission rate, the better-liked it is—at least on Facebook.

    The study, published in the March 7 edition of the Journal of General Internal Medicine (abstract only available for free), links Facebook user-supplied ratings to a commonly accepted objective measure associated with hospital quality—the facility's rate of readmissions of patients within 30 days of discharge. Using data from the Medicare Hospital Compare website, researchers identified 315 hospitals performing better than the national average for hospital-wide all-cause unplanned readmission rates (HWR), and 364 hospitals with a worse-than-average HWR. Then they tracked down each facility's Facebook page (if it had one) and looked at how user ratings compared with HWRs.

    What they found was that for every 1-star increase in a hospital's star rating on Facebook, the probability that the facility has a lower-than-average 30-day readmission rate increases by 5 times. Another finding: an in-group comparison revealed that hospitals with a Facebook page tended to have lower HWRs than those without.

    "These findings add to the small but growing body of literature suggesting that unsolicited feedback on social media and hospital ratings sites corresponds to patient satisfaction and objective measures of hospital quality," authors write.

    The study was published just 1 month before the US Centers for Medicare and Medicaid Services added a 5-star rating system based on patient satisfaction to the Hospital Compare site. In that system, only 7% of reviewed hospitals earned all 5 stars.

    Study authors cite limitations that include the fact that the HWR statistics were from 2011-2012, before Facebook started its rating system, and that "user-generated feedback … may be biased and not reflective of patient experiences, and it could also be subject to fraud."

    Still, they argue, user-generated ratings could become increasingly important "as consumers become more aware of rating services and as high-deductible plans drive patients to seek care beyond their local hospital."

    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, April 16, 2015RSS Feed

    PTs in the ED: Australian Study Supports Role of PTs as Primary Patient Contact in Certain Cases

    A new study from Australia has found that when physical therapists (PTs) serve as a primary patient contact in emergency departments (EDs), use of imaging and patient length of stay drop—all without an increase in adverse events.

    The 12-month research project analyzed outcomes of 9,037 patients who presented to an ED in 2012, at a time when Australia was investigating "expanded roles for non-medical practitioners," according to the study's authors. After being assigned ICD 9 codes, and evaluated as to whether those codes were "appropriate" for treatment by a PT, patients were divided into 2 groups: 1,249 patients received treatment managed by a PT, and 7,788 were treated by "usual medical staff."

    Conditions deemed appropriate for PTs to manage in the ED included closed limb fractures, nontraumatic spinal pain, and soft tissue conditions including strains and sprains. The study found that 12.9% of all people presenting to the ED "had ICD-9 codes suitable to be managed by a physiotherapist." Results were published in the Journal of Physiotherapy (.pdf).

    Researchers looked at "adverse events" that may have surfaced through re-presentations to the ED within 28 days, consumer complaints, and reports to a local safety reporting system, and found no evidence of adverse events from the PT group. Although there were 33 re-presentations in the 28-day window, authors write that none "were due to incorrect diagnosis or missed fracture."

    When the researchers turned to length of stay and use of imaging (a data point that authors believe contributes to longer stays), they found some significant differences between the PT and non-PT groups.

    On average, the patients whose primary contact was the PT remained in the ED 83 fewer minutes than the patients seen by usual medical staff—an average of 103 minutes compared with 185 minutes. When it came to imaging, PTs ordered fewer x-rays, CT scans, and ultrasounds than the other providers.

    Researchers also analyzed the imaging statistics in terms of "number needed to treat," and found that for every 8 patients managed by the PT, 1 x-ray was avoided. That rate was 1 CT scan avoided for every 40 patients under the care of the PT, and 1 ultrasound avoided for every 69 patients seen by the PT.

    Authors acknowledge limitations to their study, including the fact that the PT option was only available during daytime hours, and that the research lacked data on whether the patients presenting to the ED had diagnostic imaging from somewhere else. Still, they write, "the physiotherapy service was able to identify appropriate patients and provide safe management without any identified adverse events or misdiagnoses."

    "These outcomes have potentially important implications, particularly in the context of increasing pressures on [EDs] across Australia," authors write.

    APTA supports the critical role of the PT in the ED, and offers a wide range of resources on the topic at its Physical Therapist Practice in the Emergency Department webpage.

    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.

    Wednesday, April 15, 2015RSS Feed

    Study: Exercise, Education Reduce Episodes of LBP in Children

    Could a back awareness education program and a few simple daily exercises reduce the risk of low back pain (LBP) in children? Researchers in New Zealand think so.

    In a study published in the April edition of Physical Therapy (PTJ), 710 children aged 8 to 11 were divided into 2 groups: 1 group of 469 received education on "spine awareness" and were taught 4 spinal movements to be practiced daily, and 1 group of 239 received the education only. The programs were conducted in 4 schools, and monitored for 270 days. According to an APTA news release, the study is one of a "small number" of trials involving young children and LBP.

    Researchers found that while both groups reported a reduction in LBP episodes, the reduction was greater among the children who received exercise instruction—down from 23% at day 7 of the study to 13% at the study's conclusion, compared with a concluding rate of 24% of the children who received education only. Children in the exercise group were also less likely to report a lifetime first episode of LBP and experience a longer time to onset of a first episode when one did occur.

    The exercises themselves involved 4 simple movements that encouraged flexion, extension, and lateral flexion of the lumbar spine. Authors write that the exercises were designed so that "they could be completed quickly without supervision, were easy to remember, were enjoyable, and could be combined with existing routines to maximize adherence." Still, adherence did drop off over time.

    The back awareness education program, called "MySpine," teaches strategies believed to keep the spine healthy and encourages healthy behaviors.

    Authors write that "it is unlikely (although not impossible) that the 4 exercises in this study were sufficient to have a physiological effect," but they speculate that "it is possible that monitoring participants and talking about the spine … and introducing the concept of back care, movement, and spinal awareness confers some therapeutic effect."

    "Perhaps vigilance creates opportunities for control," authors write. "By participating in the MySpine program, children may have been empowered to identify and adjust behaviors to reduce the risk of LBP."

    Articles in PTJ are available for free to APTA members.

    For more research and evidence-based practice information, visit the association's PTNow website.

    Friday, April 10, 2015RSS Feed

    Study: Most of Physical Activity's Longevity Benefits Are Achieved By Simply Meeting Guidelines - But Doing a Lot More Isn't Risky

    A new study says that when it comes to leisure time physical activity, the more the better—but that doesn't mean that cranking out 10 times the minimum activity recommendations makes you 10 times more likely to live longer than someone who just meets the recommendations (or exceeds them by a bit).

    Researchers compared mortality rates with activity levels among 661,137 men and women over 14.2 years in an effort to gauge the dose-response relationship between leisure time physical activity (LTPA) and mortality generally, with a focus on finding out if an "upper limit" of activity exists in which the longevity benefits level off—or actually decrease.

    Some of what they found is already widely accepted: namely, that adhering to the 2008 Physical Activity Guidelines for Americans of 75 vigorous-intensity or 150 moderate-intensity activity minutes a week significantly reduces mortality. Other findings were new, particularly when it came to how much activity produces the biggest longevity payoff. Results were published in the April 6, 2015, online version of JAMA Internal Medicine (abstract only available for free).

    By using self-reported activity data from 6 large-scale studies and then converting those data to metabolic equivalent of task (MET) numbers, researchers were able to compare results even when the studies asked slightly different questions about physical activity. The study sample consisted of 291,485 men and 369,652 women, although with a rate of 95% Caucasian participants it was not representative of the US population.

    The analysis found that individuals who met or engaged in twice the guideline recommendations (7.5 to 14.9 METs per week) lowered their risk of mortality by 31%, and those who exceeded recommendations by 2 to 3 times (15 METs to 22.4 METs per week) saw a 37% drop. However, that benefit tapered off and finally plateaued at 3 to 5 times the minimum. From that point on, no additional activity—even activity that exceeded the guidelines by 10 times or more—seemed to make a dent in longevity rates.

    Authors described the additional benefit of increased activity as "modest," writing that "meeting the recommended guidelines by either moderate- or vigorous-intensity physical activities was associated with nearly the maximum longevity benefit." Another study from Australia, published the same day in the same journal, looked more closely at the effects of vigorous vs moderate activity and found a positive relationship between increasing proportions of vigorous activity and further declines in mortality rates.

    While spending large amounts of time engaging in physical activity didn't necessarily translate to a commensurate increase in longevity, researchers also found no support for the opposite hypothesis—that there's an upper limit to physical activity, beyond which increased activity actually negatively impacts mortality. "Thus, current trends in increasing marathon or triathlon participation should not cause alarm, at least with regard to mortality," authors write.

    In an invited commentary accompanying the article, author Todd M. Manini, PhD, points to the study results as more evidence that primary care providers need to engage patients in conversations that encourage simply following the minimum requirements, where the most significant longevity benefits occur.

    Unfortunately, according to Manini, those conversations aren't happening enough.

    "The fact that only approximately one-third of adults received counseling [in physical activity] from a physician or other health professional is disappointing, although this rate has improved by 40% from 2000 to 2010," Manini writes.

    APTA is a strong and vocal advocate for the ability of physical activity to transform society through its effects on public health. The association offers a prevention and wellness webpage with resources on how physical therapists and physical therapist assistants can help individuals become more physically active. Additionally, the association's MoveForwardPT.com website stresses the importance of physical activity in ways designed to be easily understood by the general public. The association is also on the board of the National Physical Activity Plan alliance, a high-profile effort to create a comprehensive set of policies, programs, and initiatives to increase physical activity in all segments of the American population.

    The study's authors write that their findings do a kind of double duty.

    "These findings are informative for individuals at both ends of the physical activity spectrum," they write. "They provide important evidence to inactive individuals by showing that modest amounts of activity provide benefit for postponing mortality while reassuring very active individuals of no exercise-associated increase in mortality risk."

    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, April 10, 2015RSS Feed

    Higher Proportion of Vigorous Physical Activity Lowers Mortality Risk

    A new study from Australia concludes that while achieving at least the minimum amount of recommended weekly physical activity is key to a lower mortality risk, upping the amount of vigorous physical activity in an individual's exercise mix can reduce that risk even further.

    In an 8-year observational study of 204,542 New South Wales adults aged 45 to 75, researchers paired mortality statistics with percentages of moderate to vigorous activity (MVPA) to find out whether the proportion of vigorous activity had an impact on mortality risk.

    The answer: yes, by as much as 13%. The study was published in the April 6 online edition of JAMA Internal Medicine (abstract only available for free).

    Using recommendations that individuals engage in at least 150 minutes per week of moderate physical activity or 75 minutes per week of vigorous activity, authors found that the crude death rate for individuals who met the recommendations but engaged in no vigorous activity was 3.84%, compared with a 2.35% crude death rate for individuals who engaged in "some" vigorous activity (but no more than 30% of total activity), and a 2.08% crude death rate for those who reported that 30% or more of their activity time was devoted to vigorous exercise.

    The questionnaire used to obtain the activity self-reports defined vigorous activity as an activity "that made you breathe harder and puff and pant, like jogging, cycling, aerobics, competitive tennis, but not household chores or gardening." Examples of moderate physical activity used in the questionnaire included "gentle swimming, social tennis, vigorous gardening, or work around the house."

    "In this large sample of middle-aged and older adults, we found that among those who reported any physical activity, engaging in vigorous activity was associated with risk reductions for mortality of 9% to 13%, even after adjusting for the total amount of activity," authors write. "These findings suggest that even small amounts of vigorous activity may supplement the benefits of moderate activity alone."

    Researchers write that more work needs to be done to find out exactly why vigorous activity has this effect, but they suggest the possibility that "high-intensity activities lead to more physiologic adaptations, which improve function and capacity." Those improvements enhance the delivery of oxygen and glucose to tissues.

    While the relationship between vigorous activity and mortality risk was measurable, the biggest drop in crude death rate appeared after much lower amounts (and intensities) of physical activity were reported—from a crude death rate of 8.34% who reported no MVPA, the rate dropped to 3.17% for individuals reporting 10 to 149 minutes of MVPA. Similar significant improvements were recently reported in another study that focused more widely on physical activity's effect on mortality, and whether there was an upper limit to these effects.

    Authors of the Australian study write that even more benefit can be achieved when the proportion of vigorous activity is increased—provided there are no other risks present.

    "Independent of the total amount of physical activity, engaging in some form of vigorous activity was protective against all-cause mortality," authors write. "If vigorous activities are consistently independently associated with health benefits, such activities should be more strongly encouraged in activity guidelines to maximize the population benefits of physical activity."

    Did you know that there's a national blueprint for increasing physical activity among adults 50 and older? Learn how the blueprint could guide your efforts by taking a CE course offered through the APTA Learning Center.

    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, April 09, 2015RSS Feed

    Early Guideline-Based Physical Therapy Results in Health Care Savings for Patients With LBP

    For patients with a first episode of low back pain (LBP), getting to physical therapy early—and receiving evidence-based interventions—are the keys to significantly reduced health care costs compared with delaying physical therapy or receiving "non-adherent" physical therapy treatments, according to a new study that analyzed health records of members of the US military.

    Researchers tracked health care costs over time by reviewing Military Health System records of 122,723 patients who were referred to physical therapy within 90 days of an initial visit to a primary care provider for a first episode of LBP. The study analyzed use of advanced imaging, spinal injections, surgery, opioid medication use, prescription use, and inpatient costs over a 2-year period, and linked these costs to how soon patients received physical therapy and what kind of physical therapy they received.

    To do this, researchers divided patients into 4 groups: those who received physical therapy within 14 days of the physician visit; those who received physical therapy after a wait of at least 14 days; those who received "adherent" physical therapy; and those who received "non-adherent" physical therapy. For purposes of the study, "adherent" physical therapy was defined as activities linked to CPT codes that reflected evidence-based recommendations for active physical therapy. Whenever more than 75% of the codes used in an episode of care were associated with active treatment (for example, therapeutic exercise or neuromuscular reeducation), and at least 1 active treatment code was used during each session, the episode was labeled "adherent."

    Researchers looked at the timing and adherence parameters individually and in combination, and found that the patients who received early and adherent physical therapy had a decreased likelihood of experiencing injections, surgery, advanced imaging, or opioid use compared with patients who received later, but still adherent, physical therapy. That decrease in utilization translated to health care costs that were on average 60% lower for the early adherent group.

    "When considering the various combinations, a dose-response relationship appears to exist in the sense that the results show a progressive increase in subsequent utilization and costs as care shifts from being classified as early and adherent compared to late and non-adherent care," authors write. An advance version of the article appears in the online edition of the journal BMC Health Services Research (.pdf).

    In an APTA news release, lead author John D. Childs, PT, PhD, emphasized what the study described as the "accretive" effects of timing and evidence-based practice.

    "Physical therapy as the starting point of care in your low back pain episode can have significant impact," he said. "Receiving physical therapy treatment that adheres to practice guidelines even furthers that benefit."

    The study arrives during a time when the value and efficacy of physical therapy for back pain have been getting noticed. Recent journal articles on physical therapy vs imaging for LBP, and physical therapy vs surgery for lumbar spinal stenosis have received attention in the general media as well as health care-focused publications.

    APTA President Paul Rockar Jr, PT, DPT, MS, believes that the BMC article adds another important dimension to the conversation about physical therapy's ability to transform health care—namely, the ways in which receiving physical therapy early on can reduce health care costs.

    "Given the enormous burden of excessive and unnecessary treatment for patients with low back pain, cost savings from physical therapy at the beginning of care has important implications for single-payer health care systems," Rockar said.

    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, April 07, 2015RSS Feed

    Physical Therapy's Effects Equal to Surgery for Spinal Stenosis Symptoms

    Physical therapy for spinal stenosis is as effective as surgery and should be fully considered as a first-choice treatment option, according to a new study that is the first to directly compare a single, evidence-based physical therapy regimen with decompression surgery among patients who agreed to be randomly assigned to either approach.

    The study focused on self-reported physical function among 169 participants diagnosed with lumbar spinal stenosis (LSS) after 2 years, but it also tracked function measurements along the way--at baseline, 10 weeks, 6 months, and 12 months. Researchers found that not only were 2-year effects similar for the 2 groups (87 who began with surgery and 82 who started with physical therapy), the increase in function followed similar trajectories from baseline on.

    Research was conducted between 2000 to 2007, and limited to patients 50 years and older who had no previous LSS surgery and had no additional conditions including dementia, vascular disease, metastatic cancer, or a recent history of heart attack.

    The study, which appears in the Annals of Internal Medicine (abstract only available for free), was led by Anthony Delitto, PT, PhD, FAPTA, with coauthors including Sara R. Pilva, PT, PhD, FAAOMP, OCS, Julie M. Fritz, PT, PhD, FAPTA, and Deborah A. Josbeno, PT, PhD, NCS. The findings have been reported in Reuters, the Pittsburgh Post-Gazette, Medpage Today, and other outlets.

    According to an editorial that accompanies the article (sample available for free), what makes this research important is that it restricted the nonsurgical approach to a single physical therapy regimen, and that participants—all of whom were prequalified for surgery—consented to a randomized treatment approach. Previous studies focused on surgical vs (mostly unspecified) "nonsurgical" approaches, and some allowed patients to self-select their treatment groups.

    Editorial author Jeffrey N. Katz, MD, MSc, writes that the current study more accurately represents practice, in which "clinicians and patients must choose between surgery and a particular nonoperative regimen, rather than an amalgam of regimens."

    Those particular nonoperative physical therapy treatments administered to the participants included "instruction on lumbar flexion exercises including posterior pelvic tilts and supine knee-to-chest and quadruped flexion exercises; general conditioning exercises, including stationary cycling or treadmill walking; lower extremity strengthening exercises … ; lower-extremity flexibility exercises deemed appropriate … ; and patient education to avoid postures involving hyperextension of the lumbar spine," authors write.

    Most participants in the physical therapy group attended at least 1 of the 12 prescribed sessions, with two-thirds participating in at least 6 sessions. However, over half (57%) of the physical therapy group elected to have surgery at some point within the 2-year study window. While authors write that this crossover presents "a challenge in interpretation," additional analysis revealed that even with this shift, "any differences between the groups were not significant."

    "From a clinical standpoint, Delitto and colleagues' trial suggests that a strategy of starting with an active, standardized [physical therapy] regimen results in similar outcomes to immediate decompressive surgery over the first several years," writes Katz in his editorial. "Taken together, these data suggest that patients with LSS should be offered a rigorous, standardized [physical therapy] regimen. Those who do not improve and ultimately consider surgery should be informed that the benefits are likely to diminish over time."

    Both the study's authors and Katz agree that health provider-patient communication is key.

    "Patients and health care providers should engage in shared decision-making conversations that include full disclosure of evidence involving surgical and nonsurgical treatments for LSS," authors write, with Katz's editorial arguing that "because long-term outcomes are similar for both treatments yet short-term risks may differ, patient preferences should weigh heavily in the decision of whether to have surgery for LSS."

    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.