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  • JAMA Study: 'Multicomponent' Exercise Interventions During Hospital Stay Can Reverse Functional Decline Among Patients 75 and Older

    The potential for hospitalization to have damaging, long-term effects on function and mobility among patients who are elderly is well-known. But does functional decline have to be a given? New research from Spain says no, and points to the possibility that those effects can be blunted—and even reversed—through the addition of an exercise intervention that goes beyond ambulation-only.

    The study, published in JAMA Internal Medicine (abstract only available for free), focused on a single hospital and tracked 370 patients in who were hospitalized between 2015 and 2017, all of whom were 75 years or older (mean age, 87.3). Most participants were admitted for acute illnesses by way of the hospital's accident and emergency department; all wound up in the facility's Acute Care of Elderly (ACE) unit. Median length-of-stay was 8 days.

    Over the 2-year study period, researchers divided participants into 2 groups: the control group received "usual care" consisting of "standard physiotherapy focused on walking exercises for restoring the functionality conditioned by potentially reversible abnormalities," while a second group received twice-daily exercise interventions that included progressive resistance, balance, and walking training exercises adapted from the Vivfrail exercise program. Researchers then compared patient scores on several tests administered at admission to the ACE unit and again at discharge. Tests included the Barthel Index of independence, the Short Physical Performance Battery (SPPB), the Mini-Mental Status Examination, and a quality of life (QoL) scale.

    Researchers found that not only did the exercise group register better scores than the control group on the Barthel index (a 6.9 difference on the 100-point scale), they tended to record improvements over their own baseline scores. The control group, meanwhile, lost ground, averaging a 5 point drop from baseline. The same basic pattern was found in the SPPB scores, as well as scores that assessed cognitive function, QoL, and depression.

    "Our study shows that an individualized, multicomponent exercise intervention including low-intensity resistance training…can help reverse the functional decline associated with acute hospitalization in older adults," authors write. "Acute hospitalization per se led to impairment in patients' functional ability during [activities of daily living], whereas the exercise intervention reversed this trend."

    The exercise intervention itself consisted of 2 daily 20-minute sessions through the duration of the patient's stay in the ACE unit. The first session, in the morning, included individualized supervised progressive resistance, balance, and walking exercises. The resistance exercises centered around 2 to 3 sets of 8 to 10 repetitions of a load equivalent to 30%-60% of the patient's maximum; walking and balance exercises progressed in difficulty, and included semi-tandem foot standing, line walking, stepping practice, walking with small obstacles, exercises on unstable surfaces, and weight transfer. The 20-minute evening session consisted of "unsupervised exercises using light loads" such as anklets and handgrip balls, and daily walking in facility corridors.

    While authors note that the study focused on patients who possessed "a high level of functional reserve and cognitive capacity high enough to allow them to perform the programmed exercise interventions," the research did not automatically exclude patients with dementia or an inability to walk unassisted. Moreover, the entire population was markedly older than most previous studies on the effects of hospitalization, with about 30% of the study group being 90 or older.

    "Our results indicate that, despite its short duration, a multicomponent exercise approach is effective in improving the functional status … of very old adults," authors write, describing their findings as results that "open the possibility for a shift from the traditional disease-focused approach in hospital acute care units for elders to one that recognizes functional status as a clinical vital sign that can be impaired by traditional (bed rest-based) hospitalization but effectively reversed with specific in-hospital exercises."

    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.

    From PTJ: Could Impaired Physical Performance Predict Hospitalization Risk?

    Routine assessments of mobility level by a physical therapist (PT) can help better identify older adults at highest risk for hospitalization, according to a new study in the January issue of PTJ (Physical Therapy). Authors write that their findings "suggest a future role for [PTs] in designing effective screening and intervention programs for older adults participating in…community-based long-term care programs."

    A team of researchers at University of Colorado, led by APTA member Jennifer Stevens-Lapsley, PT, PhD, analyzed data from both electronic medical records and hospital claims for over 1,000 patients participating in the Program of All-Inclusive Care for the Elderly (PACE) in the Denver area. Sponsored by the US Centers for Medicare and Medicaid Services (CMS), PACE is designed for dual Medicare/Medicaid-eligible adults as a way to provide community-based long-term care services from an interdisciplinary team of health professionals, including PTs. The program brings participants to a community day facility, where they participate in social activities and receive health services.

    Authors hoped to identify relationships between physical performance scores, using the Short Physical Performance Battery (SPPB) conducted through PACE, and both all-cause and potentially avoidable hospitalizations. "All-cause" hospitalization covered conditions such as heart disease, fractures, and infections, while "potentially avoidable" hospitalizations included incidents such as falls, congestive heart failure, and poor glycemic control.

    Researchers found that lower SPPB scores were associated with higher rates of hospitalization. Patients with the lowest scores were 1.87 times as likely as those with the highest scores to experience all-cause hospitalization, and 2.27 times as likely to experience potentially avoidable hospitalization. Patients with scores in the middle range were 1.40 times and 1.76 times as likely as the high-score group to experience all-cause and potentially avoidable hospitalization, respectively.

    While having a greater number of chronic conditions also predicted hospitalization, impaired mobility was a significant and independent risk factor for hospitalization, according to the study. "It is likely that impairments in physical performance constitute a valuable biomarker to identify PACE participants that are vulnerable to hospitalization," authors write.

    The study's findings come in the wake of a CMS proposal to include potentially avoidable hospitalizations as a quality metric for postacute and long-term care facilities. Authors of the study note that despite the emphasis on avoidable hospitalizations, there has been little research that looks at the relationship between impaired physical performance and a later hospital visit.

    "The results of this study illustrate the importance of routinely assessing mobility within long-term care settings," said APTA member and lead author Jason R. Falvey, PT, DPT, PhD, a board-certified clinical specialist in geriatric physical therapy. "The study also further supports the role of physical therapists as part of the primary care team for medically complex older adults."

    In addition to Falvey and Stevens-Lapsley, APTA member Allison Gustavson, PT, DPT, was a coauthor of the study.

    [Editor's note: for an in-depth look at PTs in primary care teams, check out "A Perspective: Exploring the Roles of Physical Therapists on Primary Care Teams," a paper produced by APTA. For more on this study, listen to a recent PTJ podcast featuring the study's lead author.]

    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.

    CoHSTAR Announces Fellowship Opportunities; Applications Due by February 15

    The Center on Health Services Training and Research (CoHSTAR) has opened its latest call for fellowship applicants for 4 research opportunities. All fellowships have a February 15, 2019, application deadline. The positions are:

    • Full-time postdoctoral fellowships: Trainees may focus their activities on a unique research focus area or craft an individual experience that involves activities at 2 or 3 collaborating sites.
    • Part-time faculty fellowship: Faculty fellows will retain their faculty appointments at their home institutions while using CoHSTAR support to maximize their protected time for research activities.
    • Part-time faculty fellowship at naviHealth: The selected faculty fellow will retain her or his faculty appointment at a home institution while using CoHSTAR support to maximize protected time to engage in research activities as a naviHealth faculty fellow. NaviHealth is a care transitions and postacute care management company serving both payer and provider marketplaces.
    • Postdoctoral fellowship at Vanderbilt University Medical Center: This 2-year postdoctoral fellowship will support an analysis of registry and trial data, particularly data related to spine surgery and associated outcomes. The fellowship is funded jointly with Vanderbilt University Medical Center's Department of Orthopaedics and Rehabilitation.

    CoHSTAR was established with a grant of $2.5 million from the Foundation for Physical Therapy. Funding for this initiative was made possible with a $1 million gift from APTA, gifts from 50 APTA components, and donations from physical therapists, foundations, and corporations with a shared passion for the field of physical therapy.

    Foundation Research Grant Awards, Kendall Scholarships Announced

    An APTA-funded $50,000 Health Services Research Pipeline grant will support an investigation into high-value early intervention (EI) for children with functional limitations. The award was among several Foundation for Physical Therapy (Foundation) grants and scholarship awards totaling more than $500,000.

    Grant recipient Beth McManus, PT, ScD, MPH, will be investigating regional variability in state and local early intervention and the ways that variability affects use and outcomes, all in an effort to improve service delivery. McManus is an associate professor in the Colorado School of Public Health's Department of Health Systems, Management, and Policy.

    APTA is the Foundation's Pinnacle Partner in Research and has been a leading donor in funding major research initiatives such as the Center on Health Services Training and Research (CoHSTAR), investing in research priorities to strengthen the physical therapy profession, and supporting the Foundation's scholarship program each year.

    Other grant and scholarship announcements from the Foundation:

    Eric Anson, PT, MPT, PhD, the recipient of the $40,000 Pittsburgh-Marquette Challenge Research Grant, will harness virtual reality to explore ways to improve self-motion perception and decrease fear of falling in older adults. This grant is funded in part by APTA's Supporting the Professions Fund.

    Annalisa Na, PT, PhD, was awarded the $40,000 Geriatric Research Grant. The goal for her project, titled "Functional Recovery in Patients with Type-2 Diabetes Mellitus following a Primary Total Knee Arthroplasty," is to improve outcomes by establishing effective guidelines. This grant is funded by the Academy of Geriatric Physical Therapy Fund.

    Michael Tevald, PT, MPT, PhD, winner of the $40,000 Acute Care Research Grant, will investigate the early impact of lung transplantation on skeletal muscle, with an eye toward enabling the development of evidence-based rehabilitation strategies that will allow acute care physical therapists to effectively address effects of surgery, hospitalization, and illness. This grant is supported by a donation from the Academy of Acute Care Physical Therapy.

    Bahar Shahidi, PT, DPT, PhD, was awarded the $100,000 Magistro Family Foundation Research Grant in support of a project that will evaluate the benefits of more intensive exercise-based program for patients with low back pain and provide a platform for future clinical trials. This project is funded by the Foundation's Magistro Family Endowment Fund and Legacy Fund.

    Marcie Harris-Hayes, PT, DPT, received the $240,000 Paris Patla Musculoskeletal Grant for the development of effective treatment strategies for people with pre-arthritic hip disorders to improve function, decrease pain, and delay or prevent the onset of osteoarthritis. This grant was made possible by the Stanley Paris and Catherine Patla Fund.

    Barbara Sargent, PT, PhD, MS, who was awarded the $40,000 Pediatric Research Grant, will be investigating the identification of cerebral palsy (CP) in early infancy and effective interventions to improve walking outcomes of individuals with CP. This grant is supported by the Pediatric Physical Therapy Fund.

    Jason Beneciuk, PT, DPT, PhD, MPH, was named winner of the $40,000 Orthopaedic Research Grant for his project titled "Discriminant and Predictive Validity Assessment of the Keele STartT MSK Tool for Patients with Musculoskeletal Pain in Outpatient Physical Therapy Settings." The study aims to develop effective health care management for people with musculoskeletal pain and implement precision medicine through risk profiling to guide individualized treatment approaches. This grant is supported by the Academy of Orthopaedic Physical Therapy Fund.

    In addition to the research grants, the Foundation also awarded 4 Florence P. Kendall Doctoral Scholarships of $5,000 each. The scholarships are presented to outstanding PTs as they begin their first year of graduate studies toward a postprofessional doctoral degree. Scholarship winners are:

    • Allison Miller, PT, DPT, University of Delaware
    • Jonathan Tsay, PT, DPT, University of California at Berkeley
    • Julia Mazarella, PT, DPT, The Ohio State University
    • Julie Stutzbach, PT, DPT, University of Colorado-Anschutz Medical Campus

    These scholarships are funded by the Kendall Fund and the Rhomberger Fund.

    "The Foundation is pleased to support promising, productive physical therapist researchers as they develop innovative and cutting-edge treatments in physical therapy," said Foundation Board of Trustees President Edelle Field-Fote, PT, PhD, FAPTA, in a Foundation news release. "Each recipient has the potential to contribute to our understanding of movement-related health conditions, interventions, and approaches to health service delivery to improve the lives of our patients and clients."

    Large-Scale Study Finds Connection Between Early Physical Therapy and Lower Opioid Use

    The evidence of physical therapy's potential to make a difference in the nation's opioid crisis continues to mount—this time, by way of a study in JAMA Network Open, which concludes that for patients experiencing back, knee, neck, or shoulder pain, a visit to a physical therapist (PT) early on can reduce the chances that they'll take any opioids for the condition. And among those who do wind up taking opioids during the episode of care, researchers identified an association, albeit less strong, between early physical therapy and reduced number of pills taken for 3 of the 4 conditions.

    The study, one of the largest to date on the effects of early physical therapy, looked at data from 88,985 privately insured "opioid naïve" patients who had an index visit with a health care provider for back, knee, neck, or shoulder pain—the 4 most common musculoskeletal conditions. Researchers divided patients into 2 groups—those receiving treatment from a PT within 90 days of the index visit, and those who didn't—and tracked data for 1 year to note prescriptions and use, paying particular attention to use between 91 and 365 days after the index date.

    The patients, a national sample from multiple health networks, were 57.7% male with an average age of 46. Comorbidities and demographic factors were similar among both groups. Overall, 29.3% of the patients received early physical therapy.

    Here's what researchers found:

    • Early physical therapy was associated with a reduced risk of any opioid use for all 4 conditions: a 16% drop for knee pain patients, a 15% reduction for those with shoulder pain, 8% for neck pain, and 7% for low back pain (LBP).
    • Among patients who were prescribed (and used) opioids, early physical therapy seemed to have an association with fewer pills taken for 3 of the 4 conditions. Patients with knee pain recorded a 10.3% drop in oral morphine milligram equivalents taken compared with the control group; those with shoulder pain saw an average 9.7% reduction; and the LBP subgroup averaged a decline of 7%. The neck pain subgroup showed a slight 3.8% drop—not enough to be statistically significant, according to the study's authors.
    • Early physical therapy for knee pain and LBP was associated with a significant reduction in the likelihood of chronic opioid use—by 66% for knee pain and 33% for LBP—compared with patients who didn't receive early physical therapy. Chronic opioid use among patients with neck and shoulder pain didn't differ between the study groups.
    • As for when the early physical therapy group began sessions, that varied by condition, ranging from an average of 13 days after index visit for neck pain to 40 days for shoulder pain. The median number of physical therapy sessions ranged from 5 for knee pain and LBP to 8 for neck pain.

    Steven George, PT, PhD, FAPTA, one of the study's contributing researchers, told APTA that the study provides "encouragement and support" for guidelines such as those produced by the US Centers for Disease Control and Prevention (CDC) calling for nonopioid treatments, including physical therapy, to be considered a first-line approach to the management of chronic pain.

    "The guidelines emphasize nonpharmacological care being delivered early in the treatment episodes," George said. "In the study the nonpharmacological care was physical therapy, and there seemed to some benefit. The results provide early evidence that the new guidelines may help decrease long-term opioid use."

    George said that the finding related to early physical therapy's lack of impact on opioid use among patients with neck pain took researchers somewhat by surprise. In the study, authors characterize that finding as dissimilar to other research on the effects of early physical therapy, and they theorize that the variation "could be explained by the differences in patient populations, the resistance of many neck conditions such as whiplash to physical therapy, the underlying rate of opioid use, the timing and rate of patients receiving early physical therapy, or our decision to limit the analysis to patients with indicators of higher severity."

    The study makes a strong case for early physical therapy as it relates to opioid use, but it shouldn't be interpreted as a statement on overall results, according to George.

    "The biggest takeaway is that early physical therapy may be a viable option for several musculoskeletal conditions, especially if preventing long-term opioid use is a treatment goal," George said. "This study does not suggest those receiving early physical therapy had better clinical outcomes. That's an important thing to remember when interpreting these findings."

    In addition to George, APTA members Chad Cook, PT, PhD, MBA; and Adam Goode, PT, DPT, PhD, were among the coauthors of the study.

    APTA has taken a leadership role in the physical therapy profession's response to the opioid crisis. In addition to its flagship #ChoosePT opioid awareness campaign, APTA also hosted a Facebook Live panel discussion and satellite media tour to highlight the effectiveness of nonopioid approaches to pain management. In addition, APTA produced a white paper on reducing opioid use and contributed to the National Quality Partners Playbook on Opioid Stewardship.

    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.

    Cochrane Researchers 'Confident' in Pelvic Floor Muscle Therapy as Effective UI Treatment

    Pelvic floor muscle therapy (PFMT) "could be included in first‐line conservative management programs" for women with urinary incontinence (UI), according to the authors of a recently updated Cochrane systematic review. While the conclusion itself isn't new, the revision includes more evidence that makes the case for PFMT even stronger.

    Authors analyzed data from 31 trials including a total of 1,817 women. The studies examined whether women were "cured" or "cured or improved" as a result of treatment for stress urinary incontinence (SUI), urgency urinary incontinence (UUI), or mixed urinary incontinence (MUI). Researchers also looked at the effects of PFMT on quality of life.

    The results were clear, according to authors: women with all types of UI experienced greater benefit from PFMT than from no treatment or control interventions, which included sham electrical stimulation, placebo drug, or other inactive treatments such as educational pamphlets.

    Other findings from the review:

    • In terms of cure, women with SUI in the PFMT groups were 8 times more likely than women who received no treatment or control interventions to a complete cessation of symptoms. Women with any type of UI in PFMT groups were 5 times more likely to report an end to symptoms.
    • Women with SUI in the PFMT groups were more likely to report improvement in symptoms and significant improvement in quality of life. Women with any type of UI reported that they experienced significant improvements in symptoms and quality of life if they received PFMT.
    • Women with any type of UI in the PFMT groups experienced fewer leakage episodes in a 24-hour period, as well as less urine leaked
    • Patient satisfaction was higher in the PFMT groups, and one study reported that women who received PFMT experienced better sexual outcomes.

    Authors’ conclusions have not changed since the 2014 version of the review, but the update contains 10 new studies, as well as an analysis of risk of bias in the included studies.

    Due the large variation the type and duration of the PFMT programs, authors were unable to assess their relative effectiveness. However, the quality of the evidence was of moderate quality, authors write, meaning that "we can be confident that PFMT can cure or improve symptoms of SUI and all other types of UI."

    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.

    New Draft CPG on Locomotor Function Seeking Comments: Deadline December 21

    If you have insight, or simply an interest, in best practice for improving locomotor function after chronic stroke, incomplete spinal cord injury, or brain injury, the clinical practice guideline (CPG) team overseeing a new CPG on that topic wants to hear from you.

    A draft of the CPG is available for review and public comment until December 21—all physical therapists, physical therapist assistants, and students are invited to comment.

    The CPG’s goal is to assess the relative efficacy of various interventions to improve walking speed and timed distance in individuals following stroke, incomplete spinal cord injury, or traumatic brain injury. For example, how does the evidence compare for training involving walking, virtual reality, strength, cycling, body-weight-supported treadmills, robotic-assistance, or sitting and standing balance; with or without virtual reality tools; alone or in combinations; and at what intensities?

    The CPG is being supported by APTA and the Academy of Neurologic Physical Therapy. Find a link to the draft and comment instructions on APTA’s CPG Development webpage under CPGs in the Review Phase, and be sure to respond by the December 21 deadline.

    Study: PTs, Family Physicians Similar in Knowledge of LBP Management

    The numbers were small and the participants limited to certain groups, but results of a recent survey seem to point to yet another reason to increase direct access to physical therapist (PT) services: namely, when it comes to management of low back pain (LBP), PTs know just as much—and sometimes more—than the family practice physicians (FPPs) who often are sought for primary care. Authors believe the results point to the need for further study of the potential for PTs in primary care settings, an issue that APTA is exploring.

    In a study published in the Journal of Manual & Manipulative Therapy (abstract only available for free), researchers provided results of a survey of 73 PTs and 30 FPPs regarding their knowledge of optimal management strategies for LBP as well as their attitudes toward and use of clinical practice guidelines for the condition. Authors of the study used 2 survey instruments that were developed for earlier studies: an 11-item review of LBP knowledge, attitudes, and guideline statements, and a modified 8-question survey on management interventions. APTA members Michael Ross, PT, DHS; Travis Enser, PT; Allyson Muehlemann, PT, DPT; and Ron Schenk, PT, PhD, were among authors of the study.

    Participants were asked to respond using a 5-point Likert scale that reflected their level of agreement with various statements on LBP (the 11-question review) or their belief in the importance of various approaches to LBP treatment (the 8-question survey). Answers were classified as correct or incorrect based on what authors describe as "the most recent reviews of the evidence." In the end, 73 PT members of the APTA Private Practice Section (PPS) and 30 members of the American Academy of Family Physicians (AAFP) provided useable responses.

    The bottom line: the PTs and FPPs achieved similar scores on nearly every item in the surveys. Both groups strongly rejected statements such as "patients should not return to work until they are almost pain free" and "X-rays of the lumbar spine are useful in the work-up of patients with acute LBP," and broadly supported the statements "encouragement of physical activity is important in the recovery of LBP" and "there is nothing physically wrong with many patients with chronic [LBP]." When it came to statements related to optimal management of LBP, PTs and FPPs reported equally strong levels of support for the importance of physical therapy, patient encouragement, and manual manipulation; and were equally emphatic in their disapproval of surgery.

    Not all scores were close, however. Researchers found that compared with the FPP group, PTs generally had more confidence in their ability to gauge the motivation of their patients, and tended to more consistently reject the idea that "interventions by doctors and other health care providers have very little positive impact on the natural history of acute LBP."

    Other areas of more modest disagreement included support for the statement "I would find clinical practice guidelines helpful in the management of LBP" (agreed with or strongly agreed with by 58.9% of PTs compared with 76% of FPPs) and disagreement with the idea that bed rest is important in recovery from LBP—83.3% of FPPs said bed rest was "not recommended" or "of minor importance," compared with 69.9% of PTs rating bed rest in a similar way. Authors characterized these differences as nonsignificant.

    As for the PTs' confidence in their ability to assess patient motivation, authors believe that the nature of the PT-patient relationship may be at work.

    "Assessing patient motivation levels is a time-consuming process," authors write. "The duration of a typical patient visit is longer with the [PT] than a[n] [FPP] and the [PT] typically sees patients on a serial basis for a period of time. This increased patient interaction may play a part in [PTs] having less difficulty in assessing patient motivation."

    Authors also cited the presence of what they describe as "guideline-discordant care" among notable percentages of both PTs and FPPs, including an inability to choose the drug treatment most preferable for patients with LBP (26% of PTs and 35% of FPPs answered incorrectly by choosing drugs other than acetominophin and nonsteroidal anti-inflammatories), a preference for imaging (18% of PTs and 10% of FPPs), and a belief that bed rest for patients with LBP was of "some importance" (30% of PTs and 17% of FPPs). The numbers indicate that "continued educational efforts in the management of LBP are indicated and represent an area of potential cost savings for the health care system while also improving the quality of care and patient outcomes," authors write.

    The study has its share of limitations, according to its authors: response rates were small, and the use of members of the APTA PPS and the AAFP may mean that results may not be generalizable. Additionally, authors write, respondents tended to describe themselves as having a "special interest in musculoskeletal medicine," which may affect the "representativeness of the results."

    Authors believe that, despite those issues, at the very least their study merits further research into the knowledge levels of PTs and what that could mean for patient care.

    "These results may have implications for health policy decisions regarding the utilization of [PTs] to provide care for patients with LBP without a referral," authors write, "including the potential placement of [PTs] in primary care clinics to initially manage patient with musculoskeletal conditions."

    [Editor's note: What's the latest on the role of PTs in primary care? Check out this feature article from the December-January issue of PT in Motion magazine for an in-depth look at where things stand, and what APTA is doing, and learn about the basis for the association's efforts in this paper on exploring the roles of PTs in primary care teams.]

    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.

    PTJ: Physical Therapy Continuity of Care Linked to Lower Rate of Surgery, Lower Costs

    Patients with low back pain (LBP) who see a single physical therapist (PT) throughout their episode of care may be less likely to receive surgery and may have lower downstream health care costs, researchers suggest in a study published in the December issue of PTJ(Physical Therapy). "Limiting the number of physical therapy providers during an episode of care might permit cost savings," authors write. "Health care systems could find this opportunity appealing, as physical therapy provider continuity is a modifiable clinical practice pattern."

    Authors examined data from nearly 2,000 patients in Utah's statewide All Payer Claims Database (APCD) to look for associations between continuity of care for LBP patients and utilization of related services such as advanced imaging, emergency department visits, epidural steroid injections, and lumbar spine surgery in the year after the first primary care visit for LBP. APTA members John Magel, PT, PhD; Anne Thackeray, PT; and Julie Fritz, PT, PhD, FAPTA, were among the authors of the study.

    Patients were between the ages of 18 to 64 who saw a PT within 30 days of a primary care visit for LBP. Researchers excluded patients with certain nonmusculoskeletal conditions; neurological conditions, such as spinal cord injury, that could affect patient management; and "red flag" conditions such as bone deficit or cauda equina syndrome.

    Researchers found that greater provider continuity significantly decreased the likelihood of receiving subsequent lumbar spine surgery, noting that "disparate management strategies across a variety of providers might inhibit or prolong the recovery in a patient with a worsening condition and contribute to the patient eventually receiving lumbar surgical intervention." They also note that a strong therapeutic alliance is associated with improved outcomes.

    Contrary to authors' expectations, high provider continuity was not associated with decreased use of advanced imaging, steroid injections, or emergency department visits. "The timing of physical therapy for LBP might have a greater impact on these outcomes than does provider continuity," they suggest. Researchers did find a link between use of these services and the presence of comorbidities, previous lumbar surgery, and use of prescription opioids or oral steroids.

    The average cost of care in the year following the initial primary care visit was $1,826 per patient. Costs were slightly less, at $1,737, for the 90% of patients with high provider continuity but rose to $2,577 for patients with a lower level of provider continuity.

    While the study's findings do not identify any cause-and-effect relationships, "it seems reasonable that physical therapists should consider approaches to managing patients with LBP that limit provider discontinuity," authors write.

    Watch for an interview with Magel by PTJ Editor in Chief Alan Jette, PT, PhD, FAPTA, coming soon to the journal's podcast webpage. "It's intriguing that so little research has been done on continuity of care in physical therapy, considering that a lot of work has been done in this area in medicine," Jette said. "Continuity of physical therapy care is highly relevant not only for practitioners but for policymakers."

    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.

    Study: Early Physical Therapy for Neck Pain Associated With Lower Imaging Rates, Opioid Prescriptions, and Overall Cost

    In findings on neck pain that echo the results of similar studies on low back pain, researchers have identified an association between early consultation with a physical therapist (PT) and lower rates of opioid prescription, imaging, and injections. Those lower-use rates contributed to significant cost savings over a 1-year study period compared with patients who waited 90 days or more before seeing a PT, according to the study's authors.

    The study, published in BMC Health Services Research, looked at health care utilization over 1 year among 308 patients who presented with neck pain. The patients were divided into 3 groups: an "early" group that consulted a PT within 14 days, a "delayed" group that received a PT consultation between 15 and 90 days after initial health care provider consultation, and a "late" group that waited from between 91 and 364 days to consult with a PT. All patients were members of the University of Utah Health Plans, either through private insurance or via Medicaid, and none had a recorded health care encounter for neck pain in the 90 days preceding initial consultation. APTA members Maggie Horn, PT, DPT, PhD; and Julie Fritz, PT, PhD, FAPTA, coauthored the study.

    Horn and Fritz tracked rates of spinal injection, opioid prescription, imaging (MRIs, X-rays, and CT scans), and overall health care costs at the 1-year mark, analyzing data for each group. Demographic and comorbidity information also was collected and compared.

    Overall, of the 3,533 patients who reported a new neck pain encounter with a health care provider, only 15.1% had a consultation with a PT over the entire 1-year study period. Of the 536 patients who consulted with a PT, 308 were deemed eligible for the study. The average age of patients in the study was 48.7 years, and most (69.2%) participants were women.

    Among the findings:

    • Overall, 35% of patients in the study received spinal injections at some point; however, compared with the early group, the delayed group was 5.34 times more likely than the early group to receive an injection, while the late group was 4.36 times more likely to receive the treatment compared with the early group.
    • Opioids were prescribed to 62.7% of all patients. However, when broken down by early, delayed, and late groupings, the late group was estimated to be 2.79 times more likely to receive an opioid prescription than the early group. The delayed group had about the same odds of receiving a prescription as the early group.
    • When it came to imaging, the delayed and late groups were more than 4 times as likely to receive an MRI and nearly 3 times as likely to receive an x-ray compared with the early group. Rates of CT scans were small—only 7% of all patients—but the late group was more likely to receive the imaging. There were no significant differences between the early and delayed groups related to CT scan rates.
    • At the end of 1 year, the average adjusted total health care cost for the early group was $1,853—about $1,000 less than the cost for the delayed group ($2,917) and less than half the cost associated with the late group, which averaged $4,026.
    • The median episode-of-care (EOC) for all 3 groups was 155 days, with the early group reporting the shortest median EOC, at 49 days, compared with the late group median EOC of 319 days. The groups reported no significant differences in the median number of physical therapist visits (3) over a median 22 days.
    • Among the 3 groups there were no significant differences in the prevalence of depression, anxiety, fibromyalgia, or obesity. The late physical therapy group tended to have more participants with low back pain, chronic or generalized pain, substance abuse, and tobacco use.

    "Current trends in health care costs are becoming unsustainable for payers and patients and are not resulting in improved outcomes," authors write. "The findings from our study indicate that consulting a physical therapist early for neck pain, within 14 days of an index visit, may provide an opportunity to mitigate downstream health care utilization while containing costs."

    Authors note that the increased odds of diagnostic testing and invasive treatments they found in their neck pain study is similar to patterns other research has uncovered in the treatment of low back pain (LBP), albeit with increased comparative risk. They speculate that this could have something to do the available evidence on the treatment of neck pain as a discrete condition.

    "In our study, providers may be more likely to use diagnostic testing or more invasive treatments prior to initiating physical therapy, potentially due to the lack of preponderance of evidence for treating neck pain," authors write. "Conversely, early physical therapy consultation may shield patients from this utilization pattern."

    Authors acknowledge that their study is limited to a single group of insured patients, in a single geographic location, using a single health care system, and that results "cannot be interpreted as causal or widely generalizable." Still, they write, the association they uncovered bears further study.

    "Future studies need to further explore improving earlier access to physical therapy for patients with neck pain," authors write. "Specifically future studies need to determine the effect of early physical therapy consultation within the primary care setting or through direct access in a formal randomized controlled trial."

    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.