Faculty Bibliography

The aim of the pilot study was to evaluate a multidisciplinary program for nonspecific low back pain (NSLBP) at a major U.S. Navy base. In this single blinded randomized clinical trial, subjects were drawn from a larger, prospective cohort of active duty service members seeking care for NSLBP pain at a U.S. Navy Branch Medical Clinic. Outcome measures included return to work, self-reported pain, function, and psychological distress. Subjects were randomly allocated to one of two study arms: a multidisciplinary reconditioning program or the current standard of care for low back pain. The intervention lasted 4 weeks with a 12-week follow-up. Thirty-three subjects were enrolled. Subjects allocated to multidisciplinary care reported significantly lower perceived disability (p = 0.014) and less pain than those allocated to usual care at the end of the intervention period. All subjects returned to their usual duty following the conclusion of the intervention. The implementation of the intervention program was successful. Subjects in the multidisciplinary program showed a clinically significant improvement in the perception of disability compared to the usual care group. This is an important finding since perception of disability is associated with long-term functional outcome.

STUDY DESIGN.: A fully blocked experimental design using clinical vignettes to query primary care physicians on prescription for management of acute nonspecific low back pain. OBJECTIVE.: To identify how nonclinical patient factors, specifically sex, patient presentation, and socioeconomic status, influence physician treatment recommendations for assessing and treating acute nonspecific low back pain. SUMMARY OF BACKGROUND DATA.: Adherence to evidence-based practice guidelines for nonspecific low back pain remains inconsistent. Therefore, it is important to understand what factors guide physician management of these cases. METHODS.: One vignette and questionnaire was distributed to primary care and emergency department clinical physicians during meetings at five teaching hospitals. The questionnaire asked for diagnostic and treatment recommendations including specific tests, medications, therapeutic procedures, activity, referral to other services, and patient education for the case represented in the vignette. RESULTS.: Subjects included 284 physicians and approximately 75% had less than 5 years of clinical practice experience. Multivariate logistic regression showed seven significant associations of patient factors with treatment recommendations for acute nonspecific low back pain (one sex, two socioeconomic status, and four patient presentation; P < 0.05). CONCLUSION.: All three assessed nonclinical factors influenced physician decisions regarding diagnostic and treatment recommendations for acute nonspecific low back pain. Patient presentation, suggestive of a patient's emotional state, was shown to be the most influential

Background Job stress has been associated with poor outcomes. In focus groups and small-sample surveys, physical therapists have reported high levels of job stress. Studies of job stress in physical therapy with larger samples are needed. Objective The purposes of this study were: (1) to determine the levels of psychological job demands and job control reported by physical therapists in a national sample, (2) to compare those levels with national norms, and (3) to determine whether high demands, low control, or a combination of both (job strain) increases the risk for turnover or work-related pain. Design This was a prospective cohort study with a 1-year follow-up period. METHODS:/b> Participants were randomly selected members of the American Physical Therapy Association (n=882). Exposure assessments included the Job Content Questionnaire (JCQ), a commonly used instrument for evaluation of the psychosocial work environment. OUTCOMES: included job turnover and work-related musculoskeletal disorders. RESULTS: /b> Compared with national averages, the physical therapists reported moderate job demands and high levels of job control. About 16% of the therapists reported changing jobs during follow-up. Risk factors for turnover included high job demands, low job control, job strain, female sex, and younger age. More than one half of the therapists reported work-related pain. Risk factors for work-related pain included low job control and job strain. Limitations The JCQ measures only limited dimensions of the psychosocial work environment. All data were self-reported and subject to associated bias. CONCLUSIONS:/b> Physical therapists' views of their work environments were positive, including moderate levels of demands and high levels of control. Those therapists with high levels of demands and low levels of control, however, were at increased risk for both turnover and work-related pain. Physical therapists should consider the psychosocial work environment, along with other factors, when choosing a job

BACKGROUND: Work-related musculoskeletal disorders (WMSDs) have a significant impact on physical therapists, but few studies have addressed the issue. Research is needed to determine the scope of the problem and the effects of specific risk factors. OBJECTIVES: The objectives of this study were: (1) to determine the 1-year incidence rate of WMSDs in physical therapists and (2) to determine the effects of specific risk factors. DESIGN: This was a prospective cohort study with 1-year follow-up. METHODS: Subjects were randomly selected American Physical Therapy Association members (N=882). Exposure assessment included demographic data, physical risk factors, job strain, and specific physical therapy tasks. The primary outcome was WMSDs, with a severity rating of at least 4/10 and present at least once a month or lasting longer than a week. RESULTS: The response rate to the baseline questionnaire was 67%. Ninety-three percent of the subjects who responded to the baseline questionnaire responded to the follow-up questionnaire. The 1-year incidence rate of WMSDs was 20.7%. Factors that increased the risk for WMSDs included patient transfers, patient repositioning, bent or twisted postures, joint mobilization, soft tissue work, and job strain. LIMITATIONS: The primary limitation of this study was the number of therapists who had a change in their job situation during the follow-up year. CONCLUSIONS: Work-related musculoskeletal disorders are prevalent in physical therapists. Physical therapy exposures, patient handling, and manual therapy, in particular, increase the risk for WMSDs

STUDY DESIGN: A cohort study of patients with nonspecific low back pain (LBP) participated in a 4-week multidisciplinary rehabilitation program. OBJECTIVE: To identify factors that predict work retention 24 months after treatment in patients with nonspecific LBP. SUMMARY OF BACKGROUND DATA: There is evidence that select physical, psychologic, and psychosocial factors are related to positive outcome for work-related nonspecific LBP. However, there is very little information related to work retention following an episode of nonspecific LBP. This is an exploratory study to identify select physical and psychosocial factors related to work retention. METHODS: Patients who returned to work after treatment (n = 67) were followed for 2 years. Physical baseline measures included tests of flexibility, strength, and functional capacity. Psychosocial baseline measures were The Symptoms Checklist 90-R, The Pain Beliefs and Perceptions Inventory, The Oswestry Scale of perceived disability, The Work Stress Inventory, and The Quality of Life Scale. All physical parameters, perceived disability, and quality of life were tested before and after treatment. The dependent variable, work retention, was defined as the number of days that the subject worked during the 2-year follow-up period. Survival analysis was used to establish the predictive model. RESULT: The average time out of work before treatment was 9 months (standard deviation 12.8) for 67 subjects (mean age 40 years [standard deviation 9.6]), including 18 females and 49 males. There were 18 participants (25%) that had interruption of work retention at follow-up. Average work retention was 362 days (range 47-682). Variables that reached a P value of <0.10 in the bivariate analysis were included in the multivariate analysis. They were trunk flexion (hazard ratio [HR = 2.4], 95% confidence interval [CI] 1.24-4.38; P = 0.01), trunk extension (HR = 2.1, 95% CI 1.02-4.16; P = 0.04), the somatization scale from the Symptom Checklist 90 revised (HR = 2.0, 95% CI 1.03-4.05; P = 0.04), and the obsessive-compulsiveness scale from the Symptom Checklist 90 revised (HR = 0.4, 95% CI 0.12-1.15; P = 0.09). Results showed that post-test trunk flexion, somatization, and obsessive compulsiveness predicted work retention (final trunk flexion HR = 2.5 [95% CI 1.26-4.79; P = 0.01], somatization scale HR = 2.5 [95% CI 1.25-4.93; P = 0.01], and obsessive compulsion HR = 0.2 [95% CI 0.07-0.77; P = 0.02]). CONCLUSION: Psychosocial and physical factors are associated with work retention for patients with nonspecific LBP. The predictive value of certain constructs may vary with the time when they are assessed and how outcome is operationalized. Further studies are needed to confirm these findings

Unremitting lower-back pain has long been a costly and personally devastating problem in society. Guidelines for the treatment of lower-back pain have provided evidence-based recommendations to help identify patients who will benefit from specific types of treatment in an effort to reduce costs and human suffering. However, there is little evidence that these guidelines are being applied in the daily practice of health care providers. Practical information is required to assist health care providers in triaging patients for specific treatments so that interventions can be targeted only to those who need them. In this way, iatrogenic complications and unnecessary costs can be contained. This chapter provides information on how to triage the patient with nonspecific lower-back pain for optimal care. The recommendations are supported by evidence-based guidelines, and when these are not available, best practice principles. Because appropriate treatment varies depending on the length of time a patient is suffering from lower-back pain, the chapter is divided into recommendations for acute, subacute, chronic and recurrent phases of lower-back pain. LEVEL OF EVIDENCE: Level V (expert opinion). See the Guidelines for Authors for a complete description of the levels of evidence