Physical Therapy and Manual Physical Therapy for Patients with Non-Specific Low-Back Pain: Differences in Patient Characteristics with Implications for Diagnostic Classification

Abstract

A previous study compared socio-demographic characteristics, health problem characteristics, and primary process data between a database sample of patients referred to physical therapy (PT) versus a sample of patients referred for specific manual physical therapy (MPT) diagnosis and management. This study did not differentiate between patients based on affected body region or diagnosis. The present study is a secondary analysis of these data for patients with non-specific low-back pain (LBP). Statistical analysis indicated that the MPT patient sample was significantly (P<0.01) different from the PT database sample with regard to socio-demographic data: The MPT patients were more often male, younger, had attained a higher level of post-secondary education, and were more often gainfully employed. The MPT sample was also significantly (P<0.01) different from the PT sample with regard to health problem characteristics indicating more often acute, recurrent, non-surgical LBP of shorter duration and unknown etiology in the MPT sample. Both samples were also significantly different with regard to the most common impairments, limitations in activities, and restrictions in participation. After correction for socio-demographic differences, both samples remained significantly different for pathology, recurrence, and mechanism of injury. Diagnosis and management with MPT resulted in a significantly better outcome at discharge than PT as determined by the therapist based on patient verbal report (P=0.0000); however, data on recurrence and the unclear influence of socio-demographic data as well as the absence of more reliable, valid, and responsive outcome measures render these outcome data somewhat equivocal. Interpretation of these data with regard to their potential use in diagnostic classification of patients with non-specific LBP is discussed.     

Dizziness in Orthopaedic Physical Therapy Practice: History and Physical Examination

Abstract

Physical therapy (PT) differential diagnosis of patients complaining of dizziness centers on distinguishing those patients who might benefit from sole management by the physical therapist from those patients who require referral for medical-surgical differential diagnosis and (co) management. There is emerging evidence that PT management may suffice for patients with benign paroxysmal positional vertigo, cervicogenic dizziness, and musculoskeletal impairments leading to dysequilibrium. This article provides information on the history taking and physical examination relevant to patients with a main complaint of dizziness. The intention of the article is to enable the therapist to distinguish between patients complaining of dizziness due to these three conditions amenable to sole PT management and those patients who likely require referral. Where available, we have provided data on reliability and validity of the history items and physical tests described to help the clinician establish a level of research-based confidence with which to interpret history and physical examination findings. The decision to refer the patient for a medical-surgical evaluation is based on our findings, the interpretation of such findings in light of data on reliability and validity of history items and physical tests, an analysis of the risk of harm to the patient, and the response to seemingly appropriate intervention.     

Influential Variables Associated with Outcomes in Patients with Cervicogenic Headache

Abstract

Cervicogenic headache (CGH) is a common sequela of upper cervical dysfunction with a significant impact on patients. Diagnosis and treatment have been well validated; however, few studies have described characteristics of patients that are associated with outcomes of physical therapy treatment of this disorder. A retrospective chart review of patient data was performed on a cohort of 44 patients with CGH. Patients had undergone a standardized physical therapy treatment approach that included spinal mobilization/manipulation and therapeutic exercise, and outcomes of treatment were determined by quantification of changes in headache pain intensity, headache frequency, and self-reported function. Multiple regression analysis was utilized to determine the relationship between a variety of patient-specific variables and these outcome measures. Increased patient age, provocation or relief of headache with movement, and being gainfully employed were all patient factors that were found to be significantly (P<0.05) related to improved outcomes.     

Physical Therapy Diagnosis and Management of a Patient with Chronic Daily Headache: A Case Report

Abstract

Chronic headaches are a significant health problem for patients and often a clinical enigma for the medical professionals who treat such patients. The purpose of this case report is to describe the physical therapy diagnosis and management of a patient with chronic daily headache. The patient was a 48-year-old woman with a medical diagnosis of combined common migraine headache and chronic tension-type headache. An exacerbation of these long-standing headache complaints had resulted in a chronic daily headache for the preceding eight months. Symptoms included bilateral headache, neck pain, left facial pain, and tinnitus. Outcome measures used included the Henry Ford Hospital Headache Disability Inventory (HDI) and the Neck Disability Index (NDI). Examination revealed myofascial, articular, postural, and neuromuscular impairments of the head and neck region. Treatment incorporated myofascial trigger point dry needling, orthopaedic manual physical therapy, exercise therapy, and patient education. On the final visit, the patient reported no headaches during the preceding month. There was a 31% improvement in the HDI emotional score, a 42% improvement in the functional score, and a 36% improvement in the total score for the HDI, the latter exceeding the minimal detectable change for the total score on this measure. The NDI at discharge showed an 18% improvement with a maximal improvement during the course of treatment of 26%. Both improvements exceeded the minimal clinically important difference for the NDI. This case report indicates that physical therapy diagnosis and management as described may be indicated for the conservative care of patients with chronic headaches.     

Cervicogenic Dizziness: A Case Report Illustrating Orthopaedic Manual and Vestibular Physical Therapy Comanagement

Abstract

The diagnosis and treatment of patients with dizziness of a cervical origin may pose a challenge for orthopaedic and vestibular physical therapy specialists. A thorough examination, which consists of a screening examination to rule out pathologies not amenable to sole physical therapy management and, if indicated, a physical therapy differential diagnostic process incorporating both cervical spine and vestibular tests and measures, may indicate an appropriate course of management. The treatment progression is then based on patient signs, symptoms, and response to physical therapy interventions. This case study describes the diagnosis, treatment, and outcomes of a patient with cervicogenic dizziness co-managed by a vestibular and an orthopaedic manual physical therapist.     

Physical Therapy Exercise Intervention Based on Classification Using the Patient Response Method: A Systematic Review of the Literature

Abstract

It has been suggested that inclusion into a study that categorizes patients in mutually exclusive, clinometric classifications should improve the outcome of an exercise based randomized clinical trial. This review examined the evidence regarding the effectiveness of physical therapist-directed therapeutic exercises when patients were classified using the patient response method. This systematic literature review restricted article inclusion to English-only articles that classified homogenous samples of low back pain patients using the patient response based method, demonstrated physical therapist-directed exercise interventions, and used specific outcome criteria for assessment of patient improvement. The PEDro scale was used to rate the methodological quality of the studies. Of 82 articles reviewed only 5 articles were accepted. All 5 met the PEDro standards for a high-quality study. Of the 5 articles, 4 demonstrated that physical therapy exercise intervention based on the patient response method of classification were significantly better than the pragmatic control comparisons; the remaining article indicated that exercise was less effective than manipulation. There appears to be a trend toward positive outcomes with physical therapy exercise intervention in trials restricted to the patient response method of classification; however, few studies have investigated this phenomenon.     

Comparison of the Quality of Patient Referrals From Physicians,Physician Assistants,and Nurse Practitioners

ObjectiveTo compare the quality of referrals of patients with complex medical problems from nurse practitioners (NPs), physician assistants (PAs), and physicians to general internists.Patients and MethodsWe conducted a retrospective comparison study involving regional referrals to an academic medical center from January 1, 2009, through December 31, 2010. All 160 patients referred by NPs and PAs combined and a random sample of 160 patients referred by physicians were studied. Five experienced physicians blinded to the source of referral used a 7-item instrument to assess the quality of referrals. Internal consistency, interrater reliability, and dimensionality of item scores were determined. Differences between item scores for patients referred by physicians and those for patients referred by NPs and PAs combined were analyzed by using multivariate ordinal logistical regression adjusted for patient age, sex, distance of the referral source from Mayo Clinic, and Charlson Index.ResultsFactor analysis revealed a 1-dimensional measure of the quality of patient referrals. Interrater reliability (intraclass correlation coefficient for individual items: range, 0.77-0.93; overall, 0.92) and internal consistency for items combined (Cronbach α=0.75) were excellent. Referrals from physicians were scored higher (percentage of agree/strongly agree responses) than were referrals from NPs and PAs for each of the following items: referral question clearly articulated (86.3% vs 76.0%; P=.0007), clinical information provided (72.6% vs 54.1%; P=.003), documented understanding of the patient's pathophysiology (51.0% vs 30.3%; P<.0001), appropriate evaluation performed locally (60.3% vs 39.0%; P<.0001), appropriate management performed locally (53.5% vs 24.1%; P<.0001), and confidence returning patient to referring health care professional (67.8% vs 41.4%; P<.0001). Referrals from physicians were also less likely to be evaluated as having been unnecessary (30.1% vs 56.2%; P<.0001).ConclusionThe quality of referrals to an academic medical center was higher for physicians than for NPs and PAs regarding the clarity of the referral question, understanding of pathophysiology, and adequate prereferral evaluation and documentation.     

Changes in Clinical Parameters in Patients with Tension-type Headache Following Massage Therapy: A Pilot Study

Abstract

Complementary and alternative medicine approaches to treatment for tension-type headache are increasingly popular among patients, but evidence supporting its efficacy is limited. The objective of this study was to assess short term changes on primary and secondary headache pain measures in patients with tension-type headache (TTH) receiving a structured massage therapy program with a focus on myofascial trigger point therapy. Participants were enrolled in an open label trial using a baseline control with four 3-week phases: baseline, massage (two 3-week phases) and follow-up. Twice weekly, 45-minute massage sessions commenced following the baseline phase. A daily headache diary was maintained throughout the study in which participants recorded headache incidence, intensity, and duration. The Headache Disability Index was administered upon study entry and at 3-week intervals thereafter. 18 subjects were enrolled with 16 completing all headache diary, evaluation, and massage assignments. Study participants reported a median of 7.5 years with TTH. Headache frequency decreased from 4.7±0.7 episodes per week during baseline to 3.7±0.9 during treatment period 2 (P<0.001); reduction was also noted during the follow-up phase (3.2±1.0). Secondary measures of headache also decreased across the study phases with headache intensity decreasing by 30% (P<0.01) and headache duration from 4.0±1.3 to 2.8±0.5 hours (P<0.05). A corresponding improvement in Headache Disability Index was found with massage (P<0.001). This pilot study provides preliminary evidence for reduction in headache pain and disability with massage therapy that targets myofascial trigger points, suggesting the need for more rigorously controlled studies.     

Roots of Physical Medicine,Physical Therapy,and Mechanotherapy in the Netherlands in the 19th Century: A Disputed Area within the Healthcare Domain

Abstract

Physical medicine, which in the context of this article includes mechanotherapy, hydrotherapy, balneotherapy, electrotherapy, light therapy, air therapy, and thermotherapy, became a new field of labor in the healthcare domain in the Netherlands around 1900. This article gives an account of the introduction and development of mechanotherapy as a professional activity in the Netherlands in the 19_th century. Mechanotherapy, which historically included exercises, manipulations, and massage, was introduced in this country around 1840 and became one of the core elements of physical medicine towards the end of that century. In contrast to what one might expect, mostly physical education teachers, referred to as "heilgymnasts," dedicated themselves to this kind of treatment, whereas only a few physicians were active in this field until the 1880s. When, in the last quarter of the 19 th century, differentiation and specialization within the medical profession took place, physicians specializing in physical medicine and orthopaedics began to claim the field of mechanotherapy exclusively for themselves. This led to tensions between them and the group of heilgymnasts that had already been active in this field for decades. The focus of attention in this article is on interprofessional relationships, on the roles played by the different professional organizations in the fields of physical education and medicine, the local and national governments, and the judicial system, and on the social, political, and cultural circumstances under which developments in the field of mechanotherapy took place. The article concludes with the hypothesis that the intra- and inter-occupational rivalries discussed have had a negative impact on the academic development of physical medicine, orthopaedics, and heilgymnastics/physical therapy in the Netherlands in the first half of the 20 th century.     

Management and Treatment of Temporomandibular Disorders: A Clinical Perspective

Abstract

A temporomandibular disorder (TMD) is a very common problem affecting up to 33% of individuals within their lifetime. TMD is often viewed as a repetitive motion disorder of the masticatory structures and has many similarities to musculoskeletal disorders of other parts of the body. Treatment often involves similar principles as other regions as well. However, patients with TMD and concurrent cervical pain exhibit a complex symptomatic behavior that is more challenging than isolated TMD symptoms. Although routinely managed by medical and dental practitioners, TMD may be more effectively cared for when physical therapists are involved in the treatment process. Hence, a listing of situations when practitioners should consider referring TMD patients to a physical therapist can be provided to the practitioners in each physical therapist's region. This paper should assist physical therapists with evaluating, treating, insurance billing, and obtaining referrals for TMD patients.     

Physician referrals to physical therapy for the treatment of musculoskeletal conditions

OBJECTIVES: To identify factors associated with orthopedic surgeons' and primary care physicians' referrals to physical therapy (PT) for musculoskeletal conditions. DESIGN: Cross-sectional analysis of National Ambulatory Medical Care Survey data. SETTING: US office-based physician practices. PARTICIPANTS: Visits to primary care physicians (N=4911) or orthopedic surgeons (N=4201) for musculoskeletal conditions. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Whether a PT referral was made. RESULTS: After controlling for diagnosis, illness severity, and PT supply, insurance status and physician characteristics remained strong predictors of PT referral. Primary care visits covered by Medicaid or a managed care plan were less likely to result in PT referral than were visits covered by private insurance or a nonmanaged care plan. Orthopedic surgeon visits covered by workers' compensation or managed care were more likely to result in PT referral than were visits not covered by workers' compensation or not covered by managed care. Osteopathic primary care visits were more likely than allopathic primary care visits to result in PT referral. Given identical visit characteristics, orthopedic surgeon visits were more likely than primary care visits to result in PT referral. CONCLUSIONS: Significant differences exist in orthopedic surgeons' and primary care physicians' referrals to PT, both within and across specialties. Variation in PT referral may be indicative of problems with access and/or inappropriate referral.     

Manipulation in the Treatment of Acute Low Back Pain

Abstract

Study Design. This prospective research project statistically analyses the difference between two randomized groups of patients, one receiving manipulation plus exercises for acute low back pain of mechanical origin, the other receiving an exercise program alone. Objectives. To determine if orthopaedic manipulation is beneficial in treating acute low back pain of mechanical origin. Summary of Background Data. Orthopaedic manipulative physiotherapists have frequently observed dramatic results including elimination of pain and restoration of pain-free range of movement following manipulation of the acute locked back. Spinal manipulative therapy is a widely used method of treating lower back pain with millions of patient treatments performed each year, the majority in Western societies. Trials have emphasized the immediate and short-term symptomatic relief of low back pain following manipulation; however, the longterm difference in effects between manipulated and control groups has required further evaluation. Methods. A sample of convenience of acute low back pain participants were randomly assigned to two groups. A pre-test/post-test experimental design approach was used with 29 participants. This design included three dependent variables (pain, range of movement, and disability assessment) and one independent variable (15 participants in Group I received an exercise program with manipulation and 14 participants in Group II received an exercise program only). Participants were assessed for pain, range of movement, and disability before treatment. Participants were reassessed weekly for four weeks, then at two months and three months after initiation of treatment. Results. The findings of this study illustrate a statistically significant difference between the two treatments (p = <0.0005). Univariate post hoc tests concluded that the two treatment regimens had significantly different effects at three months on disability (p = 0.001), pain (p = <0.0005), and ROM (p = <0.0005). As well as being statistically significant, the magnitude of the relationships was strong, with 42.8% of the variability attributed to the disability measure, 64.3% of the variability attributed to the pain measure, and 65.9% of the variability attributed to the ROM measure. Conclusion. Patients who receive orthopaedic manipulation with an exercise program for acute low back pain of mechanical origin are likely to improve more than patients who receive an exercise program alone.     

Documentation of Red Flags by Physical Therapists for Patients with Low Back Pain

Abstract

The comprehensiveness of physical therapists' adherence to the guidelines for red flag documentation for patients with low back pain has not previously been described. Therefore, the purpose of this study was to describe that comprehensiveness. Red flags are warning signs that suggest that physician referral may be warranted. Clinic charts for 160 patients with low back pain seen at 6 outpatient physical therapy clinics were retrospectively reviewed, noting the presence or absence of 11 red flag items. Seven of the 11 red flag items were documented over 98% of the time. Most charts (96.3%) had at least 64% of the red flag items documented. Documentation of red flags was comprehensive in some areas but lacking in others. Red flags that were regularly documented included age over 50, bladder dysfunction, history of cancer, immune suppression, night pain, history of trauma, saddle anesthesia, and lower extremity neurological deficit. The red flags not regularly documented included weight loss, recent infection, and fever/chills. Factors influencing item documentation comprehensiveness are discussed, and suggestions are provided to enhance the completeness of recording patient examination data. The study results provide a red flag documentation benchmark for clinicians working with patients with low back pain and they lay the groundwork for future research.     

Evaluation of an Emergency Medical Services–Based Social Services Referral Program for Elderly Patients

Objective. To describe the preliminary experience of an emergency medical services (EMS)-based follow-up program providing elderly patients access to community-based social services. Methods: This was a retrospective, case series report. Inclusion criteria were adults aged 60 years and older requesting EMS for fall or lift assist; against medical advice (AMA) refusal of transport for a medical complaint; any social service or home care needs; request for nonmedical transportation; multiple prior EMS visits; or cases of elder abuse or neglect. Patients were identified either by paramedics at the time of the call or an EMS physician during routine chart review of “no-transport” calls. Patients were then contacted and offered referral follow-up with a social services worker. Data were collected for age, gender, presence of established social services, referral strategy, complaint type, referral acceptance rate, and follow-up plan. Results: Seventy patients were referred over eight months. Paramedics provided 33% of referrals (23/70) as well as a significantly higher number of social service–related complaints (48% vs. 15%, p = 0.005). Follow-up from a fall occurred more often after EMS physician chart review (53% vs. 30%, p = 0.07). Rates of established social services were similar for patients who accepted and those who declined follow-up (89% vs. 90%, p = 0.95) and between patients who were referred by paramedics and those who were referred by EMS physicians (93% vs. 90%, p = 0.72). Paramedic referral was associated with a significantly higher rate of acceptance (94% vs. 28%, p < 0.001). Conclusion: EMS provides an invaluable opportunity to connect the elderly with social services at the time of contact. In this study, paramedics appeared to refer more social service–related complaints compared with other categories such as fall assistance. This highlights a difference in perception of social service needs among paramedics and represents an area for further training and education.     

Patient profiles at a centralized,urban, diabetes education centre

BACKGROUND: Little is known about the characteristics of patients attending diabetes education centres (DECs). To address this knowledge gap, we examined the clinical characteristics of patients referred to a centralized urban DEC. METHODS: Using a clinically detailed patient registry, we studied the profiles of 1459 patients seen in an urban DEC, and compared patients referred to the DEC by family physicians (FPs) to those referred by other physicians (usually specialists), and patients referred to the DEC for the first time to those who had been referred a number of times (multiply-referred patients). RESULTS: Among patients with a known source of referral, 73% were referred by their FP and 27% by a physician other than the FP. Eighty-seven percent of patients were being referred for the first time, and 13% had previous referrals. Blood glucose control at the time of referral was poorer for non-FP referrals and for multiply-referred patients. Patients in the former subgroup were more likely taking insulin when referred (38% v. 12%, p < 0.000), to have type 1 diabetes (19% v. 8%, p < 0.000) and to be referred for insulin initiation (12% v. 2%, p < 0.000) than were FP referrals. Meanwhile, multiply-referred patients were younger (51.9 v. 56.1 yr, p < 0.000) and were more likely to be female (59% v. 46%, p = 0.001) than were patients referred only once. INTERPRETATION: Source of referral (FP v. non-FP) and presence or absence of previous referrals define unique DEC patient subgroups. Attention to the relative size and service needs of these subgroups is relevant to the planning of diabetes services.     

Referral timing of in-hospital cancer deaths to palliative care in a Saudi tertiary care hospital

Abstract

Introduction: Late referral of advanced cancer patients to palliative care adversely affects their end-of-life care. We conducted this study to determine the referral timing of in-hospital cancer deaths to palliative care in a Saudi tertiary care hospital.

Subjects and methods: A retrospective review of cancer referrals to palliative care during a 4-year period who eventually died in-hospital. The effect of different factors on referral timing was studied.

Results: From 1567 referrals, 887 (56.6%) were eligible. Referral during the last week of life occurred in 28% of cases. The median survival from the first referral was 19 days (95% CI, 16–22). In multivariate analysis, the survival differed significantly according to the referring specialty and the setting of referral (P = 0.002, and < 0.001; respectively). The survival was shorter for patients referred from the medical, haematology and paediatric oncology specialties and for those referred in the emergency room or while in-patients.

Conclusions: Referral of in-hospital cancer deaths to palliative care occurs late in our setting and many patients are referred when death is imminent. The identification of factors related to this late referral attitude may be helpful in future improvement of end-of-life cancer care. Further research is warranted to investigate other reasons that may lead to late referral and to find ways to improve referral timing.     

Characteristics of patients referred by police to a psychiatric hospital

To identify any differences between patients referred by police compared with patients referred from other sources, to a psychiatric hospital in Australia, a retrospective audit of 200 patient files was undertaken. The two most common reasons for the involuntary referral of patients by police were bizarre ideas (33%) and threats of suicide (28%). When 101 patients referred by police were compared with 99 patients from other sources, police referrals were three times more likely to be diagnosed with a mental and behavioural disorder because of psychoactive substance use, less likely to be diagnosed with a mood disorder, and less likely to be diagnosed as psychotic. Police referrals were more likely to have worse functional scores; exhibit aggressive behaviour; spend fewer days in hospital; more likely to be admitted to the psychiatric intensive care unit, and to be secluded. The most important predictor for a police referral was drug or alcohol problems. The study indicates that patients referred by the police were more likely to demonstrate particular characteristics compared with patients referred by other sources.     

A prospective comparison of cardiac rehabilitation enrollment following automatic vs usual referral.

OBJECTIVE: Cardiac rehabilitation remains grossly under-utilized despite its proven benefits. This study prospectively compared verified cardiac rehabilitation enrollment following automatic vs usual referral, postulating that automatic referral would result in significantly greater enrollment for cardiac rehabilitation. DESIGN: Prospective controlled multi-center study. Patients and methods: A consecutive sample of 661 patients with acute coronary syndrome treated at 2 acute care centers (75% response rate) were recruited, one site with automatic referral via a computerized prompt and the other with a usual referral strategy at the physician's discretion. Cardiac rehabilitation referral was discerned in a mailed survey 9 months later (n = 506; 84% retention), and verified with 24 cardiac rehabilitation sites to which participants were referred. RESULTS: A total of 124 (52%) participants enrolled in cardiac rehabilitation following automatic referral, vs 84 (32%) following usual referral (p < 0.001). Automatically referred participants were more likely to be referred from an in- patient unit (p < 0.01), and to be referred in a shorter time period (p < 0.001). Logistic regression analyses revealed that, after controlling for sociodemographic characteristics and case-mix, automatically referred participants were significantly more likely to enroll in cardiac rehabilitation (odds ratio = 2.1; 95% confidence interval 1.4-3.3) than controls. CONCLUSION: Automatic referral resulted in over 50% verified cardiac rehabilitation enrollment; 2 times more than usual referral. It also significantly reduced utilization delays to less than one month.     

Rapid-access chest pain clinics and the traditional cardiology out-patient clinic

BACKGROUND: The National Service Framework for coronary heart disease recommends rapid-access chest pain clinics (RACPCs) for cardiological assessment of new-onset chest pain within 2 weeks of referral. AIM: To measure the extent to which an RACPC successfully substituted for an out-patient cardiology clinic (OPCC) at a general hospital, in assessing new-onset chest pain referrals. METHODS: Prospective measurement of attendance and waiting times for consecutive patients at the RACPC and OPCC, and multivariate analysis of factors associated with referral for angiography. RESULTS: From September 2002 to August 2004, 1382 patients with chest pain attended the RACPC, and 228 patients, the OPCC. All RACPC patients were seen within 24 h of referral, except those referred on Friday afternoons, or the day before national holidays. The mean +/- SD waiting time for OPCC appointments was 97 +/- 43 days. Of 208 OPCC patients, 30 (14%) fulfilled the RACPC referral criterion of recent onset chest pain (<4 weeks duration) vs. 926/1382 (67%) RACPC patients. Thus the RACPC substituted for the OPCC in 926/956 (97%) new chest pain referrals. Patients from the OPCC were 3.82 (95%CI 1.85-7.90) more likely to be referred for a coronary angiogram. compared to those attending the RACPC. DISCUSSION: The RACPC has provided efficient and effective substitution for the OPCC in the assessment of new chest pain referrals according to pre-defined referral criteria. Broadening the referral criterion of the RACPC to patients with chest pain of >4 weeks duration would result in more referrals.