ImportanceTailored treatments for low back pain (LBP) based on stratifying risk for poor prognosis have emerged as a promising approach to improve quality of care, but they have not been validated in trials at the level of individual randomization in US health systems.ObjectiveTo assess the clinical effectiveness of risk-stratified vs usual care on disability at 1 year among patients with LBP.Design, Setting, and ParticipantsThis parallel-group randomized clinical trial enrolled adults (ages 18-50 years) seeking care for LBP with any duration in primary care clinics within the Military Health System from April 2017 to February 2020. Data analysis was conducted from January to December 2022.InterventionsRisk-stratified care, in which participants received physiotherapy treatment tailored for their risk category (low, medium, or high), or usual care, in which care was determined by participants’ general practitioners and may have included a referral to physiotherapy.Main Outcomes and MeasuresThe primary outcome was the Roland Morris Disability Questionnaire (RMDQ) score at 1 year, with planned secondary outcomes of Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference (PI) and Physical Function (PF) scores. Raw downstream health care utilization was also reported within each group.ResultsAnalysis included 270 participants (99 [34.1%] female participants; mean [SD] age, 34.1 [8.5] years). Only 21 patients (7.2%) were classified as high risk. Neither group was superior on the RMDQ (least squares [LS] mean ratio of risk-stratified vs usual care: 1.00; 95% CI, 0.80 to 1.26), the PROMIS PI (LS mean difference, −0.75 points; 95% CI −2.61 to 1.11 points), or the PROMIS PF (LS mean difference, 0.05 points; 95% CI, −1.66 to 1.76 points).Conclusions and RelevanceIn this randomized clinical trial, using risk stratification to categorize and provide tailored treatment for patients with LBP did not result in better outcomes at 1 year compared with usual care.Trial RegistrationClinicalTrials.gov Identifier: NCT03127826

Objective: To examine the effectiveness of epidural steroid injection (ESI) and back education with and without physical therapy (PT) in individuals with lumbar spinal stenosis (LSS). Design: Randomized clinical trial. Setting: Orthopedic spine clinics. Participants: A total of 390 individuals were screened with 60 eligible and randomly selected to receive ESI and education with or without PT (N=54). Interventions: A total of 54 individuals received 1-3 injections and education in a 10-week intervention period, with 31 receiving injections and education only (ESI) and 23 additionally receiving 8-10 sessions of multimodal PT (ESI+PT). Main Outcome Measures: Disability, pain, quality of life, and global rating of change were collected at 10 weeks, 6 months, and 1 year and analyzed using linear mixed model analysis. Results: No significant difference was found between ESI and ESI+PT in the Oswestry Disability Index at any time point, although the sample had significant improvements at 10 weeks (P<.001; 95% confidence interval [CI], -18.01 to -5.51) and 1 year (P=.01; 95% CI, -14.57 to -2.03) above minimal clinically important difference. Significant differences in the RAND 36-Item Short Form Health Survey 1.0 were found for ESI+PT at 10 weeks with higher emotional role function (P =.03; 95% CI, -49.05 to -8.01), emotional well-being (P=.02; 95% CI, -19.52 to -2.99), and general health perception (P=.05; 95% CI, -17.20 to -.78). Conclusions: Epidural steroid injection plus PT was not superior to ESI alone for reducing disability in individuals with LSS. Significant benefit was found for the addition of PT related to quality of life factors of emotional function, emotional well-being, and perception of general health. (C) 2019 Published by Elsevier Inc. on behalf of the American Congress of Rehabilitation Medicine

BACKGROUND:Quantifying stiffness of the lumbar spine musculature using shear-wave elastography (SWE) maybe beneficial in the diagnosis and treatment of non-specific low back pain (LBP). The primary purpose of this study was to establish normative parameter and variance estimates of lumbar spine muscle stiffness at rest and during submaximal contraction levels using SWE in healthy individuals. A second aim was to determine the relationship between lumbar spine muscle stiffness and a variety of demographic, anthropometric, and medical history variables. METHODS:This cross-sectional study included stiffness measurements of the lumbar musculature in 120 asymptomatic individuals using ultrasound SWE. The lumbar erector spinae muscle was measured during rest only and lumbar multifidus muscle was measured during rest and during submaximal contraction using a prone contralateral arm lift. Statistical comparisons of shear modulus were made between sex (male vs. female) and muscle condition (erector spinae rest, lumbar multifidus rest, lumbar multifidus contracted) using 2 × 3 repeated measures analysis of variance (ANOVA). Univariate associations between shear modulus and age, sex, BMI, activity level, and history of back pain were assessed using correlation analysis. FINDINGS:Shear modulus at rest was approximately 4 kPa for the erector spinae muscles and approximately 6 kPa for the lumbar multifidus muscles. Shear modulus substantially increased during contraction, and varied by sex, BMI, and self-reported activity level, with men and more active individuals generally having stiffer muscles. INTERPRETATION:Variability in shear modulus of the lumbar musculature may be mediated through a combination of muscle size and contractile state, which is consistent with our findings of higher stiffness in the more postural lumbar multifidi muscles, during contraction, and in larger and more active individuals. These findings should inform and be accounted for in future comparative clinical studies.

Background Limited information exists regarding the cost‐effectiveness of rehabilitation strategies for individuals with knee osteoarthritis (OA). Objective The study objective was to compare the cost‐effectiveness of 4 different combinations of exercise, manual therapy, and booster sessions for individuals with knee OA. Design This economic evaluation involved a cost‐effectiveness analysis performed alongside a multicenter randomized controlled trial. Setting The study took place in Pittsburgh, Pennsylvania; Salt Lake City, Utah; and San Antonio, Texas. Participants The study participants were 300 individuals taking part in a randomized controlled trial investigating various physical therapy strategies for knee OA. Intervention Participants were randomized into 4 treatment groups: exercise only (EX), exercise plus booster sessions (EX+B), exercise plus manual therapy (EX+MT), and exercise plus manual therapy and booster sessions (EX+MT+B). Measurements For the 2‐year base case scenario, a Markov model was constructed using the United States societal perspective and a 3% discount rate for costs and quality‐adjusted life years (QALYs). Incremental cost‐effectiveness ratios were calculated to compare differences in cost per QALY gained among the 4 treatment strategies. Results In the 2‐year analysis, booster strategies (EX+MT+B and EX+B) dominated no‐booster strategies, with both lower health care costs and greater effectiveness. EX+MT+B had the lowest total health care costs. EX+B cost $1061 more and gained 0.082 more QALYs than EX+MT+B, for an incremental cost‐effectiveness ratio of $12,900/QALY gained. Limitations The small number of total knee arthroplasty surgeries received by individuals in this study made the assessment of whether any particular strategy was more successful at delaying or preventing surgery in individuals with knee OA difficult. Conclusions Spacing exercise‐based physical therapy sessions over 12 months using periodic booster sessions was less costly and more effective over 2 years than strategies not containing booster sessions for individuals with knee OA.

STUDY DESIGN Randomized clinical trial. Background The recommended initial management strategy for patients with low back pain and signs of nerve root compression is conservative treatment, but there is little evidence to guide the most appropriate management strategy. Preliminary research suggests that a treatment protocol of mechanical traction and extension-oriented exercises may be effective, particularly in a specific subgroup of patients. OBJECTIVE To examine the effectiveness of mechanical traction in patients with lumbar nerve root compression and within a predefined subgroup. METHODS One hundred twenty patients with low back pain with nerve root compression were recruited from physical therapy clinics. Using predefined subgrouping criteria, patients were stratified at baseline and randomized to receive an extension-oriented treatment approach with or without the addition of mechanical traction. During a 6-week period, patients received up to 12 treatment visits. Primary outcomes of pain and disability were collected at 6 weeks, 6 months, and 1 year by assessors blinded to group allocation. Outcomes were examined using linear mixed-model analyses examining change over time by treatment and the interaction between treatment and subgrouping status. RESULTS The mean ± SD age of participants was 41.1 ± 11.3 years, median duration of symptoms was 62 days, and 57% were male. No significant differences in disability or pain outcomes were noted between treatment groups at any time point, nor was any interaction found between subgroup status and treatment. CONCLUSION Patients with lumbar nerve root compression presenting for physical therapy can expect significant changes in disability and pain over a 6-week treatment period. There is no evidence that mechanical lumbar traction in combination with an extension-oriented treatment is superior to extension-oriented exercises alone in the management of these patients or within a predefined subgroup of patients. The study protocol was registered with ClinicalTrials.gov (NCT00942227). Level of Evidence Therapy, level 2b.

Initial management decisions following a new episode of low back pain (LBP) are thought to have profound implications for health care utilization and costs. The purpose of this study was to evaluate the impact of early and guideline adherent physical therapy for low back pain on utilization and costs within the Military Health System (MHS).

STUDY DESIGN: A factorial randomized controlled trial.OBJECTIVES: To investigate the addition of manual therapy to exercise therapy for the reduction of pain and increase of physical function in people with knee osteoarthritis (OA), and whether "booster sessions" compared to consecutive sessions may improve outcomes.BACKGROUND: The benefits of providing manual therapy in addition to exercise therapy, or of distributing treatment sessions over time using periodic booster sessions, in people with knee OA are not well established.METHODS: All participants had knee OA and were provided 12 sessions of multimodal exercise therapy supervised by a physical therapist. Participants were randomly allocated to 1 of 4 groups: exercise therapy in consecutive sessions, exercise therapy distributed over a year using booster sessions, exercise therapy plus manual therapy without booster sessions, and exercise therapy plus manual therapy with booster sessions. The primary outcome measure was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC score; 0-240 scale) at 1-year follow-up. Secondary outcome measures were the numeric pain-rating scale and physical performance tests.RESULTS: Of 75 participants recruited, 66 (88%) were retained at 1-year follow-up. Factorial analysis of covariance of the main effects showed significant benefit from booster sessions (P =.009) and manual therapy (P =.023) over exercise therapy alone. Group analysis showed that exercise therapy with booster sessions (WOMAC score, -46.0 points; 95% confidence interval [CI]: -80.0, -12.0) and exercise therapy plus manual therapy (WOMAC score, -37.5 points; 95% CI: -69.7, -5.5) had superior effects compared with exercise therapy alone. The combined strategy of exercise therapy plus manual therapy with booster sessions was not superior to exercise therapy alone.CONCLUSION: Distributing 12 sessions of exercise therapy over a year in the form of booster sessions was more effective than providing 12 consecutive exercise therapy sessions. Providing manual therapy in addition to exercise therapy improved treatment effectiveness compared to providing 12 consecutive exercise therapy sessions alone. Trial registered with the Australian New Zealand Clinical Trials Registry (ACTRN12612000460808).

BACKGROUND:Studies that have relied exclusively on web-based surveys to secure follow-up have yielded inadequate follow-up rates, resulting in the need to explore whether supplementing with other methods results in incremental improvements. The primary purpose of this study was to determine the effectiveness of each follow up strategy that was used to collect the follow up data in our ongoing Prevention of Low Back Pain in the Military (POLM) trial.METHODS:This study represents a secondary analysis of the POLM trial. Twenty companies of Soldiers (N=4,325) were cluster randomized to complete one of four exercise programs. Since web-based response rates were lower than anticipated, a telephone call center was established to contact Soldiers who had not responded to the web-based survey. A military healthcare utilization database (M2) was also used to capture additional follow-up. Descriptive statistics and pairwise comparisons were performed to determine the incremental benefits of supplementing the primary web-based follow-up strategy in our ongoing POLM trial and determine whether differences existed in demographic characteristics, pain intensity, and low back pain incidence based on follow-up strategy.RESULTS:Of the 4,325 Soldiers who were enrolled, 632 (14.6%) subjects completed the monthly web-based survey only; 571 (13.2%) responded only to the telephone call; and 233 (5.4%) responded to both the web-based and telephone survey. Adding the telephone call center contributed 804 unique contributions to follow-up, increasing the overall follow-up to 33.2% (n=1,436) and resulting in a net 18.6% increase in follow-up rate. Querying the M2 database yielded follow-up data for an additional 2,788 Soldiers, increasing the follow-up rate by 64.5%. This rate, combined with the web-based and telephone strategies, resulted in an overall follow-up rate of 97.7%. Compared to the web-based survey, those who responded to the telephone call center tended to be younger, white, have a lower income, more likely to smoke, more likely to exercise regularly, and less likely to have low back pain (all with P<.05).CONCLUSIONS:The results of this study can inform the design of future clinical trials by establishing the benefit of supplementing a web-based survey with a telephone call center to secure additional follow-up.

Low back pain is one of the top causes of disability in the US Armed Forces and the leading source of non battle injuries among those deployed. Our recent randomized trial demonstrated that high intensity progressive resistance exercise (HIPRE) for the lumbar extensor muscles resulted in significant strength gains in Soldiers, compared with core stabilization training. However, the factors influencing these strength gains have not been explored. PURPOSE: The purpose of this study was to assess the relationships of health history, anthropometric, and exercise adherence measures with lumbar extension strength gains. METHODS: Active duty Soldiers in the US Army were enrolled in a 2-arm randomized trial at Fort Sam Houston, TX. Participants were randomized by platoon to receive lumbar extensor HIPRE (n = 298) or core stabilization exercise (n = 284), 1 set, 1X/week, for 11 weeks. Isometric lumbar extension strength was assessed before and after the intervention. The relationships of various health history, anthropometric, and exercise adherence measures with lumbar extension strength gains at follow-up were assessed in the HIPRE group with correlation analyses, regression analyses, and ANOVA, as appropriate. RESULTS: For the HIPRE group, 77.2% (230/298) of participants completed follow-up assessments. The mean +/- SD lumbar extension strength gain was 14.6% +/- 19.5% (p < 0.0001). Baseline lumbar extension strength was negatively correlated with lumbar extension strength gain (r = -0.29, p < 0.001). Participants who adequately progressed in exercise load throughout the intervention period achieved greater strength gains than those who did not adequately progress (progressed: n = 208, 15.6% strength gain; not progressed: n = 22, 5.3% strength gain; p = 0.02). No significant relationships were observed between lumbar extension strength gain and sex, LBP history, physical activity history, smoking history, body height, body weight, and number of exercise sessions completed. CONCLUSIONS: Baseline strength and exercise adherence play a role in lumbar extension strength gains for active duty Soldiers completing lumbar extensor HIPRE training, while several demographic, health history, and anthropometric variables were not related. The clinical relevance of these relationships requires further research.

Assessment of spinal stiffness is widely used by manual therapy practitioners as a part of clinical diagnosis and treatment selection. Although studies have commonly found poor reliability of such procedures, conflicting evidence suggests that assessment of spinal stiffness may help predict response to specific treatments. The current study evaluated the criterion validity of manual assessments of spinal stiffness by comparing them to indentation measurements in patients with low back pain (LBP). As part of a standard examination, an experienced clinician assessed passive accessory spinal stiffness of the L3 vertebrae using posterior to anterior (PA) force on the spinous process of L3 in 50 subjects (54% female, mean (SD) age 1⁄4 33.0 (12.8) years, BMI 1⁄4 27.0 (6.0) kg/m2) with LBP. A criterion measure of spinal stiffness was performed using mechanized indentation by a blinded second examiner. Results indicated that manual assessments were uncorrelated to criterion measures of stiffness (spearman rho 1⁄4 0.06, p 1⁄4 0.67). Similarly, sensitivity and specificity estimates of judgments of hypomobility were low (0.20 e0.45) and likelihood ratios were generally not statistically significant. Sensitivity and specificity of judgments of hypermobility were not calculated due to limited prevalence. Additional analysis found that BMI explained 32% of the variance in the criterion measure of stiffness, yet failed to improve the relationship between assessments. Additional studies should investigate whether manual assessment of stiffness relates to other clinical and biomechanical constructs, such as symptom reproduction, angular rotation, quality of motion, or end feel. Published by Elsevier Ltd.

Purpose: 1) To determine whether the addition of manual therapy to exercise therapy reduces pain, disability and physical function in people with knee osteoarthritis (OA); and 2) whether distributing interventions using periodic "booster sessions" improves outcomes compared with consecutive sessions. Methods: A factorial randomized controlled trial. 75 participants with knee OA were allocated to groups: 1) exercise therapy - no booster sessions (Ex); 2) exercise therapy - with booster sessions (ExB); 3) exercise therapy plus manual therapy - no booster sessions (Ex+MT); 4) exercise therapy plus manual therapy - with booster sessions (ExB+MT). All participants were provided 12 x 40 minute sessions of physical therapist-supervised, multi-modal exercise therapy. Participants allocated to the manual therapy groups were additionally provided 12 x 30-40 minute sessions of physical therapist-provided, individualized manual therapy. Participants allocated to no booster groups were provided all 12 visits within a 9-week period. Participants allocated to the booster groups were provided 8 sessions in the initial 9-week period, 2 booster sessions at 5 months, 1 booster session at 8 months, and 1 booster session at 11 months, also for a total of 12 sessions. We report the relative risk (RR) per group for the number (proportion) of participants achieving a minimally important change of ≥20% improvement on the Western Ontario and McMaster Osteoarthritis Index (WOMAC) at 1-year follow-up, with group 1 as the reference. Results: Of 75 participants recruited, mean age (SD) 64 (10), 65 (87%) were retained at 1-year follow-up. Complete case analysis by Poisson regression models showed group 2, exercise therapy with booster sessions (RR 2.67; 95% CI 1.21, 5.93) and group 3, exercise therapy plus manual therapy - no booster sessions (2.76; 1.25, 6.09) showed superior effects compared with group 1. Group 4 was not superior to group 1. Conclusions: Providing manual therapy in addition to exercise therapy improved treatment effectiveness compared with providing 12 consecutive exercise therapy sessions only. Distributing exercise therapy over a year in the form of booster sessions was more effective than providing consecutive exercise therapy sessions. However due to an adverse interaction effect between providing manual therapy and distributing interventions over booster sessions, this combined strategy was not more effective than providing 12 consecutive exercise therapy sessions only.

BACKGROUND CONTEXT: Effective strategies for preventing low back pain (LBP) have remained elusive, despite annual direct health care costs exceeding $85 billion dollars annually. In our recently completed Prevention of Low Back Pain in the Military (POLM) trial, a brief psychosocial education program (PSEP) that reduced fear and threat of LBP reduced the incidence of health care-seeking for LBP.PURPOSE: The purpose of this cost analysis was to determine if soldiers who received psychosocial education experienced lower health care costs compared with soldiers who did not receive psychosocial education.STUDY DESIGN/SETTING: The POLM trial was a cluster randomized trial with four intervention arms and a 2-year follow-up. Consecutive subjects (n=4,295) entering a 16-week training program at Fort Sam Houston, TX, to become a combat medic in the U.S. Army were considered for participation.METHODS: In addition to an assigned exercise program, soldiers were cluster randomized to receive or not receive a brief psychosocial education program delivered in a group setting. The Military Health System Management Analysis and Reporting Tool was used to extract total and LBP-related health care costs associated with LBP incidence over a 2-year follow-up period.RESULTS: After adjusting for postrandomization differences between the groups, the median total LBP-related health care costs for soldiers who received PSEP and incurred LBP-related costs during the 2-year follow-up period were $26 per soldier lower than for those who did not receive PSEP ($60 vs. $86, respectively, p=.034). The adjusted median total health care costs for soldiers who received PSEP and incurred at least some health care costs during the 2-year follow-up period were estimated at $2 per soldier lower than for those who did not receive PSEP ($2,439 vs. $2,441, respectively, p=.242). The results from this analysis demonstrate that a brief psychosocial education program was only marginally effective in reducing LBP-related health care costs and was not effective in reducing total health care costs. Had the 1,995 soldiers in the PSEP group not received PSEP, we would estimate that 16.7% of them would incur an adjusted median LBP-related health care cost of $517 compared with the current 15.0% soldiers incurring an adjusted median cost of $399, which translates into an actual LBP-related health care cost savings of $52,846 during the POLM trial. However, it is likely that the unaccounted for direct and indirect costs might erase even these small cost savings.CONCLUSION: The results of this study will help to inform policy- and decision-making regarding the feasibility of implementing psychosocial education in military training environments across the services. It would be interesting to explore in future research whether cost savings from psychosocial education could be enhanced given a more individualized delivery method tailored to an individual's specific psychosocial risk factors. Published by Elsevier Inc.

Objective: (1) Do treatment effects differ between participants receiving manual therapy (MT) with exercise compared to subjects who don't, (2) are treatment effects sustained better when participants receive booster sessions compared to those who don't over a one year period in subjects with knee osteoarthritis (KOA)?Design: Multi-center, 2 x 2 factorial randomized clinical trial. 300 participants with knee OA were randomized to four groups: exercise-no boosters (Ex), exercise-with boosters (Ex+B), manual therapy+exercise-no boosters (MT+Ex), manual therapy+exercise-with boosters (MT+Ex+B). The primary outcome was the Western Ontario and McMaster osteoarthritis index (WOMAC) at 1 year. Secondary outcomes included knee pain, physical performance tests, and proportions of participants meeting treatment responder criteria.Results: There were no differences between groups on the WOMAC at 1 year or on any performance-based measures. Secondary analyses indicated a) better scores on the WOMAC and greater odds of being a treatment responder at 9 weeks for participants receiving MT, b) greater odds of being a treatment responder at 1 year for participants receiving boosters. Exploratory interaction analysis suggested knee pain decreases for participants receiving boosters and increases for participants not receiving boosters from 9 weeks to 1 year.Conclusions: MT or use of boosters with exercise did not result in additive improvement in the primary outcome at 1 year. Secondary outcomes suggest MT may have some short term benefit, and booster sessions may improve responder status and knee pain at 1 year. However, the role of booster sessions remains unclear in sustaining treatment effects and warrants further study. (C) 2016 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.

STUDY DESIGN Retrospective case-control. BACKGROUND AND PURPOSE Physical therapy education has been characterized by positive reform including the transition to doctoral level education and the emergence of evidence-based practice as a standard part of the curricula. However, clinical education remains largely unaffected by these advancements and continues as a highly fragmented and ill-equipped model marked by an inefficient 1:1 student to faculty ratio. Current clinical educational models provide highly variable and suboptimal learning experiences for many students, which contribute to disjointed and noncollaborative learning. The purpose of this study is to examine the implications of a one-year collaborative internship model in the US Army-Baylor University Doctoral Program in Physical Therapy in which interns train in groups rather than 1:1 on productivity and efficiency of care. CASE DESCRIPTION The Army-Baylor program culminates in a 12-month clinical internship conducted at 4 locations within south central Texas (3 military academic medical centers and one multisite outpatient privately-owned physical therapy practice). Each site can accommodate up to 8 (range=4 to 8) students who complete a standardized internship curricula across the full continuum of learning experiences. In this retrospective case-control design, productivity and staffing metrics were extracted for the 3 military sites using the Department of Defense M2 database during the period from 2006-2010. A separate analysis was conducted for each site with descriptive statistics used to assess clinic productivity and efficiency. OUTCOMES Data from all 3 sites indicate the presence of interns resulted in little variability in clinic productivity and efficiency. Decreased productivity and/or efficiency would bring into question the long term viability and sustainability of the collaborative internship model. Additionally, this model maximized the opportunity for highly engaged mentorship, individual attention, and quality instruction. COMMENT The findings suggest clinics can accommodate multiple interns and provide high quality education in a collaborative model without a decline in productivity or efficiency. In addition to the standardized curricula across sites, this model facilitates a highly collaborative and peer learning environment in which the intern class supports, challenges, and holds one another accountable to a more standardized and higher level of practice. Each site contributes 1-2 clinical faculty who no longer engage their own patient schedule but rather are able to serve in a full time clinical mentorship role with the interns. In return, the clinical site receives 3-4 full time equivalents of productivity delivered by closely supervised interns who are afforded sufficient time to conduct their examinations and treatments in collaboration with the clinical faculty. Finally, the collaborative internship model supports the mission of each internship site, providing them a critical mass of labor via economies of scale in exchange for an enriched investment into their clinical education.

STUDY DESIGN:Retrospective analysis of episodes of care.OBJECTIVE:To assess the implications of practice setting (hospital outpatient settings versus private practice) on clinical outcomes and efficiency of care in the delivery of physical therapy services.BACKGROUND:Many patients with musculoskeletal conditions benefit from care provided by physical therapists. The majority of physical therapists deliver services in either a private practice setting or in a hospital outpatient setting. There have not been any recent studies comparing whether clinical outcomes or efficiency of care differ based on practice setting.METHODS:Practices that use the Focus On Therapeutic Outcomes, Inc system were surveyed to determine the specific type of setting in which outcomes were collected in patients with musculoskeletal impairments. Patient outcome data over 12 months (2011-2012) were extracted from the database and analyzed to identify differences in the functional status achieved and the efficiency of the care delivery process between private practices and hospital outpatient settings.RESULTS:The data suggest that patients experience more efficient care when receiving physical therapy in hospital outpatient settings compared to private practice settings, as demonstrated by 3.1 points of greater improvement in functional status over 2.9 fewer physical therapy visits. However, the difference in improvement between settings is less than the minimum clinically important difference of 9 points in functional status outcome score.CONCLUSION:In this cohort, our data suggest that more efficient care was delivered in the hospital outpatient setting compared to the private practice setting. However, we cannot conclude that care delivered in the hospital setting is more cost-effective, because it is possible that any difference in efficiency of care favoring the hospital outpatient setting is more than offset by higher costs of care.

This month's issue of JOSPT includes a paper by Dr Alon Rabin and colleagues that attempts to validate a clinical prediction rule (CPR) originally developed several years ago to identify patients with low back pain likely to benefit from lumbar stabilization exercise. Regardless of one's bias as to when decision-making rules (or, perhaps better, aids) are useful for clinical decision making, few can disagree that it is beneficial to see the evolution of this CPR past the initial development stage and now into step 2 of the development process. As with all research, this study asks more questions than it answers. However, as clinicians, we now have more information on which to make decisions about the patient sitting in front of us. We believe we can all agree that this is a positive step in the right direction. J Orthop Sports Phys Ther 2014;44(1):1–2. doi:10.2519/jospt.2014.0101