Initiation Of Physical Therapy Research Articles

Unveiling Timetable for Physical Therapy after Single-Level Lumbar Surgery for Degenerative Disc Disease: Insights from a Systematic Review and Meta-Analysis.

Background: Postoperative physical therapy emerges as a pivotal element of the rehabilitation process, aimed at enhancing functional recovery, managing pain, and mitigating the risk of further complications. The debate concerning the optimal timing of physical therapy intervention post-surgery remains unresolved; in particular, whether to initiate physical therapy immediately or to wait weeks is of particular interest. The aim of this study is to review the available literature regarding the optimal timing of physical therapy initiation and the outcomes obtained. Methods: This review was carried out in accordance with the Preferential Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. This search was carried out in February 2024. Only peer-reviewed articles were considered for inclusion. Results: Fourteen studies were included. The primary outcomes assessed in the included studies were the following: 12-week and 12-month low back pain, return to work, function and disability, psychological status, patient satisfaction, and complications associated with early physical therapy. A meta-analysis was performed concerning low back pain after lumbar discectomy at 12 weeks and 12 months and complications after early physical therapy after lumbar discectomy and lumbar interbody fusion. A significant difference was found between early and standard physical therapy in terms of low back pain at 12-18 months (p = 0.0062); no significant differences were found in terms of complications, both for discectomy and arthrodesis. Conclusions: This review indicates that employing early rehabilitation strategies for intervertebral disc disease could enhance results in terms of pain and disability without an enhanced risk of complications.

Association of Case Duration with Late vs. Early Physical Therapy Initiation in Treatment of Work-Related Musculoskeletal Injuries: A Retrospective Analysis

Background:Occupational medicine providers treat patients who are injured while working. Conservative management with over-the-counter anti-inflammatory medicines, physical modalities (ice/heat), and activity restrictions are first-line treatment strategies. Physical therapy (PT) is often added to assist with patients’ return to baseline through symptom reduction and restoration of function. PT efficacy on outcomes and healthcare costs has been described in other patient populations but less described in injured worker populations. This study focused on associations between PT timing and case duration for treating musculoskeletal injuries in a regional injured workerpopulation.
 Methods:A retrospective chart review of 795 patients receiving care at Parkview Occupational Health (POH) for musculoskeletal injuries from 2017-2023 was conducted to determine if early PT was associated with case duration. Patients employed in Indiana and referred to PT within Parkview were included in the study. Age, BMI, and case duration were compared between early vs. late PT groups using two-sampled t-test. Race, sex, smoking status, and injury type were compared using chi-squared tests.
 Results:The mean case duration (73.41 days) when PT was initiated early (≤ 30 days after date of injury, DOI) was significantly shorter compared to the mean case duration (104.21 days) when PT was initiated late (p<0.0001). Case duration was even shorter (67.61 days) when early PT was defined as ≤14 days after injury (p=0.001). There was no significant difference in case duration (mean difference=9.5 days) between patients initiating PT within 14 days and within 15-30 days (p=0.15). Injury type (back vs. other musculoskeletal injuries) was significantly associated with PT timing (p=0.002).
 Conclusion/Implications:Future analysis should compare case duration, days of restricted work, advanced imaging utilization, and specialist referral rate between patients with early and late PT initiation. This comparison will aid in development of best practice guidance for treatment of work-related musculoskeletal injuries at POH.

Pericapsular nerve group block and lateral femoral cutaneous nerve block versus fascia iliaca block for multimodal analgesia after total hip replacement surgery: A retrospective analysis.

Optimal pain control with limited muscle weakness is paramount for a swift initiation of physical therapy and early discharge. Fascia iliaca compartment block (FICB) has been recommended since it offers good pain control with a low risk of motor block. Pericapsular nerve group (PENG) block with lateral femoral cutaneous block (LFCN) has been proposed as an effective alternative to FICB that offers better pain control with a considerably lower risk of motor block. We aimed to compare the aforementioned blocks and determine which one yielded the lowest numeric rating scale (NRS) score. We designed a retrospective analysis of patients undergoing elective total hip arthroplasty. The primary outcome was the NRS score at 6, 12, and 24 hours. The secondary outcomes were total opioid consumption, time to first PRN opioid, and time to first postoperative ambulation. 52 patients were recruited, (13 PENG plus LFCN, 39 FICB). PENG plus LCFN resulted in a lower NRS at all three-time points (mean difference and 95%CI at 6 h 0.378 [-0.483; 1.240], at 12 h 0.336 [-0.378; 1.050], and at 24 h 0.464 [0.013; 0.914] P = 0.02). Moreover, less PRN opioids were requested in the PENG plus LCFN vs. FICB group (0 [0;7.5] vs 60 [15;80] milligrams of morphine equivalents, P = 0.001). No delay in the first ambulation or initiation of physical rehabilitation was reported in either group. PENG plus LCFN seems to offer better pain control and lead to less PRN opioids. Neither block hindered physical therapy nor ambulation. These results need to be confirmed with a larger prospective and randomized study.

Is Arthroscopic Release a Good Treatment Option in Adhesive Capsulitis of Shoulder Refractory to Non-Operative Treatment

Adhesive capsulitis, causing shoulder pain and limited mobility, is effectively treated with arthroscopic release preferred for its proven efficacy, minimal complications, and enhanced accessibility to the whole joint capsule. Objective: To assess the outcome of arthroscopic releases in patients suffering from adhesive capsulitis in whom non-operative treatment failed. Methods: This retrospective study was conducted at Jinnah Hospital in Lahore from 2019 to 2021, encompassing 38 shoulders that underwent surgery. Among the total cohort, 15 cases were associated with female patients, and 23 male patients. Surgical interventions were carried out with patients positioned in a beach chair orientation. The initiation of physical therapy occurred at the earliest possible juncture, and evaluation of functional outcomes was undertaken employing the UCLA criteria. Results: The mean age of the individuals included in the research cohort was 51 years, exhibiting a broad age distribution ranging from 29 to 73 years. Significant improvements in the range of motion were evident, with an average augmentation of 56.71° in abduction, 38.5° in external rotation, and an additional extension of eight vertebral levels in internal rotation. As per the UCLA scoring system, the results exhibited a notably positive profile, with 16 shoulders attaining an excellent rating (42%), 16 being categorized as good (42%), and six falling within the fair or poor category (15%). Notably, five patients encountered postoperative complications. Conclusions: Arthroscopic release demonstrated effective results in alleviating pain and improving range of motion, establishing its efficacy as a treatment for adhesive capsulitis.

Reshaping the head: cranial remodeling orthoses (cranial helmet) in infants: a review

Positional skull deformity (P.D.) is a frequent occurrence in neonates and infants, and most of them go unnoticed for lack of awareness. Severe deformity may lead to physical facial deformity and long-term neurological issues. Early detection and timely management are the keys to managing the condition. The evolution of newer digital technology like three-dimensional (3D) scanners improved the diagnosis accuracy and treatment process. Early initiation of physical therapy along with Cranial Remodeling Orthosis (Cranial Helmet) has shown to be effective in treating P.D. and preventing the development of complications.

Botulinum toxin type A outcomes in infants with refractory congenital muscular torticollis.

The aim of this study was to determine the effectiveness of botulinum toxin type A (BoNT-A) injections in infants with congenital muscular torticollis (CMT) who were refractory to conservative management. This was a retrospective study in which all subjects included were seen between 2004 and 2013 and were deemed appropriate for BoNT-A injections. A total of 291 patients were reviewed for inclusion in the study, and 134 patients met the inclusion criteria. Each child was injected with 15-30 units of BoNT-A into each of the following muscles: ipsilateral sternocleidomastoid, upper trapezius, and scalene muscles. The key outcome and variable measurements analyzed included age at time of diagnosis, age at time of initiation of physical therapy, age at time of injection, total number of injection series utilized, muscles injected, and degrees of active and passive cervical rotation and lateral flexion pre- and post-injection. A successful outcome was documented if a child could achieve 45° of active lateral flexion and 80° of active cervical rotation post-injection. Secondary variables including sex, age at time of injection, number of injection series utilized, surgery required, adverse effects of botulinum toxin, presence of plagiocephaly, side of torticollis, orthosis used, presence of hip dysplasia, skeletal anomalies, complications during pregnancy or birth, and any other pertinent information regarding the delivery were also measured. Based on this criteria, 82 children (61%) had successful outcomes. However, only four of the 134 patients required surgical correction. BoNT-A may be an effective and safe method for treatment in refractory cases of congenital muscular torticollis.

Incidence, risk factors, and complications of acromial stress fractures after reverse total shoulder arthroplasty

An acromial stress fracture (ASF) is an uncommon complication after reverse total shoulder arthroplasty (RTSA) that can have severe clinical consequences on shoulder function. Although patient-specific factors have been identified to influence the risk of ASFs, it is unclear whether modifying these factors can minimize risk. Moreover, there is limited information on the treatment outcomes of these fractures. Therefore, the purpose of this study was to determine modifiable risk factors of ASFs and the complication and revision rates of conservatively and operatively managed ASFs. The PearlDiver database was queried to identify a cohort of patients who underwent RTSA with minimum 2-year follow-up. Current Procedural Terminology (CPT) and International Classification of Diseases (ICD) codes were used to compare the demographics, comorbidities, and medication use of patients with and without ASFs. Surgical complication and revision rates were compared between operatively and conservatively treated fractures. The overall incidence of ASFs was 1.4%. Patient-specific factors that were independently associated with the occurrence of an ASF included osteoporosis, rheumatologic disease, shoulder corticosteroid injection within 3 months before surgery, and chronic oral corticosteroid use. Among patients with osteoporosis, the initiation of physical therapy within 6 weeks after surgery also increased the risk of ASF. Patients who underwent surgical treatment of ASFs had a revision arthroplasty rate of 7.0% compared to a rate of 3.2% among those with conservatively managed fractures. ASFs are an infrequent complication that can occur after RTSA. Preoperative factors that affect the quality of bone independently increase the fracture risk. Moreover, this risk can be minimized by avoiding shoulder corticosteroid injections 3 months before surgery and delaying physical therapy exercises among patients with osteoporosis. Surgical fixation of these fractures should be reserved to instances when conservative management has failed given high rates of infection, instability, and revision shoulder arthroplasty.

The Effect of Steroid and Mannitol Combination Treatment on Postoperative Rehabilitation of Multiple Metacarpal Bone Fractures.

Background and Objectives: The expedient resolution of postoperative soft tissue edema is particularly important in hand surgery. Prolonged edema and pain become an obstacle to postoperative rehabilitation, delay return to daily life, and in severe cases, lead to a permanent decrease in range of motion. Based on the common physiology between postoperative hand swelling and complex regional pain syndrome (CRPS), we sought to determine if postoperative mannitol and steroid administration to multiple metacarpal bone fracture patients effectively reduces hand swelling and pain and is beneficial for hand rehabilitation. Materials and Methods: From March 2015 to February 2019, 21 patients who received closed pinning for multiple metacarpal fractures were included in a retrospective cohort study. The control group (n = 11) underwent a routine recovery, while the treatment group (n = 10) received dexamethasone and mannitol injections for five days postoperatively. Serial changes in the degree of pain and fingertip-to-palm distance (FPD) were measured in both groups. The duration from surgery to the initiation of rehabilitation and time to full grip was also compared. Results: Compared to the control, the treatment group showed a faster alleviation of pain scores from the postoperative fifth day (2.91 versus 1.80, p = 0.013), and faster recovery of FPD from postoperative two weeks (3.27 versus 1.90, p = 0.002). Time to physical therapy initiation (6.73 versus 3.80 days, p = 0.002) and full grip achievement (42.46 versus 32.70 days, p = 0.002) were also faster in the treatment group. Conclusions: The steroid-mannitol combination treatment for multiple metacarpal bone fracture patients in the acute postoperative phase promoted the reduction of hand edema and pain, leading to the earlier initiation of physical therapy, rapid improvement in joint motion, and faster achievement of full grip.

645 Getting What You Pay For: Impact of Copayments on Physical Therapy Initiation, Timing, and Continuation for Acute-Onset Low Back Pain

INTRODUCTION: Physical therapy (PT) is an important component of acute low back pain (LBP) management. Despite established guidelines, heterogeneity in medical management remains common. METHODS: The IBM Watson Health MarketScan claims database was queried for adult patients with new-onset idiopathic LBP. The primary outcomes-of-interest were timing and overall utilization of PT services. Additional outcomes-of-interest included timing of opioid prescribing. Actual and inferred copayments based on specialist visit claims were used to evaluate the relationship between PT copayment and incidence of PT initiation. Multivariable regression models were used to evaluate factors influencing PT usage. RESULTS: Overall, 2,467,389 patients were included. PT initiation, among those with at ≥1 PT service during the year after LBP diagnosis (30.6%), occurred at a median of 8 days post-diagnosis (IQR 1-55). Among those with at least one PT encounter, incidence of subsequent PT visits was significantly lower for those with high initial PT copayments. High initial PT copayments, while inversely correlated with PT utilization, were directly correlated with subsequent opioid use. High PT copayments affected relative timing of PT and opioid initiation, with every $10 increase associated with a delay in PT initiation of 3.06 days (95%CI 2.76-3.36) and an advancement of opioid prescription by 2.58 days (95%CI 2.24-2.92). For multivariable whole-cohort analyses, incidence of PT initiation among patients with inferred copayments in the 50-75th and 75th-100th percentiles was significantly lower than those below the 50th percentile (HR = 0.893 [95% CI 0.887-0.899] and HR=0.905 [95% CI 0.899-0.912], respectively). CONCLUSIONS: Higher PT copayments correlated with reduced PT utilization; higher PT copayments and lower opioid copayments were independent contributors to delayed PT initiation and higher opioid use. In patients covered by plans charging high PT copayments, opioid use was significantly higher. Co-pays impact long-term adherence to PT.

Characteristics and Outcomes of Patients Receiving Physical Therapy for Low Back Pain with a Nociplastic Pain Presentation: A Secondary Analysis.

Individuals with low back pain (LBP) may be classified based on mechanistic descriptors, such as a nociplastic pain presentation (NPP). The purpose of this secondary analysis was to examine the frequency and characteristics of patients with a NPP referred to physical therapy with LBP. Additionally, we characterized patients with LBP meeting the criteria for NPP by demographic, clinical, psychological, and pain sensitivity variables. Finally, we examined short- and long-term clinical outcomes in patients with a NPP compared to those without a NPP. Patients referred to physical therapy for LBP completed the Patient Self-report Survey for the Assessment of Fibromyalgia. Participants were categorized as "LBP with NPP" or "LBP without NPP" based on the threshold established in this measure. A rank sum test examined for differences in pain-related psychological factors and pressure-pain threshold between groups. Next, a Friedman test examined if LBP intensity and disability trajectories differed by groups at one and six months after initiation of physical therapy. 22.2% of patients referred to physical therapy for LBP met the criteria for a NPP. Patients with a NPP reported significantly greater disability, pain catastrophizing, depression, anxiety, and somatization compared to individuals without a NPP (p < 0.05). Pressure-pain threshold did not differ between groups (p > 0.05). Individuals with LBP with a NPP demonstrated nonsignificant, small to medium reductions in pain and disability at one and six months. Individuals experiencing LBP without a NPP demonstrated significant reductions in pain and disability in the short- and long term. Patients with LBP with a NPP displayed greater negative pain-related psychological factors but similar pain sensitivity compared to LBP without NPP.

Delayed timing of physical therapy initiation increases the risk of future opioid use in individuals with knee osteoarthritis: a real-world cohort study

ObjectiveWe assessed whether late versus early initiation of physical therapy (PT) was related to greater risk of future opioid use in people with knee osteoarthritis (OA) who receive PT.MethodsWe used...

Complications of First Tarsometatarsal Joint Arthrodesis

Category: Bunion Introduction/Purpose: Hallux valgus, a term introduced by Carl Hueter (1) to define static subluxation of the first metatarsophalangeal joint characterized by lateral deviation of the hallux and medial deviation of the first metatarsal, (1,2) is a disease for which different corrective surgical techniques can be used, depending on its severity. First tarsometatarsal joint (TMTJ) arthrodesis, also known as Lapidus, is one of the surgical procedures used in the treatment of severe hallux valgus, among other alterations (3-5). Despite the high satisfaction rate and high corrective power, this technique is not without complications. The main com- plications include delayed union, malunion, chronic edema, persistent pain, nonunion, joint stiffness, recurrent deformity, and varus deformity (6). However, there is little scientific evidence of these complications after first TMTJ arthrodesis. The purpose of this study was to report the complications of first TMTJ arthrodesis performed by orthopedic surgeons specializing in foot and ankle surgery. Methods: This study was approved by the institutional research ethics committee and registered at Plataforma Brasil. We evaluated 16 patients undergoing first TMTJ arthrodesis, who denied any comorbidities. The procedures were performed by 7 different orthopedic surgeons specializing in foot and ankle surgery with different levels of experience, ranging from 1 to 29 years of experience in the field. All patients underwent arthrodesis with plates and screws. The plate was placed on the plantar aspect of the first tarsometatarsal in 4 patients and on the anteromedial aspect in all other patients. The dorsomedial incision was used, centered on the first TMTJ, for the 12 cases in which the plate was positioned in the dorsomedial region, and the medial incision was used for the 4 cases in which the plate was positioned on the plantar aspect. Also, articular cartilage was resected using a chisel and microperforations. All 16 patients were followed up in an outpatient clinic at 1, 2, 4, 6, 12, and 24 weeks postoperatively. The follow-up visits included the evaluation of anteroposterior, lateral, and oblique radiographs of the foot, clinical alignment of the hallux, and patients' signs and symptoms. For all patients, postoperative care included immobilization in a non-weight-bearing cast for 4 weeks, initiation of physical therapy with range of motion gain at 4 weeks, and partial weight- bearing at 6 weeks Results: We evaluated 16 patients operated on over an 18-month period (from February 2017 to August 2018). We measured preoperative and postoperative hallux valgus and intermetatarsal angles (Table 1). Eight patients had either major or minor complications (Table 2). Three patients had recurrent deformity (1 with associated nonunion), 2 had delayed union, 2 had hardware loosening (Figure 1) - 1 with associated nonunion (Figure 2), and 1 had wound dehiscence. Conclusion: Based on our study, we can conclude that first TMTJ arthrodesis requires greater care in choosing the surgical technique for the treatment of hallux valgus. In addition, some points should be considered to avoid complications as much as possible, such as the use of implants to increase stability, instruments for better articular cartilage resection, and improvement in the correction of the pronation deformity of the hallux. The limitations of our study prevent us from drawing a robust conclusion and defining consistent parameters related to the main factors that may affect the various complications described in the study. Therefore, we believe that data are still scarce to provide a concrete basis, and further studies are needed to make substantiated conclusions.

Comparison of Diabetic and Non-Diabetic Individuals Outcomes Following Ankle ORIF Surgery Based on Physical Therapy Start Times

Category: Ankle; Trauma Introduction/Purpose: The surgical correction of ankle fractures are one of the most common orthopedic procedures performed and about 13% of individuals undergoing these procedure are classified as diabetic. Diabetes, as a disease, impairs fracture healing due to decreased bone quality and cardiometabolic dysfunction. The use of early mobilization following ankle surSgery has improved post-operative outcomes in the 'healthy' populations; however, early mobilization or early physical therapy initiation in the diabetic populations has not been elucidated. Methods: Surgical correction CPT codes for ankle fracture were used to identify eligible patients followed by a retrospective chart review to confirm diagnosis and procedure(s) as well as collection of demographic information and pertinent medical history. Patient cases were examined over a two year period. Once the inclusion criteria was met, 209 unique patients were included in the analyses. Patients were grouped by diabetes status and early (i.e., &lt;=8 weeks) or late mobilization (i.e., days post- op until physical therapy referral). Generalized linear models and a series Chi-squared tests, Fisher's Exact tests, one-way ANOVAs, and Mann Whitney U Tests were used to assess recovery duration, fracture healing, time to PT referral, medical history, and demographic information. Results: The diabetic group in our study was significantly older [60 (IQR:18) vs. 58 (26) years; p = 0.019] and had a higher BMI [34(8) vs. 29(10); p = 0.041] compared to our non-diabetic group but there were no differences in the proportions for sex or the fracture type by diabetic status. The non-diabetic group displayed a quicker fracture healing time [86(35) vs. 111(45) days; p = 0.04] but there were no differences in recovery duration or days until physical therapy was prescribed. The GLM analysis performed with recovery duration (i.e., time to medical clearance) found that late mobilization was a significant predictor (p &lt; 0.001) of recovery duration but not diabetic diagnosis (p = 0.738). Conclusion: There appears to be a different demographic profile for diabetic patients experiencing an ankle fracture when compared to non-diabetic patients. The delay in physical therapy referral and presumably early mobilization appears to be the strongest predictor of recovery duration. Future research should utilize randomized controlled trials to determine if early mobilization is safe and effective at facilitating quicker fracture healing and recovery following the surgical correction of an ankle fracture in diabetic patients.

Early initiation of physical therapy after geriatric hip fracture surgery is associated with shorter hospital length of stay and decreased thirty-day mortality

IntroductionWhile the importance of timely surgery and early mobilization are understood in geriatric fracture populations, the relationship between timing of initiation of physical therapy (PT) postoperatively on length of stay (LOS) and mortality has not been well delineated. The purpose of this investigation was to determine the effect of PT initiated on postoperative day zero (POD0) on LOS and mortality in geriatric hip fracture patients. Materials and MethodsPatients aged 60 and over who underwent hip fracture surgery, including arthroplasty or internal fixation, between January 2017 and December 2019 at three affiliated academic hospitals were identified. Retrospective chart review and review of hospital charges were used to determine patient demographics, Charlson Comorbidity Index (CCI), surgery performed, timing of postoperative PT visits, LOS, and mortality. ResultsOf 1,551 patients identified that met inclusion criteria, 83 (5.3%) received PT on POD0. Most patients (76.3%) received PT on postoperative day 1 (POD1), and 18.4% received first PT on postoperative day 2 or later (POD2+). Time from admission to surgery, CCI, sex, and BMI did not differ significantly between groups. The age difference between patients in the POD0 and the POD1/POD2+ groups was statistically significant with the mean age in the POD1/2+ group being 2.3 years older than the POD0 group (p=0.045). There was no difference in postoperative length of stay (PLOS) based on type of fixation. The average PLOS was 3.4 days in the POD0 PT group compared to 5.2 days in the POD1 group (p<0.0001) and 8.2 days in the POD2+ group (p<0.0001). The POD0/1 group had significantly lower mortality than the POD2+ group [3.7% vs. 9.8%, OR 0.354 (95% CI 0.217-0.575), p<0.0001]. ConclusionEarlier initiation of PT postoperatively is associated with significantly shorter total and postoperative LOS and initiation of PT before POD2 is associated with decreased 30-day mortality. Each day that initiation of PT is delayed is associated with a two- to three-day increase in LOS.

Initial presentation for acute low back pain: is early physical therapy associated with healthcare utilization and spending? A retrospective review of a National Database

BackgroundEarly initiation of physical therapy (PT) has been associated with lower healthcare costs and utilization; however, these studies have been limited to single institutions or healthcare systems. Our goal was to assess healthcare utilization and spending among patients who present for the first time with low back pain (LBP), according to whether they received early physical therapy (PT), using a large, nationwide sample; and geographic variation in rates of early PT and 30-day LBP-related spending.MethodsUsing the Truven MarketScan database, we identified nearly 980,000 US adults ages 18–64 years who initially presented with acute LBP from 2010 through 2014 and did not have nonmusculoskeletal causes of LBP. Approximately 110,000 patients (11%) received early PT (≤2 weeks after presentation). We compared healthcare utilization and spending at 30 days and 1 year after presentation between patients who received early PT and those who did not. Alpha = 0.05.ResultsAt 30 days, early PT was associated with lower odds of chiropractor visits (odds ratio [OR] = 0.41, 95% confidence interval [CI] = 0.40–0.42), pain specialist visits (OR = 0.49, 95% CI = 0.47–0.51), emergency department visits (OR = 0.51, 95% CI = 0.49–0.54), advanced imaging (OR = 0.57, 95% CI = 0.56–0.58), orthopaedist visits (OR = 0.67, 95% CI = 0.66–0.69), and epidural steroid injections (OR = 0.68, 95% CI = 0.65–0.70). At 1 year, early PT was associated with less healthcare utilization. At 30 days, patients with early PT had lower mean LBP-related spending ($1180 ± $1500) compared with those without early PT ($1250 ± $2560) (P < 0.001). At 1 year, LBP-related spending was significantly less among patients who did not receive early PT ($2510 ± $3826) versus those who did ($2588 ± $3704). Early PT rates (range, 4–25%; P < 0.001) and 30-day LBP-related spending differed by state (range, $421 to −$410; P < 0.001).ConclusionEarly PT for acute LBP was associated with less 30-day and 1-year healthcare utilization and less 30-day LBP-related spending. Early PT rates and 30-day spending differed by US state.Level of evidenceIV

Pediatric Research in Sports Medicine Research Interest Group Spine/Spondylolysis Clinical Practice SurveY

Background:The Pediatric Research in Sports Medicine (PRiSM) society is a multi-disciplinary group of healthcare providers who provide clinical care to young athletes with a variety of conditions, including isthmic spondylolysis. It is thought that significant practice differences exist in the way providers diagnose, image, and treat this condition.Hypothesis/Purpose:The purpose of this study is to survey the members of PRiSM on clinical practice patterns in the diagnosis, imaging, and management of isthmic spondylolysis in young athletes.Methods:An electronic, thirty-three question REDCaps survey was distributed to the PRISM membership via email during the 2021 virtual annual meeting and one reminder was sent after the meeting. Responses were collected during a 6-week period. The survey collected information based upon the following: demographics, diagnosis, imaging, and management.Results:Ninety-eight surveys were completed. Most of the respondents were divided between orthopaedic surgeons, non-operative sports medicine physicians and physical therapists, approximately half of which are fellowship trained. Approximately 42% of respondents make the diagnosis based upon MRI results in addition to history, physical examination, and plain radiographs. Approximately 24% obtain oblique radiographs as part of their assessment. MRI is the most frequently used advanced imaging modality with nearly 90% of respondents using this. The use of rigid bracing varies widely among respondents, with 20.6% bracing regularly, 35.3% sometimes bracing, and 44.1% not using rigid braces at all. The use of non-rigid bracing is similarly varied with 17.6% prescribing this regularly, 44.1% sometimes, and 38.2% not using non-rigid bracing at all. There is variance as well with regards to initiation of physical therapy (PT): prescribing immediately (42.6%) versus prescribing a period to rest prior to PT (57.4%). When young athletes are returned to sport, 52.9% of respondents indicated that they would impose restrictions to activity and 47.1% would not.Conclusion:Although there are similarities in how the diagnosis of isthmic spondylolysis in young athletes is made by PRISM members, there is variability in management, especially the use of bracing, the timing of physical therapy, and return to sport restrictions. MRI is the most common advanced imaging modality being used to help with the diagnosis.

The Association Between Early Versus Late Physical Therapy Initiation and Outcomes of Trauma Patients With and Without Traumatic Brain Injuries.

There is a lack of literature regarding the most effective timing to initiate physical therapy (PT) among traumatically injured patients. We aim to evaluate the association between early PT/mobilization versus delayed or late PT/mobilization and clinical outcomes of trauma patients. A retrospective cohort analysis of an urban level-I trauma center from 2014 to 2019 was performed. Univariate analyses and multivariable logistic regression were performed with significance defined as P < 0.05. A total of 11,937 patients were analyzed. Among patients without a traumatic brain injury (TBI), late PT initiation times were associated with 60% lower odds of being discharged home without services (P < 0.05), significantly increased hospital and ICU length of stay (H-LOS, ICU-LOS) (P < 0.05), and significantly higher odds of complications (VTE, pneumonia, pressure ulcers, ARDS) (P < 0.001). Among patients with a TBI, late PT initiation time had 76% lower odds of being discharged home without services (P < 0.05) and significantly longer H-LOS and ICU-LOS (P < 0.05) however did not experience significantly higher odds of complications (P > 0.05). Among traumatically injured patients, early PT is associated with decreased odds of complications, shorter H-LOS and ICU-LOS, and a favorable discharge disposition to home without services. Adoption of early PT initiation/mobilization protocols and establishment of prophylactic measures against complications associated with delayed PT is critical to maximize quality of care and trauma patient outcomes. Multi-center prospective studies are needed to ascertain the impact of PT initiation times in greater detail and to minimize trauma patient morbidity.

Early Initiation of Physical Therapy While on Extracorporeal Life Support Improves Patients’ Functional Activity on Discharge

PurposeTraditionally, severe acute respiratory distress syndrome (ARDS) patients on veno-venous extracorporeal membrane oxygenation (VV ECMO) receive significant sedation and neuromuscular blockade (NMB) to facilitate lung protective mechanical ventilation. However, we previously showed the feasibility of managing these patients without mechanical ventilation, sedation, or NMB. Reduced levels of sedation allows patients to begin physical and occupational therapy (PT/OT) early on. Here, we investigate the impact of early PT/OT initiation on day of discharge (DOD) functional activity for severe ARDS patients managed on VV ECMO.MethodsThis is a retrospective review of all patients who underwent VV ECMO as management for severe ARDS at a single academic center from February 2018 to June 2021. Data collected included patients’ demographics, co-morbidities, etiology of ARDS, days of ECMO support before PT/OT initiation, and ambulation distance and PT/OT Activity Measure for Post-Acute Care (AMPAC) Six-Clicks score on DOD.Results67 patients were included in this study. Those with >7 days on VV ECMO had decreased ambulation and AMPAC scores compared to those with < 7 days (N=41, 70.5 ± 113.3ft vs N=26, 162.1 ± 154.1ft, p<0.01, 12.3 ± 5.9 vs 16.4 ± 6.8, p=0.01, respectively). PT/OT initiation within 7 days after starting VV ECMO significantly improved ambulation and AMPAC scores compared to those with >7 days of VV ECMO prior to any PT/OT (N=30, 163.5 ± 160.5ft vs N=37, 59.5 ± 93.5ft, p<0.001, 16.6 ± 7.1 vs 11.8 ± 5.2, p<0.01, respectively). In patients with >7 days on VV ECMO, those who began PT/OT within 10 days of starting VV-ECMO had improved ambulation and AMPAC scores compared to those with >10 days of VV ECMO prior to PT/OT (N=9, 151.8 ± 164.8ft vs N=32, 44.2 ± 77.8ft, p<0.01, 16.5 ± 7.7 vs 11.0 ± 54.5, p<0.01, respectively).ConclusionEarly PT/OT initiation in severe ARDS patients managed on VV ECMO is associated with improved patient functional activity on DOD. This may provide benefits such as enhanced recovery, increased ability to complete activities of daily living, and improved cognitive health. Our study further supports the use of VV ECMO in treatment of severe ARDS without mechanical ventilation, sedation or NMB and specifically demonstrates PT/OT should be started early following initiation of VV ECMO to improve patients’ functional outcomes.

Physical therapy utilization, costs, and return-to-work status following lumbar spine surgery: A retrospective analysis of workers compensation claims in Australia

BackgroundNo study to our knowledge has explored physical therapy utilization following lumbar spine surgery in a workers’ compensation setting. ObjectivesDescribe physical therapy utilization and costs, and return-to-work status in patients following lumbar spine surgery under a workers’ compensation claim. MethodsUsing data from the New South Wales (NSW) State Insurance Regulatory Authority (Australia), we audited physical therapy billing codes for patients who received lumbar spine surgery from 2010 to 2017. We summarised, by fusion versus decompression, the number of physical therapy sessions patients received up to 12 months post-operatively, total cost of physical therapy and time to initiation of physical therapy. Number of physical therapy sessions and physical therapy utilization at 12 months were summarised by return-to-work status at 12 months. ResultsWe included 3524 patients (1220 had fusion; 2304 decompression). On average, patients received 22 ± 22 physical therapy sessions to 12 months post-operatively (mean cost=AU$1902, US$1217); 24% were receiving physical therapy at 12 months. Most had 9–24 (31%) or 25–50 sessions (25%); 11% had > 50 sessions, whereas 11% had no physical therapy. Patients who had fusion (compared to decompression) had more physical therapy and incurred higher physical therapy costs. Time post-surgery to initiate physical therapy increased from 2010 to 2017. Patients with > 50 sessions and still having physical therapy by 12 months were least likely to be working. ConclusionsFor most patients, physical therapy utilization following lumbar spine surgery aligns with the best available evidence. However, some patients may be receiving too much physical therapy or initiating physical therapy too early.

Regional anesthesia for orthopedic procedures: What orthopedic surgeons need to know.

Regional anesthesia is an integral component of successful orthopedic surgery. Neuraxial anesthesia is commonly used for surgical anesthesia while peripheral nerve blocks are often used for postoperative analgesia. Patient evaluation for regional anesthesia should include neurological, pulmonary, cardiovascular, and hematological assessments. Neuraxial blocks include spinal, epidural, and combined spinal epidural. Upper extremity peripheral nerve blocks include interscalene, supraclavicular, infraclavicular, and axillary. Lower extremity peripheral nerve blocks include femoral nerve block, saphenous nerve block, sciatic nerve block, iPACK block, ankle block and lumbar plexus block. The choice of regional anesthesia is a unanimous decision made by the surgeon, the anesthesiologist, and the patient based on a risk-benefit assessment. The choice of the regional block depends on patient cooperation, patient positing, operative structures, operative manipulation, tourniquet use and the impact of post-operative motor blockade on initiation of physical therapy. Regional anesthesia is safe but has an inherent risk of failure and a relatively low incidence of complications such as local anesthetic systemic toxicity (LAST), nerve injury, falls, hematoma, infection and allergic reactions. Ultrasound should be used for regional anesthesia procedures to improve the efficacy and minimize complications. LAST treatment guidelines and rescue medications (intralipid) should be readily available during the regional anesthesia administration.