Physical Therapy Management of Low Back Pain: An Exploratory Survey of Therapist Approaches.In light of the poor consensus regarding the management of lumbar lumbar /lum·bar/ (lum´bar) pertaining to the loins. lum·bar adj. Of, near, or situated in the part of the back and sides between the lowest ribs and the pelvis. impairment Impairment 1. A reduction in a company's stated capital. 2. The total capital that is less than the par value of the company's capital stock. Notes: 1. This is usually reduced because of poorly estimated losses or gains. 2. by clinicians, guidelines guidelines, n.pl a set of standards, criteria, or specifications to be used or followed in the performance of certain tasks. have been developed to provide a template (1) A pre-designed document or data file formatted for common purposes such as a fax, invoice or business letter. If the document contains an automated process, such as a word processing macro or spreadsheet formula, then the programming is already written and embedded in the for more effective clinical practice. The work of the Quebec Task Force on Spinal spinal /spi·nal/ (spi´n'l) 1. pertaining to a spine or to the vertebral column. 2. pertaining to the spinal cord's functioning independently from the brain. spi·nal adj. Disorders[1] was updated by multidisciplinary mul·ti·dis·ci·pli·nar·y adj. Of, relating to, or making use of several disciplines at once: a multidisciplinary approach to teaching. panels in the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. ,[2] the United Kingdom,[3] and New Zealand New Zealand (zē`lənd), island country (2005 est. pop. 4,035,000), 104,454 sq mi (270,534 sq km), in the S Pacific Ocean, over 1,000 mi (1,600 km) SE of Australia. The capital is Wellington; the largest city and leading port is Auckland. .[4] The US guidelines, which were sponsored by the Agency for Health Care Policy and Research (AHCPR AHCPR, n.pr See Agency for Healthcare Research and Quality. ) (now called the Agency for Healthcare Research and Quality Agency for Healthcare Research and Quality, n.pr formerly known as the Agency for Health Care Policy and Research, this agency researches the quality of medical care and health services. [AHRQ AHRQ, n.pr See Agency for Healthcare Research and Quality. ]), were released in 1994 based on what the panel considered the best evidence available on the management of acute low back pain (LBP LBP In currencies, this is the abbreviation for the Lebanese Pound. Notes: The currency market, also known as the Foreign Exchange market, is the largest financial market in the world, with a daily average volume of over US $1 trillion. ) in adults.[2] These guidelines recommended a number of assessment techniques to rule out "red flags," including cauda equina cauda e·qui·na n. The bundle of spinal nerve roots running through the lower part of the subarachnoid space within the vertebral canal below the first lumbar vertebra. , inflammatory diseases Noun 1. inflammatory disease - a disease characterized by inflammation disease - an impairment of health or a condition of abnormal functioning NEC, necrotizing enterocolitis - an acute inflammatory disease occurring in the intestines of premature infants; , fracture fracture, breaking of a bone. A simple fracture is one in which there is no contact of the broken bone with the outer air, i.e., the overlying tissues are intact. In a comminuted fracture the bone is splintered. , cancer, and infection. In the absence of such "red flags," according to according to prep. 1. As stated or indicated by; on the authority of: according to historians. 2. In keeping with: according to instructions. 3. the guidelines, nonsteroidal anti-inflammatory drugs Nonsteroidal Anti-Inflammatory Drugs Definition Nonsteroidal anti-inflammatory drugs are medicines that relieve pain, swelling, stiffness, and inflammation. could be used for pain control. Spinal manipulation For detail of manipulation in individual synovial joints, see . Definition Spinal manipulation is manipulation of synovial joints in the spinal column. The most commonly cited of these are the zygapophysial joints. was also recommended for the first 4 weeks of symptoms. Activity modification might be required during the acute phase; however, the guidelines advised against bed rest for more than 4 days. The guidelines recommend starting low-impact aerobic aerobic /aer·o·bic/ (ar-o´bik) 1. having molecular oxygen present. 2. growing, living, or occurring in the presence of molecular oxygen. 3. requiring oxygen for respiration. 4. activities in the first 2 weeks, and abdominal abdominal /ab·dom·i·nal/ (ab-dom´i-n'l) pertaining to the abdomen. ab·dom·i·nal adj. Of or relating to the abdomen. n. An abdominal muscle. conditioning exercises could be delayed at least 2 weeks after the onset of symptoms. In addition, the guidelines recommended that patients should be educated on safe and effective methods for symptom symptom /symp·tom/ (simp´tom) any subjective evidence of disease or of a patient's condition, i.e., such evidence as perceived by the patient; a change in a patient's condition indicative of some bodily or mental state. management and the means to limit recurrent recurrent /re·cur·rent/ (re-kur´ent) [L. recurrens returning] 1. running back, or toward the source. 2. returning after remissions. re·cur·rent adj. 1. low back problems.[2] Shortly after the release of the guidelines, the Canadian Physiotherapy physiotherapy: see physical therapy. Association disseminated disseminated /dis·sem·i·nat·ed/ (-sem´i-nat?ed) scattered; distributed over a considerable area. dis·sem·i·nat·ed adj. Spread over a large area of a body, a tissue, or an organ. the information among physical therapists.[5] Little is known, however, about how these guidelines affect clinical practice. The dearth of reliable data on the practice of physical therapists has limited the profession's ability to contribute to policy debates and to assess the impact of regulatory restriction. These concerns prompted our endeavor to study therapists' practice patterns in managing lumbar impairment. Our objective was to document Ontario physical therapists' reported management of acute and subacute subacute /sub·acute/ (-ah-kut´) somewhat acute; between acute and chronic. sub·a·cute adj. Between acute and chronic. lumbar impairment using hypothetical Hypothetical is an adjective, meaning of or pertaining to a hypothesis. See:
Method Subjects The study population consisted of all 4,892 physical therapists who were licensed to practice in Ontario, Canada, in 1998. A list of registered therapists was provided by the College of Physiotherapists of Ontario The College of Physiotherapist of Ontario (Also known official in french as Ordre des physiothérapeutes de l’Ontario) is the governing body in the Canadian province of Ontario responsible for the setting and regulating guildlines, policies and licensing for in January 1998. The therapists were stratified stratified /strat·i·fied/ (strat´i-fid) formed or arranged in layers. strat·i·fied adj. Arranged in the form of layers or strata. by region. Of the 4,561 therapists who practiced in southern Ontario, 454 were randomly selected for the survey. This number was based on the conservative estimation estimation In mathematics, use of a function or formula to derive a solution or make a prediction. Unlike approximation, it has precise connotations. In statistics, for example, it connotes the careful selection and testing of a function called an estimator. that 50% of therapists would use a specific assessment or treatment category (Appendix), a desired precision of 5%, with 95% confidence intervals confidence interval, n a statistical device used to determine the range within which an acceptable datum would fall. Confidence intervals are usually expressed in percentages, typically 95% or 99%. and an estimated response rate of 78%.[6-8] The entire physical therapist population of northern Ontario Northern Ontario is the part of the province of Ontario which lies north of Lake Huron (including Georgian Bay), the French River and Lake Nipissing. Northern Ontario has a land area of 802,000 km² (310,000 mi²) and constitutes 87% of the land area of Ontario, although it was surveyed due to the small size of that group (n=331). Questionnaire Development The questionnaire, patterned after one used to study Ontario physicians,[9] covered 3 areas related to physical therapy management of lumbar impairment: (1) physical examination, (2) treatment and recommendations, and (3) therapists' beliefs regarding treatment of LBP. In order to allow for further analysis to compare findings of this study and the physician survey, the same case scenarios and questionnaire formats were used. Slight modifications were made to include choices of assessment and treatment techniques that were pertinent PERTINENT, evidence. Those facts which tend to prove the allegations of the party offering them, are called pertinent; those which have no such tendency are called impertinent, 8 Toull. n. 22. By pertinent is also meant that which belongs. Willes, 319. to physical therapy practice. The 3 case scenarios were: (1) a 28-year-old woman who had acute lumbar impairment with localized Translated into the spoken language of the country. See localization. symptoms, (2) the same woman 5 weeks later with little change in pain and physical findings, and (3) a 35-year-old man with acute sciatica sciatica (sīăt`ĭkə), severe pain in the leg along the sciatic nerve and its branches. It may be caused by injury or pressure to the base of the nerve in the lower back, or by metabolic, toxic, or infectious disease. (Tab. 1). Associated with scenarios I and 3 was a list of assessment procedures and treatment modalities treatment modality Medtalk The method used to treat a Pt for a particular condition (Appendix), whereas only treatment options were provided in scenario 2. Therapists were asked whether they would or would not use a particular item to assess or treat the hypothetical patients. Open-ended questions A closed-ended question is a form of question, which normally can be answered with a simple "yes/no" dichotomous question, a specific simple piece of information, or a selection from multiple choices (multiple-choice question), if one excludes such non-answer responses as dodging a were used to help determine the assessment and treatment modalities used that were not included in the list. In addition, therapists were asked their opinion on the effectiveness of 8 treatment modalities and on the management of lumbar impairment. The questionnaire was pretested for face and content validity content validity, n the degree to which an experiment or measurement actually reflects the variable it has been designed to measure. with 9 physical therapists who were practicing in orthopedics orthopedics (ôrthəpē`dĭks), medical specialty concerned with deformities, injuries, and diseases of the bones, joints, ligaments, tendons, and muscles. and 1 therapist who had a research interest in survey development.
Table 1.
Clinical Vignettes(a)
Case No. Scenario
1 Acute low back pain
A 28-year-old woman has suffered from acute low
back pain after lifting a 10-kg box at work a
week ago. She has been unable to do her job
managing a cafeteria since then. While anxious
to return to work, she feels immobilized by the
pain. In terms of activities, she can sit about
10 minutes and walk one block before she has to
stop due to pain. She is able to sleep through
the night; however, her back is stiff in the
morning and the stiffness lasts about 10
minutes. There is no history of trauma. The pain
is limited to the low back area, without
radiation. She has not been seen by any medical
professional and now refers herself to your
outpatient clinic.
2 Subacute low back pain
The woman in Vignette #1 has now had her
symptoms for five weeks. You have managed her
during this time, and there has been little
change in pain and no change in physical
findings. Today she continues to have pain with
movement, and she has not had the confidence
to return to work. On examination today, she
still has some limitation in the anterior
flexion of the spine with a normal neurological
examination.
3 Acute low back pain with sciatica
A 35-year-old auto mechanic presents with a 4-day
history of severe acute low back pain with
radiation to the posterior calf and lateral
foot. The pain started when he was reaching
for a screwdriver by misting his body at work.
There was no history of trauma. His symptoms are
the worst when sitting or driving. He is able to
walk 1/2 a block before he has to stop due to
back and leg pain. He has been waking up a few
times at night due to discomfort. He has not
been seen by any medical professional and now
refers himself to your clinic.
(a) Vignettes quoted verbatim from questionnaire used in the study.
Mailing A modified Dillman technique[10,11] was used for mailing in order to elicit e·lic·it tr.v. e·lic·it·ed, e·lic·it·ing, e·lic·its 1. a. To bring or draw out (something latent); educe. b. To arrive at (a truth, for example) by logic. 2. the fullest participation in this survey. Three mailings were conducted between September 8 and October 23, 1998. Each mailing was separated by 3 weeks. All participants received a package, including an information letter, a questionnaire booklet, and a stamped return envelope during the first mailing. A reminder letter was sent to the nonrespondents 3 weeks later; and the complete package was sent again during the third mailing. Those therapists in southern Ontario who had moved during the survey period were replaced. Statistical Analysis Only data obtained for those therapists who reported treating people with lumbar impairment for more than 10% of the caseload case·load n. The number of cases handled in a given period, as by an attorney or by a clinic or social services agency. caseload Noun per week were included in the analysis, because our intent was to describe the practice of therapists who work with these patients on a regular basis. Descriptive analyses, based on frequency distributions and percentages, were used to describe the examinations and treatments used by physical therapists, as well as their beliefs regarding the management of lumbar impairment. Weighted frequencies were calculated for the entire sample based on the proportion of registered physical therapists who practiced in northern and southern Ontario. Although there were no prior studies suggesting regional discrepancies in physical therapy practice in orthopedic orthopedic /or·tho·pe·dic/ (-pe´dik) pertaining to the correction of deformities of the musculoskeletal system; pertaining to orthopedics. conditions, we thought some variations might exist due to differences in therapists' practice characteristics, such as caseload sizes, types of practice settings, and the number of practitioners working in each region. For this reason, the responses of those therapists from the more densely populated pop·u·late tr.v. pop·u·lat·ed, pop·u·lat·ing, pop·u·lates 1. To supply with inhabitants, as by colonization; people. 2. southern region of Ontario were compared with those from more rural northern Ontario. All nominal variables were examined using chi-square analysis, and continuous variables were examined using the Student t test.[12] A conservative level of significance was used due to the multiple comparisons. An alpha level below .001 was considered statistically significant. Results Five hundred sixty-nine physical therapists returned survey questionnaires, yielding a response rate of 72.5%. Twenty-one therapists returned the questionnaires blank and were therefore excluded from the analysis. The reasons for refusal were: (1) the therapist was no longer practicing physical therapy (n=8), (2) retirement (n=5), (3) the therapist was working outside Ontario (n=2), and (4) not specified (n=6). Nine physical therapists in southern Ontario were replaced because their mailing addresses were invalid Null; void; without force or effect; lacking in authority. For example, a will that has not been properly witnessed is invalid and unenforceable. INVALID. In a physical sense, it is that which is wanting force; in a figurative sense, it signifies that which has no effect. . In order to obtain information that was representative of therapists who treated patients with lumbar impairment on a regular basis, only those whose weekly caseload consisted of more than 10% of people with LBP were asked to complete the entire questionnaire. Thus, the responses from 274 therapists (48.2%) were included in the analysis. Most of the eligible respondents In the context of marketing research, a representative sample drawn from a larger population of people from whom information is collected and used to develop or confirm marketing strategy. practiced full-time (66.8%) and in a multidisciplinary setting (40.0%) (Tab. 2). A multidisciplinary setting was defined as a facility that offered services provided by physical therapists and other allied health care professionals, such as occupational therapists occupational therapist A person trained to help people manage daily activities of living–dressing, cooking, etc, and other activities that promote recovery and regaining vocational skills Salary $51K + 4% bonus. See ADL. , kinesiologists, and social workers. The average length of time in practice was 14.7 years (SD=10.1), with therapists in southern Ontario practicing longer than their northern counterparts (P [is less than] .001). Ninety-three percent of the respondents had completed at least one postgraduate postgraduate after first degree graduation, the registerable degree in veterinary science. postgraduate degree may be a research degree, e.g. PhD, or a course-work masterate with a vocational bias, or any combination of these. manual therapy course; however, only 8.8% of the respondents had completed a course on joint manipulation For extended detail of manipulation of spinal joints, see . Joint manipulation is a type of passive movement of a skeletal joint. It is usually aimed at one or more 'target' synovial joints with the aim of achieving a therapeutic effect. .
Table 2.
Demographic and Practice Characteristics of the Physical Therapists
Therapists From
All Therapists(a) Northern Ontario
(N = 274) (n = 131)
No. of years in practice
(SD)(b) 14.7 (10.1) 10.6 (8.9)
Female (%)(c) 86.0 78.6
Employment statusd:
Practiced full-time (%) 66.8 77.9
Practiced part-time (%) 28.8 15.3
On leave (%) 2.4 6.1
Missing data (%) 2.0 0.8
Type of practice(e):
Multidisciplinary setting (%) 40.0 49.6
Physical therapy group
practice (%) 38.5 31.3
Solo practice (%) 14.0 13.7
Other (%)(f) 7.4 4.6
Missing data (%) 0.1 0.8
Number of patients seen per
day(g):
1-5 4.6 1.5
6-10 10.4 9.9
11-15 24.2 21.4
16-20 36.2 42.0
[is greater than or equal
to] 21 24.5 25.2
Physical therapists with an
LBP(h) caseload
>20% (%)(i) 72.2 80.2
Physical therapists with >20%
WSIB(i) cases of all LBP
cases (%)(i) 31.3 45.0
Physical therapists with more
than one postsecondary
degree/diploma (%)(i) 25.0 31.3
Physical therapists who
completed at least one
postgraduate manual therapy
course (%)(i) 92.8 92.2
Therapists From
Southern Ontario
(n = 143)
No. of years in practice
(SD)(b) 15.1 (10.1)(k)
Female (%)(c) 86.7
Employment statusd:
Practiced full-time (%) 65.7(l)
Practiced part-time (%) 30.1
On leave (%) 2.1
Missing data (%) 2.1
Type of practice(e):
Multidisciplinary setting (%) 39.2
Physical therapy group
practice (%) 39.2
Solo practice (%) 14.0
Other (%)(f) 7.7
Missing data (%) 0.0
Number of patients seen per
day(g):
1-5 4.9
6-10 10.5
11-15 24.5
16-20 35.7
[is greater than or equal
to] 21 24.5
Physical therapists with an
LBP(h) caseload
>20% (%)(i) 71.4
Physical therapists with >20%
WSIB(i) cases of all LBP
cases (%)(i) 30.1(l)
Physical therapists with more
than one postsecondary
degree/diploma (%)(i) 24.5
Physical therapists who
completed at least one
postgraduate manual therapy
course (%)(i) 99.2
(a) The percentage of combined sample weighted by the proportion of
registered physical therapists who practiced in northern and southern
Ontario.
(b) Denotes the comparison between regions using the Student t test.
(c) Denotes comparison between regions using chi-square analysis.
(d) Denotes comparison between regions using chi-square analysis
(df=2).
(e) Denotes comparison between regions using chi-square analysis
(df=3).
(f) Other" includes home care agencies and industrial settings.
(g) Denotes comparison between regions using chi-square analysis
(df=4).
(h) LBP = low back pain.
(i) Denotes comparison between regions using chi-square analysis
(df= 1).
(j) WSIB = Workplace Safety Insurance Board.
(k) P<.001.
(l) .001<P<.05; comparisons of responses between northern and
southern Ontario.
Examination Preference Associated with scenarios 1 (acute LBP) and 3 (acute sciatica) were questions regarding preferences of assessment techniques (Tab. 3). Almost all of the therapists from the weighted combined sample reported that they would perform back inspection or palpation palpation /pal·pa·tion/ (pal-pa´shun) the act of feeling with the hand; the application of the fingers with light pressure to the surface of the body for the purpose of determining the condition of the parts beneath in physical diagnosis. (99.9%) and lumbar spine Lumbar spine The segment of the human spine above the pelvis that is involved in low back pain. There are five vertebrae, or bones, in the lumbar spine. Mentioned in: Low Back Pain range of motion testing (99.3%). Seventy-eight percent stated that they would assess lower extremity lower extremity n. The hip, thigh, leg, ankle, or foot. Also called inferior limb, pelvic limb. muscle weakness, and 57.5% stated that they would test sensation for the patient with localized symptoms. More than 86% reported that they would assess each of the 2 areas for the patient with sciatica. Most of the therapists stated they would administer the straight-leg-raising test (scenario 1, 89.5%; scenario 3, 97.9%) and reflex tests Reflex Tests Definition Reflex tests are simple physical tests of nervous system function. Purpose A reflex is a simple nerve circuit. (scenario 1, 64.7%; scenario 3, 94.6%) for both patients. More than half of the therapists reported that they would use other examination procedures, including McKenzie assessment, lumbar spine scan, sacroiliac joint sacroiliac joint (sak´rōil´ēak´), n an irregular synovial joint between the sacrum and ilium on either side of the pelvis. assessment, and lower-extremity scan. No statistically significant differences were found in assessment preferences between the regions of Ontario.
Table 3.
Reported Use of Physical Assessment Techniques by Ontario Physical
Therapists for Low Back Pain (LBP)
Scenario I (Acute LBP)
Therapists
From
Northern
All Therapists Ontario
Physical Assessment %(a) (95% CI(b)) % (N)
Back inspection/palpation 99.9 (99.6-100) 99.2 (129)
Lumbar spine range of
motion 99.3 (98.7-99.6) 99.2 (130)
Straight-leg-raising test 89.5 (87.8-91.0) 90.7 (129)
Lower-extremity muscle
strength 78.0 (75.8-80.1) 88.1 (126)
Reflex test 64.7 (62.3-67.1) 80.7 (119)
Sensation 57.5 (55.0-60.0) 66.9 (124)
Abdominal muscle
strength 49.0 (46.4-51.6) 49.5 (111)
Back extensor muscle
strength 39.5 (36.8-42.1) 43.0 (114)
Other(c) 64.2 (61.8-66.6) 70.2 (131)
Scenario 3
Scenario I (Acute LBP With
(Acute LBP) Sciatica)
Therapists
From
Southern
Ontario All Therapists
Physical Assessment % (N) % (95% CI)
Back inspection/palpation 100 (141) 99.9 (99.5-100)
Lumbar spine range of
motion 99.3 (141) 99.3 (98.7-99.6)
Straight-leg-raising test 89.4 (141) 97.9 (97.1-98.6)
Lower-extremity muscle
strength 77.0 (135) 86.9 (85.1-88.5)
Reflex test 63.4 (142)(d) 94.6 (93.3-95.6)
Sensation 55.3 (141) 89.7 (88.1-91.2)
Abdominal muscle
strength 48.9 (131) 27.6 (25.4-30.0)
Back extensor muscle
strength 39.2 (130)d 24.1 (22.0-26.4)
Other(c) 63.6 (143) 53.8 (51.3-56.3)
Scenario 3 (Acute LBP
With Sciatica)
Therapists Therapists
From From
Northern Southern
Ontario Ontario
Physical Assessment % (N) % (N)
Back inspection/palpation 98.5 (130) 100 (139)
Lumbar spine range of
motion 99.2 (130) 99.3 (139)
Straight-leg-raising test 98.4 (129) 97.9 (140)
Lower-extremity muscle
strength 90.1 (127) 86.3 (139)
Reflex test 97.6 (124) 94.3 (140)
Sensation 90.8 (125) 89.2 (139)
Abdominal muscle
strength 20.6 (116) 27.9 (136)
Back extensor muscle
strength 19.7 (117) 24.4 (135)
Other(c) 53.5 (131) 53.8 (143)
(a) The percentage of combined sample weighted by the proportion of
registered physical therapists who practiced in northern and southern
Ontario. The top 3 reported uses for each scenario are highlighted.
(b) CI = confidence interval.
(c) Other assessment techniques included McKenzie assessment, manual
therapy assessment, lower-extremity muscle flexibility,
lower-extremity scan, gait analysis, muscle energy testing, cervical
and thoracic spine scan, muscle energy testing, and trigger point
examination.
(d) .001<P<.05; comparisons of responses between northern and southern
Ontario, chi-square analysis (df = 1).
Treatment Preference Participants were asked to comment on the type of treatment they would prescribe pre·scribe v. To give directions, either orally or in writing, for the preparation and administration of a remedy to be used in the treatment of a disease. for the patient in each of the 3 scenarios (Tabs. 4 and 5). When patients had acute LBP with or without sciatica, patient education (scenario 1, 99.0%; scenario 3, 99.2%) and exercise at home (scenario 1, 95.9%; scenario 3, 91.5%) and at the clinic (scenario 1, 83.9%; scenario 3, 80.6%) were the interventions most preferred by physical therapists. However, exercise at home (96.4%), exercise at the clinic (93.4%), and work modification (84.3%) were reported to be the major focus when managing lumbar impairment at 6 weeks.
Table 4.
Treatment Preference for Ontario Physical Therapists for
the Three Low Back Pain (LBP) Scenarios
Scenario 1 Scenario 2
(Acute LBP) (Subacute LBP)
Treatment %(a) (95% CI(b)) % (95% CI)
Individual patient
education on back care 99.0 (98.4-99.5) 81.7 (79.6-83.6)
Exercise at home 95.9 (94.8-96.8) 96.4 (95.3-97.2)
Exercise at clinic 83.9 (81.9-85.7) 93.4 (92.0-94.6)
Referral to community
exercise programs 26.9 (24.7-29.3) 52.9 (50.3-55.5)
Physical modalities 82.8 (80.9-84.7) 65.1 (62.6-67.6)
Work modification 75.2 (72.9-77.5) 84.3 (82.4-86.2)
Spinal mobilization 44.4 (41.9-47.1) 83.7 (81.7-85.6)
Back school 18.0 (16.0-20.1) 40.8 (38.3-43.4)
Bed rest(c): 5.8 (4.7-7.2) 1.5 (0.9-2.2)
1-2 days 60.5 (48.7-71.6) 67.7 (48.6-83.3)
3-4 days 26.3 (16.9-37.7)
>4 days 13.2 (6.5-22.9) 32.3 (16.7-51.4)
Spinal manipulation 5.0 (4.0-6.3) 9.0 (7.6-10.6)
Mechanical spinal traction 4.5 (3.5-5.7) 30.7 (28.3-33.2)
Lumbar corset 1.5 (0.9-2.2) 8.9 (5.9-12.9)
Other treatment(d) 17.6 (15.8-19.6) 7.1 (5.8-8.4)
Referral to family physicians 34.4 (32.0-36.9) 84.4 (82.5-86.2)
Scenario 3
(Acute LBP With Sciatica)
Treatment % (95% CI)
Individual patient
education on back care 99.2 (98.6-99.6)
Exercise at home 91.5 (90.0-92.9)
Exercise at clinic 80.6 (78.5-82.6)
Referral to community
exercise programs 6.9 (5.6-8.3)
Physical modalities 79.5 (77.3-81.5)
Work modification 72.9 (70.5-75.1)
Spinal mobilization 34.3 (31.9-36.8)
Back school 12.1 (10.4-13.9)
Bed rest(c): 25.2 (23.0-27.5)
1-2 days 65.3 (60.0-70.4)
3-4 days 27.8 (23.1-33.0)
>4 days 6.9 (4.4-10.2)
Spinal manipulation 2.9 (2.1-3.9)
Mechanical spinal traction 30.0 (27.7-32.5)
Lumbar corset 6.4 (5.2-7.8)
Other treatment(d) 25.2 (23.1-27.5)
Referral to family physicians 65.5 (63.0-67.9)
(a) The percentage of combined sample weighted by the
proportion of registered physical therapists who practiced in
northern and southern Ontario. The top 3 choices for each scenario
are highlighted.
(b) CI= confidence interval.
(c) Percentage of therapists who would recommend bed rest
to the hypothetical patient.
(d) "Other treatment" includes McKenzie's treatment approach,
manual therapy techniques, manual traction, massage, back taping,
and myofascial release techniques.
Table 5.
Comparison of Treatment Preference Between Physical
Therapists Who Practiced in Northern and Southern Ontario
Scenario 1 (Acute LBP(a))
Therapists Therapists
From From
Northern Southern
Ontario Ontario
Treatment % (N) % (N)
Individual patient
education on back care 96.0 (125) 99.3 (140)
Exercise at home 98.4 (124) 95.7 (138)
Exercise at clinic 77.5 (120) 84.4 (135)
Referral to community
exercise programs 30.2 (116) 26.7 (135)
Physical modalities 70.3 (118) 83.9 (137)(c)
Work modification 79.8 (119) 74.8 (131)
Spinal mobilization 58.5 (118) 43.2 (132)(c)
Back school 14.5 (110) 18.3 (126)
Bed rest 3.6 (112) 6.0 (133)
Spinal manipulation 4.3 (116) 5.1 (137)
Mechanical spinal traction 13.9 (115) 3.7 (136)(c)
Lumbar corset 1.7 (118) 1.5 (137)
Other treatment(b) 19.1 (131) 17.5 (143)
Referral to family
physicians 35.5 (110) 32.2 (134)
Scenario 2 (Subacute LBP)
Therapists Therapists
From From
Northern Southern
Ontario Ontario
Treatment % (N) % (N)
Individual patient
education on back care 83.7 (123) 81.5 (135)
Exercise at home 96.0 (126) 96.4 (133)
Exercise at clinic 94.4 (125) 93.4 (136)
Referral to community
exercise programs 59.7 (119) 52.3 (132)
Physical modalities 52.6 (116) 66.2 (133)(c)
Work modification 85.4 (123) 84.2 (133)
Spinal mobilization 84.2 (120) 83.7 (135)
Back school 38.2 (123) 41.0 (134)
Bed rest 0.8 (121) 1.5 (133)
Spinal manipulation 14.5 (118) 7.7 (131)
Mechanical spinal traction 38.1 (118) 30.1 (133)
Lumbar corset 8.4 (118) 8.9 (135)
Other treatment(b) 7.6 (131) 7.0 (143)
Referral to family
physicians 82.8 (122) 84.5 (136)
Scenario 3 (Acute LBP
With Sciatica)
Therapists Therapists
From From
Northern Southern
Ontario Ontario
Treatment % (N) % (N)
Individual patient
education on back care 97.6 (126) 99.3 (140)
Exercise at home 93.6 (125) 91.3 (138)
Exercise at clinic 85.4 (124) 80.1 (136)
Referral to community
exercise programs 10.2 (118) 6.6 (137)
Physical modalities 73.5 (117) 80.0 (135)
Work modification 72.1 (122) 72.9 (133)
Spinal mobilization 44.7 (123) 33.3 (135)
Back school 11.7 (120) 12.1 (132)
Bed rest 20.8 (120) 25.6 (133)
Spinal manipulation 1.7 (120) 3.0 (133)
Mechanical spinal traction 21.6 (125) 30.8 (133)
Lumbar corset 3.3 (122) 6.7 (134)
Other treatment(b) 26.0 (131) 25.2 (143)
Referral to family
physicians 62.6 (115) 65.7 (137)
(a) LBP=Low back pain.
(b) "Other treatment" includes McKenzie's treatment approach,
manual therapy techniques, manual traction, massage, back
taping, and myofascial release techniques.
(c) P<.001, chi-square analysis, df = 1.
Spinal mobilization
Spinal mobilization is a type of passive movement of a spinal segment or region. It is usually performed with the aim of achieving a therapeutic effect. was preferred by 83.7% of the physical therapists for treating patients with subacute lumbar impairment. In contrast, the use of spinal manipulation was selected by less than 10% of the respondents for all 3 scenarios. More than 65% reported that they would use modalities Modalities The factors and circumstances that cause a patient's symptoms to improve or worsen, including weather, time of day, effects of food, and similar factors. ranging from ice or heat to magnetic therapy in their treatment, regardless of the nature of the patient's symptoms (Tab. 6). Only a small percentage of therapists indicated that they would recommend bed rest for patients with acute LBP (5.8%) or subacute LBP (1.5%) with localized symptoms, and 25.2% of the respondents reported that they would recommend bed rest when sciatica was present. For the latter scenario, 93.1% stated they would prescribe 1 to 4 days of bed rest. There were no statistically significant differences between regions in the choice of treatment (Tab. 5).
Table 6.
Preference of Modalities for the Three
Low Back Pain (LBP) Scenarios(a)
Scenario 1 Scenario 2
(Acute LBP) (Subacute LBP)
Modality %(b) (95% CI(c)) % (95% CI)
Interferential current 39.2 (36.8-41.7)(a) 15.4 (13.6-17.3)
Heat 37.0 (34.6-39.4)(a) 20.9 (18.9-23.0)(a)
Ice 35.3 (32.9-37.7)(a) 8.8 (7.4-103)
Ultrasound 33.0 (30.7-35 4) 16.3 (14.5-18.2)(a)
TENS(d) 19.4 (17.5-21.5) 18.0 (16.1-20.0)(a)
Acupuncture 4.2 (3.3-5.4) 9.5 (8.1-11.1)
Laser 3.3 (2.5-4.4) 2.0 (1.4-2.8)
Electroacupuncture 3.2 (2.4-4.2) 4.2 (3.2-5.3)
Electrical muscular
stimulation 3.0 (2.2-4.0) 3.9 (3.0-5.0)
Biofeedback 0.6 (0.3-1.2) 0.7 (3.5-12.6)
Magnetic therapy 0.6 (0.3-1.2) 0.0 (0.0-0.2)
Scenario 3
(Acute LBP With Sciatica)
Modality % (95% CI)
Interferential current 25.9 (23.8-28.2)(a)
Heat 25.2 (23 0-27.4)
Ice 42.7 (40.2-45.2)(a)
Ultrasound 26.4 (24.2-28.7)(a)
TENS(d) 20.2 (18.3-22.3)
Acupuncture 7.6 (6.4-9.1)
Laser 2.1 (1.5-3.0)
Electroacupuncture 2.7 (2.0-3.6)
Electrical muscular
stimulation 2.8 (2.1-3.8)
Biofeedback 0.6 (0.3-1.2)
Magnetic therapy 0.6 (0.3-1.2)
(a) The results reflect the preference of respondents who indicated
they would use modalities for the specific scenario. Therapists may
list more than one modality. The top 3 choices for each scenario
are highlighted.
(b) The percentage of combined sample weighted by the proportion of
registered physical therapists who practiced in northern and
southern Ontario.
(c) CI=confidence interval.
(d) TENS=transcutaneous electrical neuromuscular stimulation.
Beliefs Concerning Management of LBP When therapists were asked to comment on the effectiveness of 8 treatment modalities, 81.9% and 65.7% agreed that ice and heat were effective for acute lumbar impairment, respectively (Tab. 7). However, a majority of the therapists also agreed that ultrasound ultrasound or sonography, in medicine, technique that uses sound waves to study and treat hard-to-reach body areas. In scanning with ultrasound, high-frequency sound waves are transmitted to the area of interest and the returning echoes recorded (61.4%) and transcutaneous electrical nerve stimulation transcutaneous electrical nerve stimulation n. TENS. Transcutaneous electrical nerve stimulation (TENS) A method for relieving the muscle pain of TMJ by stimulating nerve endings that do not transmit pain. (TENS) (53.0%) were effective interventions, even though the practice guidelines practice guidelines Medical practice A set of recommendations for Pt management that identifies a specific or range of range of management strategies. See Peer review organization, Practice standards. Cf 'Cookbook' medicine. suggest otherwise.[2] Only 0.1% of the therapists agreed that bed rest should be prescribed pre·scribe v. pre·scribed, pre·scrib·ing, pre·scribes v.tr. 1. To set down as a rule or guide; enjoin. See Synonyms at dictate. 2. To order the use of (a medicine or other treatment). to patients with lumbar impairment until pain subsides, and 97.7% agreed that physical activity is crucial in the recovery from lumbar impairment. Seventy-six percent of the therapists agreed that back education programs are effective in reducing recurrences of LBP. Most of the therapists (84.9%) indicated that they were comfortable managing patients with lumbar impairment. There were no regional differences in therapists' beliefs.
Table 7.
Physical Therapists' Beliefs Concerning the Management of
Low Back Pain (LBP) (in Percentage Agree/Strongly Agree)
Therapists From
All Therapists Northern Ontario
Statement %(a) (95% CI(b)) % (N)
The following treatment
modalities are effective
in the management of most
patients with acute LBP:
Ice 81.9 (79.8-83.8) 75.2 (125)
Heat 65.7 (63.2-68.2) 58.4 (125)
Ultrasound 61.4 (58.9-63.9) 53.2 (126)
Mechanical traction 36.0 (33.5-38.5) 34.9 (126)
TENS(c) 53.0 (50.4-55.6) 50.0 (126)
Mobilization 79.9 (77.8-81.9) 84.9 (126)
Manipulation 29.9 (27.5-32.3) 39.0 (123)
Acupuncture 44.5 (41.9-47.1) 64.8 (128)
Patients with acute LBP
should be prescribed
complete bed rest until
pain goes away 0.1 (0.0-0.5) 1.6 (129)
Encouragement of physical
activity is important in
the recovery from LBP 97.7 (96.8-98.4) 96.1 (128)
Back education programs
aimed at educating
workers in safe lifting
techniques are effective
in reducing recurrences
of LBP 75.8 (73.5-77.9) 64.3 (129)
I am very comfortable
managing patients with
LBP 84.9 (83.0-86.6) 78.0 (127)
Practice guidelines would
be useful to help
physical therapists in
the management of
clinical conditions 58.6 (56.1-61.1) 65.1 (129)
I find practice
guidelines helpful in the
management of LBP 48.3 (45.7-50.8) 53.2 (126)
Therapists From
Southern Ontario
Statement % (N)
The following treatment
modalities are effective
in the management of most
patients with acute LBP:
Ice 82.5 (137)
Heat 66.4 (134)
Ultrasound 62.2 (135)
Mechanical traction 36.1 (133)
TENS(c) 53.3 (137)
Mobilization 79.4 (136)
Manipulation 29.0 (131)
Acupuncture 42.5 (134)(d)
Patients with acute LBP
should be prescribed
complete bed rest until
pain goes away 0.0 (138)
Encouragement of physical
activity is important in
the recovery from LBP 97.8 (138)
Back education programs
aimed at educating
workers in safe lifting
techniques are effective
in reducing recurrences
of LBP 76.8 (138)
I am very comfortable
managing patients with
LBP 85.5 (138)
Practice guidelines would
be useful to help
physical therapists in
the management of
clinical conditions 58.0 (138)
I find practice
guidelines helpful in the
management of LBP 47.8 (138)
(a) The percentage of combined sample weighted by the proportion
of registered physical therapists who practiced in northern and
southern Ontario.
(b) CI=confidence interval.
(c) TENS=transcutaneous electrical neuromuscular stimulation.
(d) .001<P<.05; comparisons of responses between northern and
southern Ontario, chi-square analysis.
Two statements were included in the questionnaire to assess therapists' opinions on practice guidelines. Although 58.6% of the respondents agreed that practice guidelines would be useful in managing clinical conditions, only 48.3% thought they were helpful in the management of lumbar impairment (Tab. 7). Discussion and Conclusion This study adds to our knowledge concerning physical therapy practice in managing lumbar impairment. Our findings suggest that Ontario physical therapists followed most of the recommendations from the AHCPR guidelines. A majority of the respondents chose assessment procedures that would help to rule out "red flags" such as cauda equina, inflammatory diseases, fracture, cancer, and infection.[2] Patient education and exercise were the interventions most frequently reported by therapists as part of the treatment for acute lumbar impairment. These findings also match the results of other studies. Battie et al[13] found that 86% of the therapists in the state of Washington would include patient education for patients with acute LBP and that 71% of the therapists would include patient education for patients with sciatica. In a more recent study, Mielenz et al,[14] who interviewed 1,580 patients with LBP in North Carolina North Carolina, state in the SE United States. It is bordered by the Atlantic Ocean (E), South Carolina and Georgia (S), Tennessee (W), and Virginia (N). Facts and Figures Area, 52,586 sq mi (136,198 sq km). Pop. , found that therapeutic exercise (83%) and heat treatment (74%) were the interventions that were most commonly prescribed by physical therapists. However, the use of patient education was not reported in this study. With regard to bed rest, the guidelines suggest that 2 to 4 days of bed rest may be an option only for patients with severe initial symptoms of sciatica.[2] This recommendation was supported by a study by Malmivaara et al,[15] which showed that patients with LBP who were assigned as·sign tr.v. as·signed, as·sign·ing, as·signs 1. To set apart for a particular purpose; designate: assigned a day for the inspection. 2. a 2-day bed rest recovered more slowly than those who had maintained ordinary activities. In our survey, more than 94% of the respondents advised against bed rest for someone with localized symptoms. About a quarter of the therapists indicated they would recommend bed rest for the patient with acute sciatica, but 93% of those therapists reported that they would prescribe no more than 4 days of bed rest. These findings are in agreement with the guideline guideline Medtalk A series of recommendations by a body of experts in a particular discipline. See Cancer screening guidelines, Cardiac profile guidelines, Gatekeeper guidelines, Harvard guidelines, Transfusion guidelines. recommendations. In the subacute LBP scenario, a shift in therapists' treatment focus from education to physical activity and work modification was noticed. Most of the therapists (84.4%) stated that they would refer the hypothetical patient to her family physician for further investigation, and this decision is congruent con·gru·ent adj. 1. Corresponding; congruous. 2. Mathematics a. Coinciding exactly when superimposed: congruent triangles. b. with the guideline About 85% of our respondents indicated that they felt very comfortable managing the condition. This finding is similar to the result of the Washington State study, in which 82% of the therapists felt well prepared to manage LBP.[13] A few discrepancies between the reported practice and guideline recommendations were identified. First, the reported use of spinal manipulation was low in our study. Only 5% of the therapists reported that they would use spinal manipulation to treat patients with acute lumbar impairment, as compared with more than a third of the therapists who indicated that they would use mobilization mobilization Organization of a nation's armed forces for active military service in time of war or other national emergency. It includes recruiting and training, building military bases and training camps, and procuring and distributing weapons, ammunition, uniforms, . This discrepancy DISCREPANCY. A difference between one thing and another, between one writing and another; a variance. (q.v.) 2. Discrepancies are material and immaterial. could be explained by the small number of therapists who were trained to perform spinal manipulation. Although most of the respondents had received postgraduate training in manual therapy, only 8.8% completed courses that included joint manipulation. This is an area where physical therapy practice can improve in the future. The AHCPR guidelines recommend that clinicians should teach self-application of heat or cold for pain control and discourage the use of modalities such as TENS, ultrasound, and biofeedback biofeedback, method for learning to increase one's ability to control biological responses, such as blood pressure, muscle tension, and heart rate. Sophisticated instruments are often used to measure physiological responses and make them apparent to the patient, who , which possess uncertain effectiveness for managing acute lumbar impairment.[2] Our results suggested that, although the use of heat and cold was preferred by the respondents, some still used modalities that have questionable effectiveness. For example, mechanical spinal traction Traction Definition Traction is the use of a pulling force to treat muscle and skeleton disorders. Purpose Traction is usually applied to the arms and legs, the neck, the backbone, or the pelvis. , which has consistently been shown to be of little benefit for acute and subacute lumbar impairment[15-18] and is not recommended by the guidelines, was preferred by about 30% of the therapists for acute sciatica. The selection of interventions by clinicians may be associated with a combination of clinical and nonclinical factors. In a study with 2,491 patients (50% with lumbar impairment), treated by 462 physical therapists, Jette and Jette[19] found that the use of heat and cold modalities was related not only to the acuity acuity /acu·i·ty/ (ah-ku´i-te) clarity or clearness, especially of vision. a·cu·i·ty n. Sharpness, clearness, and distinctness of perception or vision. and severity of lumbar impairment, but also to the therapist's academic degree. Furthermore, patients were more likely to receive endurance Endurance See also Longevity. Atalanta feminine name denotes power of endurance. [Gk. Myth.: Jobes, 148] Boston marathon famous 26-mile race held annually for long-distance runners. [Am. Pop. Culture: Misc. or strengthening exercises and spinal manipulation or mobilization from therapists who worked in practices with lower caseloads. Jette and Jette suggested that the uncertainties regarding the underlying cause of lumbar impairment and the effectiveness of treatments in reaching desired outcomes might have led clinicians to develop a practice style that is affected by idiosyncratic id·i·o·syn·cra·sy n. pl. id·i·o·syn·cra·sies 1. A structural or behavioral characteristic peculiar to an individual or group. 2. A physiological or temperamental peculiarity. 3. factors. Another potential explanation for the discrepancies may include therapists' perceptions about the utility of practice guidelines. Our results showed that only half of the therapists confirmed the usefulness of practice guidelines in managing any clinical conditions, including LBP. This finding may indicate some reluctance among physical therapists to embrace guidelines, especially for managing acute lumbar impairment. Some of the reasons may include patients' demands.[20] excessive commitment to particular modes of therapy,[21] and the therapists' own perceptions of treatment effectiveness.[22] Although most of the respondents in our survey believed that TENS and ultrasound were effective for managing acute lumbar impairment, only 30% said the same about spinal manipulation. Further research, therefore, is needed to explore the value of practice guidelines, the factors that hinder hin·der 1 v. hin·dered, hin·der·ing, hin·ders v.tr. 1. To be or get in the way of. 2. To obstruct or delay the progress of. v.intr. their use, and the potential solutions. In our survey, we used written case scenarios as a proxy measure of Ontario physical therapists' practice patterns. Although this is a commonly used method, it is questionable whether clinicians' responses indeed match their responses to actual clinical encounters.[23,24] Although some therapists may report treatments that they may not perform under usual practice constraints CONSTRAINTS - A language for solving constraints using value inference. ["CONSTRAINTS: A Language for Expressing Almost-Hierarchical Descriptions", G.J. Sussman et al, Artif Intell 14(1):1-39 (Aug 1980)]. , others may adopt an overcautious o·ver·cau·tious adj. Excessively cautious; unduly careful. o  ver·cau style in their answers. Validation See validate. validation - The stage in the software life-cycle at the end of the development process where software is evaluated to ensure that it complies with the requirements. of this method would involve a direct comparison with the actual clinical practice (gold standard). However, due to the constraints in resources, this process was not used in our study; thus, it serves as a limitation. Another issue is related to the development of case scenarios. In this study, therapists were required to make decisions about the choice of interventions based on the patient's medical history and complaints. The 3 scenarios were adopted from an earlier survey of family physicians in Ontario.[9] Because one of our goals was to compare the results of our survey with those of the physician survey.[9] the same scenarios were used with few modifications. However, it is possible that the lack of impairment data, such as posture posture /pos·ture/ (pos´choor) the attitude of the body.pos´tural pos·ture n. 1. A position of the body or of body parts. 2. and limitations in range of motion or strength, might have an impact on therapists' choices of interventions, as might the lack of other measurements that therapists may have wanted in their decision making. Despite the limitations, we believe that the findings from this survey are important. To our knowledge, this is the first study documenting the practice behaviors of Canadian physical therapists in treating people with musculoskeletal musculoskeletal /mus·cu·lo·skel·e·tal/ (-skel´e-t'l) pertaining to or comprising the skeleton and muscles. mus·cu·lo·skel·e·tal adj. Relating to or involving the muscles and the skeleton. impairments. The results may serve as a baseline to guide future education and research in physical therapy management of people with lumbar impairments. As experts in therapeutic exercise and manual techniques, physical therapists have been assuming the role of major health care providers in treating people with spinal impairments.[25] However, some research has suggested that ordinary physical activities, when performed within pain tolerance Pain tolerance is the amount of pain that a person can withstand before breaking down emotionally and/or physically. Pain tolerance is distinct from a pain threshold. The minimum stimulus necessary to produce pain is the pain threshold. , are superior to specific back-mobilizing exercises for treating patients with acute LBP.[15] Cherkin et al[26] also suggested that merely providing minimal intervention A procedure used in a lawsuit by which the court allows a third person who was not originally a party to the suit to become a party, by joining with either the plaintiff or the defendant. by giving patients with acute lumbar impairment an education booklet could achieve cost-effectiveness surpassing that of McKenzie exercises and "chiropractic chiropractic (kīrəprăk`tĭk) [Gr.,=doing by hand], medical practice based on the theory that all disease results from a disruption of the functions of the nerves. manipulation." Although their study was criticized for excluding patients with sciatica and those with a history of back surgery,[27-29] these findings may signal the need for physical therapists to revisit re·vis·it tr.v. re·vis·it·ed, re·vis·it·ing, re·vis·its To visit again. n. A second or repeated visit. re our roles in managing acute lumbar impairment. References [1] Scientific approach to the assessment and management of activity-related spinal disorders: a monograph mon·o·graph n. A scholarly piece of writing of essay or book length on a specific, often limited subject. tr.v. mon·o·graphed, mon·o·graph·ing, mon·o·graphs To write a monograph on. for clinicians. Report of the Quebec Task Force on Spinal Disorders. Spine. 1987;12(suppl 7): S1-S59. [2] Bigos bi·gos n. A Polish stew made with meat and cabbage, traditionally simmered for several days before serving. [Polish.] Noun 1. SJ, Bower OR, Braen GR, et al. Clinical Practice Guideline Number 14: Acute Low Back Problems in Adults. Rockville, Md: US Dept of Health and Human Services Noun 1. Health and Human Services - the United States federal department that administers all federal programs dealing with health and welfare; created in 1979 Department of Health and Human Services, HHS , Agency for Health Care Policy and Research; 1994. AHCPR publication 95-0642. [3] Clinical Guidelines for the Management of Acute Low Back Pain. London, England: Royal College of General Practitioners The Royal College of General Practitioners (RCGP) was founded in 1952 in London, England. It is a registered charity that aims to maintain the highest standards of general medical practice in education, training and research in the UK. ; 1996. [4] Guide to Assessing Psychosocial psychosocial /psy·cho·so·cial/ (si?ko-so´shul) pertaining to or involving both psychic and social aspects. psy·cho·so·cial adj. Involving aspects of both social and psychological behavior. Yellow Flags in Acute Low Back Pain: Risk Factors for Long-term Disability and Work Loss. Wellington, New Zealand: New Zealand Guidelines Group Inc; 1999. [5] Position/Information Sheet for Physiotherapists: AHCPR Back Pain Guidelines. Toronto, Ontario, Canada: Canadian Physiotherapy Association; 1995. [6] Miles-Tapping C, Rennie GAS, Duffy M, et al. Canadian physiotherapists' professional identity: an exploratory survey. Physiotherapy Canada. 1992;44(40):31-35. [7] Wolpert R, Yoshida K. Attrition Attrition The reduction in staff and employees in a company through normal means, such as retirement and resignation. This is natural in any business and industry. Notes: survey of physiotherapists in Ontario. Physiotherapy Canada. 1992;44 (2): 17-24. [8] McNeil A, Biddulph G, Walker JM. Role of physiotherapy auxiliary auxiliary In grammar, a verb that is subordinate to the main lexical verb in a clause. Auxiliaries can convey distinctions of tense, aspect, mood, person, and number. personnel in Nova Scotia Nova Scotia (nō`və skō`shə) [Lat.,=new Scotland], province (2001 pop. 908,007), 21,425 sq mi (55,491 sq km), E Canada. Geography . Physiotherapy Canada. 1990;42 (44):175-180. [9] Jansz G, Maetzel A, Bombardier C. Primary care physicians' management of acute low back pain: results of an Ontario survey. Can Med Assoc J. In press. [10] Dillman DA. Mail and Telephone Surveys: The Total Design Method. New York New York, state, United States New York, Middle Atlantic state of the United States. It is bordered by Vermont, Massachusetts, Connecticut, and the Atlantic Ocean (E), New Jersey and Pennsylvania (S), Lakes Erie and Ontario and the Canadian province of , NY: John Wiley John Wiley may refer to:
[11] Salant P, Dillman DA. How to Conduct Your Own Survey. New York, NY: John Wiley & Sons Inc; 1989. [12] Statistical First Aid: Interpretation of Health Research Data. Cambridge, Mass: Blackwell Scientific Publications; 1992. [13] Battie MC, Cherkin DC, Dunn R, et al. Managing low back pain: attitudes and treatment preferences of physical therapists. Phys Ther. 1994;74:219-226. [14] Mielenz TJ, Carey TS, Dyrek DA, et al. Physical therapy utilization by patients with acute low back pain. Phys Ther. 1997;77:1040-1051. [15] Malmivaara A, Hakkinen U, Aro T, et al. The treatment of acute low back pain: bed rest, exercises, or ordinary activity? N Engl J Med. 1995;332:351-355. [16] Beurskens AJ, de Vet HC, Koke AJ, et al. Efficacy of traction for non-specific low back pain: a randomised Adj. 1. randomised - set up or distributed in a deliberately random way randomized irregular - contrary to rule or accepted order or general practice; "irregular hiring practices" clinical trial. Lancet lancet /lan·cet/ (lan´set) a small, pointed, two-edged surgical knife. lan·cet n. . 1995; 346 (8990): 1596 -1600. [17] Beurskens AJ, de Vet HC, Koke AJ, et al. Efficacy of traction for nonspecific nonspecific /non·spe·cif·ic/ (non?spi-sif´ik) 1. not due to any single known cause. 2. not directed against a particular agent, but rather having a general effect. nonspecific 1. low back pain: 12-week and 6-month results of a randomized clinical trial randomized clinical trial, n a clinical study where volunteer participants with comparable characteristics are randomly assigned to different test groups to compare the efficacy of therapies. . Spine. 1997;22:2756-2762. [18] van der Heijden GJ, Beurskens AJ, Koes BW, et al. The efficacy of traction for back and neck pain: a systematic, blinded review of randomized clinical trial methods. Phys Ther. 1995;75:93-104. [19] Jette DU, Jette AM. Professional uncertainty and treatment choices by physical therapists. Arch Phys Med Rehabil. 1997;78:1346-1351. [20] Klingman D, Localio AR, Sugarman J, et al. Measuring defensive medicine using clinical scenario surveys. J Health Polit Policy Law. 1996;21:185-217. [21] Cherkin DC, Deyo RA, Wheeler K, Ciol MA. Physician views about treating low back pain: the results of a national survey. Spine. 1995;20: 1-9. [22] Tomlin Z, Humphrey C, Rogers S. General practitioners' perceptions of effective health care. BMJ BMJ n abbr (= British Medical Journal) → vom BMA herausgegebene Zeitschrift . 1999;318:1532-1535. [23] Jones TV, Gerrity MS, Earp J. Written case simulations: do they predict physicians' behavior? J Clin Epidemiol. 1990;43:805-815. [24] Langley Lang·ley , Mount A peak, 4,227.9 m (14,026 ft) high, in the Sierra Nevada of southern California. lang·ley n. pl. GR, Tritchler DL, Llewellyn-Thomas HA, Till JE. Use of written cases to study factors associated with regional variations in referral rates. J Clin Epidemiol. 1991;44:391-402. [25] Jayson MI. ABC ABC in full American Broadcasting Co. Major U.S. television network. It began when the expanding national radio network NBC split into the separate Red and Blue networks in 1928. of work related disorders: back pain. BMJ. 1996; 313:355-358. [26] Cherkin DC, Deyo RA, Battie M, et al. A comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for the treatment of patients with low back pain. N Engl J Med. 1998;339:1021-1029. [27] Pedigo MD. Physical therapy, chiropractic manipulation, or an educational booklet for back pain [comment on N Engl J Med. 1998;339:1021-1029]. N Engl J Med. 1999;340:388; discussion 390-391. [28] Lewis CB, Laukaitis J. Physical therapy, chiropractic manipulation, or an educational booklet for back pain [comment on N Engl J Med. 1998;339:1021-1029]. N Engl J Med. 1999;340:388-389; discussion 390. [29] Lachmann EA, Tunkel RS, Nagler W. Physical therapy, chiropractic manipulation, or an educational booklet for back pain [comment on N Engl J Med. 1998;339:1021-1029 and N Engl J Med. 1998;339: 1074-1075]. N Engl J Med. 1999;340:389; discussion 390. Appendix. Clinical Vignette Vignette A symbol or pictorial representation of the corporation on a stock certificate. Usually a complicated and artistic design, it is meant to make the counterfeiting of stock certificates as difficult as possible. (See Table 1) Please circle one number for each option. If you change your answer, please indicate with a note in the margin. 1. Which physical assessment technique(s) would you use to examine this patient et the initial assessment? Yes No a. Back inspection/palpation 1 2 b. Lumbar spine range of motion 1 2 c. Back extensor muscle strength 1 2 d. Abdominal muscle strength 1 2 e. Lower-extremity muscle strength 1 2 If "Yes," please specify the muscle group(s) you would test: -- f. Sensation 1 2 If "Yes," please specify the location(s) you would test (eg, anterior aspect of right thigh): -- g. Straight-leg-raising test 1 2 h. Reflex 1 2 If "Yes," please specify the reflex test(s) you would perform: -- i. Other test(s) (Please specify): -- 2. What type of treatment/advice would you give to this patient? Yes No a. Bed rest 1 2 If "Yes," please specify number of days: -- b. Back school 1 2 c. Education on back care (including proper posture and body mechanics) 1 2 d. Exercise (at clinic) 1 2 e. Exercise (home program) 1 2 f. Physical modalities 1 2 If "yes," please specify the type(s) of modality: -- g. Lumbar support or corset 1 2 h. Spinal manipulation 1 2 i. Spinal mobilization 1 2 j. Spinal traction 1 2 k. Work modification 1 2 l. Follow up appointment 1 2 If "yes," in how many days? -- days m. Others (please specify): -- LC Li, BSc(PT), MSc, is Research Fellow, Health Care Research Division, Arthritis arthritis, painful inflammation of a joint or joints of the body, usually producing heat and redness. There are many kinds of arthritis. In its various forms, arthritis disables more people than any other chronic disorder. & Autoimmunity Autoimmunity The occurrence in an organism of an immune response to one of its own tissues, that is, a response to a self constituent. Efficient discrimination between self and nonself, the basis of normal immune function, depends upon a function known as Research Centre, University Health Network, 610 University Ave, 16th Floor, Toronto, Ontario, Canada M5G 2M9 (lli@netcom.ca). Address all correspondence to Ms Li. C Bombardier, MD, FRCP FRCP Fellow of the Royal College of Physicians. FRCP abbr. Fellow of the Royal College of Physicians (C), is Clinical Research Coordinator, Institute for Work & Health; Director, Arthritis & Autoimmunity Research Centre, University Health Network; Professor of Clinical Epidemiology epidemiology, field of medicine concerned with the study of epidemics, outbreaks of disease that affect large numbers of people. Epidemiologists, using sophisticated statistical analyses, field investigations, and complex laboratory techniques, investigate the cause and Director, Heath heath, tract of open land heath, tract of open land characterized by a few scattered trees, abundant moss cover, and numerous low shrubs, principally of the heath family (see heath, in botany). Care Research Program, Department of Medicine, and Department of Health Administration, University of Toronto Research at the University of Toronto has been responsible for the world's first electronic heart pacemaker, artificial larynx, single-lung transplant, nerve transplant, artificial pancreas, chemical laser, G-suit, the first practical electron microscope, the first cloning of T-cells, ; and Staff Physician, Department of Medicine, Mt Sinai Hospital Sinai Hospital is a Baltimore, Maryland hospital originally founded in 1866 as the Hebrew Hospital and Asylum. It is now a Jewish-sponsored teaching hospital that provides care for all people. , Toronto, Ontario, Canada. Ms Li and Dr Bombardier provided concept/research design, fund procurement The fancy word for "purchasing." The procurement department within an organization manages all the major purchases. , and consultation (including review of manuscript manuscript, a handwritten work as distinguished from printing. The oldest manuscripts, those found in Egyptian tombs, were written on papyrus; the earliest dates from c.3500 B.C. before submission). Ms Li provided writing, subjects, data collection and analysis, and project management. Dr Bombardier provided facilities/equipment and administrative support. The study protocol was approved by the research ethics Research ethics involves the application of fundamental ethical principles to a variety of topics involving scientific research. These include the design and implementation of research involving human participants (human experimentation); animal experimentation; various aspects of board of the University Health Network. This study was partially supported by a research grant from the Physiotherapy Foundation of Canada. This article was submitted September 8, 1999, and was accepted October 18, 2000. |
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