Association of early imaging for back pain with clinical outcomes in older adults

IMPORTANCE: In contrast to the recommendations for younger adults, many guidelines allow for older adults with back pain to undergo imaging without waiting 4 to 6 weeks. However, early imaging may precipitate interventions that do not improve outcomes. OBJECTIVE: To compare function and pain at the 12-month follow-up visit among older adults who received early imaging with those who did not receive early imaging after a new primary care visit for back pain without radiculopathy. DESIGN, SETTING, AND PARTICIPANTS: Prospective cohort of 5239 patients 65 years or older with a new primary care visit for back pain (2011-2013) in 3 US health care systems. We matched controls 1:1 using propensity score matching of demographic and clinical characteristics, including diagnosis, pain severity, pain duration, functional status, and prior resource use. EXPOSURES: Diagnostic imaging (plain films, computed tomography [CT], magnetic resonance imaging [MRI]) of the lumbar or thoracic spine within 6 weeks of the index visit. PRIMARY OUTCOME: back or leg pain-related disability measured by the modified Roland-Morris Disability Questionnaire (score range, 0-24; higher scores indicate greater disability) 12 months after enrollment. RESULTS: Among the 5239 patients, 1174 had early radiographs and 349 had early MRI/CT. At 12 months, neither the early radiograph group nor the early MRI/CT group differed significantly from controls on the disability questionnaire. The mean score for patients who underwent early radiography was 8.54 vs 8.74 among the control group (difference, -0.10 [95% CI, -0.71 to 0.50]; mixed model, P = .36). The mean score for the early MRI/CT group was 9.81 vs 10.50 for the control group (difference,-0.51 [-1.62 to 0.60]; mixed model, P = .18). CONCLUSIONS AND RELEVANCE: Among older adults with a new primary care visit for back pain, early imaging was not associated with better 1-year outcomes. The value of early diagnostic imaging in older adults for back pain without radiculopathy is uncertain

Genetic mechanisms of critical illness in COVID-19.

Host-mediated lung inflammation is present1, and drives mortality2, in the critical illness caused by coronavirus disease 2019 (COVID-19). Host genetic variants associated with critical illness may identify mechanistic targets for therapeutic development3. Here we report the results of the GenOMICC (Genetics Of Mortality In Critical Care) genome-wide association study in 2,244 critically ill patients with COVID-19 from 208 UK intensive care units. We have identified and replicated the following new genome-wide significant associations: on chromosome 12q24.13 (rs10735079, P = 1.65 × 10-8) in a gene cluster that encodes antiviral restriction enzyme activators (OAS1, OAS2 and OAS3); on chromosome 19p13.2 (rs74956615, P = 2.3 × 10-8) near the gene that encodes tyrosine kinase 2 (TYK2); on chromosome 19p13.3 (rs2109069, P = 3.98 ×  10-12) within the gene that encodes dipeptidyl peptidase 9 (DPP9); and on chromosome 21q22.1 (rs2236757, P = 4.99 × 10-8) in the interferon receptor gene IFNAR2. We identified potential targets for repurposing of licensed medications: using Mendelian randomization, we found evidence that low expression of IFNAR2, or high expression of TYK2, are associated with life-threatening disease; and transcriptome-wide association in lung tissue revealed that high expression of the monocyte-macrophage chemotactic receptor CCR2 is associated with severe COVID-19. Our results identify robust genetic signals relating to key host antiviral defence mechanisms and mediators of inflammatory organ damage in COVID-19. Both mechanisms may be amenable to targeted treatment with existing drugs. However, large-scale randomized clinical trials will be essential before any change to clinical practice

SARS-CoV-2-specific immune responses and clinical outcomes after COVID-19 vaccination in patients with immune-suppressive disease

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) immune responses and infection outcomes were evaluated in 2,686 patients with varying immune-suppressive disease states after administration of two Coronavirus Disease 2019 (COVID-19) vaccines. Overall, 255 of 2,204 (12%) patients failed to develop anti-spike antibodies, with an additional 600 of 2,204 (27%) patients generating low levels (<380 AU ml−1). Vaccine failure rates were highest in ANCA-associated vasculitis on rituximab (21/29, 72%), hemodialysis on immunosuppressive therapy (6/30, 20%) and solid organ transplant recipients (20/81, 25% and 141/458, 31%). SARS-CoV-2-specific T cell responses were detected in 513 of 580 (88%) patients, with lower T cell magnitude or proportion in hemodialysis, allogeneic hematopoietic stem cell transplantation and liver transplant recipients (versus healthy controls). Humoral responses against Omicron (BA.1) were reduced, although cross-reactive T cell responses were sustained in all participants for whom these data were available. BNT162b2 was associated with higher antibody but lower cellular responses compared to ChAdOx1 nCoV-19 vaccination. We report 474 SARS-CoV-2 infection episodes, including 48 individuals with hospitalization or death from COVID-19. Decreased magnitude of both the serological and the T cell response was associated with severe COVID-19. Overall, we identified clinical phenotypes that may benefit from targeted COVID-19 therapeutic strategies

Patient education based on principles of cognitive behavioral therapy for a patient with persistent low back pain: a case report

STUDY DESIGN: Case report. BACKGROUND: Cognitive behavioral therapy (CBT) is an effective intervention for patients with persistent pain. Recent research indicates that physical therapists self-perceive a lack of knowledge, skills, and time to provide this intervention. The purpose of this case report is to describe how specific CBT strategies can be integrated with multimodal physical therapist management of a patient with persistent low back pain. CASE DESCRIPTION: The patient was a 70-year-old female with activity limitations of walking, standing, and forward bending. Oswestry Disability Questionnaire score was 19/50 and Fear-Avoidance Belief Questionnaire physical activity subscale was 23/24. The Low Back Activity Confidence Scale revealed 19%, 100%, and 84% for function, symptom self-regulation, and exercise, respectively. CBT-based patient education was provided in combination with manual therapy and exercise. CBT techniques included cognitive restructuring, goal setting, activity pacing, problem-solving strategies, graded exposure, encouraging exposure to pleasant experiences, and maintenance strategies. OUTCOMES: The patient was discharged after 7 visits distributed over 21 weeks. Her Oswestry Disability Questionnaire score was reduced 10% and Fear-Avoidance Belief Questionnaire physical activity subscale score reduced 48%. On the Low Back Activity Confidence Scale the patient\u27s scores were 19%, 87%, and 94% for function, symptom self-regulation, and exercise, respectively. DISCUSSION: This case report describes the use of CBT techniques during patient education by a physical therapist. The patient demonstrated clinically measurable and significant improvements in disability. Improvements in both self-efficacy beliefs related to exercise and activity avoidance beliefs were associated with improvement in disability. Additional research is needed to determine best practices for CBT-based patient education by physical therapists. LEVEL OF EVIDENCE: Therapy, level 4

Use case 4: from traditional documentation to ICF-based documentation

https://scholarlycommons.pacific.edu/phs-facbooks/1007/thumbnail.jp

Physical therapist management of acute and chronic low back pain using the World Health Organization\u27s International Classification of Functioning, Disability, and Health

BACKGROUND AND PURPOSE: The World Health Organization\u27s Classification of Functioning, Disability and Health (WHO-ICF) model was developed to describe, classify, and measure function in health care practice and research. Recently, this model has been promoted as a successor to the Nagi model by some authors in the physical therapy literature. However, conceptual work in demonstrating use of the WHO-ICF model in physical therapist management of individual patients remains sparse. The purpose of this case report series is to demonstrate the application of the WHO-ICF model in clinical reasoning and physical therapist management of acute and chronic low back pain. CASE DESCRIPTION: Two patients, 1 with acute low back pain and 1 with chronic low back pain, were treated pragmatically using the WHO-ICF model and other applicable models of clinical reasoning. INTERVENTION: Manual therapy, exercise, and education interventions were directed toward relevant body structure and function impairments, activity limitations, and contextual factors based on their hypothesized contribution to functioning and disability. OUTCOME: Both patients demonstrated clinically significant improvements in measures of pain, disability, and psychosocial factors after 3 weeks and 10 weeks of intervention, respectively. DISCUSSION: The WHO-ICF model appears to provide an effective framework for physical therapists to better understand each person\u27s experience with his or her disablement and assists in prioritizing treatment selection. The explicit acknowledgment of personal and environmental factors aids in addressing potential barriers. The WHO-ICF model integrates well with other models of practice such as Sackett\u27s principles of evidence-based practice, the rehabilitation cycle, and Edwards and colleagues\u27 clinical reasoning model. Future research should examine outcomes associated with the use of the WHO-ICF model using adequately designed clinical trials

Use case 4: from traditional documentation to ICF-based documentation

https://scholarlycommons.pacific.edu/phs-facbooks/1007/thumbnail.jp

Do medical conditions predispose to the development of chronic back pain? A longitudinal co-twin control study of middle-aged males with 11-year follow-up

Abstract Background Poor general health predicts the transition to chronic back pain (CBP), but the role of specific medical conditions in the development of CBP is unclear. The study aim was to examine the association of medical conditions with the development of CBP (“incident CBP”), while controlling for familial factors, including genetics. Methods This was a longitudinal co-twin control study conducted in a nationwide United States sample from the Vietnam Era Twin Registry. The study sample included 3045 males without back problems at baseline, including 662 complete twin pairs, who were followed for 11 years. Baseline surveys inquired about self-reported medical conditions (arthritis, diabetes, hypertension, and coronary artery disease [CAD]). A medical comorbidity score was calculated based on the presence and/or treatment of 8 medical conditions. Covariates included age, race, and education. At 11-year follow-up, participants reported ever having had CBP. Odds ratios (ORs) and 95% confidence intervals (CI) were estimated when considering twins as individuals, and in matched-pair co-twin control analyses adjusting for familial/genetic factors. Results Mean age at baseline was 51 years and 17% of participants developed CBP over the 11-year follow-up. Arthritis was significantly associated with incident CBP in individual-level analysis (OR 1.8 [95% CI 1.4–2.2]), but not within-pair analysis (OR 0.9 [95% CI 0.4–1.9]. CAD (OR 1.6 [95% CI 1.0–2.3]), hypertension (OR 1.3 [95% CI 1.0–1.5]), and the medical comorbidity score (OR 1.2 [95%CI 1.1–2.2]) were significantly associated with incident CBP in individual-level analyses; associations in within-pair analyses were of comparable magnitude, but not statistically significant. Diabetes was not associated with incident CBP. Conclusions Arthritis, hypertension, CAD, and medical comorbidity score were associated with incident CBP in the current study. However, the association between arthritis and incident CBP was confounded by familial factors. This suggests that prevention or treatment of arthritis is unlikely to be useful for CBP prevention. Our findings cannot exclude the possibility of causal associations between CAD, hypertension, and medical comorbidities and incident CBP