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INTRODUCTION: An international taskforce of clinician-scientists was formed by specialty groups of World Physiotherapy - International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) & International Organisation of Physiotherapists in Paediatrics (IOPTP) - to develop evidence-based practice position statements directing physiotherapists clinical reasoning for the safe and effective use of spinal manipulation and mobilisation for paediatric populations (<18 years) with varied musculoskeletal or non-musculoskeletal conditions. METHOD: A three-stage guideline process using validated methodology was completed: 1. Literature review stage (one scoping review, two reviews exploring psychometric properties); 2. Delphi stage (one 3-Round expert Delphi survey); and 3. Refinement stage (evidence-to-decision summative analysis, position statement development, evidence gap map analyses, and multilayer review processes). RESULTS: Evidence-based practice position statements were developed to guide the appropriate use of spinal manipulation and mobilisation for paediatric populations. All were predicated on clinicians using biopsychosocial clinical reasoning to determine when the intervention is appropriate.1. It is not recommended to perform:• Spinal manipulation and mobilisation on infants.• Cervical and lumbar spine manipulation on children.•Spinal manipulation and mobilisation on infants, children, and adolescents for non-musculoskeletal paediatric conditions including asthma, attention deficit hyperactivity disorder, autism spectrum disorder, breastfeeding difficulties, cerebral palsy, infantile colic, nocturnal enuresis, and otitis media.2. It may be appropriate to treat musculoskeletal conditions including spinal mobility impairments associated with neck-back pain and neck pain with headache utilising:• Spinal mobilisation and manipulation on adolescents;• Spinal mobilisation on children; or• Thoracic manipulation on children for neck-back pain only.3. No high certainty evidence to recommend these interventions was available.Reports of mild to severe harms exist; however, risk rates could not be determined. CONCLUSION: Specific directives to guide physiotherapists' clinical reasoning on the appropriate use of spinal manipulation or mobilisation were identified. Future research should focus on trials for priority conditions (neck-back pain) in children and adolescents, psychometric properties of key outcome measures, knowledge translation, and harms.

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OBJECTIVE: To identify factors and barriers, which affect the utilisation of spinal manipulation and mobilisation among infants, children, and adolescents. METHODS: Twenty-six international expert physiotherapists in manual therapy and paediatrics were invited to participate in a Delphi investigation using QualtricsⓇ. In Round-1 physiotherapists selected from a list of factors and barriers affecting their decision to use spinal manipulation and mobilisation in the paediatric population and had opportunity to add to the list. Round-2 asked respondents to select as many factors and barriers that they agreed with, resulting in a frequency count. The subset of responses to questions around barriers and facilitators are the focus of this study. RESULTS: Twelve physiotherapists completed both rounds of the survey. Medical diagnosis, mechanism of injury, patient presentation, tolerance to handling, and therapist's knowledge of techniques were the dominant deciding factors to use spinal manipulation and mobilisation among infants, children, and adolescents across spinal levels. More than 90% of the respondents selected manipulation as inappropriate among infants as their top barrier. Additional dominant barriers to using spinal manipulation among infants and children identified by ≥ 75% of the respondents included fear of injuring the patient, fear of litigation, lack of communication, lack of evidence, lack of guardian consent, and precision of the examination to inform clinical reasoning. CONCLUSION: This international survey provides much needed insight regarding the factors and barriers physiotherapists should consider when contemplating the utilisation of spinal mobilisation and manipulation in the paediatric population.

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OBJECTIVE: The aim of this study was to establish international consensus regarding the use of spinal manipulation and mobilisation among infants, children, and adolescents among expert international physiotherapists. METHODS: Twenty-six international expert physiotherapists in manual therapy and paediatrics voluntarily participated in a 3-Round Delphi survey to reach a consensus via direct electronic mail solicitation using Qualtrics®. Consensus was defined a-priori as ≥75% agreement on all items with the same ranking of agreement or disagreement. Round 1 identified impairments and conditions where spinal mobilisation and manipulation might be utilised. In Rounds 2 and 3, panelists agreed or disagreed using a 4-point Likert scale. RESULTS: Eleven physiotherapists from seven countries representing five continents completed all three Delphi rounds. Consensus regarding spinal mobilisation or manipulation included:Manipulation is not recommended: (1) for infants across all conditions, impairments, and spinal levels; and (2) for children and adolescents across most conditions and spinal levels.Manipulation may be recommended for adolescents to treat spinal region-specific joint hypomobility (thoracic, lumbar), and pain (thoracic).Mobilisation may be recommended for children and adolescents with hypomobility, joint pain, muscle/myofascial pain, or stiffness at all spinal levels. CONCLUSION: Consensus revealed spinal manipulation should not be performed on infants regardless of condition, impairment, or spinal level. Additionally, the panel agreed that manipulation may be recommended only for adolescents to treat joint pain and joint hypomobility (limited to thoracic and/or lumbar levels). Spinal mobilisation may be recommended for joint hypomobility, joint pain, muscle/myofascial pain, and muscle/myofascial stiffness at all spinal levels among children and adolescents.

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The primary objective of this review was to create a 'trustworthy,' living systematic review and meta-analysis for the application of manual therapy interventions in treating patients with shoulder dysfunction. Included studies were English-language randomized controlled trials published between 1/1/2010 and 8/3/2023, with searches performed in: PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), CINHAL, ProQuest Nursing & Allied Health, EBSCO Medline, and PEDro. The population of focus included adults 18 years and older with musculoskeletal impairments related to shoulder dysfunction. Our primary outcomes included pain and region-specific outcome measures. We excluded trials, including participants having shoulder dysfunction resulting from surgery, radicular pain, instability/dislocation, fracture, lymphedema, and radiation. Our screening methodology was based upon a previously published 'trustworthy' systematic review protocol. This included the application of our PICOTS criteria in addition to screening for prospective clinical trial registration and following of prospective intent, as well as assessment of PEDro scores, risk-of-bias ratings, GRADE scoring, and examination of confidence in estimated effects. Twenty-six randomized controlled trials met our PICOTS criteria; however, only 15 of these were registered. Only three were registered prospectively. Two of these did not have discussions and conclusions that aligned with their primary outcome. The remaining single study was found to have a high risk-of-bias, meaning the remainder of the protocol could not be employed and that no randomized controlled trials could undergo further assessment or meta-analysis. The results of this systematic review indicate there are no 'trustworthy' randomized controlled trials examining the effectiveness of manual therapy interventions for the treatment of patients with shoulder dysfunction, as defined by the prospectively established methodology. Therefore, these findings signal that creating a 'trustworthy,' living systematic review on this clinically relevant topic is not yet possible due to a lack of 'trustworthy' randomized controlled trials.

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PURPOSE: Systematically evaluate the comparative effectiveness of dry needling (DN) or local acupuncture to various types of wet needling (WN) for musculoskeletal pain disorders (MPD). METHODS: Seven databases (PubMed, PEDro, SPORTDiscus, CINAHL, Scopus, Embase, and Cochrane Central Register of Controlled Trials) were searched following PROSPERO registration. Randomized clinical trials were included if they compared DN or local acupuncture with WN for MPD. Primary outcomes were pain and/or disability. The Revised Cochrane Collaboration tool (RoB 2.0) assessed the risk of bias. RESULTS: Twenty-six studies were selected. Wet Needling types included cortisone (CSI) (N = 5), platelet-rich plasma (PRP) (N = 6), Botox (BoT) (N = 3), and local anesthetic injection (LAI) (N = 12). Evidence was rated as low to moderate quality. Results indicate DN produces similar effects to CSI in the short-medium term and superior outcomes in the long term. In addition, DN produces similar outcomes compared to PRP in the short and long term and similar outcomes as BoT in the short and medium term; however, LAI produces better pain outcomes in the short term. CONCLUSION: Evidence suggests the effectiveness of DN to WN injections is variable depending on the injection type, outcome time frame, and diagnosis. In addition, adverse event data were similar but inconsistently reported. PROSPERO Registration: 2019 CRD42019131826Implications for rehabilitationDry needling produces similar effects for pain and disability in the short and medium term compared to cortisone, Botox, and platelet-rich plasma injections. Local anesthetic injection may be more effective at reducing short-term pain.Long-term effects on pain and disability are similar between dry needling and platelet-rich plasma injections, but dry needling may produce better long-term outcomes than cortisone injections.The available adverse event data is similar between dry and wet needling.The conclusions from this study may be beneficial for patients and clinicians for considering risk and cost benefit analyses.

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BACKGROUND: Musculoskeletal pain (MSP) is the largest contributor to chronic pain and frequently occurs alongside other medical comorbidities. OBJECTIVE: Explore the relationships between the presence of pain-related comorbidities, pain intensity, and pain-related psychological distress in patients with MSP. METHODS: A longitudinal assessment of individuals 18-90 years old in the Midwestern United States beginning a new episode of physical therapy for MSP. Electronic medical records were assessed the full year prior for care-seeking of diagnoses for pain-related comorbidities (anxiety, metabolic disorder, chronic pain, depression, nicotine dependence, post-traumatic stress disorder, sleep apnea, and sleep insomnia). Pain intensity and pain-related psychological distress (Optimal Screening for Prediction of Referral and Outcome - Yellow Flags tool) were captured during the physical therapy evaluation. Generalized linear models were used to assess the association between pain intensity, psychological distress, and pain-related co-morbidities. Models were adjusted for variables shown in the literature to influence pain. RESULTS: 532 participants were included in the cohort (56.4% female; median age of 59 years, Interquartile Range [IQR]:47, 69). Comorbid depression (beta coefficient (ß) = 0.7; 95%CI: 0.2, 1.2), spine versus lower extremity pain ((ß = 0.6; 95%CI: 0.1, 1.1), and prior surgery (ß = 0.8, 95%CI: 0.3, 1.4) were associated with higher pain intensity scores. No pain-related comorbidities were associated with pain-related psychological distress (yellow flag count or number of domains). Female sex was associated with less pain-related psychological distress (ß = -0.2, 95%CI: -0.3, -0.02). CONCLUSIONS: Depression was associated with greater pain intensity. No comorbidities were able to account for the extent of pain-related psychological distress.

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OBJECTIVE: The purpose of this systematic review with meta-analysis was to investigate the effect of early physical therapy (PT) for the management of acute low back pain (LBP) on patient-reported outcomes of pain and disability, compared to delayed PT or non-PT care. LITERATURE SURVEY: Randomized controlled trials in three electronic databases (MEDLINE, CINAHL, Embase) were searched from inception to June 12, 2020, and updated on September 23, 2021. METHODOLOGY: Eligible participants were individuals with acute low back pain. The intervention was early PT compared to delayed PT or non-PT care. Primary outcomes included the patient-reported outcomes of pain and disability. The following information was extracted from included articles: demographic data, sample size, selection criteria, PT interventions, and pain and disability outcomes. Data were extracted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Methodological quality was assessed using the Physiotherapy Evidence Database (PEDro) Scale. Random effects models were used for the meta-analysis. SYNTHESIS: Seven of 391 articles met the eligibility criteria and were included in the meta-analysis. Random effects meta-analysis comparing early PT to non-PT care for acute LBP indicated a significant reduction in pain (standard mean difference [SMD] = 0.43, 95% confidence interval [CI]: -0.69 to -0.17) and disability (SMD = 0.36, 95% CI: -0.57 to -0.16) in the short term. Early PT compared to delayed PT did not result in improvement in short-term pain (SMD = -0.24, 95% CI: -0.52 to 0.04) or disability (SMD = 0.28, 95% CI: -0.56 to 0.01), or long-term pain (SMD = 0.21, 95% CI: -0.15 to 0.57) or disability (SMD = 0.14, 95% CI: -0.15 to 0.42). CONCLUSIONS: This systematic review and meta-analysis suggest early PT versus non-PT care is associated with statistically significant reductions in short-term pain and disability (up to 6 weeks) with small effect sizes. The results indicate a nonsignificant trend favoring a small benefit of early PT over delayed PT for outcomes at short-term follow-up but no effect at long-term follow-up (6 months or greater).

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PURPOSE: Burnout is identified as a workplace problem rather than a worker problem. However, it remains unclear what job stressors are associated with burnout among outpatient physical therapists. Thus, the primary objective of this study was to understand the burnout experiences of outpatient physical therapists. The secondary aim was to identify the relationship between physical therapist burnout and the work setting. METHODS: One-on-one interviews based on hermeneutics were used for qualitative analysis. Quantitative data was collected using the Maslach Burnout Inventory-Health Services Survey (MBI-HSS) and the Areas of Worklife Survey (AWS). RESULTS: Qualitative analysis found participants interpreted an increased workload with no increase in wages, loss of control, and a mismatch between organizational culture and values as the main drivers of organizational stress. Professional issues such as high debt burden, low salaries, and declining reimbursement emerged as stressors. Participants showed moderate to high emotional exhaustion per the MBI-HSS. There was a statistically significant association between emotional exhaustion and workload and control (p < 0.001). For every one-point increase in workload, emotional exhaustion increased by 6.49 while for every one-point increase in control, emotional exhaustion decreased by 4.17. CONCLUSION: Outpatient physical therapists in this study felt that increased workload with a lack of incentives and inequity, coupled with a loss of control, and a mismatch between personal and organizational values were significant job stressors. Creating awareness of outpatient physical therapist's perceived stressors may play an important role in developing strategies to diminish or prevent burnout.

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BACKGROUND: Typically treated medically, chronic rhinosinusitis (CRS) is a prevalent condition characterized by multiple craniofacial symptoms, some of which may respond favorably to dry needling intervention. OBJECTIVE: To describe the outcomes of a patient presenting with craniofacial pain and symptoms consistent with a diagnosis of CRS who was treated with dry needling. Case Description: A 41-year-old male, self-referred to physical therapy with a diagnosis of CRS, with a 20-year history of signs and symptoms associated with CRS, including craniofacial pain and headaches. The patient had been treated with multiple medication regimens over this time, including antihistamines, anti-inflammatories, decongestants, leukotriene inhibitors, and antibiotics; all of which provided only short-term relief. On initial examination, the patient was tender to palpation in multiple muscles of the head, neck, and face. Intervention consisted of dry needling to these muscular tender points once or twice weekly over 2 months. OUTCOMES: After 2 months of dry needling, the patient demonstrated clinically meaningful improvements in pain and quality of life, which included a decrease in both medication usage and the frequency of sinus infections. CONCLUSION: Although CRS is generally managed medically, we observed areas of muscular tenderness in this case, which were effectively managed with dry needling. Rehabilitative providers may consider screening CRS patients for muscular impairments that may be modifiable with dry needling. Further research should be performed to determine whether dry needling has a role in the management of CRS.

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BACKGROUND: Physical therapy for neck and low back pain is highly variable despite the availability of clinical practice guidelines (CPG). This review aimed to determine the impact of CPG implementation on patient-level outcomes for spinal pain. Implementation strategies were also examined to determine prevalence and potential impact. METHODS: Multiple databases were searched through April 2021 for studies assessing CPG implementation in physical therapy for neck and low back pain. Articles were screened for eligibility. The Modified Downs and Black checklist was utilized to determine study quality. Due to the heterogeneity between studies, a meta-analysis was not performed. RESULTS: Twenty-one studies were included in this review. Implementation strategies were significantly varied between studies. Outcomes pertaining to healthcare utilization, pain, and physical functioning were assessed in relation to the implementation of CPGs. Multiple implementation strategies were identified, with Managing Quality as the most frequently utilized key implementation process. Findings indicate CPG implementation decreased healthcare utilization, but inconsistent results were found with physical functioning and pain outcomes. CONCLUSIONS: CPG implementation appears to have a beneficial effect on healthcare utilization outcomes, but may not impact pain and physical functioning outcomes. Effective CPG implementation strategies remain unknown, though utilizing implementation framework may improve outcomes. More research is needed to determine the most effective implementation strategies and effects on pain and physical function outcomes.

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BACKGROUND: Studies consistently suggest that work as a physical therapist is associated with burnout, yet no review of the contributing factors has been conducted. OBJECTIVE: To identify and examine the risk factors associated with physical therapist burnout. DATA SOURCES: PubMed, Embase, CINAHL, and the Cochrane Library were searched from inception to May 2020. ELIGIBILITY CRITERIA: Quantitative studies of physical therapists in clinical practice who experience burnout symptoms or syndrome. DATA EXTRACTION AND DATA SYNTHESIS: Risk factors such as characteristics of the participant, environment, structures, and experiences that demonstrate a significant predisposition to burnout were extracted. The modified Downs and Black checklist was used to identify risk of bias. RESULTS: Forty-six studies (8717 participants) were included. The risk of bias assessment determined all were of fair or poor quality. Fifty-three risk factors were identified, with four being classified as unavoidable and forty-nine determined as avoidable. The avoidable risk factors were further categorized as either structural/organizational (32%), psychological/emotional (19%), environmental (19%), or sociodemographic (13%). LIMITATIONS: A risk factor's importance may not correlate with its prevalence, and the low-quality studies limit the ability to make definitive conclusions. CONCLUSION: A significant amount of literature has identified a wide variety of risk factors. The majority are avoidable, and the effect and degree to which each risk factor contributes to burnout varies. The identified risk factors can help develop targeted prevention and intervention strategies for the benefit of physical therapists, organizations, and policymakers. FUNDING: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO CRD42020136356.

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Distance running is a popular youth sport. This systematic review identified and examined the effects of youth distance running and lower extremity musculoskeletal injury. Scientific databases were searched from database inception to May 2020. Two hundred and fifty-eight full texts were screened, with nine articles retained for data extraction. Seven of the studies were case reports or case series. Two case reports involved an apophyseal hip fracture. No correlation was found between running mileage or gender and sustaining an injury. Middle school runners reported fewer injuries than high school runners. Cross country accounted for less than 10% of injuries in youth under 15 compared to other track activities. The main finding was a paucity of research. Available literature suggests youth can participate in distance running with minimal adverse effects. One exception may be increased vulnerability to growth plate injury. Additional research is needed, especially in those under 10, as literature in this population is nonexistent.

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OBJECTIVE: The purpose of this systematic review is to identify and summarise the social determinants of health (SDH) cited in the literature and evaluate their association with individuals using physical therapy services. DESIGN: A systematic review using qualitatively synthesised information to describe the association between SDH and physical therapy use. DATA SOURCES: The electronic databases Medline, Embase and Scopus were searched from inception to February 2021, identifying observational and qualitative studies. ELIGIBILITY CRITERIA: Published studies included all adults, aged 18 or older, who independently sought to use physical therapy, in all practice settings from all geographical locations. RESULTS: Of the 9248 studies screened, 36 met the inclusion criteria for the review. The participants represented 8 countries and totaled 2 699 437. The majority of the papers reported moderate strength of association for each SDH. Female gender, non-Hispanic white race/ethnicity, increased education attainment, urban environment, access to transportation, employment, high socioeconomic status and private insurance were associated with higher likelihood of physical therapy use. CONCLUSION: This systematic review identifies predisposing and enabling factors impacting physical therapy usage among adults in different countries and across physical therapy settings. The results of this study have implications for policy and future research regarding populations that have been shown to be using physical therapy services less, such as those with lower levels of education, those in a rural area, or those in a low socioeconomic class.

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OBJECTIVES: To determine the relationship between health care use and the magnitude of change in patient-reported outcomes in individuals who received treatment for subacromial pain syndrome. The secondary objective was to determine the value of care, as measured by change in pain and disability per dollar spent. DESIGN: Secondary analysis of a randomized clinical trial that investigated the effects of nonsurgical care for subacromial pain syndrome. METHODS: Two groups of treatment responders were created, based on 1-year change in Shoulder Pain and Disability Index (SPADI) score (high, 46.83 points; low, 8.21 points). Regression analysis was performed to determine the association between health care use and 1-year change in SPADI score. Baseline SPADI score was used as a covariate in the regression analysis. Value was measured by comparing health care visits and costs expended per SPADI 1-point change between responder groups. RESULTS: Ninety-eight patients were included; 38 were classified as high responders (mean 1-year SPADI change score, 46.83 points) and 60 were classified as low responders (1-year SPADI change score, 8.21 points). Neither unadjusted medical visits (5.89; 95% confidence interval [CI]: 4.35, 7.44 versus 6.30; 95% CI: 5.14, 7.46) nor medical costs ($1404.86; 95% CI: $1109.34, $1779.09 versus $1679.26; 95% CI: $1391.54, $2026.48) were significantly different between high and low responders, respectively. CONCLUSION: Neither the number of visits nor the financial cost of nonsurgical shoulder- related care was associated with improvement in shoulder pain and disability at 1 year. J Orthop Sports Phys Ther 2020;50(11):642-648. doi:10.2519/jospt.2020.9440.

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BACKGROUND: It remains unclear as to what factors influence a patient's choice to seek care from a specific healthcare provider for low back and neck pain. OBJECTIVE: Utilize Andersen's Behavioral Model of Health Service Utilization as a conceptual framework to identify the predisposing, enabling and need factors associated with choice of healthcare provider for back and/or neck pain. METHODS: PubMed, CINAHL, EMBASE, and SCOPUS databases were searched for studies that included 1) patients seeking care for acute or chronic low back or neck pain; 2) patients at least 18 years of age; 3) reported any healthcare provider type chosen to be seen. Significant factors addressing a patient's choice of provider seen for back pain, neck pain, or both were extracted from studies and analyzed under the Behavioral Model of Health Service Utilization. RESULTS: 20 studies were included in this review: 17 quantitative studies and 3 qualitative studies. Provider types identified were medical physicians, chiropractors, physical therapists, acupuncturists and CAM providers. Age and sex were the most commonly reported predisposing factors; financial and personal factors were the most common enabling factors; patients' duration of pain and self-reported level of functioning were the most commonly reported need factors. CONCLUSIONS: While predisposing and need factors are important, enabling factors also have an influence in choice of healthcare provider for back and/or neck pain.

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BACKGROUND: The effectiveness of blood flow restriction training (BFRT) as compared with other forms of training, such as resistance training, has been evaluated in the literature in clinical and nonclinical populations. However, the safety of this intervention has been summarized only in healthy populations and not in clinical populations with musculoskeletal disorders. PURPOSE: To evaluate the safety and adverse events associated with BFRT in patients with musculoskeletal disorders. STUDY DESIGN: Systematic review. METHODS: A literature search was conducted with 3 online databases (MEDLINE, CINAHL, and Embase). Eligibility criteria for selecting studies were as follows: (1) BFRT was used as a clinical intervention, (2) study participants had a disorder of the musculoskeletal system, (3) authors addressed adverse events, (4) studies were published in English, and (5) the intervention was performed with human participants. RESULTS: Nineteen studies met eligibility criteria, with a pooled sample size of 322. Diagnoses included various knee-related disorders, inclusion body myositis, polymyositis or dermatomyositis, thoracic outlet syndrome, Achilles tendon rupture, and bony fractures. Nine studies reported no adverse events, while 3 reported rare adverse events, including an upper extremity deep vein thrombosis and rhabdomyolysis. Three case studies reported common adverse events, including acute muscle pain and acute muscle fatigue. In the randomized controlled trials, individuals exposed to BFRT were not more likely to have an adverse event than individuals exposed to exercise alone. Of the 19 studies, the adverse events were as follows: overall, 14 of 322; rare overall, 3 of 322; rare BFRT, 3 of 168; rare control, 0 of 154; any adverse BFRT, 10 of 168; any adverse control, 4 of 154. A majority of studies were excluded because they did not address safety. CONCLUSION: BFRT appears to be a safe strengthening approach for knee-related musculoskeletal disorders, but further research is needed to make definitive conclusions and to evaluate the safety in other musculoskeletal conditions. Improved definitions of adverse events related to BFRT are needed to include clear criteria for differentiating among common, uncommon, and rare adverse events. Finally, further research is needed to effectively screen who might be at risk for rare adverse events.

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OBJECTIVE: To systematically determine the specific impact of therapeutic alliance (TA) on chronic musculoskeletal pain, identify factors influencing TA between physical therapists and patients with chronic musculoskeletal pain, and determine the working definition of TA across studies. Data Sources: Databases, including PubMed, CINHAL, and Embase, were searched from inception to January 2017. Study Selection: The initial search resulted in 451 papers. After screening, seven studies were identified that examined the role of TA on chronic pain (> 12 weeks) management in physical therapy settings. Data Extraction: Authors extracted data into tables. Risk of bias was assessed using Cochrane Collaboration methodology. Data Synthesis: Three studies examined the influence of a strong TA coupled with physical therapy on pain outcomes. Four studies identified factors that positively and negatively influenced TA. The working definition of TA was identified in each study. Conclusions: Emerging evidence suggests that for individuals participating in physical therapy for chronic musculoskeletal pain, a strong TA may improve pain outcomes. In order to facilitate a strong TA, physical therapists must understand factors that positively and negatively influence the relationship. Studies demonstrate that the definition of TA remains consistent as it transitions to the physical therapy setting.

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OBJECTIVE: To synthesize literature about the effect of early physical therapy (PT) for acute low back pain (LBP) on subsequent health services utilization (HSU), compared to delayed PT or usual care. DATA SOURCES: Electronic databases (MEDLINE, CINAHL, Embase) were searched from their inception to May 2018. STUDY SELECTION: Study selection included randomized control trials and prospective and retrospective cohort studies that investigated the association between early PT and HSU compared to delayed PT or usual care. Two independent authors screened titles, abstracts, and full-text articles for inclusion based on eligibility criteria, and a third author resolved discrepancies. Eleven out of 1146 articles were included. DATA EXTRACTION: Two independent reviewers extracted data on participants, timing of PT, comparisons to delayed PT or usual care, and downstream HSU, and a third reviewer assessed the information to ensure accuracy and reach consensus. Risk of bias was assessed with the Downs and Black checklist using the same method. DATA SYNTHESIS: Eleven studies met eligibility criteria. Early PT is within 30 days of the index visit for acute LBP. Five out of 6 studies that compared early PT to delayed PT found that early PT reduces future HSU. Random effects meta-analysis indicated a significant reduction in opioid use, spine injection, and spine surgery. Five studies compared early PT to usual care and reported mixed results. CONCLUSIONS: Early PT for acute LBP may reduce HSU, cost, and opioid use, and improve health care efficiency. This review may assist patients, health care providers, health care systems, and third-party payers in making decisions for the treatment of acute LBP.

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