Key Points Question Is the transition from acute to chronic low back pain (LBP) associated with risk strata, defined by a standardized prognostic tool, and/or with early exposure to guideline nonconcordant care? Findings In this cohort study of 5233 patients with acute LBP from 77 primary care practices, nearly half the patients were exposed to at least 1 guideline nonconcordant recommendation within the first 21 days after the index visit. Patients were significantly more likely to transition to chronic LBP as their risk on the prognostic tool increased and as they were exposed to more nonconcordant recommendations. Meaning In this study, the transition rate to chronic LBP was substantial and increased correspondingly with risk strata and early exposure to guideline nonconcordant care.

Background: Many patients with acute low back pain (LBP) first seek care from primary care physicians. Evidence is lacking for interventions to prevent transition to chronic LBP in this setting. We aimed to test if implementation of a risk-stratified approach to care would result in lower rates of chronic LBP and improved self-reported disability. Methods: We conducted a pragmatic, cluster randomized trial using 77 primary care clinics in four health care systems across the United States. Practices were randomly assigned to a stratified approach to care (intervention) or usual care (control). Using the STarTBack screening tool, adults with acute LBP were screened low, medium, and high-risk. Patients screened as high-risk were eligible. The intervention included electronic best practice alerts triggering referrals for psychologically informed physical therapy (PIPT). PIPT education was targeted to community clinics geographically close to intervention primary care clinics. Primary outcomes were transition to chronic LBP and self-reported disability at six months. Trial Registry: Clini-calTrials.gov NCT02647658 Findings: Between May 2016 and June 2018, 1207 patients from 38 intervention and 1093 from 37 control practices were followed. In the intervention arm, around 50% of patients were referred for physical therapy (36% for PIPT) compared to 30% in the control. At 6 months, 47% of patients reported transition to chronic LBP in the intervention arm (38 practices, n = 658) versus 51% of patients in the control arm (35 practices, n = 635; OR=0.83 95% CI 0.64, 1.09; p = 0.18). No differences in disability were detected (difference -2¢1, 95% CI -4.9À0.6; p = 0.12). Opioids and imaging were prescribed in 22%À25% and 23%À26% of initial visits, for intervention and control, respectively. Twelve-month LBP utilization was similar in the two groups. Interpretation: There were no differences detected in transition to chronic LBP among patients presenting with acute LBP using a stratified approach to care. Opioid and imaging prescribing rates were non-concordant with clinical guidelines.

Objective: To characterize physical activity (PA) in individuals with rheumatoid arthritis (RA) and determine the associations between PA participation in light to moderate intensities and cardiovascular risk factors, disability, and disease activity. Methods: Cross-sectional study using data from two RA cohorts. PA was measured using an accelerometry-based activity monitor, and characterized as minutes/day in sedentary (≤1 metabolic equivalent-MET), very light (1.1–1.9 METs), light (2–2.9 METs), and moderate activities (≥3 METs). Cardiovascular markers included body mass index, blood pressure, insulin resistance, and lipid profile. Disability and disease activity were measured with the Health Assessment Questionnaire (HAQ) and Disease Activity Score-28 (DAS-28), respectively. Associations between PA at each intensity and health-markers were assessed by multiple linear regression models adjusted by age, sex, and cohort. Results: Ninety-eight subjects (58 ± 9 years, 85% female) were included. Subjects spent 9.8 hours/day being sedentary, 3.5 hours/day in very light PA, 2.1 hours/day in light PA and 35 minutes/day in moderate PA. Only 17% were physically active (≥150 minutes/week of moderate PA in 10-minute bouts). Regression models showed that very light, light and moderate PA were inversely associated with most cardiovascular risk factors, the HAQ, and DAS-28 scores (R2Δrange: .04 to .52, p <.05). The associations between PA and cardiovascular markers were either equivalent or stronger at very light- and light-intensities as compared to moderate-intensity. Conclusions: Individuals with RA are mostly active at very light and light intensities. PA at these intensities associate favorably with cardiovascular markers, and lower disability and disease activity in RA.

Objective: Describe patient and physician characteristics, and physician recommendations for ambulatory care visits for dizziness in the US. Study Design: Cross-sectional analysis of visits for dizziness from the National Ambulatory Medical Care Survey (2013–2015). Setting: Ambulatory care clinics in the US. Patients: 20.6 million weighted adult visits [mean age 58.7 (1.0)] for dizziness, identified using ICD-9-CM codes (386.00–386.90, 780.40). Main Outcome Measures: Patient, clinical, and physician characteristics and physician diagnostic and treatment recommendations. Prevalence rates for benign paroxysmal positional vertigo (BPPV), unspecified dizziness, and other vestibular disorders were estimated, and descriptive statistics were used to characterize patients, physicians, and physicians’ recommendations. Results: The prevalence rate for dizziness visits was 8.8 per 1,000 (95% confidence interval [CI]: 7.5, 10.3). Most visits were for unspecified dizziness (75%), made by women (65%), whites (79%), and were insured by private insurance (50%). Visits for dizziness were to primary care physicians (51.9%), otolaryngologists (13.3%), and neurologists (9.6%). Imaging was ordered and medication prescription was provided in 5.5% and 20.1% of visits. Physical therapy (PT) was used for a higher percentage of BPPV visits (12.9%), than for other diagnoses (<1.0%). Physician treatment recommendations for vestibular diagnoses varied by physician specialty. Conclusions: A large percentage of visits had an unspecified diagnosis. A low number of visits for vestibular disorders were referred to PT. There are opportunities to improve care by using specific diagnoses and increasing the utilization of effective interventions for vestibular disorders.

SYNOPSIS Osteoarthritis (OA) and type 2 diabetes mellitus (T2DM) often co-exist in older adults. There is increased susceptibility to develop arthritis in those with T2DM, which is supported by observations of higher prevalence of arthritis in those with T2DM (52%) compared to those without it (27%). The association between OA and T2DM has been traditionally attributed to underlying shared risk factors of age and obesity. Emerging evidence suggests that alterations in lipid metabolism and hyperglycemia might have a direct impact on cartilage health and subchondral bone that contribute to the development and/or progression of OA. Adequate management of older persons with both OA and T2DM benefits from a comprehensive understanding of the risk factors associated with these diseases. In this review, we discuss common risk factors and emerging underlying links between OA and T2DM, and emphasize the importance of physical activity to improve metabolism and decrease disability and pain in this population. Implications for safe and effective physical activity approaches in older patients with OA and T2DM are also discussed.

Key Points Question Can exercise programs delivered at a later stage (>2 months) after total knee replacement improve the functional limitations that persist after surgery? Findings In this randomized clinical trial of 240 individuals at a later stage after knee replacement, all arms (physical therapy, community, and control) improved physical function. There were no differences between arms in the primary outcome of patient-reported physical function, whereas the secondary outcome of performance-based physical function demonstrated greater improvement in the physical therapy arm. Meaning While the primary outcome suggests no benefit of later-stage exercise programs, the secondary outcomes suggest beneficial effects of physical therapy but require confirmation.

Objective. To describe and compare triennial rates of physicians' recommendations for physical therapy (PT), lifestyle counseling, and pain medication for knee osteoarthritis (OA) and to identify patient, physician, and practice factors associated with each treatment recommendation.Methods. We conducted a cross-sectional analysis examining data between 2007 and 2015 from the National Ambulatory Medical Care Survey. Visits to orthopedists and primary care physicians for knee OA were identified and assessed for the following: PT referral, lifestyle counseling, nonsteroidal antiinflammatory drug (NSAID) prescriptions, and narcotics prescriptions. Triennial rates for each treatment were calculated. We examined associations between patient (e.g., race, insurance), physician, and practice factors (e.g., ownership, location) and treatments prescribed using multivariate logistic regression that accounted for complex sampling design.Results. A total of 2,297 physician visits related to knee OA (~67 [±4] million weighted visits) were identified. For visits to orthopedists, PT and lifestyle recommendation rates declined (158 to 88 of 1,000 visits and 184 to 86 of 1,000 visits, respectively), while NSAID and narcotics prescriptions increased (132 to 278 of 1,000 visits and 77 to 236 of 1,000 visits, respectively) over time (P < 0.05). For visits to primary care physicians, there were no significant changes in rates of PT, lifestyle counseling, and narcotics prescriptions over time, while NSAIDs prescriptions increased (221 to 498 of 1,000 visits; P < 0.05). Treatment recommendations were associated with nonclinical factors, including practice type, location, and type of provider.Conclusion. In patients with knee OA, PT and lifestyle counseling seem underutilized, while pain medication prescriptions increased during the investigated timeframe. Variation in treatment choices were associated with nonclinical factors. Future research is necessary to examine ways to improve PT and lifestyle utilization and reduce variation in care for knee OA.

Both NMES and high-intensity volitional resistance training can be used as effective approaches to improve muscle structure and function in RA. NMES may be a viable alternative to promote muscle function for patients in whom high-intensity resistance exercise may not be tolerated or is contra-indicated, but attrition needs to be considered when using this approach. This article is protected by copyright. All rights reserved.