Browsing by Author "Bishop, Mark D"

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Open Access
A value proposition for early physical therapist management of neck pain: a retrospective cohort analysis.
(BMC Health Serv Res, 2016-07-12) Horn, Maggie E; Brennan, Gerard P; George, Steven Z; Harman, Jeffrey S; Bishop, Mark D
BACKGROUND: Neck pain is one of the most common reasons for entry into the healthcare system. Recent increases in healthcare utilization and medical costs have not correlated with improvements in health. Therefore there is a need to identify management strategies for neck pain that are effective for the patient, cost efficient for the payer and provided at the optimal time during an episode of neck pain. METHODS: One thousand five hundred thirty-one patients who underwent physical therapist management with a primary complaint of non-specific neck pain from January 1, 2008 to December 31, 2012 were identified from the Rehabilitation Outcomes Management System (ROMS) database at Intermountain Healthcare. Patients reporting duration of symptoms less than 4 weeks were designated as undergoing "early" management and patients with duration of symptoms greater than 4 weeks were designated as receiving "delayed" management. These groups were compared using binary logistic regression to examine odds of achieving Minimal Clinically Important Difference (MCID) on the Neck Disability Index (NDI) and Numerical Pain Rating Scale (NPRS). Separate generalized linear modeling examined the effect of timing of physical therapist management on the metrics of value and efficiency. RESULTS: Patients who received early physical therapist management had increased odds of achieving MCID on the NDI (aOR = 2.01, 95 % CI 1.57, 2.56) and MCID on the NPRS (aOR = 1.82, 95 % CI 1.42, 2.38), when compared to patients receiving delayed management. Patients who received early management demonstrated the greatest value in decreasing disability with a 2.27 percentage point change in NDI score per 100 dollars, best value in decreasing pain with a 0.38 point change on the NPRS per 100 dollars. Finally, patients receiving early management were managed more efficiently with a 3.44 percentage point change in NDI score per visit and 0.57 point change in NPRS score per visit. CONCLUSIONS: These findings suggest that healthcare systems that provide pathways for patients to receive early physical therapist management of neck pain may realize improved patient outcomes, greater value and higher efficiency in decreasing disability and pain compared to delayed management. Further research is needed to confirm this assertion.
Open Access
Clinical Outcomes, Utilization, and Charges in Persons With Neck Pain Receiving Guideline Adherent Physical Therapy.
(Eval Health Prof, 2016-12) Horn, Maggie E; Brennan, Gerard P; George, Steven Z; Harman, Jeffrey S; Bishop, Mark D
In efforts to decrease practice variation, clinical practice guidelines for neck pain have been published. The purpose of this study was to determine the effect of receiving guideline adherent physical therapy (PT) on clinical outcomes, health care utilization, and charges for health care services in patients with neck pain. A retrospective review of 298 patients with neck pain receiving PT from 2008 to 2011 was performed. Clinical outcomes, utilization, and charges were compared between patients who received guideline adherent care and nonadherent care. Patients in the adherent care group experienced a lower percentage improvement in pain score compared to nonadherent care group (p = .01), but groups did not significantly differ on percentage improvement in disability (p = .32). However, patients receiving adherent care had an average 3.6 fewer PT visits (p < .001) and less charges for PT (p < .001). Additionally, patients receiving adherent care had 7.3 fewer visits to other health care providers (p < .001), one less prescription medication (p = .02) and 43% fewer diagnostic images (p = .02) but did not differ in their charges to other health care providers (p = .68) during the calendar year of undergoing PT. Although receiving guideline adherent care demonstrated positive effects on health care utilization and financial outcomes, there appears to be a trade-off with clinical outcomes.
Open Access
Description of Common Clinical Presentations and Associated Short-Term Physical Therapy Clinical Outcomes in Patients With Neck Pain.
(Arch Phys Med Rehabil, 2015-10) Horn, Maggie E; Brennan, Gerard P; George, Steven Z; Harman, Jeffrey S; Bishop, Mark D
OBJECTIVE: To determine the effect of clinical presentations of neck pain on short-term physical therapy outcomes. DESIGN: Retrospective analysis of pair-matched groups from a clinical cohort. SETTING: Thirteen outpatient physical therapy clinics in 1 health care system. PARTICIPANTS: Patients (N=1069) grouped by common clinical presentations of neck pain: nonspecific neck pain (NSNP) with duration <4 weeks; NSNP with duration >4 weeks; neck pain with arm pain; neck pain with headache; and neck pain from whiplash. INTERVENTION: Conservative interventions provided by physical therapists. MAIN OUTCOME MEASURES: Neck Disability Index (NDI) and numerical pain rating scale (NPRS) recorded at the initial and last visits. The main outcome of interest was achieving recovery status on the NDI. Changes in NDI and NPRS were compared between clinical presentation groups. RESULTS: Compared with patients presenting with NSNP >4 weeks, patients with NSNP <4 weeks had increased odds of achieving recovery status on the NDI (P<.0001) and demonstrated the greatest changes in clinical outcomes of pain (P≤.0001) and disability (P≤.0001). Patients with neck pain and arm pain demonstrated an increased odds of achieving recovery status on the NDI (P=.04) compared with patients presenting with NSNP >4 weeks. CONCLUSIONS: Treating patients with NSNP within <4 weeks of onset of symptoms may lead to improved clinical outcomes from physical therapy compared with other common clinical presentations.
Open Access
Effect of a single session of muscle-biased therapy on pain sensitivity: A systematic review and meta-analysis of randomized controlled trials
(Journal of Pain Research, 2013-03-12) Gay, Charles W; Alappattu, Meryl J; Coronado, Rogelio A; Horn, Maggie E; Bishop, Mark D
Background: Muscle-biased therapies (MBT) are commonly used to treat pain, yet several reviews suggest evidence for the clinical effectiveness of these therapies is lacking. Inadequate treatment parameters have been suggested to account for inconsistent effects across studies. Pain sensitivity may serve as an intermediate physiologic endpoint helping to establish optimal MBT treatment parameters. The purpose of this review was to summarize the current literature investigating the short-term effect of a single dose of MBT on pain sensitivity in both healthy and clinical populations, with particular attention to specific MBT parameters of intensity and duration. Methods: A systematic search for articles meeting our prespecified criteria was conducted using Cumulative Index to Nursing and Allied Health Literature (CINAHL) and MEDLINE from the inception of each database until July 2012, in accordance with guidelines from the Preferred Reporting Items for Systematic reviews and Meta-Analysis. Relevant characteristics from studies included type, intensity, and duration of MBT and whether short-term changes in pain sensitivity and clinical pain were noted with MBT application. Study results were pooled using a random-effects model to estimate the overall effect size of a single dose of MBT on pain sensitivity as well as the effect of MBT, dependent on comparison group and population type. Results: Reports from 24 randomized controlled trials (23 articles) were included, representing 36 MBT treatment arms and 29 comparative groups, where 10 groups received active agents, 11 received sham/inert treatments, and eight received no treatment. MBT demonstrated a favorable and consistent ability to modulate pain sensitivity. Short-term modulation of pain sensitivity was associated with short-term beneficial effects on clinical pain. Intensity of MBT, but not duration, was linked with change in pain sensitivity. A meta-analysis was conducted on 17 studies that assessed the effect of MBT on pressure pain thresholds. The results suggest that MBT had a favorable effect on pressure pain thresholds when compared with no-treatment and sham/inert groups, and effects comparable with those of other active treatments. Conclusion: The evidence supports the use of pain sensitivity measures by future research to help elucidate optimal therapeutic parameters for MBT as an intermediate physiologic marker. © 2013 Artner et al, publisher and licensee Dove Medical Press Ltd.
Open Access
Exercise-induced pain intensity predicted by pre-exercise fear of pain and pain sensitivity.
(Clin J Pain, 2011-06) Bishop, Mark D; Horn, Maggie E; George, Steven Z
OBJECTIVES: Our primary goals were to determine whether preexisting fear of pain and pain sensitivity contributed to post-exercise pain intensity. METHODS: Delayed-onset muscle pain was induced in the trunk extensors of 60 healthy volunteers using an exercise paradigm. Levels of fear of pain and experimental pain sensitivity were measured before exercise. Pain intensity in the low back was collected at 24 and 48 hours post-exercise. Participants were grouped based on pain intensity. Group membership was used as the dependent variable in separate regression models for 24 and 48 hours. Predictor variables included fear, pain sensitivity, torque lost during the exercise protocol, and demographic variables. RESULTS: The final models predicting whether a participant reported clinically meaningful pain intensity at 24 hours only included baseline fear of pain at each level of pain intensity tested. The final model at 48 hours included average baseline pain sensitivity and the loss of muscle performance during the exercise protocol for 1 level of pain intensity tested (greater than 35 mm of 100 mm). DISCUSSION: Combined, these findings suggest that the initial reports of pain after injury may be more strongly influenced by fear whereas the inflammatory process and pain sensitivity may play a larger role for later pain intensity reports.
Open Access
Magnitude of spinal muscle damage is not statistically associated with exercise-induced low back pain intensity.
(Spine J, 2011-12) Bishop, Mark D; Horn, Maggie E; Lott, Donovan J; Arpan, Ishu; George, Steven Z
BACKGROUND CONTEXT: Findings on imaging of noncontractile anatomic abnormalities and the intensity of low back pain have weak associations because of false-positive rates among asymptomatic individuals. This association might be stronger for contractile tissues. PURPOSE: The purpose of this study was to examine the relationship between location and reports of pain intensity in the low back and exercise-induced muscle damage to the lumbar paraspinal muscles. STUDY DESIGN: Nondiagnostic observational study in a laboratory setting. METHODS: Delayed onset muscle soreness was induced in the low back of healthy pain-free volunteers. Measures of pain intensity (100-mm visual analog scale [VAS]) and location (area on the pain diagram) were taken before and 48 hours after exercise. Muscle damage was quantified using mechanical pain thresholds, motor performance deficits, and transverse relaxation time (T2)-weighted magnetic resonance imaging (MRI). Changes pre- to postexercise in signal intensity on T2-weighted imaging within the erector spinae, pain intensity, pain area, mechanical pain threshold, and isometric torque were assessed using paired t tests. Bivariate correlations were conducted to assess associations among muscle damage, pain intensity, and pain drawing area. RESULTS: Twenty participants volunteered (11 women; average age, 22.3 years; average body mass index, 23.5) for study participation. Reports of pain intensity at 48 hours ranged from 0 to 59 mm on the VAS. Muscle damage was confirmed by reductions in mechanical threshold (p=.011) and motor performance (p<.001) and by changes in T2-weighted MRI (p=.007). This study was powered to find an association of at least r=0.5 to be statistically significant. Correlations of continuous variables revealed no significant correlations between pain intensity and measures of muscle damage (ranging between -0.075 and 0.151). There was a significant association between the remaining torque deficit at 48 hours and pain area. CONCLUSIONS: The results of this study indicate that there was no association between the magnitude of muscle damage in the lumbar erector spinae and reported pain intensity in the low back. In future studies, larger cohorts may report statistically significant associations, but our data suggest that there will be low magnitude potentially indicating limited clinical relevance.
Open Access
Relationship of intersession variation in negative pain-related affect and responses to thermally-evoked pain.
(J Pain, 2010-02) Bishop, Mark D; Craggs, Jason G; Horn, Maggie E; George, Steven Z; Robinson, Michael E
UNLABELLED: The purpose of this study was to determine whether session-specific measures of negative pain-related affect would account for longitudinal variability in the ratings of the evoked thermal pain. Pain-free subjects rated pain evoked on the posterior leg using thermal stimuli of 45 degrees , 47 degrees , 49 degrees , and 51 degrees C on 3 occasions, each separated by 2 weeks. Session-specific negative pain-related affect measures were also collected. Ratings of pain decreased significantly with repeated testing, demonstrating a systematic change in rating from the first to second sessions that ranged from a mean of 5.3 at 47 degrees C to 9.1 at 49 degrees C. In addition, large random variation occurred across all sessions, resulting in minimal detectable change ranging from 14 to 27. The least variability occurred when a mean rating of the 4 temperatures was used. Session-specific measures of pain-related affect decreased with repeated testing; however, the significant between-subject variability in both rating of pain and pain-related affect were not related to each other. No associations were identified between psychological measures and variability in rating of evoked pain. Future studies of the variability in ratings should consider other factors such as attentional focus. PERSPECTIVE: The individual variability in thermal rating was not explained by individual variation in session-specific measures of negative pain-related affect. The results of this study support the use of repeated baseline measures of thermal stimuli when feasible. When this is not possible, the variability in ratings of thermal stimuli over multiple sessions is reduced when the mean of multiple temperatures is used.
Open Access
Self-reported pain and disability outcomes from an endogenous model of muscular back pain.
(BMC Musculoskelet Disord, 2011-02-02) Bishop, Mark D; Horn, Maggie E; George, Steven Z; Robinson, Michael E
BACKGROUND: Our purpose was to develop an induced musculoskeletal pain model of acute low back pain and examine the relationship among pain, disability and fear in this model. METHODS: Delayed onset muscle soreness was induced in 52 healthy volunteers (23 women, 17 men; average age 22.4 years; average BMI 24.3) using fatiguing trunk extension exercise. Measures of pain intensity, unpleasantness, and location, and disability, were tracked for one week after exercise. RESULTS: Pain intensity ranged from 0 to 68 with 57.5% of participants reporting peak pain at 24 hours and 32.5% reporting this at 48 hours. The majority of participants reported pain in the low back with 33% also reporting pain in the legs. The ratio of unpleasantness to intensity indicated that the sensation was considered more unpleasant than intense. Statistical differences were noted in levels of reported disability between participants with and without leg pain. Pain intensity at 24 hours was correlated with pain unpleasantness, pain area and disability. Also, fear of pain was associated with pain intensity and unpleasantness. Disability was predicted by sex, presence of leg pain, and pain intensity; however, the largest amount of variance was explained by pain intensity (27% of a total 40%). The second model, predicting pain intensity only included fear of pain and explained less than 10% of the variance in pain intensity. CONCLUSIONS: Our results demonstrate a significant association between pain and disability in this model in young adults. However, the model is most applicable to patients with lower levels of pain and disability. Future work should include older adults to improve the external validity of this model.