Subjective and objective descriptors of clinical lumbar spine instability: A Delphi study

Manual therapists' appraisal of optimal non-pharmacological conservative management of patients with lumbar spinal stenosis. An international Delphi study

BACKGROUND

Lumbar Spinal Stenosis (LSS) is a slow progressive degenerative disorder associated with chronic pain and disability. Although consensus-based international guidelines for invasive treatment of patients with LSS exist, few consensus-based guidelines for optimal conservative management strategies have been published.

OBJECTIVE

To achieve manual therapists' consensus on optimal physiotherapeutic management strategies for LSS.

METHODS

The study employed a three-round, email-based International Delphi survey. All qualified members of the International Maitland Teacher Association (IMTA) (n = 30) were invited to participate.

RESULTS

Twelve IMTA teachers participated in the study. Eight essential physiotherapy management strategies were identified, as follows: 1. Detailed assessment with in-depth interview; 2. Recognition of red flags, contraindications and precautions; 3. Neurological examination; 4. Postural and movement analysis with related ergonomics; 5. Functional analysis; 6. Individualized treatment based on assessment findings and research evidence; 7. Aerobic training and 8. Patient education.

CONCLUSION

This Delphi survey provides a foundation for physiotherapists to individualize and optimise management approaches for patients with LSS. With a growing elderly population, there is an increasing need for evidence-based conservative management guidelines based on high quality research.

Interrater reliability of the modified prone instability test for lumbar segmental instability in individuals with mechanical low back pain

OBJECTIVE

The purpose of this study was to establish the interrater reliability of measures obtained with a novel Modified Prone Instability Test (mPIT), which, like the original Prone Instability Test (PIT), is proposed to identify lumbar segmental instability. The mPIT has clinical feasibility advantages to the PIT, but its psychometric properties are yet to be determined.

DESIGN

Repeated measures (test-retest) design, methods study.

METHODS

The mPIT was administered by two blinded testers, an orthopedic physical therapy resident with < 1 year experience and board-certified orthopedic specialist physical therapist with >25 years' experience. Procedures were administered at an outpatient physical therapy clinic of a tertiary Medical Center. Participants included 50 adults (≥18 years old) with mechanical low back pain and no radicular (below the knee) symptoms (mean age 50.7 years, 66% female, 76% reported previous episodes of low back pain). Interrater reliability was measured via Fleiss' kappa coefficient.

RESULTS

Assessments of the mPIT had moderate interrater agreement (κ = .579 [95% CI = .302 to .856], p < .001.).

CONCLUSION

Measures obtained using the mPIT demonstrated moderate interrater reliability between a new graduate and an experienced clinician, which aligns with several studies examining interrater reliability of the original PIT. Further study examining comparative validation of the mPIT with other lumbar instability measures is warranted.

Assessment of the Acute Effects of Wearable Sensor Derived Auditory Biofeedback on Gross Lumbar Proprioception

Lower back disorders (LBDs) affect a large proportion of the population, and treatment for LBDs have been shifting toward individualized, patient-centered approaches. LBDs are typically associated with poor proprioception. Therefore, there has been a recent uptake in the utilization of wearable sensors that can administer biofeedback in various industrial, clinical, and performance-based settings to improve lumbar proprioception. The aim of this study was to investigate whether wearable sensor-derived acute auditory biofeedback can be used to improve measures of gross lumbar proprioception. To assess this, healthy participants completed an active target repositioning protocol, followed by a training period where lumbar-spine posture referenced auditory feedback was provided for select targets. Target re-matching abilities were captured before and after acute auditory biofeedback training to extract measures related to accuracy and precision across spine flexion targets (i.e., 20%, 40%, 60%, 80% maximum). Results suggest a heterogenous response to proprioceptive training whereby certain individuals and spine flexion targets experienced positive effects (i.e., improved accuracy and precision). Specifically, results suggest that mid-range flexion targets (i.e., 40-60% maximum flexion) benefited most from the acute auditory feedback training. Further, individuals with poorer repositioning abilities in the pre-training assessment showed the greatest improvements from the auditory feedback training.

Objective and subjective measures to guide upper extremity return to sport testing: A modified Delphi survey

OBJECTIVE

To identify which subjective and objective tests do content experts utilize to help guide return to sport (RTS) decision making for an athlete after an upper extremity (UE) injury?

METHODS

A modified Delphi survey was utilized, including content experts in UE rehabilitation. Survey items were identified based on a literature review identifying current best evidence and practice for UE RTS decision making. Content experts (n = 52) were identified, having a minimum of 10 years of experience with rehabilitation of UE athletic injuries, and 5 years of experience using an UE RTS algorithm to guide decision making.

RESULTS

Expert consensus was achieved on a combination of tests utilized within an UE RTS algorithm: 1. Tissue healing time frame is an important consideration in RTS decision making; 2. Patient reported outcome measures should be utilized specifically, DASH and NPRS 3. Strength is measured by handheld dynamometer and is an important consideration. 4. ROM should be utilized and is an important consideration. 5. Physical performance tests utilized include: Closed Kinetic Chain Upper Extremity Stability test, Seated shot-put test and lower extremity/core tests.

CONCLUSIONS

This survey reached expert consensus on which subjective and objective measures to utilize to evaluate RTS readiness after UE injury.

The relationship between clinical examination measures and ultrasound measures of fascia thickness surrounding trunk muscles or lumbar multifidus fatty infiltrations: An exploratory study

Patients with chronic low back pain (CLBP) exhibit remodelling of the lumbar soft tissues such as muscle fatty infiltrations (MFI) and fibrosis of the lumbar multifidus (LuM) muscles, thickness changes of the thoracolumbar fascia (TLF) and perimuscular connective tissues (PMCT) surrounding the abdominal lateral wall muscles. Rehabilitative ultrasound imaging (RUSI) parameters such as thickness and echogenicity are sensitive to this remodelling. This experimental laboratory study aimed to explore whether these RUSI parameters (LuM echogenicity and fascia thicknesses), hereafter called dependent variables (DV) were linked to independent variables (IV) such as (1) other RUSI parameters (trunk muscle thickness and activation) and (2) physical and psychological measures. RUSI measures, as well as a clinical examination comprising physical tests and psychological questionnaires, were collected from 70 participants with LBP. The following RUSI dependent variables (RUSI-DV), measures of passive tissues were performed bilaterally: (1) LuM echogenicity (MFI/fibrosis) at three vertebral levels (L3/L4, L4/L5 and L5/S1); (2) TLF posterior layer thickness, and (3) PMCT thickness of the fasciae between subcutaneous tissue thickness (STT) and external oblique (PMCTSTT/EO ), between external and internal oblique (PMCTEO/IO ), between IO and transversus abdominis (PMCTIO/TrA ) and between TrA and intra-abdominal content (PMCTTrA/IA ). RUSI measures of trunk muscle's function (thickness and activation), also called measures of active muscle tissues, were considered as independent variables (RUSI-IV), along with physical tests related to lumbar stability (n = 6), motor control deficits (n = 7), trunk muscle endurance (n = 4), physical performance (n = 4), lumbar posture (n = 2), and range of motion (ROM) tests (n = 6). Psychosocial measures included pain catastrophizing, fear-avoidance beliefs, psychological distress, illness perceptions and concepts related to adherence to a home-based exercise programme (physical activity level, self-efficacy, social support, outcome expectations). Six multivariate regression models (forward stepwise selection) were generated, using RUSI-DV measures as dependent variables and RUSI-IV/physical/psychosocial measures as independent variables (predictors). The six multivariate models included three to five predictors, explaining 63% of total LuM echogenicity variance, between 41% and 46% of trunk superficial fasciae variance (TLF, PMCTSTT/EO ) and between 28% and 37% of deeper abdominal wall fasciae variance (PMCTEO/IO , PMCTIO/TrA and PMCTTrA/IA ). These variables were from RUSI-IV (LuM thickness at rest, activation of IO and TrA), body composition (percent fat) and clinical physical examination (lumbar and pelvis flexion ROM, aberrant movements, passive and active straight-leg raise, loaded-reach test) from the biological domain, as well as from the lifestyle (physical activity level during sports), psychological (psychological distress-cognitive subscale, fear-avoidance beliefs during physical activities, self-efficacy to exercise) and social (family support to exercise) domains. Biological, psychological, social and lifestyle factors each accounted for substantial variance in RUSI-passive parameters. These findings are in keeping with a conceptual link between tissue remodelling and factors such as local and systemic inflammation. Possible explanations are discussed, in keeping with the hypothesis-generating nature of this study (exploratory). However, to impact clinical practice, further research is needed to determine if the most plausible predictors of trunk fasciae thickness and LuM fatty infiltrations have an effect on these parameters.

Rasch analysis, reliability, and validity of the Turkish version of the Lumbar Spine Instability Questionnaire

Background/aim

Lumbar instability is an important condition that can be seen frequently in people with low back pain, affecting both the progression and the choice of appropriate exercise. The Lumbar Spine Instability Questionnaire (LSIQ) is a simple and low-cost tool for evaluating disturbed back stability in people with low back pain. The aim of this study is to develop the Turkish version of the LSIQ (LSIQ-T) and to evaluate its psychometric properties using the Rasch model.

Materials and methods

One hundred participants with chronic low back pain completed the LSIQ-T. The LSIQ-T was repeated for 30 participants after 1 week to establish its test-retest reliability. While internal and external construct validity were investigated using Rasch analysis and the Spearman correlation coefficient, respectively, reliability was evaluated in terms of internal consistency by Cronbach's alpha and the Person Separation Index (PSI).

Results

All items of the LSIQ-T were found to fit the Rasch model (chi-square: 34.07 (df = 15), p = 0.0033). The internal construct validity was good, the overall mean item fit residual was 0 (SD: 0.765), and the mean person fit residual was 0.322 (SD: 1.123). Internal consistency reliability was low with a PSI of 0.63 although Cronbach's alpha was acceptable (0.68). When the test-retest reliability was examined via differential item functioning (DIF) by time, none of the items showed DIF.

Conclusion

The LSIQ-T is a valid unidimensional scale for the Turkish population. Although the LSIQ-T had low internal consistency, it demonstrated unidimensionality and is appropriate for use. Therefore, the LSIQ-T can be used in clinical practice and scientific research.

Measurement Properties of the Simplified Chinese Version of the Lumbar Spine Instability Questionnaire for Patients With Low Back Pain in Mainland China

STUDY DESIGN

A prospective study.

OBJECTIVE

To develop a simplified Chinese version of Lumbar Spine Instability Questionnaire (SC-LSIQ) and test its measurement properties.

SUMMARY OF BACKGROUND DATA

The LSIQ has been translated into several languages. Different versions of LSIQ have proved good reliability and validity in evaluating patients with low back pain. However, there is no simplified Chinese version of LSIQ (SC-LSIQ).

MATERIALS AND METHODS

The SC-LSIQ has been translated into a simplified Chinese version according to a standard procedure. A total of 155 patients with low back pain completed the SC-LSIQ along with Oswestry Disability Index, Roland-Morris disability questionnaire, Tampa Scale for Kinesiophobia, and visual analogue scale (VAS). The internal consistency, test-retest reliability, and validity of SC-LSIQ were then calculated to evaluate the measurement properties of SC-LSIQ.

RESULTS

The results of SC-LSIQ demonstrated that there was no ceiling or floor effect detected. The Cronbach α coefficient of 0.911 determined a well internal consistency. The intraclass correlation coefficient (0.98) presented an excellent reliability of SC-LSIQ. The Pearson correlation coefficient (r) showed that the SC-LSIQ was excellent correlated to Oswestry Disability Index (r=0.809), Roland-Morris disability questionnaire (r=0.870), and Tampa Scale for Kinesiophobia (r=0.945,). Furthermore, it moderately correlated to visual analogue scale (r=0.586).

CONCLUSION

The SC-LSIQ features good internal consistency, reliability, and validity for evaluating Chinese patients with LBP. Results suggest that the SC-LSIQ can be appropriately applied to patients with LBP in routine clinical practice.

The Swedish version of the Lumbar Spine Instability Questionnaire: A clinimetric study of validity and reliability

INTRODUCTION

The Lumbar Spine Instability Questionnaire (LSIQ) is a patient-reported outcome measure (PROM) suggested to measure clinical instability of the spine.

OBJECTIVE

The aim was to translate and cross-culturally adapt the LSIQ into Swedish and to test its measurement properties.

METHODS

We included people with low back pain (LBP) seeking primary care (n = 101). The LSIQ was translated using international recommendations. Construct validity was investigated via the Roland Morris Disability Questionnaire (RM) and the Numeric Pain Rating Scale (NPRS). Reliability was tested via test-retest (Intra Class Correlation, ICC_2.1) (n = 50) and by analyzing internal consistency (Cronbach Alpha). A suggested cutoff score was used to study discriminative ability.

RESULTS

The LSIQ was successfully translated into Swedish. For construct validity, a moderate correlation was shown with the RM (rho 0.58) and the NPRS (rho 0.47). Test-retest demonstrated high reliability for the total score (ICC_2.1 0.94, 95% CI 0.86-0.96). Internal consistency reached a Cronbach Alpha of 0.64. Participants scoring higher on the LSIQ (≥9) showed significantly higher pain and lower disability levels, were of higher age and less physically active.

CONCLUSION

The Swedish LSIQ shows acceptable measurement properties regarding test-retest reliability and validity. To further study the usefulness of the LSIQ and the suggested cutoff score, the dimensionality needs to be investigated.

Cultural adaptation and psychometric assessment of the Persian version of the lumbar spine instability questionnaire

BACKGROUND

The Lumbar Spine Instability Questionnaire (LSIQ) is a self-reported measure of clinical instability of the lumbar spine. This study aimed to translate and culturally adapt the LSIQ into Persian language (LSIQ-P) and to evaluate its reliability and validity in a sample of patients with chronic non-specific low back pain (LBP).

METHODS

In a cross-sectional study, the LSIQ was translated using guidelines. Participants with chronic non-specific LBP, aged ≥ 18 years old, answered an online survey consisting of LSIQ-P, the Persian Functional Rating Index (FRI), and the pain Numeric Rating Scale (NRS). Construct validity, internal consistency reliability, test-retest reliability, standard error of measurement (SEM), smallest detectable change (SDC), discriminant validity, and factor analysis were evaluated.

RESULTS

The LSIQ was successfully adapted into Persian. A sample of 100 participants with LBP and 100 healthy subjects completed the survey. Floor and ceiling effects were not observed. Cronbach's alpha = 0.767 and ICC_agreement = 0.78 indicated good internal consistency and test-retest reliability. The SEM and SDC were 1.53 and 4.24, respectively. Construct validity of LSIQ-P was confirmed with significant correlation with Persian FRI (r = 0.44, p < 0.001) and pain NRS (r = 0.30, p = 0.003). An evidence of discriminant validity was demonstrated by significant difference in LSIQ-P total scores between the patients with LBP and healthy subjects, and between the patients with high total score ≥ 9 and those with low total score < 9 on the LSIQ-P. The LSIQ-P was found a multidimensional instrument with eight items appeared being redundant.

CONCLUSIONS

The Persian LSIQ showed satisfactory metric characteristics of reliability and validity. Further studies are required to elucidate the internal structure of the LSIQ-P.

Aberrant Lumbopelvic Movements Predict Prospective Functional Decline in Older Adults with Chronic Low Back Pain

OBJECTIVE

To investigate if clinically observable aberrant lumbopelvic movements are associated with physical function at 12-month follow-up in older adults with chronic low back pain (CLBP), both directly and indirectly through baseline physical function.

DESIGN

Secondary analysis of a yearlong prospective cohort study.

SETTING

Clinical Research Laboratory.

PARTICIPANTS

Community-dwelling older adults with CLBP (N=250).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Data from 239 participants were analyzed. Participants were screened at baseline for aberrant lumbopelvic movements during active trunk flexion; total observable aberrant movements were recorded and summed (range 0-4). Latent constructs of physical function were developed from an array of perception-based and performance-based outcome measures at baseline and 12 months, respectively. Structural Equation Modeling was used to assess the direct effect of baseline aberrant movement score on the latent construct of 12-month physical function, and its indirect effect through baseline physical function.

RESULTS

Aberrant movements were present in most participants (64.7%) and had a significant negative total effect on 12-month physical function (γ= -0.278, P<.001). Aberrant movement score's direct effect and indirect effect, through baseline functioning, were significantly negatively associated with physical function at 12-months, after adjusting for covariates (γ=-0.068, P=.038; γ= -0.210, P<.001, respectively).

CONCLUSIONS

Aberrant lumbopelvic movements are associated with decreased physical function at 12-month follow-up in older adults with CLBP, independent of baseline physical function and covariates. Future studies should evaluate if screening for aberrant movements may inform prognostic and interventional efforts in this patient population.

A diagnostic tool for people with lumbar instability: a criterion-related validity study

BACKGROUND

Several clinical tests used to identify patients with lumbar instability have reported diagnostic accuracy in separate studies with conflicting results. To augment the diagnostic process, tests that are better able to identify lumbar instability suitable for use in the clinical setting are required. The aim of this study was to identify the probability to diagnose patients with lumbar instability, using x-ray imaging as the reference standard.

METHODS

This study was a cross-sectional, diagnostic validity study. One hundred forty participants with chronic low back pain underwent an x-ray assessment and 14 clinical examinations. Data were analysed using multivariate regression methods to determine which clinical tests were most diagnostic for lumbar instability when they were applied together.

RESULTS

Eighteen (12.85%) participants had radiological lumbar instability. Three clinical tests i) interspinous gap change during flexion-extension, ii) passive accessory intervertebral movement tests, iii) posterior shear test demonstrated an ability to diagnose lumbar instability of 67% when they were all positive. At this probability threshold, sensitivity, specificity, positive likelihood ratio (+LR), and negative likelihood ratio (-LR) were 5.56, 99.18%, 6.78, and 0.95.

CONCLUSIONS

These 3 clinical tests could be useful in identifying patients with lumbar instability in the general community. These three tests are simple to perform by physical therapists, reliable to use in a clinical setting, and safe for patients. We recommend physical therapists use these three tests to assess patients who are suspected of having lumbar instability, in the absence of an x-ray assessment, to receive appropriate targeted intervention or referral for further investigation.

TRIAL REGISTRATION

Thai Clinial Trial Registry (TCTR 20180820001; 19th August 2018).

Validity of a Screening Tool for Patients with a Sub-Threshold Level of Lumbar Instability: A Cross-Sectional Study

Lumbar instability (LI) comprises one subgroup of those with chronic low back pain (CLBP); it indicates the impairment of at least one of the spinal stabilizing systems, and radiographic criteria of translation and rotation are used for its diagnosis. Previous studies have developed and tested a screening tool for LI where patients with sub-threshold lumbar instability (STLI) were detected in the initial stage of lumbar pathology using radiographs as a gold standard for diagnosis. The radiographic measurement in STLI lies between the range of translation and rotation of the LI and asymptomatic lumbar motion. However, there are no studies indicating the validity and cut-off points of the screening tool for STLI. The current study aimed to determine the validity of an LI screening tool to support the diagnostic process in patients with STLI. This study design was cross-sectional in nature. A total of 135 participants with CLBP, aged between 20 and 60 years, who had undergone flexion and extension radiographs, answered a screening tool with 14 questions. The cut-off score for identifying STLI using the screening tool was at least 6/14 positive responses to the LI questions. The findings suggested that the LI screening tool we tested is effective for the detection of STLI. The tool can be used in outpatient settings.

Development of a Screening Tool for Pediatric Neuropathic Pain and Complex Regional Pain Syndrome: Pediatric PainSCAN

OBJECTIVE

Neuropathic pain (NP) and complex regional pain syndrome (CRPS) in children can result in significant disability and emotional distress. Early assessment and treatment could potentially improve pain, function, quality of life, and reduce costs to the health care system. Currently, there are no screening tools for pediatric NP and CRPS. This research aimed to develop and establish the content validity of a screening tool for pediatric NP and CRPS using a phased approach.

MATERIALS AND METHODS

Phase I surveyed clinical experts using a modified Delphi procedure to elicit disease concepts for inclusion. In phase II, a consensus conference including clinicians, researchers, and people with lived experience, informed the initial item pool. Consensus for item inclusion was achieved using a nominal group technique for voting. Phase III used iterative rounds of cognitive interviews with children aged 8 to 18 years with CRPS or NP to evaluate the tool's comprehensiveness and individual item relevance and comprehensibility. Descriptive statistics were used to describe participant characteristics. Content analysis was used to analyze patient interviews.

RESULTS

Phase I (n=50) generated an initial item pool (22 items). Phase II generated a comprehensive item pool (50 items), after which an initial version of the screening tool was drafted. Following phase III (n=26) after item revision and elimination, 37 items remained.

DISCUSSION

The Pediatric PainSCAN is a novel screening tool that has undergone rigorous development and content validity testing. Further research is needed to conduct item reduction, determine scoring, and test additional measurement properties.

Manual Therapy in Preadolescent Children: A Delphi Investigation of Physical Therapists in the United States

OBJECTIVE

Limited research has investigated the use of manual therapy to treat the preadolescent (0-12 years of age) population with musculoskeletal and neurological impairments. The purpose of this study was to identify the following among physical therapists holding advanced credentials in pediatrics, neurodevelopmental treatment, or manual therapy: (1) consensus regarding effective techniques in the preadolescent population, (2) differences in opinion, and (3) perceived decision-making barriers and factors regarding use of manual therapy techniques.

METHODS

Credentialed physical therapists in the United States were recruited for a 3-round Delphi investigation. An electronic survey in Round 1 identified musculoskeletal and neurological impairments and the manual techniques considered effective to treat such conditions, in addition to factors and barriers. Responses were used to create the second round, during which a 4-point Likert scale was used to score each survey item. A third round of scoring established consensus. Descriptive statistics and composite scores were calculated for each manual technique by impairment. Between-group differences were calculated using the Mann-Whitney U test with Bonferroni correction.

RESULTS

Consensus was determined for several concepts. First, neuromuscular techniques were considered effective across all impairments, and joint mobilizations (grades I-IV) were believed to be effective to treat joint and muscle and myofascial impairments. Second, visceral manipulation and craniosacral therapy were considered ineffective in treating most impairments. There was lack of consensus and clear differences of opinion regarding the use of grade V mobilizations and dry needling. Significant barriers to use of manual therapy were: lack of knowledge, lack of evidence, and fear of litigation and harming patients.

CONCLUSION

This study is an initial step for developing manual therapy guidelines, research, and educational opportunities regarding manual therapy in pediatric physical therapy.

Which Exercise for Low Back Pain? (WELBack) trial predicting response to exercise treatments for patients with low back pain: a validation randomised controlled trial protocol

INTRODUCTION

Exercise therapy is the most recommended treatment for chronic low back pain (LBP). Effect sizes for exercises are usually small to moderate and could be due to the heterogeneity of people presenting with LBP. Thus, if patients could be better matched to exercise based on individual factors, then the effects of treatment could be greater. A recently published study provided evidence of better outcomes when patients are matched to the appropriate exercise type. The study demonstrated that a 15-item questionnaire, the Lumbar Spine Instability Questionnaire (LSIQ), could identify patients who responded best to one of the two exercise approaches for LBP (motor control and graded activity). The primary aim of the current study isill be to evaluate whether preidentified baseline characteristics, including the LSIQ, can modify the response to two of the most common exercise therapies for non-specific LBP. Secondary aims include an economic evaluations with a cost-effectiveness analysis.

METHODS AND ANALYSIS

Participants (n=414) will be recruited by primary care professionals and randomised (1:1) to receive motor control exercises or graded activity. Participants will undergo 12 sessions of exercise therapy over an 8-week period. The primary outcome will be physical function at 2 months using the Oswestry Disability Index. Secondary outcomes will be pain intensity, function and quality of life measured at 2, 6 and 12 months. Potential effect modifiers will be the LSIQ, self-efficacy, coping strategies, kinesiophobia and measures of nociceptive pain and central sensitisation. We will construct linear mixed models with terms for participants (fixed), treatment group, predictor (potential effect modifier), treatment group×predictor (potential effect modifier), physiotherapists, treatment group×physiotherapists and baseline score for the dependent variable.

ETHICS AND DISSEMINATION

This study received ethics approval from the Hamilton Integrate Research Ethics Board. Results will be submitted for publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04283409.

Self-reports vs. physical measures of spinal stiffness

Background

Objectively measured reduction in lumbar posterior-to-anterior (PA) stiffness is associated with pain relief in some, but not all persons with low back pain. Unfortunately, these measurements can be time consuming to perform. In comparison, the Lumbar Spine Instability Questionnaire (LSIQ) is intended to measure spinal instability and the Lumbar Spine Disability Index (LSDI) is created for self-reporting functional disability due to increased spinal stiffness. Given the above, the aim of this study is to compare measures of the LSIQ and LSDI with objective measures of lumbar PA stiffness as measured by a mechanical device, Vertetrack (VT), in patients with persistent non-specific low back pain (nsLBP).

Methods

Twenty-nine patients with nsLBP completed the LSIQ and LSDI at baseline and after two weeks. On these same occasions, PA spinal stiffness was measured using the VT. Between measurements, patients received four sessions of spinal manipulation. The resulting data was analyzed to determine the correlation between the self-report and objective measures of stiffness at both time points. Further, the patients were categorized into responders and non-responders based on pre-established cut points depending on values from the VT and compared those to self-report measures in order to determine whether the LSIQ and the LSDI were sensitive to change.

Results

Twenty-nine participants completed the study. Measures from the LSIQ and LSDI correlated poorly with objectively measured lumbar PA stiffness at baseline and also with the change scores. The change in objectively measured lumbar PA stiffness following spinal manipulation did not differ between those who improved, and those who did not improve according to the pre-specified cut-points. Finally, a reduction in lumbar PA stiffness following intervention was not associated with improvement in LSIQ and LSDI outcomes.

Conclusions

The current data indicate that the LSIQ and LSDI questionnaires do not correlate with measures obtained objectively by VT. Our results suggest that these objective and self- reported measures represent different domains and as such, cannot stand in place of one another.

Clinical utility of a cluster of tests as a diagnostic support tool for clinical lumbar instability

BACKGROUND

Numerous clinical tests have been proposed for the diagnosis of clinical lumbar instability (CLI), but a cluster of clinical tests is still needed to increase the accuracy of CLI diagnosis.

OBJECTIVE

To evaluate a diagnostic support tool intended to identify the presence of CLI using a cluster of clinical tests.

DESIGN

Analytical cross-sectional study.

METHODS

Two hundred participants with chronic low back pain (LBP) were diagnosed with or without CLI by an orthopedic surgeon. The orthopedic surgeon made the diagnosis from classic clinical symptoms and signs. The diagnosis was used as the reference standard. An orthopedic physical therapist used four clinical tests to identify CLI in each participant, including the apprehension sign, the instability catch sign with/without the abdominal drawing-in maneuver (ADIM), the painful catch sign with/without the ADIM, and the prone instability test.

RESULTS

For an individual test, the apprehension sign showed a high specificity (92.6%) and a positive likelihood ratio (LR+; 2.4) but a very low sensitivity of 17.4%. A cluster of three of the four examined tests provided the most diagnostic accuracy for CLI, with a high LR+ (5.8) and a high specificity (91.7%) but low sensitivity (47.8%) and a negative likelihood ratio (LR-; 0.6).

CONCLUSIONS

A cluster of three of the four examined tests was determined to comprise a powerful clinical support tool for the identification of CLI patients as tested against a reference standard diagnosis.

CLINICAL TRIAL REGISTRATION

Name of the registry: Thai Clinical Trials Registry. Registration number: TCTR20190426002.

A Screening Tool for Patients With Lumbar Instability: A Criteria-related Validity of Thai Version

STUDY DESIGN

The study is a cross-sectional, diagnostic validity study.

OBJECTIVE

The aim of this study was to examine the performance characteristics and validity of an existing lumbar instability questionnaire as a screening tool for lumbar instability among chronic low back pain (CLBP) patients.

SUMMARY OF BACKGROUND DATA

Lumbar instability is an initial stage of more severe spinal pathology. Early screening for this condition should help prevent more structural damage. To meet this need, the present study developed numerical cutoff scores for the lumbar instability screening tool.

METHODS

Lumbar instability screening tool responses and x-ray assessments were reviewed from a sample of 110 patients with CLBP (aged 20-59 years). Receiver operator curves were constructed to optimize sensitivity and specificity of the tool.

RESULTS

Fourteen (12.73%) patients had radiological lumbar instability. These patients reported a higher mean lumbar instability questionnaire score than those without radiological lumbar instability. A questionnaire score of at least 7 had a sensitivity of 100% (95% CI, 100-100) and a specificity of 26.04% (95% CI = 17.84-34.24) for detecting lumbar instability when compared with x-ray examination. Receiver operator curve analysis revealed the lumbar instability screening had an area under the curve of 0.62 (95% CI, 0.47-0.77).

CONCLUSION

A lumbar instability screening tool total score of at least 7 was ruled out lumbar instability in CLBP patients. This cutoff score may be used as a marker of conservative treatment response. The sample size of patients with lumbar instability in this study was small, which may hinder the reliability of the data. Further studies are needed.

LEVEL OF EVIDENCE

4.

Common musculoskeletal impairments in postpartum runners: an international Delphi study

Background

Postpartum runners report musculoskeletal pain with running. Because of inadequate research, little is known about the origin and pain-related classification. Through expert consensus, this study is the first attempt to understand the musculoskeletal impairments that these runners present with. The objective of this survey was to gather expert consensus on characteristics of reported impairments in postpartum runners that have musculoskeletal pain.

Methods

A web-based Delphi survey was conducted and was composed of five categories: strength, range of motion, alignment and flexibility impairments, as well as risk factors for pain in postpartum runners.

Results

A total of 117 experts were invited. Forty-five experts completed round I and forty-one completed rounds II and III. The strength impairments that reached consensus were abdominal, hip and pelvic floor muscle weakness. The range of motion impairments that reached consensus were hip extension restriction, anterior pelvic tilt and general hypermobility. The alignment impairments that reached consensus were a Trendelenburg sign, dynamic knee valgus, lumbar lordosis, over-pronation and thoracic kyphosis. The flexibility impairments that reached consensus were abdominal wall laxity, and tightness in hip flexors, lumbar extensors, iliotibial band and hamstrings. The risk factors for pain in postpartum runners were muscular imbalance, poor lumbopelvic control, too much too soon, life stressors, pain during pregnancy and pelvic floor trauma.

Conclusion

This study presents a framework for clinicians to understand pain in postpartum runners and that can be investigated in future cohort studies.

Level of evidence

5.

Alternating lumbar lateral shift: a case report

BACKGROUND

A lumbar lateral shift (LLS) is a common clinical observation in patients with low back pain (LBP), and a shift contralateral to the side of pain is the most common presentation. An LLS that can rapidly alternate sides presents several treatment difficulties and has rarely been described. The purpose of the current case report was to describe the presentation and management of a patient with an alternating LLS.

CASE DESCRIPTION

A 39-year-old male with a 7-week history of LBP and previous lower extremity radicular pain was referred to physical therapy. An alternating LLS was present.

OUTCOMES

The patient was treated for six visits over 37 days. Treatment included modified self-correction of the LLS, motor control and trunk muscle endurance training, and development of an activity management program. The patient's LLS resolved, his worst pain improved from 3/10 to 0/10, and the Oswestry Disability Index improved from 26% to 4% disability. The patient reported maintenance of improvement at 6-month follow-up.

DISCUSSION

The current approach produced a positive outcome in a patient with an alternating LLS. The current understanding of mechanisms and optimal treatment of an alternating LLS is limited.

LEVEL OF EVIDENCE

4.

International consensus on the most useful assessments used by physical therapists to evaluate patients with temporomandibular disorders: A Delphi study

OBJECTIVE

To identify assessment tools used to evaluate patients with temporomandibular disorders (TMD) considered to be clinically most useful by a panel of international experts in TMD physical therapy (PT).

METHODS

A Delphi survey method administered to a panel of international experts in TMD PT was conducted over three rounds from October 2017 to June 2018. The initial contact was made by email. Participation was voluntary. An e-survey, according to the Checklist for Reporting Results of Internet E-Surveys (CHERRIES), was posted using SurveyMonkey for each round. Percentages of responses were analysed for each question from each round of the Delphi survey administrations.

RESULTS

Twenty-three experts (completion rate: 23/25) completed all three rounds of the survey for three clinical test categories: 1) questionnaires, 2) pain screening tools and 3) physical examination tests. The following was the consensus-based decision regarding the identification of the clinically most useful assessments. (1) Four of 9 questionnaires were identified: Jaw Functional Limitation (JFL-8), Mandibular Function Impairment Questionnaire (MFIQ), Tampa Scale for Kinesiophobia for Temporomandibular disorders (TSK/TMD) and the neck disability index (NDI). (2) Three of 8 identified pain screening tests: visual analog scale (VAS), numeric pain rating scale (NRS) and pain during mandibular movements. (3) Eight of 18 identified physical examination tests: physiological temporomandibular joint (TMJ) movements, trigger point (TrP) palpation of the masticatory muscles, TrP palpation away from the masticatory system, accessory movements, articular palpation, noise detection during movement, manual screening of the cervical spine and the Neck Flexor Muscle Endurance Test.

CONCLUSION

After three rounds in this Delphi survey, the results of the most used assessment tools by TMD PT experts were established. They proved to be founded on test construct, test psychometric properties (reliability/validity) and expert preference for test clusters. A concordance with the screening tools of the diagnostic criteria of TMD consortium was noted. Findings may be used to guide policymaking purposes and future diagnostic research.

Balance Control in Patients with Subacute Non-Specific Low Back Pain, with and without Lumbar Instability: A Cross-Sectional Study

BACKGROUND

Patients with low back pain (LBP) have poorly coordinated neuromuscular control, which may alter the normal postural stability of the spine. Altered movement control may occur at any stage of LBP.

PURPOSE

(1) To identify differences in balance control and proprioceptive sense between subacute non-specific LBP (NSLBP) patients with and without lumbar instability (LI) and healthy subjects and (2) to investigate the correlation between factors of motor control deficits and balance.

PATIENTS AND METHODS

Thirty-six participants matched by gender, age, and body mass index (BMI) were allocated into three groups of 12: subacute NSLBP patients with LI, subacute NSLBP patients without LI, and healthy subjects. Balance, proprioceptive sense, pain, functional disability, and fear of movement were evaluated.

RESULTS

Subacute NSLBP patients with LI exhibited greater impairments in balance control, proprioceptive sense, and functional ability than patients without LI (p<0.05). Subacute NSLBP patients showed more impairments in balance control, proprioceptive sense, and fear of movement than healthy subjects (p<0.001), with the following effect sizes (partial η2) for static balance on stable and unstable surface: 0.597 and 0.560, anticipatory balance: 0.417, and dynamic balance: 0.536; proprioceptive sense: 0.676; and fear of movement: 0.379. Significant fair correlations were found between (1) static balance and proprioceptive sense, functional disability, and fear of movement; (2) functional reach test (FRT) and pain; and (3) the five times sit to stand test (FTSTS) and functional disability.

CONCLUSION

Subacute NSLBP patients with LI showed greater impairment in balance control than patients without LI. Reduced proprioceptive sense, increased pain, functional disability, and fear of movement were fairly related to impaired balance.

A Delphi study to establish consensus on an educational package of musculoskeletal clinical prediction rules for physiotherapy clinical educators

BACKGROUND

Clinical prediction rules (CPRs) are evidence-based tools to aid clinical decision-making, and there are many that are relevant for physiotherapists, especially in the musculoskeletal field. However, a lack of awareness and understanding by physiotherapy clinical educators could limit students' exposure to these potentially valuable tools. An educational package tailored for clinical educators could help them recognise the value of CPRs and implement them in clinical practice with students.

OBJECTIVES

To determine consensus on the essential content and optimal delivery of an educational package on musculoskeletal CPRs for physiotherapy clinical educators.

DESIGN

An online survey of physiotherapy experts who have published on CPRs, using a Delphi approach.

METHOD

Sixteen experts were recruited for a two-round reactive Delphi study in which they rated previously identified elements, as well as suggesting new items for an educational package.

FINDINGS

A pre-defined consensus of ≥70% identified that the content of an educational package should cover fundamental aspects of CPRs including why, when and how to use them clinically, and their limitations. Information on the evidence-base of different types of CPRs, with specific examples, was also identified as important. Online delivery was recommended via self-directed learning and webinars, along with electronic versions of actual CPRs. A self-assessment component was also supported.

CONCLUSIONS

An educational package on musculoskeletal CPRs for clinical educators was supported with key elements outlined by an international panel of experts.

IMPLICATIONS

Improving clinical educators' knowledge of CPRs may lead to physiotherapy students having a greater understanding and ability to use CPRs.

A Rasch analysis of the lumbar spine instability questionnaire

Purpose: A 2014 study found that the Lumbar Spine Instability questionnaire predicts response to two different types of exercise therapy. This is the first decision tool that has predicted response to exercise for chronic low back pain. The objective of this study was to evaluate the Lumbar Spine Instability questionnaire using Rasch analysis. Methods: Baseline data from patients included in a randomized controlled trial with chronic non-specific low back pain were included. Rasch Measurement Theory was used to assess the ordering of items along a common scale, data-to-model fit, Person Separation Index, unidimensionality and Differential Item Functioning. Results: Responses from 172 patients (102 females) underwent Rasch analysis. All Lumbar Spine Instability questionnaire items had fit residuals between ± 2.5 and Chi-Square values were non-significant with Bonferroni corrections. The Lumbar Spine Instability questionnaire demonstrated a Person Separation Index of 0.64, which is below the recommended cut-off of 0.7. Differential Item Functioning by different pain levels was identified for one item. Conclusion: The Lumbar Spine Instability questionnaire was found to be unidimensional, suggesting that the use of a summary score is appropriate. However, the low Person Separation Index value suggests that more items may be needed to increase the questionnaire's ability to discriminate among individuals with high and low clinical instability.

Clinical spinal instability: 10 years since the derivation of a clinical prediction rule. A narrative literature review

BACKGROUND

Between 2005 and 2015 significant changes in the clinical decision making paradigm for the treatment of spinal instability occurred. This was largely motivated by a clinical prediction rule (CPR) derivation study that was developed to specifically identify patients with low back pain who are more likely to respond positively to lumbar stabilization exercises.

OBJECTIVE

This is a narrative literature review on the recent advances physiotherapy has made in the treatment of clinical spinal instability.

METHODS

Literature discussing the conservative treatment of lumbar spinal instability published from 2005-2015 was identified with electronic searches of PubMed (MEDLINE) Advanced search, Web of Science, BIOSIS Previews, MEDLINE (EBSCO), SportDISCUS (EBSCO), CINAHL (EBSCO), PEDro, Scopus and Cochrane and reviewed.

RESULTS

Five systematic reviews, 2 with meta-analyses, and 1 systematic review on the quality of systematic reviews were found. There seems to be some benefit from specific stabilization exercise programs in regards to pain reduction, but they might not be more effective than other forms of exercise. The currently existing CPR for stabilization exercises is not far enough developed to use in clinical practice and is not validated as of yet.

CONCLUSION

Stabilization exercises seem to decrease chronic low back pain, although it is not clear that this pain has to be caused by clinical spinal instability. Caution should be exercised when using CPRs in the clinic; they are not meant to be strict treatment guidelines, but rather a tool that helps facilitate clinical decision-making.

Association Between Clinical Tests Related to Motor Control Dysfunction and Changes in Pain and Disability After Lumbar Stabilization Exercises in Individuals With Chronic Low Back Pain

OBJECTIVE

To investigate whether clinical tests used to detect motor control dysfunction can predict improvements in pain and disability in patients with chronic nonspecific low back pain (LBP) who have undergone an 8-week lumbar stabilization exercise program.

STUDY DESIGN

A prospective cohort study.

SETTING

Outpatient physical therapy university clinic.

PARTICIPANTS

Seventy people with chronic nonspecific LBP were recruited, and 64 completed the exercise program (N=64).

INTERVENTIONS

The lumbar stabilization program was provided twice a week for 8 weeks.

MAIN OUTCOME MEASURES

Pain intensity (11-point numerical rating scale) and disability (Roland Morris Disability Questionnaire) and clinical tests, such as the Deep Muscle Contraction (DMC) scale, Clinical Test of Thoracolumbar Dissociation (CTTD), and Passive Lumbar Extension (PLE) test. Univariate and multivariate linear regression models were used in the prediction analysis.

RESULTS

Mean changes in pain intensity and disability following the 8-week stabilization program were -3.8 (95% confidence interval [CI], -3.2 to -4.4) and -7.4 (95% CI, -6.3 to -8.5), respectively. Clinical test scores taken at baseline did not predict changes in pain and disability at 8-week follow-up.

CONCLUSION

Our findings revealed that the DMC scale, CTTD, PLE test, clinical tests used to assess motor control dysfunction, do not predict improvements in pain and disability in patients with chronic nonspecific LBP following an 8-week lumbar stabilization exercise program.

Clinimetric Testing of the Lumbar Spine Instability Questionnaire

BACKGROUND

The Lumbar Spine Instability Questionnaire (LSIQ) is a self-report measure of 15 items. Previous studies have used the LSIQ as a measure of clinical instability; however, a comprehensive evaluation of its clinimetric properties has not been conducted.

OBJECTIVES

The aim of this study was to evaluate the clinimetric properties of the LSIQ in patients with chronic nonspecific low back pain (LBP).

METHODS

In this clinical measurement study, the authors included patients with nonspecific LBP presenting to primary care clinicians in Australia. Rasch analysis was conducted to assess item hierarchy, targeting, unidimensionality, person fit, internal consistency, and differential item functioning. The researchers assessed test-retest reliability of total scores and individual item scores, as well as convergent and divergent validity.

RESULTS

A total of 107 participants with LBP (60 men and 47 women) were recruited. The results were variable. The LSIQ appeared to constitute a unidimensional measure, targeted the sample well, and showed adequate test-retest reliability. However, the scale had poor internal consistency, did not appear to function as an interval-level measure, and had unclear construct validity. Although no items appeared to be redundant, several items were biased by factors other than the proposed construct of the measure.

CONCLUSION

The LSIQ does not seem to be ready to be implemented in clinical practice and may require theoretical reconsideration. Although the LSIQ provided satisfactory estimates for some clinimetric features, the authors do not consider the instrument to be useful as an interval-level measure but rather as an index. Future studies are needed to investigate whether the LSIQ could measure clinical instability or some other construct. J Orthop Sports Phys Ther 2018;48(12):915-922. Epub 22 Jun 2018. doi:10.2519/jospt.2018.7866.

Altered postural sway during quiet standing in women with clinical lumbar instability

[Purpose] The current study aimed to investigate the center of pressure, as an indicator of postural sway, to determine any differences between women with clinical lumbar instability and asymptomatic low back pain. [Participants and Methods] Thirty healthy and fifteen clinical lumbar instability participants were measured for their postural sway in the anterior-posterior and medial-lateral directions. The women were tested for postural sway on a force plate in quiet standing and eyes closed. Center of pressure path length and mean velocity in the anterior-posterior and medial-lateral directions and total area of excursion were measured and analyzed for 30 seconds. [Results] Clinical lumbar instability participants showed a significantly increase when compared with healthy participants, in path length and mean velocity in both directions and total area of excursion. [Conclusion] The findings suggest that chronic low back pain patients with clinical lumbar instability have increased postural sway when vision is deprived. The clinical significance of this has not yet been determined but may provide an opportunity for therapy directed at improving balance control in this patient group.

Measurement Properties of the Brazilian-Portuguese Version of the Lumbar Spine Instability Questionnaire

STUDY DESIGN

Cross-cultural adaptation and analysis of measurement properties.

OBJECTIVE

To translate and cross-culturally adapt the Lumbar Spine Instability Questionnaire (LSIQ) into Brazilian-Portuguese and to test its measurement properties in Brazilian patients with low back pain.

SUMMARY OF BACKGROUND DATA

The selection of subgroup of patients that respond better to specific interventions is the top research priority in the field of back pain. The LSIQ is a tool able to stratify patients with low back pain who responds better to motor control exercises. There is no Brazilian-Portuguese version of the LSIQ available.

METHODS

The original version of the LSIQ was translated and cross-culturally adapted. We collected data from 100 patients with low back pain. In addition to LSIQ, we also collected information about physical activity levels (measured by the International Physical Activity Questionnaire short version), disability (measured by the Roland Morris Disability Questionnaire), pain intensity (measured by the Pain numerical Rating Scale), kinesiophobia (measured by the Tampa Scale of Kinesiophobia), and depression (measured by the Beck Depression Inventory). The measurement properties tested were internal consistency, reproducibility (reliability and agreement), construct validity, and ceiling and floor effects.

RESULTS

The Brazilian-Portuguese version of the LSIQ showed good measurement properties with a Cronbach alpha of 0.79, an intraclass correlation coefficient of 0.75, a standard error of measurement of 1.65 points, and a minimal detectable change of 3.54 points. We did not detect ceiling and floor effects. The construct validity analysis was observed a moderate correlation between the LSIQ and Pain Numerical Rating Scale r = 0.46, Roland Morris Disability Questionnaire r = 0.66, Tampa Scale of Kinesiophobia r = 0.49, and Beck Depression Inventory r = 0.44.

CONCLUSION

The Brazilian-Portuguese version of LIQ has adequate measurement properties and can be used in clinical practice and research.

LEVEL OF EVIDENCE

NA.

Important clinical descriptors to include in the examination and assessment of patients with femoroacetabular impingement syndrome: an international and multi-disciplinary Delphi survey

PURPOSE

Determine which examination findings are key clinical descriptors of femoroacetabular impingement syndrome (FAIS) through use of an international, multi-disciplinary expert panel.

METHODS

A three-round Delphi survey utilizing an international, multi-disciplinary expert panel operationally defined from international publications and presentations was utilized.

RESULTS

All six domains (subjective examination, patient-reported outcome measures, physical examination, special tests, physical performance measures, and diagnostic imaging) had at least one descriptor with 75% consensus agreement for diagnosis and assessment of FAIS. Diagnostic imaging was the domain with the highest level of agreement. Domains such as patient-reported outcome measures (PRO's) and physical examination were identified as non-diagnostic measures (rather as assessments of disease impact).

CONCLUSION

Although it also had the greatest level of variability in description of examination domains, diagnostic imaging continues to be the preeminent diagnostic measure for FAIS. No single domain should be utilized as the sole diagnostic or assessment parameter for FAIS. While not all investigated domains provide diagnostic capability for FAIS, those that do not are able to serve purpose as a measure of disease impact (e.g., impairments and activity limitations). The clinical relevance of this Delphi survey is the understanding that a comprehensive assessment measuring both diagnostic capability and disease impact most accurately reflects the patient with FAIS.

LEVEL OF EVIDENCE

V.

Development of a repository of individual participant data from randomized controlled trials of therapists delivered interventions for low back pain

Background

Individual patient data (IPD) meta‐analysis of existing randomized controlled trials (RCTs) is a promising approach to achieving sufficient statistical power to identify sub‐groups. We created a repository of IPD from multiple low back pain (LBP) RCTs to facilitate a study of treatment moderators. Due to sparse heterogeneous data, the repository needed to be robust and flexible to accommodate millions of data points prior to any subsequent analysis.

Methods

We systematically identified RCTs of therapist delivered intervention for inclusion to the repository. Some were obtained through project publicity. We requested both individual items and aggregate scores of all baseline characteristics and outcomes for all available time points. The repository is made up of a hybrid database: entity‐attribute‐value and relational database which is capable of storing sparse heterogeneous datasets. We developed a bespoke software program to extract, transform and upload the shared data.

Results

There were 20 datasets with more than 3 million data points from 9328 participants. All trials collected covariates and outcomes data at baseline and follow‐ups. The bespoke standardized repository is flexible to accommodate millions of data points without compromising data integrity. Data are easily retrieved for analysis using standard statistical programs.

Conclusions

The bespoke hybrid repository is complex to implement and to query but its flexibility in supporting datasets with varying sets of responses and outcomes with different data types is a worthy trade off. The large standardized LBP dataset is also an important resource useable by other LBP researchers.

Significance

A flexible adaptive database for pain studies that can easily be expanded for future researchers to map, transform and upload their data in a safe and secure environment. The data are standardized and harmonized which will facilitate future requests from other researchers for secondary analyses.

Factors affecting confidence and knowledge in spinal palpation among International Manual Physical Therapists

OBJECTIVES

We sought to find if there was a relationship between the confidence in use of static palpation, passive physiological intervertebral motion (PPIVM) and passive accessory intervertebral motion (PAIVM) and the manual therapist's (MTs) knowledge of the literature on these topics.

METHODS

We designed an international survey to achieve our objectives. Each skill was surveyed for the cervical, thoracic and lumbar spines. We also included several other factors that we believed might influence the use of these skills.

RESULTS

We concluded that familiarity of the literature was significantly associated with a MTs' confidence in the use of static palpation, PPIVM and PAIVM techniques. We also found a relationship with the country of practice of the MT and their confidence using these techniques.

DISCUSSION

Spinal palpation is an integral part of the MT's evaluation and treatment abilities. The vast majority of MTs use spinal palpation and nearly all entry-level education programmes include it in their training. Knowing what factors influence MTs' confidence assessing and treating the spine may allow for more effective teaching and training, as well as improved patient outcomes.

How should we teach lumbar manipulation? A consensus study

BACKGROUND

Spinal manipulation is an effective intervention for low back pain, yet there is little consistency in how this skill is taught.

OBJECTIVES

The purpose of this study was to identify what educators and clinicians believe are important characteristics of the patient and operator position prior to side-lying lumbar manipulation and the patient position and operator motion during the manipulative thrust.

DESIGN

A multi-disciplinary correspondence-based Delphi method.

METHODS

Three rounds of questionnaires were sent to physical therapists, osteopaths and chiropractors. Consensus was established in Round 3 if at least 75% of respondents identified a characteristic as very important/extremely important on a 5-point Likert scale.

RESULTS

265 educators and clinicians completed the three rounds of questioning. There was consensus that localization to target segment, patient comfort, table height, and logrolling the patient towards the operator are important characteristics of patient position during the preparatory phase. During the manipulation phase, respondents agreed that it is important to maintain localization to the segment and rotate the patient's pelvis and lumbar spine. For the operator characteristics, consensus was reached for the following items; moving up and over the patient, maintaining contact using forearms, and close contact between the operator and patient (preparatory phase); generating force through the body and legs, dropping the body downwards, maintaining localization, and providing a high-velocity and low-amplitude thrust (manipulation phase).

CONCLUSIONS

This Delphi study successfully identified key characteristics of patient position and operator position and motion for effective delivery of side-lying lumbar spine manipulations.

The Effect of Current Low Back Pain on Volitional Preemptive Abdominal Activation During a Loaded Forward Reach Activity

BACKGROUND

A volitional preemptive abdominal contraction (VPAC) supports trunk stability during functional activity. Pain-free individuals can sustain VPAC during function, but such has not been reported for individuals with current low back pain (cLBP).

OBJECTIVE

To examine whether cLBP affects VPAC performance during a loaded forward reach (LFR) task.

DESIGN

Observational crossover study.

SETTING

Laboratory.

PARTICIPANTS

A total of 18 controls and 17 subjects with cLBP with pain ratings of 1/10 to 4/10 on a visual analog scale.

INTERVENTIONS

Transverse abdominis (TrA) thickness measurements were recorded by blinded researchers from M-mode ultrasound imaging during 4 conditions: (1) quiet standing without abdominal drawing-in maneuver (ADIM); (2) quiet standing with ADIM; (3) LFR without ADIM; and (4) LFR with ADIM. A physical therapist with 29 years of experience collected historical and examination data.

MAIN OUTCOME MEASURES

TrA muscle thickness (mm).

RESULTS

A 2 (group) × 2 (contraction) × 2 (reach) analysis of variance demonstrated a significant group × contraction interaction (F [1, 31] = 4.499, P = .04) where ADIM produced greater TrA thickness increases in PLBP subjects (2.18 mm) versus controls (1.36 mm). We observed a significant main effect for reach (F [1, 31] = 14.989, P < .001), where LFR activity produced a greater TrA thickness (6.15 ± 2.48 mm) versus quiet standing (5.30 ± 2.12 mm).

CONCLUSIONS

Subjects with cLBP demonstrated a greater increase in TrA activation during ADIM versus controls.

The Influence of Centralization and Directional Preference on Spinal Control in Patients With Nonspecific Low Back Pain

STUDY DESIGN

Prospective cohort, test-retest design.

BACKGROUND

Directional preference (DP) with centralization (CEN) and DP without CEN are common pain-pattern responses assessed by Mechanical Diagnosis and Therapy (MDT). Although there is evidence that MDT can reduce pain and disability in the short term by treating the patient with direction-specific exercises concordant with the patient's DP, the mechanism responsible for this is unclear.

OBJECTIVE

To determine whether clinical signs of impaired spinal control improve immediately after eliciting a DP-with-CEN response or a DP-without-CEN response in patients with nonspecific low back pain.

METHODS

Participants underwent a standardized MDT assessment and were classified into the following pain-pattern subgroups: DP with CEN, DP without CEN, or no DP. Clinical signs of impaired spinal control were assessed pre-MDT assessment and post-MDT assessment by an independent examiner. Four spinal control tests were conducted: aberrant lumbar movements while bending forward, the active straight leg raise (ASLR) test, the Trendelenburg test, and the prone instability test. Differences in spinal control pre-MDT assessment and post-MDT assessment were calculated for the 3 pain-pattern subgroups and compared with chi-square tests. We hypothesized that a larger proportion of patients in the DP-with-CEN subgroup would exhibit improved spinal control than patients categorized as DP without CEN or no DP.

RESULTS

Of 114 patients recruited, 51 patients (44.7%) were categorized as DP with CEN, 23 (20.2%) as DP without CEN, and 40 (35.1%) as no DP. Before MDT assessment, between 28.9% (Trendelenburg test) and 63.7% (ASLR test) of patients showed impaired spinal control. After MDT assessment, a larger proportion of patients in the DP-with-CEN subgroup (43%) showed improvement than those in the no-DP subgroup (7%) on aberrant lumbar movements (P = .02). Likewise, more patients in the DP-with-CEN subgroup (50%) improved on the ASLR test than those in the no-DP subgroup (8%, P<.01) or the DP-without-CEN subgroup (7%, P = .01). Changes in Trendelenburg test and prone instability test outcomes did not reach statistical significance.

CONCLUSION

Immediately following MDT assessment, a larger proportion of patients with a DP-with-CEN pain pattern showed improvement in clinical signs of spinal control compared to patients with a DP-without-CEN or no-DP pain pattern. The current study was registered in the Dutch trial registry at http://www.trialregister.nl/trialreg/index.asp (NTR4246).

LEVEL OF EVIDENCE

Therapy, level 2b.

An exploratory examination of the association between altered lumbar motor control, joint mobility and low back pain in athletes

Background:

Low back pain (LBP) is a common cause of lost playing time and can be a challenging clinical condition in competitive athletes. LBP in athletes may be associated with joint and ligamentous hypermobility and impairments in activation and coordination of the trunk musculature, however there is limited research in this area.

Objectives:

To determine if there is an association between altered lumbar motor control, joint mobility and low back pain (LBP) in a sample of athletes.

Materials and Methods:

Fifteen athletes with LBP were matched by age, gender and body mass index (BMI) with controls without LBP. Athletes completed a questionnaire with questions pertaining to demographics, activity level, medical history, need to self-manipulate their spine, pain intensity and location. Flexibility and lumbar motor control were assessed using: active and passive straight leg raise, lumbar range of motion (ROM), hip internal rotation ROM (HIR), Beighton ligamentous laxity scale, prone instability test (PIT), observation of lumbar aberrant movements, double leg lowering and Trendelenburg tests. Descriptive statistics were compiled and the chi square test was used to analyze results.

Results:

Descriptive statistics showed that 40% of athletes with LBP exhibited aberrant movements (AM), compared to 6% without LBP. 66% of athletes with LBP reported frequently self-manipulating their spine compared to 40% without LBP. No significant differences in motor control tests were found between groups. Athletes with LBP tended to have less lumbar flexion (63 ± 11°) compared to those without LBP (66 ± 13°). Chi-Square tests revealed that the AM were more likely to be present in athletes with LBP than those without (X2 = 4.66, P = 0.03).

Conclusions:

The presence of aberrant movement patterns is a significant clinical finding and associated with LBP in athletes.

Prevalence and individual risk factors associated with clinical lumbar instability in rice farmers with low back pain

INTRODUCTION

Clinical lumbar instability (CLI) is one of the subgroups of chronic non-specific low back pain. Thai rice farmers often have poor sustained postures during a rice planting process and start their farming at an early age. However, individual associated factors of CLI are not known and have rarely been diagnosed in low back pain. This study aimed to determine the prevalence and individual associated factors of CLI in Thai rice farmers.

METHODS

A cross-sectional survey was conducted among 323 Thai rice farmers in a rural area of Khon Kaen province, Thailand. Face-to-face interviews were conducted using the 13-item Delphi criteria questionnaire, after which an objective examination was performed using aberrant movement sign, painful catch sign, and prone instability test to obtain information. Individual factors such as sex, body mass index, waist-hip ratio, smoking, and number of years of farming experience, were recorded during the face-to-face interview.

RESULTS

The prevalence of CLI in Thai rice farmers calculated by the method described in this study was 13% (age 44±10 years). Number of years of farming experience was found to be significantly correlated with the prevalence of CLI (adjusted odds ratio =2.02, 95% confidence interval =1.03-3.98, P<0.05).

CONCLUSION

This study provides prevalence of CLI in Thai rice farmers. Those with long-term farming experience of at least 30 years have a greater risk of CLI.

Predicting response to motor control exercises and graded activity for patients with low back pain: preplanned secondary analysis of a randomized controlled trial

BACKGROUND

Current treatments for low back pain have small effects. A research priority is to identify patient characteristics associated with larger effects for specific interventions.

OBJECTIVE

The aim of this study was to identify simple clinical characteristics of patients with chronic low back pain who would benefit more from either motor control exercises or graded activity.

DESIGN

This study was a secondary analysis of the results of a randomized controlled trial.

METHODS

One hundred seventy-two patients with chronic low back pain were enrolled in the trial, which was conducted in Australian physical therapy clinics. The treatment consisted of 12 initial exercise sessions over an 8-week period and booster sessions at 4 and 10 months following randomization. The putative effect modifiers (psychosocial features, physical activity level, walking tolerance, and self-reported signs of clinical instability) were measured at baseline. Measures of pain and function (both measured on a 0-10 scale) were taken at baseline and at 2, 6, and 12 months by a blinded assessor.

RESULTS

Self-reported clinical instability was a statistically significant and clinically important modifier of treatment response for 12-month function (interaction: 2.72; 95% confidence interval=1.39 to 4.06). Participants with high scores on the clinical instability questionnaire (≥9) did 0.76 points better with motor control exercises, whereas those who had low scores (<9) did 1.93 points better with graded activity. Most other effect modifiers investigated did not appear to be useful in identifying preferential response to exercise type.

LIMITATIONS

The psychometric properties of the instability questionnaire have not been fully tested.

CONCLUSIONS

A simple 15-item questionnaire of features considered indicative of clinical instability can identify patients who respond best to either motor control exercises or graded activity.

Clinical identifiers for early-stage primary/idiopathic adhesive capsulitis: are we seeing the real picture?

BACKGROUND

Adhesive capsulitis is often difficult to diagnose in its early stage and to differentiate from other common shoulder disorders.

OBJECTIVE

The aim of this study was to validate any or all of the 8 clinical identifiers of early-stage primary/idiopathic adhesive capsulitis established in an earlier Delphi study.

DESIGN

This was a cross-sectional study.

METHODS

Sixty-four patients diagnosed with early-stage adhesive capsulitis by a physical therapist or medical practitioner were included in the study. Eight active and 8 passive shoulder movements and visual analog scale pain scores for each movement were recorded prior to and immediately following an intra-articular injection of corticosteroid and local anesthetic. Using the local anesthetic as the reference standard, pain relief of ≥70% for passive external rotation was deemed a positive anesthetic response (PAR).

RESULTS

Sixteen participants (25%) demonstrated a PAR. Univariate logistic regression identified that of the proposed identifiers, global loss of passive range of movement (odds ratio [OR]=0.26, P=.03), pain at the end of range of all measured active movements (OR=0.06, P=.02), and global loss of passive glenohumeral movements (OR=0.23, P=.02) were associated with a PAR. Following stepwise removal of the variables, pain at the end of range of all measured active movements remained the only identifier but was associated with reduced odds of a PAR.

LIMITATIONS

The lack of a recognized reference standard for diagnosing early-stage adhesive capsulitis remains problematic in all related research.

CONCLUSIONS

None of the clinical identifiers for early-stage adhesive capsulitis previously proposed by expert consensus have been validated in this study. Clinicians should be aware that commonly used clinical identifiers may not be applicable to this stage.

Clinical observation of standing trunk movements: what do the aberrant movement patterns tell us?

STUDY DESIGN

Clinical measurement, cross-sectional study.

OBJECTIVE

To investigate the reliability of observation of aberrant movement patterns (altered lumbopelvic rhythm, deviation from sagittal plane, instability catch or judder, and painful arc of motion) and to determine whether each pattern is associated with current low back pain (LBP).

BACKGROUND

Identification of aberrant movement patterns during trunk motion is an important component of subclassifying patients with LBP and prescribing evidence-based interventions. However, reported reliability for observation of specific aberrant patterns is low, and observation of any aberrant pattern (clinical definition of positive test) has ranged from poor to moderate. In addition, the validity of the association of clinical observations of aberrant movements during forward bending with LBP or dysfunction has yet to be determined.

METHODS

Experienced physical therapists simultaneously observed trunk movements of 102 subjects with no LBP, current LBP, or history of LBP. Kappa statistics were used to evaluate interrater agreement in identifying different types of aberrant patterns. Associations were used to determine the validity of the hypothesized relationship between aberrant patterns and LBP.

RESULTS

Interrater reliability of identifying the different types of aberrant patterns in subjects with LBP ranged from fair (κ = 0.35; 95% confidence interval: 0.00, 0.71) to excellent (κ = 0.89; 95% confidence interval: 0.69, 1.00). Using the clinical definition of 1 observation of any aberrant motion, interrater agreement was substantial (κ = 0.65; 95% confidence interval: 0.00, 1.00). Significant association was found between judder, deviation, and LBP. The frequency of observed aberrant patterns was significantly associated with LBP.

CONCLUSION

Simultaneous observation for specific aberrant movement patterns suggests that identification can be performed with at least fair interrater agreement, and observation of any pattern with substantial agreement. Aberrant patterns are more frequently observed in patients with current complaints of LBP; however, they also appear in individuals with a history of LBP and no LBP.

Nature and determinants of the course of chronic low back pain over a 12-month period: a cluster analysis

BACKGROUND

It has been suggested that low back pain (LBP) is a condition with an unpredictable pattern of exacerbation, remission, and recurrence. However, there is an incomplete understanding of the course of LBP and the determinants of the course.

OBJECTIVE

The purposes of this study were: (1) to identify clusters of LBP patients with similar fluctuating pain patterns over time and (2) to investigate whether demographic and clinical characteristics can distinguish these clusters.

DESIGN

This study was a secondary analysis of data extracted from a randomized controlled trial.

METHODS

Pain scores were collected from 155 participants with chronic nonspecific LBP. Pain intensity was measured monthly over a 1-year period by mobile phone short message service. Cluster analysis was used to identify participants with similar fluctuating patterns of pain based on the pain measures collected over a year, and t tests were used to evaluate if the clusters differed in terms of baseline characteristics.

RESULTS

The cluster analysis revealed the presence of 3 main clusters. Pain was of fluctuating nature within 2 of the clusters. Out of the 155 participants, 21 (13.5%) had fluctuating pain. Baseline disability (measured with the Roland-Morris Disability Questionnaire) and treatment groups (from the initial randomized controlled trial) were significantly different in the clusters of patients with fluctuating pain when compared with the cluster of patients without fluctuating pain.

LIMITATIONS

A limitation of this study was the fact that participants were undergoing treatment that may have been responsible for the rather positive prognosis observed.

CONCLUSIONS

A small number of patients with fluctuating patterns of pain over time were identified. This number could increase if individuals with episodic pain are included in this fluctuating group.

Effect of recurrent low back pain history on volitional pre-emptive abdominal activation during a loaded functional reach activity

STUDY DESIGN

A 2 (group) × 2 (abdominal contraction) × 2 (reach activity) crossover mixed design with repeated measures for contraction and activity examined the effects of a loaded (4.6 kg) forward-reach activity and abdominal drawing-in maneuver (ADIM) on transversus abdominis (TrA) contraction in subjects with nonspecific low back pain (NSLBP) history versus controls.

OBJECTIVE

We measured TrA contraction during a loaded forward-reach activity while using the ADIM and examined if a NSLBP history affects TrA activity.

SUMMARY OF BACKGROUND DATA

The ADIM supports trunk stability during function. Clinicians incorporate ADIM during patients' functional tasks. Pain-free individuals can sustain ADIM during function, such as forward-reach. However, this has not been tested in those with a NSLBP history.

METHODS

Eighteen normal subjects and 18 subjects with a history of NSLBP participated. A blinded investigator recorded M-mode ultrasound imaging measurements of TrA thickness (mm) during 4 conditions as follows: (1) quiet standing without ADIM; (2) quiet standing with ADIM; (3) loaded forward-reach without ADIM; and (4) loaded forward-reach with ADIM.

RESULTS

A mixed analysis of variance demonstrated a significant main effect for group (F [1, 34] = 5.404, P = 0.026; ), where TrA thickness was greater for NSLBP history (7.41 + 2.34 mm) versus controls (5.9 + 2.46 mm). A significant main effect was observed for abdominal contraction (F [1, 34] = 49.57, P < 0.0001; ), where TrA thickness was greater during ADIM (7.47 + 2.7 mm) versus without ADIM (5.84, 1.92 m). A significant main effect was observed for forward-reach activity (F [1, 34] = 12.79, P = 0.001; ), where TrA thickness was greater during a loaded forward-reach (7.04 + 2.6 mm) versus quiet standing (6.2 + 2.4 mm). There were no significant interactions.

CONCLUSION

Individuals can use a volitional pre-emptive ADIM for trunk protection during loaded forward-reach, potentially reducing injury risk. A NSLBP history increases TrA activation during ADIM, suggesting an enhanced protective role.

LEVEL OF EVIDENCE

2.

Clinical presentation and physiotherapy treatment of 4 patients with low back pain and isthmic spondylolisthesis

OBJECTIVE

Spondylolisthesis is a pathological condition characterized by the slipping of a vertebral body, compared with the underlying one, following structural and/or degenerative changes of the spine. The purpose of this case series is to describe clinical presentations and the conservative physiotherapy management of 4 patients with low back pain and lumbar isthmic spondylolisthesis.

CLINICAL FEATURES

Four patients aged 25, 43, 36, and 50 years presented with low back pain of various duration. Radiographs confirmed the presence of lumbar isthmic spondylolisthesis. Outcome measures included numerical rating scale, disability outcome measure (Oswestry Disability Index), spinal instability tests (Prone Instability Test, Passive Lumbar Extension test), and muscle function tests (Aberrant Movement Patterns, Active Straight Leg Raising, Prone and Supine Bridge Tests).

INTERVENTION AND OUTCOMES

Treatment consisted of postural reeducation, stretching, and strengthening exercises. Over the course of individualized treatment, ranging from 8 to 10 treatment visits, outcomes improved for all 4 patients.

CONCLUSION

This report describes varying clinical presentations and treatment of 4 patients with isthmic spondylolisthesis, suggesting that different pain generators could be managed by different conservative approaches.

Efficacy of segmental stabilization exercise for lumbar segmental instability in patients with mechanical low back pain: A randomized placebo controlled crossover study

Background:

Lumbar segmental stability is an important biomechanical component that influences symptoms amongst patients with Mechanical low back pain.

Aims:

To compare the efficacy of segmental stabilization exercises utilizing multifidus and transversus abdominis muscles versus a placebo treatment in patients with lumbar segmental instability.

Materials and methods:

The study was an observer-blinded randomized placebo-controlled cross-over study of 18 adults (12 men, 6 women), of mean age 22.5 ± 1.09 yrs who scored 7/13 in subjective aspects and 8/14 in objective aspects of Delphi criteria for lumbar segmental instability. The selected subjects were then randomized to receive either placebo-control (prone lying) or experimental (lumbar segmental stabilization) as a first treatment. Each treatment was followed by a wash-out period of 24 hours. Outcomes were measured four times- pre- and post- first intervention, pre- and post- second intervention. The outcome measures used were pain on Visual analogue scale, Pressure pain threshold and Joint play grading scale (0-6 scale) on that level.

Results:

Two-way analysis of variance and post-hoc analysis using Bonferonni test were used with level of significance set at p<.05 using Statistical package for social sciences version 12.0.1 for Windows. Visual analogue scale changed significantly in both the periods of intervention- in control (P =.016) and experimental (P =.000) periods. However this improvement was more significant in the experimental period. The Joint play grading scale scores improved only in the experimental condition compared to the control condition significantly. The Pressure pain threshold also improved significantly in the experimental condition (P =.000) while the changes in control condition was not statistically significant (P=.816).

Conclusion:

Segmental stabilization exercise was more effective than placebo intervention in symptomatic lumbar segmental instability.

Multifidus atrophy is localized and bilateral in active persons with chronic unilateral low back pain

OBJECTIVE

To compare the lumbar multifidi muscle volume devoid of fat local to the site of pain in persons with and without chronic unilateral lower lumbar pain.

DESIGN

Prospective cross-sectional design.

SETTING

University biokinesiology laboratory.

PARTICIPANTS

Active individuals (n=14) with chronic unilateral lower lumbar pain (>1 y) were matched for age, height, weight, and activity level with healthy individuals (n=14). Individuals with back pain had minimal disability (Oswestry Disability Index [mean ± SD], 14.9%±6.3%) at the time of testing.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Multifidus and erector spinae muscle volumes at the L5-S1 levels, multifidus muscle volumes at the L4 and S2-3 levels.

RESULTS

Average multifidus volume was diminished by 18.1% between groups (P=.026) only at the L5-S1 levels. There was no difference between painful and pain-free sides. There were no volume differences between groups above L5, below S1, or in erector spinae at the L5-S1 levels.

CONCLUSIONS

The results of this study indicate that despite a low level of disability and an activity level similar to that of matched control subjects, considerable localized, bilateral multifidus atrophy is present. Such impaired size of the multifidus will likely reduce its capacity to control intersegmental motion, thus increasing the susceptibility to further injury. Unlike acute unilateral low back pain (LBP), muscle size is reduced bilaterally in persons with chronic unilateral LBP.