Does targeting manual therapy and/or exercise improve patient outcomes in nonspecific low back pain? A systematic review

Comparison of the effects of dry needling and spinal manipulative therapy versus spinal manipulative therapy alone on functional disability and endurance in patients with nonspecific chronic low back pain: An experimental study

BACKGROUND

Low back pain (LBP) is a global musculoskeletal ailment. Over the past few years, dry needling (DN) has garnered interest from both physical therapists and patients. Physical therapy commonly employs spinal manipulation to alleviate persistent LBP and other musculoskeletal disorders. The aim of this study was to investigate the effects of spinal manipulation alone and in combination with DN on functional disability and endurance in individuals suffering from chronic nonspecific LBP.

METHODS

Patients of both genders who had chronic nonspecific LBP and who had not received physical therapy within the last 3 months were included in this single-blind, randomized controlled trial using purposive sampling. All participants were randomly assigned to either the experimental (SMT + DN) or control (SMT alone) group using computer-generated random numbers. The data were analyzed using the Statistical Package for Social Sciences (SPSS) version 23.0. For between-group comparisons, the Mann-Whitney U test was used. A P-value < .05 was considered to indicate statistical significance.

RESULTS

The analysis of the difference between the 2 groups revealed that the mean ± standard deviation (SD) for the SMT alone group was 16.09 ± 3.963 at baseline and 12.66 ± 3.801 at 8 weeks, whereas for the DN + ST group, it was 13.67 ± 3.904 at baseline and 10.92 ± 3.534 at 8 weeks, with a P-value of .003. Thus, the RMDQ score improved gradually in both groups, and the mean endurance score reported for the ST group was 2.5 to 4.5, while that reported for the DN + ST group was 3.1 to 5.1.

CONCLUSION

The results of this study showed that both therapies effectively reduced LBP. When comparing the effects of spinal manipulation alone to those of spinal manipulation combined with DN, the latter showed significantly greater benefits.

Inter- and intra-rater-reliability of a clinical framework for spine-related neck-arm pain

OBJECTIVE

A mechanism-based clinical framework for spine-related pain differentiates (i) somatic referred pain, ii) heightened nerve mechanosensitivity, iii) radicular pain, iv) radiculopathy and mixed-pain. This study aimed to determine the reliability of proposed framework.

METHOD

Fifty-one people with unilateral spine-related neck-arm pain were assessed and categorized by examiner-1. The classifications were compared to those made by two other examiners, based on written documentation of examiner-1. Cohens kappa was calculated between examiner-pairs; Fleiss Kappa among all examiners to assess agreement in classifying subgroups and entire framework.

RESULT

Inter-rater-reliability showed moderate to almost perfect reliability (somatic: no variation, mechanosensitivity: 0.96 (95% CI 0.87-1.0) to 1.0 (95% CI: 1.0-1.0), radicular pain: 0.46 (95% CI: 0.19-0.69) to 0.62 (95% CI: 0.42-0.81), radiculopathy: 0.65 (95% CI: 0.43-0.84) to 0.80 (95% CI: 0.63-0.96) mixed-pain: 0.54 (95% CI: 0.21-0.81) to 0.75 (95% CI: 0.48-0.94). There was almost perfect to moderate reliability among all examiners (somatic: no variation, mechanosensitivity: 0.97 (95% CI: 0.82-1.0), radicular pain: 0.56 (95% CI: 0.40-0.71), radiculopathy: 0.74 (95% CI: 0.58-0.90), mixed-pain: 0.63 (95% CI: 0.47-0.79), entire framework: 0.64 (95% CI: 0.57-0.71)). Intra-rater-reliability showed substantial to almost perfect reliability (somatic: no variation, mechanosensitivity: 0.96 (95% CI: 0.87-1.0), radicular pain: 0.76 (95% CI: 0.57-0.92), radiculopathy: 0.84 (95% CI: 0.67-0.96), mixed-pain: 0.83 (95% CI: 0.60-1.0), entire framework: 0.80 (95% CI: 0.61-0.92).

CONCLUSION

Moderate to almost perfect reliability in subgrouping people with spine-related neck-arm pain and substantial reliability for entire framework support this classification's reliability.

Spinal Manipulative Therapy for Nonspecific Low Back Pain: Does Targeting a Specific Vertebral Level Make a Difference?: A Systematic Review With Meta-analysis

OBJECTIVE: We aimed to examine whether targeting spinal manipulative therapy (SMT), by applying the intervention to a specific vertebral level, produces superior clinical outcomes than a nontargeted approach in patients with nonspecific low back pain. DESIGN: Systematic review with meta-analysis. LITERATURE SEARCH: MEDLINE, Embase, CENTRAL, CINAHL, Scopus, PEDro, and Index to Chiropractic Literature were searched up to May 31, 2023. STUDY SELECTION CRITERIA: Randomized controlled trials comparing targeted SMT (mobilization or manipulation) to a nontargeted approach in patients with nonspecific low back pain, and measuring the effects on pain intensity and patient-reported disability. DATA SYNTHESIS: Data extraction, risk of bias, and evaluation of the overall certainty of evidence using the GRADE approach were performed by 2 authors independently. Meta-analyses were performed using the restricted maximum likelihood method. RESULTS: Ten randomized controlled trials (n = 931 patients) were included. There was moderate-certainty evidence of no difference between targeted SMT and a nontargeted approach for pain intensity at postintervention (weighted mean difference = -0.20 [95% CI: -0.51, 0.10]) and at follow-up (weighted mean difference = 0.05 [95% CI: -0.26, 0.36]). For patient-reported disability, there was moderate-certainty evidence of no difference at postintervention (standardized mean difference = -0.04 [95% CI: -0.36, 0.29]) and at follow-up (standardized mean difference = -0.05 [95% CI: -0.24, 0.13]). Adverse events were reported in 4 trials, and were minor and evenly distributed between groups. CONCLUSION: Targeting a specific vertebral level when administering SMT for patients with nonspecific low back pain did not result in improved outcomes on pain intensity and patient-reported disability compared to a nontargeted approach. J Orthop Sports Phys Ther 2023;53(9):1-11. Epub: 28 July 2023. doi:10.2519/jospt.2023.11962.

Classification Approaches for Treating Low Back Pain Have Small Effects That Are Not Clinically Meaningful: A Systematic Review With Meta-analysis

OBJECTIVE

To determine whether classification systems improve patient-reported outcomes for people with low back pain (LBP).

DESIGN

Systematic review with meta-analysis.

LITERATURE SEARCH

The MEDLINE, Embase, CINAHL, Web of Science Core Collection, and Cochrane Central Register of Controlled Trials databases were searched from inception to June 21, 2021. Reference lists of prior systematic reviews and included trials were screened.

STUDY SELECTION CRITERIA

We included randomized trials comparing a classification system (eg, the McKenzie method or the STarT Back Tool) to any comparator. Studies evaluating participants with specific spinal conditions (eg, fractures or tumors) were excluded.

DATA SYNTHESIS

Outcomes were patient-reported LBP intensity, leg pain intensity, and disability. We used the revised Cochrane Collaboration Risk of Bias Tool to assess risk of bias, and the Grading of Recommendations Assessment, Development and Evaluation approach to judge the certainty of evidence. We used random-effects meta-analysis, with the Hartung-Knapp-Sidik- Jonkman adjustment, to estimate the standardized mean difference (SMD; Hedges' g) and 95% confidence interval (CI). Subgroup analyses explored classification system, comparator type, pain type, and pain duration.

RESULTS

Twenty-four trials assessing classification systems and 34 assessing subclasses were included. There was low certainty of a small effect at the end of intervention for LBP intensity (SMD, -0.31; 95% CI: -0.54, -0.07; P = .014, n = 4416, n = 21 trials) and disability (SMD, -0.27; 95% CI: -0.46, -0.07; P = .011, n = 4809, n = 24 trials), favoring classified treatments compared to generalized interventions, but not for leg pain intensity. At the end of intervention, no specific type of classification system was superior to generalized interventions for improving pain intensity and disability. None of the estimates exceeded the effect size that one would consider clinically meaningful.

CONCLUSION

For patient-reported pain intensity and disability, there is insufficient evidence supporting the use of classification systems over generalized interventions when managing LBP. J Orthop Sports Phys Ther 2022;52(2):67-84. Epub 15 Nov 2021. doi:10.2519/jospt.2022.10761.

Evaluating the effectiveness of patient tailored treatment for patients with non-specific low back pain: A systematic review

OBJECTIVE

This systematic review summarizes the relevant literature on the effectiveness of tailored interventions in non-specific low back pain (NSLBP).

METHODS

The search strategy has been executed in December 2019 in the electronic databases PubMed, Web of Science and Embase. Study selection, data extraction and quality assessment were done independently by two authors.

RESULTS

A total six eligible studies were identified. Five out of six articles used a classification system to subgroup patients. All active patient tailored interventions had similar or better results than the non-patient tailored interventions, most importantly on pain (short- and mid-term, not for long term follow-up). Two motor control interventions revealed sustained or increased effects at 12 months follow-up for disability. For cost-effectiveness, medication use and work absenteeism, results were inconclusive. Global rating of change evaluation confirmed significant between-group results at 10 weeks to 4 months follow-up, but results were not maintained at 12-month evaluation. DISCUSSION & CONCLUSION: Our findings support the preliminary evidence for the use of patient tailored treatment for reductions in pain and disability. However, our results are of very low to moderate quality evidence and the observed effects strongly depend on the subgroups and the chosen interventions. More high-quality RCT's with homogenous designs and larger sample sizes are needed.

Application and utility of a clinical framework for spinally referred neck-arm pain: A cross-sectional and longitudinal study protocol

BACKGROUND

The clinical presentation of neck-arm pain is heterogeneous with varying underlying pain types (nociceptive/neuropathic/mixed) and pain mechanisms (peripheral/central sensitization). A mechanism-based clinical framework for spinally referred pain has been proposed, which classifies into (1) somatic pain, (2) neural mechanosensitivity, (3) radicular pain, (4) radiculopathy and mixed pain presentations. This study aims to (i) investigate the application of the clinical framework in patients with neck-arm pain, (ii) determine their somatosensory, clinical and psychosocial profile and (iii) observe their clinical course over time.

METHOD

We describe a study protocol. Patients with unilateral neck-arm pain (n = 180) will undergo a clinical examination, after which they will be classified into subgroups according to the proposed clinical framework. Standardized quantitative sensory testing (QST) measurements will be taken in their main pain area and contralateral side. Participants will have to complete questionnaires to assess function (Neck Disability Index), psychosocial factors (Tampa Scale of Kinesiophobia, Pain Catastrophizing Scale, Depression, anxiety and stress scale), neuropathic pain (Douleur Neuropathique 4 Questions, PainDETECT Questionnaire) and central sensitization features (Central Sensitization Inventory). Follow-ups at three, six and 12 months include the baseline questionnaires. The differences of QST data and questionnaire outcomes between and within groups will be analyzed using (M)AN(C)OVA and/or regression models. Repeated measurement analysis of variance or a linear mixed model will be used to calculate the differences between three, six, and 12 months outcomes. Multiple regression models will be used to analyze potential predictors for the clinical course.

CONCLUSION

The rationale for this study is to assess the usability and utility of the proposed clinical framework as well as to identify possible differing somatosensory and psychosocial phenotypes between the subgroups. This could increase our knowledge of the underlying pain mechanisms. The longitudinal analysis may help to assess possible predictors for pain persistency.

Potential treatment effect modifiers for manipulative therapy for children complaining of spinal pain.Secondary analyses of a randomised controlled trial

Background

In children, spinal pain is transitory for most, but up to 20% experience recurrent and bothersome complaints. It is generally acknowledged that interventions may be more effective for subgroups of those affected with low back pain. In this secondary analysis of data from a randomized clinical trial, we tested whether five indicators of a potential increased need for treatment might act as effect modifiers for manipulative therapy in the treatment of spinal pain in children. We hypothesized that the most severely affected children would benefit more from manipulative therapy.

Method

This study was a secondary analysis of data from a randomised controlled trial comparing advice, exercises and soft tissue treatment with and without the addition of manipulative therapy in 238 Danish school children aged 9-15 years complaining of spinal pain. A text message system (SMS) and clinical examinations were used for data collection (February 2012 to April 2014).Five pre-specified potential effect modifiers were explored: Number of weeks with spinal pain 6 months prior to inclusion, number of weeks with co-occurring musculoskeletal pain 6 months prior to inclusion, expectations of the clinical course, pain intensity, and quality of life.Outcomes were number of recurrences of spinal pain, number of weeks with pain, length of episodes, global perceived effect, and change in pain intensity. To explore potential effect modification, various types of regression models were used depending on the type of outcome, including interaction tests.

Results

We found that children with long duration of spinal pain or co-occurring musculoskeletal pain prior to inclusion as well as low quality of life at baseline tended to benefit from manipulative therapy over non-manipulative therapy, whereas the opposite was seen for children reporting high intensity of pain. However, most results were statistically insignificant.

Conclusions

This secondary analysis indicates that children more effected by certain baseline characteristics, but not pain intensity, have a greater chance to benefit from treatment that include manipulative therapy. However, these analyses were both secondary and underpowered, and therefore merely exploratory. The results underline the need for a careful choice of inclusion criteria in future investigations of manipulative therapy in children.

Trial registration

NCT01504698; results.

The Evolving Case Supporting Individualised Physiotherapy for Low Back Pain

Low-back pain (LBP) is one of the most burdensome health problems in the world. Guidelines recommend simple treatments such as advice that may result in suboptimal outcomes, particularly when applied to people with complex biopsychosocial barriers to recovery. Individualised physiotherapy has the potential of being more effective for people with LBP; however, there is limited evidence supporting this approach. A series of studies supporting the mechanisms underpinning and effectiveness of the Specific Treatment of Problems of the Spine (STOPS) approach to individualised physiotherapy have been published. The clinical and research implications of these findings are presented and discussed. Treatment based on the STOPS approach should also be considered as an approach to individualised physiotherapy in people with LBP.

The type and pain provoking nature of exercise prescribed for low back pain: A survey of Australian health professionals

OBJECTIVES

To explore the type of exercise prescribed by Australian health professionals for LBP, and whether the exercises prescribed are pain-free or into pain.

METHODS

A survey of physiotherapists and exercise physiologists was conducted from all states/territories in Australia. The survey contained two chronic LBP vignettes with different pain mechanisms (dominant nociceptive or central sensitisation pain) and one acute LBP vignette. Respondents were asked if they would prescribe advice to stay active and exercise. If exercise was prescribed, respondents were asked to specify the type and pain provoking nature (exercise with no pain, exercise to the start of pain, exercise with pain at a tolerable level or exercise irrespective of pain).

RESULTS

The response rate was 17%(218/1276). Most respondents prescribed advice to stay active(≥95%) and exercise(≥90%) for all vignettes. Irrespective of the vignette, several exercises were prescribed [aerobic (57-85% of clinicians), motor control (62-84% of clinicians), range of motion (72-75% of clinicians)]. Strengthening exercise was prescribed more for chronic(>60%) than acute LBP(23%). Irrespective of the exercise, between 20 and 25% of respondents prescribed pain-free exercise, between 71 and 79% of respondents prescribed exercise into pain, and ≤4% prescribed exercise irrespective of pain for acute and chronic LBP.

CONCLUSIONS

Several exercises are prescribed for LBP, irrespective of pain mechanism or duration, with more clinicians prescribing strengthening exercise for chronic than acute LBP. Most clinicians prescribed exercise into pain for acute and chronic LBP, irrespective of the exercise. Further research should determine which exercises are beneficial based on pain mechanism and duration, and whether exercise into pain should be prescribed for LBP.

Role of posterior-anterior vertebral mobilization versus thermotherapy in non specific lower back pain

Background & Objective:

Low back pain (LBP) is the foremost cause to hamper an individual’s functional activities in Pakistan. Its impact on the quality of life and work routine makes it a major reason for therapeutic consultations. About 90% of the cases with LBP are non-specific. Various options are available for the treatment of LBP. Posterior-anterior vertebral mobilization, a manual therapy technique; and thermotherapy are used in clinical practice, however evidence to gauge their relative efficacy is yet to be synthesised. This study aimed to compare the effectiveness of posterior-anterior vertebral mobilization versus thermotherapy in the management of non-specific low back pain along with general stretching exercises.

Methods:

A randomised controlled trial with two-group pretest-posttest design was conducted at IPM&R, Dow University of Health Sciences (DUHS). A total of 60 Non-specific low back pain (NSLBP) patients with ages from 18 to 35 years were inducted through non-probability and purposive sampling technique. Baseline screening was done using an assessment form (Appendix-I). Subjects were allocated into two groups through systematic random sampling. Group-A (experimental group) received posterior-anterior vertebral mobilization with general stretching exercises while group B (control group) received thermotherapy with general stretching exercises. Pain and functional disability were assessed using NPRS and RMDQ respectively. Pre & post treatment scores were documented. A maximum drop-out rate of 20% was assumed. Recorded data were entered into SPSS V-19. Frequency and percentages were calculated for categorical variables. Intragroup and intergroup analyses were done using Wilcoxon signed ranked test and Mann-Whitney Test respectively. A P-value of 0.05 was considered statistically significant.

Results:

Pre and post treatment analysis revealed that P-values for both pain and disability were less than 0.05, suggesting significant difference in NPRS and RMDQ scores. Whereas, median scores for both pain and disability were decreased by 75% in experimental group and 50% in control group. For inter group analysis p-values for both pain and disability were found to be less than 0.05.

Conclusion:

Both physiotherapeutic interventions, the PAVMs and thermotherapy, have significant effects on NSLBP in terms of relieving pain and improving functional disability. However PAVMs appeared to be more effective than thermotherapy.

The efficacy of manual therapy and exercise for treating non-specific neck pain: A systematic review

OBJECTIVE

To review and update the evidence for different forms of manual therapy (MT) and exercise for patients with different stages of non-specific neck pain (NP).

DATA SOURCES

MEDLINE, Cochrane-Register-of-Controlled-Trials, PEDro, EMBASE.

METHOD

A qualitative systematic review covering a period from January 2000 to December 2015 was conducted according to updated-guidelines. Specific inclusion criteria only on RCTs were used; including differentiation according to stages of NP (acute - subacute [ASNP] or chronic [CNP]), as well as sub-classification based on type of MT interventions: MT1 (HVLA manipulation); MT2 (mobilization and/or soft-tissue-techniques); MT3 (MT1 + MT2); and MT4 (Mobilization-with-Movement). In each sub-category, MT could be combined or not with exercise and/or usual medical care.

RESULTS

Initially 121 studies were identified for potential inclusion. Based on qualitative and quantitative evaluation criteria, 23 RCTs were identified for review. Evidence for ASNP: MODERATE-evidence: In favour of (i) MT1 to the cervical spine (Cx) combined with exercises when compared to MT1 to the thoracic spine (Tx) combined with exercises; (ii) MT3 to the Cx and Tx combined with exercise compared to MT2 to the Cx with exercise or compared to usual medical care for pain and satisfaction with care from short to long-term. Evidence for CNP: STRONG-evidence: Of no difference of efficacy between MT2 at the symptomatic Cx level(s) in comparison to MT2 on asymptomatic Cx level(s) for pain and function. MODERATE to STRONG-evidence: In favour of MT1 and MT3 on Cx and Tx with exercise in comparison to exercise or MT alone for pain, function, satisfaction with care and general-health from short to moderate-terms. MODERATE-evidence: In favour (i) of MT1 as compared to MT2 and MT4, all applied to the Cx, for neck mobility, and pain in the very short term; (ii) of MT2 using sof-tissue-techniques to the Cx and Tx or MT3 to the Cx and Tx in comparison to no-treatment in the short-term for pain and disability.

CONCLUSION

This systematic review updates the evidence for MT combined or not with exercise and/or usual medical care for different stages of NP and provides recommendations for future studies. Two majors points could be highlighted, the first one is that combining different forms of MT with exercise is better than MT or exercise alone, and the second one is that mobilization need not be applied at the symptomatic level(s) for improvements of NP patients. These both points may have clinical implications for reducing the risk involved with some MT techniques applied to the cervical spine.

Latent class analysis derived subgroups of low back pain patients - do they have prognostic capacity?

BACKGROUND

Heterogeneity in patients with low back pain is well recognised and different approaches to subgrouping have been proposed. One statistical technique that is increasingly being used is Latent Class Analysis as it performs subgrouping based on pattern recognition with high accuracy. Previously, we developed two novel suggestions for subgrouping patients with low back pain based on Latent Class Analysis of patient baseline characteristics (patient history and physical examination), which resulted in 7 subgroups when using a single-stage analysis, and 9 subgroups when using a two-stage approach. However, their prognostic capacity was unexplored. This study (i) determined whether the subgrouping approaches were associated with the future outcomes of pain intensity, pain frequency and disability, (ii) assessed whether one of these two approaches was more strongly or more consistently associated with these outcomes, and (iii) assessed the performance of the novel subgroupings as compared to the following variables: two existing subgrouping tools (STarT Back Tool and Quebec Task Force classification), four baseline characteristics and a group of previously identified domain-specific patient categorisations (collectively, the 'comparator variables').

METHODS

This was a longitudinal cohort study of 928 patients consulting for low back pain in primary care. The associations between each subgroup approach and outcomes at 2 weeks, 3 and 12 months, and with weekly SMS responses were tested in linear regression models, and their prognostic capacity (variance explained) was compared to that of the comparator variables listed above.

RESULTS

The two previously identified subgroupings were similarly associated with all outcomes. The prognostic capacity of both subgroupings was better than that of the comparator variables, except for participants' recovery beliefs and the domain-specific categorisations, but was still limited. The explained variance ranged from 4.3%-6.9% for pain intensity and from 6.8%-20.3% for disability, and highest at the 2 weeks follow-up.

CONCLUSIONS

Latent Class-derived subgroups provided additional prognostic information when compared to a range of variables, but the improvements were not substantial enough to warrant further development into a new prognostic tool. Further research could investigate if these novel subgrouping approaches may help to improve existing tools that subgroup low back pain patients.

Effect on healthcare utilization and costs of spinal manual therapy for acute low back pain in routine care: A propensity score matched cohort study

Spinal manual therapy (SMT) is a popular treatment option for low back pain (LBP). The aim of our analysis was to evaluate the effects of manual therapy delivered by general practitioners and ambulatory orthopedic surgeons in routine care on follow up consultations, sick leave, health service utilization and costs for acute LBP compared to matched patients not receiving manual therapy. This is a propensity score matched cohort study based on health claims data. We identified a total of 113.652 adult patients with acute LBP and no coded red flags of whom 21.021 (18%) received SMT by physicians. In the final analysis 17.965 patients in each group could be matched. Balance on patients’ coded characteristics, comorbidity and prior health service utilization was achieved. The provision of SMT for acute LBP had no relevant impact on follow up visits and days of sick leave for LBP in the index billing period and the following year. SMT was associated with a higher proportion of imaging studies for LBP (30.6% vs. 23%, SMD: 0.164 [95% CI 0.143–0.185]). SMT did not lead to meaningful savings by replacing other health services for LBP. SMT for acute non-specific LBP in routine care was not clinically meaningful effective to reduce sick leave and reconsultation rates compared to no SMT and did not lead to meaningful savings by replacing other health services from the perspective of health insurance. This does not imply that SMT is ineffective but might reflect a problem with selection of suitable patients and the quality and quantity of SMT in routine care. National Manual Medicine societies should state clearly that imaging is not routinely needed prior to SMT in patients with low suspicion of presence of red flags and monitor the quality of provided services.

Clinical classification in low back pain: best-evidence diagnostic rules based on systematic reviews

Background

Clinical examination findings are used in primary care to give an initial diagnosis to patients with low back pain and related leg symptoms. The purpose of this study was to develop best evidence Clinical Diagnostic Rules (CDR] for the identification of the most common patho-anatomical disorders in the lumbar spine; i.e. intervertebral discs, sacroiliac joints, facet joints, bone, muscles, nerve roots, muscles, peripheral nerve tissue, and central nervous system sensitization.

Methods

A sensitive electronic search strategy using MEDLINE, EMBASE and CINAHL databases was combined with hand searching and citation tracking to identify eligible studies. Criteria for inclusion were: persons with low back pain with or without related leg symptoms, history or physical examination findings suitable for use in primary care, comparison with acceptable reference standards, and statistical reporting permitting calculation of diagnostic value. Quality assessments were made independently by two reviewers using the Quality Assessment of Diagnostic Accuracy Studies tool. Clinical examination findings that were investigated by at least two studies were included and results that met our predefined threshold of positive likelihood ratio ≥ 2 or negative likelihood ratio ≤ 0.5 were considered for the CDR.

Results

Sixty-four studies satisfied our eligible criteria. We were able to construct promising CDRs for symptomatic intervertebral disc, sacroiliac joint, spondylolisthesis, disc herniation with nerve root involvement, and spinal stenosis. Single clinical test appear not to be as useful as clusters of tests that are more closely in line with clinical decision making.

Conclusions

This is the first comprehensive systematic review of diagnostic accuracy studies that evaluate clinical examination findings for their ability to identify the most common patho-anatomical disorders in the lumbar spine. In some diagnostic categories we have sufficient evidence to recommend a CDR. In others, we have only preliminary evidence that needs testing in future studies. Most findings were tested in secondary or tertiary care. Thus, the accuracy of the findings in a primary care setting has yet to be confirmed.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-017-1549-6) contains supplementary material, which is available to authorized users.

Sub-classification based specific movement control exercises are superior to general exercise in sub-acute low back pain when both are combined with manual therapy: A randomized controlled trial

Background

Clinical guidelines recommend research on sub-groups of patients with low back pain (LBP) but, to date, only few studies have been published. One sub-group of LBP is movement control impairment (MCI) and clinical tests to identify this sub-group have been developed. Also, exercises appear to be beneficial for the management of chronic LBP (CLBP), but very little is known about the management of sub-acute LBP.

Methods

A randomized controlled trial (RCT) was conducted to compare the effects of general exercise versus specific movement control exercise (SMCE) on disability and function in patients with MCI within the recurrent sub-acute LBP group. Participants having a MCI attended five treatment sessions of either specific or general exercises. In both groups a short application of manual therapy was applied. The primary outcome was disability, assessed by the Roland-Morris Disability Questionnaire (RMDQ). The measurements were taken at baseline, immediately after the three months intervention and at twelve-month follow-up.

Results

Seventy patients met the inclusion criteria and were eligible for the trial. Measurements of 61 patients (SMCE n = 30 and general exercise n = 31) were completed at twelve months. (Drop-out rate 12.9 %). Patients in both groups reported significantly less disability (RMDQ) at twelve months follow-up. However, the mean change on the RMDQ between baseline and the twelve-month measurement showed statistically significantly superior improvement for the SMCE group -1.9 points (-3.9 to -0.5) 95 % (CI). The result did not reach the clinically significant three point difference. There was no statistical difference between the groups measured with Oswestry Disability Index (ODI).

Conclusion

For subjects with non-specific recurrent sub-acute LBP and MCI an intervention consisting of SMCE and manual therapy combined may be superior to general exercise combined with manual therapy.

Trial registration

The study protocol registration number is ISRCTN48684087. It was registered retrospectively 18th Jan 2012.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-016-0986-y) contains supplementary material, which is available to authorized users.

Using the template for intervention description and replication (TIDieR) as a tool for improving the design and reporting of manual therapy interventions

The detailed reporting of any research intervention is crucial to evaluate its applicability into a routinely practice-based context. However, it has been estimated that, especially in non-pharmacological interventions, the published literature typically includes incomplete intervention details. In the field of manual medicine, where interventions are delivered with a high degree of individualization and variability, poorly reported studies could compromise internal and external validity of the results. Among the various initiatives that have been undertaken to improve the intervention description, the Template for Intervention Description and Replication (TIDieR) has to be highlighted as the most promising. TIDieR offers both to researchers and clinicians a helpful and comprehensive guidance on how manual therapy interventions have to be designed and reported, taking into account the clinical complexity of manual therapy and the need to satisfy research gold standards.

Effects of postural specific sensorimotor training in patients with chronic low back pain: study protocol for randomised controlled trial

Background

Sensorimotor training (SMT) is popularly applied as a preventive or rehabilitative exercise method in various sports and rehabilitation settings. Yet, there is only low-quality evidence on its effect on pain and function. This randomised controlled trial will investigate the effects of a theory-based SMT in rehabilitation of chronic (>3 months) non-specific low back pain (CNLBP) patients.

Methods/Design

A pilot study with a parallel, single-blinded, randomised controlled design. Twenty adult patients referred to the clinic for CNLBP treatment will be included, randomised, and allocated to one of two groups. Each group will receive 9 x 30 minutes of standard physiotherapy (PT) treatment. The experimental group will receive an added 15 minutes of SMT. For SMT, proprioceptive postural exercises are performed on a labile platform with adjustable oscillation to provoke training effects on different entry levels. The active comparator group will perform 15 minutes of added sub-effective low-intensity endurance training. Outcomes are assessed on 4 time-points by a treatment blinded tester: eligibility assessment at baseline (BL) 2–4 days prior to intervention, pre-intervention assessment (T0), post-intervention assessment (T1), and at 4 weeks follow-up (FU). At BL, an additional healthy control group (n = 20) will be assessed to allow cross-sectional comparison with symptom-free participants. The main outcomes are self-reported pain (Visual Analogue Scale) and functional status (Oswestry Disability Index). For secondary analysis, postural control variables after an externally perturbed stance on a labile platform are analysed using a video-based marker tracking system and a pressure plate (sagittal joint-angle variability and centre of pressure confidence ellipse). Proprioception is measured as relative cervical joint repositioning error during a head-rotation task. Effect sizes and mixed-model MANOVA (2 groups × 4 measurements for 5 dependent variables) will be calculated.

Discussion

This is the first attempt to systematically investigate effects of a theory-based sensorimotor training in patients with CNLBP. It will provide analysis of several postural segments during a dynamic task for quantitative analysis of quality and change of the task performance in relation to changes in pain and functional status.

Trial registration

Trial registry number on cliniclatrials.gov is NCT02304120, first registered on 17 November 2014.

Do MRI findings identify patients with low back pain or sciatica who respond better to particular interventions? A systematic review

PURPOSE

Magnetic resonance imaging (MRI) can reveal a range of degenerative findings and anatomical abnormalities; however, the clinical importance of these remains uncertain and controversial. We aimed to investigate if the presence of MRI findings identifies patients with low back pain (LBP) or sciatica who respond better to particular interventions.

METHODS

MEDLINE, EMBASE and CENTRAL databases were searched. We included RCTs investigating MRI findings as treatment effect modifiers for patients with LBP or sciatica. We excluded studies with specific diseases as the cause of LBP. Risk of bias was assessed using the criteria of the Cochrane Back Review Group. Each MRI finding was examined for its individual capacity for effect modification.

RESULTS

Eight published trials met the inclusion criteria. The methodological quality of trials was inconsistent. Substantial variability in MRI findings, treatments and outcomes across the eight trials prevented pooling of data. Patients with Modic type 1 when compared with patients with Modic type 2 had greater improvements in function when treated by Diprospan (steroid) injection, compared with saline. Patients with central disc herniation when compared with patients without central disc herniation had greater improvements in pain when treated by surgery, compared with rehabilitation.

CONCLUSIONS

Although individual trials suggested that some MRI findings might be effect modifiers for specific interventions, none of these interactions were investigated in more than a single trial. High quality, adequately powered trials investigating MRI findings as effect modifiers are essential to determine the clinical importance of MRI findings in LBP and sciatica (

PROSPERO

CRD42013006571).

Knowledge translation from continuing education to physiotherapy practice in classifying patients with low back pain

OBJECTIVES

Physical therapists have used continuing education as a method of improving their skills in conducting clinical examination of patients with low back pain (LBP). The purpose of this study was to evaluate how well the pathoanatomical classification of patients in acute or subacute LBP can be learned and applied through a continuing education format. The patients were seen in a direct access setting.

METHODS

The study was carried out in a large health-care center in Finland. The analysis included a total of 57 patient evaluations generated by six physical therapists on patients with LBP. We analyzed the consistency and level of agreement of the six physiotherapists' (PTs) diagnostic decisions, who participated in a 5-day, intensive continuing education session and also compared those with the diagnostic opinions of two expert physical therapists, who were blind to the original diagnostic decisions. Evaluation of the physical therapists' clinical examination of the patients was conducted by the two experts, in order to determine the accuracy and percentage agreement of the pathoanatomical diagnoses.

RESULTS

The percentage of agreement between the experts and PTs was 72-77%. The overall inter-examiner reliability (kappa coefficient) for the subgroup classification between the six PTs and two experts was 0.63 [95% confidence interval (CI): 0.47-0.77], indicating good agreement between the PTs and the two experts. The overall inter-examiner reliability between the two experts was 0.63 (0.49-0.77) indicating good level of agreement.

DISCUSSION

Our results indicate that PTs' were able to apply their continuing education training to clinical reasoning and make consistently accurate pathoanatomic based diagnostic decisions for patients with LBP. This would suggest that continuing education short-courses provide a reasonable format for knowledge translation (KT) by which physical therapists can learn and apply new information related to the examination and differential diagnosis of patients in acute or subacute LBP.

Use of localized human growth hormone and testosterone injections in addition to manual therapy and exercise for lower back pain: a case series with 12-month follow-up

Objective

The objective of this case series was to investigate the feasibility and safety of a novel method for the management of chronic lower back pain. Injections of recombinant human growth hormone and testosterone to the painful and dysfunctional areas in individuals with chronic lower back pain were used. In addition, the participants received manual therapies and exercise addressing physical impairments such as motor control, strength, endurance, pain, and loss of movement. Pain ratings and self-rated functional outcomes were assessed.

Study design

This is a case series involving consecutive patients with chronic lower back pain who received the intervention of injections of recombinant human growth hormone and testosterone, and attended chiropractic and/or physical therapy. Outcomes were measured at 12 months from the time of injection.

Setting

A community based hospital affiliated office, and a private practice block suite.

Participants

A total of 60 consecutive patients attending a pain management practice for chronic lower back pain were recruited for the experimental treatment. Most participants were private pay.

Interventions

Participants who provided informed consent and were determined not to have radicular pain received diagnostic blocks. Those who responded favorably to the diagnostic blocks received injections of recombinant human growth hormone and testosterone in the areas treated with the blocks. Participants also received manipulation- and impairment-based exercises.

Outcome measures

Outcomes were assessed at 12 months through pain ratings with the Mankowski Pain Scale and the Oswestry Disability Index.

Results

Of the 60 patients recruited, 49 provided informed consent, and 39 completed all aspects of the study. Those patients receiving the intervention reported a significant decrease in pain ratings (P<0.01) and a significant improvement in self-rated Oswestry Disability Index scores (P<0.01). In addition, in the Oswestry Disability Index results, 41% of the patients demonstrated a 50% or greater change in their disability score. Of the subjects who withdrew from the study, one was due to the pain created by the injections and nine were for nonstudy factors.

Conclusion

The intervention appeared to be safe and the results provide a reasonable expectation that the intervention would be beneficial for a population of individuals with chronic nonradicular lower back pain. Due to the design of the study, causality cannot be inferred, but the results do indicate that further study of the intervention may be warranted.

What are patient beliefs and perceptions about exercise for nonspecific chronic low back pain? A systematic review of qualitative studies

OBJECTIVES

The global burden of low back pain is the highest ranked condition contributing to years of living with disability. Exercise is moderately effective, and adherence to exercise may improve if participants are engaged. Identification of elements that enhance engagement would enable clinicians to prescribe appropriate interventions. The review objective was to identify and synthesize qualitative empirical studies that have explored beliefs about exercise therapy of people with nonspecific chronic low back pain.

METHODS

Two independent reviewers conducted a structured review and metasynthesis informed by Cochrane and Campbell Collaboration guidelines and the PRISMA statement. Fifteen papers were included for data extraction, method quality assessment, and thematic analysis.

RESULTS

Four key themes emerged: (1) perceptions and classification of exercise; (2) role and impact of the health professional; (3) exercise and activity enablers/facilitators; (4) exercise and activity barriers. Participants believed that there were distinctions between general activity, real/fitness exercise, and medical exercise. Levels of acquired skills and capability and participant experience with exercise culture require consideration in program design. People participating in exercise classes and group work may be more comfortable when matched for abilities and experience. When an intervention interferes with everyday life and appears to be ineffective or too difficult to implement, people make a reasoned decision to discontinue.

DISCUSSION

People are likely to prefer and participate in exercise or training programs and activities that are designed with consideration of their preferences, circumstances, fitness levels, and exercise experiences.

The effect of changing movement and posture using motion-sensor biofeedback, versus guidelines-based care, on the clinical outcomes of people with sub-acute or chronic low back pain-a multicentre, cluster-randomised, placebo-controlled, pilot trial

Background

The aims of this pilot trial were to (i) test the hypothesis that modifying patterns of painful lumbo-pelvic movement using motion-sensor biofeedback in people with low back pain would lead to reduced pain and activity limitation compared with guidelines-based care, and (ii) facilitate sample size calculations for a fully powered trial.

Methods

A multicentre (8 clinics), cluster-randomised, placebo-controlled pilot trial compared two groups of patients seeking medical or physiotherapy primary care for sub-acute and chronic back pain. It was powered for longitudinal analysis, but not for adjusted single-time point comparisons. The intervention group (n = 58) received modification of movement patterns augmented by motion-sensor movement biofeedback (ViMove, dorsaVi.com) plus guidelines-based medical or physiotherapy care. The control group (n = 54) received a placebo (wearing the motion-sensors without biofeedback) plus guidelines-based medical or physiotherapy care.

Primary outcomes were self-reported pain intensity (VAS) and activity limitation (Roland Morris Disability Questionnaire (RMDQ), Patient Specific Functional Scale (PSFS)), all on 0–100 scales. Both groups received 6–8 treatment sessions. Outcomes were measured seven times during 10-weeks of treatment and at 12, 26 and 52 week follow-up, with 17.0 % dropout. Patients were not informed of group allocation or the study hypothesis.

Results

Across one-year, there were significant between-group differences favouring the intervention group [generalized linear model coefficient (95 % CI): group effect RMDQ −7.1 (95 % CI–12.6;–1.6), PSFS −10.3 (−16.6; −3.9), QVAS −7.7 (−13.0; −2.4); and group by time effect differences (per 100 days) RMDQ −3.5 (−5.2; −2.2), PSFS −4.7 (−7.0; −2.5), QVAS −4.8 (−6.1; −3.5)], all p < 0.001. Risk ratios between groups of probability of improving by >30 % at 12-months = RMDQ 2.4 (95 % CI 1.5; 4.1), PSFS 2.5 (1.5; 4.0), QVAS 3.3 (1.8; 5.9).

The only device-related side-effects involved transient skin irritation from tape used to mount motion sensors.

Conclusions

Individualised movement retraining using motion-sensor biofeedback resulted in significant and sustained improvements in pain and activity limitation that persisted after treatment finished. This pilot trial also refined the procedures and sample size requirements for a fully powered RCT.

This trial (Australian New Zealand Clinical Trials Registry NCT01572779) was equally funded by dorsaVi P/L and the Victorian State Government.

Improving acute pain management in emergency medicine

Undertreatment of pain (oligoanalgesia) in the emergency department is common, and it negatively impacts patient care. Both failure of appropriate pain assessment and the potential for unsafe analgesic use contribute to the problem. As a result, achieving satisfactory analgesia while minimizing side effects remains particularly challenging for emergency physicians, both in the emergency department and after a patient is discharged. Improvements in rapid pain assessment and in evaluation of noncommunicative populations may result in a better estimation of which patients require analgesia and how much pain is present. New formulations of available treatments, such as rapidly absorbed, topical, or intranasal nonsteroidal anti-inflammatory drug formulations or intranasal opioids, may provide effective analgesia with an improved risk-benefit profile. Other pharmacological therapies have been shown to be effective for certain pain modalities, such as the use of antidepressants for musculoskeletal pain, γ-aminobutyric acid agonists for neuropathic and postsurgical pain, antipsychotics for headache, and topical capsaicin for neuropathic pain. Nonpharmacological methods of pain control include the use of electrical stimulation, relaxation therapies, psychosocial/manipulative therapies, and acupuncture. Tailoring of available treatment options to specific pain modalities, as well as improvements in pain assessment, treatment options, and formulations, may improve pain control in the emergency department setting and beyond.

Do MRI findings identify patients with chronic low back pain and Modic changes who respond best to rest or exercise: a subgroup analysis of a randomised controlled trial

BACKGROUND

No previous clinical trials have investigated MRI findings as effect modifiers for conservative treatment of low back pain. This hypothesis-setting study investigated if MRI findings modified response to rest compared with exercise in patients with chronic low back pain and Modic changes.

METHODS

This study is a secondary analysis of a randomised controlled trial comparing rest with exercise. Patients were recruited from a specialised outpatient spine clinic and included in a clinical trial if they had chronic low back pain and an MRI showing Modic changes. All patients received conservative treatment while participating in the trial. Five baseline MRI findings were investigated as effect modifiers: Modic changes Type 1 (any size), large Modic changes (any type), large Modic changes Type 1, severe disc degeneration and large disc herniation. The outcome measure was change in low back pain intensity measured on a 0-10 point numerical rating scale at 14-month follow-up (n = 96). An interaction ≥ 1.0 point (0-10 scale) between treatment group and MRI findings in linear regression was considered clinically important.

RESULTS

The interactions for Modic Type 1, with large Modic changes or with large Modic changes Type 1 were all potentially important in size (-0.99 (95 % CI -3.28 to 1.29), -1.49 (-3.73 to 0.75), -1.49 (-3.57 to 0.58), respectively) but the direction of the effect was the opposite to what we had hypothesized-that people with these findings would benefit more from rest than from exercise. The interactions for severe disc degeneration (0.74 (-1.40 to 2.88)) and large disc herniation (-0.92 (3.15 to 1.31)) were less than the 1.0-point threshold for clinical importance. As expected, because of the lack of statistical power, no interaction term for any of the MRI findings was statistically significant.

CONCLUSIONS

Three of the five MRI predictors showed potentially important effect modification, although the direction of the effect was surprising and confidence intervals were wide so very cautious interpretation is required. Further studies with adequate power are warranted to study these and additional MRI findings as potential effect modifiers for common interventions.

Evaluation of a modified clinical prediction rule for use with spinal manipulative therapy in patients with chronic low back pain: a randomized clinical trial

Background

Spinal Manipulative Therapy (SMT) and Active Exercise Therapy (AET) have both demonstrated efficacy in the treatment of Chronic Lower Back Pain (CLBP). A Clinical Prediction Rule (CPR) for responsiveness to SMT has been validated in a heterogeneous lower back pain population; however there is a need to evaluate this CPR specifically for patients with CLBP, which is a significant source of disability.

Methods

We conducted a randomized controlled trial (RCT) in Veteran Affairs and civilian outpatient clinics evaluating a modification of the original CPR (mCPR) in CLBP, eliminating acute low back pain and altering the specific types of SMT to improve generalizability. We enrolled and followed 181 patients with CLBP from 2007 to 2010. Patients were randomized by status on the mCPR to undergo either SMT or AET twice a week for four weeks. Providers and statisticians were blinded as to mCPR status. We collected outcome measures at 5, 12 and 24-weeks post baseline. We tested our study hypotheses by a general linear model repeated measures procedure following a univariate analysis of covariance approach. Outcome measures included, Visual Analogue Scale, Bodily pain subscale of SF-36 and the Oswestry Disability Index, Patient Satisfaction and Patient Expectation.

Results

Of the 89 AET patients, 69 (78%) completed the study and of the 92 SMT patients, 76 (83%) completed the study. As hypothesized, we found main effects of time where the SMT and AET groups showed significant improvements in pain and disability from baseline. There were no differences in treatment outcomes between groups in response to the treatment, given the lack of significant treatment x time interactions. The mCPR x treatment x time interactions were not significant. The differences in outcomes between treatment groups were the same for positive and negative on the mCPR groups, thus our second hypothesis was not supported.

Conclusions

We found no evidence that a modification of the original CPR can be used to discriminate CLBP patients that would benefit more from SMT. Further studies are needed to further clarify the patient characteristics that moderate treatment responsiveness to specific interventions for CLBP.

Trial registration

ISRCTN30511490

Several submaximal exercise tests are reliable, valid and acceptable in people with chronic pain, fibromyalgia or chronic fatigue: a systematic review

QUESTION

Are submaximal and maximal exercise tests reliable, valid and acceptable in people with chronic pain, fibromyalgia and fatigue disorders?

DESIGN

Systematic review of studies of the psychometric properties of exercise tests.

PARTICIPANTS

People older than 18 years with chronic pain, fibromyalgia and chronic fatigue disorders.

INTERVENTION

Studies of the measurement properties of tests of physical capacity in people with chronic pain, fibromyalgia or chronic fatigue disorders were included.

OUTCOME MEASURES

Studies were required to report: reliability coefficients (intraclass correlation coefficient, alpha reliability coefficient, limits of agreements and Bland-Altman plots); validity coefficients (intraclass correlation coefficient, Spearman's correlation, Kendal T coefficient, Pearson's correlation); or dropout rates.

RESULTS

Fourteen studies were eligible: none had low risk of bias, 10 had unclear risk of bias and four had high risk of bias. The included studies evaluated: Åstrand test; modified Åstrand test; Lean body mass-based Åstrand test; submaximal bicycle ergometer test following another protocol other than Åstrand test; 2-km walk test; 5-minute, 6-minute and 10-minute walk tests; shuttle walk test; and modified symptom-limited Bruce treadmill test. None of the studies assessed maximal exercise tests. Where they had been tested, reliability and validity were generally high. Dropout rates were generally acceptable. The 2-km walk test was not recommended in fibromyalgia.

CONCLUSION

Moderate evidence was found for reliability, validity and acceptability of submaximal exercise tests in patients with chronic pain, fibromyalgia or chronic fatigue. There is no evidence about maximal exercise tests in patients with chronic pain, fibromyalgia and chronic fatigue.

Indicating spinal joint mobilisations or manipulations in patients with neck or low-back pain: protocol of an inter-examiner reliability study among manual therapists

BACKGROUND

Manual spinal joint mobilisations and manipulations are widely used treatments in patients with neck and low-back pain. Inter-examiner reliability of passive intervertebral motion assessment of the cervical and lumbar spine, perceived as important for indicating these interventions, is poor within a univariable approach. The diagnostic process as a whole in daily practice in manual therapy has a multivariable character, however, in which the use and interpretation of passive intervertebral motion assessment depend on earlier results from the diagnostic process. To date, the inter-examiner reliability among manual therapists of a multivariable diagnostic decision-making process in patients with neck or low-back pain is unknown.

METHODS

This study will be conducted as a repeated-measures design in which 14 pairs of manual therapists independently examine a consecutive series of a planned total of 165 patients with neck or low-back pain presenting in primary care physiotherapy. Primary outcome measure is therapists' decision about whether or not manual spinal joint mobilisations or manipulations, or both, are indicated in each patient, alone or as part of a multimodal treatment. Therapists will largely be free to conduct the full diagnostic process based on their formulated examination objectives. For each pair of therapists, 2×2 tables will be constructed and reliability for the dichotomous decision will be expressed using Cohen's kappa. In addition, observed agreement, prevalence of positive decisions, prevalence index, bias index, and specific agreement in positive and negative decisions will be calculated. Univariable logistic regression analysis of concordant decisions will be performed to explore which demographic, professional, or clinical factors contributed to reliability.

DISCUSSION

This study will provide an estimate of the inter-examiner reliability among manual therapists of indicating spinal joint mobilisations or manipulations in patients with neck or low-back pain based on a multivariable diagnostic reasoning and decision-making process, as opposed to reliability of individual tests. As such, it is proposed as an initial step toward the development of an alternative approach to current classification systems and prediction rules for identifying those patients with spinal disorders that may show a better response to manual therapy which can be incorporated in randomised clinical trials. Potential methodological limitations of this study are discussed.

The use of "stabilization exercises" to affect neuromuscular control in the lumbopelvic region: a narrative review

It is well-established that the coordination of muscular activity in the lumbopelvic region is vital to the generation of mechanical spinal stability. Several models illustrating mechanisms by which dysfunctional neuromuscular control strategies may serve as a cause and/or effect of low back pain have been described in the literature. The term "core stability" is variously used by clinicians and researchers, and this variety has led to several rehabilitative approaches suggested to affect the neuromuscular control strategies of the lumbopelvic region (e.g. "stabilization exercise", "motor control exercise"). This narrative review will highlight: 1) the ongoing debate in the clinical and research communities regarding the terms "core stability" and "stabilization exercise", 2) the importance of sub-grouping in identifying those patients most likely to benefit from such therapeutic interventions, and 3) two protocols that can assist clinicians in this process.

The efficacy of manual therapy and exercise for different stages of non-specific low back pain: an update of systematic reviews

OBJECTIVE

to review and update the evidence for different forms of manual therapy (MT) for patients with different stages of non-specific low back pain (LBP).

DATA SOURCES

MEDLINE, Cochrane-Register-of-Controlled-Trials, PEDro, EMBASE.

METHOD

A systematic review of MT with a literature search covering the period of January 2000 to April 2013 was conducted by two independent reviewers according to Cochrane and PRISMA guidelines. A total of 360 studies were evaluated using qualitative criteria. Two stages of LBP were categorized; combined acute-subacute and chronic. Further sub-classification was made according to MT intervention: MT1 (manipulation); MT2 (mobilization and soft-tissue-techniques); and MT3 (MT1 combined with MT2). In each sub-category, MT could be combined or not with exercise or usual medical care (UMC). Consequently, quantitative evaluation criteria were applied to 56 eligible randomized controlled trials (RCTs), and hence 23 low-risk of bias RCTs were identified for review. Only studies providing new updated information (11/23 RCTs) are presented here.

RESULTS

Acute-subacute LBP: STRONG-evidence in favour of MT1 when compared to sham for pain, function and health improvements in the short-term (1-3 months). MODERATE-evidence to support MT1 and MT3 combined with UMC in comparison to UMC alone for pain, function and health improvements in the short-term. Chronic LBP: MODERATE to STRONG-evidence in favour of MT1 in comparison to sham for pain, function and overall-health in the short-term. MODERATE-evidence in favour of MT3 combined with exercise or UMC in comparison to exercise and back-school was established for pain, function and quality-of-life in the short and long-term. LIMITED-evidence in favour of MT2 combined with exercise and UMC in comparison to UMC alone for pain and function from short to long-term. LIMITED-evidence of no effect for MT1 with extension-exercise compared to extension-exercise alone for pain in the short to long-term.

CONCLUSION

This systematic review updates the evidence for MT with exercise or UMC for different stages of LBP and provides recommendations for future studies.

Exercise only, exercise with mechanical traction, or exercise with over-door traction for patients with cervical radiculopathy, with or without consideration of status on a previously described subgrouping rule: a randomized clinical trial

STUDY DESIGN

Randomized clinical trial.

OBJECTIVES

To examine the effectiveness of cervical traction in addition to exercise for specific subgroups of patients with neck pain.

BACKGROUND

Cervical traction is frequently used, but its effectiveness has not been adequately examined. Existing studies have failed to target patients most likely to respond. Traction is typically recommended for patients with cervical radiculopathy. A prediction rule has been described to identify a narrower subgroup of patients likely to respond to cervical traction.

METHODS

Patients with neck pain and signs of radiculopathy were randomized to 4 weeks of treatment with exercise, exercise with mechanical traction, or exercise with over-door traction. Baseline assessment included subgrouping-rule status. The primary outcome measure (Neck Disability Index, scored 0-100) and secondary outcome measure (neck and arm pain intensity) were assessed at 4 weeks, 6 months, and 12 months after enrollment. The primary analyses examined 2-way treatment-by-time interactions. Secondary analyses examined validity of the subgrouping rule by adding 3-way interactions.

RESULTS

Eighty-six patients (53.5% female; mean age, 46.9 years) were enrolled in the study. Intention-to-treat analysis found lower Neck Disability Index scores at 6 months in the mechanical traction group compared to the exercise group (mean difference between groups, 13.3; 95% confidence interval: 5.6, 21.0) and over-door traction group (mean difference between groups, 8.1; 95% confidence interval: 0.8, 15.3), and at 12 months in the mechanical traction group compared to the exercise group (mean difference between groups, 9.8; 95% confidence interval: 0.2, 19.4). Secondary outcomes favored mechanical traction at several time points. The validity of the subgrouping rule was supported on the Neck Disability Index at the 6-month time point only.

CONCLUSION

Adding mechanical traction to exercise for patients with cervical radiculopathy resulted in lower disability and pain, particularly at long-term follow-ups. The study protocol was registered at http://clinicaltrials.gov (NCT00979108).

Immediate effects of region-specific and non-region-specific spinal manipulative therapy in patients with chronic low back pain: a randomized controlled trial

BACKGROUND

Manual therapists typically advocate the need for a detailed clinical examination to decide which vertebral level should be manipulated in patients with low back pain. However, it is unclear whether spinal manipulation needs to be specific to a vertebral level.

OBJECTIVE

The purpose of this study was to analyze the immediate effects of a single, region-specific spinal manipulation defined during the clinical examination versus a single non-region-specific spinal manipulation (applied on an upper thoracic vertebra) in patients with chronic nonspecific low back pain for the outcome measures of pain intensity and pressure pain threshold at the time of the assessment.

DESIGN

This was a 2-arm, prospectively registered, randomized controlled trial with a blinded assessor.

SETTING

The study was conducted in an outpatient physical therapy clinic in Brazil.

PATIENTS

The study participants were 148 patients with chronic nonspecific low back pain (with pain duration of at least 12 weeks).

RANDOMIZATION

The randomization schedule was generated by an independent statistician and was concealed by using consecutively numbered, sealed, opaque envelopes.

INTERVENTIONS

A single high-velocity manipulation was administered to the upper thoracic region of the participants allocated to the non-region-specific manipulation group and to the painful lumbar levels of the participants allocated to the region-specific manipulation group.

MEASUREMENTS

Pain intensity was measured by a 0 to 10 numeric pain rating scale. Pressure pain threshold was measured using a pressure algometer.

LIMITATIONS

It was not possible to blind the therapist and participants.

RESULTS

A total of 148 patients participated in the study (74 in each group). There was no loss to follow-up. Both groups improved in terms of immediate decrease of pain intensity; however, no between-group differences were observed. The between-group difference for pain intensity and pressure pain threshold were 0.50 points (95% confidence interval=-0.10 to 1.10) and -1.78 points (95% confidence interval=-6.40 to 2.82), respectively. No adverse reactions were observed.

CONCLUSION

The immediate changes in pain intensity and pressure pain threshold after a single high-velocity manipulation do not differ by region-specific versus non-region-specific manipulation techniques in patients with chronic low back pain.

Interpretation of subgroup effects in published trials

With the rapidly expanding number of studies reporting on treatment subgroups come new challenges in analyzing and interpreting this sometimes complex area of the literature. This article discusses 3 important issues regarding the analysis and interpretation of existing trials or systematic reviews that report on treatment effect modifiers (subgroups) for specific physical therapy interventions. The key messages are: (1) point estimates of treatment modifier effect size (interaction effect) and their confidence intervals can be calculated using group-level data when individual patient-level data are not available; (2) interaction effects do not define the total effect size of the intervention in the subgroup but rather how much more effective it is in the subgroup than in those not in the subgroup; (3) recommendations regarding the use of an intervention in a subgroup need to consider the size and direction of the main effect and the interaction effect; and (4) rather than simply judging whether a treatment modifier effect is clinically important based only on the interaction effect size, a better criterion is to determine whether the combined effect of the interaction effect and main effect makes the difference between an overall effect that is clinically important and one that is not clinically important.

Systematic review of randomized controlled trials of clinical prediction rules for physical therapy in low back pain

STUDY DESIGN

Systematic review.

OBJECTIVE

To evaluate randomized controlled trials validating the effects of a clinical prediction rule for patients with non-specific low back pain (LBP). The outcomes of interest were any back pain or pain-related measures.

SUMMARY OF BACKGROUND DATA

LBP is a common and costly condition. Interventions for back pain seem to have, at best, small to moderate mean beneficial effects. Identifying subgroups of patients who may respond better to certain treatments may help to improve clinical outcomes in back pain. The development of clinical prediction rules is an attempt to determine who will respond best to certain treatments.

METHODS

We conducted electronic searches of MEDLINE (1980-2009), EMBASE (1980-2009), PsycINFO (1980-2009), Allied and Complementary Medicine (1980-2009), PubMed (1980-2009), ISI Web of Knowledge (1980-2009), and the Cochrane Library (1980-2009). The reference lists of relevant articles were searched for further references.

RESULTS

We identified 1821 potential citations; 3 articles were included. The results from the available data do not support the use of clinical prediction rules in the management of non-specific LBP.

CONCLUSION

There is a lack of good quality randomized controlled trials validating the effects of a clinical prediction rule for LBP. Furthermore, there is no agreement on appropriate methodology for the validation and impact analysis. The evidence for, and development of, the existing prediction rules is generally weak.

Predictors for half-year outcome of impairment in daily life for back pain patients referred for physiotherapy: a prospective observational study

BACKGROUND AND OBJECTIVE

From observational studies, there is only sparse information available on the predictors of development of impairment in daily life for patients receiving physiotherapy. Therefore, our aim was to identify factors which predict impairment in daily life for patients with back pain 6 months after receiving physiotherapy.

METHODS

We conducted a prospective cohort study with 6-month follow-up. Patients were enrolled for treatment in private physiotherapy practices. Patients with a first physiotherapy referral because of thoracic or low back pain, aged 18 to 65 years were included. Primary outcome impairment was measured utilising the 16-item version of the Musculoskeletal Function Assessment Questionnaire. Therapy was documented on a standardized form. Baseline scores for impairment in daily life, symptom characteristics, sociodemographic and psychosocial factors, physical activity, nicotine consumption, intake of analgesics, comorbidity and delivered primary therapy approach were investigated as possible predictors. Univariate and multiple linear regression analyses were performed.

RESULTS

A total of 792 patients participated in the study (59% female, mean age 44.4 (SD 11.4), with 6-month follow-up results available from 391 patients. In univariate analysis 17 variables reached significance. In multiple linear regression identified predictors were: impairment in daily life before therapy, mental disorders, duration of the complaints, self-prognosis on work ability, rheumatoid arthritis, age, form of stress at work and physical activity. The variables explain 34% of variance (adjusted R(2), p<0.001).

CONCLUSIONS

With minimal information available from observational studies on the predictors of development of back problems for physiotherapy patients, this study adds new knowledge for forming appropriate referral guidelines. Impairment in daily life before therapy, mental disorder as comorbidity and the duration of the complaints can be named as outstanding factors. The results of this study can be used to facilitate comparison of patient therapy goals with the prognosis in everyday practice.

Quantitative sensory testing changes in the successful management of chronic low back pain

Individuals with chronic low back pain (LBP) represent a significant percentage of patients in physical therapy practice. The clinical pattern often includes diffuse pain and a variety of sensory complaints, making categorization difficult and leading to diagnoses such as non-specific LBP. Objective measures of sensory changes through quantitative sensory testing may help identify central sensitization of nociceptive pathways in this population. Identification of these somatosensory changes may contribute to clinical decision making and patient management. The purpose of this case report is to present objective evaluation findings, including altered somatosensation, in a patient with a 2-year history of LBP, and to describe changes in function and quantitative sensory testing with successful management.

Patients with low back pain differ from those who also have leg pain or signs of nerve root involvement - a cross-sectional study

Background

Leg pain associated with low back pain (LBP) is recognized as a risk factor for a poor prognosis, and is included as a component in most LBP classification systems. The location of leg pain relative to the knee and the presence of a positive straight leg raise test have been suggested to have clinical implications. To understand differences between such leg pain subgroups, and whether differences include potentially modifiable characteristics, the purpose of this paper was to describe characteristics of patients classified into the Quebec Task Force (QTF) subgroups of: 1) LBP only, 2) LBP and pain above the knee, 3) LBP and pain below the knee, and 4) LBP and signs of nerve root involvement.

Methods

Analysis of routine clinical data from an outpatient department. Based on patient reported data and clinical findings, patients were allocated to the QTF subgroups and described according to the domains of pain, activity limitation, work participation, psychology, general health and clinical examination findings.

Results

A total of 2,673 patients aged 18–95 years (median 47) who were referred for assessment of LBP were included. Increasing severity was consistently observed across the subgroups from LBP only to LBP with signs of nerve root involvement although subgroup differences were small. LBP patients with leg pain differed from those with LBP only on a wide variety of parameters, and patients with signs of nerve root involvement had a more severe profile on almost all measures compared with other patients with back-related leg pain.

Conclusion

LBP patients with pain referral to the legs were more severely affected than those with local LBP, and patients with signs of nerve root involvement were the ones most severily affected. These findings underpin the concurrent validity of the Quebec Task Force Classification. However, the small size of many between-subgroup differences amid the large variability in this sample of cross-sectional data also underlines that the heterogeneity of patients with LBP is more complex than that which can be explained by leg pain patterns alone. The implications of the observed differences also require investigation in longitudinal studies.

Clinical equipoise and personal equipoise: two necessary ingredients for reducing bias in manual therapy trials

Clinical and personal equipoise exists when a clinician has no good basis for a choice between two or more care options or when one is truly uncertain about the overall benefit or harm offered by the treatment to his/her patient. For most manual therapy trials, equipoise does not likely exist. Because of the nature of the intervention a lack of equipoise can lead to bias and may account for a portion of the 'effect' that has traditionally been assigned to the intervention. Although there are methodological mechanisms to reduce the risk of bias associated with a lack of equipoise, most of the manual therapy trials to date are likely guilty of this form of bias.

IFOMPT 2012: a rendez-vous of hands and minds

Since its founding in Montreal, Canada in 1974, the International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) has been providing orthopaedic and manual therapists from around the world with the highest-quality learning opportunities through a conference held every 4 years. In 2012, IFOMPT is partnering with The International Private Practitioners Association (IPPA) to host this prestigious event in Quebec City, Canada. As more than 51% of the Canadian Physiotherapy Association membership is working in private practice, this adds even greater value to this quadrennial event. This conference emulates best-evidence practice in the marriage of research and clinical excellence by pulling together some of the best and brightest hands and minds in orthopaedic physiotherapy. Through a call for proposals that equally emphasized research, clinical excellence, and the knowledge translation link between the two, the IFOMPT mandate of clinical and academic excellence has been kept at the forefront of this year's conference. Included in this supplement are the IFOMPT 2012 keynote addresses, schedule, and abstracts.

Effects of tailored neck-shoulder pain treatment based on a decision model guided by clinical assessments and standardized functional tests. A study protocol of a randomized controlled trial

Background

A major problem with rehabilitation interventions for neck pain is that the condition may have multiple causes, thus a single treatment approach is seldom efficient. The present study protocol outlines a single blinded randomised controlled trial evaluating the effect of tailored treatment for neck-shoulder pain. The treatment is based on a decision model guided by standardized clinical assessment and functional tests with cut-off values. Our main hypothesis is that the tailored treatment has better short, intermediate and long-term effects than either non-tailored treatment or treatment-as-usual (TAU) on pain and function. We sub-sequentially hypothesize that tailored and non-tailored treatment both have better effect than TAU.

Methods/Design

120 working women with minimum six weeks of nonspecific neck-shoulder pain aged 20–65, are allocated by minimisation with the factors age, duration of pain, pain intensity and disability in to the groups tailored treatment (T), non-tailored treatment (NT) or treatment-as-usual (TAU). Treatment is given to the groups T and NT for 11 weeks (27 sessions evenly distributed). An extensive presentation of the tests and treatment decision model is provided. The main treatment components are manual therapy, cranio-cervical flexion exercise and strength training, EMG-biofeedback training, treatment for cervicogenic headache, neck motor control training. A decision algorithm based on the baseline assessment determines the treatment components given to each participant of T- and NT-groups. Primary outcome measures are physical functioning (Neck Disability Index) and average pain intensity last week (Numeric Rating Scale). Secondary outcomes are general improvement (Patient Global Impression of Change scale), symptoms (Profile Fitness Mapping neck questionnaire), capacity to work in the last 6 weeks (quality and quantity) and pressure pain threshold of m. trapezius. Primary and secondary outcomes will be reported for each group with effect size and its precision.

Discussion

We have chosen not to include women with psychological ill-health and focus on biomedical aspects of neck pain. Future studies should aim at including psychosocial aspects in a widened treatment decision model. No important adverse events or side-effects are expected.

Trial registration

Current Controlled Trials registration ISRCTN49348025.

Efficacy of movement control exercises versus general exercises on recurrent sub-acute nonspecific low back pain in a sub-group of patients with movement control dysfunction. Protocol of a randomized controlled trial

Background

Practice guidelines recommend various types of exercise for chronic back pain but there have been few head-to-head comparisons of these interventions. General exercise seems to be an effective option for management of chronic low back pain (LBP) but very little is known about the management of a sub-acute LBP within sub-groups.

Recent research has developed clinical tests to identify a subgroup of patients with chronic non-specific LBP who have movement control dysfunction (MD).

Method/Design

We are conducting a randomized controlled trial (RCT) to compare the effects of general exercise and specific movement control exercise (SMCE) on disability and function in patients with MD within recurrent sub-acute LBP. The main outcome measure is the Roland Morris Disability Questionnaire.

Discussion

European clinical guideline for management of chronic LBP recommends that more research is required to develop tools to improve the classification and identification of specific clinical sub-groups of chronic LBP patients. Good quality RCTs are then needed to determine the effectiveness of specific interventions aimed at these specific target groups. This RCT aims to test the hypothesis whether patients within a sub-group of MD benefit more through a specific individually tailored movement control exercise program than through general exercises.

The efficacy of targeted interventions for modifiable psychosocial risk factors of persistent nonspecific low back pain - a systematic review

BACKGROUND

There is considerable interest in whether best practice management of nonspecific low back pain (NSLBP) should include the targeting of treatment to subgroups of people with identifiable clinical characteristics. However, there are no published systematic reviews of the efficacy of targeted psychosocial interventions.

AIM

This review aimed to determine if the efficacy of interventions for psychosocial risk factors of persistent NSLBP is improved when targeted to people with particular psychosocial characteristics.

METHOD

Bibliographic databases were searched. Inclusion criteria were randomised controlled trials of targeted psychosocial interventions that used trial designs capable of providing robust information on the efficacy of targeted treatment (treatment effect modification) for the outcomes of pain, activity limitation and psychosocial factors (fear avoidance, catastrophisation, anxiety and depression).

RESULTS AND CONCLUSION

Four studies met the inclusion criteria and collectively investigated nine hypotheses about targeted treatment on 28 subgroup/treatment outcomes. There were only two statistically significant results. Graded activity plus Treatment Based Classification targeted to people with high movement-related fear was more effective than Treatment Based Classification at reducing movement-related fear at 4 weeks. Active rehabilitation (physical exercise classes with cognitive-behavioural principles) was more effective than usual GP care at reducing activity limitation at 12 months, when targeted to people with higher movement-related pain. Few studies have investigated targeted psychosocial interventions in NSLBP, using trial designs suitable for measuring treatment effect modification, and they do not provide consistent evidence supporting such targeting. There is a need for appropriately designed and adequately powered trials to investigate targeted psychosocial interventions.

Clinical equipoise and personal equipoise: two necessary ingredients for reducing bias in manual therapy trials

Clinical and personal equipoise exists when a clinician has no good basis for a choice between two or more care options or when one is truly uncertain about the overall benefit or harm offered by the treatment to his/her patient. For most manual therapy trials, equipoise does not likely exist. Because of the nature of the intervention a lack of equipoise can lead to bias and may account for a portion of the 'effect' that has traditionally been assigned to the intervention. Although there are methodological mechanisms to reduce the risk of bias associated with a lack of equipoise, most of the manual therapy trials to date are likely guilty of this form of bias.