Centralization: prevalence and effect on treatment outcomes using a standardized operational definition and measurement method

How to tackle non-specific low back pain among adult patients? A systematic review with a meta-analysis to compare four interventions

OBJECTIVE

To tackle non-specific low back pain (NSLBP) among patients and find the most effective solution and to quantitatively synthesize the overall effect of motor control training (MCT) compared with Pilates, McKenzie method, and physical therapy (PT) in pain and physical function.

METHODS

Randomized controlled trials (RCTs) of four types of intervention (MCT, Pilates, McKenzie method, and PT) for LBP were collected by searching PubMed, Web of Science, EBSCOhost (Cochrane Central Register of Controlled Trials), and Scopus databases from the establishment of the database to September 30, 2023. The risk of bias was evaluated for included studies using the Revised Cochrane Risk of Bias tool for randomized trials (RoB 2.0). Taking pain and physical function in the experimental and control groups as outcome indicators, subgroup analysis was performed according to the intervention method to calculate the standardized mean difference (SMD) and 95% confidence interval (CI).

RESULTS

A total of 25 RCTs, including 1253 patients, were included. Meta-analysis showed that MCT effectively relieved pain [SMD = -0.65, 95% CI (- 1.00, - 0.29), p < 0.01] and improved physical function [SMD = -0.76, 95% CI (- 1.22, - 0.31), p < 0.01] comparing with other 3 types of intervention. Subgroup analysis suggested that MCT could alleviate pain [SMD = -0.92, 95% CI (- 1.34, - 0.50), p < 0.01] and improve physical function [SMD = -1.15, 95% CI (- 1.72, - 0.57), p < 0.01] compared with PT, but it had no statistical significance compared with Pilates [pain: SMD = 0.13, 95% CI (- 0.56, 0.83), p = 0.71; physical function: SMD = 0.10, 95% CI (- 0.72, 0.91), p = 0.81] and the McKenzie method [pain: SMD = -0.03, 95% CI (- 0.75, 0.68), p = 0.93; physical function: SMD = -0.03, 95% CI (- 1.00, 0.94), p = 0.95].

CONCLUSIONS

MCT can effectively relieve pain and improve physical function in patients with NSLBP. It is more effective compared with PT for LBP, while no differences were detected between MCT and Pilates, as well as McKenzie method. Therefore, MCT, Pilates, and the McKenzie method should be encouraged as exercise interventions for NSLBP rehabilitation.

Sustained versus repetitive standing trunk extension results in greater spinal growth and pain improvement in back pain:A randomized clinical trial

BACKGROUND

McKenzie standing trunk extension exercises have been used for the management of low back pain (LBP). However, no study to date has investigated the effect of standing trunk extension postures on spinal height and clinical outcomes.

OBJECTIVE

To evaluate in subjects with LBP following a period of trunk loading how spinal height, pain, symptoms' centralization and function outcome measures respond to two standing postures interventions: (1) repetitive trunk extension (RTE) and (2) sustained trunk extension (STE).

METHODS

A consecutive sample of convenience of people with LBP were recruited to participate in 2-session physical therapy using either RTE or STE in standing.

RESULTS

Thirty participants (18 women) with a mean age of 53 ± 17.5 years completed the study. The first session resulted in spinal height increase (spinal growth) of 2.07 ± 1.32 mm for the RTE intervention and 4.54 ± 1.61 mm for the STE group (p< 0.001; ES = 1.67), while the second session (2-week following the first session) resulted in spinal growth of 2.39 ± 1.46 mm for the RTE group and 3.91 ± 2.06 mm for the STE group (p= 0.027; ES = 0.85). The STE group presented with the larger reduction in most pain from 6 to 2 as compared to the RTE group from 6 to 4 between Session 1 and Session 2 (p< 0.001). There was no difference between the groups in Modified Oswestry score and symptoms centralization (p= 0.88 and p= 0.77, respectively).

CONCLUSION

People with LBP experienced greater spine growth and improvements of pain during standing STE as compared to RTE. People with LBP could use such postures and movements to alleviate their LBP and improve spine height while in a weight bearing position.

Effects of the Addition of Hands-on Procedures to McKenzie Exercises on Pain, Functional Disability and Back Mobility in Patients with Low Back Pain: A Randomised Clinical Trial

Background

Low back pain (LBP) is a common musculoskeletal disorder that affects people of all ages. This study investigates the effects of the addition of hands-on procedures to McKenzie exercises on patients with LBP and derangement syndrome.

Methods

Forty-eight female patients were randomly assigned to either the experimental group or control group. All the patients in both groups underwent McKenzie exercises, transcutaneous electrical nerve stimulation (TENS) and education for 35 min/session-45 min/ session, with three sessions/week for 2 weeks. Hands-on procedures were added to the McKenzie extension exercises only for the patients in the experimental group. A visual analogue scale (VAS), the Oswestry disability index (ODI), back range of motion (BROM) and body diagrams were used to measure pain, functional disability, BROM and the centralisation of symptoms, respectively.

Results

The mean values of VAS, ODI and BROM significantly improved after the interventions in both groups (P < 0.05), whereas the results of repeated measures ANOVA and Mann-Whitney U tests showed statistically non-significant differences between the two groups (P > 0.05).

Conclusion

The addition of hands-on procedures to McKenzie exercises, TENS and education significantly alleviated back pain and functional disability and improved the back mobility and centralisation of symptoms in patients with LBP and derangement syndrome; however, these measures did not result in any significant additional benefits for such patients.

The association between self-efficacy on function and pain outcomes among patients with chronic low back pain managed using the McKenzie approach: a prospective cohort study

INTRODUCTION

Self-efficacy is a determinant of function and pain outcomes in patients with chronic low back pain receiving physiotherapy. The McKenzie approach is an effective intervention for patients with back pain that may affect self-efficacy. Study aims were to determine if, among patients with back pain being managed by McKenzie-credentialed physiotherapists: intake self-efficacy is correlated with intake function and pain; intake self-efficacy is associated with changes in function and pain during treatment; self-efficacy improves during treatment; and improvements in self-efficacy during treatment are associated with improvements in function and pain at discharge.

METHODS

Two-hundred-eighty-two subjects with chronic low back pain seen by McKenzie-credentialed clinicians provided data on self-efficacy, function and pain at intake and discharge.

RESULTS

Self-efficacy was correlated with function and pain at intake; however, intake self-efficacy was not associated with function or pain outcomes. Self-efficacy increased during treatment. This increase was associated with improvements in function and pain at discharge.

CONCLUSION

While intake self-efficacy was associated with function and pain when initiating physiotherapy, it did not result in improved treatment outcomes. Specific interventions may be necessary to improve self-efficacy. The increases in self-efficacy observed during treatment were associated with improvements in function and pain outcomes at discharge.

Influence of Tensioner's Mobilization on the Centralization of Symptoms in Cervicobrachial Pain Syndrome: A Randomized Controlled Trial

Study Design

This study was designed as a randomized controlled trial.

Purpose

The present study aimed to determine the impact of neural mobilization by tensioner’s technique (NMTT) on the centralization of symptoms and pain in patients with cervicobrachial pain syndrome (CBPS).

Overview of Literature

CBPS is a disabling condition of the neck that is characterized by pain and paresthesia in the upper quarter. Several techniques have successfully provided immediate and long-term relief in CBPS; however, few studies have evaluated the effect of these techniques on the centralization of symptoms.

Methods

Thirty patients aged 18–45 years with a complaint of pain in the neck that had persisted for 2–12 weeks radiating to the arm and fulfilling Elvey’s criteria were randomly selected and divided into two groups. Group A received NMTT plus conventional treatment (hot pack and postural advice with cervical lateral glide), and group B received only conventional treatment 3 times a week for 2 weeks. The outcome measures were Wernicke’s scale score for the centralization of symptoms and Visual Analog Scale score for pain intensity. Within- and between-group comparisons were made before initiating treatment and at the end of the 3rd and 6th sessions. Within group analyses for the centralization values were performed using Friedmann test, and between-group analyses were performed using Mann-Whitney test. A 2×3 mixed model of the analysis of variance was used for analyzing the pain levels.

Results

There was a significant difference (p<0.05) within and between the groups for both the measures at the end of the 3rd and 6th sessions. Thus, NMTT may be beneficial in decreasing the peripheralization of symptoms and pain intensity in patients with CBPS.

Conclusions

NMTT can be used as an alternative and effective treatment option for patients with CBPS.

Effectiveness of mechanical diagnosis and therapy in patients with non-specific chronic low back pain: a literature review with meta-analysis

OBJECTIVE

To determine the effectiveness of mechanical diagnosis and therapy (MDT) in patients with chronic low back pain (CLBP) compared to other traditional physical therapy interventions.

METHODS

Randomized controlled trials investigating the effect of MDT compared to other traditional physical therapy interventions in individuals with CLBP were considered eligible. For the purpose of this review, MDT was compared to active and passive physical therapy interventions. Independent reviewers assessed the eligibility of studies, extracted data, and assessed the risk of bias. The primary outcomes investigated were pain and disability.

RESULTS

Fourteen studies were included in the review. Of these, 11 provided data to be included in the meta-analyses. Our findings showed that MDT was no more effective in decreasing pain (standardized mean difference [SMD]=0.01, 95% confidence interval [CI]: -0.44, 0.46) and disability (SMD=0.08, 95% CI: -0.53, 0.68) than other active treatments. Similar results were found when comparing MDT to other passive treatments for pain (SMD=-0.39, 95% CI: -0.90, 0.11) and disability (SMD=-0.13, 95% CI: -0.29, 0.03).

CONCLUSION

There is low to moderate quality evidence that MDT is not superior than other traditional physical therapy interventions in improving pain and disability in people with CLBP.

Do patients with low back pain remember physiotherapists' advice? A mixed-methods study on patient-therapist communication

OBJECTIVES

The primary aim of this study was to determine if the advice physiotherapists think they provide to patients with low back pain (LBP) is what the patients remember and take away from the clinical encounter. The secondary aim was to determine which factors may influence the retention of this advice.

METHODS

The first component of the study used questionnaires completed by patients and therapists after the initial visit. Related questionnaires of patients and therapists were screened for inconsistencies. The second component of the study involved semi-structured interviews.

RESULTS

Ninety pairs of questionnaires were completed. Therapists provided patients with one (N = 90), two (N = 85) or three (N = 51) items of advice regarding the management of their LBP. All patients remembered the first item of advice, 92% remembered a second, and 67% remembered the third piece of advice. All items of advice were deemed either 'relevant' or 'very relevant' by 97% of the patients. After the analysis of 14 interviews, data saturation was reached. Four themes emerged from the data analysis of the interviews: (a) Evaluation type, (b) Exercise factors, (c) Patient concerns about their diagnosis, and (d) Patient expectations.

DISCUSSION

In most cases, patients remembered what therapists told them and considered that the advice provided was relevant. Based on the qualitative data, patients were more likely to remember what therapists said when: (a) shared decision making was used during the initial encounter, (b) prescribed exercises were simple to perform and few in number, (c) patients' concerns about their diagnosis were addressed, and (d) patients' expectations were identified and addressed.

Does the Keele STarT Back Screening Tool Contribute to Effectiveness in Treatment and Cost and Loss of Follow-Up of the Mechanical Diagnosis and Therapy for Patients with Low Back Pain?

Background: Mechanical diagnosis and therapy (MDT) and the stratified approach using the Keele STarT Back Screening Tool (SBST) are examples of stratified low back pain (LBP) management. We investigated whether the medium–high risk in SBST can contribute to the time and sessions until discharge from MDT (Question 1) and to the loss of follow-up before identifying a promising management strategy (Question 2). Methods: A retrospective chart study was conducted. Multiple regression modeling was constructed using 10 independent variables, including whether the SBST was medium–high risk or not for Question 1, and the 9/10 independent variables for Question 2. Results: The data of 89 participants for Question 1 and 166 participants for Question 2 were analyzed. SBST was not a primary contributing factor for Question 1 (R² = 0.17–0.19). The model for Question 2 included SBST as a primary contributing factor and the shortest distance from the patient address to the hospital as a secondary contributing factor (93.4% correct classification). Conclusion: SBST status was not a primary contributing factor for time and sessions until discharge from MDT, but was a critical factor for the loss of MDT follow-up before identifying a promising management strategy.

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.

Classification by pain pattern for patients with cervical spine radiculopathy

OBJECTIVES

A prospective observational cohort study was conducted to (1) report the prevalence of Mechanical Diagnosis and Therapy (MDT) classifications, Centralization (CEN), and Non-CEN among patients with Cervical Spine Radiculopathy (CSR), and (2) describe the association between classification via CEN and Non-CEN and clinical outcomes at follow-up.

METHODS

Data were collected from 680 consecutive patients who presented to outpatient, orthopedic physical therapy clinics with primary complaints of neck pain with and without radiculopathy; thirty-nine patients (6%) met the physical examination inclusion criteria for CSR. First examination and follow-up data were completed by 19 patients.

RESULTS

Seventy-nine percent of patients' conditions were classified as Reducible Derangement at first examination and 21% were classified as either Irreducible Derangement, Entrapment, or Mechanically Inconclusive. The prevalence of CEN and Non-CEN was 36.8% and 47.4%, respectively. All patients treated via MDT methods made clinically significant improvements in disability, but not pain intensity, at follow-up. The magnitude of change in clinical outcomes was greatest for patients who exhibited CEN; however, the changes in disability and pain intensity at follow-up were not statistically significant compared to patients who exhibited Non-CEN at first examination. Patients who exhibited CEN were discharged, on average, ten days earlier and had one less treatment visit compared to patients who exhibited Non-CEN.

DISCUSSION

The findings of this study show that patients with CSR can be classified and treated via MDT methods and experienced clinically significant improvements in disability, but not pain intensity, at follow-up. Providers should consider MDT classification and treatment to improve clinical outcomes for their patients affected by CSR.

Are within and/or between session improvements in pain and function prognostic of medium and long-term improvements in musculoskeletal problems? A systematic review

BACKGROUND

Initial or between session improvements in pain and/or function are often considered to be predictive of ultimate outcomes in musculoskeletal problems.

OBJECTIVE

To determine the long-term prognostic value of within and between session improvements to pain and function.

DESIGN

Systematic review of relevant literature.

METHOD

A search was made of multiple databases (Pubmed/Medline, Cochrane, Cinahl, and AMed) using relevant search terms. Titles, abstracts, and then full texts were filtered to find articles that met the strict inclusion/exclusion criteria. Searching, data extraction, and quality assessment, using GRADE, were done independently by two authors. Disagreements were resolved by consensus.

RESULTS

Only 13 articles met the criteria for inclusion. For the effect of pain location or pain intensity changes in the first treatment session on medium or long-term pain, disability, return-to-work, or global outcomes nine outcomes were available. Findings were mostly inconclusive (5) or negative (3). There was only one study evaluating between session improvements with ambiguous results. There were no studies evaluating the prognostic value of early improvements in function.

CONCLUSIONS

There is no conclusive evidence to support the concept that early changes in pain location or pain intensity offer a good longer-term prognosis on a variety of outcomes; and no evidence relating to early improvements in function. The idea that patients who appear to improve in the first treatment session will do well longer term is not supported by the literature.

Initial pain and disability characteristics can assist the prediction of the centralization phenomenon on initial assessment of patients with low back pain

OBJECTIVES

Determine whether the achievement of the centralization phenomenon on initial assessment of patients with low back pain (LBP) can be predicted by history and physical examination variables.

METHODS

Ninety patients referred to physical therapy due to LBP completed pain, disability, and fear-avoidance questionnaires, followed by a complete history and a physical examination based on mechanical diagnosis and therapy principles. Patients were subsequently classified as centralizers or noncentralizers. Univariate, followed by multivariate analysis was performed to identify history and physical examination variables that predicted the occurrence of the CP. Factors retained in the multivariate analysis were used to develop a clinical prediction rule (CPR).

RESULTS

Twenty-eight patients (31%) were classified as centralizers immediately following assessment. Three predictors were retained in the multivariate analysis: (1) modified Oswestry Disability Index score lower than 33%; (2) intensity of the most distal symptom lower than 6/10; and (3) back pain equal to or greater than leg pain. The resultant CPR indicated the presence of all three variables increased the post-test likelihood of the CP to 57%.

DISCUSSION

The findings of this study suggest the CP may be considerably more likely in less severe cases of LBP characterized by lower disability, lower intensity of distal symptoms, and a greater back-versus-leg pain intensity. Pending future validation, the CPR developed in this study may aide decision making regarding the initial management strategy of patients with LBP.

Directional preference constructs for patients' neck pain in the absence of centralization

Objectives: We conducted a secondary analysis of a prospective, observational cohort study to (1) report the prevalence of Directional Preference (DP) constructs at first examination for patients with cervical spine challenges, and (2) determine the association between DP constructs and clinical outcomes at discharge from physical therapy. Methods: We analyzed data collected from 718 consecutive patients who presented to outpatient, private practice clinics with primary complaints of non-specific neck pain; 200 patients met the inclusion criteria and completed first examination and discharge data. Statistical analysis determined the association between DP constructs at first examination and clinical outcomes at discharge. Results: The findings in this investigation were that (1) the most prevalent DP constructs at first examination were related to ROM and pain intensity including Patient Reported Improvement in ROM (79.5%), Increase in Spine ROM (32.5%), and Pain Intensity Change (15.0%), (2) all DP groups improved and met the MCID for disability and pain intensity change at discharge except for the group that did not exhibit Increase in Spine ROM for pain intensity, (3) no clinically significant differences in pain intensity or disability existed between DP groups at discharge, and (4) 28.5% and 6.5% of patients exhibited a relative increase in cervical spine extension and flexion ROM, respectively, post-repeated movement testing on the first examination. Discussion: The most prevalent DP constructs at first examination were related to ROM and pain intensity, and each was associated with a comparable clinical trajectory in terms of pain and disability outcomes at discharge. The findings of this study help Mechanical Diagnosis and Therapy (MDT) providers understand the common DP constructs encountered in routine clinical practice and their relation to pain and disability outcomes for patients with cervical spine challenges. Level of Evidence: 2b.

Fascial manipulation vs. standard physical therapy practice for low back pain diagnoses: A pragmatic study

BACKGROUND

Connective tissue mobility alters motor unit recruitment, but the restoration of fascial mobility allows for optimal motor function. The Fascial Manipulation^® (FM^®) method is a multiplanar approach that assesses and treats the mobility of deep fascia in specific anatomical locations where motor units converge.

OBJECTIVES

To assess the effects of FM^® vs. standard physical therapy treatment (SPT) in patients with low back pain (LBP).

DESIGN

Six-months controlled clinical trial.

METHOD

102 participants with LBP received SPT or FM^®. Numeric Pain Rating Scale (NPRS), 15- point Global Rating of Change (GROC), and Oswestry Disability Index (ODI) were used to monitor progress.

RESULTS

The FM^® group had a significantly lower ODI (p < 0.009) and NPS scores (p < 0.0001) and significantly higher GROC scores (p < 0.003) once their means were adjusted for initial scores. When comparing the SPT to FM^®, the final ODI decreased by at least 1 category in 48.9% of the SPT cases, while in 36.2% of the cases was no change. ODI minimal clinical importance difference (MCID) change of 10% decrease in scores occurred in 70.2% of the SPT group compared to 96% of the FM^® group (p = 0.003). ODI MCID change of 50% decrease in scores occurred in 40% of the SPT group compared to 64.6% of the FM^® group (p = 0.02) 44.7% of the participants in the SPT group had final GROC values above +5 at discharge, compared to 92% of the participants from the FM^® group (p = 0.0001). The FM^® subjects had almost three times the change in NPRS compared to SPT counterparts (-4.3 ± 2.2 to -1.5  ± 2.4, p=0.0001).

CONCLUSIONS

FM^® appears to improve NPRS, GROC, and ODI more than SPT. FM^® may provide an effective treatment technique for LBP.

Directional preference constructs for patients' low back pain in the absence of centralization

Objectives: A detailed description of how Directional Preference (DP) constructs are measured could accelerate research to practice translation and improve research findings for Mechanical Diagnosis and Therapy (MDT) stakeholders. A secondary analysis of a prospective, observational cohort study was conducted to understand (1) the type and prevalence of DP constructs at first examination and (2) the relationships between DP constructs and clinical outcomes at follow-up. Methods: Data were collected and analyzed from 1485 consecutive patients who presented to outpatient, private practice clinics with primary complaints of non-specific low back pain (LBP); 400 patients met the inclusion criteria and completed first examination and follow-up data. Statistical analysis determined prevalence and the relationships between DP constructs at first examination and clinical outcomes at follow-up. Results: The primary findings in this investigation were that (1) the most prevalent DP constructs at first examination were related to range of motion (ROM) and pain intensity (Patient Reported Improvement in ROM (74.8%), Increase in Spine ROM (29.5%), and Pain Intensity Change (17.3%)), (2) all groups improved and made clinically meaningful improvements in disability and pain intensity at follow-up, (3) no clinically significant differences in disability or pain intensity were found between the groups at follow-up, and (4) 26.5% and 6.5% of patients exhibited a relative increase in lumbar spine extension and flexion ROM, respectively, post repeated movement testing on the first examination. Discussion: The findings in this study assist providers in making assessment and treatment decisions with their patients by offering insight regarding the most prevalent DP constructs typically found at the first examination and their subsequent association with outcome when Centralization (CEN) does not occur. Recommendations for researchers have been made to further explore the DP framework used in this study.

McKenzie mechanical syndromes coincide with biopsychosocial influences, including central sensitization: a descriptive study of individuals with chronic neck pain

BACKGROUND

Mechanical diagnosis and therapy (MDT) aims to assess and classify patients into theoretically mutually exclusive subgroups, in order to direct treatment. However, the latest evidence for biopsychosocial influence-central sensitization (CS) and psychological distress-have not been assessed in conjunction with MDT.

OBJECTIVES

(1) Determine the percentage of patients categorized into the MDT subgroups; (2) characterize the biopsychosocial clinical profile (presence of CS and psychological distress); and (3) identify associations between pain, disability, and biopsychosocial influences among this cohort.

METHODS

Eighty four patients with chronic neck pain were recruited by 10 certified MDT therapists using a convenience (consecutive) sampling method. Patients were evaluated using MDT principles and also completed an online survey to measure CS (using the Central Sensitization Inventory [CSI]), pain catastrophizing and kinesiophobia.

RESULTS

The proportions of the subgroups derangement (DER), dysfunction, postural and 'other' were 74.4, 2.4, 1.2, 20.7%, respectively. CS was observed in 62% of our sample (CSI score ≥ 40). CS was also observed in 64.7% of patients of the DER subgroup. Almost half of our sample (47.8%) demonstrated the co-occurrence of CS and DER, while 38% presented with DER syndrome, CS, and kinesiophobia.

CONCLUSION

The majority of our patients were classified as DER; they also presented with high levels of CS and/or psychological distress. This suggests that MDT mechanical subgroups, particularly DER, can present with co-occurring biopsychosocial influences. Without assessing CS and psychological distress, MDT therapists may miss crucial information. Further research is required to determine the optimal management of patients presenting with mechanical and non-mechanical drivers of pain.

Effectiveness of the McKenzie Method of Mechanical Diagnosis and Therapy for Treating Low Back Pain: Literature Review With Meta-analysis

Study Design Literature review with meta-analysis. Background The McKenzie Method of Mechanical Diagnosis and Therapy (MDT), a classification-based system, was designed to classify patients into homogeneous subgroups to direct treatment. Objectives To examine the effectiveness of MDT for improving pain and disability in patients with either acute (less than 12 weeks in duration) or chronic (greater than 12 weeks in duration) low back pain (LBP). Methods Randomized controlled trials examining MDT in patients with LBP were identified from 6 databases. Independent investigators assessed the studies for exclusion, extracted data, and assessed risk of bias. The standardized mean difference (SMD) and 95% confidence interval were calculated to compare the effects of MDT to those of other interventions in patients with acute or chronic LBP. Results Of the 17 studies that met the inclusion criteria, 11 yielded valid data for analysis. In patients with acute LBP, there was no significant difference in pain resolution (P = .11) and disability (P = .61) between MDT and other interventions. In patients with chronic LBP, there was a significant difference in disability (SMD, -0.45), with results favoring MDT compared to exercise alone. There were no significant differences between MDT and manual therapy plus exercise (P>.05) for pain and disability outcomes. Conclusion There is moderate- to high-quality evidence that MDT is not superior to other rehabilitation interventions for reducing pain and disability in patients with acute LBP. In patients with chronic LBP, there is moderate- to high-quality evidence that MDT is superior to other rehabilitation interventions for reducing pain and disability; however, this depends on the type of intervention being compared to MDT. Level of Evidence Therapy, level 1a. J Orthop Sports Phys Ther 2018;48(6):476-490. Epub 30 Mar 2018. doi:10.2519/jospt.2018.7562.

Pain pattern classification and directional preference for patients with neck pain

Objectives: Pain Pattern Classification (PPC) and Directional Preference (DP) have been shown to be predictive of health care outcomes and serve to guide orthopedic clinical decision making. We conducted a prospective, observational cohort study to verify the association between PPC, DP, and clinical outcomes. Methods: Clinical outcome measures including pain intensity and disability were completed at first examination and follow-up by 335 patients. A Pearson's chi-squared test was used to determine differences in prevalence rates for the categorical variables, and two-sample t-tests were used to determine differences in rates for the continuous variables. A Tukey's range test was used to determine differences in follow-up pain intensity and disability for neck pain dual-classification schemes. Results: The prevalence of DP was 82.4%. The prevalence of CEN, Non-CEN, and Non-Classifiable (NC) was 15.2%, 42.1%, and 25.1%, respectively. The prevalence of DP was lowest for patients with sub-acute symptoms and who were <45 years old. Patients classified as DP CEN had, on average 2.62 NDI units less than patients classified as Non-DP. Patients classified as DP CEN had, on average, 0.90 pain intensity units less than patients classified as Non-DP at follow-up. Patients who demonstrated DP CEN did not have clinically significant lower pain intensity or disability at follow-up than patients who demonstrated Non-DP. Discussion: The results of this investigation need to be interpreted with caution with respect to the study design and it's subsequent strengths and limitations. Level of Evidence: 1b.

A preliminary analysis of outcomes and end range procedures used to achieve centralization in people with low back pain

OBJECTIVES

To investigate the relationship between clinical outcome and the types of end range procedures used to achieve centralization in a sample of patients with low back pain (LBP) and/or peripheral symptoms.

METHODS

Small sample retrospective analysis of an observational cohort. Patients with LBP who centralized during initial visit at two physical therapy clinics were recruited to participate. The types of end range procedures used to achieve centralization were documented during each office visit and a chart review was performed after 4 weeks. Outcomes were determined by improvement in the Oswestry Disability Index (ODI) score after 4 weeks. Statistical analysis determined the association between the types of end range procedures and outcomes.

RESULTS

Thirty-one patients gave consent to participate. Nineteen patients met inclusion criteria and were included in data analysis. After 4 weeks, the improvement in mean ODI scores was 15.89 ± 16.28. Differing end range procedures were used to achieve centralization within this cohort. The types of end range procedures used to achieve centralization were not significantly associated with outcomes.

DISCUSSION

The results observed in this study promote exhausting many different types of end range procedures to determine if centralization can be achieved. Limiting the end range procedures used to assess centralization may fail to identify patients who can achieve centralization and subsequently have positive clinical outcomes. Larger cohort studies investigating relationships between outcomes and the types of end range procedures used to achieve centralization would contribute to management of people with LBP.

LEVEL OF EVIDENCE

4.

Pain pattern classification and directional preference are associated with clinical outcomes for patients with low back pain

Pain Pattern Classification (PPC) and Directional Preference (DP) have shown merit as reliable and predictable clinical solutions to help reduce the burden posed by low back pain (LBP). We conducted a prospective, observational cohort study to verify the association between PPC, DP, and clinical outcomes. We hypothesized that (1) patients who demonstrated DP Centralization (CEN) would have lower pain intensity and disability at follow-up than patients who demonstrated Non-DP Non-CEN, and (2) the prevalence of DP at first examination would be lowest for patients with chronic LBP and are greater than 65 years old. First examination and follow-up data were completed by 639 patients. Clinical outcome measures, including pain intensity and disability, were collected at first examination and follow-up. Baseline comparisons were made between groups with first examination data only and groups with first examination data and follow-up data. A Pearson's chi-squared test was used to determine differences in prevalence rates for the categorical variables, and two-sample t-tests were used for the continuous variables. A Turkey's range test was used to determine differences in follow-up pain intensity and disability for LBP dual-classifications. Multiple regression was used to investigate DP prevalence considering risk adjusted factors. Overall prevalence of DP was 84.5% and prevalence was lowest for patients with sub-acute symptoms. No significant difference existed for the prevalence of DP for patients based on age. Patients classified as DP CEN had, on average, 1.99 pain intensity units less than patients classified as Non-DP Non-CEN at follow-up. Patients classified as DP CEN had, on average, 3.43 RMDQ units less than patients classified as Non-DP Non-CEN at follow-up.These findings support previous reports, verifying the association between LBP dual-classification schemes and clinical outcomes.

Measurement of outcomes for patients with centralising versus non-centralising neck pain

OBJECTIVE

The purpose of this study is to determine whether individuals with neck pain who demonstrate centralisation of symptoms have more favourable outcome than individuals who do not demonstrate centralisation.

METHODS

Eleven subjects with neck pain were evaluated and treated by two physical therapists certified in Mechanical Diagnosis and Therapy (MDT). Eleven physical therapy patients underwent a routine initial evaluation and were treated 2-3 times per week using MDT principles and other physical therapy interventions. The Neck Disability Index (NDI) tool was administered at the initial examination, approximately 2 weeks following the initial examination, each subsequent re-evaluation, and at discharge from the study to measure changes in functional outcomes for each subject. Patients continued with treatments until they were discharged or removed from the study. Four subjects were referred back to their physician by treating physical therapist secondary to non-centralisation (NC) and worsening of symptoms.

RESULTS

Of the 11 subjects, six demonstrated centralisation (CEN) and five demonstrated NC. At initial evaluation, the average NDI score for the CEN group was 51.0 (SD ± 19.4) and 56.4 (SD ± 17.6) for the NC group. For the CEN group, the average change in NDI score between initial evaluation and discharge was 41.2 (SD ± 13.2 and 12.2 (SD ± 13.0) for the NC group. The correlation coefficient of CEN and change in NDI score was 0.772 and was statistically significant (P = 0.005).

CONCLUSIONS

In this limited sample, people with neck pain demonstrated more favourable outcomes when the CEN phenomenon was observed. Future research on CEN should be investigated with a larger sample size and with a greater number of clinicians trained in the MDT approach.

Effect of Adding McKenzie Syndrome, Centralization, Directional Preference, and Psychosocial Classification Variables to a Risk-Adjusted Model Predicting Functional Status Outcomes for Patients With Lumbar Impairments

Study Design Retrospective cohort. Background Patient-classification subgroupings may be important prognostic factors explaining outcomes. Objectives To determine effects of adding classification variables (McKenzie syndrome and pain patterns, including centralization and directional preference; Symptom Checklist Back Pain Prediction Model [SCL BPPM]; and the Fear-Avoidance Beliefs Questionnaire subscales of work and physical activity) to a baseline risk-adjusted model predicting functional status (FS) outcomes. Methods Consecutive patients completed a battery of questionnaires that gathered information on 11 risk-adjustment variables. Physical therapists trained in Mechanical Diagnosis and Therapy methods classified each patient by McKenzie syndromes and pain pattern. Functional status was assessed at discharge by patient-reported outcomes. Only patients with complete data were included. Risk of selection bias was assessed. Prediction of discharge FS was assessed using linear stepwise regression models, allowing 13 variables to enter the model. Significant variables were retained in subsequent models. Model power (R(2)) and beta coefficients for model variables were estimated. Results Two thousand sixty-six patients with lumbar impairments were evaluated. Of those, 994 (48%), 10 (<1%), and 601 (29%) were excluded due to incomplete psychosocial data, McKenzie classification data, and missing FS at discharge, respectively. The final sample for analyses was 723 (35%). Overall R(2) for the baseline prediction FS model was 0.40. Adding classification variables to the baseline model did not result in significant increases in R(2). McKenzie syndrome or pain pattern explained 2.8% and 3.0% of the variance, respectively. When pain pattern and SCL BPPM were added simultaneously, overall model R(2) increased to 0.44. Although none of these increases in R(2) were significant, some classification variables were stronger predictors compared with some other variables included in the baseline model. Conclusion The small added prognostic capabilities identified when combining McKenzie or pain-pattern classifications with the SCL BPPM classification did not significantly improve prediction of FS outcomes in this study. Additional research is warranted to investigate the importance of classification variables compared with those used in the baseline model to maximize predictive power. Level of Evidence Prognosis, level 4. J Orthop Sports Phys Ther 2016;46(9):726-741. Epub 31 Jul 2016. doi:10.2519/jospt.2016.6266.

A Randomized Controlled Trial Comparing the McKenzie Method to Motor Control Exercises in People With Chronic Low Back Pain and a Directional Preference

Study Design Randomized clinical trial. Background Motor control exercises are believed to improve coordination of the trunk muscles. It is unclear whether increases in trunk muscle thickness can be facilitated by approaches such as the McKenzie method. Furthermore, it is unclear which approach may have superior clinical outcomes. Objectives The primary aim was to compare the effects of the McKenzie method and motor control exercises on trunk muscle recruitment in people with chronic low back pain classified with a directional preference. The secondary aim was to conduct a between-group comparison of outcomes for pain, function, and global perceived effect. Methods Seventy people with chronic low back pain who demonstrated a directional preference using the McKenzie assessment were randomized to receive 12 treatments over 8 weeks with the McKenzie method or with motor control approaches. All outcomes were collected at baseline and at 8-week follow-up by blinded assessors. Results No significant between-group difference was found for trunk muscle thickness of the transversus abdominis (-5.8%; 95% confidence interval [CI]: -15.2%, 3.7%), obliquus internus (-0.7%; 95% CI: -6.6%, 5.2%), and obliquus externus (1.2%; 95% CI: -4.3%, 6.8%). Perceived recovery was slightly superior in the McKenzie group (-0.8; 95% CI: -1.5, -0.1) on a -5 to +5 scale. No significant between-group differences were found for pain or function (P = .99 and P = .26, respectively). Conclusion We found no significant effect of treatment group for trunk muscle thickness. Participants reported a slightly greater sense of perceived recovery with the McKenzie method than with the motor control approach. Level of Evidence Therapy, level 1b-. Registered September 7, 2011 at www.anzctr.org.au (ACTRN12611000971932). J Orthop Sports Phys Ther 2016;46(7):514-522. Epub 12 May 2016. doi:10.2519/jospt.2016.6379.

Benchmarking Outpatient Rehabilitation Clinics Using Functional Status Outcomes

OBJECTIVE

To utilize functional status (FS) outcomes to benchmark outpatient therapy clinics.

DATA SOURCES

Outpatient therapy data from clinics using Focus on Therapeutic Outcomes (FOTO) assessments.

STUDY DESIGN

Retrospective analysis of 538 clinics, involving 2,040 therapists and 90,392 patients admitted July 2006-June 2008. FS at discharge was modeled using hierarchical regression methods with patients nested within therapists within clinics. Separate models were estimated for all patients, for those with lumbar, and for those with shoulder impairments. All models risk-adjusted for intake FS, age, gender, onset, surgery count, functional comorbidity index, fear-avoidance level, and payer type. Inverse probability weighting adjusted for censoring.

DATA COLLECTION METHODS

Functional status was captured using computer adaptive testing at intake and at discharge.

PRINCIPAL FINDINGS

Clinic and therapist effects explained 11.6 percent of variation in FS. Clinics ranked in the lowest quartile had significantly different outcomes than those in the highest quartile (p < .01). Clinics ranked similarly in lumbar and shoulder impairments (correlation = 0.54), but some clinics ranked in the highest quintile for one condition and in the lowest for the other.

CONCLUSIONS

Benchmarking models based on validated FS measures clearly separated high-quality from low-quality clinics, and they could be used to inform value-based-payment policies.

Inter-examiner reliability of diplomats in the mechanical diagnosis and therapy system in assessing patients with shoulder pain

OBJECTIVE

To investigate the inter-examiner reliability of Mechanical Diagnosis and Therapy (MDT)-trained diplomats in classifying patients with shoulder disorders. The MDT system has demonstrated acceptable reliability when used in patients with spinal disorders; however, little is known about its utility when used for appendicular conditions.

METHODS

Fifty-four clinical scenarios were created by a group of 11 MDT diploma holders based on their clinical experience with patients with shoulder pain. The vignettes were made anonymous, and their clinical diagnoses sections were left blank. The vignettes were sent to a second group of six international McKenzie Institute diploma holders who were asked to classify each vignette according to the MDT categories for upper extremity. Inter-examiner agreement was evaluated with kappa statistics.

RESULTS

There was 'very good' agreement among the six MDT diplomats for classifying the McKenzie syndromes in patients with shoulder pain (kappa = 0.90, SE = 0.018). The raw overall level of multi-rater agreement among the six clinicians in classifying the vignettes was 96%. After accounting for the actual MDT category for each vignette, kappa and the raw overall level of agreement decreased negligibly (0.89 and 95%, respectively).

DISCUSSION

Using clinical vignettes, the McKenzie system of MDT has very good reliability in classifying patients with shoulder pain. As an alternative, future reliability studies could use real patients instead of written vignettes.

Association between centralization and directional preference and functional and pain outcomes in patients with neck pain

STUDY DESIGN

Retrospective cohort.

OBJECTIVES

In subjects with neck pain, the present study aimed (1) to describe the prevalence of centralization (CEN), noncentralization (non-CEN), directional preference (DP), and no directional preference (no DP); (2) to determine if age, sex, fear-avoidance beliefs about physical activity, number of comorbid conditions, or symptom duration varies among subjects who demonstrate CEN versus non-CEN and DP versus no DP; and (3) to determine if CEN and/or DP are associated with changes in function and pain.

BACKGROUND

CEN and DP are prevalent among patients with low back pain and should be considered when determining treatment strategies and predicting outcomes; however, these findings are not well investigated in patients with neck pain.

METHODS

Three hundred four subjects contributed data. CEN and DP prevalence were calculated, as was the association between CEN and DP, and age, sex, number of comorbid conditions, fear-avoidance beliefs, and symptom duration. Multivariate models assessed whether CEN and DP predicted change in function and pain.

RESULTS

CEN and DP prevalence were 0.4 and 0.7, respectively. Younger subjects and those with fewer comorbid conditions were more likely to centralize; however, subjects who demonstrated DP were more likely to have acute symptoms. Subjects who centralized experienced, on average, a 3.6-point (95% confidence interval: -0.3, 7.4) improvement in function scores, whereas subjects with a DP averaged a 5.4-point (95% confidence interval: 0.8, 10.0) improvement. Neither CEN nor DP was associated with pain outcomes.

CONCLUSION

DP and, to a lesser extent, CEN represent evaluation categories that are associated with improvements in functional outcomes.

Prevalence of classification methods for patients with lumbar impairments using the McKenzie syndromes, pain pattern, manipulation, and stabilization clinical prediction rules

OBJECTIVES

Aims were (1) to determine the proportion of patients with lumbar impairments who could be classified at intake by McKenzie syndromes (McK) and pain pattern classification (PPCs) using Mechanical Diagnosis and Therapy (MDT) assessment methods, manipulation, and stabilization clinical prediction rules (CPRs) and (2) for each Man CPR or Stab CPR category, determine classification prevalence rates using McK and PPC.

METHODS

Eight physical therapists practicing in eight diverse clinical settings classified patients typically referred to rehabilitation by McKenzie syndromes (i.e. derangement, dysfunction, posture, or other), pain pattern classification [i.e. centralization (CEN), not centralization (Non CEN), and not classified (NC)], Manipulation CPR (positive, negative), and stabilization CPR (positive, negative). Prevalence rates with 95% confidence intervals (CI) were calculated for each classification category by McK, PPC, and manipulation and stabilization CPRs. Prevalence rates (95% CIs) for McK and PPC were calculated for each CPR category separately.

RESULTS

Data from 628 adults [mean age: 52±17 years, 56% female] were analyzed. Prevalence rates were: McK - derangement 67%, dysfunction 5%, posture 0%, other 28%; PPC - CEN 43%, Non CEN 39%, NC 18%; manipulation CPR - positive 13%; Stab CPR - positive 7%. For patients positive for manipulation CPR (n = 79), prevalence rates for derangement were 89% and CEN 68%. For patients positive for stabilization CPR (n = 41), prevalence rates for derangement were 83% and CEN 80%.

DISCUSSION

The majority of patients classified based on initial clinical presentation by manipulation and stabilization CPRs were also classified as derangements whose symptoms centralized. Manipulation and stabilization CPRs may not represent a mutually exclusive treatment subgroup but may include patients who can be initially treated using a different classification method.

A treatment-based classification approach to examination and intervention of lumbar disorders

CONTEXT

Low back injuries are a common occurrence in athletes and often result in missed competition and practice time. The examination of athletes with low back pain commonly involves diagnostic imaging, which rarely guides the clinician in selecting the appropriate interventions.

DATA ACQUISITION

All years of PubMed, CINAHL, PEDro, and SPORTDiscus were searched in December 2010. Keywords included treatment based classification and lumbar with the following terms: rehabilitation, treatment, athlete, low back pain, sports, and outcomes.

RESULTS

A treatment-based classification approach is preferred for the management of the athlete with low back pain. The treatment-based classification approach involves 3 steps. First is to screen the patient for potentially serious conditions that are not appropriate for conservative management. Second is staging the athlete (based on current disability ratings and ability to perform functional activities). Finally, treatment interventions are selected on the basis of the athlete's signs and symptoms.

CONCLUSION

The treatment-based classification scheme provides the clinician with a reliable algorithm for matching an athlete's symptom presentation to the optimal intervention, potentially reducing participation loss. Managing individuals with low back pain using a treatment-based classification approach significantly reduces disability and pain compared with current clinical practice guideline standards.

Subgrouping patients with low back pain: a treatment-based approach to classification

Context:

Low back pain (LBP) is a prevalent condition imposing a large socioeconomic burden. Despite intensive research aimed at the efficacy of various therapies for patients with LBP, most evidence has failed to identify a superior treatment approach. One proposed solution to this dilemma is to identify subgroups of patients with LBP and match them with targeted therapies. Among the subgrouping approaches, the system of treatment-based classification (TBC) is promoted as a means of increasing the effectiveness of conservative interventions for patients with LBP.

Evidence acquisition:

MEDLINE and PubMed databases were searched from 1985 through 2010, along with the references of selected articles.

Results:

TBC uses a standardized approach to categorize patients into 1 of 4 subgroups: spinal manipulation, stabilization exercise, end-range loading exercise, and traction. Although the TBC subgroups are in various stages of development, recent research lends support to the effectiveness of this approach.

Conclusions:

While additional research is required to better elucidate this method, the TBC approach enhances clinical decision making, as evidenced by the improved clinical outcomes experienced by patients with LBP.

Therapeutic exercise for athletes with nonspecific neck pain: a current concepts review

Context:

Benign neck pain is common in athletes and is usually the result of minor sprains, strains, or contusions. Athletes with neck pain may have deficits in cervical and/or upper thoracic mobility, muscle recruitment, strength and endurance, repositioning acuity, postural stability, and oculomotor control.

Evidence Acquisition:

A Medline search was performed via PubMed to locate articles of any publication date through December 2011 using the search terms cervical pain, neck pain, athlete, athletic, therapeutic exercise, and rehabilitation. Reference lists of retrieved articles were searched for additional relevant references.

Results:

Therapeutic exercise has promise as an intervention for individuals with neck pain, although reports on isolated athletic populations are lacking. To date, recommendations for specific therapeutic exercises have been derived largely from anecdotal or uncontrolled level IV or V evidence.

Conclusion:

Clinicians should consider deficits, functional limitations, irritability level, and the sport’s cervical spine stress profile when selecting exercises for athletes with neck pain.

Centralization and directional preference: a systematic review

Centralization is a symptom response to repeated movements that can be used to classify patients into sub-groups, determine appropriate management strategies, and prognosis. The aim of this study was to systematically review the literature relating to centralization and directional preference, and specifically report on prevalence, prognostic validity, reliability, loading strategies, and diagnostic implications. Search was conducted to June 2011; multiple study designs were considered. 62 studies were included in the review; 54 related to centralization and 8 to directional preference. The prevalence of centralization was 44.4% (range 11%-89%) in 4745 patients with back and neck pain in 29 studies; it was more prevalent in acute (74%) than sub-acute or chronic (42%) symptoms. The prevalence of directional preference was 70% (range 60%-78%) in 2368 patients with back or neck pain in 5 studies. Twenty-one of 23 studies supported the prognostic validity of centralization, including 3 high quality studies and 4 of moderate quality; whereas 2 moderate quality studies showed evidence that did not support the prognostic validity of centralization. Data on the prognostic validity of directional preference was limited to one study. Centralization and directional preference appear to be useful treatment effect modifiers in 7 out of 8 studies. Levels of reliability were very variable (kappa 0.15-0.9) in 5 studies. Findings of centralization or directional preference at baseline would appear to be useful indicators of management strategies and prognosis, and therefore warrant further investigation.

Efficacy of directional preference management for low back pain: a systematic review

BACKGROUND

Providing specific treatment based on symptom response for people with low back pain (LBP) and a directional preference (DP) is a widely used treatment approach. The efficacy of treatment using the principles of directional preference management (DPM) for LBP is unclear.

OBJECTIVE

The purpose of this study was to determine the efficacy of treatment using the principles of DPM for people with LBP and a DP.

METHODS

Computer databases were searched for randomized controlled trials (RCTs) published in English up to January 2010. Only RCTs investigating DPM for people with LBP and a DP were included. Outcomes for pain, back specific function, and work participation were extracted.

RESULTS

Six RCTs were included in this review. Five were considered high quality. Clinical heterogeneity of the included trials prevented meta-analysis. GRADE quality assessment revealed mixed results; however, moderate evidence was identified that DPM was significantly more effective than a number of comparison treatments for pain, function, and work participation at short-term, intermediate-term, and long-term follow-ups. No trials found that DPM was significantly less effective than comparison treatments.

CONCLUSIONS

Although this systematic review showed mixed results, some evidence was found supporting the effectiveness of DPM when applied to participants with a DP, particularly at short-term and intermediate-term follow-ups. Further high-quality RCTs are warranted to evaluate the effect of DPM applied to people with LBP and a DP.

Low back pain

The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization’s International Classification of Functioning, Disability, and Health (ICF). The purpose of these low back pain clinical practice guidelines, in particular, is to describe the peer-reviewed literature and make recommendations related to (1) treatment matched to low back pain subgroup responder categories, (2) treatments that have evidence to prevent recurrence of low back pain, and (3) treatments that have evidence to influence the progression from acute to chronic low back pain and disability.

Change in psychosocial distress associated with pain and functional status outcomes in patients with lumbar impairments referred to physical therapy services

STUDY DESIGN

Prospective, longitudinal, observational cohort design.

OBJECTIVE

The primary aim was to examine the association between changes in psychosocial distress (PD), and functional status (FS) and pain intensity at discharge from physical therapy.

BACKGROUND

Patients with lumbar impairments seeking physical therapy commonly demonstrate elevated PD. However, it is not clear if PD changes that occur during physical therapy management are associated with improved clinical outcomes.

METHODS

Data from adults (n = 692) with lumbar impairment were analyzed. Patients were screened using the Symptom Checklist Back Pain Prediction Model questionnaire (SCL BPPM) to identify patients at intake and discharge into 3 levels of risk for persistent disability (high, intermediate, or low). SCL BPPM classifications allowed for 5 patterns of change in PD during therapy (decreased, stable low, stable intermediate, stable high, or increased). Associations between PD change patterns and discharge FS and pain intensity were assessed using multivariable linear regression models, controlling for selected risk-adjustment variables.

RESULTS

Proportions of patients classified by patterns of PD change for decreased, stable low, stable intermediate, stable high, and increased were 0.34, 0.52, 0.05, 0.06, and 0.03, respectively. Compared to the decreased PD group, (1) increased, stable high, and stable intermediate PD patterns were associated with worse discharge FS scores (-7.9 [95% CI: -13.5, -2.21], -10.9 [95% CI: -15.25, -6.49], and -8.9 [95% CI: -13.65, -4.21] units, respectively), and (2) stable high and stable intermediate PD patterns were associated with higher pain intensity (2.59 [95% CI: 1.81, 3.56] and 2.14 [95% CI: 1.25, 3.04] units, respectively).

CONCLUSIONS

Lower FS and higher pain intensity outcomes were associated in similar but not identical patterns with patients whose SCL BPPM classification of PD increased, or remained at high or intermediate levels during physical therapy. Serial assessments of change in PD during rehabilitation are recommended as a possible treatment-monitoring tool.

Centralization in patients with sciatica: are pain responses to repeated movement and positioning associated with outcome or types of disc lesions?

AIM

To determine the frequency of different patterns of centralization and their association with outcomes and MRI findings in patients experiencing sciatica.

METHODS

A prospective longitudinal cohort study of 176 patients with radicular pain below the knee, who all had an MDT clinical assessment. Based on their pain response, patients were divided into five groups: abolition centralization, reduction centralization, unstable centralization, peripheralization, and "no effect". Patients had an MRI.

RESULTS

Overall, 84.8% of patients reported experiencing centralization, 7.3% peripheralized and 7.9% reported "no effect". The median reduction in RMQ scores across all the three centralization groups was 9.5 points at 3 months, and 12.0 points at 12 months. The peripheralization group improved similarly. The 'no effect' group improved significantly lower (p < 0.001), by 3.0 at both time points. Patients who centralized, and peripheralized had a significantly reduction in leg pain, the "no effect" group demonstrated a less favorable outcome (p < 0.02). There was no association between pain responses and the type of disc lesion.

CONCLUSION

In patients with sciatica, centralization was common and associated with improvement in activity limitation and leg pain. Centralization was very common in ruptured disc therefore the study does not support the theory, that centralization only occurs if the intra-discal hydrostatic mechanism is functional.

Immediate changes in spinal height and pain after aquatic vertical traction in patients with persistent low back symptoms: a crossover clinical trial

OBJECTIVE

To investigate the effect of aquatic vertical traction on spinal height, pain intensity, and centralization response compared with a land-based supine flexion position for patients with low back pain and signs of nerve root compression.

DESIGN

Single-blind, repeated-measures crossover design.

SETTING

Outpatient physical therapy clinic.

SUBJECTS

Ninety-eight subjects were recruited using consecutive sampling, with 28 men and 32 women of a mean ± standard deviation (SD) age of 59.6 ± 11.6 years completing testing.

INTERVENTION

Each subject participated in 2 sessions that consisted of loaded walking for 15 minutes, followed by either 15 minutes of land-based supine position or 15 minutes of aquatic vertical traction.

MEASUREMENTS

Spinal height change, measured using a commercial stadiometer, was determined after completing loaded walking and after each intervention.

RESULTS

The mean ± SD height change of 4.99 ± 2.88 mm after aquatic vertical traction was similar to that of 4.21 ± 2.53 mm after the land-based supine flexion (P = .0969). Paired t-test indicated that both interventions resulted in significant increased height (P < .0001). Decreases in pain after aquatic intervention (2.7 ± 2.1 cm) were significantly greater than decreases after land intervention (1.7 ± 1.7 cm; P = .0034), and centralization of symptoms was more pronounced after aquatic vertical suspension compared with the supine land-based flexion condition (P < .0001). A significant correlation between height change and both pain reduction (r = 0.39; P = .001) and centralization (r = 0.29; P = .013) was observed for the aquatic intervention only.

CONCLUSION

Although both the aquatic and land interventions produced significant increases in overall spinal height, the aquatic intervention produced greater pain relief and centralization response in subjects with low back pain and signs of nerve root compression.

Effect of fear-avoidance beliefs of physical activities on a model that predicts risk-adjusted functional status outcomes in patients treated for a lumbar spine dysfunction

STUDY DESIGN

Retrospective analysis of a prospective, longitudinal cohort study of 30 858 patients being treated for a lumbar spine dysfunction in outpatient physical therapy.

OBJECTIVES

To determine effect of adding a single-item screening variable classifying patients with elevated versus not-elevated scores of fear-avoidance beliefs of physical activities at intake, on a model predicting risk-adjusted functional status (FS) outcomes.

BACKGROUND

Outcomes must be risk-adjusted before making meaningful interpretations. Elevated fear-avoidance beliefs scores have been predictive of poor outcomes. But the importance of elevated fear-avoidance scores in a multivariable model predicting FS outcomes needs further study.

METHODS

Using retrospective analyses, predictive ability (R2) of multivariable linear regression models of discharge FS with and without classification by elevated versus not-elevated fear-avoidance scores were compared, while controlling for intake FS, age, symptom acuity, surgical history, gender, number of comorbidities, and payer. Percent variance controlled and beta coefficients (95% confidence intervals) of each variable in both models were compared. A split-half design was used for model cross-validation. Predictive ratios (predicted FS, divided by actual discharge FS) were assessed.

RESULTS

Adding fear-avoidance beliefs classification to the discharge FS model improved (P<.001) model predictive ability but only slightly (R2 without, and with, fear-avoidance classification, 0.2997 and 0.3010, respectively). Variables impacted models similarly (95% confidence intervals not different). Fear-avoidance classification added 0.2% data variance control to the existing model. Cross-validation was supported. Predictive ratios were 1.09 and 1.10, without and with fear-avoidance, respectively.

CONCLUSION

Although screening for elevated fear-avoidance beliefs of physical activities significantly improves the FS outcomes predictive model, the amount of additional meaningful interpretation of FS outcomes was minimal. Exploration of other clinically relevant variables designed to improve outcomes prediction is warranted.

LEVEL OF EVIDENCE

Prognosis, level 2c.

Association between directional preference and centralization in patients with low back pain

STUDY DESIGN

Prospective, longitudinal, observational cohort.

OBJECTIVES

Primary aims were to determine (1) baseline prevalence of directional preference (DP) or no directional preference (no-DP) observed for patients with low back pain whose symptoms centralized (CEN), did not centralize (non-CEN), or could not be classified (NC), and (2) to determine if classifying patients at intake by DP or no-DP combined with CEN, non-CEN, or NC predicted functional status and pain intensity at discharge from rehabilitation.

BACKGROUND

Although evidence suggests that patient response classification criteria DP or CEN improve outcomes, previous studies did not delineate relations between DP and CEN findings and outcomes.

METHODS

Eight therapists classified patients using standardized definitions for DP and CEN. Prevalence rates for DP and no-DP and CEN,non-CEN, and NC were calculated. Ordinary least-squares multivariate regression models assessed whether multilevel classification combining DP and CEN (DP/CEN, DP/non-CEN, DP/NC, no-DP/non-CEN, and no-DP/NC categories) predicted discharge functional status (scale range, 0 to 100, with higher values representing better function) or pain intensity (scale range, 0 to 10, with higher values representing more pain).

RESULTS

Overall prevalence of DP and CEN was 60% and 41%, respectively. For those with DP, prevalence rates for DP/CEN, DP/non-CEN, and DP/NC were 65%, 27%, and 8%, respectively. The amount of variance explained (R2 values) for function and pain models was 0.50 and 0.39, respectively. Compared to patients classified as DP/CEN, patients classified as DP/non-CEN or no-DP/non-CEN reported 7.7 and 11.6 functional status units less at discharge (P<.001), respectively, and patients classified as no-DP/non-CEN reported 1.7 pain units more at discharge (P<.001).

CONCLUSIONS

Findings suggest that classification by pain pattern and DP can improve a therapist's ability to provide a short-term prognosis for function and pain outcomes.

LEVEL OF EVIDENCE

Prognosis, level 1b-.

Association between centralization, depression, somatization, and disability among patients with nonspecific low back pain

STUDY DESIGN

Secondary analysis of a prospective observational cohort study.

OBJECTIVES

To evaluate whether depression and somatization subscores of the Symptom Checklist-90-Revised (SCL-90-R), which have been shown to identify chronic disability in individuals with nonspecific low back pain, are applicable to a different population of individuals with low back pain; and to determine if this potential association is confounded by a combination of centralization and subsequent treatment based on centralization.

BACKGROUND

To help direct management of patients with nonspecific low back pain, recommendations include performing tests designed to identify psychosocial risk factors predictive of poor patient outcomes. SCL-90-R depression and somatization subscores have been shown to predict chronic disability among patients with low back pain.

METHODS

SCL-90-R depression and somatization subscores and data on centralization were collected during the initial physical therapy examination of 231 consecutive patients treated for low back pain in 2 clinics. Disability was assessed by the Oswestry Disability Questionnaire at intake and discharge from physical therapy, and work status was determined by patient self-report at 6 and 12 months after discharge. Pain intensity was assessed by the numeric pain rating scale at the initial visit, and at 6- and 12-month follow-ups. Data were analyzed using logistic regression.

RESULTS

Odds ratios for the association between depression and somatization subscores and patient outcomes ranged from 0.76 to 2.93. For analyses in which the data suggested a trend toward an association, the association was less evident following adjustment for centralization and centralization-based treatment.

CONCLUSIONS

In our sample, in which all individuals received physical therapy, and those who centralized received interventions based on the direction of centralization, SCL-90-R depression and somatization subscores were moderately associated with chronic pain and disability. This association was reduced when centralization and centralization-based treatment was considered in multivariable analyses.

Computerized adaptive test for patients with lumbar spine impairments produced valid and responsive measures of function

STUDY DESIGN

Outcomes instrument validation study.

OBJECTIVE

We evaluated administrative efficiency and psychometric adequacy of a computerized adaptive test (CAT) for patients with lumbar spine impairments seeking rehabilitation in outpatient therapy clinics.

SUMMARY OF BACKGROUND DATA

CATs promise efficient outcomes data collection in clinical applications with little loss of measurement precision compared to paper and pencil surveys. The lumbar CAT has been developed and simulated and is currently used routinely in therapy clinics. The CAT has not been assessed for administrative efficiency, and the outcomes measures estimated using the CAT have not been assessed using prospective data collection for validity, sensitivity to change, or responsiveness.

METHODS

Data from 17,439 patients with lumbar spine impairments receiving outpatient rehabilitation in 377 clinics in 30 states (United States) were analyzed. We evaluated efficiency of routine CAT administration and assessed construct validity, sensitivity to change, and responsiveness of CAT measures of lumbar functional status (FS).

RESULTS

On average, patients took less than 2 minutes (standard deviation <1 minute) to answer 7 CAT items (standard deviation, 3), which produced precise estimates of FS that adequately covered the content range with negligible floor and ceiling effects. Patients who were older had more chronic symptoms, had more surgeries, had more comorbidities, and did not exercise before receiving rehabilitation reported worse discharge FS. A total of 66% of patients obtained statistically significant change (95% confidence interval minimal detectable change) at discharge. Change of 5 FS units (scale, 0-100) represented minimal clinically important improvement, which 70% of patients obtained. Minimal detectable change and minimal clinically important improvement were associated with intake FS.

CONCLUSION

We concluded the lumbar CAT administration was efficient, and CAT FS measures were precise, valid, sensitive, and responsive, supporting lumbar CAT use in clinical and research applications.

Pain response classification does not predict long-term outcome in patients with low back pain who are sick-listed

STUDY DESIGN

Prospective cohort study nested in a randomized clinical trial.

OBJECTIVE

To investigate the prognostic value of pain response classification at initial physiotherapy examination in patients with low back pain (LBP) who are sick-listed.

BACKGROUND

Recurrent and chronic LBP accounts for a substantial proportion of all absence from work. In predicting outcome in patients with LBP, psychosocial factors are thought to play an important role, while findings from clinical examination seem to be of more limited value. Mechanical evaluation, using repeated end range spinal movements that result in specific pain responses, has been shown to be of some value.

METHODS

The study included 351 patients sick-listed because of LBP with or without sciatica. Prior to clinical examination, the patients completed a comprehensive questionnaire including questions on pain, function, and psychosocial factors. The physiotherapy examination included a standardized mechanical evaluation. Patients were classified into 3 groups according to their pain response: centralization, peripheralization, or no response. Outcomes were obtained by national register data, medical records, and a postal questionnaire at 1 year.

RESULTS

At 1-year follow-up, 65% of the patients had returned to work. All pain response groups showed significant and clinically important improvements in both pain and disability. No significant differences were found between pain response groups in any outcome measure. Results remained unchanged after adjustment for potential confounders.

CONCLUSION

The prognostic value of pain response classification seems limited in patients sick-listed from work because of LBP.

A computerized adaptive test for patients with shoulder impairments produced responsive measures of function

BACKGROUND

Computerized adaptive tests (CATs) promise efficient outcomes data collection with little loss of measurement precision. The shoulder CAT has not been assessed for administrative efficiency, nor have prospective studies been completed to evaluate the sensitivity to change or the responsiveness of CAT-based functional status (CAT-FS) measures.

OBJECTIVE

The purpose of this study was to evaluate the efficiency and responsiveness of the shoulder CAT.

DESIGN

This was a secondary analysis of prospectively collected data.

METHODS

Data were analyzed from patients with shoulder impairments who received outpatient rehabilitation in 518 clinics in 30 US states. Over the testing time, 30,987 patients completed the shoulder CAT at intake, and of these, 13,805 completed the CAT at discharge (45% completion rate). The efficiency of routine CAT administration was evaluated, and the sensitivity to change and responsiveness of CAT-FS measures were assessed.

RESULTS

On average, patients took about 1.5 minutes (SD <2 minutes) to answer 6 CAT items (SD=2), which produced precise estimates of CAT-FS measures that adequately covered the content range and had negligible floor and minimal ceiling effects. Ninety-four percent of the patients had CAT-FS scores between 20 and 80, where upper-level 95% confidence interval (CI) standard errors were between 3.2 and 4.6 (out of 100). Of patients with both intake and discharge data, 79% had CAT-FS change scores greater than minimal detectable change, and 76% had changes greater than minimal clinically important improvement.

LIMITATIONS

Because this study was a secondary analysis, the results may have been affected by patient selection bias. Future studies would benefit from more complete data.

CONCLUSIONS

The results indicate the shoulder CAT was efficient and support the precision, sensitivity, and responsiveness of CAT-FS measures.