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

Understanding social determinants of health and physical therapy outcomes in patients with low back pain: A scoping review

BACKGROUND

Low back pain (LBP) is the number one cause of disability worldwide; however, it is not clear how social determinants of health (SDOH) impact care management and outcomes related to physical therapy (PT) services for patients with LBP.

OBJECTIVE

The purposes of this scoping review are to examine and assimilate the literature on how SDOH and PT care relate to non-specific LBP outcomes and identify gaps in the literature to target for future research.

METHODS

Data were extracted from eight electronic databases from January 2011 to February 2022. Reviewers independently screened all studies using the PRISMA extension for scoping review guidelines. Data related to study design, type of PT, type of non-specific LBP, patient demographics, PT intervention, SDOH, and PT outcomes were extracted from the articles.

RESULTS

A total of 30,523 studies were screened, with 1961 articles undergoing full text review. Ultimately, 76 articles were identified for inclusion. Sex and age were the most frequent SDOH examined (88% and 78% respectively) followed by education level (18%). Approximately half of the studies that examined age, sex, and education level identified no effect on outcomes. The number of studies examining other factors was small and the types of outcomes evaluated were variable, which limited the ability to pool results.

CONCLUSIONS

Sex and age were the most frequent SDOH examined followed by education level. Other factors were evaluated less frequently, making it difficult to draw conclusions. Study design and heterogeneity of determinants and outcomes were barriers to examining the potential impact on patients with LBP.

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.

Comparison of magnetic resonance imaging findings among sciatica patients classified as centralizers or non-centralizers

OBJECTIVE

To compare if the degenerative findings from MRI differ between the sciatica patients classified as centralizers (CEN) and non-centralizers (Non-CEN) according to the McKenzie Method of mechanical diagnosis and therapy.

STUDY DESIGN

A cross-sectional study.

METHODS

Patients (N = 100) referred to a spine clinic of a single tertiary hospital for specialist consultation for sciatica. The McKenzie-based assessment was performed by the mechanical diagnosis and therapy-trained physiotherapists. Clinical data and prevalence of lumbar MRI findings were compared between the groups.

RESULTS

There was no significant difference in leg pain intensity between the groups. The Non-CEN had significantly more intense back pain, mean 56 (SD 30) and were more disabled 44 (SD 15) compared to the CEN mean 41 (SD 25) and mean 31 (11), measured with a visual analogue scale (0-100), and the Oswestry Disability Index (0-100), respectively. The CEN had more severe degenerative findings on MRI than the Non-CEN: vertebral end-plate changes were 63% and 43%; mean Pfirrmann's disc degeneration lumbar summary score was 12.8, and 10.6; and severity score of total damage was 12.0 and 10.1, respectively. There were differences neither in disc contour changes nor nerve root stenosis on MRI.

CONCLUSIONS

Sciatica patients classified as non-centralizers had significantly more severe back pain, and were significantly more disabled than centralizers, who instead had more severe degenerative findings on MRI. Thus, classification to non-centralizers by the McKenzie method seems not predict higher incidence of degenerative findings on MRI compared to centralizers.

A novel physical functioning test to complement subjective questionnaires in chronic low back pain assessments

BACKGROUND CONTEXT

Lifting disability commonly affects patients with chronic low back pain (CLBP) and may not correlate with the existing lifting-related physical assessment tests, such as the loaded forward reach (LFR) test.

PURPOSE

The Lift and Place (LAP) test was developed to assess lifting disability in CLBP based on known risk factors. The LAP test was compared with established physical assessment test, including the LFR test and self-reported disability questionnaires.

STUDY DESIGN/SETTING

This cross-sectional study measured self-reported disability questionnaires along with LAP and other physical assessment test results PATIENT SAMPLE: Eighty three CLBP and 82 asymptomatic participants aged 18 to 55 with normal BMI according to WHO classification.

OUTCOME MEASURES

Oswestry disability index (ODI), Roland-Morris disability questionnaire (RMDQ), Numerical Pain Rating Scale, Trunk Extensor Endurance test, 5 Repetition Sit-To-Stand test, LAP and LFR test.

METHODS

Physical assessment test scores were compared between the two groups. The correlation of assessment test scores with ODI and RMDQ in patients with CLBP was calculated. Receiver operating characteristic (ROC) curve analysis was performed to calculate the area under the curve (AUC) of each assessment tests. Assessment tests, ODI, and RMDQ were measured twice for CLBP patients on separate days to calculate the test-retest intraclass correlation (ICC) reliability. Two researchers scored the assessment tests independently to calculate the inter-rater ICC.

RESULTS

Patients with CLBP were slower in the LAP test (CLBP vs asymptomatic: 21.6±4.9 s vs 18.6±3.6 s) and had shorter reach in the LFR test (CLBP vs asymptomatic: 33.6±6.0 cm vs 36.3±6.6 cm). The LAP was correlated with both ODI (r=0.418) and RMDQ (r=0.390), while the LFR was not. In the ROC analysis, the LAP and LFR bore AUCs of 0.685 and 0.379, respectively. Their test-retest ICCs were 0.913 and 0.858, and their inter-rater ICCs were 0.997 and 0.969, respectively.

CONCLUSIONS

The LAP test demonstrated higher reliability and significant correlation with the ODI and RMDQ, indicating its potential as performance assessment for lifting disability in CLBP. Further studies should investigate the use of LAP and other physical assessments for rapid CLBP screening.

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.

Rehabilitation and return to sport of a high-level track & field athlete with low back pain - a case report

INTRODUCTION: Low back pain is prevalent among elite athletes with initial high levels of physical activity. Currently, there is a lack of evidence describing the optimal management strategy of high-level track and field athletes presenting with low back pain. CASE DESCRIPTION: This case report describes the clinical management and return-to-sport strategies of a male high-level track and field athlete presenting with low back pain in an outpatient physiotherapy clinic. Mechanical diagnosis and therapy (MDT) served as an important tool in the clinical management of the athlete. Patient-Specific Function Scale (PSFS), an 11-point scale (0 = unable to perform activity to 10 = able to perform activity at preinjury level), was used during three activities: hammer throw, squats and getting socks and shoes on.OUTCOMES: Eight weeks after initial consultation (15 weeks after the index injury), the athlete returned to sport and competition at national championship-level. PFPS scores at final consultation: hammer throw - 10/10; squats - 10/10 and getting socks and shoes on - 10/10. CONCLUSION: In combination with modern rehabilitation strategies, MDT provided the opportunity to engage the athlete as an active collaborator, which is in accordance with current clinical guidelines and best practice.

Chiropractic Nimmo Receptor-Tonus Technique and McKenzie Self-Therapy Program in the Management of Adjacent Segment Disease: A Case Report

Objective

The objective of the present study objective was to describe adjacent segment disease (ASD) from a chiropractic management prospective and subsequently to stimulate further research into the chiropractic therapeutic effects on such cases and to contribute to chiropractic literature.

Clinical Features

A 44-year-old woman had a history of lumbar stabilization revision operation by pedicle screw fixation for spondylolisthesis. Her intractable back pain episodes, which were diagnosed as ASD, began shortly after this surgery. At presentation, she was taking pregabalin 75 mg 2 times a day for postoperative neuropathic pain without any pain relief. Clinical testing revealed myofascial tender points reproducing the pain.

Intervention and Outcome

After taking the case history and performing a physical examination, the patient was managed with chiropractic Nimmo receptor-tonus technique in combination with McKenzie exercises. Nimmo was applied by manually pressing on clinically relevant points for 5 to 15 seconds in 11 visits over 3 weeks. The patient by herself did McKenzie exercises 5 to 10 times a day for 10 to 12 repetitions over 2 months. After 3 weeks of therapy, visual analog scale and Oswestry Disability Index scores were improved. Furthermore, because of the amelioration of the patient's symptoms, her neurosurgeon successfully discontinued pregabalin 75 mg 2 times a day without negative consequences to care.

Conclusion

As far as the authors are aware, there is currently no published case of ASD care in chiropractic literature. Our rehabilitative management received a favorable response. It can be hypothesized that it offers a perspective that informs improved patient care.

Computer Kinesiology: New Diagnostic and Therapeutic Tool for Lower Back Pain Treatment (Pilot Study)

The aim of this study was to demonstrate the effectiveness of the diagnostic and therapeutic medical information system Computer Kinesiology in physiotherapy in patients with low back pain who were not responding to conventional therapy. Computer Kinesiology is primarily intended for the diagnostics and therapy of functional disorders of the locomotor system. This pilot study population included 55 patients (Group 1) with acute and chronic back pain and 51 persons (Group 2) without back pain. The third group was a control group of 67 healthy volunteers with no evidence of musculoskeletal pathologies and no back pain. All 173 subjects were examined three times by the diagnostic part of the Computer Kinesiology method. Groups 1 and 2 were treated after every diagnostics. Group 3 was not treated. The effect was evaluated by H score. Improvements after therapy were defined by reducing the H score by at least 1 point. In Group 1, the H score decreased by at least 1 point in 87.3% (95% CI: 75.5-94.7) and in Group 2 in 78.4% (95% CI: 64.7-88.7). There was no change of distribution of H Score grade in Group 3. The improvement neither depended on gender, age, and BMI nor was it influenced by the length of the therapy. This study demonstrated a high therapeutic efficacy of the Computer Kinesiology system in patients with back pain (Group 1) and in persons without back pain (Group 2) who used the Computer Kinesiology system for primary and secondary prevention of back pain.

A prospective study of patients with knee pain and mechanical diagnosis and therapy (MDT) classification

OBJECTIVES

A prospective observational cohort study was conducted to 1) determine the prevalence of Mechanical Diagnosis and Therapy (MDT) syndromes for patients with knee impairments, and 2) report the interaction between MDT classification and clinical outcomes, including pain intensity and disability, at discharge.

METHODS

Clinical outcome measures were completed at intake and discharge on 186 patients. A two-way mixed model analysis of variance with subsequent pairwise comparisons was done to examine differences between the following MDT classifications: Knee Derangement, Knee Dysfunction, and Other.

RESULTS

The primary findings were that: 1) 61.3% (54.3, 68.3), 9.7% (5.4, 13.9), and 29.0% (22.5, 35.5) of patients' conditions were classified as Knee Derangement, Knee Dysfunction, and Other, respectively; 2) all groups managed via MDT methods made clinically significant improvements in disability and pain intensity at discharge with the exception of the Other classification for pain intensity (NPRS difference score = 1.8); 3) a clinically significant difference was observed between the Knee Derangement and Other for pain and between the Knee Derangement and Other and the Knee Dysfunction and Other classifications for disability; and 4) the Knee Derangement classification was discharged, on average, 15.8 days earlier than the Knee Dysfunction classification.

DISCUSSION

This was the first prospective study of the application of MDT in patients with knee impairments. Results should be interpreted with caution as follow-up data were only completed on 58% of patients that started data collection. Assuming that none of the dropouts were Derangement, the overall prevalence of Derangement would be 32.2% and 79.7% if all dropouts were classified as Derangement. This study adds insight into understanding the unique clinical trajectories of these MDT classifications for the knee and offers recommendations for future work in this growing field of research.

The McKenzie Method and its association with psychosocial outcomes in low back pain: a systematic review

Study Design: Systematic Literature Review.Background: The McKenzie Method (MDT) is a comprehensive conservative approach commonly used for the management of low back pain (LBP); however, its association with psychosocial outcomes in this population is less clear.Objectives: Evaluate whether MDT has an association with psychosocial outcomes for individuals with LBP.Methods: The following electronic databases were searched: Medline, Pubmed, Cochrane, CINAHL, Embase and AMED. They were systematically searched from the date of inception to August 2019. Included studies had to have participants experiencing LBP who were over 18 years old, utilize MDT as an assessment or intervention, and report outcomes for at least one psychosocial variable. Three reviewers independently evaluated methodological quality of randomized control trials (RCT) using the PEDro scale and observational studies using the GRACE scale.Results: The initial search resulted in 181 articles to review. After screening abstracts, then full articles, a total of 16 studies were included, 5 of which were RCTs rated 5-8/10 on the PEDro scale. A qualitative review was performed and the studies' results were synthesized into five main findings: fear-avoidance beliefs, depression symptoms, pain self-efficacy, psychological distress, and return to work (RTW).Conclusions: There is evidence that MDT has an association with improving fear-avoidance beliefs, pain self-efficacy, depression, and psychological distress. These results should be interpreted with caution as further high-quality randomized control trials addressing this topic are necessary due to the varying methodological and statistical constructs of the included studies.

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.

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.

An international survey of the comprehensiveness of the McKenzie classification system and the proportions of classifications and directional preferences in patients with spinal pain

BACKGROUND

Classification of spinal pain has been a key goal identified in the research. However it is not clear if existing classification systems are comprehensive.

OBJECTIVE

To examine the comprehensiveness and distribution of classifications within the McKenzie classification system (MDT), and the directional preference in consecutive patients with spine pain.

STUDY DESIGN

Prospective, observational study.

METHODS

Clinicians with a Diploma in MDT provided data on patients that they had assessed, classified, managed, and then confirmed their classification at discharge. They provided data on the spinal area, the MDT classification, and the loading strategy used in management.

RESULTS

Fifty-four clinicians from at least 15 different countries provided data on 750 patients: lumbar 64.8%, cervical 29.6%, thoracic 5.6%. The distribution of classifications was as follows: Derangement 75.4%, OTHER 22.8%, Dysfunction 1.7%, Postural syndrome 0.1%. In Derangements 82.5% had a directional preference for extension, 12.9% for lateral forces, and 4.6% for flexion. Those patients classified as one of the OTHER subgroups were given specific classifications.

CONCLUSION

Derangement was the most common classification and extension was by far the most common directional preference. A substantial proportion were classified as OTHER subgroups, for whom management is less straightforward.

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.

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.

Directional preference and functional outcomes among subjects classified at high psychosocial risk using STarT

BACKGROUND AND PURPOSE

Physiotherapy has an important role in managing patients with non-specific low back pain who experience elevated psychosocial distress or risk for chronic disability. In terms of evidence-based physiotherapy practice, cognitive-behavioural approaches for patients at high psychosocial risk are the recommended management to improve patient treatment outcomes. Evidence also suggests that directional preference (DP) is an important treatment effect modifier for prescribing specific exercises for patients to improve outcomes. Little is known about the influence of treatment techniques based on DP on outcomes for patients classified as high psychosocial risk using the Subgroups for Targeted Treatment (STarT) Back Screening Tool. This study aimed to examine the association between functional status (FS) at rehabilitation discharge for patients experiencing low back pain classified at high STarT psychosocial risk and whose symptoms showed a DP versus No-DP.

METHODS

High STarT risk patients (n = 138) completed intake surveys, that is, the lumbar FS of Focus On Therapeutic Outcomes, Inc., and STarT, and were evaluated for DP by physiotherapists credentialed in McKenzie methods. The FS measure of Focus On Therapeutic Outcomes, Inc., was repeated at discharge. DP and No-DP prevalence rates were calculated. Associations between first-visit DP and No-DP and change in FS were assessed using univariate and multivariate regression models controlling for 11 risk-adjusted variables.

RESULTS

One hundred nine patients classified as high STarT risk had complete intake and discharge FS and DP data. Prevalence rate for DP was 65.1%. A significant and clinically important difference (7.98 FS points; p = .03) in change in function at discharge between DP and No-DP was observed after controlling for all confounding variables in the final model.

CONCLUSION

Findings suggest that interventions matched to DP are effective for managing high psychological risk patients and may provide physiotherapists with an alternative treatment pathway compared to managing similar patients with cognitive-behavioural approaches. Stricter research designs are required to validate study conclusions.

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.

Consistency of commonly used orthopedic special tests of the shoulder when used with the McKenzie system of mechanical diagnosis and therapy

BACKGROUND

Shoulder Orthopedic Special Tests (OSTs) are used to assist with diagnosis in shoulder disorders. Issues with reliability and validity exist, making their interpretation challenging. Exploring OST results on repeated testing within Mechanical Diagnosis and Therapy (MDT) shoulder classifications may offer insight into the poor performance of these tests.

OBJECTIVES

To investigate in patients with shoulder complaints, whether MDT classifications affect the agreement of OST results over the course of treatment.

METHODS

An international group of MDT clinicians recruited 105 patients with shoulder problems. Three commonly used OSTs (Empty Can, Hawkins-Kennedy, and Speed's tests) were utilized. Results of the OSTs were collected at sessions 1, 3, 5 and 8, or at discharge from an MDT classification-based treatment. The Kappa statistic was utilized to determine the agreement of the OST results over time for each of the MDT classifications.

RESULTS

The overall Kappa values for Empty Can, Hawkins-Kennedy and Speed's tests were 0.28 (SE = 0.07), 0.28 (SE = 0.07) and 0.29 (SE = 0.07), respectively. The highest level of agreement was for Articular Dysfunction for the Empty Can test (0.84, SE = 0.19). For shoulder Derangements, there was no agreement for any of the OSTs (P values > 0.05).

CONCLUSION

The lack of agreement when the OSTs were consecutively tested in the presence of the MDT Derangement classification contrasted with the other MDT classifications. The presence of Derangement was responsible for reducing the overall agreement of commonly used OSTs and may explain the poor consistency for OSTs.

Application of the McKenzie system of Mechanical Diagnosis and Therapy (MDT) in patients with shoulder pain; a prospective longitudinal study

Objectives

The primary objective was to determine if the pain and function response to the McKenzie system of Mechanical Diagnosis and Therapy (MDT) differs by MDT classification category at two and four weeks following the start of MDT treatment for shoulder complaints. The secondary objective was to describe the frequency of discharge over time by MDT classification.

Methods

International, MDT-trained study collaborators recruited 93 patients attending physiotherapy for rehabilitation of a shoulder problem. The Numeric Pain Rating Scale (NPRS) and the Upper Extremity Functional Index (UEFI) were collected at the initial assessment and two and four weeks after treatment commenced. A two-way mixed model analysis of variance with planned pairwise comparisons was performed to identify where the differences between MDT classification groups actually existed.

Results

The Derangement and Spinal classifications had significantly lower NPRS scores than the Dysfunction group at week 2 and week 4 (p < 0.05). The Derangement and Spinal classifications had significantly higher UEFI scores than the Dysfunction group at week 2 and week 4 (p < 0.05). The frequency of discharge at week 2 was 37% for both Derangement and Spinal classifications, with no discharges for the Dysfunction classification at this time point. The frequency of discharge at week 4 was 83, 82 and 15% for the Derangement, Spinal and Dysfunction classifications, respectively.

Discussion

Classifying patients with shoulder pain using the MDT system can impact treatment outcomes and the frequency of discharge. When MDT-trained clinicians are allowed to match the intervention to a specific MDT classification, the outcome is aligned with the response expectation of the classification.Level of Evidence: 2b.

Pain provocation following sagittal plane repeated movements in people with chronic low back pain: Associations with pain sensitivity and psychological profiles

BACKGROUND AND AIMS

Provocative pain responses following standardised protocols of repeated sagittal plane spinal bending have not been reported in people with chronic low back pain (CLBP). Potential differing pain responses to movement likely reflect complex sensorimotor interactions influenced by physical, psychological and neurophysiological factors. To date, it is unknown whether provocative pain responses following repeated bending are associated with different pain sensitivity and psychological profiles. Therefore the first aim of this study was to determine whether data-driven subgroups with different, clinically-important pain responses following repeated movement exist in a large CLBP cohort, specifically using a standardised protocol of repeated sagittal plane spinal bending. The second aim was to determine if the resultant pain responses following repeated movement were associated with pain and disability, pain sensitivity and psychological factors.

METHODS

Clinically-important (≥2-points, 11-point numeric rating scale) changes in pain intensity following repeated forward/backward bending were examined. Participants with different provocative pain responses to forward and backward bending were profiled on age, sex, pain sensitivity, psychological variables, pain characteristics and disability.

RESULTS

Three groups with differing provocative pain responses following repeated movements were derived: (i) no clinically-important increased pain in either direction (n=144, 49.0%), (ii) increased pain with repeated bending in one direction only (unidirectional, n=112, 38.1%), (iii) increased pain with repeated bending in both directions (bidirectional, n=38, 12.9%). After adjusting for psychological profile, age and sex, for the group with bidirectional pain provocation responses following repeated spinal bending, higher pressure and thermal pain sensitivity were demonstrated, while for the group with no increase in pain, better cognitive and affective psychological questionnaire scores were evident. However, these associations between provocative pain responses following movement and pain sensitivity and psychological profiles were weak.

CONCLUSIONS

Provocative pain responses following repeated movements in people with CLBP appear heterogeneous, and are weakly associated with pain sensitivity and psychological profiles.

IMPLICATIONS

To date, suboptimal outcomes in studies examining exercise interventions targeting directional, movement-based subgroups in people with CLBP may reflect limited consideration of broader multidimensional clinical profiles associated with LBP. This article describes heterogeneous provocative pain responses following repeated spinal bending, and their associated pain sensitivity and psychological profiles, in people with CLBP. These findings may help facilitate targeted management. For people with no increase in pain, the lack of pain provocation following repeated spinal bending, in combination with a favourable psychological profile, suggests this subgroup may have fewer barriers to functional rehabilitation. In contrast, those with pain provoked by both forward and backward bending may require specific interventions targeting increased pain sensitivity and negative psychological cognitions and affect, as these may be may be important barriers to functional rehabilitation.

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.

Spine Kinematics During Prone Extension in People With and Without Low Back Pain and Among Classification-Specific Low Back Pain Subgroups

Study Design Cross-sectional observational design. Background Spine extension is used in physical therapy during examination and treatment for low back pain (LBP). However, kinematics during prone extension have not been examined using 3-D motion capture. Objectives The primary purpose was to determine differences in spine kinematics during prone extension between subjects with and without LBP. An exploratory analysis was conducted to examine kinematic differences among LBP subgroups. Methods Kinematics of the thoracic and lumbar spine were examined during prone extension, using optical motion capture, in 18 subjects with LBP and 17 subjects without LBP (control group). Excursion of each spinal region was calculated for the entire movement and during 25% increments of extension movement duration. Subjects with LBP were examined and assigned to subgroups using 3 different classification systems for LBP. Repeated-measures analysis-of-variance tests were used to examine effects of group (LBP, control), spine region, and increment of movement duration, and to explore effects of LBP subgroup. Results For spine kinematics, there was a significant group-by-region interaction effect (P<.05). Subjects with LBP displayed less lower lumbar extension (13.3° ± 4.9°) than control subjects (21.4° ± 9.2°). The majority of lower lumbar extension occurred during the first 50% of the motion for subjects with LBP. Subgroup-by-region interaction effects were significant for 2 of 3 LBP classification systems (P<.05). Conclusion Subjects with LBP displayed less lower lumbar extension than control subjects during prone extension. These differences should be considered when evaluating and prescribing prone extension. The interpretation of subgroup differences with prone extension kinematics is limited in the current study by the small sample size, but may need to be considered in future studies of spine kinematics. Level of Evidence Diagnosis, level 4. J Orthop Sports Phys Ther 2016;46(7):571-579. Epub 12 May 2016. doi:10.2519/jospt.2016.6159.

Transforaminal epidural steroid injections influence Mechanical Diagnosis and Therapy (MDT) pain response classification in candidates for lumbar herniated disc surgery

STUDY DESIGN

Prospective cohort study.

BACKGROUND

Although lumbar radiculopathy is regarded as a specific diagnosis, the most effective treatment strategy is unclear. Commonly used treatments include transforaminal epidural steroid injections (TESIs) and Mechanical Diagnosis & Therapy (MDT), but no studies have investigated the effectiveness of this combination. MDT differentiates pain centralization (C) from non-centralization (NC), which indicates good vs. poor prognostic validity respectively.

OBJECTIVE

The main aims were 1) to determine changes in Mechanical Diagnosis and Therapy (MDT) pain response classifications after transforaminal epidural steroid injections (TESIs) in candidates for lumbar herniated disc surgery and 2) to evaluate differences in short and long term outcomes for patients with different pain response classifications.

METHODS

Candidates for lumbar herniated disc surgery were assessed with a MDT protocol and their pain response classified as centralizing or peripheralizing. For this study,only patients were eligible who showed a peripheralizing pain response at intake. All patients then received TESIs and were reassessed and classified using the MDT protocol, into groups according to pain response (resolved, centralizing, peripheralizing with less pain and peripheralising with severe pain). After receiving targeted treatment based on pain response after TESIs, ranging from advice, MDT or surgery, follow-up assessments were completed at discharge and at 12 months. The primary outcomes were disability (Roland-Morris Disability Questionnaire [RMDQ] for Sciatica), pain severity in leg (visual analogue scale [VAS], 0-100) and global perceived effect (GPE). Linear mixed-models were used to determine between-groups differences in outcome.

RESULTS

A total of 77 patients with lumbar disc herniation and peripheralizing symptoms were included. Patients received an average of 2 (SD 0.7) TESIs. After TESIs, 17 patients (22%) were classified as peripheralizing with continuing severe pain.These patients underwent surgery and were not further evaluated. Eleven (14%) patients were classified as resolved, 37 (48%) as centralizing with significant less pain, and 12 (16%) as peripheralizing with significant less pain. None of these patients underwent surgery. Resolved and centralizer subgroups had better outcomes in terms of VAS and RMDQ than the non-operated peripheralizers at discharge and at 12 months. The succes rates (GPE) for the resolved, centralizing, and peripheralizing with less pain patients were 100%, 100% and 33% respectively at short term, and 100%, 92% and 50% respectively at long term.

CONCLUSION

After TESIs, a peripheralizing pain pattern changed to resolved or centralizing in 62% of the patients. For the non-operated patients, those with a centralising pattern after TESIs reported better pain and disability outcomes than those with peripheralizing pattern at short and long term.

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

STUDY DESIGN

Prospective cohort, test-retest design.

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Therapy, level 2b.

Physical therapists' level of McKenzie education, functional outcomes, and utilization in patients with low back pain

STUDY DESIGN

Longitudinal, prospective, observational cohort.

OBJECTIVE

To examine associations between McKenzie training, functional status (FS) at discharge, and number of physical therapy visits (utilization) in patients receiving physical therapy for low back pain.

BACKGROUND

The McKenzie method is commonly used in treating patients with low back pain.

METHODS

A McKenzie postgraduate educational program was initiated in a large outpatient physical therapy service. Functional status data were collected at intake and at discharge. Separate hierarchical linear mixed models were used to examine associations between physical therapists' McKenzie training level (none; Parts A, B, C, and D; and credentialed), FS score at discharge, and utilization, controlling for patient risk factors.

RESULTS

The final data set included 20 882 patients (mean ± SD age, 51 ± 16 years; 57% women) who completed FS surveys at both admission and discharge. Patients treated by physical therapists with any McKenzie training had better outcomes (additional 0.7 to 1.3 FS points; P<.05 to <.001) and fewer visits (0.6 to 0.9, P<.001) compared to patients treated by physical therapists with no training. For patients treated by therapists with no versus some McKenzie education, 65% versus 70% achieved at least the minimal clinically important improvement, respectively. There were no significant differences in outcomes or utilization by level of McKenzie training.

CONCLUSION

There was a slightly greater improvement of 0.7 to 1.3 points in FS at discharge in patients receiving physical therapy for low back pain by physical therapists who underwent McKenzie training. This difference was clinically important for an additional 5% of patients who achieved the minimal clinically important improvement when treated by therapists with some McKenzie training. Reduction in physical therapy utilization was 0.6 to 0.9 visits, with the fewest visits utilized by patients of physical therapists at the McKenzie Part D and credentialed levels. Together, these findings suggest improved cost-effectiveness at advanced McKenzie training levels. Ways to improve ongoing education and patient outcomes were proposed.

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.

Treatment of shoulder pain utilizing mechanical diagnosis and therapy principles

This case report describes the effectiveness of mechanical diagnosis and therapy (MDT) in the management of a patient referred with a diagnosis of shoulder tendonitis. The patient was a 56-year-old male with a 3-month history of left anterior shoulder pain. Upon initial assessment, he presented with a positive open-can test, lift-off test, and Hawkins-Kennedy impingement test. A MDT assessment quickly ruled out cervical involvement and identified a loss of end-range shoulder mobility and pain during active shoulder movement. After the patient underwent a repeated movement examination and treatment based on responses to end-range movements over three visits, his shoulder pain was abolished and motion was fully restored. Despite having positive rotator cuff and impingement signs, this patient was effectively treated with repeated end-range movements over a short period of 2 weeks. This case demonstrates that treatment based on MDT sub-classification principles may be an effective way to manage shoulder pain as it is in the spine.

A randomized controlled trial of limited range of motion lumbar extension exercise in chronic low back pain

STUDY DESIGN

Randomized controlled trial.

OBJECTIVE

To compare the effects of full range of motion (ROM) and limited ROM isolated lumbar extension exercise upon full ROM lumbar extension strength, ROM, perceived pain, and disability.

SUMMARY OF BACKGROUND DATA

Limited ROM is common in chronic low back pain as is lumbar extensor deconditioning. Limited ROM exercise is a common prescription but is yet to be empirically tested.

METHODS

Males (n = 21) and females (n = 17) with nonspecific chronic low back pain were initially recruited. Participants were randomized to either a full ROM (FullROM) or limited ROM (LimROM) training group or a control group. A total of 24 participants (males: n = 14, females: n = 10) completed the study and were included in analysis. The intervention lasted 12 weeks. FullROM and LimROM groups completed isolated lumbar extension resistance training once per week, performing one set of exercise at 80% of their maximal tested functional torque to failure. FullROM group trained through a full ROM. LimROM group trained through the mid 50% of their full ROM.Full ROM isolated lumbar extension strength, lumbar and standing ROM (Schobers test), perceived pain (visual analogue scale), and disability (Revised Oswestry Disability Index) were measured pre- and postintervention.

RESULTS

FullROM and LimROM significantly improved in full ROM lumbar extension strength, perceived pain, and disability compared with the control group. No changes occurred in lumbar or standing ROM. No significant differences were found between either FullROM or LimROM for any outcome measure. Changes in perceived pain and disability met minimal clinically important change values for FullROM (visual analogue scale, -30.3 + 25.76 mm and Oswestry Disability Index, -18.2 + 6.63 patients) and LimROM (visual analogue scale, -16.29 + 10.97 mm and Oswestry Disability Index, -12 + 5.16 patients).

CONCLUSION

The results suggest that both FullROM and LimROM are equally effective in increasing full ROM lumbar extension strength and producing clinically meaningful improvement in perceived pain and disability.

To establish whether McKenzie lumbar flexion and extension mobility exercises performed in lying affect central as well as systemic hemodynamics: a crossover experimental study

OBJECTIVE

Examine systemic and central hemodynamic responses following McKenzie lumbar flexion and extension mobility exercises performed in lying (FIL and EIL).

DESIGN

Crossover experimental study.

SETTING

Clinical laboratory.

PARTICIPANTS

Healthy male volunteers (n=25) (mean(SD) age: 28(3)years; range 21 to 34).

INTERVENTIONS

Based on alternating assignment of either FIL or EIL to participants, three sets of the first exercise (10, 15, 20 repetitions) were performed with 5-minute rest between sets; after 15-minute rest, the protocol was repeated for the other exercise.

MAIN OUTCOME MEASURES

Systemic hemodynamic parameters included heart rate (HR), and systolic and diastolic blood pressures (SBP, DBP). Central hemodynamic parameters included abdominal aortic diameter (AD), peak systolic velocity (PSV/AD), end diastolic velocity (EDV/AD) and resistive index (RI). Measures recorded after each exercise set.

RESULTS

FIL RPP at baseline was 9.1 (1.4), after 20 repetitions 18.3 (2.5), mean difference 8.9 (95% confidence interval (CI) 7.9 to 9.8) compared to EIL at baseline 9.1 (1.5), after 20 repetitions 13.0 (3.1), mean difference 4.1 (95% CI 3.3 to 5.0). FIL RI at baseline was 0.78 (0.03), after 20 repetitions 0.87 (0.03), mean difference 0.08 (95% CI 0.06 to 0.10) compared to EIL at baseline 0.78 (0.03), after 20 repetitions 0.83 (0.03), mean difference 0.05 (95% CI 0.04 to 0.07).

CONCLUSIONS

Although 10 repetitions of FIL and EIL may be regarded as safe, our findings support screening patients with lifestyle risk factors, and cautioning about adhering to recommended repetition number given associated increased work of the heart. The extent of AD mechanical perturbation remains unclear.

Referral source and outcomes of physical therapy care in patients with low back pain

STUDY DESIGN

Retrospective longitudinal cohort.

OBJECTIVES

To describe the clinical characteristics of patients with low back pain according to physician referral source, and to identify associations between referral source and discharge functional status, as well as number of physical therapy visits.

BACKGROUND

Little is known about associations between physician referral source and outcomes of physical therapy care for patients with low back pain. Exploring these associations can contribute to better understanding of physician-physical therapist relationships and may lead to improved referral patterns.

METHODS

Data from a proprietary clinical database were examined retrospectively. Physician referral source was classified as primary care, specialist, or occupational medicine. Outcomes were overall health status at discharge and number of physical therapy visits. Descriptive statistics and bivariate associations between referral source and each outcome were assessed by calculating differences and 95% confidence intervals (CIs) in means and proportions. To account for potential confounding, multilevel linear regression was used to adjust for baseline clinical covariates, effects related to clustering of patients treated by individual clinicians, and clinicians working within individual clinics.

RESULTS

Bivariate and multilevel analyses revealed significant associations between referral source and discharge overall health status, as well as number of visits. After multilevel adjustment for covariate and clustering effects, primary care and occupational medicine referrals were associated, on average, with point increases of 1.6 (95% CI: 0.7, 2.6) and 4.8 (95% CI: 2.7, 6.9) in discharge overall health status scores, respectively, compared to specialist referral. Similarly, primary care and occupational medicine referrals were associated, on average, with 0.44 (95% CI: 0.27, 0.61) and 0.83 (95% CI: 0.44, 1.22) fewer visits, respectively, compared to specialist referral.

CONCLUSION

After accounting for clinical covariates and clustering, patients with low back pain who were referred by occupational medicine and primary care physicians tended to have better functional outcomes and required fewer physical therapy visits per episode of care.

LEVEL OF EVIDENCE

Prognosis, level 2c.

A randomized controlled trial on the effectiveness of a classification-based system for subacute and chronic low back pain

STUDY DESIGN

A randomized controlled trial.

OBJECTIVE

To assess the effectiveness of Delitto's classification-based treatment approach compared with usual physical therapy care in patients with subacute or chronic low back pain.

SUMMARY OF BACKGROUND DATA

No trial has evaluated this approach in patients with subacute and chronic low back pain.

METHODS

Before randomization, all patients were classified by research physical therapists according to a modified version of Delitto's classification-based system. Randomization was computer-generated, with centralized allocation concealment. The statistician and the physical therapists were unblinded. Patients and assistants who collected follow-up questionnaires were blinded. Follow-up assessments were completed at 8, 26, and 52 weeks. The primary analysis was performed according to the intention-to-treat principle, using multilevel analysis. The main outcomes were global perceived effect, disability (Oswestry Disability Index, 0-100), and pain intensity (Numerical Rating Scale, 0-10). Secondary outcomes were quality of life, fear-avoidance beliefs, and psychosocial status. RESULTS.: A total of 156 patients were included (classification-based group, n = 74; usual physical therapy group, n = 82). There were no statistically significant differences between the treatment groups for any of the outcomes at any of the follow-up time points. After 8 weeks, patients in the classification-based group had greater global perceived effect scores; adjusted odds ratio of 1.01 (95% confidence interval [CI], 0.31 to 3.28), and higher adjusted Oswestry Disability Index and Numerical Rating Scale scores; mean adjusted differences of 0.48 points (95% CI, -4.59 to 3.63) and 0.49 points (95% CI, -1.34 to 0.37) respectively, but all differences were statistically nonsignificant.

CONCLUSION

The classification-based system used in this study was not effective for improving physical therapy care outcomes in a population of patients with subacute and chronic low back 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.

Lumbar computerized adaptive test and Modified Oswestry Low Back Pain Disability Questionnaire: relative validity and important change

STUDY DESIGN

Retrospective analysis of longitudinal, observational cohort data.

OBJECTIVES

To compare discriminating ability and minimal clinically important improvement (MCII) calculated using functional status (FS) measures estimated from the lumbar computerized adaptive test (LCAT) and Modified Oswestry Low Back Pain Disability Questionnaire (ODQ).

BACKGROUND

The LCAT and ODQ are commonly used to estimate FS in patients seeking outpatient therapy but have not been compared directly.

METHODS

Data from 8198 adult patients who completed the LCAT and ODQ at intake were analyzed, 3379 (41%) of whom completed both surveys at discharge. Global ratings of change data were available for 980 patients. Discriminating ability of FS estimates from the LCAT and ODQ was estimated using relative validity, calculated by dividing F values from LCAT and ODQ analyses of covariance for important risk-adjustment variables. MCII was estimated using receiver-operating-characteristic analyses by quartiles of intake FS values, and areas under the curves were compared.

RESULTS

Relative validity ratios favored the LCAT for age (3.7; 95% confidence interval [CI]: 2.0, 8.9), acuity (1.3; 95% CI: 1.1, 1.6), comorbidities (1.8; 95% CI: 1.3, 2.6), and surgical history (1.8; 95% CI: 1.2, 2.9). MCII cut scores per quartile favored the LCAT. Receiver-operating-characteristic areas under the curves were not different.

CONCLUSION

FS measures estimated by both questionnaires had similar psychometric characteristics. The LCAT FS estimates tended to be more discriminating than ODQ FS estimates. MCII cut scores by quartile of intake FS favored the LCAT. Given the need to be efficient and precise in estimating measures of FS, particularly in older patients, results favor the LCAT in busy, automated outpatient therapy clinics, which are increasingly serving an aging population.

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.

Using intake and change in multiple psychosocial measures to predict functional status outcomes in people with lumbar spine syndromes: a preliminary analysis

BACKGROUND

Managing patients with lumbar spine syndromes who are seeking outpatient physical therapy represents a complex problem where psychosocial constructs such as fear-avoidance beliefs regarding physical activities or work activities, somatization, and depressive symptoms may affect functional status (FS) outcomes.

OBJECTIVE

The purpose of this study was to determine whether intake or changes in fear-avoidance beliefs regarding physical or work activities, somatization, and depressive symptoms assessed simultaneously affect FS outcomes prediction.

DESIGN

This study was a secondary analysis of prospectively collected, longitudinal, observational cohort data.

METHODS

Data analyzed were from adult patients (n=323) with lumbar syndromes classified as elevated versus not elevated on single-item screening instruments for fear-avoidance beliefs regarding physical or work activities, somatization, and depressive symptoms at intake and discharge. Prediction of minimal clinically important difference in FS was assessed separately for intake and change from intake to discharge classifications using logistic regression models controlling for important variables.

RESULTS

Intake and change models were strong (McFadden rho-squared values=.31 and .49, respectively). Patients classified as not elevated in fear-avoidance beliefs regarding physical activities but elevated in fear-avoidance beliefs regarding work activities, somatization, and depressive symptoms at intake were 5 out of 100 times less likely to report clinically important outcomes compared with being elevated in each measure. Patients not elevated in fear-avoidance beliefs regarding work activities and somatization at intake and discharge were 8 to 14 times more likely to report clinically important outcomes compared with being elevated in each measure.

LIMITATIONS

Sample size was limited. Data analyses were retrospective with no control of missing data.

CONCLUSIONS

Combinations of multiple psychosocial constructs were important predictors of FS outcomes and may assist patient management by: (1) identifying patients with elevated psychosocial constructs at intake and (2) tracking change in psychosocial variables for improved outcomes prediction. This model may prove helpful for future clinical and research applications to determine optimal psychosocial screening methods.

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.