Alice Kvåle

Efficacy of classification-based cognitive functional therapy in patients with non-specific chronic low back pain: A randomized controlled trial

Non‐specific chronic low back pain disorders have been proven resistant to change, and there is still a lack of clear evidence for one specific treatment intervention being superior to another.

Integration of subclassification strategies in randomised controlled clinical trials evaluating manual therapy treatment and exercise therapy for non-specific chronic low back pain: a systematic review

Background There is lack of evidence for specific treatment interventions for patients with non-specific chronic low back pain (NSCLBP) despite the substantial amount of randomised controlled clinical trials evaluating treatment outcome for this disorder. Hypothesis It has been hypothesised that this vacuum of evidence is caused by the lack of subclassification of the heterogeneous population of patients with chronic low back pain for outcome research. Study design A systematic review. Methods A systematic review with a meta-analysis was undertaken to determine the integration of subclassification strategies with matched interventions in randomised controlled clinical trials evaluating manual therapy treatment and exercise therapy for NSCLBP. A structured search for relevant studies in Embase, Cinahl, Medline, PEDro and the Cochrane Trials Register database, followed by hand searching all relevant studies in English up to December 2008. Results Only 5 of 68 studies (7.4%) subclassified patients beyond applying general inclusion and exclusion criteria. In the few studies where classification and matched interventions have been used, our meta-analysis showed a statistical difference in favour of the classification-based intervention for reductions in pain (p=0.004) and disability (p=0.0005), both for short-term and long-term reduction in pain (p=0.001). Effect sizes ranged from moderate (0.43) for short term to minimal (0.14) for long term. Conclusion A better integration of subclassification strategies in NSCLBP outcome research is needed. We propose the development of explicit recommendations for the use of subclassification strategies and evaluation of targeted interventions in future research evaluating NSCLBP.

Quantitative sensory testing of patients with long lasting Patellofemoral pain syndrome

Background: Anterior knee pain, diagnosed as Patellofemoral Pain Syndrome (PFPS), is one of the most common musculoskeletal problems found in adolescents and young adults. There is no consensus in medical literature concerning the aetiology of the PFPS.

Reliability and validity of a palpation technique for identifying the spinous processes of C7 and L5

The objective was to examine inter-tester reliability and validity of two therapists identifying the spinous processes (SP) of C7 and L5, using one predefined surface palpation procedure for each level. One identification method made it possible to examine the reliability and the validity of the procedure itself. Two manual therapists examined 49 patients (29 women). Aged between 26 and 79 years, 18 were cervical and 31 lumbar patients. An invisible marking pen and ultraviolet light were used, and the findings were compared. X-rays were taken as an objective measure of the correct spinal level. Percentage agreement and kappa statistics were used to evaluate reliability and validity. The best inter-therapist agreement was found for the skin marks. Percentage agreement within 10mm and 20mm was 67% and 85%, respectively. The inter-tester reliability for identifying a radiological nominated SP by palpation was found to be poor for C7 and moderate for L5, with kappa of 0.18 and 0.48, respectively. The results indicated acceptable inter-therapist surface palpation agreement, but the chosen procedures did not identify the correct SP. This indicates that the procedures are not precise enough. Future reliability studies should test other non-invasive palpation procedures, both individually and in combination, and compare these with radiological investigation.

Is pain in patellofemoral pain syndrome neuropathic

ObjectiveThere is no consensus among experts regarding the etiology or management of patellofemoral pain syndrome (PFPS). Observations indicating dysfunction of the peripheral nervous system around the patellae have been reported. To what extent these sensory abnormalities cause pain has so far not been investigated. The aim of this study was to assess whether a subgroup of patients with unilateral PFPS have neuropathic pain related to the painful knee. MethodA total of 91 patients with unilateral PFPS, between 18 and 40 years of age, and a comparable group of 23 healthy participants aged 18 to 44 years were included. Level of knee function, pain intensity, and qualities were assessed. Somatosensory assessments were carried out by bedside neurologic tests and quantitative sensory testing, assessing thermal, tactile, and vibration thresholds. ResultsAmple signs of sensory aberrations with considerable heterogeneity and overlap regarding the degree and type of dysfunction of the nervous system were found in the painful area of the PFPS patients. No clear subgroup of patients with neuropathic pain or clustering of features related to neuropathic pain was identified. DiscussionThis study hypothesizes that the observed sensory aberrations may cause neuropathic pain in patients with PFPS. There is no validated method for subgrouping patients with possible neuropathic pain and in this study considerable heterogeneity and overlap regarding signs and symptoms of neuropathic pain made subgrouping even more difficult. A mechanism-based understanding of the pain is, however, essential for the selection of adequate treatment strategies in painful musculoskeletal disorders.

Physical findings in patients with dizziness undergoing a group exercise programme.

BACKGROUND AND PURPOSE Although there have been studies on patients with persistent dizziness, physical findings have not been formerly focused. The aim of this study was to investigate localization and extent of physical dysfunctions in patients with long-lasting dizziness. To investigate physical change, we re-examined patients who had completed a vestibular rehabilitation (VR) programme. METHODS A longitudinal design was used. Patients with peripheral vestibular dysfunction were examined with the Global Physiotherapy Examination (GPE-52) and the Vertigo Symptom Scale-short form (VSS-SF). The GPE-52 consists of 52 standardized items within posture, respiration, movement, muscle and skin. Initially, 32 patients were included; 20 completed the VR programme. The programme, based upon traditional VR exercises combined with a body awareness approach, was administered as group sessions taking place once weekly for nine weeks. RESULTS The majority of patients had a flexed head posture, and their respiration was restricted. Reduced flexibility, reduced ability to relax, measured with passive movements, and restricted range of motion (ROM) were found in about half of the patients in the neck, jaw, shoulder girdle and thorax. On palpation of muscles, 70-94% of the patients had reduced stretch in the abdominals/diaphragm, upper trapezius, sternocleidomastoid and medial gastrocnemius muscles. After the VR programme, significant improvements (p < 0.05) were shown in the following areas: respiration, flexibility and passive movement tests in the shoulder and cervical region, and ROM in the neck and jaw. Significant improvement (p < 0.05) was also reported in the balance subscale of the VSS-SF. CONCLUSIONS This study documents that postural changes, restricted respiration, lack of flexibility, ability to relax and reduced muscular stretch seem quite common in patients with dizziness. A modified VR comprising body awareness significantly improved respiration and movements in the upper body as well as self-reported balance.

Discriminative Validity of the Global Physiotherapy Examination-52 in Patients with Long-Lasting Musculoskeletal Pain versus Healthy Persons

Objectives: The aims of this study were to evaluate the discriminative ability of a body examination in healthy subjects versus patients with long-lasting musculoskeletal pain, and further to compare physical findings in patients with localized versus widespread pain, and between women and men. Methods: The Global Physiotherapy Examination [GPE-52] was used to evaluate bodily aberrations in 247 patients [159 women, 88 men] with long-lasting musculoskeletal pain. The GPE consists of 52 standardized tests within five main domains: Posture, Respiration, Movement, Muscle, and Skin. Patients were categorized into three subgroups according to pain distribution: pain localized either to the upper or lower body, or widespread pain. For comparison, 104 healthy persons without pain [64 women, 40 men] were also examined. Results: Significant differences were found between healthy persons and patients within all five main domains, most within the Movement and Muscle domains, least within the Respiration and Skin domains. Patients with widespread pain had significantly higher scores, indicating aberrations, within the Movement and Muscle domains compared to patients with localized pain. Men had higher scores within Posture and Movement, whereas female patients had significantly higher scores within Skin. Conclusions: Indications were provided that the GPE-52, especially the Movement and Muscle domains, discriminate between patients groups and healthy subjects, and give information about degree of bodily aberrations. Different characteristics were found depending on gender and pain distribution.

Palpation of Muscle and Skin. Is this a Reliable and Valid Procedure in Assessment of Patients with Long-lasting Musculoskeletal Pain?

The aims of this study were to investigate reliability and aspects of validity of a previously developed method called the Global Physiotherapeutic Muscle Examination (GPM), which comprises items related to palpation of Muscle (18 items) and Skin (12 items). Inter-tester reliability was examined by three physiotherapists examining 19 persons. Construct and discriminative validity was studied by data from 247 patients with long-lasting musculoskeletal pain and 104 healthy subjects. For the patients, concurrent validity was examined by correlating psychological functioning, measured with the revised version of the Minnesota Multiphasic Personality Inventory (MMPI-2), as well as information about pain, with the domains of Muscle and Skin. Reliability was acceptable, with overall intra-class correlation coefficients ranging from 0.54 to 0.84, but with low measurement error. Construct evaluation was done by means of Structural Equation Modeling (SEM), resulting in a modified and improved model with fewer tests: 12 within Muscle and eight within Skin. Composite scores of palpation differed significantly between healthy subjects and patients, and between sub-groups of patients. A relationship was found between Muscle and Skin and psychological characteristics, but differently for females and males. Pain showed a low but significant correlation only to the Muscle domain. The items included in a modified model of palpation can be used in a reliable and valid way when screening patients with long-lasting pain.

Examination of Respiration in Patients with Long-lasting Musculoskeletal Pain: Reliability and Validity

Clinical examination of respiration may be an important aspect of musculoskeletal problems, but has scarcely been reported. The aims of this study were to evaluate the reliability and validity of the domain Respiration, containing 12 items oriented towards the inspection of respiratory movement and rhythm. Inter-tester reliability was examined by three physiotherapists examining 19 persons. Construct and discriminative validity of the Respiration method was studied by data from 247 patients with long-lasting muscu loskeletal pain and 104 healthy subjects. Concurrent validity to psychological variables and pain was also examined. Responsiveness was studied by comparing change in Respiration in patients who returned fully to work vs. those still on sick leave 6 months after rehabilitation. The results indicated fair but acceptable reliability. A modified Respiration scale consisting of eight items was obtained by means of Structural Equation Modeling (SEM). Respiration scores differed significantly between healthy subjects and patients. A relationship was found between Respiration and psychological characterisin tics, and between Respiration and pain, particularly in patients with widespread pain. Responsiveness of the Respiration method to clinically important change was demonstrated. Respiration can be reliably and validly assessed, and the method seems useful in the evaluation of patients with musculoskeletal problems and used as an outcome measure in rehabilitation.

The effect of psychomotor physical therapy on subjective health complaints and psychological symptoms

BACKGROUND AND PURPOSE The objective of this study was to examine the effect of Norwegian psychomotor physical therapy on subjective health complaints and psychological symptoms. METHOD A non-randomized waiting list controlled design was used. Physiotherapists in Norway recruited patients for a treatment group (n = 40) and waiting list control group (n = 22). Patients on the waiting list could only be included for 6 months, as they then started treatment. Symptoms registration was obtained from both groups at baseline and 6 months, and only for the treatment group also at 12 months. The following self-report forms were used; Subjective Health Complaints Inventory (SCH); Beck Depression Inventory-II (BDI-II); Spielberger State-Trait Anxiety Inventory-Trait (STAI-T); Bergen Insomnia Scale (BIS); Fatigue Questionnaire (FQ); Quality of Life Inventory (QOLI); The Client Satisfaction Questionnaire (CSQ). RESULTS The patients had had widespread and clinically significant health problems for an average of 9 years upon entrance to the study. After 6 months in psychomotor physical therapy, all the measured symptoms in the treatment group were significantly reduced, but only quality of life was significantly reduced when compared to the waiting list control group. After 12 months in therapy, the patients in the treatment group had continued to improve on all measured variables. The symptoms of anxiety and depression, as well as quality of life, were improved from clinical to non-clinical level. CONCLUSIONS Norwegian psychomotor physical therapy seems to have potential for reducing symptoms of subjective health complaints, depression, anxiety, insomnia, fatigue and improving quality of life, although the process takes time. Further research is needed to gain more rigorous data, and randomized controlled studies are highly welcomed.