Anthony Delitto

Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy

Study Design. A blinded, prospective diagnostic test study was conducted. Objectives. To assess the reliability and accuracy of individual clinical examination items and self-report instruments for the diagnosis of cervical radiculopathy, and to identify and assess the accuracy of an optimum test-item cluster for the diagnosis of cervical radiculopathy. Summary of Background Data. Although cervical radiculopathy remains largely a clinical diagnosis, the reliability and diagnostic accuracy of clinical examination items, individually or in combination, for cervical radiculopathy is largely unknown. Methods. Patients with suspected cervical radiculopathy or carpal tunnel syndrome received standardized electrophysiologic examination of the symptomatic upper quarter followed by a standardized clinical examination by physical therapist examiners blinded to diagnosis. Diagnostic properties were assessed using a neural impairment reference criterion standard. Results. The study involved 82 patients. More than two thirds of 34 clinical examination items had reliability coefficients rated at least fair or better, and 13 items had likelihood ratio point estimates above 2 or below 0.50. A single diagnostic test item cluster of four variables was identified and produced a positive likelihood ratio point estimate of 30.3. The 95% confidence intervals for all likelihood ratio point estimates in this study were wide. Conclusions. Many items of the clinical examination were found to be reliable and to have acceptable diagnostic properties, but the test item cluster identified was more useful for indicating cervical radiculopathy than any single test item. Upper limb tension Test A was the most useful test for ruling out cervical radiculopathy. Further investigation is required both to validate the test item cluster and to improve point estimate precision.

Identifying subgroups of patients with acute/subacute nonspecific low back pain : Results of a randomized clinical trial

Study Design. Randomized clinical trial. Objective. Compare outcomes of patients with low back pain receiving treatments matched or unmatched to their subgrouping based on initial clinical presentation. Summary of Background Data. Patients with “nonspecific” low back pain are often viewed as a homogeneous group, equally likely to respond to any particular intervention. Others have proposed methods for subgrouping patients as a means for determining the treatment most likely to benefit patients with particular characteristics. Methods. Patients with low back pain of less than 90 days’ duration referred to physical therapy were examined before treatment and classified into one of three subgroups based on the type of treatment believed most likely to benefit the patient (manipulation, stabilization exercise, or specific exercise). Patients were randomly assigned to receive manipulation, stabilization exercises, or specific exercise treatment during a 4-week treatment period. Disability was assessed in the short-term (4 weeks) and long-term (1 year) using the Oswestry. Comparisons were made between patients receiving treatment matched to their subgroup, versus those receiving unmatched treatment. Results. A total of 123 patients participated (mean age, 37.7 ± 10.7 years; 45% female). Patients receiving matched treatments experienced greater short- and long-term reductions in disability than those receiving unmatched treatments. After 4 weeks, the difference favoring the matched treatment group was 6.6 Oswestry points (95% CI, 0.70–12.5), and at long-term follow-up the difference was 8.3 points (95% CI, 2.5–14.1). Compliers-only analysis of long-term outcomes yielded a similar result. Conclusions. Nonspecific low back pain should not be viewed as a homogenous condition. Outcomes can be improved when subgrouping is used to guide treatment decision-making.

Comparison of Classification-Based Physical Therapy With Therapy Based on Clinical Practice Guidelines for Patients with Acute Low Back Pain : A Randomized Clinical Trial

Study Design. A randomized clinical trial was conducted. Objective. To compare the effectiveness of classification-based physical therapy with that of therapy based on clinical practice guidelines for patients with acute, work-related low back pain. Summary of Background Data. Clinical practice guidelines recommend minimal intervention during the first few weeks after acute low back injury. However, studies supporting this recommendation have not attempted to identify which patients are likely to respond to particular interventions. Methods. For this study, 78 subjects with work-related low back pain of less than 3 weeks duration were randomized to receive therapy based on a classification system that attempts to match patients to specific interventions or therapy based on the Agency for Health Care Policy and Research guidelines. The subjects were followed for 1 year. Outcomes included the impairment index, Oswestry scale, SF-36 component scores, satisfaction, medical costs, and return to work status. Results. After adjustment for baseline factors, subjects receiving classification-based therapy showed greater change on the Oswestry (P = 0.023) and the SF-36 physical component (P = 0.029) after 4 weeks. Patient satisfaction was greater (P = 0.006) and return to full-duty work status more likely (P = 0.017) after 4 weeks in the classification-based group. After 1 year, there was a trend toward reduced Oswestry scores in the classification-based group (P = 0.063). Median total medical costs for 1 year after injury were

Total Contact Casting in Treatment of Diabetic Plantar Ulcers: Controlled Clinical Trial

1003.68 for the guideline-based group and

Interrater reliability of clinical examination measures for identification of lumbar segmental instability.

774.00 for the classification-based group (P = 0.13). Conclusions. For patients with acute, work-related low back pain, the use of a classification-based approach resulted in improved disability and return to work status after 4 weeks, as compared with therapy based on clinical practice guidelines. Further research is needed on the optimal timing and methods of intervention for patients with acute low back pain.

Lumbar spinal stenosis: A review of current concepts in evaluation, management, and outcome measurements

This study compared the treatment of total contact casting (TCC) with traditional dressing treatment (TDT) in the management of diabetic plantar ulcers. Forty patients with diabetes mellitus and a plantar ulcer but with nogross infection, osteomyelitis, or gangrene were randomly assigned to the TCC group (n = 21) or TDT group (n = 19). Age, sex, ratio of insulin-dependent diabetes mellitus to non-insulin-dependent diabetes mellitus, duration of diabetes mellitus, vascular status, size and duration of ulcer, and sensation were not significantly different between groups (P > .05). In the experimental group, TCC was applied on the initial visit, and subjects were instructed to limit ambulation to ∼33% of their usual activity. Subjects in the control group were prescribed dressing changes and accommodative footwear and were instructed to avoid bearing weight on the involved extremity. Ulcers were considered healed if they showed complete skin closure with no drainage. Ulcers were considered not healed if they showed no decrease in size by 6 wk or if infection developed that required hospitalization. In the TCC group, 19 of 21 ulcers healed in 42 ± 29 days; in the TDT group, 6 of 19 ulcers healed in 65 ± 29 days. Significantly more ulcers healed (χ2 = 12.4, P < .05) and fewer infections developed (χ2 = 4.1, P < .05) in the TCC group. We conclude TCC is a successful method of treating diabetic plantar ulcers but requires careful application, close follow-up, and patient compliance with scheduled appointments to minimize complications.

Unilateral hip rotation range of motion asymmetry in patients with sacroiliac joint regional pain

OBJECTIVE To determine the interrater reliability of common clinical examination procedures proposed to identify patients with lumbar segmental instability. DESIGN Single group repeated-measures interrater reliability study. SETTING Outpatient physical therapy (PT) clinic and university PT department. PARTICIPANTS A consecutive sample of 63 subjects (38 women, 25 men; 81% with previous episodes of low back pain [LBP]) with current LBP was examined by 3 pairs of raters. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Repeat measurements of clinical signs and tests proposed to identify lumbar segmental instability. RESULTS Kappa values for the trunk range of motion (ROM) findings varied (range,.00-.69). The prone instability test (kappa=.87) showed greater reliability than the posterior shear test (kappa=.22). The Beighton Ligamentous Laxity Scale (LLS) for generalized ligamentous laxity showed high reliability (intraclass correlation coefficient=.79). Judgments of pain provocation (kappa range,.25-.55) were generally more reliable than judgments of segmental mobility (kappa range, -.02 to.26) during passive intervertebral motion testing. CONCLUSIONS The results agree with previous studies suggesting that segmental mobility testing is not reliable. The prone instability test, generalized LLS, and aberrant motion with trunk ROM demonstrated higher levels of reliability.

Interrater reliability of judgments of the centralization phenomenon and status change during movement testing in patients with low back pain

The purpose of this review is to present current information from the literature regarding the pathoanatomy, clinical presentation, differential diagnosis, treatment, and outcome assessment methods for patients with lumbar spinal stenosis. Lumbar spinal stenosis is a frequently encountered condition, particularly in the elderly. Treatment requires an accurate diagnosis, but differential diagnosis of lumbar stenosis can be difficult. The literature to date has focused primarily on surgical treatment. The long-term efficacy of surgery has been questioned, and surgical procedures are associated with increased costs and risks of morbidity in an elderly population. A trial of conservative care is recommended in most cases, but there are presently no randomized controlled studies in the literature comparing surgical versus conservative management, or evaluating the effectiveness of any specific conservative treatment approach. The existing literature has further been criticized for having poorly defined outcome measures. The assessment of treatment outcomes should be multifactorial, including measures of pathoanatomy and impairments, as well as patient-centered measures such as level of disability, patient expectations, and satisfaction. The present level of understanding of lumbar spinal stenosis is deficient in many areas, including differential diagnosis, treatment, and outcome assessment. Future research should address these deficits to improve the management of patients with this condition.

Achilles Pain, Stiffness, and Muscle Power Deficits: Achilles Tendinitis

Study Design. A cross‐sectional study was used to determine whether limited range of motion in the hip was present in 100 patients‐one group with unspecified low back pain and another group with signs suggesting sacroiliac joint dysfunction. Objectives. To determine whether a characteristic pattern of range of motion in the hip is related to low back pain in patients and to determine whether such a pattern is associated with and without signs of sacroiliac joint dysfunction. Summary of Background Data. The sacroiliac joint is often considered a potential site of low back pain. Problems with the sacroiliac joint, as well as with the low back, have often been related to reduced or asymmetric range of motion in the hip. The correlation between sacroiliac joint dysfunction and hip range of motion, however, has not been thoroughly evaluated with reliable tests in a population of patients with low back pain. Methods. Passive hip internal and external rotation goniometric measurements were taken by a blinded examiner, while a separate examiner evaluated the patient for signs of sacroiliac joint dysfunction. Patients with sacroiliac joint dysfunction were further classified as having a left or a right posteriorly tilted innominate. Results. The patients with low back pain but without evidence of sacroiliac joint dysfunction had significantly greater external hip rotation than internal rotation bilaterally, whereas those with evidence of sacroiliac joint dysfunction had significantly more external hip rotation than internal rotation unilaterally, specifically on the side of the posterior innominate. Conclusions. Clinicians should consider evaluating for unilateral asymmetry in range of motion in the hip in patients with low back pain. The presence of such asymmetry in patients with low back pain may help identify those with sacroiliac joint dysfunction.

Reliability of isokinetic measurements of trunk muscle performance

OBJECTIVE To determine the interrater reliability of judgments of status change, including the centralization phenomenon during examination of the lumbar spine, and to determine the effects of training and experience on reliability. DESIGN A videotape study of judgments by physical therapists and physical therapy students of the results of movement testing during the examination of patients with low back pain. SETTING Outpatient physical therapy clinic. PATIENTS Patients receiving physical therapy treatment for low back pain. INTERVENTION Patients with low back pain were videotaped while performing a variety of movement tests including single, repeated, and sustained movements. Forty licensed physical therapists and 40 physical therapy students were provided with operational definitions of the three potential judgments of status change with movement testing; centralization, peripheralization, status quo. All therapists and students viewed the videotape and made a judgment regarding the patients status change in response to the test. MAIN OUTCOME MEASURE Percentage agreement and kappa coefficient values for agreement. RESULTS Interrater reliability was excellent for the total sample of examiners (kappa = .793), for the licensed physical therapists (kappa = .823), and for the students (kappa = .763). CONCLUSIONS Judgments of status change are reliable when operational definitions are provided. Clinical experience does not appear to substantially improve reliability.