Giorgio Zeppieri

Immediate effects of spinal manipulation on thermal pain sensitivity: an experimental study.

BackgroundThe underlying causes of spinal manipulation hypoalgesia are largely unknown. The beneficial clinical effects were originally theorized to be due to biomechanical changes, but recent research has suggested spinal manipulation may have a direct neurophysiological effect on pain perception through dorsal horn inhibition. This study added to this literature by investigating whether spinal manipulation hypoalgesia was: a) local to anatomical areas innervated by the lumbar spine; b) correlated with psychological variables; c) greater than hypoalgesia from physical activity; and d) different for A-delta and C-fiber mediated pain perception.MethodsAsymptomatic subjects (n = 60) completed baseline psychological questionnaires and underwent thermal quantitative sensory testing for A-delta and C-fiber mediated pain perception. Subjects were then randomized to ride a stationary bicycle, perform lumbar extension exercise, or receive spinal manipulation. Quantitative sensory testing was repeated 5 minutes after the intervention period. Data were analyzed with repeated measures ANOVA and post-hoc testing was performed with Bonferroni correction, as appropriate.ResultsSubjects in the three intervention groups did not differ on baseline characteristics. Hypoalgesia from spinal manipulation was observed in lumbar innervated areas, but not control (cervical innervated) areas. Hypoalgesic response was not strongly correlated with psychological variables. Spinal manipulation hypoalgesia for A-delta fiber mediated pain perception did not differ from stationary bicycle and lumbar extension (p > 0.05). Spinal manipulation hypoalgesia for C-fiber mediated pain perception was greater than stationary bicycle riding (p = 0.040), but not for lumbar extension (p = 0.105).ConclusionLocal dorsal horn mediated inhibition of C-fiber input is a potential hypoalgesic mechanism of spinal manipulation for asymptomatic subjects, but further study is required to replicate this finding in subjects with low back pain.

Spinal Manipulative Therapy Has an Immediate Effect on Thermal Pain Sensitivity in People With Low Back Pain: A Randomized Controlled Trial

Background Current evidence suggests that spinal manipulative therapy (SMT) is effective in the treatment of people with low back pain (LBP); however, the corresponding mechanisms are unknown. Hypoalgesia is associated with SMT and is suggestive of specific mechanisms. Objective The primary purpose of this study was to assess the immediate effects of SMT on thermal pain perception in people with LBP. A secondary purpose was to determine whether the resulting hypoalgesia was a local effect and whether psychological influences were associated with changes in pain perception. Design This study was a randomized controlled trial. Setting A sample of convenience was recruited from community and outpatient clinics. Participants Thirty-six people (10 men, 26 women) currently experiencing LBP participated in the study. The average age of the participants was 32.39 (SD=12.63) years, and the average duration of LBP was 221.79 (SD=365.37) weeks. Intervention and Measurements Baseline demographic and psychological measurements were obtained, followed by quantitative sensory testing to assess temporal summation and Aδ fiber–mediated pain perception. Next, participants were randomly assigned to ride a stationary bicycle, perform low back extension exercises, or receive SMT. Finally, the same quantitative sensory testing protocol was reassessed to determine the immediate effects of each intervention on thermal pain sensitivity. Results Hypoalgesia to Aδ fiber–mediated pain perception was not observed. Group-dependent hypoalgesia of temporal summation specific to the lumbar innervated region was observed. Pair-wise comparisons indicated significant hypoalgesia in participants who received SMT, but not in those who rode a stationary bicycle or performed low back extension exercises. Psychological factors did not significantly correlate with changes in temporal summation in participants who received SMT. Limitations Only immediate effects of SMT were measured, so the authors are unable to comment on whether the inhibition of temporal summation is a lasting effect. Furthermore, the authors are unable to comment on the relationship between their findings and changes in clinical pain. Conclusions Inhibition of Aδ fiber–mediated pain perception was similar for all groups. However, inhibition of temporal summation was observed only in participants receiving SMT, suggesting a modulation of dorsal horn excitability that was observed primarily in the lumbar innervated area.

A Randomized Trial of Behavioral Physical Therapy Interventions for Acute and Sub-Acute Low Back Pain (NCT00373867)

Abstract Psychological factors consistent with fear‐avoidance models are associated with the development of chronic low back pain (LBP). As a result, graded activity (GA) and graded exposure (GX) have been suggested as behavioral treatment options. This clinical trial compared the effectiveness of treatment‐based classification (TBC) physical therapy alone to TBC augmented with GA or GX for patients with acute and sub‐acute LBP. Our primary hypothesis was that GX would be most effective for those with elevated pain‐related fear. In total, 108 patients enrolled in this clinical trial and were randomly assigned to receive TBC, GA, or GX. Outcomes were assessed by a blinded evaluator at 4 weeks and by mail at 6 months. The primary outcomes for this trial were disability and pain intensity, and the secondary outcomes were fear‐avoidance beliefs, pain catastrophizing, and physical impairment. There were no differences in 4‐week and 6‐month outcomes for reduction of disability, pain intensity, pain catastrophizing, and physical impairment. GX and TBC were associated with larger reductions in fear‐avoidance beliefs at 6 months only. Six‐month reduction in disability was associated with reduction in pain intensity, while 6‐month reduction in pain intensity was associated with reductions in fear‐avoidance beliefs and pain catastrophizing. This trial suggests that supplementing TBC with GA or GX was not effective for improving important outcomes related to the development of chronic LBP.

Longitudinal Changes in Psychosocial Factors and Their Association With Knee Pain and Function After Anterior Cruciate Ligament Reconstruction

Background Evidence in the musculoskeletal rehabilitation literature suggests that psychosocial factors can influence pain levels and functional outcome. Objective The purpose of this study was to examine changes in select psychosocial factors and their association with knee pain and function over 12 weeks after anterior cruciate ligament (ACL) reconstruction. Design This was a prospective, longitudinal, observational study. Methods Patients with ACL reconstruction completed self-report questionnaires for average knee pain intensity (numeric rating scale [NRS]), knee function (International Knee Documentation Committee Subjective Knee Form [IKDC-SKF]), and psychosocial factors (pain catastrophizing [Pain Catastrophizing Scale], fear of movement or reinjury [shortened version of the Tampa Scale for Kinesiophobia (TSK-11)], and self-efficacy for rehabilitation tasks [modified Self-Efficacy for Rehabilitation Outcome Scale (SER)]). Data were collected at 4 time points after surgery (baseline and 4, 8, and 12 weeks). Repeated-measures analyses of variance determined changes in questionnaire scores across time. Hierarchical linear regression models were used to examine the association of psychosocial factors with knee pain and function. Results Seventy-seven participants completed the study. All questionnaire scores changed across 12 weeks. Baseline psychosocial factors did not predict the 12-week NRS or IKDC-SKF score. The 12-week change in modified SER score predicted the 12-week change in NRS score (r2=.061), and the 12-week change in modified SER and TSK-11 scores predicted the 12-week change in IKDC-SKF score (r2=.120). Limitations The psychometric properties of the psychosocial factor questionnaires are unknown in people with ACL reconstruction. The study focused on short-term outcomes using only self-report measures. Conclusions Psychosocial factors are potentially modifiable early after ACL reconstruction. Baseline psychosocial factor levels did not predict knee pain or function 12 weeks postoperatively. Interventions that increase self-efficacy for rehabilitation tasks or decrease fear of movement or reinjury may have potential to improve short-term outcomes for knee pain and function.

Comparison of Physical Impairment, Functional, and Psychosocial Measures Based on Fear of Reinjury/Lack of Confidence and Return-to-Sport Status After ACL Reconstruction

Background: Fear of reinjury and lack of confidence influence return-to-sport outcomes after anterior cruciate ligament (ACL) reconstruction. The physical, psychosocial, and functional recovery of patients reporting fear of reinjury or lack of confidence as their primary barrier to resuming sports participation is unknown. Purpose: To compare physical impairment, functional, and psychosocial measures between subgroups based on return-to-sport status and fear of reinjury/lack of confidence in the return-to-sport stage and to determine the association of physical impairment and psychosocial measures with function for each subgroup at 6 months and 1 year after surgery. Study Design: Case-control study; Level of evidence, 3. Methods: Physical impairment (quadriceps index [QI], quadriceps strength/body weight [QSBW], hamstring:quadriceps strength ratio [HQ ratio], pain intensity), self-report of function (International Knee Documentation Committee [IKDC]), and psychosocial (Tampa Scale for Kinesiophobia–shortened form [TSK-11]) measures were collected at 6 months and 1 year after surgery in 73 patients with ACL reconstruction. At 1 year, subjects were divided into “return-to-sport” (YRTS) or “not return-to-sport” (NRTS) subgroups based on their self-reported return to preinjury sport status. Patients in the NRTS subgroup were subcategorized as NRTS-Fear/Confidence if fear of reinjury/lack of confidence was the primary reason for not returning to sports, and all others were categorized as NRTS-Other. Results: A total of 46 subjects were assigned to YRTS, 13 to NRTS-Other, and 14 to NRTS-Fear/Confidence. Compared with the YRTS subgroup, the NRTS-Fear/Confidence subgroup was older and had lower QSBW, lower IKDC score, and higher TSK-11 score at 6 months and 1 year; however, they had similar pain levels. In the NRTS-Fear/Confidence subgroup, the IKDC score was associated with QSBW and pain at 6 months and QSBW, QI, pain, and TSK-11 scores at 1 year. Conclusion: Elevated pain-related fear of movement/reinjury, quadriceps weakness, and reduced IKDC score distinguish patients who are unable to return to preinjury sports participation because of fear of reinjury/lack of confidence. Despite low average pain ratings, fear of pain may influence function in this subgroup. Assessment of fear of reinjury, quadriceps strength, and self-reported function at 6 months may help identify patients at risk for not returning to sports at 1 year and should be considered for inclusion in return-to-sport guidelines.

Analysis of shortened versions of the tampa scale for kinesiophobia and pain catastrophizing scale for patients after anterior cruciate ligament reconstruction.

ObjectiveRecent work suggests that psychological influence on pain intensity and knee function should be considered for patients after anterior cruciate ligament reconstruction (ACLR). The Tampa Scale for Kinesiophobia (TSK) and Pain Catastrophizing Scale (PCS) have been used to determine psychological influence in these patients. However, TSK and PCS factor structures have not been described for patients with ACLR. This study investigated 2 groups of patients post-ACLR to determine if the use of shortened questionnaires is warranted. MethodsCross-sectional study in which patients completed measures during early (n=105, median days from surgery=56.0) and late (n=184, median days from surgery=195.0) postoperative phases of ACLR rehabilitation. ResultsShortened questionnaires for fear of pain, fear of injury, and somatic focus were generated for the TSK-11. A shortened questionnaire for magnification/helplessness and rumination was generated for the PCS in the late group only. There were minimal differences in the shortened questionnaires for clinical subgroups based on sex, ACLR graft type, method of injury, or nature of injury. Correlation and regression analyses suggested a shortened version of the TSK-11 for fear of injury was appropriate for use in the early postoperative phase, whereas the original TSK-11 scale may be appropriate for use in the late postoperative phase. There were no shortened versions of the PCS for consideration in the early postoperative phase, but a shortened version for magnification/helplessness was appropriate for use in the late postoperative phase. DiscussionShortened versions of the TSK-11 and PCS may be appropriate for ACLR populations, depending on the postoperative phase. These data may guide future research of psychological factors in ACLR populations so that levels predictive of risk for developing chronic pain and/or inability to return to pre-injury activity levels can be determined.

Physical Therapy Utilization of Graded Exposure for Patients With Low Back Pain

SYNOPSIS The fear-avoidance model of musculoskeletal pain suggests that elevated pain-related fear is a precursor to chronic low back pain. Recent prospective studies support the predictive validity of this model, and treatment approaches based on the model have also been reported in the literature. Graded exercise/activity is one treatment approach that has been well described in the literature, with reports describing physical-therapy-specific application. Graded exposure is another intervention with the potential to reduce pain-related fear, yet physical-therapy-specific application of graded exposure has not been widely described in the literature. The purpose of this clinical commentary was to provide information on the theoretical aspects of graded exposure, to briefly review available evidence for graded exposure, and to describe physical therapy application of graded exposure for 2 patients enrolled in a physical therapy clinical trial. LEVEL OF EVIDENCE Therapy, level 5. J Orthop Sport Phys Ther 2009;39(7):496-505, Epub 24 February 2009. doi:10.2519/jospt.2009.2983.

Development of a Self-Report Measure of Fearful Activities for Patients With Low Back Pain: The Fear of Daily Activities Questionnaire

Background: Self-report measures for assessing specific fear of activities have not been reported in the peer-reviewed literature, but are necessary to adequately test treatment hypotheses related to fear-avoidance models. Objective: This study described psychomotor properties of a novel self-report measure, the Fear of Daily Activities Questionnaire (FDAQ). Design: A prospective cohort design was used. Methods: Reliability and validity cohorts were recruited from outpatient physical therapy clinics. Analyses for the reliability cohort included internal consistency and 48-hour test-retest coefficients, as well as standard error of measurement and minimal detectable change estimates. Analyses for the validity cohort included factor analysis for construct validity and correlation and multiple regression analyses for concurrent and predictive validity. Four-week responsiveness was assessed by paired t test, effect size calculation, and percentage of patients meeting or achieving MDC criterion. Results: The FDAQ demonstrated adequate internal consistency (Cronbach alpha=.91, 95% confidence interval=.87–.95) and 48-hour test-retest properties (intraclass correlation coefficient=.90, 95% confidence interval=.82–.94). The standard error of measurement for the FDAQ was 6.6, resulting in a minimal detectable change of 12.9. Factor analysis suggested a 2- or 3-factor solution consisting of loaded spine, postural, and spinal movement factors. The FDAQ demonstrated concurrent validity by contributing variance to disability (baseline and 4 weeks) and physical impairment (baseline) scores. In predictive validity analyses, baseline FDAQ scores did not contribute variance to 4-week disability and physical impairment scores, but changes in FDAQ scores were associated with changes in disability. The FDAQ scores significantly decreased over a 4-week treatment period, with an effect size of .86 and 55% of participants meeting the minimal detectable change criterion. Limitations: The validity cohort was a secondary analysis of a clinical trial, and additional research is needed to confirm these findings in other samples. Conclusions: The FDAQ is a potentially viable measure for fear of specific activities in physical therapy settings. These analyses suggest the FDAQ may be appropriate for determining graded exposure treatment plans and monitoring changes in fear levels, but is not appropriate as a screening tool.

Preliminary results of patient-defined success criteria for individuals with musculoskeletal pain in outpatient physical therapy settings

OBJECTIVES (1) To investigate patient-defined parameters of treatment success in an outpatient physical therapy setting with musculoskeletal pain, (2) to determine whether patient-defined treatment success was influenced by selected demographic and clinical factors, and (3) to examine whether patient subgroups existed for ratings of importance for each treatment outcome domain. DESIGN Cross-sectional study. SETTING Outpatient physical therapy clinic. PARTICIPANTS Consecutive patients (N=110) with complaints of musculoskeletal pain. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE We reported patient-defined treatment success targets for pain, fatigue, emotional distress, and interference with daily activities using the Patient-Centered Outcomes Questionnaire (PCOQ). We also investigated whether patient subgroups existed based on perceived importance of improvement for these same outcome domains. RESULTS Patient-defined criteria for treatment success included mean reductions (from baseline scores) in pain of 3.0 points, in fatigue of 2.3 points, in emotional distress of 1.4 points, and in interference with daily activities of 3.4 points. There were no differences in patient-defined criteria for treatment success based on sex, age, postoperative rehabilitation, prior physical therapy, other prior health care interventions, duration of symptoms, and anatomical location of symptoms (P>.01). Cluster analysis of the PCOQ importance ratings indicated a 2-cluster solution. The multifocused subgroup demonstrated higher importance for improvement ratings in each treatment outcome domain when compared with the pain-focused subgroup (P>.05). CONCLUSIONS These data indicate that patient-defined criteria for treatment success required greater reductions in the studied outcome domains to be considered successful. These data suggest the potential existence of patient subgroups that either rate improvement in all outcome domains as important or rate pain relief as the most important outcome.

Development of a Yellow Flag Assessment Tool for Orthopaedic Physical Therapists: Results From the Optimal Screening for Prediction of Referral and Outcome (OSPRO) Cohort

Study Design Clinical measurement, cross-sectional. Background Pain-associated psychological distress adversely influences outcomes for patients with musculoskeletal pain. However, assessment of pain-associated psychological distress (ie, yellow flags) is not routinely performed in orthopaedic physical therapy practice. A standardized yellow flag assessment tool will better inform treatment decision making related to psychologically informed practice. Objectives To describe the development of a concise, multidimensional yellow flag assessment tool for application in orthopaedic physical therapy clinical practice. Methods A 136-item yellow flag item bank was developed from validated psychological questionnaires across domains related to pain vulnerability (negative mood, fear avoidance) and resilience (positive affect/coping). Patients seeking physical therapy with neck, back, knee, or shoulder pain completed the item bank. Iterative statistical analyses determined minimal item sets meeting thresholds for identifying elevated vulnerability or low resilience (ie, upper or lower quartile, as indicated). Further item reduction yielded a concise yellow flag assessment tool to assess 11 psychological constructs measuring pain-associated psychological distress. Correlations between the assessment tool and individual psychological questionnaires were measured and compared between anatomical regions. Concurrent validity was assessed by determining variance explained in pain and disability scores by the assessment tool. Results Subjects with elevated vulnerability and decreased resilience were identified with a high degree of accuracy (minimum of 85%) using a 17-item tool. Correlations were moderate to high between the 17-item tool and individual psychological questionnaires, with no significant differences in correlations between different anatomical regions. Shorter 10- and 7-item versions of the assessment tool allow clinicians the flexibility to assess for yellow flags quickly with acceptable trade-offs in accuracy (81% and 75%, respectively). All versions of the tool explained significant additional variance in pain and disability scores (range, 19.3%-36.7%) after accounting for demographics, historical variables, and anatomical region of pain. Conclusion Concise assessment of yellow flags is feasible in outpatient physical therapy settings. This multidimensional tool advances assessment of pain-associated psychological distress through the addition of positive affect/coping constructs and estimation of full questionnaire scores. Further study is warranted to determine how this tool complements established risk-assessment tools by providing the option for efficient treatment monitoring. J Orthop Sports Phys Ther 2016;46(5):327-345. Epub 21 Mar 2016. doi:10.2519/jospt.2016.6487.