John D. Childs

Responsiveness of the numeric pain rating scale in patients with low back pain

Study Design. Cohort study of patients with low back pain (LBP) receiving physical therapy. Objective. To examine the responsiveness characteristics of the numerical pain rating scale (NPRS) in patients with LBP using a variety of methods. Summary of Background Data. Although several studies have assessed the reliability and validity of the NPRS, few studies have characterized its responsiveness in patients with LBP. Methods. Determination of change on the NPRS during 1 and 4 weeks was examined by calculating mean change, standardized effect size, Guyatt Responsiveness Index, area under a receiver operating characteristic curve, minimum clinically important difference, and minimum detectable change. Change in the NPRS from baseline to the 1 and 4-week follow-up was compared to the average of the patient and therapist’s perceived improvement using the 15-point Global Rating of Change scale. Results. The majority of patients had clinically meaningful improvement after both 1 and 4 weeks of rehabilitation. The standard error of measure was equal to 1.02, corresponding to a minimum detectable change of 2 points. The area under the curve at the 1 and 4-week follow-up was 0.72 (0.62, 0.81) and 0.92 (0.86, 0.97), respectively. The minimum clinically important difference at the 1 and 4-week follow-up corresponded to a change of 2.2 and 1.5 points, respectively. Conclusions. Clinicians can be confident that a 2-point change on the NPRS represents clinically meaningful change that exceeds the bounds of measurement error.

Psychometric Properties of the Neck Disability Index and Numeric Pain Rating Scale in Patients With Mechanical Neck Pain

OBJECTIVE To examine the psychometric properties including test-retest reliability, construct validity, and minimum levels of detectable and clinically important change for the Neck Disability Index (NDI) and the numeric rating scale (NRS) for pain in a cohort of patients with neck pain. DESIGN Single-group repeated-measures design. SETTING Outpatient physical therapy (PT) clinics. PARTICIPANTS Patients (N=137) presenting to PT with a primary report of neck pain. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES All patients completed the NDI and the NRS at the baseline examination and at a follow-up. At the time of the follow-up, all patients also completed the global rating of change, which was used to dichotomize patients as improved or stable. Baseline and follow-up scores were used to determine the test-retest reliability, construct validity, and minimal levels of detectable and clinically important change for both the NDI and NRS. RESULTS Test-retest reliability was calculated using an intraclass correlation coefficient (ICC) (NDI ICC=.50; 95% confidence interval [CI], .25-.67; NRS ICC=.76; 95% CI, .51-.87). The area under the curve was .83 (95% CI, .75-.90) for the NDI score and .85 (95% CI, .78-.93) for the NRS score for determining between stable and improved patients. Thresholds for the minimum clinically important difference (MCID) for the NDI were 19-percentage points and 1.3 for the NRS. CONCLUSIONS Both the NDI and NRS exhibit fair to moderate test-retest reliability in patients with mechanical neck pain. Both instruments also showed adequate responsiveness in this patient population. However, the MCID required to be certain that the change in scores has surpassed a level that could be contributed to measurement error for the NDI was twice that which has previously been reported. Therefore the ongoing analyses of the properties of the NDI in a patient population with neck pain are warranted.

Development of a Clinical Prediction Rule for Guiding Treatment of a Subgroup of Patients With Neck Pain: Use of Thoracic Spine Manipulation, Exercise, and Patient Education

Background and Purpose To date, no studies have investigated the predictive validity of variables from the initial examination to identify patients with neck pain who are likely to benefit from thoracic spine thrust manipulation. The purpose of this study was to develop a clinical prediction rule (CPR) to identify patients with neck pain who are likely to experience early success from thoracic spine thrust manipulation. Subjects This was a prospective, cohort study of patients with mechanical neck pain who were referred for physical therapy. Methods Subjects underwent a standardized examination and then a series of thoracic spine thrust manipulation techniques. They were classified as having experienced a successful outcome at the second and third sessions based on their perceived recovery. Potential predictor variables were entered into a stepwise logistic regression model to determine the most accurate set of variables for prediction of treatment success. Results Data for 78 subjects were included in the data analysis, of which 42 had a successful outcome. A CPR with 6 variables was identified. If 3 of the 6 variables (positive likelihood ratio=5.5) were present, the chance of experiencing a successful outcome improved from 54% to 86%. Discussion and Conclusion The CPR provides the ability to a priori identify patients with neck pain who are likely to experience early success with thoracic spine thrust manipulation. However, future studies are necessary to validate the rule.

Short-term effects of thrust versus nonthrust mobilization/manipulation directed at the thoracic spine in patients with neck pain: a randomized clinical trial.

Background and Purpose Evidence supports the use of manual physical therapy interventions directed at the thoracic spine in patients with neck pain. The purpose of this study was to compare the effectiveness of thoracic spine thrust mobilization/manipulation with that of nonthrust mobilization/manipulation in patients with a primary complaint of mechanical neck pain. The authors also sought to compare the frequencies, durations, and types of side effects between the groups. Subjects The subjects in this study were 60 patients who were 18 to 60 years of age and had a primary complaint of neck pain. Methods For all subjects, a standardized history and a physical examination were obtained. Self-report outcome measures included the Neck Disability Index (NDI), a pain diagram, the Numeric Pain Rating Scale (NPRS), and the Fear-Avoidance Beliefs Questionnaire. After the baseline evaluation, the subjects were randomly assigned to receive either thoracic spine thrust or nonthrust mobilization/manipulation. The subjects were reexamined 2 to 4 days after the initial examination, and they again completed the NDI and the NPRS, as well as the Global Rating of Change (GROC) Scale. The primary aim was examined with a 2-way repeated-measures analysis of variance (ANOVA), with intervention group (thrust versus nonthrust mobilization/manipulation) as the between-subjects variable and time (baseline and 48 hours) as the within-subject variable. Separate ANOVAs were performed for each dependent variable: disability (NDI) and pain (NPRS). For each ANOVA, the hypothesis of interest was the 2-way group × time interaction. Results Sixty patients with a mean age of 43.3 years (SD=12.7) (55% female) satisfied the eligibility criteria and agreed to participate in the study. Subjects who received thrust mobilization/manipulation experienced greater reductions in disability, with a between-group difference of 10% (95% confidence interval [CI]=5.3–14.7), and in pain, with a between-group difference of 2.0 (95% CI=1.4–2.7). Subjects in the thrust mobilization/manipulation group exhibited significantly higher scores on the GROC Scale at the time of follow-up. No differences in the frequencies, durations, and types of side effects existed between the groups. Discussion and Conclusion The results suggest that thoracic spine thrust mobilization/manipulation results in significantly greater short-term reductions in pain and disability than does thoracic nonthrust mobilization/manipulation in people with neck pain.

A comparison between two physical therapy treatment programs for patients with lumbar spinal stenosis : A randomized clinical trial

Study Design. Multicenter randomized, controlled trial. Objective. To compare two physical therapy programs for patients with lumbar spinal stenosis. Summary of Background Data. Scant evidence exists regarding effectiveness of nonsurgical management programs for lumbar spinal stenosis. Methods. Fifty-eight patients with lumbar spinal stenosis were randomized to one of two 6-week physical therapy programs. One program included manual physical therapy, body weight supported treadmill walking, and exercise (Manual Physical Therapy, Exercise, and Walking Group), while the other included lumbar flexion exercises, a treadmill walking program, and subtherapeutic ultrasound (Flexion Exercise and Walking Group). Perceived recovery was assessed with a global rating of change scale. Secondary outcomes included: Oswestry, a numerical pain rating scale, a measure of satisfaction, and a treadmill test. Testing occurred at baseline, 6 weeks, and 1 year. Perceived recovery, pain, and other healthcare resources used were collected with a long-term follow-up questionnaire. Results. A greater proportion of patients in the manual physical therapy, exercise, and walking group reported recovery at 6 weeks compared with the flexion exercise and walking group (P = 0.0015), with a number needed to treat for perceived recovery of 2.6 (confidence interval, 1.8–7.8). At 1 year, 62% and 41% of the manual therapy, exercise, and walking group and the flexion exercise and walking group, respectively, still met the threshold for recovery. Improvements in disability, satisfaction, and treadmill walking tests favored the manual physical therapy, exercise, and walking group at all follow-up points. Conclusions. Patients with lumbar spinal stenosis can benefit from physical therapy. Additional gains may be realized with the inclusion of manual physical therapy interventions, exercise, and a progressive body-weight supported treadmill walking program.

Comparison of the effectiveness of three manual physical therapy techniques in a subgroup of patients with low back pain who satisfy a clinical prediction rule: a randomized clinical trial.

Study Design. Randomized clinical trial. Objective. The purpose of this randomized clinical trial was to examine the generalizability of 3 different manual therapy techniques in a patient population with low back pain that satisfy a clinical prediction rule (CPR). Summary of Background Data. Recently a CPR that identifies patients with LBP who are likely to respond rapidly and dramatically to thrust manipulation has been developed and validated. The generalizability of the CPR requires further investigation. Methods. A total of 112 patients were enrolled in the trial and provided demographic information and completed a number of self-report questionnaires including the Oswestry Disability Questionnaire (ODQ) and the Numerical Pain Rating Scale (NPRS) at baseline, 1-week, 4-weeks, and 6-months. Patients were randomly assigned to receive 1 of the 3 manual therapy techniques for 2 consecutive treatment sessions followed by exercise regimen for an additional 3 sessions. We examined the primary aim using a linear mixed model for repeated measures, using the ODQ and NPRS as dependent variables. The hypothesis of interest was the group by time interaction, which was further explored with pair-wise comparisons of the estimated marginal means. Results. There was a significant group x time interaction for the ODQ (P < 0.001) and NPRS scores (P = 0.001). Pair-wise comparisons revealed no differences between the supine thrust manipulation and side-lying thrust manipulation at any follow-up period. Significant differences in the ODQ and NPRS existed at each follow-up between the thrust manipulation and the nonthrust manipulation groups at 1-week and 4-weeks. There was also a significant difference in ODQ scores at 6-months in favor of the thrust groups. Conclusion. The results of the study support the generalizability of the CPR to another thrust manipulation technique, but not to the nonthrust manipulation technique that was used in this study. In general, our results also provided support that the CPR can be generalized to different settings from which it was derived and validated. However, additional research is needed to examine this issue.

The Functional Movement Screen: a reliability study.

STUDY DESIGN Reliability study. OBJECTIVES To determine intrarater test-retest and interrater reliability of the Functional Movement Screen (FMS) among novice raters. BACKGROUND The FMS is used by various examiners to assess movement and predict time-loss injuries in diverse populations (eg, youth to professional athletes, firefighters, military service members) of active participants. Unfortunately, critical analysis of the reliability of the FMS is currently limited to 1 sample of active college-age participants. METHODS Sixty-four active-duty service members (mean ± SD age, 25.2 ± 3.8 years; body mass index, 25.1 ± 3.1 kg/m2) without a history of injury were enrolled. Participants completed the 7 component tests of the FMS in a counterbalanced order. Each component test was scored on an ordinal scale (0 to 3 points), resulting in a composite score ranging from 0 to 21 points. Intrarater test-retest reliability was assessed between baseline scores and those obtained with repeated testing performed 48 to 72 hours later. Interrater reliability was based on the assessment from 2 raters, selected from a pool of 8 novice raters, who assessed the same movements on day 2 simultaneously. Descriptive statistics, weighted kappa (κw), and percent agreement were calculated on component scores. Intraclass correlation coefficients (ICCs), standard error of the measurement, minimal detectable change (MDC95), and associated 95% confidence intervals (CIs) were calculated on composite scores. RESULTS The average ± SD score on the FMS was 15.7 ± 0.2 points, with 15.6% (n = 10) of the participants scoring less than or equal to 14 points, the recommended cutoff for predicting time-loss injuries. The intrarater test-retest and interrater reliability of the FMS composite score resulted in an ICC3,1 of 0.76 (95% CI: 0.63, 0.85) and an ICC2,1 of 0.74 (95% CI: 0.60, 0.83), respectively. The standard error of the measurement of the composite test was within 1 point, and the MDC95 values were 2.1 and 2.5 points on the 21-point scale for interrater and intrarater reliability, respectively. The interrater agreement of the component scores ranged from moderate to excellent (κw = 0.45-0.82). CONCLUSION Among novice raters, the FMS composite score demonstrated moderate to good interrater and intrarater reliability, with acceptable levels of measurement error. The measures of reliability and measurement error were similar for both intrarater reliability that repeated the assessment of the movement patterns over a 48-to-72-hour period and interrater reliability that had 2 raters assess the same movement pattern simultaneously. The interrater agreement of the FMS component scores was good to excellent for the push-up, quadruped, shoulder mobility, straight leg raise, squat, hurdle, and lunge. Only 15.6% (n = 10) of the participants were identified to be at risk for injury based on previously published cutoff values.

Psychometric properties of the Fear-Avoidance Beliefs Questionnaire and Tampa Scale of Kinesiophobia in patients with neck pain.

Cleland JA, Fritz JM, Childs JD: Psychometric properties of the fear-avoidance beliefs questionnaire and Tampa scale of kinesiophobia in patients with neck pain. Am J Phys Med Rehabil 2008;87:109–117. Objective:To examine selected psychometric properties of these instruments in a cohort of patients with mechanical neck pain. Design:Cohort design of 78 subjects completing self-report measures of pain, disability, and the Fear-Avoidance Beliefs Questionnaire Work (FABQW) and Physical Activity (FABQPA) subscales, as well as the Tampa Scale of Kinesiophobia (TSK) at baseline and a 2-day follow-up. Intraclass correlation coefficients were used to calculate test–retest reliability, and Cronbachs alpha was used to calculate internal consistency. Concurrent validity was analyzed between the FABQPA, FABQW, TSK, pain, and disability using Pearson correlation coefficients and hierarchical linear regression modeling. Results:The FABQPA and FABQW subscales exhibited substantial test–retest reliability, whereas the TSK exhibited moderate reliability. Internal consistency was high for all measures. The FABQW subscale was the only measure that significantly contributed to the regression model for both pain and disability in this group of patients with neck pain. Conclusions:Whereas the reliability and internal consistency of all measures ranged between moderate and substantial, the results of this study suggest weaker relationships between measures of fear and avoidance beliefs and pain/disability among patients with mechanical neck pain than has been reported among patients with low-back pain.

Pragmatic application of a clinical prediction rule in primary care to identify patients with low back pain with a good prognosis following a brief spinal manipulation intervention

BackgroundPatients with low back pain are frequently encountered in primary care. Although a specific diagnosis cannot be made for most patients, it is likely that sub-groups exist within the larger entity of nonspecific low back pain. One sub-group that has been identified is patients who respond rapidly to spinal manipulation. The purpose of this study was to examine the association between two factors (duration and distribution of symptoms) and prognosis following a spinal manipulation intervention.MethodsData were taken from two previously published studies. Patients with low back pain underwent a standardized examination, including assessment of duration of the current symptoms in days, and the distal-most distribution of symptoms. Based on prior research, patients with symptoms of <16 days duration and no symptoms distal to the knee were considered to have a good prognosis following manipulation. All patients underwent up to two sessions of spinal manipulation treatment and a range of motion exercise. Oswestry disability scores were recorded before and after treatment. If ≥ 50% improvement on the Oswestry was achieved, the intervention was considered a success. Sensitivity, specificity, and positive likelihood ratio were calculated for the association of the two criteria with the outcome of the treatment.Results141 patients (49% female, mean age = 35.5 (± 11.1) years) participated. Mean pre- and post-treatment Oswestry scores were 41.9 (± 10.9) and 24.1 (± 14.2) respectively. Sixty-three subjects (45%) had successful treatment outcomes. The sensitivity of the two criteria was 0.56 (95% CI: 0.43, 0.67), specificity was 0.92 (95% CI: 0.84, 0.96), and the positive likelihood ratio was 7.2 (95% CI: 3.2, 16.1).ConclusionThe results of this study demonstrate that two factors; symptom duration of less than 16 days, and no symptoms extending distal to the knee, were associated with a good outcome with spinal manipulation.

Effectiveness of an Extension-Oriented Treatment Approach in a Subgroup of Subjects With Low Back Pain: A Randomized Clinical Trial

Background and Purpose: The purpose of this multicenter randomized clinical trial was to examine the effectiveness of an extension-oriented treatment approach (EOTA) in a subgroup of subjects with low back pain (LBP) who were hypothesized to benefit from the treatment compared with similar subjects who received a lumbar spine strengthening exercise program. Methods: Subjects with LBP and symptoms distal to the buttocks that centralized with extension movements were included. Forty-eight subjects were randomly assigned to groups that received an EOTA (n=26) or a strengthening exercise program (n=22). Subjects attended 8 physical therapy sessions and completed a home exercise program. Follow-up data were obtained at 1 week, 4 weeks, and 6 months after randomization. Primary outcome measures were disability (modified Oswestry Low Back Pain Disability Questionnaire) and pain (Numeric Pain Rating Scale). Results: Subjects in the EOTA group experienced greater improvements in disability compared with subjects who received trunk strengthening exercises at 1 week (mean difference between groups from baseline=8.9, 95% confidence interval [CI]=2.0, 15.9), 4 weeks, (mean difference=14.4, 95% CI=4.8, 23.9), and 6 months (mean difference=14.6, 95% CI=4.6, 24.6). The EOTA group demonstrated greater change in pain at the 1-week follow-up only. Discussion and Conclusion: An EOTA was more effective than trunk strengthening exercise in a subgroup of subjects hypothesized to benefit from this treatment approach. Additional research is needed to explore whether an EOTA may benefit other subgroups of patients.