Julie M. Whitman

A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation.

Study Design. A prospective, cohort study of patients with nonradicular low back pain referred to physical therapy. Objective. Develop a clinical prediction rule for identifying patients with low back pain who improve with spinal manipulation. Summary of Background Data. Development of clinical prediction rules for classifying patients with low back pain who are likely to respond to a particular intervention, such as manipulation, would improve clinical decision-making and research. Methods. Patients with nonradicular low back pain underwent a standardized examination and then underwent a standardized spinal manipulation treatment program. Success with treatment was determined using percent change in disability scores over three sessions and served as the reference standard for determining the accuracy of examination variables. Examination variables were first analyzed for univariate accuracy in predicting success and then combined into a multivariate clinical prediction rule. Results. Seventy-one patients participated. Thirty-two had success with the manipulation intervention. A clinical prediction rule with five variables (symptom duration, fear–avoidance beliefs, lumbar hypomobility, hip internal rotation range of motion, and no symptoms distal to the knee) was identified. The presence of four of five of these variables (positive likelihood ratio = 24.38) increased the probability of success with manipulation from 45% to 95%. Conclusion. It appears that patients with low back pain likely to respond to manipulation can be accurately identified before treatment.

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.

The reliability and construct validity of the Neck Disability Index and patient specific functional scale in patients with cervical radiculopathy.

Study Design. Cohort study of patients with cervical radiculopathy undergoing physical therapy. Objectives. Examine the test-retest reliability, construct validity, and minimum levels of detectable and clinically important change for the Neck Disability Index (NDI) and Patient Specific Functional Scale (PSFS) in cohort of patients with cervical radiculopathy. Summary of Background Data. To date, no studies have investigated the psychometric properties of the NDI or PSFS in a cohort of patients with cervical radiculopathy. Methods. Thirty-eight patients with cervical radiculopathy undergoing physical therapy completed the NDI and PSFS, and Numerical Pain Rating Scale (NPRS) at the baseline examination and at a follow-up. In addition, at follow-up, patients completed a 15-point global rating of change (GROC), which was used to dichotomize patients as improved or stable. Changes in the NDI and PSFS were then used to assess test-retest reliability, construct validity, and minimal levels of detectable and clinically important change. Results. Test-retest reliability was moderate for the NDI (intraclass correlation coefficient [ICC] = 0.68; 95% confidence interval [CI], 0.30–0.90) and high for the PSFS (ICC = 0.82; 95% CI, 0.54–0.93). The PSFS was more responsive to change than the NDI. The minimal detectable change for the NDI was 10.2 and for the PSFS 2.1. The minimally clinically important change for the NDI was 7.0 and PSFS 2.0. Conclusions. Our results suggest that the PSFS exhibits superior reliability, construct validity, and responsiveness in this cohort of patients with cervical radiculopathy compared with the NDI. Further research is needed to examine the ability of these measures to accurately reflect changes in individuals, as well as large samples of patients.

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.

Some Factors Predict Successful Short-Term Outcomes in Individuals With Shoulder Pain Receiving Cervicothoracic Manipulation: A Single-Arm Trial

Background It has been reported that manipulative therapy directed at the cervical and thoracic spine may improve outcomes in patients with shoulder pain. To date, limited data are available to help physical therapists determine which patients with shoulder pain may experience changes in pain and disability following the application of these interventions. Objective The purpose of this study was to identify prognostic factors from the history and physical examination in individuals with shoulder pain who are likely to experience rapid improvement in pain and disability following cervical and thoracic spine manipulation. Design This was a prospective single-arm trial. Setting This study was conducted in outpatient physical therapy clinics. Participants The participants were individuals who were seen by physical therapists for a primary complaint of shoulder pain. Intervention and Measurements Participants underwent a standardized examination and then a series of thrust and nonthrust manipulations directed toward the cervicothoracic spine. Individuals were classified as having achieved a successful outcome at the second and third sessions based on their perceived recovery. Potential prognostic 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 80 individuals were included in the data analysis, of which 49 had a successful outcome. Five prognostic variables were retained in the final regression model. If 3 of the 5 variables were present, the chance of achieving a successful outcome improved from 61% to 89% (positive likelihood ratio=5.3). Limitations A prospective single-arm trial lacking a control group does not allow for inferences to be made regarding cause and effect. The statistical procedures used may result in “overfitting” of the model, which can result in low precision of the prediction accuracy, and the bivariate analysis may have resulted in the rejection of some important variables. Conclusions The identified prognostic variables will allow clinicians to make an a priori identification of individuals with shoulder pain who are likely to experience short-term improvement with cervical and thoracic spine manipulation. Future studies are necessary to validate these findings.

Examination of a Clinical Prediction Rule to Identify Patients With Neck Pain Likely to Benefit From Thoracic Spine Thrust Manipulation and a General Cervical Range of Motion Exercise: Multi-Center Randomized Clinical Trial

Background A clinical prediction rule (CPR) purported to identify patients with neck pain who are likely to respond to thoracic spine thrust manipulation has recently been developed, but has yet to be validated. Objective The purpose of this study was to examine the validity of this CPR. Design This was a multi-center randomized clinical trial. Methods One hundred forty patients with a primary report of neck pain were randomly assigned to receive either 5 sessions of stretching and strengthening exercise (exercise-only group) or 2 sessions of thoracic spine manipulation and cervical range of motion exercise followed by 3 sessions of stretching and strengthening exercise (manipulation + exercise group). Data on disability and pain were collected at baseline, 1 week, 4 weeks, and 6 months. The primary aim (treatment group × time × status on the prediction rule) was examined using a linear mixed model with repeated measures. Time, treatment group, and status on the rule, as well as all possible 2-way and 3-way interactions, were modeled as fixed effects, with disability (and pain) as the dependent variable. Effect sizes were calculated for both pain and disability at each follow-up period. Results There was no 3-way interaction for either disability or pain. A 2-way (group × time) interaction existed for both disability and pain. Pair-wise comparisons of disability demonstrated that significant differences existed at each follow-up period between the manipulation + exercise group and the exercise-only group. The patients who received manipulation exhibited lower pain scores at the 1-week follow-up period. The effect sizes were moderate for disability at each follow-up period and were moderate for pain at the 1-week follow-up. Limitations Different exercise approaches may have resulted in a different outcome. Conclusions The results of the current study did not support the validity of the previously developed CPR. However, the results demonstrated that patients with mechanical neck pain who received thoracic spine manipulation and exercise exhibited significantly greater improvements in disability at both the short- and long-term follow-up periods and in pain at the 1-week follow-up compared with patients who received exercise only.

Responsiveness of the Neck Disability Index in patients with mechanical neck disorders

PURPOSE Report the test-retest reliability, construct validity, minimum clinically important difference (MCID), and minimal detectable change (MDC) for the Neck Disability Index (NDI). STUDY DESIGN/SETTING Cohort study of patients presenting to outpatient physical therapy clinics. PATIENT SAMPLE Ninety-one subjects with a primary complaint of neck pain, with or without concomitant upper extremity (UE) symptoms, who were participants in a randomized clinical trial. OUTCOME MEASURES NDI and the 15-point Global Rating of Change (GRC) self-report measures. METHODS All subjects completed the NDI at baseline and at a 3-week follow-up. Additionally, subjects completed the GRC scale, which was used to dichotomize patients into improved or stable groups. Changes in the NDI were used to assess test-retest reliability, construct validity, MCID, and MDC. RESULTS Test-retest reliability was moderate for the NDI (intraclass correlation coefficient, 0.64; 95% confidence interval, 0.19-0.84). For the NDI, the MCID was 7.5 points and the MDC was 10.2 points. CONCLUSIONS The NDI appears to demonstrate adequate responsiveness based on statistical reference criteria when used in a sample that approximates the high percentage of patients with neck pain and concomitant UE referred symptoms. Because the MCID is within the bounds of measurement error, a 10-point change (the MDC) should be used as the MCID.

The Effectiveness of Manual Physical Therapy and Exercise for Mechanical Neck Pain : A Randomized Clinical Trial

Study Design. Randomized clinical trial. Objective. To assess the effectiveness of manual physical therapy and exercise (MTE) for mechanical neck pain with or without unilateral upper extremity (UE) symptoms, as compared to a minimal intervention (MIN) approach. Summary of Background Data. Mounting evidence supports the use of manual therapy and exercise for mechanical neck pain, but no studies have directly assessed its effectiveness for UE symptoms. Methods. A total of 94 patients referred to 3 physical therapy clinics with a primary complaint of mechanical neck pain, with or without unilateral UE symptoms, were randomized to receive MTE or a MIN approach of advice, motion exercise, and subtherapeutic ultrasound. Primary outcomes were the neck disability index, cervical and UE pain visual analog scales (VAS), and patient-perceived global rating of change assessed at 3-, 6-, and 52-weeks. Secondary measures included treatment success rates and post-treatment healthcare utilization. Results. The MTE group demonstrated significantly larger reductions in short- and long-term neck disability index scores (mean 1-year difference −5.1, 95% confidence intervals (CI) −8.1 to −2.1; P = 0.001) and short-term cervical VAS scores (mean 6-week difference −14.2, 95% CI −22.7 to −5.6; P = 0.001) as compared to the MIN group. The MTE group also demonstrated significant within group reductions in short- and long-term UE VAS scores at all time periods (mean 1-year difference −16.3, 95% CI −23.1 to −9.5; P = 0.000). At 1-year, patient perceived treatment success was reported by 62% (29 of 47) of the MTE group and 32% (15 of 47) of the MIN group (P = 0.004). Conclusion. An impairment-based MTE program resulted in clinically and statistically significant short- and long-term improvements in pain, disability, and patient-perceived recovery in patients with mechanical neck pain when compared to a program comprising advice, a mobility exercise, and subtherapeutic ultrasound.