Matthew B. Garber

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.

Effectiveness of manual physical therapy and exercise in osteoarthritis of the knee. A randomized, controlled trial.

Arthritis has been identified as the most common cause of disability in the United States (1, 2). Thirty-three percent of persons 63 to 94 years of age are affected by osteoarthritis of the knee, which often limits the ability to rise from a chair, stand comfortably, walk, and use stairs (3, 4). Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used to treat osteoarthritis. Use of NSAIDs can lead to gastric complications, increased risk for hospitalization, and death (5). Other treatment options for persons with osteoarthritis of the knee include physical therapy exercise and treatment programs, cortisone injections, and joint replacement surgery. Puett and Griffin (6) reviewed 15 controlled trials of nonmedicinal, noninvasive therapies for hip and knee osteoarthritis from 1966 through 1993 (6). The authors concluded that exercise reduces pain and improves function in patients with osteoarthritis of the knee, but the optimal exercise regimen has not been determined. Fitness walking, aerobic exercise, and strength training have all been reported to result in functional improvement in patients with osteoarthritis of the knee (6-12). Unweighted treadmill walking has not been shown to decrease pain associated with osteoarthritis of the knee (13). Other researchers (14, 15) have concluded that exercise may benefit patients with osteoarthritis but advise that long-term studies are required to determine the appropriate amounts of exercise to avoid accelerating the underlying process of arthritis. Active and passive range-of-motion exercise is considered an important part of rehabilitation programs for patients with osteoarthritis (16-18). Physical therapists frequently use manual therapy procedures as part of comprehensive rehabilitation programs to help patients regain joint mobility and function (19). We evaluated the effectiveness of manual physical therapy for osteoarthritis of the knee, as applied by physical therapists with formal training in such an approach (20). Our hypothesis was that physical therapy consisting of manual therapy to the knee, hip, ankle, and lumbar spine combined with range-of-motion, strengthening, and cardiovascular exercises would be more effective than placebo for improving function, decreasing pain and stiffness, and increasing the distance walked in 6 minutes. Methods Patients Eighty-three patients with osteoarthritis of the knee were randomly assigned to receive treatment (n=42; 15 men and 27 women [mean age, 60 11 years]) or placebo (n=41; 19 men and 22 women [mean age, 62 10 years]). All patients were referred by physicians to physical therapy for osteoarthritis of the knee. Physicians at the various clinics in the medical center who normally see patients with osteoarthritis of the knee were informed of the study so that appropriate referrals could be made. If the patients met our inclusion criteria, they were offered the opportunity to participate. The main inclusion criterion was a diagnosis of osteoarthritis of the knee based on fulfillment of one of the following clinical criteria developed by Altman and colleagues [21]: 1) knee pain, age 38 years or younger, and bony enlargement; 2) knee pain, age 39 years or older, morning stiffness for more than 30 minutes, and bony enlargement; 3) knee pain, crepitus on active motion, morning stiffness for more than 30 minutes, and bony enlargement; or 4) knee pain, crepitus on active motion, morning stiffness for more than 30 minutes, and age 38 years or older. Altman and colleagues found this criteria to be 89% sensitive and 88% specific (21-23). Patients were required to be eligible for military health care, have had no surgical procedure on either lower extremity in the past 6 months, and have no physical impairment unrelated to the knee that would prevent safe participation in a timed 6-minute walk test or any other aspect of the study. Patients had to have sufficient English-language skills to comprehend all explanations and to complete the assessment tools. They were also required to live within a 1-hour drive of the physical therapy clinic. Patients who could not attend the required number of visits or had received a cortisone injection to the knee joint within the previous 30 days were not enrolled. Patients were instructed to keep taking any current medications and not to start taking new medications for osteoarthritis during the clinical treatment and 8-week follow-up. Therapy with any osteoarthritis medication must have been initiated at least 30 days before participation in the study. The study was approved by the institutional review board of Brooke Army Medical Center, Fort Sam Houston, Texas. All patients completed an informed consent form and were advised of the risks of the study, including increased symptoms, injuries from falls, and cardiovascular events. No external funding was received for this study. Procedure Patients who met the inclusion criteria were randomly assigned to one of two groups. Blank folders were numbered from 1 to 100 and were given concealed codes for the group of assignment, determined by a random-number generator. When a patient was eligible and gave consent to participate, the treating therapist drew the next folder from the file, which determined the group of assignment. The treatment group received a combination of manual physical therapy and supervised exercise. The placebo group received ultrasound at a subtherapeutic intensity. Neither group was aware of the treatment that the other group was receiving. Demographic data collected for each patient included age, sex, occupation, height, weight, duration of symptoms, presence of symptoms in one or both knees, previous knee surgery, medications, and present activity level. Knee radiographs were obtained and read by a radiologist who assigned a radiographic severity rating for osteoarthritis (24). Dependent variables measured in this study were the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score (25) and distance covered during a timed 6-minute walk test. The WOMAC Osteoarthritis Index consists of 24 questions, each corresponding to a visual analogue scale. This test has been shown to be a reliable, valid, and responsive multidimensional outcome measure for evaluation of patients with osteoarthritis of the hip or knee (26). The timed 6-minute walk test measures the distance a patient walks in 6 minutes and has been demonstrated to be a reliable measurement of functional exercise capacity (27). All measurements of dependent variables were obtained by a trained research assistant who was blinded to group assignment. After research assistants obtained pretreatment values for the dependent variables, patients returned to the treating physical therapist for thorough standardized clinical examination of the knee, hip, ankle, and lumbar spine. Treatment was initiated according to group assignment. The treatment group received manual physical therapy as indicated by the results of the examination. The manual therapy treatment techniques, consisting of passive physiologic and accessory joint movements, muscle stretching, and soft-tissue mobilization, were applied primarily to the knee. The same treatments were also administered to the lumbar spine, hip, or ankle if these areas showed limitation in active or passive movement, were symptomatic, or were contributing to overall lower limb dysfunction (28-31). A minimal pain level was not exceeded in any treatment. The treatment group also performed a closely supervised standardized knee exercise program at each of the eight treatment sessions. This program consisted of active range-of-motion exercises for the knee, muscle strengthening exercises for the hip and knee, muscle stretching for the lower limbs, and riding a stationary bike. All of the activities were mutually reinforcing, with repeated gentle challenges to the end ranges of movement. An outline of the exercise program is shown in the Appendix Figure. The physical therapist increased the number of strengthening exercise bouts and the stationary bike riding time on the basis of patient tolerance. The current literature provides efficient methods to produce the desired effects of increasing strength, flexibility, and range of motion (32-35). At each session, the physical therapist examined the patient for adverse signs and symptoms, such as increased pain, joint effusion, and increased skin temperature over knee joints. These signs and symptoms of osteoarthritis had to be stable or decreasing before manual therapy or exercise was progressed. Patients exercised in a painless or minimally painful manner. If any post-treatment or exercise soreness lasted more than a few hours, the regimen was decreased accordingly for that patient. The placebo group received treatment by the physical therapist that consisted of subtherapeutic ultrasound for 10 minutes at an intensity of 0.1 W/cm2 and 10% pulsed mode (lowest setting and greatest cycle interruption) to the area of knee symptoms. The placebo group received the same subjective and hands-on objective reevaluation before and after each session as the treatment group. The amount of time directly spent with the treating therapist was approximately 30 minutes for both groups. The treatment group required an additional 30 to 45 minutes to perform their exercises in the clinic. Both groups were treated twice weekly for 4 weeks, for a total of eight clinic treatments. Patients in the treatment group also performed the same exercises at home, except for the closed-chain strengthening exercises, on the days on which they were not treated in the physical therapy clinic. They also walked at home each day at a comfortable pace and distance. The treating physical therapist instructed each patient in the performance of the exercises and provided a detailed handout containing instructions and photographs of the exercises. Each patient maintained a home exercise program

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.

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.

Lumbopelvic Manipulation for the Treatment of Patients With Patellofemoral Pain Syndrome: Development of a Clinical Prediction Rule

STUDY DESIGN Prospective cohort/predictive validity study. OBJECTIVE To determine the predictive validity of selected clinical exam items and to develop a clinical prediction rule (CPR) to determine which patients with patellofemoral pain syndrome (PFPS) have a positive immediate response to lumbopelvic manipulation. BACKGROUND Quadriceps muscle function in patients with PFPS was recently shown to improve following treatment with lumbopelvic manipulation. No previous study has determined if individuals with PFPS experience symptomatic relief of activity-related pain immediately following this manipulation technique. METHODS AND MEASURES Fifty subjects (26 male, 24 female; age range, 18-45 years) with PFPS underwent a standardized history and physical examination. After the evaluation, each subject performed 3 typically pain-producing functional activities (squatting, stepping up a 20-cm step, and stepping down a 20-cm step). The pain level perceived during each activity was rated on a numerical pain scale (0 representing no pain and 10 the worst possible pain). Following the assessment, all subjects were treated with a lumbopelvic manipulation, which was immediately followed by retesting the 3 functional activities to determine if there was any change in pain ratings. An immediate overall 50% or greater reduction in pain, or moderate or greater improvement on a global rating of change questionnaire, was considered a treatment success. Likelihood ratios (LRs) were calculated to determine which examination items were most predictive of treatment outcome. RESULTS Data for 49 subjects were included in the data analysis, of which 22 (45%) had a successful outcome. Five predictor variables were identified. The most powerful predictor of treatment success was a side-to-side difference in hip internal rotation range of motion greater than 14 masculine (+LR, 4.9). If this variable was present, the chance of experiencing a successful outcome improved from 45% to 80%. CONCLUSION A CPR was developed to predict an immediate successful response to lumbopelvic manipulation in patients with PFPS. However, in light of a limited sample size and omission of potentially meaningful predictor variables, future studies are necessary to validate the CPR.