Paul E. Mintken

Psychometric properties of the shortened disabilities of the Arm, Shoulder, and Hand Questionnaire (QuickDASH) and Numeric Pain Rating Scale in patients with shoulder pain.

PURPOSE To examine the psychometric properties of the Shortened Disabilities of the Arm, Shoulder, and Hand Questionnaire (QuickDASH) and the Numeric Pain Rating Scale (NPRS) in patients with shoulder pain. METHODS Single-group repeated measures design in which 101 patients presenting to physical therapy completed the QuickDASH and the NPRS at the baseline examination and at a follow-up visit. At the follow-up all patients also completed the Global Rating of Change (GRC), 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 QuickDASH and NPRS. RESULTS Test-retest reliability was 0.90 for the QuickDASH and 0.74 for the NPRS. The minimal clinically important difference (MCID) was 8.0 points for the QuickDASH and 1.1 for the NPRS. CONCLUSION The NPRS and QuickDASH exhibit good test-retest reliability and responsiveness in patients with shoulder pain.

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.

Predicting Short-Term Response to Thrust and Nonthrust Manipulation and Exercise in Patients Post Inversion Ankle Sprain

STUDY DESIGN Prospective-cohort/predictive-validity study. OBJECTIVES To develop a clinical prediction rule (CPR) to identify patients who had sustained an inversion ankle sprain who would likely benefit from manual therapy and exercise. BACKGROUND No studies have investigated the predictive value of items from the clinical examination to identify patients with ankle sprains likely to benefit from manual therapy and general mobility exercises. METHODS AND MEASURES Consecutive patients with a status of post inversion ankle sprain underwent a standardized examination followed by manual therapy (both thrust and nonthrust manipulation) and general mobility exercises. Patients 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 Eighty-five patients were included in the data analysis, of which 64 had a successful outcome (75%). A CPR with 4 variables was identified. If 3 of the 4 variables were present the accuracy of the rule was maximized (positive likelihood ratio, 5.9; 95% CI: 1.1, 41.6) and the posttest probability of success increased to 95%. CONCLUSIONS The CPR provides the ability to a priori identify patients with an inversion ankle sprain who are likely to exhibit rapid and dramatic short-term success with a treatment approach, including manual therapy and general mobility exercises. LEVEL OF EVIDENCE Prognosis, level 2b.

Thoracic Spine Thrust Manipulation Versus Cervical Spine Thrust Manipulation in Patients With Acute Neck Pain : A Randomized Clinical Trial

STUDY DESIGN Randomized clinical trial. OBJECTIVE To determine if patients who met the clinical prediction rule (CPR) criteria for the success of thoracic spine thrust joint manipulation (TJM) for the treatment of neck pain would have a different outcome if they were treated with a cervical spine TJM. BACKGROUND A CPR had been proposed to identify patients with neck pain who would likely respond favorably to thoracic spine TJM. Research on validation of that CPR had not been completed when this trial was initiated. In our clinical experience, though many patients with neck pain responded favorably to thoracic spine TJM, they often reported that their symptomatic cervical spine area had not been adequately addressed. METHODS Twenty-four consecutive patients, who presented to physical therapy with a primary complaint of neck pain and met 4 out of 6 of the CPR criteria for thoracic TJM, were randomly assigned to 1 of 2 treatment groups. The thoracic group received thoracic TJM and a cervical range-of-motion (ROM) exercise for the first 2 sessions, followed by a standardized exercise program for an additional 3 sessions. The cervical group received cervical TJM and the same cervical ROM exercise for the first 2 sessions, and the same exercise program given to the thoracic group for the next 3 sessions. Outcome measures collected at 1 week, 4 weeks, and 6 months from start of treatment included the Neck Disability Index, numeric pain rating scale, and Fear-Avoidance Beliefs Questionnaire. RESULTS Patients who received cervical TJM demonstrated greater improvements in Neck Disability Index (P ≤.001) and numeric pain rating scale (P ≤.003) scores at all follow-up times. There was also a statistically significant improvement in the Fear-Avoidance Beliefs Questionnaire physical activity subscale score at all follow-up times for the cervical group (P ≤.004). The number needed to treat to avoid an unsuccessful overall outcome was 1.8 at 1 week, 1.6 at 4 weeks, and 1.6 at 6 months. CONCLUSION Patients with neck pain who met 4 of 6 of the CPR criteria for successful treatment of neck pain with a thoracic spine TJM demonstrated a more favorable response when the TJM was directed to the cervical spine rather than the thoracic spine. Patients receiving cervical TJM also demonstrated fewer transient side-effects. LEVEL OF EVIDENCE Therapy, level 1b.

Psychometric Properties of the Fear-Avoidance Beliefs Questionnaire and Tampa Scale of Kinesiophobia in Patients With Shoulder Pain

OBJECTIVE To investigate the reliability and validity of 2 commonly used measures of pain related fear in patients with shoulder pain. DESIGN A preplanned secondary analysis of a prospective single-arm trial involving a repeated-measures design. SETTING Outpatient physical therapy clinics. PARTICIPANTS Patients (N=80) with a primary report of shoulder pain. INTERVENTION All patients completed the outcome measures at baseline and at follow-up. MAIN OUTCOME MEASURES Patients completed a modified Fear-Avoidance Beliefs Questionnaire (FABQ), the 11-item version of Tampa Scale of Kinesiophobia (TSK-11), and the Shoulder Pain and Disability Index (SPADI) at baseline and at a 48-hour follow-up. Patients were dichotomized as improved or stable at follow-up based on the Global Rating of Change. RESULTS Factor analysis indicated 3 stable factors for the FABQ and 1 stable factor for the TSK-11. Shoulder specific scoring for the FABQ and TSK-11 were used in subsequent analyses. Test-retest reliability intraclass correlation coefficient (ICC) was substantial for the FABQ and the TSK-11. The FABQ correlated significantly with SPADI pain and disability scores, while the TSK-11 correlated significantly only with SPADI pain scores. The shoulder-specific FABQ-W (work beliefs subscale) was a better than chance predictor of missing days of work during the 48-hour study period. CONCLUSIONS The modified FABQ and TSK-11 may be appropriate for use in patients with shoulder pain. Shoulder-specific scoring of these measures resulted in substantial test-retest reliability, and the FABQ correlated with the SPADI for pain and disability. The FABQ also showed potential for prediction of short-term work loss in this sample. Pain-related fear may be an important variable in patients with shoulder pain and merits future consideration in longitudinal studies.

A Model for Standardizing Manipulation Terminology in Physical Therapy Practice

Research supporting the efficacy of manual therapy, manipulation in particular, is growing. The ability to communicate clearly and accurately regarding this important intervention, regardless of region or background, is essential if clinicians are to incorporate this research in clinical practice. In February 2007, the American Academy of Orthopaedic Manual Physical Therapists formed a task force to standardize manual therapy terminology, starting with the intervention of manipulation. The ultimate goal of this task force was to create a template that has the potential to be used internationally by the community of physical therapists in order to standardize manual therapy nomenclature. The following document reflects the work and recommendations of this task force. We propose describing a manipulative technique using 6 characteristics:

Use of an abbreviated neuroscience education approach in the treatment of chronic low back pain: A case report

Chronic low back pain (CLBP) remains prevalent in society, and conservative treatment strategies appear to have little effect. It is proposed that patients with CLBP may have altered cognition and increased fear, which impacts their ability to move, perform exercise, and partake in activities of daily living. Neuroscience education (NE) aims to change a patients cognition regarding their pain state, which may result in decreased fear, ultimately resulting in confrontation of pain barriers and a resumption of normal activities. A 64-year-old female with history of CLBP was the patient for this case report. A physical examination, the Numeric Pain Rating Scale (NPRS), Oswestry Disability Index (ODI), Fear-Avoidance Beliefs Questionnaire (FABQ), and Zung Depression Scale were assessed during her initial physical therapy visit, immediately after her first physical therapy session, and at 7-month follow-up. Treatment consisted of an abbreviated NE approach, exercises (range of motion, stretches, and cardiovascular), and aquatic therapy. She attended twice a week for 4 weeks, or 8 visits total. Pre-NE, the patient reported NPRS = 9/10; ODI = 54%; FABQ-W = 25/42,; FABQ-PA = 20/24, and Zung = 58. Immediately following the 75-minute evaluation and NE session, the patient reported improvement in all four outcome measures, most notably a reduction in the FABQ-W score to 2/42 and the FABQ-PA to 1/24. At a 7-month follow-up, all outcome measures continued to be improved. NE aimed at decreasing fear associated with movement may be a valuable adjunct to movement-based therapy, such as exercise, for patients with CLBP.

Manual Physical Therapy and Exercise Versus Supervised Home Exercise in the Management of Patients With Inversion Ankle Sprain: A Multicenter Randomized Clinical Trial

STUDY DESIGN Randomized clinical trial. OBJECTIVE To compare the effectiveness of manual therapy and exercise (MTEX) to a home exercise program (HEP) in the management of individuals with an inversion ankle sprain. BACKGROUND An in-clinic exercise program has been found to yield similar outcomes as an HEP for individuals with an inversion ankle sprain. However, no studies have compared an MTEX approach to an HEP. METHODS Patients with an inversion ankle sprain completed the Foot and Ankle Ability Measure (FAAM) activities of daily living subscale, the FAAM sports subscale, the Lower Extremity Functional Scale, and the numeric pain rating scale. Patients were randomly assigned to either an MTEX or an HEP treatment group. Outcomes were collected at baseline, 4 weeks, and 6 months. The primary aim (effects of treatment on pain and disability) was examined with a mixed-model analysis of variance. The hypothesis of interest was the 2-way interaction (group by time). RESULTS Seventy-four patients (mean ± SD age, 35.1 ± 11.0 years; 48.6% female) were randomized into the MTEX group (n = 37) or the HEP group (n = 37). The overall group-by-time interaction for the mixed-model analysis of variance was statistically significant for the FAAM activities of daily living subscale (P<.001), FAAM sports subscale (P<.001), Lower Extremity Functional Scale (P<.001), and pain (P ≤.001). Improvements in all functional outcome measures and pain were significantly greater at both the 4-week and 6-month follow-up periods in favor of the MTEX group. CONCLUSION The results suggest that an MTEX approach is superior to an HEP in the treatment of inversion ankle sprains. Registered at clinicaltrials.gov (NCT00797368). LEVEL OF EVIDENCE Therapy, level 1b-.

Upper Cervical Ligament Testing in a Patient With Os Odontoideum Presenting With Headaches

STUDY DESIGN Residents case problem. BACKGROUND The role of premanipulative testing of the cervical spine is an area of controversy, and there are very few data to inform and guide practitioners on the use of ligamentous stability tests when assessing the upper cervical spine. DIAGNOSIS A 23-year-old female was referred to physical therapy by a neurologist for the management of intractable headaches of possible musculoskeletal origin. Her Neck Disability Index score was 54% and she rated her headache pain from 3/10 to 9/10 on a Numerical Pain Rating Scale. She reported a 2-year history of intermittent lower extremity paresthesias without a known mechanism or current symptoms. She was treated in physical therapy for 11 visits with improvements in cervical range of motion, strength, and intensity of her headaches, but noted no change in the frequency of headaches. She was subsequently referred to the primary author for a second opinion and potential manual therapy interventions. Initial neurological screening examination for upper and lower motor neuron lesions was unremarkable. Assessment of the transverse ligament, using the anterior shear test in supine, brought on paresthesias in both feet and her toes. The paresthesias continued after the cessation of the test. The Sharp-Purser test performed in sitting, immediately after the transverse ligament test, abolished the paresthesias. She was then referred back to her primary care physician for further evaluation. Subsequent radiographs and magnetic resonance imaging revealed that the patient had a C2-C3 Klippel-Feil congenital fusion and os odontoideum. The patient was examined by a neurosurgeon who concluded that she was not a surgical candidate. Her neurological symptoms completely resolved, but she continued to have headaches. DISCUSSION Os odontoideum is a clinically important condition, given that the mobile dens may render the transverse ligament incompetent, leading to atlantoaxial instability. Both the role and sequencing of upper cervical ligamentous testing is controversial. The results of this case report suggest that physical therapists should be cognizant of this condition and consider screening the upper cervical ligaments prior to manual or mechanical interventions to this region. LEVEL OF EVIDENCE Differential diagnosis, level 4.