Paul F. Beattie

Clinical prediction rules: What are they and what do they tell us?

QUESTION Clinical prediction rules are research-based tools that quantify the contributions of relevant patient characteristics to provide numeric indices that assist clinicians in making predictions. Clinical prediction rules have been used to describe the likelihood of the presence or absence of a condition, assist in determining patient prognosis, and help the classification of patients for treatment. The recent rapid rise in the use of clinical prediction rules raises questions about the conditions under which they may be used most appropriately. What is the potential role of clinical prediction rules in physiotherapy practice and what are the strategies by which clinicians can determine their appropriate use for a given clinical setting? CONCLUSION Clinical prediction rules use quantitative methods to build upon the body of literature and expert opinion and can provide quick and inexpensive estimates of probability. Clinical prediction rules can be of great value to assist clinical decision making but should not be used indiscriminately. They are not a replacement for clinical judgment and should complement rather than supplant clinical opinion and intuition. The development of valid clinical prediction rules should be a goal of physiotherapy research. Specific areas in need of attention include deriving and validating clinical prediction rules to screen patients for potentially serious conditions for which current tests lack adequate diagnostic accuracy or have unacceptable cost and risk, and to assist in classification of patients for treatments that are likely to result in substantially different outcomes in heterogeneous groups of patients.

Heel Pain—Plantar Fasciitis: Revision 2014

The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organizations International Classification of Functioning, Disability, and Health (ICF). The purpose of these revised clinical practice guidelines is to review recent peer-reviewed literature and make recommendations related to nonarthritic heel pain.

Measurement of health outcomes in the clinical setting: applications to physiotherapy

The purpose of this paper is to provide an overview of health-outcome measurement in the physiotherapy clinical environment and to discuss the role of performance tests and self-report measures in achieving this task. Although the principles of outcome assessment are similar for different patient populations, the examples used as illustrations in this paper relate primarily to those people with musculoskeletal dysfunction. Traditional clinical examination findings, although important for establishing diagnosis and treatment planning, do not include all of the dimensions necessary to adequately describe outcome. To overcome this, the emerging field of health-outcomes measurement has provided many useful tools that, when used properly, provide critical information to patients, clinicians, third-party payers, and health care policy administrators. The numeric indices generated by outcome measures allow statistical comparisons that are useful for patient care decisions, research, and health care policy determination. Patient performance tests provide valuable information regarding a persons ability to complete a relevant task in a controlled environment. In many cases, however, the results of performance tests do not provide complete information regarding a patients status. The use of patient self-report measures, in the form of standardized questionnaires, has been gaining popularity as an adjunct, or replacement for, physical performance tests. Self-report measures provide a mechanism to assess the multiple dimensions of outcome and are typically easy to administer while assisting the determination of meaningful clinical change. When selecting tools to use for outcome assessment, clinicians should determine which dimensions are important to sample and identify performance or self-report measures that have appropriate reliability and validity. When used appropriately, these outcome measures are efficient and useful clinical tools for physiotherapy.

Diffusion-Weighted Magnetic Resonance Imaging of Normal and Degenerative Lumbar Intervertebral Discs: A New Method to Potentially Quantify the Physiologic Effect of Physical Therapy Intervention

STUDY DESIGN Observational, repeated measures design. OBJECTIVES To determine the reliability of the apparent diffusion coefficient (ADC) calculated from diffusion-weighted magnetic resonance images (MRI) of the nuclear region of lumbar intervertebral discs (IVDs), to investigate the differences in the ADC based upon T2-signal intensity, and to examine the test-retest variation in these measures obtained from subjects undergoing serial, diffusion-weighted MRI scans. BACKGROUND Impaired diffusion of water within the lumbar IVD is a central characteristic of degenerative disc disease. Diffusion-weighted MRI scans can provide quantitative estimates of water diffusion and may be useful to evaluate the physiologic effects of healing or the change in hydration related to interventions such as traction, manual therapy, or exercise on normal and degenerative lumbar IVDs. METHODS AND MEASURES Thirty subjects underwent T2 -weighted and diffusion-weighted lumbar MRI scans. Twenty-one of these subjects underwent a second diffusion-weighted MRI scan 4 to 7 weeks after the initial scan. The ADC was calculated from midsagittal diffusion-weighted images for the IVDs of L1-2 to L5-S1. To assess reliability, repeated measures of the ADC were performed on the first 16 scans. The T2-signal of the nuclear region of each disc was classified as hyperintense, intermediate, or hypointense, and its relationship to the mean ADC of the nuclear region was determined. Test-retest variation in the ADC was described using the coefficient of variation (CV), plus or minus the width of the 95% confidence interval of the standard error of measurement (SEM). RESULTS Intraclass correlation coefficients for estimates of intrarater and interrater reliability ranged from 0.95 to 0.99 and the SEM ranged from 0.006 to 0.026 X 10-3 mm2/s. The mean ADC was significantly greater for hyperintense IVDs compared to intermediate and hypointense IVDs. The CV plus or minus the 95% CI of the SEM between scans ranged from 9.0% to 13.6% for all discs, 6.1% to 10.1% for hyperintense discs, and 13.1% to 23.7% for intermediate discs. The prevalence of hypointense discs was too low to make meaningful judgments about their normal degree of variation over time. CONCLUSION The ADC of the nuclear region of the lumbar IVDs may be reliably measured from diffusion-weighted images. Degenerative discs had lower mean ADC values than normal discs but demonstrated greater variation between scans. Diffusion-weighted imaging may be a useful procedure to assess change in diffusion of water in lumbar discs that occurs over time.

The role of functional status questionnaires for low back pain.

This article provides an introduction to the use of functional status questionnaires in the management of patients with low back pain (LBP). The paper highlights some problems with traditional outcome measures such as the straight leg raise and argues for the use of outcomes that are more meaningful to patients. It is recommended that physiotherapists evaluate the effect of their treatment on the health-related quality of life of a patient with LBP by assessing the patients functional limitations and disabilities. Three questionnaires appropriate for this purpose, which are also feasible for use in the typical physiotherapy clinic, are reviewed and the use of one of the questionnaires is demonstrated in a case study.

The Immediate Reduction in Low Back Pain Intensity Following Lumbar Joint Mobilization and Prone Press-ups Is Associated With Increased Diffusion of Water in the L5-S1 Intervertebral Disc

STUDY DESIGN Single-group, prospective, repeated-measures design. OBJECTIVES To determine differences in the changes of diffusion of water in the L5-S1 intervertebral disc between subjects with nonspecific low back pain (LBP) who reported an immediate reduction in pain intensity of 2 or greater on an 11-point (0-10) numeric rating scale after a 10-minute session of lumbar joint mobilization, followed by prone press-up exercises, compared to those who did not report an immediate reduction in pain intensity of 2 or greater on the pain scale. BACKGROUND Combining lumbar joint mobilization and prone press-up exercises is a common intervention for patients with LBP; however, there is conflicting evidence regarding the effectiveness and efficacy of this approach. Increased knowledge of the physiologic effects of the combined use of these treatments, and the relationship to pain reports, can lead to refinement of their clinical application. METHODS Twenty adults, aged 22 to 54, participated in this study. All subjects reported LBP of at least 2 on an 11-point (0-10) verbally administered numeric rating scale at the time of enrollment in the study and were classified as being candidates for the combination of joint mobilization and prone press-ups. Subjects underwent T2- and diffusion-weighted lumbar magnetic resonance imaging scans before and immediately after receiving a 10-minute session of lumbar pressures in a posterior-to-anterior direction and prone press-up exercises. Subjects who reported a decrease in current pain intensity of 2 or greater immediately following treatment were classified as immediate responders, while the remainder were classified as not-immediate responders. The apparent diffusion coefficient, representing the diffusion of water in the nucleus pulposis, was calculated from the midsagittal diffusion-weighted images. RESULTS Following treatment, immediate responders (n = 10) had a mean increase in the apparent diffusion coefficient in the middle portion of the L5-S1 intervertebral disc of 4.2% compared to a mean decrease of 1.6% for the not-immediate responders (P<.005). CONCLUSION In a group of subjects with LBP, who were classified as being candidates for extension-based treatment, the report of an immediate reduction in pain intensity of 2/10 of greater after a treatment of posterior-to-anterior-directed pressures, followed by prone press-up exercises, was associated with an increase in diffusion of water in the nuclear region of the L5-S1 intervertebral disc. Subjects who did not report a pain reduction of at least 2/10 did not have a change in diffusion. J Orthop Sports Phys Ther 2010;40(5):256-264, Epub 12 March 2010. doi:10.2519/jospt.2010.3284.

The change in the diffusion of water in normal and degenerative lumbar intervertebral discs following joint mobilization compared to prone lying.

STUDY DESIGN Prospective, repeated measures obtained under treatment and control conditions. OBJECTIVES The purposes of this study were to provide preliminary evidence regarding the immediate change in the diffusion of water in the nuclear region of normal and degenerative lumbar intervertebral discs (IVDs) following a single session of lumbar joint mobilization, and to compare these findings to the immediate change in the diffusion of water following a 10-minute session of prone lying. BACKGROUND There is conflicting evidence regarding the effectiveness and efficacy of lumbar joint mobilization. Increased knowledge of the physiologic effects of lumbar joint mobilization can lead to refinement of its clinical application. METHODS AND MEASURES A total of 24 people (15 males and 9 females), ranging in age from 22 to 58 years, participated in this study. All subjects had a history of activity-limiting low back pain. Diffusion-weighted magnetic resonance images (DW-MRIs) were obtained immediately before and after a 10-minute session of lumbar joint mobilization. At least 1 month later, a second session was performed in which DW-MRIs were obtained immediately before and after a 10-minute session of prone lying. RESULTS Following lumbar joint mobilization, a significant increase (P = .002) in the mean values for diffusion of water was observed within degenerative IVDs at L5-S1 (22.2% increase; effect size, 0.97). Degenerative IVDs at L1-2 to L4-5 and normal IVDs at L1-2 to L5-S1 did not demonstrate a change in diffusion following joint mobilization. Prone lying was not associated with a change in diffusion for normal or degenerative IVDs. CONCLUSIONS The stimulus provided by lumbar joint mobilization may influence the diffusion of water in degenerative IVDs at L5-S1; however, these are preliminary findings and the relationship of these findings to pain and function needs further investigation.

Current Understanding of Lumbar Intervertebral Disc Degeneration: A Review With Emphasis Upon Etiology, Pathophysiology, and Lumbar Magnetic Resonance Imaging Findings

Degeneration of the lumbar intervertebral discs (IVDs) is highly prevalent in adults and is nearly universal in the elderly population. Degenerative changes within, and adjacent to, the IVDs are likely to contribute to a variety of pain syndromes; however, the exact association between these findings and symptoms remains speculative. Recent research has provided new information regarding the etiology, pathophysiology, and clinical relevance of degeneration of the IVD. This information will assist clinicians and researchers in understanding the development and clinical course of lumbar disc degeneration, as well as its potential impact upon patients seeking physical therapy care for back pain. The purposes of this clinical commentary are to review the structure and metabolic capacity of the normal and degenerative lumbar IVD, and to discuss factors that influence the onset and progression of disc degeneration. Lumbar magnetic resonance images will be used to illustrate the common findings associated with this condition.

Evaluating Research Studies That Address Prognosis for Patients Receiving Physical Therapy Care: A Clinical Update

A prognosis is a broad statement that predicts a patients likely status, or degree of change, at some time in the future. Clinicians are likely to improve the accuracy of their judgments of prognosis by incorporating relevant research findings. In recent years, there has been substantial growth in the number of primary studies and systematic reviews addressing prognosis for people likely to receive physical therapy care. The purpose of this clinical update is to provide a framework for identifying, appraising, and utilizing these research findings to help make prognostic judgments.

The evolving role of physical therapists in the long-term management of chronic low back pain: longitudinal care using assisted self-management strategies

ABSTRACT Background Longitudinal studies have shown that the symptoms of chronic low back pain (CLBP) will follow an episodic trajectory characterized by periods of high and low pain intensity that can persist for many years. There is a growing belief that the contemporary approach of limiting physical therapy to short, but intense courses of treatment for (CLBP) may be sub-optimal because these limited “windows” of clinical care are not congruent with the natural history of this condition. Recent research has suggested that people with CLBP undergo substantial, and individualized long-term variations in the neural processing of nociception over time. This has led to the concept of a “unique biosignature of pain” that may explain much of the variation in a person’s clinical picture. These and other findings have led to the reconceptualization of CLBP as an individualized, and continually evolving condition that may be more suitably managed by empowering the patient toward self-management strategies that can be modified as needed over time by the PT. Objectives The purpose of this Master Class Paper is to describe an emerging approach for the treatment of CLBP that emphasizes the formation of a long-term therapeutic alliance between the patient and the PT with an emphasis on individualized, patient-preferred approaches for activity-based self-management as an alternative to the contemporary approach of short, intense episodes of care directed toward pain reduction. Conclusion Longitudinal care using assisted self-management strategies is more congruent with the natural history of CLBP than are traditional approaches for PT intervention. This approach may empower patients to undergo lifestyle changes that will favorably influence long-term outcomes; however additional research is needed.