Richard E. Erhard

Identifying subgroups of patients with acute/subacute nonspecific low back pain : Results of a randomized clinical trial

Study Design. Randomized clinical trial. Objective. Compare outcomes of patients with low back pain receiving treatments matched or unmatched to their subgrouping based on initial clinical presentation. Summary of Background Data. Patients with “nonspecific” low back pain are often viewed as a homogeneous group, equally likely to respond to any particular intervention. Others have proposed methods for subgrouping patients as a means for determining the treatment most likely to benefit patients with particular characteristics. Methods. Patients with low back pain of less than 90 days’ duration referred to physical therapy were examined before treatment and classified into one of three subgroups based on the type of treatment believed most likely to benefit the patient (manipulation, stabilization exercise, or specific exercise). Patients were randomly assigned to receive manipulation, stabilization exercises, or specific exercise treatment during a 4-week treatment period. Disability was assessed in the short-term (4 weeks) and long-term (1 year) using the Oswestry. Comparisons were made between patients receiving treatment matched to their subgroup, versus those receiving unmatched treatment. Results. A total of 123 patients participated (mean age, 37.7 ± 10.7 years; 45% female). Patients receiving matched treatments experienced greater short- and long-term reductions in disability than those receiving unmatched treatments. After 4 weeks, the difference favoring the matched treatment group was 6.6 Oswestry points (95% CI, 0.70–12.5), and at long-term follow-up the difference was 8.3 points (95% CI, 2.5–14.1). Compliers-only analysis of long-term outcomes yielded a similar result. Conclusions. Nonspecific low back pain should not be viewed as a homogenous condition. Outcomes can be improved when subgrouping is used to guide treatment decision-making.

Comparison of Classification-Based Physical Therapy With Therapy Based on Clinical Practice Guidelines for Patients with Acute Low Back Pain : A Randomized Clinical Trial

Study Design. A randomized clinical trial was conducted. Objective. To compare the effectiveness of classification-based physical therapy with that of therapy based on clinical practice guidelines for patients with acute, work-related low back pain. Summary of Background Data. Clinical practice guidelines recommend minimal intervention during the first few weeks after acute low back injury. However, studies supporting this recommendation have not attempted to identify which patients are likely to respond to particular interventions. Methods. For this study, 78 subjects with work-related low back pain of less than 3 weeks duration were randomized to receive therapy based on a classification system that attempts to match patients to specific interventions or therapy based on the Agency for Health Care Policy and Research guidelines. The subjects were followed for 1 year. Outcomes included the impairment index, Oswestry scale, SF-36 component scores, satisfaction, medical costs, and return to work status. Results. After adjustment for baseline factors, subjects receiving classification-based therapy showed greater change on the Oswestry (P = 0.023) and the SF-36 physical component (P = 0.029) after 4 weeks. Patient satisfaction was greater (P = 0.006) and return to full-duty work status more likely (P = 0.017) after 4 weeks in the classification-based group. After 1 year, there was a trend toward reduced Oswestry scores in the classification-based group (P = 0.063). Median total medical costs for 1 year after injury were

Lumbar spinal stenosis: A review of current concepts in evaluation, management, and outcome measurements

1003.68 for the guideline-based group and

A comparison of fear-avoidance beliefs in patients with lumbar spine pain and cervical spine pain

774.00 for the classification-based group (P = 0.13). Conclusions. For patients with acute, work-related low back pain, the use of a classification-based approach resulted in improved disability and return to work status after 4 weeks, as compared with therapy based on clinical practice guidelines. Further research is needed on the optimal timing and methods of intervention for patients with acute low back pain.

Spinal palpation for lumbar segmental mobility and pain provocation: an interexaminer reliability study.

The purpose of this review is to present current information from the literature regarding the pathoanatomy, clinical presentation, differential diagnosis, treatment, and outcome assessment methods for patients with lumbar spinal stenosis. Lumbar spinal stenosis is a frequently encountered condition, particularly in the elderly. Treatment requires an accurate diagnosis, but differential diagnosis of lumbar stenosis can be difficult. The literature to date has focused primarily on surgical treatment. The long-term efficacy of surgery has been questioned, and surgical procedures are associated with increased costs and risks of morbidity in an elderly population. A trial of conservative care is recommended in most cases, but there are presently no randomized controlled studies in the literature comparing surgical versus conservative management, or evaluating the effectiveness of any specific conservative treatment approach. The existing literature has further been criticized for having poorly defined outcome measures. The assessment of treatment outcomes should be multifactorial, including measures of pathoanatomy and impairments, as well as patient-centered measures such as level of disability, patient expectations, and satisfaction. The present level of understanding of lumbar spinal stenosis is deficient in many areas, including differential diagnosis, treatment, and outcome assessment. Future research should address these deficits to improve the management of patients with this condition.

Side-to-side weight-bearing asymmetry in subjects with low back pain.

Study Design. A prospective consecutive cohort study of patients with cervical spine pain and patients with lumbar spine pain referred to an academic medical center. Objectives. To investigate the presence of fear-avoidance beliefs in a sample of patients with cervical spine pain and to compare the association of pain intensity, disability, and fear-avoidance beliefs in patients with cervical spine pain with that in patients with lumbar spine pain. Summary of Background Data. Fear-avoidance beliefs are a specific psychosocial variable involved in the development of disability from low back pain. Psychosocial variables are believed to play a role in cervical disability, but specific variables have not been investigated. Methods. Consecutive patients referred to a multidisciplinary center completed self-reports of disability, pain intensity, and fear-avoidance beliefs during an initial evaluation session. Gender, type of symptom onset, acuity, and payer source were also recorded. Associations between disability, pain intensity, and fear-avoidance beliefs were investigated in patients with cervical spine pain and patients with lumbar spine pain. Results. In all, 163 patients completed the self-reports and were included in this study. Weaker relations between fear-avoidance beliefs and disability were found in patients with cervical pain than in those with lumbar pain. Significant differences in fear-avoidance beliefs were found for gender, type of symptom onset, and payer source (workers’ compensation, auto insurance, and traditional insurance). Conclusion. The associations among fear-avoidance beliefs, pain intensity, and disability differed between patients with cervical spine pain and patients with lumbar spine pain. Fear-avoidance beliefs were significantly different in subgroups of patients.

Kyphoscoliosis Improvement While Treating a Patient for Adhesive Capsulitis Using the Active Therapeutic Movement Version 2

OBJECTIVE This study determined the degree of interexaminer reliability using 2 experienced clinicians performing 3 palpation procedures over the lumbar facet joints and sacroiliac joints. METHODS The sample consisted of 39 patients with low back pain who had a recent history of low back pain. Two doctors of chiropractic independently examined each of these patients in the prone position with 3 different procedures: (1) springing palpation for pain provocation, (2) springing palpation for segmental mobility testing, and (3) the prone instability test. The doctors were blinded to each others findings and the patients clinical status, and performed the examinations on the same day. Standard and adjusted kappa values were calculated for each test. RESULTS The kappa values for palpation of segmental motion restriction were poor (range, -.20 to .17) and in many cases less than chance observation (negative kappa values). The prone instability test showed reasonable reliability (kappa = .54), and palpation for segmental pain provocation also showed fair to good reliability (kappa range, .21 to .73). CONCLUSIONS Palpation methods that are used to provoke pain responses are more reliable than palpation methods in which the clinician purports to find segmental motion restriction. The prone instability test shows good reliability.

Reliability of measuring iliac crest level in the standing and sitting position using a new measurement device

The purpose of this project was to determine if subjects with low back pain (LBP) exhibit greater side-to-side weight-bearing (WB) asymmetry compared to healthy control subjects without LBP. This study utilized an observational double cohort design and consisted of 35 subjects with LBP and 31 healthy control subjects. Side-to-side WB asymmetry was calculated as the average of the absolute value of the difference between the right and left lower extremity from three trials. The percentage of the average side-to-side WB asymmetry relative to the total body weight was calculated to normalize expected differences in magnitude of asymmetry based on a subjects total body weight. An 11-point numeric pain rating scale was used to represent the subjects current level of pain. Patients with LBP demonstrated significantly greater normalized side-to-side WB asymmetry than healthy control subjects (8.8% vs. 3.6%, respectively, P<0.001). In patients with LBP, higher magnitudes of side-to-side WB asymmetry were significantly associated with increased pain (r=0.39, P=0.021). In conclusion patients with LBP exhibited increased side-to-side WB asymmetry compared to healthy control subjects without LBP. This asymmetry was associated with increased levels of pain. This finding is relevant for planning future studies that will attempt to provide evidence for the construct validity of manipulation by determining if side-to-side WB asymmetry normalizes after a manipulation intervention and if this improvement is associated with improvements in pain and function.

Systemic malignancy presenting as neck and shoulder pain

OBJECTIVE This article presents a case report illustrating an improvement in the curvature of idiopathic scoliosis as a secondary benefit from treatment of adhesive capsulitis with an active therapeutic movement (ATM) device. CLINICAL FEATURES The patient was a 55-year-old school teacher who was referred to physical therapy for adhesive capsulitis. It was determined that part of the patients limited shoulder range of motion was due to her significant kyphoscoliosis posture, which resulted in decreased mobility of her thoracic spine. INTERVENTION AND OUTCOME The patient was treated with an ATM device as a means to help mobilize her thoracic spine. The patient completed several weeks of therapy, which consisted of using the ATM exclusively. The patient gained near-normal range of motion in both arms and had improvement in her kyphoscoliosis posture. CONCLUSION A nonsurgical treatment was a useful intervention for some of the physical and psychosocial aspects that this patient with kyphoscoliosis encountered.

Besluitvorming bij een pijnlijke heup: een casus voor doorverwijzing

BACKGROUND To date, the reliability studies of iliac crest (IC) level used nominal scales and presented conflicting results. To perform the IC level measurement, we propose the use of a measurement device that is composed of an inclinometer mounted on a crest level tester that measures IC level in degrees. OBJECTIVES To determine the interrater reliability of measuring iliac crest level in the standing and sitting position using an experimental device and to assess the precision of the measurements taken with the experimental device. METHOD Forty individuals (mean age 40 +/- 12 years) referred to physical therapy for treatment of low back pain (LBP) participated in the study (16 male participants). Six examiners performed the measurements. Three of the 6 examiners performed the measurements on each individual. Each examiner independently performed the measurement of IC level in standing and in sitting using the measurement device. RESULTS Intraclass correlation coefficients, [formula (1,1)] for measurement of IC level in standing and sitting, were 0.80 (95% CI = 0.7-0.9) and 0.73 (95% CI = 0.6-0.8), respectively. Standard errors of measurement for IC level in standing and sitting were 0.91 and 0.86 degrees, respectively. CONCLUSION The use of a measurement device resulted in good reliability of IC level measurement in degrees in standing and moderate reliability of IC level in sitting position. This finding is relevant to plan future studies that will investigate if changes in IC level may be associated with outcomes of pain and function in patients with low back or pelvic dysfunctions.