Robert S. Wainner

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.

Development of a patient-reported measure of function of the knee

The purpose of the present study was to demonstrate the reliability, validity, and responsiveness of the Activities of Daily Living Scale of the Knee Outcome Survey, a patient-reported measure of functional limitations imposed by pathological disorders and impairments of the knee during activities of daily living. The study comprised 397 patients; 213 were male, 156 were female, and the gender was not recorded for the remaining twenty-eight. The mean age of the patients was 33.3 years (range, twelve to seventy-six years). The patients were referred to physical therapy because of a wide variety of disorders of the knee, including ligamentous and meniscal injuries, patellofemoral pain, and osteoarthrosis. The Activities of Daily Living Scale was administered four times during an eight-week period: at the time of the initial evaluation and after one, four, and eight weeks of therapy. Concurrent measures of function included the Lysholm Knee Scale and several global measures of function. The subjects also provided an assessment of the change in function, with responses ranging from greatly worse to greatly better, at one, four, and eight weeks. The Activities of Daily Living Scale was administered to an additional sample of fifty-two patients (thirty-two male and twenty female patients with a mean age of 31.6 years [range, fourteen to sixty-six years]) before and after treatment within a single day to establish test-retest reliability. Factor analysis revealed two dominant factors: one that reflected a combination of symptoms and functional limitations and the other, only symptoms. The internal consistency of the Activities of Daily Living Scale was substantially higher than that of the Lysholm Knee Scale (coefficient alpha, 0.92 to 0.93 compared with 0.60 to 0.73), resulting in a smaller standard error of measurement for the former scale. Validity was demonstrated by moderately strong correlations with concurrent measures of function, including the Lysholm Knee Scale (r = 0.78 to 0.86) and the global assessment of function as measured on a scale ranging from 0 to 100 points (r = 0.66 to 0.75). Analysis of variance with repeated measures revealed significant improvements in the score on the Activities of Daily Living Scale during the eight weeks of physical therapy (F2,236 = 108.13; p < 0.0001); post hoc testing indicated that the change in the score at eight weeks was significantly greater than the change at four weeks and that the change at four weeks was significantly greater than that at one week (p < 0.0001 for both). As had been hypothesized, the patients in whom the knee had somewhat improved had a significantly smaller change in the score, both at four weeks (F1,189 = 33.50; p < 0.001) and at eight weeks (F1,156 = 22.48; p < 0.001), compared with those in whom the knee had greatly improved. The test-retest reliability coefficient (intraclass correlation coefficient[2,1]) was 0.97. These results suggest that the Activities of Daily Living Scale is a reliable, valid, and responsive instrument for the assessment of functional limitations that result from a wide variety of pathological disorders and impairments of the knee.

Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy

Study Design. A blinded, prospective diagnostic test study was conducted. Objectives. To assess the reliability and accuracy of individual clinical examination items and self-report instruments for the diagnosis of cervical radiculopathy, and to identify and assess the accuracy of an optimum test-item cluster for the diagnosis of cervical radiculopathy. Summary of Background Data. Although cervical radiculopathy remains largely a clinical diagnosis, the reliability and diagnostic accuracy of clinical examination items, individually or in combination, for cervical radiculopathy is largely unknown. Methods. Patients with suspected cervical radiculopathy or carpal tunnel syndrome received standardized electrophysiologic examination of the symptomatic upper quarter followed by a standardized clinical examination by physical therapist examiners blinded to diagnosis. Diagnostic properties were assessed using a neural impairment reference criterion standard. Results. The study involved 82 patients. More than two thirds of 34 clinical examination items had reliability coefficients rated at least fair or better, and 13 items had likelihood ratio point estimates above 2 or below 0.50. A single diagnostic test item cluster of four variables was identified and produced a positive likelihood ratio point estimate of 30.3. The 95% confidence intervals for all likelihood ratio point estimates in this study were wide. Conclusions. Many items of the clinical examination were found to be reliable and to have acceptable diagnostic properties, but the test item cluster identified was more useful for indicating cervical radiculopathy than any single test item. Upper limb tension Test A was the most useful test for ruling out cervical radiculopathy. Further investigation is required both to validate the test item cluster and to improve point estimate precision.

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 short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement syndrome

The study was an exploratory, one group pretest/post-test study, with the objective of investigating the short-term effects of thoracic spine thrust manipulations (TSTMs) on patients with shoulder impingement syndrome (SIS). There is evidence that manual physical therapy that includes TSTM and non-thrust manipulation and exercise is effective for the treatment of patients with SIS. However, the relative contributions of specific manual therapy interventions are not known. To date, no published studies address the short-term effects of TSTM in the treatment of SIS. Fifty-six patients (40 males, 16 females; mean age 31.2+/-8.9) with SIS underwent a standardized shoulder examination, immediately followed by TSTM techniques. Outcomes measured were the Numeric Pain and Rating Scale (NPRS) and the Shoulder Pain and Disability Index (SPADI), all collected at baseline and at a 48-h follow-up period. Additionally, the Global Rating of Change Scale (GRCS) was collected at 48-h follow-up to measure patient perceived change. At 48-h follow-up, the NPRS change scores for Neer impingement sign, Hawkins impingement sign, resisted empty can, resisted external rotation, resisted internal rotation, and active abduction were all statistically significant (p<0.01). The reduction in the SPADI score was also statistically significant (p<0.001) and the mean GRCS score=1.4+/-2.5. In conclusion, TSTM provided a statistically significant decrease in self reported pain measures and disability in patients with SIS at 48-h follow-up.

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.

The Audible Pop Is Not Necessary for Successful Spinal High-Velocity Thrust Manipulation in Individuals With Low Back Pain

OBJECTIVE To determine the relationship between an audible pop and symptomatic improvement with spinal manipulation in patients with low back pain (LBP). DESIGN A prospective cohort study. SETTING Two outpatient physical therapy clinics located in military medical centers. PARTICIPANTS A cohort of 71 patients with nonradicular LBP referred to physical therapy. INTERVENTIONS Participants underwent a standardized examination and standardized spinal manipulation treatment program. All patients were treated with a sacroiliac (SI) region manipulative technique and the presence or absence of an audible pop was noted. MAIN OUTCOME MEASURES Subjects were reassessed 48 hours after the manipulation for changes in range of motion (ROM), numeric pain rating scale (PRS) scores, and modified Oswestry Disability Questionnaire (ODQ) scores. RESULTS An audible pop occurred in 50 of the 71 subjects during the manipulative procedure. Both groups-those who had an audible pop and those who did not-improved over time in flexion ROM, PRS scores, and modified ODQ scores; however, there were no differences between groups (P>.05). Nineteen of the 71 (27%) patients improved dramatically (mean drop in modified ODQ, 67.6%). In 14 of the 19 dramatic responders, an audible pop occurred. However, the odds ratio (1.2; 95% confidence interval, 0.38-4.04) suggested that the occurrence of a manipulative pop would not improve the odds of achieving a dramatic reduction in symptoms after the manipulation. CONCLUSION There is no relationship between an audible pop during SI region manipulation and improvement in ROM, pain, or disability in individuals with nonradicular LBP. Additionally, the occurrence of a pop did not improve the odds of a dramatic improvement with manipulation treatment.

Primary Care Referral of Patients With Low Back Pain to Physical Therapy Impact on Future Health Care Utilization and Costs

Study Design. A retrospective cohort. Objective. To describe physical therapy utilization following primary care consultation for low back pain (LBP) and evaluate associations between the timing and content of physical therapy and subsequent health care utilization and costs. Summary of Background Data. Primary care management of LBP is highly variable and the implications for subsequent costs are not well understood. The importance of referring patients from primary care to physical therapy has been debated, and information on how the timing and content of physical therapy impact subsequent costs and utilization is needed. Methods. Data were extracted from a national database of employer-sponsored health plans. A total of 32,070 patients with a new primary care LBP consultation were identified and categorized on the basis of the use of physical therapy within 90 days. Patients utilizing physical therapy were further categorized based on timing (early [within 14 d] or delayed)] and content (guideline adherent or nonadherent). LBP-related health care costs and utilization in the 18-months following primary care consultation were examined. Results. Physical therapy utilization was 7.0% with significant geographic variability. Early physical therapy timing was associated with decreased risk of advanced imaging (odds ratio [OR] = 0.34, 95% confidence interval [CI]: 0.29, 0.41), additional physician visits (OR = 0.26, 95% CI: 0.21, 0.32), surgery (OR = 0.45, 95% CI: 0.32, 0.64), injections (OR = 0.42, 95% CI: 0.32, 0.64), and opioid medications (OR = 0.78, 95% CI: 0.66, 0.93) compared with delayed physical therapy. Total medical costs for LBP were

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

2736.23 lower (95% CI: 1810.67, 3661.78) for patients receiving early physical therapy. Physical therapy content showed weaker associations with subsequent care. Conclusion. Early physical therapy following a new primary care consultation was associated with reduced risk of subsequent health care compared with delayed physical therapy. Further research is needed to clarify exactly which patients with LBP should be referred to physical therapy; however, if referral is to be made, delaying the initiation of physical therapy may increase risk for additional health care consumption and costs.

Development of a Clinical Prediction Rule to Identify Patients With Knee Pain and Clinical Evidence of Knee Osteoarthritis Who Demonstrate a Favorable Short-Term Response to Hip Mobilization

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.