Rogelio A. Coronado

Bibliometric Analysis of Articles Published from 1980 to 2009 in Physical Therapy, Journal of the American Physical Therapy Association

Background Recent evidence demonstrates growth in both the quality and quantity of evidence in physical therapy. Much of this work has focused on randomized controlled trials and systematic reviews. Objective The purpose of this study was to conduct a comprehensive bibliometric assessment of Physical Therapy (PTJ) over the past 30 years to examine trends for all types of studies. Design This was a bibliometric analysis. Methods All manuscripts published in PTJ from 1980 to 2009 were reviewed. Research reports, topical reviews (including perspectives and nonsystematic reviews), and case reports were included. Articles were coded based on type, participant characteristics, physical therapy focus, research design, purpose of article, clinical condition, and intervention. Coding was performed by 2 independent reviewers, and author, institution, and citation information was obtained using bibliometric software. Results Of the 4,385 publications identified, 2,519 were included in this analysis. Of these, 67.1% were research reports, 23.0% were topical reviews, and 9.9% were case reports. Percentage increases over the past 30 years were observed for research reports, inclusion of “symptomatic” participants (defined as humans with a current symptomatic condition), systematic reviews, qualitative studies, prospective studies, and articles focused on prognosis, diagnosis, or metric topics. Percentage decreases were observed for topical reviews, inclusion of only “asymptomatic” participants (defined as humans without a current symptomatic condition), education articles, nonsystematic reviews, and articles focused on anatomy/physiology. Limitations Quality assessment of articles was not performed. Conclusions These trends provide an indirect indication of the evolution of the physical therapy profession through the publication record in PTJ. Collectively, the data indicated an increased emphasis on publishing articles consistent with evidence-based practice and clinically based research. Bibliometric analyses indicated the most frequent citations were metric studies and references in PTJ were from journals from a variety of disciplines.

Experimental Pain Responses Support Peripheral and Central Sensitization in Patients with Unilateral Shoulder Pain

Objective:The aims of this study were to (1) examine the pattern of experimental pain responses in the affected and nonaffected extremities in patients with shoulder pain and (2) explore the intraindividual association between sensitization states derived from experimental pain testing. Methods:Experimental pain responses from 58 patients with shoulder pain (17 women, aged 18 to 52 y) were compared with those from 56 age-matched and sex-matched pain-free volunteers (16 women, aged 21 to 58 y). Experimental pain responses included pressure pain threshold (PPT), thermal pain threshold and tolerance, and suprathreshold heat pain response. Comparisons were made between the affected and nonaffected extremities of clinical participants and the average response of extremities in control participants. Peripheral and central sensitization indexes were computed for clinical participants using standardized scores and percentile cutoffs on the basis of the data from the control sample. Experimental pain responses in clinical participants observed beyond the 25th and 75th percentile of control sample responses were used for investigation of intraindividual association of sensitization states. Results:PPT at the acromion and masseter on the affected side of clinical participants were diminished compared with that on their nonaffected side (P<0.015). Bilateral sensitivity in clinical participants was noted for PPT at the acromion and suprathreshold heat pain response (P<0.015). Peripheral and central sensitization indexes demonstrated that individuals with shoulder pain present with variable patterns of peripheral and central sensitization. Conclusions:Collectively, experimental pain responses supported peripheral and central sensitization in response to pressure and thermal stimuli. No clear association was made between individuals exhibiting peripheral or central sensitization, thus suggesting heterogeneity in pain processing in this clinical population.

Depressive Symptoms, Anatomical Region, and Clinical Outcomes for Patients Seeking Outpatient Physical Therapy for Musculoskeletal Pain

Background Clinical guidelines advocate the routine identification of depressive symptoms for patients with pain in the lumbar or cervical spine, but not for other anatomical regions. Objective The purpose of this study was to investigate the prevalence and impact of depressive symptoms for patients with musculoskeletal pain across different anatomical regions. Design This was a prospective, associational study. Methods Demographic, clinical, depressive symptom (Symptom Checklist 90–Revised), and outcome data were collected by self-report from a convenience sample of 8,304 patients. Frequency of severe depressive symptoms was assessed by chi-square analysis for demographic and clinical variables. An analysis of variance examined the influence of depressive symptoms and anatomical region on intake pain intensity and functional status. Separate hierarchical multiple regression models by anatomical region examined the influence of depressive symptoms on clinical outcomes. Results Prevalence of severe depression was higher in women, in industrial and pain clinics, and in patients who reported chronic pain or prior surgery. Lower prevalence rates were found in patients older than 65 years and those who had upper- or lower-extremity pain. Depressive symptoms had a moderate to large effect on pain ratings (Cohen d=0.55–0.87) and a small to large effect on functional status (Cohen d=0.28–0.95). In multivariate analysis, depressive symptoms contributed additional variance to pain intensity and functional status for all anatomical locations, except for discharge values for the cervical region. Conclusions Rates of depressive symptoms varied slightly based on anatomical region of musculoskeletal pain. Depressive symptoms had a consistent detrimental influence on outcomes, except on discharge scores for the cervical anatomical region. Expanding screening recommendations for depressive symptoms to include more anatomical regions may be indicated in physical therapy settings.

Thermal and Pressure Pain Sensitivity in Patients with Unilateral Shoulder Pain: Comparison of Involved and Uninvolved Sides

STUDY DESIGN Cross-sectional. BACKGROUND In the examination of patients with unilateral shoulder pain, pain provocation testing to compare the involved and uninvolved sides has been considered useful. However, side-to-side comparisons of experimental pain sensitivity in patients with unilateral shoulder pain are not widely reported in the literature. OBJECTIVES To compare experimental pain sensitivity between the involved and uninvolved sides in patients with unilateral shoulder pain. METHODS In consecutive patients seeking operative treatment for shoulder pain, sensitivity measures of bilateral pressure pain threshold at the shoulder and forearm, and thermal pain threshold, tolerance, and temporal summation at the forearm, were examined. Pressure sensitivity was tested with a Fischer pressure algometer, and thermal sensitivity with a computer-controlled Medoc neurosensory analyzer. The involved and uninvolved sides were compared with an analysis of variance. Influence of sex and location of testing were considered as covariates in the analysis. RESULTS Fifty-nine consecutively recruited participants completed experimental pain sensitivity testing. Participants reported significantly lower pressure pain thresholds in the involved side compared to the uninvolved side (F1,56 = 4.96, P = .030). In addition, female compared to male participants demonstrated lower pressure pain thresholds in the bilateral shoulder regions (F1,56 = 10.84, P = .002). There was no difference in thermal pain sensitivity between sides. Average clinical pain intensity was negatively correlated with pressure pain threshold at the involved local site (r = -0.284, P = .029), indicating an influence of clinical pain intensity on local pressure pain. CONCLUSION The results of this study provide evidence for higher experimental pressure pain sensitivity in the involved side of patients with unilateral shoulder pain and no difference between sides for thermal pain sensitivity. Females demonstrated higher pain sensitivity than males to pressure stimuli at the local shoulder region but not at the distal regions. Future studies should incorporate multiple stimuli when describing the pain profile of clinical populations.

The relative effectiveness of segment specific level and non-specific level spinal joint mobilization on pain and range of motion: results of a systematic review and meta-analysis

Abstract Study design: Systematic literature review and meta-analysis. Objective: In symptomatic subjects to: (1) examine the effects of a single session of joint mobilization on pain at rest and with most painful movement, and (2) compare the effects when joint mobilization is provided to a specific or non-specific spinal level. Background: Joint mobilization is routinely used for treating spinal pain in conjunction with other interventions, but its unique effect is not well understood. Further, there is controversy about the role of ‘specific level’ techniques in producing benefit. Methods: Searches were performed for randomized controlled trials (RCTs) using electronic databases (MEDLINE, CINAHL, and PEDro) from 1966 through November 2010. Methodological quality was assessed using previously detailed criteria. Meta-analysis and meta-regression were conducted on eligible studies. Results: Eight RCTs with a mean methodological score of 10/12 were included. Significant heterogeneity (P = 0·075) was found in the overall meta-analysis estimate. When stratified by body location, no significant individual effect was found for pain at rest. However, there was a statistical mean difference [0·71 (95% confidence interval: 0·13–1·28)] between pain at rest for the cervical and lumbar individual means. Conclusions: We found multiple studies which provided evidence that a single session of joint mobilization can lead to a reduction of pain at rest and with most painful movement. When using joint mobilization, the need for specific versus non-specific level mobilization may be influenced by anatomical region; the direction of effect in the cervical spine was toward specific mobilization and in the lumbar spine towards non-specific mobilization.

Pain Sensitivity Subgroups in Individuals With Spine Pain: Potential Relevance to Short-Term Clinical Outcome

Background Cluster analysis can be used to identify individuals similar in profile based on response to multiple pain sensitivity measures. There are limited investigations into how empirically derived pain sensitivity subgroups influence clinical outcomes for individuals with spine pain. Objective The purposes of this study were: (1) to investigate empirically derived subgroups based on pressure and thermal pain sensitivity in individuals with spine pain and (2) to examine subgroup influence on 2-week clinical pain intensity and disability outcomes. Design A secondary analysis of data from 2 randomized trials was conducted. Methods Baseline and 2-week outcome data from 157 participants with low back pain (n=110) and neck pain (n=47) were examined. Participants completed demographic, psychological, and clinical information and were assessed using pain sensitivity protocols, including pressure (suprathreshold pressure pain) and thermal pain sensitivity (thermal heat threshold and tolerance, suprathreshold heat pain, temporal summation). A hierarchical agglomerative cluster analysis was used to create subgroups based on pain sensitivity responses. Differences in data for baseline variables, clinical pain intensity, and disability were examined. Results Three pain sensitivity cluster groups were derived: low pain sensitivity, high thermal static sensitivity, and high pressure and thermal dynamic sensitivity. There were differences in the proportion of individuals meeting a 30% change in pain intensity, where fewer individuals within the high pressure and thermal dynamic sensitivity group (adjusted odds ratio=0.3; 95% confidence interval=0.1, 0.8) achieved successful outcomes. Limitations Only 2-week outcomes are reported. Conclusions Distinct pain sensitivity cluster groups for individuals with spine pain were identified, with the high pressure and thermal dynamic sensitivity group showing worse clinical outcome for pain intensity. Future studies should aim to confirm these findings.

The temporal effects of a single session of high-velocity, low-amplitude thrust manipulation on subjects with spinal pain

Abstract Background: A high velocity, low amplitude thrust manipulation (HVLAT) is an intervention commonly used in the treatment of patients with spinal pain. Recent studies have reported on the possible neurophysiological effects of this technique which may be pertinent to the therapeutic value of these procedures. However, few studies have examined the temporal neurophysiological nature of a HVLAT beyond the immediate effects. Objectives: The purpose of this review is to summarize the literature on the temporal neurophysiological effects of a single HVLAT in patients with spinal pain. Methods: A systematic search of English articles was conducted using MEDLINE, CINAHL, and PEDro. Additional studies were identified with a hand search of the references of relevant articles. Search terms included spinal manipulation, chiropractic manipulation, osteopathic manipulation, spinal adjustment, cervical manipulation, lumbar manipulation, sacroiliac manipulation, neck pain, back pain, and sacroiliac pain. Quality scoring of the included articles was based on the Newcastle–Ottawa criteria. Results: Of the 478 articles identified, five articles ultimately met inclusion criteria into this review. These studies were of moderate to high quality. In all, follow-up measures after a single HVLAT were taken within a 30-minute to 5-hour period. Conclusion: In the absence of concurrent intervention, the neurophysiological effects seen after administration of a HVLAT were observed to be immediate in nature, with a return to baseline or reduction in effect noted at follow-up. Future studies examining the mechanisms of HVLAT should include dedicated follow-up periods to establish the temporal changes related to these techniques.

Thalamic Functional Connectivity in Mild Traumatic Brain Injury: Longitudinal Associations With Patient-Reported Outcomes and Neuropsychological Tests

OBJECTIVES (1) To examine differences in patient-reported outcomes, neuropsychological tests, and thalamic functional connectivity (FC) between patients with mild traumatic brain injury (mTBI) and individuals without mTBI and (2) to determine longitudinal associations between changes in these measures. DESIGN Prospective observational case-control study. SETTING Academic medical center. PARTICIPANTS A sample (N=24) of 13 patients with mTBI (mean age, 39.3±14.0y; 4 women [31%]) and 11 age- and sex-matched controls without mTBI (mean age, 37.6±13.3y; 4 women [36%]). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Resting state FC (3T magnetic resonance imaging scanner) was examined between the thalamus and the default mode network, dorsal attention network, and frontoparietal control network. Patient-reported outcomes included pain (Brief Pain Inventory), depressive symptoms (Patient Health Questionnaire-9), posttraumatic stress disorder ([PTSD] Checklist - Civilian Version), and postconcussive symptoms (Rivermead Post-Concussion Symptoms Questionnaire). Neuropsychological tests included the Delis-Kaplan Executive Function System Tower test, Trails B, and Hotel Task. Assessments occurred at 6 weeks and 4 months after hospitalization in patients with mTBI and at a single visit for controls. RESULTS Student t tests found increased pain, depressive symptoms, PTSD symptoms, and postconcussive symptoms; decreased performance on Trails B; increased FC between the thalamus and the default mode network; and decreased FC between the thalamus and the dorsal attention network and between the thalamus and the frontoparietal control network in patients with mTBI as compared with controls. The Spearman correlation coefficient indicated that increased FC between the thalamus and the dorsal attention network from baseline to 4 months was associated with decreased pain and postconcussive symptoms (corrected P<.05). CONCLUSIONS Findings suggest that alterations in thalamic FC occur after mTBI, and improvements in pain and postconcussive symptoms are correlated with normalization of thalamic FC over time.

Effect of a single session of muscle-biased therapy on pain sensitivity: A systematic review and meta-analysis of randomized controlled trials

Background Muscle-biased therapies (MBT) are commonly used to treat pain, yet several reviews suggest evidence for the clinical effectiveness of these therapies is lacking. Inadequate treatment parameters have been suggested to account for inconsistent effects across studies. Pain sensitivity may serve as an intermediate physiologic endpoint helping to establish optimal MBT treatment parameters. The purpose of this review was to summarize the current literature investigating the short-term effect of a single dose of MBT on pain sensitivity in both healthy and clinical populations, with particular attention to specific MBT parameters of intensity and duration. Methods A systematic search for articles meeting our prespecified criteria was conducted using Cumulative Index to Nursing and Allied Health Literature (CINAHL) and MEDLINE from the inception of each database until July 2012, in accordance with guidelines from the Preferred Reporting Items for Systematic reviews and Meta-Analysis. Relevant characteristics from studies included type, intensity, and duration of MBT and whether short-term changes in pain sensitivity and clinical pain were noted with MBT application. Study results were pooled using a random-effects model to estimate the overall effect size of a single dose of MBT on pain sensitivity as well as the effect of MBT, dependent on comparison group and population type. Results Reports from 24 randomized controlled trials (23 articles) were included, representing 36 MBT treatment arms and 29 comparative groups, where 10 groups received active agents, 11 received sham/inert treatments, and eight received no treatment. MBT demonstrated a favorable and consistent ability to modulate pain sensitivity. Short-term modulation of pain sensitivity was associated with short-term beneficial effects on clinical pain. Intensity of MBT, but not duration, was linked with change in pain sensitivity. A meta-analysis was conducted on 17 studies that assessed the effect of MBT on pressure pain thresholds. The results suggest that MBT had a favorable effect on pressure pain thresholds when compared with no-treatment and sham/inert groups, and effects comparable with those of other active treatments. Conclusion The evidence supports the use of pain sensitivity measures by future research to help elucidate optimal therapeutic parameters for MBT as an intermediate physiologic marker.

Unraveling the mechanisms of manual therapy: Modeling an approach

• SYNOPSIS: Manual therapy interventions are popular among individual health care providers and their patients; however, systematic reviews do not strongly support their effectiveness. Small treatment effect sizes of manual therapy interventions may result from a “one‐size‐fits‐all” approach to treatment. Mechanistic‐based treatment approaches to manual therapy offer an intriguing alternative for identifying patients likely to respond to manual therapy. However, the current lack of knowledge of the mechanisms through which manual therapy interventions inhibit pain limits such an approach. The nature of manual therapy interventions further confounds such an approach, as the related mechanisms are likely a complex interaction of factors related to the patient, the provider, and the environment in which the intervention occurs. Therefore, a model to guide both study design and the interpretation of findings is necessary. We have previously proposed a model suggesting that the mechanical force from a manual therapy intervention results in systemic neurophysiological responses leading to pain inhibition. In this clinical commentary, we provide a narrative appraisal of the model and recommendations to advance the study of manual therapy mechanisms.