Stephen C. Allison

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.

Effectiveness of manual physical therapy and exercise in osteoarthritis of the knee. A randomized, controlled trial.

Arthritis has been identified as the most common cause of disability in the United States (1, 2). Thirty-three percent of persons 63 to 94 years of age are affected by osteoarthritis of the knee, which often limits the ability to rise from a chair, stand comfortably, walk, and use stairs (3, 4). Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used to treat osteoarthritis. Use of NSAIDs can lead to gastric complications, increased risk for hospitalization, and death (5). Other treatment options for persons with osteoarthritis of the knee include physical therapy exercise and treatment programs, cortisone injections, and joint replacement surgery. Puett and Griffin (6) reviewed 15 controlled trials of nonmedicinal, noninvasive therapies for hip and knee osteoarthritis from 1966 through 1993 (6). The authors concluded that exercise reduces pain and improves function in patients with osteoarthritis of the knee, but the optimal exercise regimen has not been determined. Fitness walking, aerobic exercise, and strength training have all been reported to result in functional improvement in patients with osteoarthritis of the knee (6-12). Unweighted treadmill walking has not been shown to decrease pain associated with osteoarthritis of the knee (13). Other researchers (14, 15) have concluded that exercise may benefit patients with osteoarthritis but advise that long-term studies are required to determine the appropriate amounts of exercise to avoid accelerating the underlying process of arthritis. Active and passive range-of-motion exercise is considered an important part of rehabilitation programs for patients with osteoarthritis (16-18). Physical therapists frequently use manual therapy procedures as part of comprehensive rehabilitation programs to help patients regain joint mobility and function (19). We evaluated the effectiveness of manual physical therapy for osteoarthritis of the knee, as applied by physical therapists with formal training in such an approach (20). Our hypothesis was that physical therapy consisting of manual therapy to the knee, hip, ankle, and lumbar spine combined with range-of-motion, strengthening, and cardiovascular exercises would be more effective than placebo for improving function, decreasing pain and stiffness, and increasing the distance walked in 6 minutes. Methods Patients Eighty-three patients with osteoarthritis of the knee were randomly assigned to receive treatment (n=42; 15 men and 27 women [mean age, 60 11 years]) or placebo (n=41; 19 men and 22 women [mean age, 62 10 years]). All patients were referred by physicians to physical therapy for osteoarthritis of the knee. Physicians at the various clinics in the medical center who normally see patients with osteoarthritis of the knee were informed of the study so that appropriate referrals could be made. If the patients met our inclusion criteria, they were offered the opportunity to participate. The main inclusion criterion was a diagnosis of osteoarthritis of the knee based on fulfillment of one of the following clinical criteria developed by Altman and colleagues [21]: 1) knee pain, age 38 years or younger, and bony enlargement; 2) knee pain, age 39 years or older, morning stiffness for more than 30 minutes, and bony enlargement; 3) knee pain, crepitus on active motion, morning stiffness for more than 30 minutes, and bony enlargement; or 4) knee pain, crepitus on active motion, morning stiffness for more than 30 minutes, and age 38 years or older. Altman and colleagues found this criteria to be 89% sensitive and 88% specific (21-23). Patients were required to be eligible for military health care, have had no surgical procedure on either lower extremity in the past 6 months, and have no physical impairment unrelated to the knee that would prevent safe participation in a timed 6-minute walk test or any other aspect of the study. Patients had to have sufficient English-language skills to comprehend all explanations and to complete the assessment tools. They were also required to live within a 1-hour drive of the physical therapy clinic. Patients who could not attend the required number of visits or had received a cortisone injection to the knee joint within the previous 30 days were not enrolled. Patients were instructed to keep taking any current medications and not to start taking new medications for osteoarthritis during the clinical treatment and 8-week follow-up. Therapy with any osteoarthritis medication must have been initiated at least 30 days before participation in the study. The study was approved by the institutional review board of Brooke Army Medical Center, Fort Sam Houston, Texas. All patients completed an informed consent form and were advised of the risks of the study, including increased symptoms, injuries from falls, and cardiovascular events. No external funding was received for this study. Procedure Patients who met the inclusion criteria were randomly assigned to one of two groups. Blank folders were numbered from 1 to 100 and were given concealed codes for the group of assignment, determined by a random-number generator. When a patient was eligible and gave consent to participate, the treating therapist drew the next folder from the file, which determined the group of assignment. The treatment group received a combination of manual physical therapy and supervised exercise. The placebo group received ultrasound at a subtherapeutic intensity. Neither group was aware of the treatment that the other group was receiving. Demographic data collected for each patient included age, sex, occupation, height, weight, duration of symptoms, presence of symptoms in one or both knees, previous knee surgery, medications, and present activity level. Knee radiographs were obtained and read by a radiologist who assigned a radiographic severity rating for osteoarthritis (24). Dependent variables measured in this study were the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score (25) and distance covered during a timed 6-minute walk test. The WOMAC Osteoarthritis Index consists of 24 questions, each corresponding to a visual analogue scale. This test has been shown to be a reliable, valid, and responsive multidimensional outcome measure for evaluation of patients with osteoarthritis of the hip or knee (26). The timed 6-minute walk test measures the distance a patient walks in 6 minutes and has been demonstrated to be a reliable measurement of functional exercise capacity (27). All measurements of dependent variables were obtained by a trained research assistant who was blinded to group assignment. After research assistants obtained pretreatment values for the dependent variables, patients returned to the treating physical therapist for thorough standardized clinical examination of the knee, hip, ankle, and lumbar spine. Treatment was initiated according to group assignment. The treatment group received manual physical therapy as indicated by the results of the examination. The manual therapy treatment techniques, consisting of passive physiologic and accessory joint movements, muscle stretching, and soft-tissue mobilization, were applied primarily to the knee. The same treatments were also administered to the lumbar spine, hip, or ankle if these areas showed limitation in active or passive movement, were symptomatic, or were contributing to overall lower limb dysfunction (28-31). A minimal pain level was not exceeded in any treatment. The treatment group also performed a closely supervised standardized knee exercise program at each of the eight treatment sessions. This program consisted of active range-of-motion exercises for the knee, muscle strengthening exercises for the hip and knee, muscle stretching for the lower limbs, and riding a stationary bike. All of the activities were mutually reinforcing, with repeated gentle challenges to the end ranges of movement. An outline of the exercise program is shown in the Appendix Figure. The physical therapist increased the number of strengthening exercise bouts and the stationary bike riding time on the basis of patient tolerance. The current literature provides efficient methods to produce the desired effects of increasing strength, flexibility, and range of motion (32-35). At each session, the physical therapist examined the patient for adverse signs and symptoms, such as increased pain, joint effusion, and increased skin temperature over knee joints. These signs and symptoms of osteoarthritis had to be stable or decreasing before manual therapy or exercise was progressed. Patients exercised in a painless or minimally painful manner. If any post-treatment or exercise soreness lasted more than a few hours, the regimen was decreased accordingly for that patient. The placebo group received treatment by the physical therapist that consisted of subtherapeutic ultrasound for 10 minutes at an intensity of 0.1 W/cm2 and 10% pulsed mode (lowest setting and greatest cycle interruption) to the area of knee symptoms. The placebo group received the same subjective and hands-on objective reevaluation before and after each session as the treatment group. The amount of time directly spent with the treating therapist was approximately 30 minutes for both groups. The treatment group required an additional 30 to 45 minutes to perform their exercises in the clinic. Both groups were treated twice weekly for 4 weeks, for a total of eight clinic treatments. Patients in the treatment group also performed the same exercises at home, except for the closed-chain strengthening exercises, on the days on which they were not treated in the physical therapy clinic. They also walked at home each day at a comfortable pace and distance. The treating physical therapist instructed each patient in the performance of the exercises and provided a detailed handout containing instructions and photographs of the exercises. Each patient maintained a home exercise program

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.

Reliability of the Modified Ashworth Scale in the assessment of plantarflexor muscle spasticity in patients with traumatic brain injury

Although the Modified Ashworth Scale (MAS) is commonly used to assess the severity of muscle spasticity for ankle plantarflexors, its reliability has only been established for elbow muscles. Interrater reliability, intrarater reliability and temporal (between-days) reliability were examined in this study. Also, interrater reliability for use of the scale with plantarflexors was compared with reported results from the measurement of elbow flexors. Thirty adult volunteers with traumatic brain injuries participated. There were 20 men and 10 women; the mean age was 28.3 years (SD = 10.8). Two physical therapists used the MAS to score the subjects independently. Measurements were repeated to yield multiple scores for intrarater reliability assessment. Twenty-one of the subjects returned individually on separate days to be measured again, so that temporal reliability could be assessed. Spearmans correlation coefficients were 0.73 for interrater reliability 0.74 and 0.55 for intrarater reliability, and 0.82 for temporal reliability. Overall, reliability of the MAS for assessing plantarflexor spasticity in patients with traumatic brain injury was found to be minimally adequate to support its continued use. However, interrater reliability was less than that which has been reported for elbow flexors, and intrarater reliability findings were mixed.

A rehabilitative ultrasound imaging investigation of lateral abdominal muscle thickness in healthy aging adults.

Purpose: Rehabilitative ultrasound imaging (RUSI) is used to evaluate lateral abdominal muscle size and function during the abdominal drawing‐in maneuver (ADIM), an exercise used to improve lumbar spine stability. Little is known about the size and performance of these muscles in healthy aging adults. The purpose of this study was to investigate, using RUSI, the size and symmetry of the lateral abdominal muscles bilaterally at rest and during the ADIM in healthy older adults and the reliability of these measurements. Methods: Three ultrasound images of the right and left lateral abdominal muscles were taken at rest and during the ADIM in 12 healthy older adults. Thickness of the transversus abdominis muscles (TrA), internal oblique (IO), and external oblique (EO) were measured for all images. Intraclass correlation coefficients were computed using model 3, form 1 (ICC3,1). Two ratios of the abdominal muscles were calculated in the relaxed and contracted states. Paired t‐tests were used to compare relaxed muscle thickness to contracted muscle thickness for all 3 muscles for each side. To test further for interactions of side and contractile state, 2 × 2 repeated measures ANOVAs were performed. Side‐to‐side differences in absolute and relative thickness were assessed with paired t‐tests for the TrA and IO muscles. Absolute and relative side‐to‐side muscle symmetry indices were computed for each muscle at rest. Results: There was a signi⊠cant difference in muscle thickness between the contracted and relaxed states for both the TrA and IO. There was no signi⊠cant difference between left/right muscle thickness for the TrA or IO at rest or during the ADIM. The TrA nearly doubled in size while thickness of the IO + EO stayed relatively constant during the ADIM. Reliability for absolute muscle thickness was generally excellent: ICCs3,1 ranged from 0.95 to 1.00 for intra‐image reliability; 0.77 to 0.97 for inter‐image reliability. Conclusions: These ⊠ndings support symmetrical and preferential activation of the TrA during the ADIM in healthy older adults. Continued research on the use of RUSI as a tool for both assessment and intervention in older adults is needed.

Correlation of quantitative measures with the modified Ashworth scale in the assessment of plantar flexor spasticity in patients with traumatic brain injury

This study of plantar flexor spasticity describes relationships among a traditional qualitative spasticity scale, three potential quantitative spasticity measures and a measure of voluntary ankle muscle function. Thirty-four volunteer adult patients with traumatic brain injuries participated. There were 28 males and 6 females; the mean age was 30.3 years. A battery of five randomly sequenced tests was performed for each subject on one ankle. Tests were: modified Ashworth scale (MAS) scoring; H-reflex testing with and without Achilles tendon vibration; H-reflex testing with and without dorsiflexor contraction; reflex threshold angle and timed toe tapping (TTT). Twenty-six subjects returned to have the second ankle tested, resulting in 60 ankles for the analyses. Spearmans coefficients for correlation of quantitative spasticity measures with MAS scores ranged from 0.39 to 0.49 with associated probabilities ≤ 0.002. Pearson coefficients for correlation of quantitative spasticity measures with TTT scores were lower but also significant (P ≤ 0.07). Multiple correlation for the set of quantitative measures yieldedR = 0.614 (P < 0.001) with MAS scores andR = 0.365 (P = 0.045) with TTT scores. These findings reveal statistically significant relationships of low to moderate strength among potential quantitative spasticity measures, a traditional qualitative spasticity scale and a simple measure of voluntary ankle muscle function. Understanding these relationships is an essential part of the ongoing search for quantitative spasticity measures.

A Primer on Selected Aspects of Evidence-Based Practice Relating to Questions of Treatment, Part 2: Interpreting Results, Application to Clinical Practice, and Self-Evaluation

The process of evidence-based practice (EBP) guides clinicians in the integration of individual clinical expertise, patient values and expectations, and the best available evidence. Becoming proficient with this process takes time and consistent practice, but should ultimately lead to improved patient outcomes. The EBP process entails 5 steps: (1) formulating an appropriate question, (2) performing an efficient literature search, (3) critically appraising the best available evidence, (4) applying the best evidence to clinical practice, and (5) assessing outcomes of care. This second commentary in a 2-part series will review principles relating to steps 3 through 5 of this 5-step model. The purpose of this commentary is to provide a perspective to assist clinicians in interpreting results, applying the evidence to patient care, and evaluating proficiency with EBP skills in studies of interventions for orthopaedic and sports physical therapy.

Derivation of a Preliminary Clinical Prediction Rule for Identifying a Subgroup of Patients With Low Back Pain Likely to Benefit From Pilates-Based Exercise

STUDY DESIGN Prospective cohort study. OBJECTIVE To derive a preliminary clinical prediction rule for identifying a subgroup of patients with low back pain (LBP) likely to benefit from Pilates-based exercise. BACKGROUND Pilates-based exercise has been shown to be effective for patients with LBP. However, no previous work has characterized patient attributes for those most likely to have a successful outcome from treatment. METHODS Ninety-six individuals with nonspecific LBP participated in the study. Treatment response was categorized based on changes in the Oswestry Disability Questionnaire scores after 8 weeks. An improvement of 50% or greater was categorized as achieving a successful outcome. Thirty-seven variables measured at baseline were analyzed with univariate and multivariate methods to derive a clinical prediction rule for successful outcome with Pilates exercise. Accuracy statistics, receiver-operator curves, and regression analyses were used to determine the association between standardized examination variables and treatment response status. RESULTS Ninety-five of 96 participants completed the study, with 51 (53.7%) achieving a successful outcome. A preliminary clinical prediction rule with 5 variables was identified: total trunk flexion range of motion of 70° or less, duration of current symptoms of 6 months or less, no leg symptoms in the last week, body mass index of 25 kg/m2 or greater, and left or right hip average rotation range of motion of 25° or greater. If 3 or more of the 5 attributes were present (positive likelihood ratio, 10.64), the probability of experiencing a successful outcome increased from 54% to 93%. CONCLUSION These data provide preliminary evidence to suggest that the response to Pilates-based exercise in patients with LBP can be predicted from variables collected from the clinical examination. If subsequently validated in a randomized clinical trial, this prediction rule may be useful to improve clinical decision making in determining which patients are most likely to benefit from Pilates-based exercise.

A Primer on Selected Aspects of Evidence-Based Practice Relating to Questions of Treatment, Part 1: Asking Questions, Finding Evidence, and Determining Validity

The process of evidence-based practice (EBP) guides clinicians in the integration of individual clinical expertise, patient values and expectations, and the best available evidence. Becoming proficient with this process takes time and consistent practice, but should ultimately lead to improved patient outcomes. The EBP process entails 5 steps: (1) formulating an appropriate question, (2) performing an efficient literature search, (3) critically appraising the best available evidence, (4) applying the best evidence to clinical practice, and (5) assessing outcomes of care. This first commentary in a 2-part series will review principles relating to steps 1, 2, and 3 of this 5-step model. The purpose of this commentary is to provide a perspective to assist clinicians in formulating foreground questions, searching for the best available evidence, and determining validity of results in studies of interventions for orthopaedic and sports physical therapy.

Joint mobilization forces and therapist reliability in subjects with knee osteoarthritis

Abstract Objectives: This study determined biomechanical force parameters and reliability among clinicians performing knee joint mobilizations. Methods: Sixteen subjects with knee osteoarthritis and six therapists participated in the study. Forces were recorded using a capacitive-based pressure mat for three techniques at two grades of mobilization, each with two trials of 15 seconds. Dosage (force–time integral), amplitude, and frequency were also calculated. Analysis of variance was used to analyze grade differences, intraclass correlation coefficients determined reliability, and correlations assessed force associations with subject and rater variables. Results: Grade IV mobilizations produced higher mean forces (P<0·001) and higher dosage (P<0·001), while grade III produced higher maximum forces (P = 0·001). Grade III forces (Newtons) by technique (mean, maximum) were: extension 48, 81; flexion 41, 68; and medial glide 21, 34. Grade IV forces (Newtons) by technique (mean, maximum) were: extension 58, 78; flexion 44, 60; and medial glide 22, 30. Frequency (Hertz) ranged between 0·9–1·1 (grade III) and 1·4–1·6 (grade IV). Intra-clinician reliability was excellent (>0·90). Inter-clinician reliability was moderate for force and dosage, and poor for amplitude and frequency. Discussion: Force measurements were consistent with previously reported ranges and clinical constructs. Grade III and grade IV mobilizations can be distinguished from each other with differences for force and frequency being small, and dosage and amplitude being large. Intra-clinician reliability was excellent for all biomechanical parameters and inter-clinician reliability for dosage, the main variable of clinical interest, was moderate. This study quantified the applied forces among multiple clinicians, which may help determine optimal dosage and standardize care.