Biomedical subjects

Julie M Fritz

Publications and source records attributed to Julie M Fritz.

At least 19 recordsLinked to original sources

PubMed2006

Development of a clinical prediction rule for guiding treatment of a subgroup of patients with neck pain: use of thoracic spine manipulation, exercise, and patient education.

BACKGROUND AND PURPOSE: To date, no studies have investigated the predictive validity of variables from the initial examination to identify patients with neck pain who are likely to benefit from thoracic spine thrust manipulation. The purpose of this study was to develop a clinical prediction rule (CPR) to identify patients with neck pain who are likely to experience early success from thoracic spine thrust manipulation. SUBJECTS: This was a prospective, cohort study of patients with mechanical neck pain who were referred for physical therapy. METHODS: Subjects underwent a standardized examination and then a series of thoracic spine thrust manipulation techniques. They were classified as having experienced a successful outcome at the second and third sessions based on their perceived recovery. Potential predictor variables were entered into a stepwise logistic regression model to determine the most accurate set of variables for prediction of treatment success. RESULTS: Data for 78 subjects were included in the data analysis, of which 42 had a successful outcome. A CPR with 6 variables was identified. If 3 of the 6 variables (positive likelihood ratio=5.5) were present, the chance of experiencing a successful outcome improved from 54% to 86%. DISCUSSION AND CONCLUSION: The CPR provides the ability to a priori identify patients with neck pain who are likely to experience early success with thoracic spine thrust manipulation. However, future studies are necessary to validate the rule.

Adult↗

PubMed2006

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.

Aged↗

PubMed2006

A perspective for considering the risks and benefits of spinal manipulation in patients with low back pain.

The purpose of this study was to determine if patients who do not receive manipulation for their low back pain (LBP) are at an increased risk for worsening disability compared to patients receiving an exercise intervention without manipulation. One hundred and thirty-one consecutive patients with LBP were randomly assigned to receive manipulation and an exercise intervention (n = 70) or an exercise intervention without manipulation (n = 61). Patients were classified as to whether they had experienced a worsening in disability upon follow-up. Relative risk and number needed to treat (NNT) statistics and associated 95% confidence intervals (CI) were calculated. Patients who completed the exercise intervention without manipulation were eight (95% CI: 1.1, 63.5) times more likely to experience a worsening in disability than patients who received manipulation. The NNT with manipulation to prevent one additional patient from experiencing a worsening in disability was 9.9 (95% CI: 4.9, 65.3) and 4 weeks with manipulation was 11.6 (95% CI: 5.2, 219.2). The results of this study offer an additional perspective for considering the risks and benefits of spinal manipulation and help to inform the integration of current evidence for spinal manipulation into healthcare policy.

Adult↗

PubMed2006

Lumbar segmental mobility disorders: comparison of two methods of defining abnormal displacement kinematics in a cohort of patients with non-specific mechanical low back pain.

BACKGROUND: Lumbar segmental rigidity (LSR) and lumbar segmental instability (LSI) are believed to be associated with low back pain (LBP), and identification of these disorders is believed to be useful for directing intervention choices. Previous studies have focussed on lumbar segmental rotation and translation, but have used widely varying methodologies. Cut-off points for the diagnosis of LSR & LSI are largely arbitrary. Prevalence of these lumbar segmental mobility disorders (LSMDs) in a non-surgical, primary care LBP population has not been established. METHODS: A cohort of 138 consecutive patients with recurrent or chronic low back pain (RCLBP) were recruited in this prospective, pragmatic, multi-centre study. Consenting patients completed pain and disability rating instruments, and were referred for flexion-extension radiographs. Sagittal angular rotation and sagittal translation of each lumbar spinal motion segment was measured from the radiographs, and compared to a reference range derived from a study of 30 asymptomatic volunteers. In order to define reference intervals for normal motion, and define LSR and LSI, we approached the kinematic data using two different models. The first model used a conventional Gaussian definition, with motion beyond two standard deviations (2sd) from the reference mean at each segment considered diagnostic of rotational LSMD and translational LSMD. The second model used a novel normalised within-subjects approach, based on mean normalised contribution-to-total-lumbar-motion. An LSMD was then defined as present in any segment that contributed motion beyond 2sd from the reference mean contribution-to-normalised-total-lumbar-motion. We described reference intervals for normal segmental mobility, prevalence of LSMDs under each model, and the association of LSMDs with pain and disability. RESULTS: With the exception of the conventional Gaussian definition of rotational LSI, LSMDs were found in statistically significant prevalences in patients with RCLBP. Prevalences at both the segmental and patient level were generally higher using the normalised within-subjects model (2.8 to 16.8% of segments; 23.3 to 35.5% of individuals) compared to the conventional Gaussian model (0 to 15.8%; 4.7 to 19.6%). LSMDs are associated with presence of LBP, however LSMDs do not appear to be strongly associated with higher levels of pain or disability compared to other forms of non-specific LBP. CONCLUSION: LSMDs are a valid means of defining sub-groups within non-specific LBP, in a conservative care population of patients with RCLBP. Prevalence was higher using the normalised within-subjects contribution-to-total-lumbar-motion approach.

Adult↗

PubMed2006

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.

Acute Disease↗

PubMed2006

The reliability and construct validity of the Neck Disability Index and patient specific functional scale in patients with cervical radiculopathy.

STUDY DESIGN: Cohort study of patients with cervical radiculopathy undergoing physical therapy. OBJECTIVES: Examine the test-retest reliability, construct validity, and minimum levels of detectable and clinically important change for the Neck Disability Index (NDI) and Patient Specific Functional Scale (PSFS) in cohort of patients with cervical radiculopathy. SUMMARY OF BACKGROUND DATA: To date, no studies have investigated the psychometric properties of the NDI or PSFS in a cohort of patients with cervical radiculopathy. METHODS: Thirty-eight patients with cervical radiculopathy undergoing physical therapy completed the NDI and PSFS, and Numerical Pain Rating Scale (NPRS) at the baseline examination and at a follow-up. In addition, at follow-up, patients completed a 15-point global rating of change (GROC), which was used to dichotomize patients as improved or stable. Changes in the NDI and PSFS were then used to assess test-retest reliability, construct validity, and minimal levels of detectable and clinically important change. RESULTS: Test-retest reliability was moderate for the NDI (intraclass correlation coefficient [ICC] = 0.68; 95% confidence interval [CI], 0.30-0.90) and high for the PSFS (ICC = 0.82; 95% CI, 0.54-0.93). The PSFS was more responsive to change than the NDI. The minimal detectable change for the NDI was 10.2 and for the PSFS 2.1. The minimally clinically important change for the NDI was 7.0 and PSFS 2.0. CONCLUSIONS: Our results suggest that the PSFS exhibits superior reliability, construct validity, and responsiveness in this cohort of patients with cervical radiculopathy compared with the NDI. Further research is needed to examine the ability of these measures to accurately reflect changes in individuals, as well as large samples of patients.

Cohort Studies↗

PubMed2006

Comparison of the effectiveness of three manual physical therapy techniques in a subgroup of patients with low back pain who satisfy a clinical prediction rule: study protocol of a randomized clinical trial [NCT00257998].

BACKGROUND: Recently a clinical prediction rule (CPR) has been developed and validated that accurately identifies patients with low back pain (LBP) that are likely to benefit from a lumbo-pelvic thrust manipulation. The studies that developed and validated the rule used the identical manipulation procedure. However, recent evidence suggests that different manual therapy techniques may result similar outcomes. The purpose of this study is to investigate the effectiveness of three different manual therapy techniques in a subgroup of patient with low back pain that satisfy the CPR. METHODS/DESIGN: Consecutive patients with LBP referred to physical therapy clinics in one of four geographical locations who satisfy the CPR will be invited to participate in this randomized clinical trial. Subjects who agree to participate will undergo a standard evaluation and complete a number of patient self-report questionnaires including the Oswestry Disability Index (OSW), which will serve as the primary outcome measure. Following the baseline examination patients will be randomly assigned to receive the lumbopelvic manipulation used in the development of the CPR, an alternative lumbar manipulation technique, or non-thrust lumbar mobilization technique for the first 2 visits. Beginning on visit 3, all 3 groups will receive an identical standard exercise program for 3 visits (visits 3,4,5). Outcomes of interest will be captured by a therapist blind to group assignment at 1 week (3rd visit), 4 weeks (6th visit) and at a 6-month follow-up. The primary aim of the study will be tested with analysis of variance (ANOVA) using the change in OSW score from baseline to 4-weeks (OSWBaseline - OSW4-weeks) as the dependent variable. The independent variable will be treatment with three levels (lumbo-pelvic manipulation, alternative lumbar manipulation, lumbar mobilization). DISCUSSION: This trial will be the first to investigate the effectiveness of various manual therapy techniques for patients with LBP who satisfy a CPR.

Adolescent↗

PubMed2006

An examination of the reliability of a classification algorithm for subgrouping patients with low back pain.

STUDY DESIGN: Test-retest design to examine interrater reliability. OBJECTIVE: Examine the interrater reliability of individual examination items and a classification decision-making algorithm using physical therapists with varying levels of experience. SUMMARY OF BACKGROUND DATA: Classifying patients based on clusters of examination findings has shown promise for improving outcomes. Examining the reliability of examination items and the classification decision-making algorithm may improve the reproducibility of classification methods. METHODS: Patients with low back pain less than 90 days in duration participating in a randomized trial were examined on separate days by different examiners. Interrater reliability of individual examination items important for classification was examined in clinically stable patients using kappa coefficients and intraclass correlation coefficients. The findings from the first examination were used to classify each patient using the decision-making algorithm by clinicians with varying amounts of experience. The reliability of the classification algorithm was examined with kappa coefficients. RESULTS: A total of 123 patients participated (mean age 37.7 [+/-10.7] years, 44% female), 60 (49%) remained stable between examinations. Reliability of range of motion, centralization/peripheralization judgments with flexion and extension, and the instability test were moderate to excellent. Reliability of centralization/peripheralization judgments with repeated or sustained extension or aberrant movement judgments were fair to poor. Overall agreement on classification decisions was 76% (kappa = 0.60, 95% confidence interval 0.56, 0.64), with no significant differences based on level of experience. CONCLUSION: Reliability of the classification algorithm was good. Further research is needed to identify sources of disagreements and improve reproducibility.

Adolescent↗

PubMed2006

Interrater reliability of the history and physical examination in patients with mechanical neck pain.

OBJECTIVE: To examine the interrater reliability of the history and physical examination in patients with mechanical neck pain. DESIGN: Single-group repeated measures for interrater reliability. SETTING: Outpatient physical therapy clinic. PARTICIPANTS: Twenty-two patients with mechanical neck pain underwent a standardized history and physical examination by a physical therapist. INTERVENTION: Following a 5-minute break, a second therapist who was blind to the findings of examiner 1 performed the second standardized history and physical examination. MAIN OUTCOME MEASURES: The Cohen kappa and weighted kappa were used to calculate the interrater reliability of ordinal level data from the history and physical examination. Intraclass correlation coefficients model 2,1 (ICC(2,1)) and the 95% confidence intervals were calculated to determine the interrater reliability for continuous variables. RESULTS: The kappa coefficients ranged from -.06 to .90 for the variables obtained from the history. Reliability values for categorical data collected during the physical examination ranged from no to substantial agreement depending on the particular test and measure. ICC(2,1) for cervical range of motion (ROM) measurements ranged between .66 and .78. CONCLUSIONS: We have reported the interrater reliability of the history and physical examination in a group of patients with a primary report of neck pain. The reliability variables varied considerably for manual assessment techniques and were significantly higher for the examination of muscle length and cervical ROM. Ultimately, it will be up to each clinician to determine if a particular test or measure poses adequate reliability to assist in the clinical decision making process.

Adult↗

PubMed2006

The audible pop from high-velocity thrust manipulation and outcome in individuals with low back pain.

OBJECTIVE: To determine the relationship between an audible pop with spinal manipulation and improvement in pain and function in patients with low back pain. METHODS: In this pragmatic study, 70 patients from a multicenter clinical trial were randomly assigned to receive high-velocity thrust manipulation and included in this secondary analysis. Patients were managed in physical therapy twice the first week, then once a week for the next 3 weeks, for a total of 5 sessions. A single high-velocity thrust manipulative intervention purported to affect the lumbopelvic region was used during the first two sessions. Therapists recorded whether an audible pop was heard by the patient or therapist. Outcome was assessed with an 11-point pain rating scale, the Oswestry Disability Questionnaire, and measurement of lumbopelvic flexion range of motion. Repeated measures analyses of variance were used to examine whether achievement of a pop resulted in improved outcome. RESULTS: An audible pop was perceived in 59 (84%) of the patients. No differences were detected at baseline or at any follow-up period in the level of pain, the Oswestry score, or lumbopelvic range of motion based on whether a pop was achieved (P > .05). The odds ratios and 95% confidence intervals for achieving a successful outcome at each of the follow-up periods all approximated a value of 1, suggesting no improvement in the odds of successful outcome among patients in which an audible pop occurred. CONCLUSIONS: The results of this pragmatic study suggest that a perceived audible pop may not relate to improved outcomes from high-velocity thrust manipulation for patients with nonradicular low back pain at either an immediate or longer-term follow-up.

Adult↗

PubMed2006

Fear-avoidance beliefs as measured by the fear-avoidance beliefs questionnaire: change in fear-avoidance beliefs questionnaire is predictive of change in self-report of disability and pain intensity for patients with acute low back pain.

OBJECTIVES: The purposes of this study were to investigate the association among measures of fear-avoidance beliefs, pain intensity, and lumbar flexion and to determine if changes in these measures were predictive of treatment outcome following physical therapy for acute low back pain. It was hypothesized that items of the Fear-Avoidance Beliefs Questionnaire would be correlated with concurrent measures of pain intensity and lumbar flexion. In addition, it was hypothesized that changes in fear-avoidance beliefs would be predictive of changes in self-report of pain intensity and disability. STUDY DESIGN: Patients underwent a standard examination that included measures of fear-avoidance beliefs, pain intensity, lumbar flexion, and disability from low back pain. Patients were then re-examined after 4 weeks of physical therapy treatment. PATIENTS: Sixty-three patients with acute low back pain enrolled in a clinical trial of physical therapy treatment. RESULTS: Fear-Avoidance Beliefs Questionnaire items were consistently correlated with lumbar flexion, but not with measures of pain intensity. Pearson correlations indicated that changes in disability were significantly associated with changes in fear-avoidance beliefs and pain intensity, but not changes in lumbar flexion. Changes in fear-avoidance beliefs explained significant amounts of variance in changes in average pain intensity while controlling for changes in lumbar flexion. Changes in fear-avoidance beliefs explained significant amounts of variance in changes in disability while controlling for changes in average pain intensity. CONCLUSIONS: These results suggest that fear-avoidance beliefs have a similar association with pain intensity, physical impairment, and disability for patients with acute and chronic low back pain. This study provides preliminary support for the use of the Fear-Avoidance Beliefs Questionnaire as an outcome measure for patients with acute low back pain.

Acute Disease↗

PubMed2006

Spinal manipulation in physical therapist professional degree education: A model for teaching and integration into clinical practice.

Spinal manipulation for low back complaints is an intervention supported by randomized clinical trials and its use recommended by clinical practice guidelines. Physical therapists in this country and internationally have used thrust spinal manipulation at much lower-than-expected rates, despite evidence supporting its efficacy for the treatment of acute low back pain (LBP). The purpose of this clinical commentary is to describe a physical therapist professional degree curriculum in thrust spinal manipulation and outline a method of monitoring ongoing student performance during the clinical education experience. Increased emphasis on evidence-based decision making and on the psychomotor skills of thrust spinal manipulation was introduced into a physical therapist professional degree curriculum. As part of ongoing student performance monitoring, physical therapy students on their first full-time (8-week) clinical education experience, collected practice pattern and outcome data on individuals with low back complaints. Eight of 18 first-year students were in outpatient musculoskeletal clinical settings and managed 61 individuals with low back complaints. Patients were seen for an average (+/-SD) of 6.2 +/- 4.0 visits. Upon initial visit the student therapists employed spinal manipulation at a rate of 36.2% and spinal mobilization at 58.6%. At the final visit, utilization of manipulation and mobilization decreased (13% and 37.8%, respectively), while the utilization of exercise interventions increased, with 75% of patients receiving some form of lumbar stabilization training. Physical therapist students used thrust spinal manipulation at rates that are more consistent with clinical practice guidelines and substantially higher then previously reported by practicing physical therapists. Education within an evidence-based framework is thought to contribute to practice behaviors and outcomes that are more consistent with best practice guidelines.

Clinical Competence↗

PubMed2006

Sex differences in predictors of outcome in selected physical therapy interventions for acute low back pain.

STUDY DESIGN: Secondary analysis of pooled data from 3 randomized trials. OBJECTIVE: This study investigated sex differences in response to physical therapy intervention for acute low back pain. BACKGROUND: Sex differences in experimental pain sensitivity have been consistently described in the literature. However, clinical consequences of these sex differences have not been widely reported. METHODS AND MEASURES: Subjects (n=165) were participants in 3 randomized trials of physical therapy interventions from outpatient physical therapy clinics in the general and military communities. Subjects were randomly assigned spinal manipulation with range-of-motion exercise, lumbar stabilization exercise, or directional-preference exercise. Outcomes were measured at 4 weeks through self-report of pain intensity and pain-related disability. Sex differences were investigated with independent t tests (baseline data), 2 x 3 analysis of variance (4-week reductions in pain and pain-related disability), and regression models (predictors of outcome). RESULTS: Men and women had similar reductions of pain intensity (raw mean difference, 0.5; 95% Cl, -1.4 to 0.4) and pain-related disability (raw mean difference, 5.3; 95% CI, -0.1 to 10.7) over 4 weeks. Baseline pain intensity, duration of symptoms, and baseline pain-related disability significantly predicted change in pain intensity for women (r2 = 26%, P < .01). Baseline pain intensity and stabilization exercise predicted change in pain intensity for men (r2 = 33%, P<.01). Baseline pain-related disability, duration of pain, and pain intensity predicted change in disability for women (r2 = 24%, P < .01). Baseline pain-related disability, fear-avoidance beliefs, stabilization exercise, and leg pain predicted change in disability for men (r2 = 32%, P < .01). CONCLUSION: For patients with acute low back pain, men and women had similar physical therapy outcomes for reductions in pain intensity and pain-related disability. However, men and women had different factors that predicted treatment outcome.

Acute Disease↗

PubMed2006

The use of a lumbar spine manipulation technique by physical therapists in patients who satisfy a clinical prediction rule: a case series.

STUDY DESIGN: A case series of patients with low back pain (LBP) who satisfy a clinical prediction rule (CPR). BACKGROUND: A CPR that identifies patients with LBP who are likely to respond with rapid and prolonged reductions in pain and disability following spinal manipulation was developed and recently validated. The CPR developed to predict favorable response to manipulation investigated the effects of only 1 manipulation technique. The accuracy of the CPR for predicting outcomes using other manipulation techniques is not known. The purpose of the case series was to describe the outcomes of patients presenting to physical therapy with LBP who met the CPR and were treated with an alternative lumbar manipulation technique. CASE DESCRIPTION: Consecutive patients referred to physical therapy who satisfied the eligibility criteria, including the presence of at least 4 of the 5 criteria on the CPR, were invited to participate in the case series. Patients were treated for 2 visits with a side-lying lumbar manipulation technique, followed by a basic range of motion exercise. Patients who exhibited a 50% reduction or greater in disability, as measured by the Oswestry Disability Index (ODI), were considered to have experienced a successful outcome. OUTCOMES: A total of 12 patients participated in the case series. The mean age of the group was 39 years (SD, 8.9 years) and the median duration of symptoms was 19 days (range, 8-148 days). Of the 12 patients who participated in this case series, the mean reduction in disability as measured with the ODI was 57% (SD, 9%). Only 1 patient did not surpass the 50% reduction in ODI scores. DISCUSSION: Eleven of the 12 patients (92%) in this case series who satisfied the CPR and were treated with an alternative lumbar manipulation technique demonstrated a successful outcome in 2 visits. It is plausible that patients with LBP who satisfy the CPR may obtain a successful outcome with either manipulation technique directed at the lumbopelvic region.

Adult↗

PubMed2006

Impact of continuing education interventions on clinical outcomes of patients with neck pain who received physical therapy.

BACKGROUND AND PURPOSE: Physical therapists frequently attend continuing education courses with the goal of providing better care, yet the effectiveness of continuing education for improving outcomes has not been examined. SUBJECTS: Data were obtained for all eligible patients (n=1,365; mean age=42.1 years, SD=14.0 years; 69.9% female) with a chief complaint of neck pain who were treated in 13 physical therapy clinics over a 24-month period. Disability data (Neck Disability Index scores) from the initial and final therapy sessions were recorded from clinical databases. METHODS: Thirty-four of 57 physical therapists employed within the 13 clinics attended a 2-day continuing education course. Eleven of the 34 attendees also participated in an ongoing clinical improvement project for patients with neck pain. Clinical outcomes were compared in the pre- and post-course periods for therapists attending or not attending the course, and for therapists participating or not participating in the ongoing project. RESULTS: There were no differences in clinical outcomes based on attendance at the continuing education course. There was an interaction between time and participation in the ongoing project, such that participants achieved greater change in disability after the course. The percentage of patients achieving at least the minimum detectable amount of change in disability with treatment increased significantly for participants after the course. DISCUSSION AND CONCLUSION: Attendance at a 2-day continuing education course was not associated with improvement in clinical outcomes, but participation in an ongoing improvement project did result in greater clinical improvement for patients with neck pain. Further investigation of educational methods to improve clinical outcomes is needed. These results suggest that traditional continuing education formats may not be effective for improving patient care.

Adult↗

PubMed2005

Accuracy of the clinical examination to predict radiographic instability of the lumbar spine.

Forty-nine patients with low-back pain referred for flexion-extension radiographs due to suspicion of lumbar instability were studied to examine the relationship between the clinical presentation and the presence of radiographic instability of the lumbar spine. Patients had a mean age of 39.2 (+/-11.3) years, with a mean Oswestry score of 20.4% (+/-13.3). The median duration of symptoms was 78 days. All patients underwent both a radiographic and clinical examination. The reliability of the radiographic variables was high, while the reliability of clinical variables ranged from moderate to good. Twenty-eight patients (57%) had radiographic instability based on published norms. Clinical variables related to the presence of radiographic instability were age, lumbar flexion range of motion, total extension range of motion, the Beighton scale for general ligamentous laxity, and segmental intervertebral motion testing. The presence of at least 53 degrees of lumbar flexion or a lack of hypomobility with intervertebral motion testing resulted in a positive likelihood ratio of 4.3 (95% CI: 1.8, 10.6), for predicting radiographic instability. The results of this study indicate that various factors from the clinical examination are useful for predicting radiographic instability. If the findings of this study can be replicated, these clinical factors could be used to inform treatment decision-making without a sole reliance on radiographic assessment.

Adult↗

PubMed2005

Pragmatic application of a clinical prediction rule in primary care to identify patients with low back pain with a good prognosis following a brief spinal manipulation intervention.

BACKGROUND: Patients with low back pain are frequently encountered in primary care. Although a specific diagnosis cannot be made for most patients, it is likely that sub-groups exist within the larger entity of nonspecific low back pain. One sub-group that has been identified is patients who respond rapidly to spinal manipulation. The purpose of this study was to examine the association between two factors (duration and distribution of symptoms) and prognosis following a spinal manipulation intervention. METHODS: Data were taken from two previously published studies. Patients with low back pain underwent a standardized examination, including assessment of duration of the current symptoms in days, and the distal-most distribution of symptoms. Based on prior research, patients with symptoms of <16 days duration and no symptoms distal to the knee were considered to have a good prognosis following manipulation. All patients underwent up to two sessions of spinal manipulation treatment and a range of motion exercise. Oswestry disability scores were recorded before and after treatment. If >or= 50% improvement on the Oswestry was achieved, the intervention was considered a success. Sensitivity, specificity, and positive likelihood ratio were calculated for the association of the two criteria with the outcome of the treatment. RESULTS: 141 patients (49% female, mean age = 35.5 (+/- 11.1) years) participated. Mean pre- and post-treatment Oswestry scores were 41.9 (+/- 10.9) and 24.1 (+/- 14.2) respectively. Sixty-three subjects (45%) had successful treatment outcomes. The sensitivity of the two criteria was 0.56 (95% CI: 0.43, 0.67), specificity was 0.92 (95% CI: 0.84, 0.96), and the positive likelihood ratio was 7.2 (95% CI: 3.2, 16.1). CONCLUSION: The results of this study demonstrate that two factors; symptom duration of less than 16 days, and no symptoms extending distal to the knee, were associated with a good outcome with spinal manipulation.

Adult↗

PubMed2005

Responsiveness of the numeric pain rating scale in patients with low back pain.

STUDY DESIGN: Cohort study of patients with low back pain (LBP) receiving physical therapy. OBJECTIVE: To examine the responsiveness characteristics of the numerical pain rating scale (NPRS) in patients with LBP using a variety of methods. SUMMARY OF BACKGROUND DATA: Although several studies have assessed the reliability and validity of the NPRS, few studies have characterized its responsiveness in patients with LBP. METHODS: Determination of change on the NPRS during 1 and 4 weeks was examined by calculating mean change, standardized effect size, Guyatt Responsiveness Index, area under a receiver operating characteristic curve, minimum clinically important difference, and minimum detectable change. Change in the NPRS from baseline to the 1 and 4-week follow-up was compared to the average of the patient and therapist's perceived improvement using the 15-point Global Rating of Change scale. RESULTS: The majority of patients had clinically meaningful improvement after both 1 and 4 weeks of rehabilitation. The standard error of measure was equal to 1.02, corresponding to a minimum detectable change of 2 points. The area under the curve at the 1 and 4-week follow-up was 0.72 (0.62, 0.81) and 0.92 (0.86, 0.97), respectively. The minimum clinically important difference at the 1 and 4-week follow-up corresponded to a change of 2.2 and 1.5 points, respectively. CONCLUSIONS: Clinicians can be confident that a 2-point change on the NPRS represents clinically meaningful change that exceeds the bounds of measurement error.

Adult↗