Biomedical subjects
Julie M Fritz
Publications and source records attributed to Julie M Fritz.
Development of a clinical prediction rule for the diagnosis of carpal tunnel syndrome.
OBJECTIVES: To develop a clinical prediction rule (CPR) and to assess the reliability and diagnostic accuracy of individual clinical examination items for the diagnosis of carpal tunnel syndrome (CTS). DESIGN: Prospective diagnostic test study with blind comparison to a reference criterion of a compatible clinical presentation and abnormal electrophysiologic findings. SETTING: Multicenter medical center and community hospital with patient referrals from ambulatory primary care and specialty practice settings. PARTICIPANTS: Eight-two consecutively referred patients (50% men; mean age, 45+/-12 y) with suspected cervical radiculopathy or CTS referred for electrophysiologic examination. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Sensitivity, specificity, and likelihood ratios. RESULTS: The CPR identified in this study consisted of 1 question (shaking hands for symptom relief), wrist-ratio index greater than .67, Symptom Severity Scale score greater than 1.9, reduced median sensory field of digit 1, and age greater than 45 years. The likelihood ratio for the CPR was 18.3 when all 5 tests were positive. Interrater reliability was acceptable for all but 2 clinical examination items. CONCLUSIONS: The CPR identified was more useful for the diagnosis of CTS than any single test item and resulted in posttest probability changes of up to 56%. Further investigation is required both to validate the test-item cluster and to improve point-estimate precision.
Lumbar spine segmental mobility assessment: an examination of validity for determining intervention strategies in patients with low back pain.
OBJECTIVE: To examine the predictive validity of posterior-anterior (PA) mobility testing in a group of patients with low back pain (LBP). DESIGN: Randomized controlled trial. SETTING: Outpatient physical therapy clinics. PARTICIPANTS: Patients with LBP (N=131; mean age +/- standard deviation, 33.9+/-10.9 y; range, 19-59 y), and a median symptom duration of 27 days (range, 1-5941 d). Patients completed a baseline examination, including PA mobility testing, and were categorized with respect to both hypomobility and hypermobility (present or absent), and treated for 4 weeks. INTERVENTION: Seventy patients were randomized to an intervention involving manipulation and 61 to a stabilization exercise intervention. MAIN OUTCOME MEASURES: Oswestry Disability Questionnaire (ODQ) scores were collected at baseline and after 4 weeks. Three-way repeated measures analyses of variance (ANOVAs) were performed to assess the effect of mobility categorization and intervention group on the change on the ODQ with time. Number-needed-to-treat (NNT) statistics were calculated. RESULTS: Ninety-three (71.0%) patients were judged to have hypomobility present and 15 (11.5%) were judged with hypermobility present. The ANOVAs resulted in significant interaction effects. Pairwise comparisons showed greater improvements among patients receiving manipulation categorized with hypomobility present versus absent (mean difference, 23.7%; 95% confidence interval [CI], 5.1%-42.4%), and among patients receiving stabilization categorized with hypermobility present versus absent (mean difference, 36.4%; 95% CI, 10.3%-69.3%). For patients with hypomobility, failure rates were 26% with manipulation and 74.4% with stabilization (NNT=2.1; 95% CI, 1.6-3.5). For patients with hypermobility, failure rates were 83.3% and 22.2% for manipulation and stabilization, respectively (NNT=1.6; 95% CI, 1.2-10.2). CONCLUSIONS: Patients with LBP judged to have lumbar hypomobility experienced greater benefit from an intervention including manipulation; those judged to have hypermobility were more likely to benefit from a stabilization exercise program.
Preliminary development of a clinical prediction rule for determining which patients with low back pain will respond to a stabilization exercise program.
OBJECTIVE: To develop a clinical prediction rule to predict treatment response to a stabilization exercise program for patients with low back pain (LBP). DESIGN: A prospective, cohort study of patients with nonradicular LBP referred to physical therapy (PT). SETTING: Outpatient PT clinics. PARTICIPANTS: Fifty-four patients with nonradicular LBP. INTERVENTION: A standardized stabilization exercise program. MAIN OUTCOME MEASURE: Treatment response (success or failure) was categorized based on changes in the Oswestry Disability Questionnaire scores after 8 weeks. RESULTS: Eighteen subjects were categorized as treatment successes, 15 as treatment failures, and 21 as somewhat improved. After using regression analyses to determine the association between standardized examination variables and treatment response status, preliminary clinical prediction rules were developed for predicting success (positive likelihood ratio [LR], 4.0) and failure (negative LR, .18). The most important variables were age, straight-leg raise, prone instability test, aberrant motions, lumbar hypermobility, and fear-avoidance beliefs. CONCLUSIONS: It appears that the response to a stabilization exercise program in patients with LBP can be predicted from variables collected from the clinical examination. The prediction rules could be used to determine whether patients with LBP are likely to benefit from stabilization exercises.
Manual physical therapy, cervical traction, and strengthening exercises in patients with cervical radiculopathy: a case series.
STUDY DESIGN: A case series of consecutive patients with cervical radiculopathy. BACKGROUND: A multitude of physical therapy interventions have been proposed to be effective in the management of cervical radiculopathy. However, outcome studies using consistent treatment approaches on a well-defined sample of patients are lacking. The purpose of this case series is to describe the outcomes of a consecutive series of patients presenting to physical therapy with cervical radiculopathy and managed with the use of manual physical therapy, cervical traction, and strengthening exercises. CASE DESCRIPTION: Eleven consecutive patients (mean age, 51.7 years; SD, 8.2) who presented with cervical radiculopathy on the initial examination were treated with a standardized approach, including manual physical therapy, cervical traction, and strengthening exercises of the deep neck flexors and scapulothoracic muscles. At the initial evaluation all patients completed self-report measures of pain and function, including a numeric pain rating scale (NPRS), the Neck Disability Index (NDI), and the Patient-Specific Functional Scale (PSFS). All patients again completed the outcome measures, in addition to the global rating of change (GROC), at the time of discharge from therapy and at a 6-month follow-up session OUTCOMES: Ten of the 11 patients (91%) demonstrated a clinically meaningful improvement in pain and function following a mean of 7.1 (SD, 1.5) physical therapy visits and at the 6-month follow-up. DISCUSSION: Ninety-one percent (10 of 11) of patients with cervical radiculopathy in this case series improved, as defined by the patients classifying their level of improvement as at least "quite a bit better" on the GROC. However, because a cause-and-effect relationship cannot be inferred from a case series, follow-up randomized clinical trials should be performed to further investigate the effectiveness of manual physical therapy, cervical traction, and strengthening exercises in a homogeneous group of patients with cervical radiculopathy.
Screening for vertebrobasilar insufficiency in patients with neck pain: manual therapy decision-making in the presence of uncertainty.
Growing evidence supports the effectiveness of manual therapy interventions in patients with neck pain; however, considerable attention has also been afforded to the potential risks such as vertebrobasilar insufficiency (VBI). Despite the existence of guidelines advocating specific screening procedures, research does not support the ability to accurately identify patients at risk. The logical question becomes, "How does one proceed in the absence of certainty?" Given the lack of clear direction for decision making in the peer-reviewed literature, this commentary discusses the uncertainties that exist regarding the ability to identify patients at risk for VBI. The authors hope that this commentary adds additional perspective on manual therapy decision-making strategies in the presence of uncertainty.
A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study.
BACKGROUND: Conflicting evidence exists about the effectiveness of spinal manipulation. OBJECTIVE: To validate a manipulation clinical prediction rule. DESIGN: Multicenter randomized, controlled trial. SETTING: Physical therapy clinics. PATIENTS: 131 consecutive patients with low back pain, 18 to 60 years of age, who were referred to physical therapy. INTERVENTION: Patients were randomly assigned to receive manipulation plus exercise or exercise alone by a physical therapist for 4 weeks. MEASUREMENTS: Patients were examined according to the clinical prediction rule criteria (symptom duration, symptom location, fear-avoidance beliefs, lumbar mobility, and hip rotation range of motion). Disability and pain at 1 and 4 weeks and 6 months were assessed. RESULTS: Outcome from spinal manipulation depends on a patient's status on the prediction rule. Treatment effects are greatest for the subgroup of patients who were positive on the rule (at least 4 of 5 criteria met); health care utilization among this subgroup was decreased at 6 months. Compared with patients who were negative on the rule and received exercise, the odds of a successful outcome among patients who were positive on the rule and received manipulation were 60.8 (95% CI, 5.2 to 704.7). The odds were 2.4 (CI, 0.83 to 6.9) among patients who were negative on the rule and received manipulation and 1.0 (CI, 0.28 to 3.6) among patients who were positive on the rule and received exercise. A patient who was positive on the rule and received manipulation has a 92% chance of a successful outcome, with an associated number needed to treat for benefit at 4 weeks of 1.9 (CI, 1.4 to 3.5). LIMITATIONS: The response rate for the 6-month follow-up resulted in inadequate power to detect statistically significant differences for some comparisons. CONCLUSIONS: The spinal manipulation clinical prediction rule can be used to improve decision making for patients with low back pain.
The influence of experience and specialty certifications on clinical outcomes for patients with low back pain treated within a standardized physical therapy management program.
STUDY DESIGN: Secondary analysis of a randomized trial. OBJECTIVES: To examine the influence of experience and specialty certification on outcomes for patients with low back pain receiving a standardized manipulation or stabilization exercise intervention program. BACKGROUND: Little research has examined the impact of therapist-related factors on the outcomes of clinical care for patients with low back pain. It is assumed that therapists with more clinical experience or specialty certification will achieve better clinical outcomes; however, few studies have examined this hypothesis. METHODS AND MEASURES: One hundred thirty-one participants in a randomized trial were included (70 randomized to receive manipulation, 61 stabilization). All subjects completed an Oswestry Disability Questionnaire at baseline, and after 1 and 4 weeks of treatment. Therapists were categorized based on total years of experience, years of experience with manual therapy, and specialty certification status. Two-way repeated-measures analyses of covariance were performed within each intervention group to examine the effects of the therapist characteristics on outcomes. Hierarchical linear regression models were used to examine the relative effects of therapist characteristics and intervention on clinical outcomes. RESULTS: Thirteen therapists participated (average 6.0 years of experience [standard deviation, 4.01, 4 (30.8%) with specialty certification). A significant interaction between time and specialty certification status (P = .04) was detected for subjects receiving the manipulation intervention. No significant interactions were detected in the stabilization group. The regression models found that the intervention group significantly contributed to explaining clinical outcomes, but that therapist characteristics did not. CONCLUSIONS: With the standardized protocol utilized in this study, it appears that the therapist-related factors of increased experience and specialty certification status do not result in an improvement in patients' disability associated with low back pain.
Proposal of a classification system for patients with neck pain.
It is likely that patients with neck pain are not a homogeneous group, but, instead, consist of a variety of subgroups, each of which may benefit from a specific intervention matched to the patient's signs and symptoms. Studies to date have largely failed to account for this possibility, which may compromise the statistical power of research and ultimately fail to provide guidance for clinical decision making. Classification provides a means of breaking down a larger entity into more homogeneous subgroups of patients, based on examination data. Classification can guide the determination of a patient's prognosis, and the selection of the most appropriate intervention strategy. Classification has received considerable attention in the management of patients with low back pain, and evidence is emerging regarding its benefits. There has been considerably less effort made towards examining classification as it pertains to patients with neck pain. The purpose of this clinical commentary is to examine the current literature and to propose a classification system for patients with neck pain, based on the overall goal of treatment. The approach is based on published evidence when possible and is also informed by clinical experience and expert opinion. Classification decisions are based on the integration of data from a variety of information from the history and physical examination. The end result of the classification process is to determine the treatment approach believed to be most likely to maximize the clinical outcome for an individual patient with neck pain.
Effectiveness of manual physical therapy to the cervical spine in the management of lateral epicondylalgia: a retrospective analysis.
DESIGN: Retrospective ex-post facto design. OBJECTIVES: To retrospectively review the management of patients with lateral epicondylalgia, and to compare self-reported outcomes to assess the potential benefit of manual physical therapy to the cervical spine. BACKGROUND: It has been postulated that dysfunction of the cervical spine may contribute to the symptoms associated with lateral epicondylalgia; however, the literature assessing the effectiveness of manual physical therapy to the cervicothoracic region in this patient population has been inconclusive. Documentation and analysis of outcomes of management strategies focusing on the cervical spine may lead to determining the most effective and efficient clinical practices. METHODS AND MEASURES: Of the 213 charts reviewed, 112 satisfied inclusion-exclusion criteria and were divided into 2 groups: those who received treatment solely directed at the elbow (local management [LM]), or those who received treatment directed at the elbow and cervical manual therapy (LM+C). Telephone follow-up interviews were used to determine the number of successful outcomes. Percentages of successful outcomes in each group were compared using chi-square analysis. An independent samples t test was used to compare the total number of visits per group. RESULTS: Sixty-one of the 112 patients were in the LM group, while 51 received LM+C. Seventy five percent of the patients available for follow-up in the LM group and 80% in the LM+C group reported a successful outcome. Patients in the LM group received a greater number of visits (mean, 9.7; SD, 2.4) than patients in the LM+C group (mean, 5.6; SD, 1.7; P<.01). CONCLUSIONS: The results of this retrospective review suggest that most patients had successful outcomes regardless of the inclusion of manual therapy interventions to the cervical spine. The LM+C group achieved the successful long-term outcome in significantly fewer visits.
The interrater reliability among physical therapists newly trained in a classification system for acute low back pain.
STUDY DESIGN: A prospective methodological interrater reliability study. OBJECTIVES: To calculate the interrater reliability among clinicians newly trained in a classification system for acute low back pain and to determine the level of agreement at key junctures within the classification algorithm. BACKGROUND: The utility of a classification system for patients with low back pain depends on its reliability and generalizability. To be practical, clinicians must be able to apply the system after a reasonable amount of training. Identifying key points in the classification algorithm where disagreement occurs can lead to better operational definitions. METHODS: Four physical therapists read an article and attended a 1-day training session in the classification system. Randomly paired therapists classified patients referred for treatment of acute low back pain and noted decisions at key junctures in the system algorithm. RESULTS: Forty-five patients were classified. Repeated examinations did not increase the patient's pain (P>.05). For 3 out of the 4 therapists, the interrater reliability showed a kappa value of 0.45. The fourth therapist, excluded from the overall analysis, exhibited a bias towards the immobilization classification. Among the 3 therapists, major disagreement occurred with the determination of symmetry with trunk side bending and the effects of repeated movements. CONCLUSIONS: Three out of 4 clinicians newly trained in the system showed moderate reliability. The reliability was slight when the fourth therapist was included. Refinement of the operational definitions and criteria for determining lumbar capsular patterns are needed. One day of training is probably not adequate for all therapists, especially for those biased towards specific low back pain syndromes.
Factors related to the inability of individuals with low back pain to improve with a spinal manipulation.
BACKGROUND AND PURPOSE: Although spinal manipulation is one of the few interventions for low back pain supported by evidence, it appears to be underutilized by physical therapists, possibly due to therapists' concerns that a patient may not benefit from the intervention. The purpose of this study was to identify factors that are associated with an inability to benefit from manipulation. SUBJECTS: Seventy-five people with nonradicular low back pain (mean age=37.6 years, SD=10.6, range=19-59; mean duration of symptoms=41.7 days, SD=54.7, range=1-252) participated. METHODS: Subjects underwent a standardized examination that included history-taking; self-reports of pain, disability, and fear-avoidance beliefs; measurement of lumbar and hip range of motion; and use of various tests. All subjects received a spinal manipulation intervention for a maximum of 2 sessions. Subjects who did not show greater than 5 points of improvement on the modified Oswestry Low Back Pain Disability Questionnaire were considered to have shown no improvement with the manipulation. Baseline variables were tested for univariate relationship with the outcome of the manipulation. Variables showing a univariate relationship were entered into a logistic regression equation, and adjusted odds ratios were calculated. RESULTS: Twenty subjects (28%) did not improve with manipulation. Six variables were identified as being related to inability to improve with manipulation: longer symptom duration, having symptoms in the buttock or leg, absence of lumbar hypomobility, less hip rotation range of motion, less discrepancy in left-to-right hip medial rotation range of motion, and a negative Gaenslen sign. The resulting logistic regression model explained 63% of the variance in manipulation outcome. DISCUSSION AND CONCLUSION: The majority of subjects improved with manipulation. Baseline variables could be identified that were predictive of which subjects would not improve.
Physical therapist management of a patient with acute low back pain and elevated fear-avoidance beliefs.
BACKGROUND AND PURPOSE: Elevated fear-avoidance beliefs are believed to be a precursor of chronic disability, yet effective intervention options have not been described in the literature. The purpose of this case report is to describe physical therapist management of a patient with acute low back pain and elevated fear-avoidance beliefs. CASE DESCRIPTION: The patient was a 42-year-old sales manager with acute low back pain. The patient had no previous history of activity-limiting low back pain and initially had limitations in straight leg raising, limitations in lumbar movement, and elevated fear-avoidance beliefs. INTERVENTION: Treatment-based classification and graded exercise were used. OUTCOME: Disability, fear-avoidance beliefs, and pain decreased 4 weeks after starting physical therapy. Six months later, disability and fear-avoidance beliefs had increased, but were still improved when compared with the initial measurements. DISCUSSION: Disability and fear-avoidance beliefs improved following a fear-avoidance-based physical therapy intervention. Research is warranted to investigate the effectiveness of this approach.
The effect of a fear-avoidance-based physical therapy intervention for patients with acute low back pain: results of a randomized clinical trial.
STUDY DESIGN: A randomized clinical trial with 4-week and 6-month follow-up periods. OBJECTIVE: To compare the effect of a fear-avoidance-based physical therapy intervention with standard care physical therapy for patients with acute low back pain. SUMMARY OF BACKGROUND DATA: The disability reduction strategy of secondary prevention involves providing specific treatment for patients that are likely to have chronic disability from low back pain. Previous studies have indicated that elevated fear-avoidance beliefs are a precursor to chronic disability from low back pain. However, the effectiveness of physical therapy intervention based on a fear-avoidance model is unknown. METHODS: Sixty-six consecutive patients referred to physical therapy with low back pain of less than 8 weeks' duration were randomly assigned to receive fear-avoidance-based physical therapy (n = 34) or standard care physical therapy (n = 32). The intervention period lasted 4 weeks for this study. Disability, pain intensity, and fear-avoidance beliefs measures were recorded before and after treatment. A 6-month follow-up of the same measures was obtained by mail. RESULTS: An intention-to-treat principle (last value forward) was used for data analyses that tested the primary and secondary hypotheses. The prediction of disability at 4 weeks and 6 months after treatment was significantly improved by considering the interaction between the type of treatment and the initial level of fear-avoidance beliefs. Both groups had significant within group improvements for disability and pain intensity. The fear-avoidance treatment group had a significant improvement in fear-avoidance beliefs, and fear-avoidance beliefs about physical activity were significantly lower than the standard care group at 4 weeks and 6 months after treatment. CONCLUSION: Patients with elevated fear-avoidance beliefs appeared to have less disability from fear-avoidance-based physical therapy when compared to those receiving standard care physical therapy. Patients with lower fear-avoidance beliefs appeared to have more disability from fear-avoidance-based physical therapy, when compared to those receiving standard care physical therapy. In addition, physical therapy supplemented with fear-avoidance-based principles contributed to a positive shift in fear-avoidance beliefs.
Comparison of classification-based physical therapy with therapy based on clinical practice guidelines for patients with acute low back pain: a randomized clinical trial.
STUDY DESIGN: A randomized clinical trial was conducted. OBJECTIVE: To compare the effectiveness of classification-based physical therapy with that of therapy based on clinical practice guidelines for patients with acute, work-related low back pain. SUMMARY OF BACKGROUND DATA: Clinical practice guidelines recommend minimal intervention during the first few weeks after acute low back injury. However, studies supporting this recommendation have not attempted to identify which patients are likely to respond to particular interventions. METHODS: For this study, 78 subjects with work-related low back pain of less than 3 weeks duration were randomized to receive therapy based on a classification system that attempts to match patients to specific interventions or therapy based on the Agency for Health Care Policy and Research guidelines. The subjects were followed for 1 year. Outcomes included the impairment index, Oswestry scale, SF-36 component scores, satisfaction, medical costs, and return to work status. RESULTS: After adjustment for baseline factors, subjects receiving classification-based therapy showed greater change on the Oswestry (P = 0.023) and the SF-36 physical component (P = 0.029) after 4 weeks. Patient satisfaction was greater (P = 0.006) and return to full-duty work status more likely (P = 0.017) after 4 weeks in the classification-based group. After 1 year, there was a trend toward reduced Oswestry scores in the classification-based group (P = 0.063). Median total medical costs for 1 year after injury were 1003.68 dollars for the guideline-based group and 774.00 dollars for the classification-based group (P = 0.13). CONCLUSIONS: For patients with acute, work-related low back pain, the use of a classification-based approach resulted in improved disability and return to work status after 4 weeks, as compared with therapy based on clinical practice guidelines. Further research is needed on the optimal timing and methods of intervention for patients with acute low back pain.
Physical impairment index: reliability, validity, and responsiveness in patients with acute low back pain.
STUDY DESIGN: Cohort study of patients with acute low back pain undergoing physical therapy. OBJECTIVES: Examine the reliability and validity of the Physical Impairment Index in a group of patients with acute low back pain and determine the responsiveness and minimum detectable change of the index and its component tests. SUMMARY OF THE BACKGROUND DATA: The Physical Impairment Index was originally described as a reliable and valid means of assessing physical impairment in patients with low back pain. The psychometric properties of the index have not been reported in patients with acute low back pain, nor has its responsiveness been examined. METHODS: Seventy-eight patients with acute (<3 weeks duration) low back pain participating in a clinical trial were assessed at baseline and after 4 weeks. Interrater reliability of the index was examined in a subgroup of 20 patients. Validity was examined through correlations with concurrent measures of pain, disability, and psychosocial variables. Changes in the index over 4 weeks were used to assess responsiveness and minimum detectable change. RESULTS: Interrater reliability of the index was high (intraclass correlation coefficient = 0.89), and its validity was generally supported by the pattern of correlations. The index was more responsive to change than any of its component tests but was less responsive than the Oswestry disability score. The minimum detectable change on the index was approximately 1 point. CONCLUSIONS: The Physical Impairment Index appears to be a reliable and valid measure of physical impairment for patients with acute low back pain and may be useful as an adjunct outcome measure for studies involving these patients. Further research on patients with chronic pain is needed before it can be advocated for outcomes research with this population.
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.
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.