Inter-tester reliability of passive intervertebral and active movements of the cervical spine.

Measurements of active range of motion (AROM) and passive intervertebral movements (PIM) of the cervical spine are frequently used for patients with neck pain. However, there is a paucity of studies that investigate the psychometric properties of these measurements. Objectives of this study were to: (1) determine the inter-tester reliability of PIM, AROM, and the effects of AROM on symptom provocation; (2) establish the minimal detectable change (MDC) in cervical AROM; and (3) determine the association between AROM and disability. Thirty subjects (age 41+/- 12) with neck pain participated in this study. Two masked examiners performed the measurements during the same testing session. PIM was assessed manually and recorded as hypomobile or normal. AROM was measured in degrees with a gravity goniometer. The effect of AROM on patient's symptoms was recorded as no change, decreased, increased, centralization, or peripheralization. Measures of AROM had moderate to substantial reliability (.78 - .91) and resulted in a MDC adequate for clinical use (from 9 degrees to 16 degrees). The effect of AROM on symptom provocation resulted in Kappa values that ranged from slight to substantial (.25 - .87). Measures of PIM resulted in substantial and moderate reliability of assessing occipital-atlas mobility, tenderness of the transverse processes of atlas, and symptom provocation during PIM testing of the lower cervical segments. Fair Kappa values were observed during judgment of mobility in the C2 segment and symptom reproduction during PIM of C2 and C5. The additional PIM had Kappa values that ranged from none to slight. Low prevalence of positive findings likely resulted in an artificial deflation of the Kappa statistic during some PIM measures. Measures of AROM in saggital and transverse planes were associated with disability scores (r = .43 and .40, respectively). Findings are relevant to the planning of future studies to establish the criterion validity of these tests to guide the selection of interventions and establish prognosis in patients with neck pain.

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.

Decision making for a painful hip: a case requiring referral.

STUDY DESIGN: Resident's case problem. BACKGROUND: The purpose of this resident's case problem is to describe a 39-year-old female patient with insidious onset of hip pain. This patient had discrete findings on subjective physical examination that prompted referral for further imaging studies of the left hip and pelvis. Despite having seen multiple providers, no imaging of the involved hip or pelvis had been performed. A prolonged duration of symptoms, severe gait disturbance with an associted Trendelenburg sign, difficulty sleeping, and an empty end feel with passive range of motion increased concern that a pathological process might be present. DIAGNOSIS: Imaging studies revealed a large destructive soft-tissue tumor later found to be non-Hodgkin's lymphoma. DISCUSSION: It is incumbent upon physical therapists to be aware of the potential for severe pathological conditions that mimic musculoskeletal complaints to exist and understand how to identify patients for whom further testing and/or referral may be appropriate. Existing guidelines for low back pain may assist with decision making in the absence of specific guidelines for when to request imaging in patients with nontraumatic hip and pelvis pain. Proficiency in screening for conditions not amenable to physical therapy treatment or that require consultation to other health care professionals is essential to physical therapy practice.

Cervical radiculopathy or Parsonage-Turner syndrome: differential diagnosis of a patient with neck and upper extremity symptoms.

STUDY DESIGN: Resident's case problem. BACKGROUND: The signs and symptoms of cervical radiculopathy (CR) warrant the consideration of several other conditions in CR's differential diagnosis. One condition that may mimic CR, which is not well known amongst physical therapists, is Parsonage-Turner syndrome (PTS). PTS is characterized by an onset of intense pain that typically subsides within days to weeks. However, as pain subsides, weakness and/or paralysis may develop in upper extremity muscles. The purpose of this resident's case problem is to describe a patient who presented to our clinic with a diagnosis of CR, but had findings consistent with PTS. DIAGNOSIS: The patient was a 43-year-old male referred to physical therapy with a diagnosis of CR. He had a previous episode of CR 1 year ago that was treated successfully. He had positive magnetic resonance imaging findings of structural abnormalities suggestive of causative factors for CR. The patient was treated for CR with thoracic and cervical spine manipulations and intermittent cervical traction. The initial acute severe pain subsided, but weakness in the upper extremity worsened. Diagnosis of PTS was made upon exclusion of other potential confounding diagnoses and the findings of fibrillation potentials and positive waves in electrodiagnostic studies. DISCUSSION: CR and PTS are characterized by pain in the cervical spine, shoulder, and upper extremity. CR generally has an insidious onset, while PTS has a rapid onset of intense pain. Symptoms of CR are exacerbated with neck movements, while symptoms related to PTS should not be exacerbated with neck movements. In patients that do not respond to conventional therapy and have a progression of upper extremity muscle weakness, regardless of decreased pain, the diagnosis of PTS should be considered.

Patient with metastatic adenocarcinoma imitating lumbar herniated nucleus pulposis.

OBJECTIVE: To highlight the utility of Cyriax's selective tissue-tensioning principles, specifically the "Sign of the Buttock," in identifying mechanical behavior of pain of pathologies not amenable to conservative treatment. CLINICAL FEATURES: A 41-year-old man was referred to the University of Pittsburgh Medical Center Spine Specialty Center with a diagnosis of L5-S1 herniated nucleus pulposis that was recalcitrant to treatment. The onset of symptoms had been 5 months before the patient's appointment at the Spine Center and 6 months after an apparent precipitating trauma. The patient had been followed up by his primary care physician, referred to urology, neurosurgery, and physical medicine and rehabilitation before being referred to the Spine Specialty Center. INTERVENTION AND OUTCOME: Clinical examination using Cyriax's Sign of the Buttock implicates the hip joint, while it helps to rule out the lumbar spine. Review of previous imaging studies failed to rule out hip pathology. Pelvis and hip magnetic resonance imaging led to suspicion of lytic lesions, and a diagnosis of metastatic adenocarcinoma was made via biopsy. CONCLUSION: We have found Cyriax's Sign of the Buttock to have diagnostic value in this case. When positive, this test may help identify serious extracapsular hip or pelvic pathology.

Intermittent cervical traction and thoracic manipulation for management of mild cervical compressive myelopathy attributed to cervical herniated disc: a case series.

STUDY DESIGN: Case series. OBJECTIVE: To describe the management of 7 patients with grade 1 cervical compressive myelopathy attributed to herniated disc using intermittent cervical traction and manipulation of the thoracic spine. BACKGROUND: Intermittent cervical traction has been indicated for the treatment of patients with herniated disc and has been suggested to be helpful for patients with cervical compressive myelopathy. Manipulation of the thoracic spine has been utilized to safely improve active range of motion and decrease pain in patients with neck pain. METHODS AND MEASURES: Seven women with neck pain, 35 to 45 years of age, were identified as having signs and symptoms consistent with grade 1 cervical compressive myelopathy. Symptom duration ranged from less than 1 week to 52 weeks. All patients were treated with intermittent cervical traction and thoracic manipulation for a median of 9 sessions (range, 2-12 sessions) over a median of 56 days (range, 14-146 days). Numeric Pain Rating Scale and Functional Rating Index scores served as the primary outcome measures. RESULTS: The median decrease in pain scores was 5 (range, 2-8) from a baseline of 6 (range, 4-8), and median improvement in Functional Rating Index scores was 26% (range, 10%-50%) from a baseline of 44% (range, 35%-71%). Dizziness was eliminated in 3 out of 4 patients and chronic headache symptoms were improved in 3 out of 3 patients. There were no adverse events or outcomes. CONCLUSIONS: Intermittent cervical traction and manipulation of the thoracic spine seem useful for the reduction of pain scores and level of disability in patients with mild cervical compressive myelopathy attributed to herniated disc. A thorough neurological screening exam is recommended prior to mechanical treatment of the cervical spine.

Immediate improvements in side-to-side weight bearing and iliac crest symmetry after manipulation in patients with low back pain.

BACKGROUND: Although there is good evidence that spinal manipulation is an effective treatment to improve pain and function for patients with low back pain (LBP), there is little evidence to support the mechanism by which manipulation works. OBJECTIVES: To determine if iliac crest (IC) and weight-bearing (WB) symmetry improve after spinal manipulation and to determine if improvements in IC and WB symmetry are associated with improvements in pain and function in patients with low back pain. DESIGN: Single group, within-subjects, repeated measures design. METHOD: Thirty consecutive patients (mean age = 40+/-13) who came to a spine specialty center for treatment of acute or chronic LBP and who would be receiving spinal manipulation participated in the study (14 male patients). Patients completed a series of self-report measures of pain and function and received a standardized physical examination, including the assessment of IC and WB symmetry. Patients received a standardized manipulative intervention, and immediate and 3- to 4-day follow-up examinations were performed by a blinded examiner. Paired t tests were performed to determine within-group changes, and Pearson product moment correlation coefficients were calculated to determine the relationship between improvements in IC and WB symmetry and improvements in pain and function. To control for the potential that an association between changes in IC and/or WB symmetry and changes in pain and function could be confounded by the baseline outcome measure, simultaneous linear regression was performed on any significant correlation. Partial F tests were used to determine if the additional explained variability was significant. RESULTS: Patients with LBP demonstrated significant improvements in IC and WB symmetry after manipulation (P<.001). Improvements in WB symmetry were associated with improvements in the patients' self-reported levels of pain 3 to 4 days after manipulation (r=.5, P=.007). Based on the significant association between improvements in WB symmetry and improvements in pain, the final pain score was regressed on the change in WB symmetry, after controlling for the baseline level of pain. The addition of the change in WB symmetry explained a 10% additional increase in variability in the patient's level of pain at the 3- to 4-day follow-up (P =.01). No relationship was found between improvements in IC and WB symmetry and improvements in function as determined by the Oswestry Disability Questionnaire 3 to 4 days after manipulation. CONCLUSION: IC and WB symmetry improved immediately after spinal manipulation. Improvements in WB symmetry were related to improvements in the patients' self-reported levels of pain, even after controlling for the baseline level of pain. Improvements in IC and WB symmetry were not related to changes in function. The results of this study provide initial data to elucidate how manipulation may work to improve pain and function in patients with LBP.

Far-lateral disk herniation: case report, review of the literature, and a description of nonsurgical management.

OBJECTIVE: To review the history and examination of a far-lateral lumbar intervertebral disk herniation (FLLIDH), as well as the treatment and outcomes of a nonsurgical approach. CLINICAL FEATURES: A 60-year-old healthy male subject had a 3-week history of right buttock and calf pain. He initially had a left lateral list and asymmetrical pelvic landmarks. Range of motion (ROM) of the lumbar spine revealed full and pain-free lumbar flexion, right-sided pain with lumbar extension and left side bending, and painful and restricted left side bending. Neurologic examination was unremarkable. INTERVENTION AND OUTCOME: The patient was treated with a lumbar epidural and nerve root injection, as well as manipulation. Physical therapy consisted of deweighting treadmill, autotraction, and strengthening exercises. Outcomes were measured by using the Modified Oswestry Questionnaire, as well as a numerical pain rating scale. His initial Oswestry was 73%, pain 9/10 at presentation. Upon discharge, the Oswestry was 0% and pain was rated as 0/10. CONCLUSION: A significant decrease was noted in both the Oswestry Questionnaire, as well as the pain rate. The patient returned to running on alternate days for a minimum of 30 minutes, which was his primary goal. This case demonstrated a positive outcome using a multidisciplinary approach in a patient diagnosed with a FLLIDH. He obtained his goals and his function was fully restored.

Reliability of measuring iliac crest level in the standing and sitting position using a new measurement device.

BACKGROUND: To date, the reliability studies of iliac crest (IC) level used nominal scales and presented conflicting results. To perform the IC level measurement, we propose the use of a measurement device that is composed of an inclinometer mounted on a crest level tester that measures IC level in degrees. OBJECTIVES: To determine the interrater reliability of measuring iliac crest level in the standing and sitting position using an experimental device and to assess the precision of the measurements taken with the experimental device. METHOD: Forty individuals (mean age 40 +/- 12 years) referred to physical therapy for treatment of low back pain (LBP) participated in the study (16 male participants). Six examiners performed the measurements. Three of the 6 examiners performed the measurements on each individual. Each examiner independently performed the measurement of IC level in standing and in sitting using the measurement device. RESULTS: Intraclass correlation coefficients, [formula (1,1)] for measurement of IC level in standing and sitting, were 0.80 (95% CI = 0.7-0.9) and 0.73 (95% CI = 0.6-0.8), respectively. Standard errors of measurement for IC level in standing and sitting were 0.91 and 0.86 degrees, respectively. CONCLUSION: The use of a measurement device resulted in good reliability of IC level measurement in degrees in standing and moderate reliability of IC level in sitting position. This finding is relevant to plan future studies that will investigate if changes in IC level may be associated with outcomes of pain and function in patients with low back or pelvic dysfunctions.

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.