Side-to-side weight-bearing asymmetry in subjects with low back pain.

The purpose of this project was to determine if subjects with low back pain (LBP) exhibit greater side-to-side weight-bearing (WB) asymmetry compared to healthy control subjects without LBP. This study utilized an observational double cohort design and consisted of 35 subjects with LBP and 31 healthy control subjects. Side-to-side WB asymmetry was calculated as the average of the absolute value of the difference between the right and left lower extremity from three trials. The percentage of the average side-to-side WB asymmetry relative to the total body weight was calculated to normalize expected differences in magnitude of asymmetry based on a subject's total body weight. An 11-point numeric pain rating scale was used to represent the subject's current level of pain. Patients with LBP demonstrated significantly greater normalized side-to-side WB asymmetry than healthy control subjects (8.8% vs. 3.6%, respectively, P<0.001). In patients with LBP, higher magnitudes of side-to-side WB asymmetry were significantly associated with increased pain (r=0.39, P=0.021). In conclusion patients with LBP exhibited increased side-to-side WB asymmetry compared to healthy control subjects without LBP. This asymmetry was associated with increased levels of pain. This finding is relevant for planning future studies that will attempt to provide evidence for the construct validity of manipulation by determining if side-to-side WB asymmetry normalizes after a manipulation intervention and if this improvement is associated with improvements in pain and function.

A comparison of fear-avoidance beliefs in patients with lumbar spine pain and cervical spine pain.

STUDY DESIGN: A prospective consecutive cohort study of patients with cervical spine pain and patients with lumbar spine pain referred to an academic medical center. OBJECTIVES: To investigate the presence of fear-avoidance beliefs in a sample of patients with cervical spine pain and to compare the association of pain intensity, disability, and fear-avoidance beliefs in patients with cervical spine pain with that in patients with lumbar spine pain. SUMMARY OF BACKGROUND DATA: Fear-avoidance beliefs are a specific psychosocial variable involved in the development of disability from low back pain. Psychosocial variables are believed to play a role in cervical disability, but specific variables have not been investigated. METHODS: Consecutive patients referred to a multidisciplinary center completed self-reports of disability, pain intensity, and fear-avoidance beliefs during an initial evaluation session. Gender, type of symptom onset, acuity, and payer source were also recorded. Associations between disability, pain intensity, and fear-avoidance beliefs were investigated in patients with cervical spine pain and patients with lumbar spine pain. RESULTS: In all, 163 patients completed the self-reports and were included in this study. Weaker relations between fear-avoidance beliefs and disability were found in patients with cervical pain than in those with lumbar pain. Significant differences in fear-avoidance beliefs were found for gender, type of symptom onset, and payer source (workers' compensation, auto insurance, and traditional insurance). CONCLUSION: The associations among fear-avoidance beliefs, pain intensity, and disability differed between patients with cervical spine pain and patients with lumbar spine pain. Fear-avoidance beliefs were significantly different in subgroups of patients.

An examination of the selective tissue tension scheme, with evidence for the concept of a capsular pattern of the knee.

BACKGROUND AND PURPOSE: The purpose of this study was to examine whether there is evidence to support 2 elements of the passive-range-of-motion (PROM) portion of Cyriax's selective tissue tension scheme for patients with knee dysfunction: a capsular pattern of motion restriction and the pain-resistance sequence. SUBJECTS: One hundred fifty-two subjects with unilateral knee dysfunction participated. The subjects had a mean age of 40.0 years (SD=15.9, range=13-82). METHODS: Passive range of motion of the knee and the relationship between the onset of pain and resistance to PROM (pain-resistance sequence) were measured, and 4 tests for inflammation were used. Interrater reliability was assessed on 35 subjects. RESULTS: Kappa values for the individual inflammatory tests ranged from .21 to .66 for categorization of the joint as inflamed, based on at least 2 positive inflammatory tests (kappa=.76). Reliability of PROM measurements was indicated by intraclass correlation coefficients of .72 to .97. Reliability of measurements of the pain-resistance sequence was indicated by a weighted kappa of .28. A capsular pattern, defined as a ratio of loss of extension to loss of flexion during PROM of between 0.03 and 0.50, was more likely than a noncapsular pattern in patients with an inflamed knee or osteoarthrosis (likelihood ratio=3.2). An association was found between a capsular pattern and arthrosis or arthritis. CONCLUSION AND DISCUSSION: These findings provide evidence to support the concept of a capsular pattern of motion restriction in persons with inflamed knees or evidence of osteoarthrosis.

Lumbar spinal stenosis: a review of current concepts in evaluation, management, and outcome measurements.

The purpose of this review is to present current information from the literature regarding the pathoanatomy, clinical presentation, differential diagnosis, treatment, and outcome assessment methods for patients with lumbar spinal stenosis. Lumbar spinal stenosis is a frequently encountered condition, particularly in the elderly. Treatment requires an accurate diagnosis, but differential diagnosis of lumbar stenosis can be difficult. The literature to date has focused primarily on surgical treatment. The long-term efficacy of surgery has been questioned, and surgical procedures are associated with increased costs and risks of morbidity in an elderly population. A trial of conservative care is recommended in most cases, but there are presently no randomized controlled studies in the literature comparing surgical versus conservative management, or evaluating the effectiveness of any specific conservative treatment approach. The existing literature has further been criticized for having poorly defined outcome measures. The assessment of treatment outcomes should be multifactorial, including measures of pathoanatomy and impairments, as well as patient-centered measures such as level of disability, patient expectations, and satisfaction. The present level of understanding of lumbar spinal stenosis is deficient in many areas, including differential diagnosis, treatment, and outcome assessment. Future research should address these deficits to improve the management of patients with this condition.

Differential diagnosis of the hip vs. lumbar spine: five case reports.

With recent health care policy changes and the implementation of direct access in many states, physical therapists must be able to identify pathology that is beyond their scope of practice. The five case reports presented in this series required the differential diagnosis of hip vs. lumbar spine pathology. All of the cases required a referral from the physical therapist to either the patient's physician or a specialist because of abnormal screening test results. Each referral resulted in a new diagnosis of pathology that was beyond the scope of physical therapy. Cyriax's concepts of capsular and noncapsular patterns of joint restriction and the "Sign of the Buttock" proved useful in differentiating between hip and lumbar spine pathology in each patient. Our clinical experience indicates that utilizing the presence/absence of a capsular pattern and a "Sign of the Buttock" to screen out hip pathology in patients may be effective; however, further research is needed to support these claims.

Preliminary results of the use of a two-stage treadmill test as a clinical diagnostic tool in the differential diagnosis of lumbar spinal stenosis.

This study assesses the ability of a two-stage treadmill test to distinguish stenotic from nonstenotic subjects by capitalizing on the postural dependency of stenotic symptoms. Forty-five subjects (26 stenotic, 19 nonstenotic) participated. An earlier onset of symptoms with level walking (p = 0.0009), increased total walking time on an inclined treadmill (p = 0.014), and prolonged recovery time after level walking (p = 0.001) were significantly associated with stenosis. Only one of four self-reported postural variables were significantly associated with stenosis. Linear discriminant analysis performed using the treadmill variables resulted in the correct classification of 76.9 and 94.7% of stenotic and nonstenotic subjects, respectively. Likelihood ratios for all treadmill variables were > 2.50, and < 2.00 for all self-report variables. A two-stage treadmill test may be useful in the differential diagnosis of lumbar stenosis, and clinical measurement of the postural nature of symptoms seems to be superior to subjects' self-reports.

A nonsurgical treatment approach for patients with lumbar spinal stenosis.

The purpose of this case report is to describe a physical therapy approach to the evaluation, treatment, and outcome assessment of two patients diagnosed with lumbar spinal stenosis. Evaluation consisted of assessment of neurological status, spinal range of motion, and lower-extremity muscle force production and flexibility; administration of the Modified Oswestry Low Back Pain Questionnaire and the Roland-Morris Disability Questionnaire; assessment of pain using a visual analog scale; and performance of a two-stage treadmill test. The treatment program was designed to treat the impairments, and harness-supported treadmill ambulation (unloading) was used to address the limitation in ambulation identified by the treadmill test. Outcome assessment included measuring changes in the status of the impairments and assessing responses to the disability questionnaires and performance of the two-stage treadmill test. Improvements were noted on all outcome measures for both patients after 6 weeks of physical therapy and at the 4-week follow-up examination. Larger case series and randomized trials with long-term follow-ups are recommended.

Diagnosis of trochanteric bursitis versus femoral neck stress fracture.

This case report describes a 46-year-old male runner who reported the sudden onset of right hip pain. A diagnosis of trochanteric bursitis was established by a physiatrist, and the patient underwent two courses of physical therapy for moist heat, ultrasound, and exercise. Because minimal improvement was seen in the patient's pain level and gait limitations following physical therapy, a consultation was requested of a fellow staff member in the same physical therapy department, who is both a chiropractor and a physical therapist. The consultant felt that the absence of tenderness to deep palpation of the greater trochanter, the presence of a noncapsular pattern of restriction of the right hip, and the patient's nonresponsiveness to physical therapy warranted further investigation. A differential diagnosis of avascular necrosis, fracture, or a loose body was made by the consultant. Magnetic resonance imaging (MRI) testing ordered by the consultant indicated a nondisplaced, complete stress fracture of the femoral neck. The results of the consultation and the MRI testing were communicated to the referring physiatrist. The patient was referred to an orthopedic surgeon, who performed an open reduction and internal fixation of the right hip. The patient was ambulatory without an assistive device or weight-bearing restrictions 5 weeks after surgery.

Lumbar spinal stenosis.

Symptoms for spinal stenosis apparently result from an incongruity between the capacity and contents of the spinal nerve passages. These symptoms are most frequently seen in men in their fifth or sixth decade of life. Spinal extension generally exacerbates the claudication-type symptoms (lower-extremity pain and paresthesia), whereas spinal flexion diminishes these symptoms. Differential diagnosis is needed to rule out vascular claudication due to atherosclerosis. Decisions regarding surgery should be made based not only on diagnostic imaging but also on a thorough history and clinical examination.

A treatment-based classification approach to low back syndrome: identifying and staging patients for conservative treatment.

We present a treatment-based classification approach to the conservative management of low back syndrome. The approach has three levels of classification based on historical information, behavior of symptoms, and clinical signs. We first distinguish patients whose conservative care can be managed predominantly and independently by physical therapists versus patients who require consultation with other services (eg, psychology) or who require referral because of possible serious nonmusculoskeletal pathology. Once patients who can be managed by physical therapists are identified, the next level of classification is to stage their condition with regard to severity. We propose three stages: stage I for patients in the acute phase where the therapeutic goal is symptom relief, stage II for patients in a subacute phase where symptom relief and quick return to normal function are encouraged, and stage III for selected patients who must return to activities requiring high physical demands and who demonstrate a lack of physical conditioning necessary to perform the desired activities safely. The remainder of the article focuses on a third level of classification for stage I only in which patients are classified into distinct categories that are treatment-based and that specifically guide conservative management. The entire approach is diagnosis based, with specific algorithms and decision rules as well as examples presented.

Relative effectiveness of an extension program and a combined program of manipulation and flexion and extension exercises in patients with acute low back syndrome.

BACKGROUND AND PURPOSE: The relative effectiveness of an extension program and a manipulation program with flexion and extension exercises was examined in patients with low back syndrome. SUBJECTS: Forty-nine patients with less than a 3-month history of low back pain were seen at physical therapy clinics in western Pennsylvania, southern Mississippi, and eastern Missouri during a 6-month period. Twenty-seven of the 49 patients were classified a priori into a treatment-oriented category of extension/mobilization and were then randomly assigned to participate in an extension program or a program of manipulation followed by hand-heel rocks (flexion and extension). Two patients dropped out of the study (1 patient returned to work, and the other patient was unable to comply with the treatment schedule), and 1 patient was eliminated from the study because of magnified illness behavior. The remaining 24 patients (15 male, 9 female; mean age = 44 years, SD = 15, range = 14-73) were assigned randomly and equally to the two groups. Eight physical therapists participated in the study. METHODS: A randomized clinical trial comparing the two regimens was conducted for a 1-week period. Outcome was assessed using an Oswestry Low Back Pain Questionnaire initially (before treatment) and at 3 and 5 days posttreatment, and data were analyzed using a 2 x 3 (group x time) analysis of variance. RESULTS: A significant interaction of the group and time variables was demonstrated, indicating that the rate of positive response was greater in the manipulation/hand-heel rock group than in the extension group. CONCLUSION AND DISCUSSION: In this category of patients with low back pain, the use of manipulation as an adjunct to an ongoing exercise program appears to be warranted.

Evidence for use of an extension-mobilization category in acute low back syndrome: a prescriptive validation pilot study.

BACKGROUND AND PURPOSE: The prescriptive validity of a treatment-oriented extension-mobilization category for patients with low back syndrome (LBS) was examined. SUBJECTS: Of a total of 39 patients with LBS referred for physical therapy, 24 patients (14 male, 10 female), aged 14 to 50 years (means = 31.3, SD = 11.6), were classified as having signs and symptoms indicating treatment with an extension-mobilization approach. The remaining subjects were dismissed from the study. Patients in the extension-mobilization category were randomly assigned to either an experimental (treatment) group (n = 14) or a comparison group (n = 10). METHODS: The experimental and comparison group subjects were treated with either mobilization and extension (a treatment matched to the category) or a flexion exercise regimen (an unmatched treatment). Outcome was assessed with a modified Oswestry Low Back Pain Questionnaire administered initially and at 3 and 5 days after initiation of treatment. Data were analyzed with a 2 x 3 (treatment group x treatment period) analysis of variance. RESULTS: The subjects' rate of improvement, as indicated by the Oswestry questionnaire scores, was dependent on the treatment group to which they were assigned. Subjects treated with extension and mobilization positively responded at a faster rate than did those treated with a flexion-oriented program. CONCLUSION AND DISCUSSION: This study illustrates that a priori classification of selected patients with LBS into a treatment category of extension and mobilization and subsequently treating the patients accordingly with specified interventions can be an effective approach to conservative management of selected patients.