Older adults are impaired in the release of grip force during a force tracking task.

Age-related changes in force generation have been implicated in declines in older adult manual dexterity. While force generation is a critical aspect of the successful manipulation of objects, the controlled release of force represents the final component of dexterous activities. The impact of advancing age on the release of grip force has received relatively little investigation despite its importance in dexterity. The primary aim of this project was to determine the effects of age on the control of force release during a precision grip tracking task. Young adults (N = 10, 18-28 years) and older adults (N = 10, 57-77 years) completed a ramp-hold-release (0-35% of maximum grip force) force tracking task with their dominant hand. Compared to young adults, older adults were disproportionately less accurate (i.e., less time within target range) and had more error (i.e., greater relative root mean squared error) in the release of force, compared to generation of grip force. There was a significant difference between groups in two-point discrimination of the thumb, which was moderately correlated to force control across all phases of the task. The decline in force release performance associated with advanced age may be a result of sensory deficits and changes in central nervous system circuitry.

High-intensity locomotor training during inpatient rehabilitation improves the discharge ambulation function of patients with stroke. A systematic review with meta-analysis.

OBJECTIVE: To evaluate the evidence of high-intensity locomotor training on outcomes related to gait and balance for patients with stroke in inpatient rehabilitation. METHODS: Four databases were searched (PubMed, CINAHL, Web of Science, and MedLINE) for articles published prior to 13 June 2023. Studies of adults (>18 years old) with a diagnosis of stroke who received a high-intensity locomotor intervention while admitted to an inpatient rehabilitation facility were included. A functional outcome in the domain of gait speed, gait endurance, or balance must have been reported. Following the screening of 1052 studies, 43 were selected for full-text review. Studies were assessed for risk of bias using the tool appropriate to the study type. Gait speed, gait endurance, and balance outcome data were extracted for further analysis. RESULTS: Eight studies were selected with risk of bias ratings as moderate (4), high (2), and low (2). Six studies were analyzed in the meta-analysis (N = 635). A random-effects model analyzed between-group differences. Standard mean differences demonstrated that high-intensity locomotor training produces a moderate effect on gait endurance (0.50) and gait speed (0.41) and a negligible effect on balance (0.08) compared with usual care. CONCLUSIONS: The meta-analysis supports the use of high-intensity locomotor training over usual care for improving gait speed and gait endurance during inpatient post-stroke. Future studies should investigate dose-response relationships of high-intensity locomotor training in this setting. PROSPERO REGISTRATION: #CRD42022341329.

Modernizing patient-centered manual therapy: Findings from a Delphi study on orthopaedic manual therapy application.

BACKGROUND: Recent literature challenges the process by which orthopaedic manual therapy (OMT) has traditionally been applied. Progressive understanding of the complexities surrounding OMT analgesia and the decreased reliance on technique specific characteristics in determining treatment effectiveness promotes an update to training paradigms related to OMT. OBJECTIVES: The purpose of this Delphi study was to establish consensus on what trainees should be focusing on when demonstrating OMT techniques and how candidates for OMT should be identified. DESIGN: An international three-round Delphi study following recommended guidelines for conducting and reporting of Delphi studies (CREDES) was performed. METHODS: One-hundred sixty-four expert manual therapy educators were identified for participation across four countries. Participants were asked to provide what concepts trainees should be focusing on when demonstrating OMT techniques and how candidates for OMT should be identified. Twenty-one themes were identified for each question. RESULTS: Twenty-eight participants completed all three rounds of the Delphi. Consensus was reached on nineteen themes and eighteen themes respectively. Results from this Delphi stress patient-centered care within a biopsychosocial pain management model. Representation across all pillars of evidence-based practice were represented. Themes reaching consensus within this study favored the importance of neurophysiological, psychological, and biomechanical principles. CONCLUSION: This Delphi presents consensus-based recommendations for what manual therapy trainees should focus on when demonstrating OMT techniques and on how candidates for OMT should be identified. These findings in collaboration with previous consensus recommendations on concepts to focus on within OMT education promote restructuring of OMT curriculum to evidence-based patient-centered care models.

Priorities in updating training paradigms in orthopedic manual therapy: an international Delphi study

PURPOSE: Orthopedic manual therapy (OMT) education demonstrates significant variability between philosophies and while literature has offered a more comprehensive understanding of the contextual, patient specific, and technique factors which interact to influence outcome, most OMT training paradigms continue to emphasize the mechanical basis for OMT application. The purpose of this study was to establish consensus on modifications & adaptions to training paradigms which need to occur within OMT education to align with current evidence. METHODS: A 3-round Delphi survey instrument designed to identify foundational knowledge to include and omit from OMT education was completed by 28 educators working within high level manual therapy education programs internationally. Round 1 consisted of open-ended questions to identify content in each area. Round 2 and Round 3 allowed participants to rank the themes identified in Round 1. RESULTS: Consensus was reached on 25 content areas to include within OMT education, 1 content area to omit from OMT education, and 34 knowledge components which should be present in those providing OMT. Support was seen for education promoting understanding the complex psychological, neurophysiological, and biomechanical systems as they relate to both evaluation and treatment effect. While some concepts were more consistently supported there was significant variability in responses which is largely expected to be related to previous training. CONCLUSION: The results of this study indicate manual therapy educators understanding of evidence-based practice as support for all 3 tiers of evidence were represented. The results of this study should guide OMT training program development and modification.

Symptom response to mobilization and outcomes in patients with subacromial pain syndrome: A cohort study.

OBJECTIVES: The objectives of this study were the following: (1) to determine if there was a difference in outcomes between immediate responders to glenohumeral mobilizations at the initial evaluation, 2-week, 4-week, and 6-month follow-up as compared to those that do not respond in participants with subacromial pain syndrome; (2) to see if there were statistically significant differences in outcomes within these groups between these time frames of interest, and (3) to see if symptom response at the initial evaluation was predictive of a favorable recovery. METHODS: This was a prospective, single-group observational design. Clinicians pragmatically identified positive responders as improving at least two points on the Numeric Pain Rating Scale and/or a 20° improvement in shoulder active range of motion (AROM) following shoulder mobilization at the initial evaluation. Data were collected for the subjective and objective variables of interest at the initial evaluation, 2-week, 4-week, and 6-month follow-up. RESULTS: The prevalence of responders at the initial evaluation was 99 (81.8%). There were no statistically significant between-group differences for the variables of interest except for the Global Rating of Change (GRoC; f = 2.79, p = 0.006). The shoulder abduction AROM between-group difference exceeded the minimal detectable change at 4 weeks. The pair-wise comparison showed statistically significant differences for the outcomes of interest at each time point except for the GRoC between 4 weeks and 6 months. There was a statistically significant correlation between responders at the initial evaluation and shoulder abduction AROM at the 4-week follow-up (rpb (112) = 0.27, p = 0.004). CONCLUSION: Individuals with SAPS may benefit from shoulder mobilization independent of their within-session response to shoulder mobilization at the initial evaluation. Future research should seek to differentiate if these improvements are related to the within-session positive treatment response at the initial evaluation in individuals who are randomized to receive shoulder mobilization or not.

The Effects of Exercise Dosage on Neck-Related Pain and Disability: A Systematic Review With Meta-analysis.

OBJECTIVE: To (1) evaluate whether exercise therapy is effective for managing neck pain, and (2) investigate the relationship between exercise therapy dosage and treatment effect. DESIGN: Intervention systematic review with meta-analysis and meta-regression. LITERATURE SEARCH: An electronic search of 6 databases was completed for trials assessing the effects of exercise therapy on neck pain. STUDY SELECTION CRITERIA: We included randomized controlled trials that compared exercise therapy to a no-exercise therapy control for treating neck pain. Two reviewers screened and selected studies, extracted outcomes, assessed article risk of bias, and rated the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. DATA SYNTHESIS: Data were pooled using random-effects meta-analysis. We used meta-regression to analyze the effect of exercise dosage on neck pain and disability. RESULTS: Fourteen trials were included in the review. Seven trials were at high risk of bias, 4 were at unclear risk of bias, and 3 were at low risk of bias. Exercise therapy was superior to control for reducing pain (visual analog scale mean difference, -15.32 mm) and improving disability (Neck Disability Index mean difference, -3.64 points). Exercise dosage parameters did not predict pain or disability outcomes. CONCLUSION: Exercise was beneficial for reducing pain and disability, regardless of exercise therapy dosage. Therefore, optimal exercise dosage recommendations remain unknown. We encourage clinicians to use exercise when managing mechanical neck pain. J Orthop Sports Phys Ther 2020;50(11):607-621. doi:10.2519/jospt.2020.9155.

Self-reported sinus headaches are associated with neck pain and cervical musculoskeletal dysfunction: a preliminary observational case control study.

Objectives: Headaches can be associated with rhinosinusitis and may present a diagnostic challenge because of symptomatic overlap with other recurring headaches. Neck pain has received extensive attention in migraine, tension-type and cervicogenic headache but not as a comorbid feature of headache in those with rhinosinusitis. This study investigated the occurrence of neck pain and cervical musculoskeletal dysfunction in individuals with self-reported sinus headaches (SRSH). Methods: Participants with and without SRSH attended a single data collection session. Participants completed the Headache Impact Test (HIT)-6 and the Sino-Nasal Outcome Test (SNOT)-22. Cervical range of motion (ROM), segmental examination, muscle endurance and pressure-pain threshold (PPT) were measured . Results: Participants included 31 with SRSH (77.4% female; age 43.7 (9.9) years) and 30 without headache. Average symptom duration was 89.7 (±85.6) months. Mean SNOT-22 and HIT-6 scores were 36.2 (15.3) and 56.7 (7.1), respectively. In the SRSH group, 83.9% (n = 26) reported neck pain. There was a significant difference between groups for cervical sagittal (14.3° [5.3°, 23.3°], p = 0.002) and transverse plane ROM (21.5° [12.4°, 30.6°], p < 0.001), but no difference in frontal plane motion (p = 0.017). There were significant between groups difference in neck flexor endurance (19.5 s [10.1 s, 28.9 s], <0.001), segmental dysfunction O-C4 (p < 0.001) but not in PPT (p = 0.04). Discussion: Neck pain and cervical musculoskeletal dysfunction are common among persons with SRSH and may be a comorbid feature or contributing factor to headaches attributed to rhinosinusitis. Further research is needed to understand these associations.

An exploration of trunk reposition error in subjects with acute stroke: An observational design.

BACKGROUND & OBJECTIVE: Trunk reposition error (TRE) is a component of trunk control, yet has not been reported in acute stroke. The purpose of this study was to quantify TRE in acute stroke and report this with related rehabilitation outcomes. METHODS: Sixty subjects, 30 with acute stroke and 30 healthy controls, completed this study. Subjects with acute stroke were measured before and after an in-patient acute rehabilitation stay. MEASURES: TRE using an electromagnetic tracking device, Berg Balance Scale, Postural Assessment Scale for Stroke, and Functional Independence Measures. Pre-post measures were analyzed with paired t-tests. Between-group measures were analyzed with independent w-tests. RESULTS: There were significant between group differences (acute stroke vs. controls) for all functional outcome measures (P < 0.001) and for three-dimensional TRE (P = 0.001). There were significant improvements in all functional outcome measures following an in-patient rehabilitation stay (P < 0.001). All measures of TRE reduced but did not achieve significance. CONCLUSION: TRE was not as severely impaired as anticipated and was variable based on plane of measure. Time in a rehabilitation setting produced significant improvements in functional outcomes but TRE improvements were not as robust. These results indicate a need for further investigation of the strength of the interrelationship between TRE and function.

Can experienced physiotherapists identify which patients are likely to succeed with physical therapy treatment?

BACKGROUND: The purpose of the study was to determine if clinician predicted prognosis is associated with patient outcomes. METHODS: The study was a secondary analysis of data that were collected in 8 physiotherapy outpatient clinics. Nine physiotherapists with post-graduate training in manual therapy (mean 20.3 years of experience) were asked at baseline to project the outcome of the patients evaluated. In total, 112 patients with low back (74 %) or neck (26 %) pain were treated pragmatically with interventions consisting of manual therapy, strengthening, and patient-specific education. Outcomes measures consisted of percent change in disability (Oswestry or Neck Disability Index), self-reported rate of recovery (0-100 %), and percent change in pain (numerical pain rating scale). Hierarchical logistic regression determined potential factors (clinician predicted prognosis score (1-10) at baseline, dichotomised as poor (1-6) and good (7-10); symptom duration categorised as acute, subacute or chronic; same previous injury (yes/no); baseline pain and disability scores; within-session improvement at initial visit (yes/no); and presence of ≥ one psychological factor) associated with meaningful changes in each of the three outcomes at discharge (disability and pain > 50 % improvement, rate of recovery ≥82.5 % improvement). RESULTS: Clinician predicted prognosis (OR 4.15, 95%CI = 1.31, 13.19, p = 0.02) and duration of symptoms (OR subacute 0.24, 95%CI = 0.07, 0.89, p = 0.03; chronic 0.21, 95%CI = 0.05, 0.90, p = 0.04) were associated with rate of recovery, whereas only clinician predicted prognosis was associated with disability improvement (OR 4.28, 95 % CI 1.37, 13.37, p = 0.01). No variables were associated with pain improvement. CONCLUSIONS: Clinician predicted prognosis is potentially valuable for patients, as a good predicted prognosis is associated with improvements in disability and rate of recovery.

The effect of abdominal strength or endurance exercises on abdominal peak torque and endurance field tests of healthy participants: A randomized controlled trial.

OBJECTIVE: To compare the effects of muscular endurance and resisted strengthening protocols on abdominal strength and endurance in a sample of young subjects. DESIGN: Randomized Clinical Trial. SETTING: University fitness laboratory. PARTICIPANTS: 79 healthy subjects, (45 males and 34 females) aged 23.5 ± 5.8 years. MAIN OUTCOME MEASURES: Measurements were taken at baseline and 12 weeks. Abdominal strength and endurance were evaluated using an isokinetic dynamometer (IKD) and four floor tests including the timed front plank (FP), angle sit (AS), sit-up (SU), and handheld dynamometer (HD). RESULTS: Multivariate analysis revealed no between group differences for the outcomes or group × time interaction (P = 0.52 and P = 0.31 respectively). The univariate within group analysis was significant for SU P = .001, HD rectus P = .007, HD oblique P = .005, and for the IKD peak eccentric torque P = .025. CONCLUSIONS: A 12-week intervention program addressing endurance or strength did not produce between-group differences over a control group of routine activity maintenance.

The relationship between chief complaint and comparable sign in patients with spinal pain: An exploratory study.

Many musculoskeletal management philosophies advocate the exploration of the relationship between the patient's chief complaint (CC) and the physical examination findings that reproduce/reduce/change that CC. Geoffrey Maitland developed the concept "comparable sign(s) (CS), which are physical examination findings related to the CC(s) that are reproduced during an examination/treatment. These include observed abnormalities of movement, postures or motor control, abnormal responses to movement, static deformities, and abnormal joint assessment findings. There are no studies that have explored the potential clinical relationships between the patient's CC and a CS, thus this exploratory study evaluated the associations, outcomes, and prevalence of the findings. This cohort study involved 112 subjects age 54.3 years (SD = 13.4 years), with neck (25.9%) or low back pain (74.1%) who were treated with physiotherapy for an average of 42 days. Data analysis revealed 88.4% identified a CC at baseline. There was a moderate statistical association between CC and the active physiological finding of a CS (r = 0.36), and small-moderate associations between all examination phases (r = 0.25-0.37). There were no statistical differences in pain and disability outcomes for those with and without a CC or CS; however, baseline pain levels were higher for those without CC (p = 0.04). Further, rate of recovery was lower in those without a CS during passive physiological examination. The results would suggest that there may be content validity to the concept of CS but further research with larger samples sizes is required to explore the extent of the validity is warranted.

Is there preliminary value to a within- and/or between-session change for determining short-term outcomes of manual therapy on mechanical neck pain?

OBJECTIVES: The primary purpose of this study was to determine whether occurrences of within- and between-session changes were significantly associated with functional outcomes, pain, and self-report of recovery in patients at discharge who were treated with manual therapy for mechanical neck pain. A secondary purpose was to determine the extent of change needed for the within- and between-session change in association to function. METHODS: This secondary data analysis examined 56 patients who demonstrated a positive response to manual therapy during the initial assessment within a randomized controlled trial (RCT) that examined manual therapy techniques and a home exercise program (HEP). Within- and between-session findings were defined as 'changes in pain report during the initial session (within)' and 'changes in pain from baseline to 48-hours post initial assessment (between)'. Outcomes were analyzed for associations with the global rating of change (GRoC), self-report activity scale (SRAS), and a 50% reduction of the neck disability index (NDI) by discharge at 96 hours. RESULTS: Findings indicate that within-session pain changes of 36.7% are strongly associated with a 50% change in NDI at 96 hours. Between-session changes in pain were associated with 50% change in NDI and a ≧3-point change in GRoC at 96 hours. CONCLUSION: Both within- and between-session measures may be useful to predict success levels at 96 hours for NDI; however, between-session changes are more useful to predict success in GRoC. Measures used during clinical examination may help guide clinicians in identification of candidates best suited for the treatment.

Physical therapists' clinical knowledge of multidisciplinary low back pain treatment guidelines.

BACKGROUND: Numerous clinical practice guidelines (CPGs) have been developed to assist clinicians in care options for low back pain (LBP). Knowledge of CPGs has been marginal across health-related professions. OBJECTIVE: The aims of this study were: (1) to measure US-based physical therapists' knowledge of care recommendations associated with multidisciplinary LBP CPGs and (2) to determine which characteristics were associated with more correct responses. DESIGN: A cross-sectional survey was conducted. METHODS: Consenting participants attending manual therapy education seminars read a clinical vignette describing a patient with LBP and were asked clinical decision-making questions regarding care, education, and potential referral. Descriptive statistics illustrating response accuracy and binary logistic regression determined adjusted associations between predictor variables and appropriate decisions. RESULTS: A total of 1,144 of 3,932 surveys were eligible for analysis. Correct responses were 55.9% for imaging, 54.7% for appropriate medication, 62.0% for advice to stay active, 92.7% for appropriate referral with failed care, and 16.6% for correctly answering all 4 questions. After adjustment, practicing in an outpatient facility was significantly associated with a correct decision on imaging. Female participants were more likely than male participants to correctly select proper medications, refer the patient to another health care professional when appropriate, and answer all 4 questions correctly. Participants reporting caseloads of greater than 50% of patients with LBP were more likely to select proper medications, give advice to stay active, and answer all 4 questions correctly. Participants attending more continuing education were more likely to give advice to stay active and older, and more experienced participants were more likely to appropriately refer after failed care. LIMITATIONS: There was potential selection bias, which limits generalizability. CONCLUSIONS: The survey identified varied understanding of CPGs when making decisions that were similar in recommendation to the CPGs. No single predictor for correct responses for LBP CPGs was found.

No Differences in Outcomes in People with Low Back Pain Who Met the Clinical Prediction Rule for Lumbar Spine Manipulation When a Pragmatic Non-thrust Manipulation Was Used as the Comparator.

PURPOSE: To investigate differences in pain and disability between patients treated with thrust manipulation (TM) and those treated with non-thrust manipulation (NTM) in a group of patients with mechanical low back pain (LBP) who had a within-session response to an initial assessment and met the clinical prediction rule (CPR). METHODS: Data from 71 patients who met the CPR were extracted from a database of patients in a larger randomized controlled trial comparing TM and NTM. Treatment of the first two visits involved either TM or NTM (depending on allocation) and a standardized home exercise programme. Data analysis included descriptive statistics and a two-way ANOVA examining within- and between-groups effects for pain and disability, as well as total visits, total days in care, and rate of recovery. RESULTS: No between-group differences in pain or disability were found for NTM versus TM groups (p=0.55), but within-subjects effects were noted for both groups (p<0.001). CONCLUSIONS: This secondary analysis suggests that patients who satisfy the CPR benefit as much from NTM as from TM.

Objectif : Étudier les différences au niveau de la douleur et de la capacité entre les patients traités par manipulation avec pression (MP) et ceux qui sont traités par manipulation sans pression (MSP) chez un groupe de patients souffrant de lombalgie mécanique (LM) qui ont réagi au cours d'une séance après une évaluation initiale et satisfaisaient à la règle de prévision clinique (RPC). Méthodes : On a extrait des données sur 71 patients qui satisfaisaient à la RPC d'une base de données sur des patients d'un essai contrôlé randomisé de plus grande envergure comparant la MP et la MSP. Au cours des deux premières visites, le traitement a comporté une MP ou une MSP (selon l'affectation) et un programme normalisé d'exercice domicile. L'analyse des données a inclus des statistiques descriptives et une analyse bidirectionnelle des écarts portant sur les effets à l'intérieur d'un même groupe et entre les groupes en ce qui a trait à la douleur et à l'incapacité, ainsi que le nombre total de visites, le nombre total de jours de soins et la rapidité du rétablissement. Résultats : On n'a constaté aucune différence entre les groupes au niveau de la douleur ou de l'incapacité pour le traitement MSP par rapport au traitement MP (p=0,55), mais on a constaté des effets chez les mêmes sujets pour les deux groupes (p<0,001). Conclusions : Cette analyse secondaire indique que les patients qui satisfont aux critères de la RPC bénéficient autant d'une MSP que d'une MP.

The role of patients' expectation of appropriate initial manual therapy treatment in outcomes for patients with low back pain.

OBJECTIVES: The purpose of this study was to compare the outcomes of patients with low back pain who had a matched, unmatched, or were indifferent with their pretreatment expectation/preference to the manual therapy thrust or nonthrust intervention. A secondary purpose was to explore baseline patient characteristics affiliated with a preference of manual therapy treatment type (thrust or nonthrust manipulation). METHODS: The study is a secondary analysis of a prospective randomized controlled trial that enrolled 149 patients with low back pain, from 16 distinct outpatient physical therapy practices within the United States. Patient's pretreatment expectations were identified before randomization. The intervention included manual therapy (thrust or nonthrust manipulation) with a standardized exercise program, which was carried out for 2 treatment sessions. Six outcomes captured the constructs of (a) disability, (b) pain perception, (c) care intensity, (d) fear avoidance behaviors, and (e) perception of extent of recovery. Descriptive statistics, analysis of variance (and Tukey, a post hoc test), Fisher exact test, and a multivariate logistic regression analysis were used for analysis. RESULTS: There were no statistical differences in any of the 6 dedicated outcomes measures between the matched, unmatched, and no preference groups. Therapist-determined patient "irritability" was associated with patient preference of nonthrust treatment, and higher body mass index was associated with patient preference of thrust treatment. CONCLUSIONS: This study shows that patients demonstrated no statistical difference in disability or pain outcome measures when matched, unmatched, or indifferent to the intervention.

Thrust and nonthrust manipulation for older adults with low back pain: an evaluation of pain and disability.

OBJECTIVE: The purpose of the study was to compare the effects of thrust manipulation (TM) and non-TM (NTM) on a sample of older subjects with low back pain. METHODS: This is a secondary data analysis of a randomized control trial. Forty-nine subjects aged 55 to 88 years participated in the trial, who received either a TM or NTM on at least 2 occasions during the course of care, and were extracted from the larger data set. The treatment program included a standardized home exercise program for the first 2 sessions, which could be modified by the therapist after those 2 sessions. Numeric pain rating scale and Oswestry Disability Index (ODI) were the outcomes for this study. RESULTS: Multivariate analysis revealed no significant between-group differences for treatment group (P=.99) without group×time interaction (P=.90). Significant within-group changes were observed for both groups for ODI and numeric pain rating scale (P<.001); the average self-report of recovery was 78.0% (SD, 19.8%). Age stratification of the older subset revealed between-group differences in ODI change scores for the oldest subjects (>70 years) compared with 60 to 69 years (P=.02). CONCLUSIONS: This study showed that outcomes for both TM and NTM improved in older adults with low back pain.

Early use of thrust manipulation versus non-thrust manipulation: a randomized clinical trial.

The purpose of this study was to investigate the comparative effectiveness of early use of thrust (TM) and non-thrust manipulation (NTM) in sample of patients with mechanical low back pain (LBP). The randomized controlled trial included patients with mechanically reproducible LBP, ≥ age 18-years who were randomized into two treatment groups. The main outcome measures were the Oswestry Disability Index (ODI) and a Numeric Pain Rating Scale (NPRS), with secondary measures of Rate of Recovery, total visits and days in care, and the work subscale of the Fears Avoidance Beliefs Questionnaire work subscale (FABQ-w). A two-way mixed model MANCOVA was used to compare ODI and pain, at baseline, after visit 2, and at discharge and total visits, days in care, and rate of recovery (while controlling for patient expectations and clinical equipoise). A total of 149 subjects completed the trial and received care over an average of 35 days. There were no significant differences between TM and NTM at the second visit follow-up or at discharge with any of the outcomes categories. Personal equipoise was significantly associated with ODI and pain. The findings suggest that there is no difference between early use of TM or NTM, and secondarily, that personal equipoise affects study outcome. Within-groups changes were significant for both groups.

Which prognostic factors for low back pain are generic predictors of outcome across a range of recovery domains?

BACKGROUND: Recovery from low back pain (LBP) is multidimensional and requires the use of multiple-response (outcome) measures to fully reflect these many dimensions. Predictive prognostic variables that are present or stable in all or most predictive models that use different outcome measures could be considered "universal" prognostic variables. OBJECTIVE: The aim of this study was to explore the potential of universal prognostic variables in predictive models for 4 different outcome measures in patients with mechanical LBP. DESIGN: Predictive modeling was performed using data extracted from a randomized controlled trial. Four prognostic models were created using backward stepwise deletion logistic, Poisson, and linear regression. METHODS: Data were collected from 16 outpatient physical therapy facilities in 10 states. All 149 patients with LBP were treated with manual therapy and spine strengthening exercises until discharge. Four different measures of response were used: Oswestry Disability Index and Numeric Pain Rating Scale change scores, total visits, and report of rate of recovery. RESULTS: The set of statistically significant predictors was dependent on the definition of response. All regression models were significant. Within both forms of the 4 models, meeting the clinical prediction rule for manipulation at baseline was present in all 4 models, whereas no irritability at baseline and diagnosis of sprains and strains were present in 2 of 4 of the predictive models. LIMITATIONS: The primary limitation is that this study evaluated only 4 of the multiple outcome measures that are pertinent for patients with LBP. CONCLUSIONS: Meeting the clinical prediction rule was prognostic for all outcome measures and should be considered a universal prognostic predictor. Other predictive variables were dependent on the outcomes measure used in the predictive model.

Different minimally important clinical difference (MCID) scores lead to different clinical prediction rules for the Oswestry disability index for the same sample of patients.

BACKGROUND: Minimal clinically important difference (MCID) scores for outcome measures are frequently used evidence-based guides to gage meaningful changes. There are numerous outcome instruments used for analyzing pain, disability, and dysfunction of the low back; perhaps the most common of these is the Oswestry disability index (ODI). A single agreed-upon MCID score for the ODI has yet to be established. What is also unknown is whether selected baseline variables will be universal predictors regardless of the MCID used for a particular outcome measure. OBJECTIVE: To explore the relationship between predictive models and the MCID cutpoint on the ODI. SETTING: Data were collected from 16 outpatient physical therapy clinics in 10 states. DESIGN: Secondary database analysis using backward stepwise deletion logistic regression of data from a randomized controlled trial (RCT) to create prognostic clinical prediction rules (CPR). PARTICIPANTS AND INTERVENTIONS: One hundred and forty-nine patients with low back pain (LBP) were enrolled in the RCT. All were treated with manual therapy, with a majority also receiving spine-strengthening exercises. RESULTS: The resultant predictive models were dependent upon the MCID used and baseline sample characteristics. All CPR were statistically significant (P < 001). All six MCID cutpoints used resulted in completely different significant predictor variables with no predictor significant across all models. LIMITATIONS: The primary limitations include sub-optimal sample size and study design. CONCLUSIONS: There is extreme variability among predictive models created using different MCIDs on the ODI within the same patient population. Our findings highlight the instability of predictive modeling, as these models are significantly affected by population baseline characteristics along with the MCID used. Clinicians must be aware of the fragility of CPR prior to applying each in clinical practice.