Manual Therapy versus Localisation (Tactile, Sensory Training) in Patients with Non-Specific Neck Pain: A Randomised Clinical Pilot Trial.

Manual therapy (MT) techniques typically incorporate localised touch on the skin with the application of specific kinetic forces. The contribution of localised touch to the effectiveness of MT techniques has not been evaluated. This study investigated the immediate effects of MT versus localisation training (LT) on pain intensity and range of movement (ROM) for neck pain. In this single-blind randomised controlled trial thirty eligible neck pain volunteers (23 females and 7 males), aged 28.63 ± 12.49 years, were randomly allocated to MT or to a motionless (LT) group. A single three-minute treatment session was delivered to each group's cervico-thoracic area. The LT involved tactile sensory stimulation applied randomly to one out of a nine-block grid. Subjects were asked to identify the number of the square being touched, reflecting a different location on the region of skin. MT involved three-minute anteroposterior (AP) glides and sustained natural apophyseal glides (SNAG) techniques. Pre- and post-intervention pain intensity were assessed using a pressure pain threshold (PPT) algometer and the numeric pain rating scale (NPRS). Neck ROM was recorded with a bubble inclinometer. Improvements in ROM and self-reported pain were recorded in both groups (p < 0.001) without differences in NPRS, ROM or PPT scores between groups (p > 0.05). Tactile sensory training (localisation) was as effective as MT in reducing neck pain, suggesting a component of MT's analgesic effect to be related with the element of localised touch rather than the forces induced during passive movements.

A process of subgroup identification in non-specific low back pain using a standard clinical examination and cluster analysis.

BACKGROUND AND PURPOSE: Non-specific low back pain (NSLBP) accounts for over 85% of all low back pain. Homogenous subgroups may exist within this diagnosis. This study derived a clinical examination and evaluated the examination's ability to identify homogenous subgroups in NSLBP. METHODS: Patients with NSLBP were examined using a standardized clinical examination. Each patient was examined by two physiotherapists. Data were analysed for item reliability and the presence of distinct subgroups using cluster analysis. Cross-validation of the clusters identified was conducted. RESULTS: Three hundred and one patients were examined. The inter-tester reliability of the majority of items was moderate to substantial (52% of items with kappa > 0.40). A K-means cluster analysis of the two data sets revealed agreement on the presence of two subgroups. One group (n = 47, 16%) had higher fear avoidance beliefs, anxiety and disability. They were more likely to be provoked by pain provocative tests. They were also more likely to be judged as having central sensitization and a dominant psychosocial component to their presentation. CONCLUSION: The identification of a group of hypervigilant NSLBP patients should allow the interventions to be targeted towards this group. A valid, standardized clinical examination does contribute to the diagnostic management of NSLBP.

The reliability of the clinical tests and questions recommended in international guidelines for low back pain.

STUDY DESIGN: An intertester reliability study of the questions and tests recommended in guidelines for the management of low back pain (LBP). OBJECTIVE: This study undertook a reliability study to evaluate the reliability of the items of the LBP clinical examination with a large sample of LBP patients. SUMMARY OF BACKGROUND DATA: A crucial part of the diagnostic triage process, recommended by many national and international guidelines for the management of LBP, is the clinical examination. The questions and tests used in this process have never been rigorously evaluated for their intertester reliability in first contact clinicians who are not medically trained. METHODS: Patients, referred to physiotherapy departments across the United Kingdom with LBP (n = 301) were recruited in a sample of convenience. The 50 questions and physical tests were administered by a physiotherapist and then repeated by another physiotherapist within the same day. Data were analyzed using kappa and weighted kappa correlation coefficients (kappa). Confidence intervals (95% CIs) were calculated. RESULTS: Eighty-six percent (n = 43) of the questions and test demonstrated kappa of 0.41 (fair agreement) or above. Five questions and 2 physical tests (prone knee bend and myotomal assessment) demonstrated agreement of only slight levels. CIs were generally narrow and the uncertainty regarding the kappa coefficients demonstrated correspondingly low. CONCLUSIONS: This study has rigorously evaluated the intertester reliability of the clinical examination process of the diagnostic triage. These clinicians generally demonstrated fair agreement when testing features of the "nerve root," "yellow" and "red flag" presentations recommended in international guidelines for the management of LBP and nonspecific LBP. However, reliance on single tests with only fair levels of agreement may be unwise. Further work is required to investigate the validity of the tests.

Pulsed electromagnetic energy treatment offers no clinical benefit in reducing the pain of knee osteoarthritis: a systematic review.

BACKGROUND: The rehabilitation of knee osteoarthritis often includes electrotherapeutic modalities as well as advice and exercise. One commonly used modality is pulsed electromagnetic field therapy (PEMF). PEMF uses electro magnetically generated fields to promote tissue repair and healing rates. Its equivocal benefit over placebo treatment has been previously suggested however recently a number of randomised controlled trials have been published that have allowed a systematic review to be conducted. METHODS: A systematic review of the literature from 1966 to 2005 was undertaken. Relevant computerised bibliographic databases were searched and papers reviewed independently by two reviewers for quality using validated criteria for assessment. The key outcomes of pain and functional disability were analysed with weighted and standardised mean differences being calculated. RESULTS: Five randomised controlled trials comparing PEMF with placebo were identified. The weighted mean differences of the five papers for improvement in pain and function, were small and their 95% confidence intervals included the null. CONCLUSION: This systematic review provides further evidence that PEMF has little value in the management of knee osteoarthritis. There appears to be clear evidence for the recommendation that PEMF does not significantly reduce the pain of knee osteoarthritis.

Cost-effectiveness of a supplementary class-based exercise program in the treatment of knee osteoarthritis.

OBJECTIVES: The aim of this study was to assess the cost-effectiveness of a class-based exercise program supplementing a home-based program when compared with a home-based program alone. In addition, we estimated the probability that the supplementary class program is cost-effective over a range of values of a decision maker's willingness to pay for an additional quality-adjusted life-year (QALY). METHODS: The resource use and effectiveness data were collected as part of the clinical trial detailed elsewhere. Unit costs were estimated from published sources. The net benefit approach to cost-effectiveness analysis is used to estimate the probability of the intervention being cost-effective. RESULTS: The addition of a supplementary class-based group results in an increase in QALYs and lower costs. For all plausible values of a decision maker's willingness to pay for a QALY, the supplementary class group is likely to be cost-effective. CONCLUSIONS: The addition of a class-based exercise program is likely to be cost-effective and, on current evidence, should be implemented.