Treatment Based Classification of the SpineAn Evidence Based Journey for the Physical Therapist

Development of Clinical Prediction Rules

Tara J. Manal, PT, DPT, OCS, SCS Gregory E. Hicks, PT, PhD

What are we looking for in the first place? „ „

„

„

„

Cause of the illness/problem Severity of an illness (in addition to its cause) Subsequent clinical course and prognosis Likely responsiveness to therapy (future) Actual response to therapy (present)

Clinical Prediction Rules „

„

„

– Accuracy of diagnosing ankle fractures (Stiell, Ann Emerg Med, 1992) – Likelihood of death in coronary disease (Mark, N Engl J Med, 1991) – Diagnosis of cervical radiculopathy (Wainner, Spine, 2003) – When to order cervical radiographs (Stiell, JAMA, 2001)

Prediction Rule Experiments

Development of a CPR „

Step 1: Derivation Identify factors with predictive value

Step 2: Validation Reproduce the rule in a different population

Step 3: Impact Analysis Does the rule change clinician behavior, improve patient-centered outcomes and/or reduce costs?

Tools to assist in decision-making process Improve diagnostic accuracy or predict outcome Examples in the medical literature

Derivation – Admit a series of patients – Collect baseline data – Administer one treatment (e.g., manipulation) – Separate responders from non-responders (those that do much better than expected) – Analyze baseline data with respect to responders and non-responders

„

Validation – Conduct RCT to assess the effectiveness of matched versus unmatched

1

Lumbar “Instability”Background for Developing a Clinical Prediction Rule for Lumbar Stabilization

Lumbar Segmental Instability „

„

„

The pathoanatomical cause is unknown in most cases of low back pain. Many authorities suggest segmental instability as a pathoanatomical mechanism underlying mechanical low back pain. Defining, identifying and treating segmental instability remains elusive.

Defining Instability „ „ „

Mechanical Clinical Neutral Zone Concept

Mechanical Definition

„

In mechanical terms, segmental instability is defined as: – “A loss of spinal motion segment stiffness such that applied forces produce displacements exceeding those found in a normal spine.” (Pope, 1985)

Mechanical Definition „

„

Requires a definition of normal movement. Initial thresholds for defining instability were based on the values previously cited: – Anterior translation > 3 mm, or 9% of vertebral body width

2

Mechanical Definition „

Asymptomatic subjects have been found to exhibit wide variability in segmental motion characteristics. (Dvorak et al, Spine, 1991)

„

3.5 mm anterior translation

Hayes et al (Spine, 1989) found 42% of asymptomatic subjects had at least one segment exceeding the instability thresholds.

Mechanical Definition „

Mechanical Definition

Strictly mechanical definitions of instability are known to be problematic at other joints.

„

– Strength – Neuromuscular Control

– Functional instability in ACL-deficient patients is not correlated with the amount of laxity present. (Snyder-Mackler et al, AJSM, 1998)

Clinical Definitions „

“Instability exists only when, during the performance of an active motion, there is a sudden aberrant motion, such as a visible shift, catch, or shaking of the section, or when there is a palpable difference in the bony position between standing and lying.” (Paris, Spine, 1985)

Other factors may determine the functional ability of patients with joint laxity.

Clinical Definitions „

“Instability can be defined as the clinical status of the patient with back problems who with the least provocation steps from the mildly symptomatic to the severe episode.” (Kirkaldy-Willis and Farfan, Clin Orthop, 1982)

3

Clinical Definitions „

„

The validity of clinical definitions of instability has not been shown previously. Numerous clinical factors have been proposed: – – – –

“Instability catch” Palpable “step-off” Increased passive inter-vertebral motion General ligamentous laxity

Clinical Definitions „

Others have focused on findings from the history: – Frequent recurrent episodes with minimal perturbation – History of trauma – Dramatic, short-lived response to manipulation – Self-manipulation – Response to immobilization

The Neutral Zone Concept of Instability

Integrated Definition „

“Clinical instability is defined as the loss of the spine’s ability to maintain its patterns of displacement under physiologic loads so there is no initial or additional neurologic deficit, no major deformity, and no incapacitating pain”

„

„

Joint Laxity

(White and Panjabi, 1990)

The load-displacement characteristics of spinal motion segments is highly nonlinear. Total ROM

Neutral Zone

Stress

Strain

Elastic Zone

Instability

Neutral Zone Concept

Neutral Zone Concept „

Recognizes multi-factorial nature of clinical instability Differentiates between:

„

Total ROM = Neutral Zone + Elastic Zone „Neutral Zone = The part of the total ROM within which spinal motion is produced with minimal resistance from passive tissues. „Elastic Zone = The part of the total ROM from the end of the neutral zone up to the physiological limit within which motion is produced against significant resistance from passive tissues.

4

Neutral Zone

Elastic Zone

Neutral Zone

Neutral Zone Concept „

The size of the NZ relative to the total ROM may be a better indicator of instability than an increase in total ROM.

NORMAL

– Experimentally-induced trauma increases the size of the NZ relative to total ROM – Sequential sectioning studies result in increases in both the NZ and total ROM – The application of muscle forces decreases the size of the NZ, but not total ROM

Elastic Zone

Muscle Contraction

Neutral Zone

Elastic Zone

Trauma

Neutral Zone Concept „

“Spinal instability represents a significant decrease in the capacity of the stabilizing system of the spine to maintain the NZ within physiological limits so that there is no neurological deficit, no major deformity, or incapacitating pain.”

Spinal Stabilizing System The spinal stabilizing system consists of three inter-related subsystems: Neuromuscular Control

Passive Subsystem

(Panjabi, J Spinal Dis, 1992)

Neutral Zone Concept „

This definition has several advantages: – It directs attention away from the terminal behavior of a joint to its midrange behavior. – It accounts for influence of factors such as muscular strength and neuromuscular control.

Active Subsystem

Passive Stabilizing System „

„

„

Includes vertebrae, facet joints, discs, ligaments, and passive properties of muscle tissue Primary role is near the end-range of motions (i.e., elastic zone) The role of passive structures has been studied extensively

5

Passive Stabilizing System „

„

Passive Stabilizing System

Within NZ, passive structures may function as force transducers, providing proprioceptive feedback to neuromuscular subsystem.

„

– Disruption of posterior ligaments

Mechanoreceptors have been found in most passive structures:

– Degeneration of intervertebral discs – Bony failure (e.g., pars fracture, laminectomy)

– intervertebral discs „

– facet joint capsule – posterior ligaments

Active Stabilizing System „ „

„

„

Injury to the passive stabilizing system will increase the size of the NZ relative to EZ.

Injury to passive structures places greater demands on the other subsystems for maintaining stability.

Active Stabilizing System

Consists of spinal muscles and tendons

„

The lumbar spine devoid of musculature is highly unstable at even low applied loads.

– Intertransversarii, interspinales „

Primarily responsible for stability in the NZ along with the neuromuscular control system.

„

– Iliocostalis lumborum

Each muscle consists of two components: – pars thoracis – pars lumborum

Pars thoracis portions have no attachment to lumbar spine. – Produce extension or side-bending of lumbar spine – Provide the majority of the extensor force for lifting – Contraction also produces large compressive forces

– Longissimus thoracis

„

Erector spinae Abdominals Multifidus Quadratus lumborum

Erector Spinae

Erector Spinae Consists of two muscles:

Larger, multisegmental muscles function as primary movers. – – – –

The role of specific muscles in maintaining spinal stability is not completely understood.

„

Small, unisegmental muscles may play a primarily proprioceptive role.

„

Pars lumborum portions attach to individual lumbar vertebrae – may help control segmental motions

6

Abdominals „

„

„

Abdominals

Rectus Abdominus

„

Obliques (Internal, External)

„

Transversus Abdominus

Abdominals „

„

Co-contraction in response to movements

Attachments: – Anterior to pubic crest, linea aspera – Posterior to lumbar vertebrae via the thoracodorsal fascia

– Oblique abdominals and rectus abdominus „

Actions: – Acting bilateral will “draw in” the abdominal wall – Increase expiratory capacity

– Transversus abdominus „

Goal of therapeutic exercise is to maximize activity of oblique abdominals, minimize rectus abdominus

Transversus Abdominus

Individual abdominal muscles may contribute to spinal stability in different ways:

„

The role of the abdominal muscles may be in their co-contraction with the segmental extensors to stiffen the trunk

Anticipatory postural stabilization response

Multifidus „

„

„

Control Subjects

LBP Subjects

Originates from the individual lumbar spinous processes Series of fascicles attaching to the inferior vertebrae and pelvis. Able to exert force on individual lumbar motion segments.

7

Multifidus „

Proposed functions: – Control anterior sagittal rotation during flexion – Oppose the flexion moment produced by the abdominals during rotations. – Co-contract with antero-lateral abdominals to stabilize the trunk

Multifidus „

Multifidus

Research Findings:

„

– Biopsies of patients with chronic LBP shows multifidus atrophy – Multifidus atrophy is more pronounced on side of symptoms (Mattila, Spine, 1986) – Recovery of multifidus cross-sectional area did not occur within 4 weeks even in patients who recovered. (Hides et al, Spine,

Research Findings: – Poor outcomes after laminectomy have been correlated with the degree of multifidus atrophy (Rantanen et al, Spine, 1993)

1996)

Quadratus Lumborum „

„

Attaches the transverse processes of L1-L4 to the pelvis Suggested to be the primary stabilizer for side-bending movements

The Active Stabilizing System Implications for Rehabilitation „

Rehabilitation should focus on strengthening: – erector spinae – Abdominals, obliques and transversus abdominus – multifidus – quadratus lumborum

„

Exercises need to be developed to target these muscle groups without imposing excessive stresses on the lumbar spine.

8

Neuromuscular Control System „

„

„

Research Evidence

Receives input from the passive and active subsystems to determine the specific requirements for maintaining stability.

„

– Proprioception

The effectiveness of the neuromuscular control system may be compromised following injury.

™

Angular repositioning

™

Passive motion detection

– Postural Control

Failure to regain neuromuscular control may place the patient at risk for re-injury.

Positioning Accuracy

™

Center of gravity sway

™

Reaction time

™

Weight distribution

Postural Control

8.1

9

Mean Deviation (degrees)

Studies of Neuromuscular Control:

LBP Control

6.7

8 7

„

5.6

6

Luoto et al (Spine, 1996, 1998) – Subjects:

4.5

5

i61 control

4

i99 chronic LBP

– Testing:

3 2

iForce plate used to assess center point of force

1

iReaction time for upper and lower extremities

0

Standing

Kneeling Gill and Callaghan, Spine, 1998

Postural Control „

Luoto et al (Spine, 1996, 1998)

Implications for Rehabilitation „

– Results: „

„

Patients with LBP had increased sway of CPF in one-leg and eyes open condition After rehabilitation:

„

„

Deficits in neuromuscular control appear to be a problem in some patients with LBP Effective exercises to challenge this system have not been identified. Proposed treatments include:

– Sway worsened in patients whose disability increased

– Therapy balls

– Reaction times improved in patients whose disability decreased

– Unstable surface training – Etc…

9

Treatment: Lumbar Stabilization „

Address the 3 components of the spinal stabilizing system – Passive Stabilizing System – Active Stabilizing System – Neuromuscular Control System

Passive Stabilizing System „

„

Patient Education – Avoid end-range movements to avoid overstressing the passive stabilizing system. – Lifting even light loads at end-range flexion can impose damaging forces on the passive stabilizing structures of the spine. – Emphasize the importance of maintaining muscular strength and endurance to minimize stress on the passive stabilizing system.

Active Stabilizing System

Bracing – Bracing to avoid flexion in conjunction with an extension exercise program was found to be effective in reducing pain (Spratt et al, Spine, 1993) – May be more appropriate for people with higher levels of disability.

Strengthening the Erector Spinae Muscles „

Passive Stabilizing System

„

Primary Stabilizers of the Spine – Erector Spinae/Multifidus – Transversus Abdominus – Oblique Abdominals – Quadratus Lumborum

Exercise #1 – Single leg extension

Callaghan et al (Phys Ther, 1998) – Studied 4 different exercises – 14 healthy male subjects – Recorded EMG activity and L4/L5 compressive forces

Exercise #2 contralateral arm and leg extension

10

Exercise #3 – Active trunk and leg extension

EMG Activity (%MVC) 60 50 40 External Oblique

30

Multifidus

20

Exercise #4 Extension from flexed position

0

Arm

Arm+Leg

Hyperext

Full Ext

Strengthening the Erector Spinae

4500 3500 Force (N)

Erector Spinae

10

„

Arokoski et al (Arch Phys Med, 1999)

2500

– 11 healthy subject (6 male, 5 female)

1500

– EMG recording from erector spinae at L2 and L5

500 -500

– 18 different exercises:

Arm

Arm+Leg Hyperext

Full Ext

Compression Shear

u prone bilateral hip extension

u Prone trunk lift

u Walking

u Prone isometric extension hold

Average Erector Spinae EMG (%MVC)

Conclusions

60

50

„

40

„ 30

„

20

10

„

0 Quadruped

uQuadruped arm/leg lift

Prone ext

Iso ext

Prone hip ext

Leg extension tasks produce low compressive loads and low muscle activity Adding arm extension increased the demands Exercises involving extension in prone place high compressive loads on the spine Full extension from a flexed position produced high anterior shear forces

Walking

11

Strengthening the Multifidus

Erector Spinae & Multifidus Strengthening

60 50 40 External Oblique

30

Multifidus

20

Erector Spinae

10 0

Arm

Arm+Leg

Hyperext

Full Ext

Transversus Abdominus „

O’Sullivan et al. – Chronic LBP pts. have decreased ability to preferentially activate internal obliques and TrA while performing the abdominal hollowing maneuver without activation of rectus abdominus. – After a 10-week intervention, the specific exercise group (abdominal hollowing) had a statistically signif. increase in activation of IO and TrA relative to rectus abdominus.

Transversus Abdominus „

O’Sullivan et al. – RCT on patients with chronic LBP (spondylosis and spondylolisthesis) with a 10-week specific exercise intervention vs. a conservative treatment program. – Specific exercise group had a statistically significant reduction in pain intensity and functional disability levels maintained at 30 months.

Strengthening the Abdominals

Abdominal Hollowing or Bracing „

Axler and McGill (Med Sci Sports Exerc,

1997) – 12 different abdominal exercises – Measured activity of different abdominal muscles (rectus abdominus, int/ext obliques) – Measured compressive cost to the spine

12

Compressive Forces L4/L5 Comp (Thousands N)

3.5 3 2.5 2 1.5 1 0.5 0 Curl-Up

Muscle Activity

SLR

SideSupport

Hanging SLR

Cross Bent-Leg StraightCurl-Up SU Leg SU

Conclusions

120

„

EMG (%MVC)

100 80 60

EO RA

40 20

„

0 Curl-Up

SLR

SideSupport

Sit-up

Cross Curl-up

Hanging SLR

Conclusions „

Not Recommended ¾

Supine SLR

¾

Supine Bent-leg raise

¾

Hanging bent-leg raise

¾

Sit-ups (emphasize rectus abdominus)

Low Compression, Low Challenge ¾

Curl-up feet free or fixed

Horizontal Side Support with Knees Flexed

High Challenge-to-Compression Ratio ¾

Isometric side-support

¾

Cross-knee curl-up

¾

Hanging SLR

13

Strengthening the Quadratus Lumborum

Horizontal Side Support with Knees Extended „

„

Neuromuscular Control System

Strengthening the Transversus Abdominus 70

„

60 50 40 TA EO RA

30 20

„

10 0 Sit-up

Curl-up

Cross Side Curl-up Support

SLR

Juker&McGill, 1998

Dynamic Stabilization „

„

„

„

McGill has found the isometric side-support exercise to be most effective in activating the quadratus lumborum Side support produces 54%MVC of the quadratus with low compressive loads

Begin with simple weight shifts Progress to unilateral movements of UE/LE Then, progress to contralateral movements of UE and LE PNF patterns may be used

„

In order to regain control of proprioception and postural control, a progression through dynamic stabilization exercises (emphasis on unstable support surfaces) is appropriate. During all of these exercises, encourage the pt. to maintain abdominal bracing in order to promote spinal stability. Avoid extreme positions which may reproduce symptoms.

Dynamic Stabilization „

To increase difficulty: – Progress to standing activities. – Progress from a wider base of support to a narrower one. – Decrease stability with different surfaces, e.g. a foam roll, a trampoline, or a wobble board.

14

Exercise Prescription „

Exercise Prescription

Focus on endurance of stabilizers rather than just strength.

„

– Changes due to re-training of the trunk muscles will not occur quickly. – It may take as long as 3 months to see desired results. (Manniche, Scand J Med Sci Sports, 1996) (O’Sullivan et al., Spine, 1997)

– Since stabilization is main function of these muscles, sustained, sub-maximal efforts will be the key to effective training. „

Low back exercises are most effective when performed daily. (Mayer et al., Spine, 1985)

Diagnosis

Who Needs Stabilization? •Usually, LSI is “presumed” to be present and is treated with stabilization programs in an effort to enhance the function of the critical spinal stabilizing muscles. (McGill 2001)

•Until recently, little information was available to help clinicians decide which patients are most likely to benefit from a stabilization program.

Persistence is the key.

„

“A diagnostic test is most valuable to a clinician when it is able to predict treatment outcome and to help define the course of treatment.” (Sackett, 1992)

Research Objective „

To develop clinical prediction rules for predicting success and failure in response to a stabilization exercise program for patients with low back pain. – Change in disability level was used as the reference standard.

15

Methods

Methods Subjects Recruited by PT

„ „

Standardized Evaluation by PT

Stabilization Program

Re-Evaluation by Masked PT (8 weeks)

ROM Testing Aberrant Motion Assessment 1. Painful Arc in Flexion

2. 3. 4. 5.

Painful Arc on Return from Flexion Gower’s Sign Instability Catch Reversal of Lumbopelvic Rhythm

Demographics Historical Questions – – – – – – – –

Duration of Symptoms Mode of Onset (Traumatic?) Distribution of Symptoms (Lumbar vs Leg) Worst Position (Sitting vs Standing/Walking) Worst Time (Evening vs Morning/Midday) Number of Prior Episodes of LBP Deformity with Prior Episodes Increased Frequency of Episodes

Mobility Assessment Prone Posterior-Anterior Segmental Mobility Assessment „segmental

mobility

– (hyper-, hypo- or normal) „pain

provocation

– (present, absent)

Prone Instability Test 1. P-A test for pain provocation – Identify painful segments

2. Repeat P-A with hips extended – Positive finding – previously painful segments become painfree

Methods Physical Examination Physical Impairment Index – – – – – – –

(Waddell 1992)

Average Trunk Side-Bending Total Trunk Flexion Total Trunk Extension Average Straight Leg Raise Active Bilateral Straight Leg Raise Active Sit-up Test Spinal Tenderness

16

Methods Physical Examination Beighton Scale „ 4 tests are assessed bilaterally with a point given for each positive finding. – – – – „

Passive Passive Passive Passive

hyperextension of elbow >10o hyperextension of finger 5 to >90o Abduction of thumb to contact forearm hyperextension of knees >10o

The final test is the ability to flex the trunk and place both hands flat on the floor.

Stabilization Program „

Methods Subjects Recruited by PT

Stabilization Program

Re-Evaluation by Masked PT (8 weeks)

Exercise Intervention Transversus Abdominus

Exercise Prescription – Criterion-Based Program – Focus on repeated sub-maximal efforts „

Standardized Evaluation by PT

Quadratus Lumborum Oblique Abdominals

Increased hold times and high reps

– Goal: Attend PT twice weekly for 8 weeks – Goal: Perform HEP on non-PT days

Multifidus/ Erector Spinae

Stabilization Treatment Transversus Abdominus

Stabilization Treatment

Abdominal Bracing Bracing with Heel Slides Bracing With Leg Lifts Bracing with Bridging

Multifidus/ Erector Spinae

Quadruped Arm Lifts with Bracing Quadruped Leg Lifts with Bracing Quadruped Alternate Arm and Leg Lifts with Bracing

Bracing in Standing Bracing with Standing Row Exercise Bracing with Walking

17

Methods

Stabilization Treatment Quadratus Lumborum Oblique Abdominals

Side Support with Knees Flexed

Subjects Recruited by PT

Side Support with Knees Extended Side Support with Knees Flexed Side Support with Knees Extended

Stabilization Program

Hanging Leg Lifts

Data Analysis

Re-Evaluation by Masked PT (8 weeks)

Data Analysis „

„

Standardized Evaluation by PT

Outcome Variable (Change in Oswestry Score) Success

Improved

Failure

> 50% change

6 point change

910)

FABQ – physical activity subscale ( 6 point change)

Number of Variables Present

Sensitivity

Specificity

+LR

-LR

At least one (+) finding

0.28 (0.16,0.44)

0.94 (0.74, 0.99)

1.3 (1.0, 1.6)

0.20 (0.03, 1.4)

At least two (+) findings

0.83 (0.61, 0.94)

0.56 (0.40, 0.71)

1.9 (1.2, 2.9)

0.30 (0.10, 0.88)

At least three (+) findings

0.56 (0.34, 0.75)

0.86 (0.71, 0.94)

4.0 0.52 (1.6, 10.0) (0.30, 0.88)

Prediction of Success

CPR for predicting failure with stabilization treatment. Number of Variables Present

Sensitivity

Specificity

+LR

-LR

One or more positive tests

0.97 (0.88, 1.0)

0.13 (0.04, 0.38)

1.1 (0.92, 1.3)

0.20 (0.02, 2.0)

Two or more positive tests

0.85 (0.70, 0.93)

0.87 (0.62, 0.96)

6.3 (1.7, 23.2)

0.18 (0.08, 0.38)

Three or more positive tests

0.59 (0.43, 0.73)

1.0 (0.80, 1.0)

18.8 (10.9, 32.3)

0.43 (0.29, 0.65)

Four or more positive tests

0.18 (0.09, 0.33)

1.0 (0.80, 1.0)

6.0 (2.9, 12.4)

0.84 (0.70, 1.1)

Pre-Test Probability of Success = 33%

Post-Test Probability of Success

= 67% Success CPR •Prone Instability Test •Aberrant Movement •SLR >91o

At least 3/4

•Age9 •Hypermobility

•FABQ-PA >9 •Hypermobility

At least 3/4

Less than 2/4

(+) LR = 18.8

(-) LR = .18

Implications

Summary „

„

This is the first step in the development of clinical prediction rules for use of stabilization exercises in patients with low back pain. It appears that response to stabilization can be predicted from variables collected in the clinical examination.

Development of a Clinical Prediction Rule for Manipulation

„

„

„ „

These types of prediction rules can improve the speed and accuracy of the clinical decision-making process for physical therapists who treat patients with LBP. The ability to identify patients a priori who will likely fail with stabilization allows the clinician to consider alternative interventions.

Admitted consecutive patients Collected baseline information – Historical data – Physical examination (e.g., pelvic landmarks)

„

Responders „

Must have improved 50% within one week

20

Enroll into Study

What predicts success?

Visit 1 Examination Spinal Manipulation YES

50% Reduction in ODQ

Visit 2

Success

NO

Examination it 3 Vis

SI Region Manipulation NO

YES

50% Reduction in ODQ

NonSuccess

Success Flynn et al, Spine, 2002

Criteria for a positive response Criteria

Definition of Positive

1. Duration of current episode 2. Extent of Distal Sxs

< 16 Days None distal to knee

3. FABQ subscale score < 19 points 4. Segmental Mobility Test 5. Hip Internal ROM

Spinal Manipulation CPR Flynn et al, Spine, 2002 History Symptoms < 16 days

At least one hypomobile segment One hip > 35 degrees IR

SIJ Mobilization

FABQWK < 19

No symptoms distal to the knee

Physical Exam Hip IR > 35 degrees

Lumbar hypomobility

21

The positive likelihood ratio for patients who met at least 4/5 of the criteria was 24.4 (95% CI: 4.6, 139.4)

Limitations „ „

No control group Do the factors simply predict the favorable natural history of LBP?

“…it is impossible from these data to conclude anything about the response of these patients to spinal manipulative therapy versus any other therapy or even no therapy….the most strongly predictive variable…was duration of pain, which most strongly predicts recovery even in the absence of treatment.” Shekelle PG, Assesndelft WJ. Spinal manipulation for low back pain: In response. Ann Int Med. 2004;140:665-666

Design „ „

Multicenter RCT Total of 14 PTs on 8 centers participated – 2 academic medical centers, one armed services based facility and the remainder public and private outpatient clinics

„

Patients with LBP in Physical Therapy

R

Manipulation Group

Exercise Group

Consecutive patients 18-60 years of age – No red flags, no pregnancy, no previous surgery, no compressive nerve root

+CPR

-CPR

+CPR

-CPR

22

Research Design Patients with LBP (n=543) Ineligible (n=386) Met Inclusion/Exclusion Criteria (n=157) Elected not to participate (n=26) Baseline Examination/Randomization (n=131)

Manipulation Group (n=70)

Exercise Group (n=61)

-CPR (n=47)

+CPR (n=23)

+CPR (n=24)

-CPR (n=37)

Spinal Manipulation CPR

Results

Flynn et al, Spine, 2002 History

50

Symptoms < 16 days

45

FABQWK < 19

ODQ Score

40 35

+ CPR (manip)

30

- CPR (manip)

25

No symptoms distal to the knee

+ CPR (exercise)

20

- CPR (exercise)

15 10 5 0 Baseline

1-week

4-weeks

P 35 degrees

Number of Criteria Present

All five present

Sensitivity

Specificity

Positive Likelihood Ratio

Probability of Success

Negative Likelihood Ratio

Probability of Success

.07 (.02, .21)

1.0 (.91, 1.0)

infinite (.22, infinite)

indeterminate

.93 (.79, 1.08)

43%

Lumbar hypomobility

Who should not be manipulated? Pre-Test Probability of Success = 45%

Four or more present

.68 (.50, .81)

.95 (.83, .99)

13.2 (3.4, 52.1)

.34 (.20, .57)

21%

Three or more present

.94 (.79, 98)

.62 (.46, .75)

2.4 (1.6, 3.7)

66%

.10 (.03, .41)

7%

Two or more present

1.0 (.89, 1)

.21 (.11, .36)

1.3 (1, 1.6)

50%

0 (0, 1)

approaching 0%

One or more present

1.0 (.89, 1.0)

.05 (.01, .17)

1.1 (.89, 1.2)

46%

0 (0, 1)

approaching 0%

91%

The patient has symptoms distal to the knee Negative LR = 0.16 Post-Test Probability = 12%

Longer symptom duration Less hip rotation ROM Negative Gaenslen sign Absence of hypomobility of the spine Fritz Physical Therapy 2004

23

Alternative Manipulation „ „ „ „

Alternative Manipulation

Case series of patients (n=12) with LBP who meet CPR for manipulation Used Side-lying Lumbar Manipulation 11/12 had >50% reduction as seen in Flynn and Childs studies Possible that patients who meet the CPR may benefit from either type of lumbopelvic manipulation Cleland, JOSPT, 2006

Does it Matter Which Exercise?: A Randomized Control Trial of Exercise for Low Back Pain „ „

Long, A; Donelson, Ron; Fung, T Spine 2004; 29(23)2593-2602

24

„ „ „

120 patients classified and treated. Test-Retest reliability on 43 patients. Outcomes assessed: – Disability (Oswestry score) – Duration of therapy – Numbers of visits

Lumbar Immob. Mob.

SI Mob.

9

0

0

1

1

0

Lumbar Mob.

0

3

1

3

0

1

Immob.

1

2

6

0

0

0

Ext.

1

0

1

6

0

0

2

0

0

0

3

0

1

0

0

0

0

1

Percent Agreement = 28/43 (65%)

Lumbar Mobilization

Sacroiliac Mobilization

Extension Syndrome

Flexion Syndrome

Lateral Shift

Traction

Lateral Tractio Shift n

SI Mob.

Lateral Shift Tractio n

Immobilization

Ext.

Kappa = 0.56

60 58.3

50 40 39.4

9%

3%

Stabilization Traction Mobilization Specific Ex.

38.3

30

18% 7%

18%

38.9

20 10

18%

27%

5.9 7.3 5.7 5.2

0 Oswestry

Pain

25

PreTreatment

37.4

ti o ac

ci se

c

Tr

za ob

n

21.1

ti o

n

ili

za

ifi Sp

ec

Im

m

Sp

ob

ec

ili

if i

M

37.2

18.1

tio

n tio ac

Duration of Treatment (days)

c

ob

ili

Ex er

za

ci

t io

se

n

n io za t il i ob m Im

7.7

5.6

5.3

37.3 30.4

Tr

7.1

38.4

er

Number of Appointments

M

20.6

58.3

n

23.8

22.2

60 50 40 30 20 10 0

Ex

31.0

M e a n O s w e s try S c o re

35 30 25 20 15 10 5 0

Will effect size increase if matching takes place? Prediction Rule

Self Treatment

Centralization Matched ? 4 of 5 (duration, etc.) 3 of 4 (age