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Look at this validation study guys, worth reading!
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Look at this validation study guys, worth reading! - December 27, 2004 12:29:00 PM
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jma
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The following was taken from the APTA website: I like this prediction rule and hope to apply it. Thoughts, comments???
"Clinical Prediction Rule Identifies Patients with Lower Back Pain who will Benefit from Spinal Manipulation
ALEXANDRIA, VA, Dec. 21, 2004 -- A patient's status on a clinical prediction rule for low back pain indicates the likelihood of successful outcome from spinal manipulation treatment, according to a study recently published this month in the Annals of Internal Medicine.
Physical therapist Maj John D Childs, PT, PhD, of Wilford Hall Medical Center, Lackland Air Force Base, Texas, and other physical therapist researchers have validated a clinical prediction rule that determined the likelihood that a patient with low back pain will benefit from spinal manipulation. Factors in the prediction rule include symptom duration, symptom location, fear-avoidance beliefs, lumbar mobility, and hip rotation range of motion. The best results were from those patients who were positive on the rule, defined as meeting at least 4 out of 5 criteria. To view an online instructional video on the prediction rule, click here.
"Attempts to identify effective interventions for individuals with low back pain have been largely unsuccessful, especially where spinal manipulation is concerned," Childs explained. "Conflicting conclusions may be attributable to the failure of researchers to adequately consider the importance of classification. Developing methods for matching patients with low back pain to treatments that are most likely to benefit them is an important research priority."
The study examined 131 patients with low back pain, 18 to 60 years of age, who were referred to care provided by physical therapists. Patients were randomly assigned to receive physical therapy that included two sessions of high-velocity thrust spinal manipulation plus an exercise program (manipulation group) or an exercise program without spinal manipulation (exercise group). During the first two sessions, patients in the manipulation group received high-velocity thrust spinal manipulation and a range-of-motion exercise only. Patients in the exercise group (and patients in the manipulation group after the first two sessions of high-velocity thrust manipulation) were treated with a low-stress aerobic and lumbar spine-strengthening program. Patients in both groups attended physical therapy twice during the first week and then once a week for the next 3 weeks, for a total of five sessions.
Significantly greater improvements in pain and disability were observed after 1 and 4 weeks of treatment among patients receiving physical therapy that included spinal manipulation compared with patients receiving an exercise program without manipulation. At the 6-month follow-up, patients who did not receive spinal manipulation demonstrated statistically significantly greater use of medication, health care utilization, and lost time from work due to back pain than did patients in the manipulation group. Results indicated that a patient who is positive on the rule and treated with spinal manipulation has a 92% chance of achieving a successful outcome by the end of one week. "A patient's status on the rule was of little relevance in determining the outcome of patients treated with the exercise intervention," Childs said, supporting the notion that the rule is specifically predicting a response to spinal manipulation. "The results of this study mean that physical therapists can have increased confidence in using the rule to identify patients with low back pain who are good candidates for spinal manipulation."
Because patients with chronic, disabling low back pain account for a disproportionate share of health care expenditures and workers' compensation costs, the potential cost savings of an early, effective intervention to prevent individuals from progressing to chronic disability may be considerable.
In this study, having symptoms for less than 16 days was the most accurate individual predictor. However, only 35% of patients (46 of 131) had symptoms for less than 16 days. "In support of previous evidence demonstrating the value of early access to physical therapist services, the results of this study also emphasize the need for early access to physical therapy intervention in the rehabilitation of patients with low back pain," Childs said.
The full-text article is available to APTA members."
JMA
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Re: Look at this validation study guys, worth reading! - December 27, 2004 6:40:00 PM
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steve
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I'm just reviewing the article myself, but its methodology looks quite sound. Check out this cool link. Check closely, there's video content.
Steve
http://www.apta.org/Foundation/news/spinal_manipulation#
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Re: Look at this validation study guys, worth reading! - December 29, 2004 10:04:00 AM
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treybien
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As PT studies go these days it seems pretty good.
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Re: Look at this validation study guys, worth reading! - December 30, 2004 4:18:00 PM
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Alex Brenner PT MPT OCS
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These studies are great steps forward in our profession and I have been referring to these in several topics in the past on rehabedge. Unfortunately they have not been well received by many that frequently post on this website. Maybe with this new validation study more will learn to apply these techniques. These manipulation techniques are easy to learn and easy to use in the clinic. I feel they are tools that should be in ALL of our toolboxes.
_____________________________
Alex Brenner, PT, MPT, OCS
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Re: Look at this validation study guys, worth reading! - December 31, 2004 2:38:00 AM
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SJBird55
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For anyone interested in the manipulation techniques, Wainner, Flynn and Whitman have a CD available for purchase. [URL=http://www.optp.com]www.optp.com[/URL]
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Re: Look at this validation study guys, worth reading! - December 31, 2004 2:46:00 AM
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PTupdate.com
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I have not read the full article yet, but do believe that manipulative therapy can and will improve outcomes, as this study suggests.
However, why did these authors have their non-manipulation group perform different exercises than the study group? It skews the study and creates an easy opening for argument against the study.
I would have much rather seen the control group perform the same exercises as the study group, just omitting the manipulation. In that situation, a significant improvement could easily be tied to the manipulation. Instead, the control group performed strengthening and aerobic exercise, which may have prevented the natural progression of healing, at least in the acute group.
John Duffy, PT OCS
[URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
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John M. Duffy, PT
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www.PTupdate.com
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Re: Look at this validation study guys, worth reading! - December 31, 2004 3:13:00 AM
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SJBird55
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Joh, what did you read? Both groups performed the same exercises. The only difference was that the first two treatment sessions were different for the manipulation group (manipulation and range of motion only).
Read the full article.
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Re: Look at this validation study guys, worth reading! - December 31, 2004 4:04:00 AM
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PTupdate.com
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As I said, I did not read the whole article, but the abstract indicates that the exercise only group performed aerobic/strengthening during the first two sessions, not the ROM that the manipulation group performed:
During the first two sessions, patients in the manipulation group received high-velocity thrust spinal manipulation and a range-of-motion exercise only. Patients in the exercise group (and patients in the manipulation group after the first two sessions of high-velocity thrust manipulation) were treated with a low-stress aerobic and lumbar spine-strengthening program.
Duffy
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John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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Re: Look at this validation study guys, worth reading! - December 31, 2004 5:14:00 AM
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SJBird55
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So, you would want to argue that the study isn't as strong because group 1 = manipulation and range of motion exercise for 1st two treatment sessions followed by the generalized exercise and lumbar spine strengthening compared to group 2 = generalized exercise and lumbar strengthening exercises for all treatment sessions.
So, you think it would be a stronger, more valid study if group 2 only did range of motion exercises for the first 2 visits? Meaning that the the differences in results may have been because of the range of motion exercise for 2 visits?
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Re: Look at this validation study guys, worth reading! - December 31, 2004 8:29:00 AM
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Jon Newman
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I think this is a good study and I like the use of likelihood ratios and 'number needed to treat' information.
Publishing in an MD oriented journal will be much more effective marketing than publishing it in the APTA journal.
This article validates that manipulation (1 specific technique) was more effective than aerobic exercise and choreographed lumbar ROM therex alone. Does it follow that the theory upon which spinal manipulation is taught is valid?
What do others think about the predictive factors as they pertain to the theoretical underpinnings of spinal manipulations?
jon
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[URL=http://www.sonymusic.com/clips/selection/30/064887/064887_03_03_30.wav]Evidence[/URL]
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Re: Look at this validation study guys, worth reading! - December 31, 2004 10:26:00 AM
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PTupdate.com
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SJ
Yup, that's my argument. Since 35% of the subjects were within 16 days of injury, that one week (2 visits) of just ROM may have been enough to improve their condition, skewing those results in one direction. The strengthening/aerobic program, without ROM, may have been enough to skew those results in the opposite direction.
Maybe comparing apples to oranges, but if you took persons with impingment syndrome and did the same thing, odds are those performing ROM only before strengthening would fare better than those jumping right into strengthening (especially if they have ROM deficits that were causing the impingement to begin with)
I'd bet if they did this study the way I prefer, they probably would still be able to make their same conclusions. But, they left a twinge of doubt that some may exploit. I know some very intelligent physicians that would point this out, especially if I gave them this article under the premise of "here is what PT can do for your low back patients".
Well, it's New Years and time for me to go drink a gallon of Guinness.
Happy NY to everybody!
Duffy
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John M. Duffy, PT
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www.PTupdate.com
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Re: Look at this validation study guys, worth reading! - December 31, 2004 12:10:00 PM
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SJBird55
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Kind of a weak argument you have, actually. A better argument would have been to have a control group where no intervention was provided. Don't you instead wonder if subjects within 16 days of injury would heal and reach good outcomes on their own... and if they they probably would how much time that would take?
And, yes... Happy New Year!
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Re: Look at this validation study guys, worth reading! - January 1, 2005 2:53:00 AM
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PTupdate.com
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OK, lets work on this before the Bowl games start.
SJ, my argument against the study is not weak....it is a very valid argument. You can jump on the opportunity to say my idea for a different approach to the study is weak, and then propose your own (as you did)
As the authors are trying to validate manipulation as an addition to a standard PT practice, it is best to have this standard procedure provided with and without the tested variable.
I am sure we all agree that some type of movement exercise is beneficial to those with LBP....some may use a McKenzie approach, others positioning to reduce neural tension, etc. To me, it seems that the study seeks to idenfity if and when manipulation can accelerate the program. In this case, I simply would have used manipulation as the only variable, to see if it indeed altered the results in two age/sex/condition matched groups.
Having a control group that gets notreatment would not have worked in this study group. Because 35% were fairly acute, and we know that a high percentage of persons with acute LBP end up with resolution after no treatment, we cannot be sure how many of these folks would have had resolution anyway.
I am curious, and since you read the article, what is the make up of the patients? Is there a mixture of radiculopathy and mechanical pain, or is this all just one base condition?
Duffy
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John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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Re: Look at this validation study guys, worth reading! - January 1, 2005 4:44:00 AM
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SJBird55
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LOL Don't the bowl games start in the afternoon? Ah... well, I am only focused on the Michigan/Texas game.
Pasted from article - and for some reason parentheses are not allowed so I had to cut them out - my high school English teacher would be very disappointed with this next bit. I had put a dash where parentheses should be, yuck!: Inclusion criteria were age 18 to 60 years; a primary symptom of low back pain, with or without referral into the lower extremity; and an Oswestry Disability Questionnaire -ODQ- score of at least 30%. We excluded patients who had "red flags" for a serious spinal condition -for example, tumor, compression fracture, or infection-, those who had signs consistent with nerve root compression -that is, positive straight-leg increase < 45 degrees or diminished reflexes, sensation, or lower-extremity strength-, those who were pregnant, or those who had previous surgery to the lumbar spine or buttock. These criteria are consistent with those used in Flynn and colleagues' study -17- and were designed to include patients without a contraindication to manipulation. Once patients were admitted to the study, we used intention-to-treat principles, and no patient was removed for nonadherence.
I don't remember if I read or saw the aspect dealing with lower extremity symptoms, but if the patient had lower extremity symptoms from the knee or higher they were included.
If I remember correctly... this particular article is a progression from another study these guys did. The first study lead them to question whether there were certain variables that would lead to sucess with manipulation. So, I could be wrong, but I believe that they already did the "simply used manipulation as the only variable." It was from doing that study that they came up with this particular study.
I think you had too much Guinness last night... reread that second to last paragraph of yours. I believe that a nontreat group for control would be another good group to have. Exactly what I was saying... only 16 days post injury the chances of independent recovery is great... so how much of a difference does treatment make? They did make a comment that there was less re-entry into the medical system for the manipulation + exercise group.
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Re: Look at this validation study guys, worth reading! - January 1, 2005 5:41:00 AM
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Jon Newman
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I would like to have had a better understanding of the exercise prescribed. I think they were doing bike riding or treadmill and pelvic tilts, knees to chest or perhaps prone on elbows. Maybe they were doing "core stabilization".
One safe conclusion to draw from this study is that if you're not going to individualize treatment and you're trying to decide whether to tell someone to sit and bike and perform posterior pelvic tilts, or to manipulate them, you should manipulate them. I'm not so sure that I can draw any more of a conclusion than that.
What are all the factors that manipulation offers that the alternate treatment did not? Note that the specific manipulation technique was not individualized.
jon
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[URL=http://www.sonymusic.com/clips/selection/30/064887/064887_03_03_30.wav]Evidence[/URL]
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Re: Look at this validation study guys, worth reading! - January 1, 2005 8:18:00 AM
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Bournephysio
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I agree with Duffy. Though a non-treatment control group would have been nice it would have drastically decreased the power of the study and required many more subjects. The exercises for both groups should have been the same. It might not have made much of a difference in this study (which I haven't read).
Jon, what is the theory upon which spinal manipulation is taught?
Just bought an HD reciever yesterday. I'm watching LSU vs Iowa right now. It looks great in HD.
Doug
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Re: Look at this validation study guys, worth reading! - January 1, 2005 10:39:00 AM
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Jon Newman
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Hi Doug,
Good question. There are many theories of spinal manipulation, some more far fetched than others. What I am specifically referring to is
1 the idea that we can detect, with inter-rater reliability, the presence of a biomechanic abnormality at the spine that is the source of pain (versus being present because of the pain or simply being unrelated).
2 The pain causing biomechanical abnormality is subsequently correctable by spinal manipulation.
In sum, the "theory" I was referring to are the concepts upon which the physical exam and subsequent treatments are built.
jon
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[URL=http://www.sonymusic.com/clips/selection/30/064887/064887_03_03_30.wav]Evidence[/URL]
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Re: Look at this validation study guys, worth reading! - January 2, 2005 9:06:00 AM
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JeffCPTA
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SJ Bird55 - Do you know if Wainner, Flynn and Whitman have any courses coming up? Happen to know of any helpful links? Thanks! -- Jeff
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Re: Look at this validation study guys, worth reading! - January 2, 2005 10:20:00 AM
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SJBird55
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Jon posted the courses.
I've gone to the cervical spine one.
Childs and Wainner will also be a part of a Research Information Exchange at the CSM on Friday from 2-4.
And, the manual/manipulation stuff can also be purchased in CD format from [URL=http://www.optp.com]www.optp.com[/URL]
Jon, what's different with what I learned from Childs and Wainner is that they really do keep the manipulation stuff simple. It's almost as if they've tossed out all the stuff about flexed, rotated, sidebent that isn't valid and reliable and seem to keep the evaluative process very general and generic. And... I know when I was learning muscle energy - all that time spent trying to figure out which side of the body to treat... well, even from that perspective, they don't actually have a philosphy regarding which side of the body to treat. They propose that you assess, do the manipulation and reassess... if no objective change happened, treat the other side of the body. I did debate with them the theory behind manipulation. There wasn't much of a debate because no one knows how or why manipulation gives results (they didn't even offer any rationale). They've got the "how" to do it question answered...they've got the "when" to do it question answered... but the "why" it works questions remains unanswered.
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