RRS readers should be familiar with the Clinical Prediction Rule (CPR) that has been in development for low back pain patients for the last few years.
This important and unique work has been authored mainly by Cleland, Fritz, Childs et al.
- we have reviewed a number of these studies to help our readers understand this process and incorporate this important concept into their patient care (see Related Reviews below).
To quickly review, Clinical Prediction Rules (CPR) are tools designed to assist clinical decision making by using combinations of specific historical information and physical examination findings to guide treatment decisions.
Developing a CPR takes time, and requires numerous steps involving a variety of study designs.
The multi-center, randomized clinical trial reviewed here is important for this LBP CPR; an appropriate project that addresses recent concerns among the CPR's critics (1), as well as a common question from field practitioners.
The question under investigation here is: "For patients who satisfy the CPR for low back pain (as potential responders to spinal manipulation) - Does the method of lumbar manipulation matter to patient outcome?" As you know, the authors of this line of research have always employed a supine lumbar manipulation, which is quite different than the side-posture techniques utilized by most chiropractors and many physiotherapists.
In general, the literature to date indicates that similar clinical outcomes can result from a variety of thrust manipulation methods.
A trial published in 2009 involving older adults with LBP comes to mind as a recent example of this (2) (see Related Reviews and Additional References).
The literature is not as clear on the difference in efficacy between thrust and non-thrust manipulation however - and this question is also investigated here.
Study Methods: In this study - 122 patients (average age ~ 40, 49% female) were randomized to receive one of three treatment interventions for a short course of 2 treatments, followed by a standardized exercise program that was given to all groups.
Patients were recruited from New Hampshire, Utah and Los Angeles.
In order to be eligible, patients had to: •have a modified OSWESTRY Disability Questionnaire (ODQ) score of > 25% •be between 18-65 years of age •be positive for the LBP CPR for manipulation by having at least 4 of the 5 findings (* see below) * LBP CPR Criteria (4 of 5 required): 1.
Pain duration35° on at least one side Exclusion criteria were standard and included: the presence of any red flags (tumour, infection etc.
), signs consistent with nerve root compression (+ve SLR, muscle weakness, sensory deficit, reflex deficit), prior lumbar surgery, or pregnancy.
All subjects completed the following outcome measures at baseline, 1 week, 4 weeks, and 6 months: •Numeric Pain Rating Scale - to capture the patient's level of pain •ODQ - to assess the patient's level of disability •Fear Avoidance Beliefs Questionnaire (FABQ) - to quantify the patient's fear of pain and beliefs about avoiding activity Treatment Interventions (each subject treated twice over a few days): 1.
Supine thrust manipulation group (n=37): received the manipulation used in the creation and validation of the CPR - The patient is supine with fingers interlocked behind the head.
The clinician stands on the side opposite of that to be manipulated.
The patient is passively moved into side-bending away from the clinician, who stabilizes the contralateral ASIS while passively rotating the patient using the contralateral shoulder (rotating upper body toward clinician) - a thrust is then applied.
If no cavitation was heard, the clinician repositioned the patient and attempted the treatment again (a maximum of 2 times).
2.
Side-Posture thrust manipulation group (n=38): the patient is positioned in side-lying with the painful side up.
The clinician then stabilizes the upper torso while flexing the up-side leg until motion is perceived at the target level.
A thrust is then delivered, imparting segmental side flexion and rotation into the target segment using a hand contact (this will be familiar to most chiropractors as a "Bonyun" manipulation).
As above, a second attempt was made if no cavitation was heard on the first thrust.
3.
Non-thrust manipulation group (n=37): patients were prone and received lumbar posterior-anterior non-thrust mobilization directed at L4-5 via the hypothenar eminence of the treating clinician.
Mobilizations were oscillatory (roughly 2Hz) and were delivered for 60 seconds at each spinal level (L4 and L5).
Subjects in all groups were given general exercise instructions for supine lumbar mobility exercises (flexion/extension) to be performed 10 times, 3-4 times daily until the third treatment/assessment session.
Pertinent Results: •Baseline characteristics (including symptom duration and severity) were similar for the three treatment groups, aside from a slightly higher Body Mass Index in the side-posture group •Repeated measures analysis revealed significant group X time interactions for the ODQ (P
This important and unique work has been authored mainly by Cleland, Fritz, Childs et al.
- we have reviewed a number of these studies to help our readers understand this process and incorporate this important concept into their patient care (see Related Reviews below).
To quickly review, Clinical Prediction Rules (CPR) are tools designed to assist clinical decision making by using combinations of specific historical information and physical examination findings to guide treatment decisions.
Developing a CPR takes time, and requires numerous steps involving a variety of study designs.
The multi-center, randomized clinical trial reviewed here is important for this LBP CPR; an appropriate project that addresses recent concerns among the CPR's critics (1), as well as a common question from field practitioners.
The question under investigation here is: "For patients who satisfy the CPR for low back pain (as potential responders to spinal manipulation) - Does the method of lumbar manipulation matter to patient outcome?" As you know, the authors of this line of research have always employed a supine lumbar manipulation, which is quite different than the side-posture techniques utilized by most chiropractors and many physiotherapists.
In general, the literature to date indicates that similar clinical outcomes can result from a variety of thrust manipulation methods.
A trial published in 2009 involving older adults with LBP comes to mind as a recent example of this (2) (see Related Reviews and Additional References).
The literature is not as clear on the difference in efficacy between thrust and non-thrust manipulation however - and this question is also investigated here.
Study Methods: In this study - 122 patients (average age ~ 40, 49% female) were randomized to receive one of three treatment interventions for a short course of 2 treatments, followed by a standardized exercise program that was given to all groups.
Patients were recruited from New Hampshire, Utah and Los Angeles.
In order to be eligible, patients had to: •have a modified OSWESTRY Disability Questionnaire (ODQ) score of > 25% •be between 18-65 years of age •be positive for the LBP CPR for manipulation by having at least 4 of the 5 findings (* see below) * LBP CPR Criteria (4 of 5 required): 1.
Pain duration35° on at least one side Exclusion criteria were standard and included: the presence of any red flags (tumour, infection etc.
), signs consistent with nerve root compression (+ve SLR, muscle weakness, sensory deficit, reflex deficit), prior lumbar surgery, or pregnancy.
All subjects completed the following outcome measures at baseline, 1 week, 4 weeks, and 6 months: •Numeric Pain Rating Scale - to capture the patient's level of pain •ODQ - to assess the patient's level of disability •Fear Avoidance Beliefs Questionnaire (FABQ) - to quantify the patient's fear of pain and beliefs about avoiding activity Treatment Interventions (each subject treated twice over a few days): 1.
Supine thrust manipulation group (n=37): received the manipulation used in the creation and validation of the CPR - The patient is supine with fingers interlocked behind the head.
The clinician stands on the side opposite of that to be manipulated.
The patient is passively moved into side-bending away from the clinician, who stabilizes the contralateral ASIS while passively rotating the patient using the contralateral shoulder (rotating upper body toward clinician) - a thrust is then applied.
If no cavitation was heard, the clinician repositioned the patient and attempted the treatment again (a maximum of 2 times).
2.
Side-Posture thrust manipulation group (n=38): the patient is positioned in side-lying with the painful side up.
The clinician then stabilizes the upper torso while flexing the up-side leg until motion is perceived at the target level.
A thrust is then delivered, imparting segmental side flexion and rotation into the target segment using a hand contact (this will be familiar to most chiropractors as a "Bonyun" manipulation).
As above, a second attempt was made if no cavitation was heard on the first thrust.
3.
Non-thrust manipulation group (n=37): patients were prone and received lumbar posterior-anterior non-thrust mobilization directed at L4-5 via the hypothenar eminence of the treating clinician.
Mobilizations were oscillatory (roughly 2Hz) and were delivered for 60 seconds at each spinal level (L4 and L5).
Subjects in all groups were given general exercise instructions for supine lumbar mobility exercises (flexion/extension) to be performed 10 times, 3-4 times daily until the third treatment/assessment session.
Pertinent Results: •Baseline characteristics (including symptom duration and severity) were similar for the three treatment groups, aside from a slightly higher Body Mass Index in the side-posture group •Repeated measures analysis revealed significant group X time interactions for the ODQ (P
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