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RESEARCH COMMENTARY
Ejona (Ona) Jeblonski, DPT, COMT
Fellow in Training, MAPS Accredited Fellowship in Orthopedic Therapy

Chris R. Showalter, PT, COMT, OCS, FAAOMPT
MAPS Fellowship Program Director

Mobilization Increases Dorsiflexion in Chronic Ankle Instability (CAI) Patients


 
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Landmark Study Achieves 3 SIGNIFICANT FIRSTS in the Manual Therapy Management of Mechanical Low Back Pain

May 22, 2012

RESEARCH COMMENTARY

Chris Showalter PT, OCS, COMT, FAAOMPT

MAPS Clinical Director

Full Disclosure: This month’s Research Commentary discusses a peer reviewed research article By MAPS Research Consultant Chad Cook, myself, and Senior Faculty Members Vincent Kabbaz and Bryan O’Halloran. Additionally, a number of MAPS Faculty members and COMTs were also involved in data collection. The full article will be available in the upcoming issue of Manual Therapy.

Landmark Study Achieves 3 SIGNIFICANT FIRSTS in the Manual Therapy Management of Mechanical Low Back Pain

1) FIRST STUDY to substantiate the construct validity of Geoff Maitland’s “Comparable Sign� in Clinical Reasoning and Manual Therapy Intervention by evaluating both within AND between session changes. (Details Below)

2) FIRST STUDY to show that within and/or between sessions changes in pain scores have a significant association with pain scores and Oswestry Disability Index (ODI) at discharge. (Details Below)

3) FIRST STUDY to show that a 2 point change or greater on pain scores (VAS) is associated with functional recovery at discharge. (Details Below)

The essential details of the article follows:

Man Ther. 2012 Mar 21. [Epub ahead of print]

Can a within/between-session change in pain during reassessment predict outcome using a manual therapy intervention in patients with mechanical low back pain?

Cook CE, Showalter C, Kabbaz V, O'Halloran B

This study is a secondary database analysis involving n=100 patients with mechanical low back pain. The parent RCT compared thrust and non-thrust manipulation. Both groups received a standardized evaluation and were randomized to receive either thrust or non-thrust interventions (the RCT is currently in publishing review…thus I cannot discuss details here…a subsequent Research Commentary will discuss our findings).

Our intention was to reflect “real world� clinical decision making and treatment intervention by incorporating both within session AND between session changes as a component of the decision making process.

FIRST STUDY to Substantiate the construct validity of Geoff Maitland’s “Comparable Sign� in Clinical Reasoning and Manual Therapy Treatment by including both within AND between session changes.

Assessment of within session and between session changes is the essence of Maitland’s “Comparable Sign� (Maitland 1957). A Comparable Sign refers to any combination of pain, stiffness and/or spasm, during a specific movement, which the examiner finds on examination and considers to be comparable with the patients symptoms. (Maitland 1986).

Manual therapists often use the clinical reasoning thought process which incorporates assessment of movement. In the Maitland approach, an important component is the reproduction of the patient’s comparable sign during specific movements including: Active Physiological Movements (APMs), Passive Physiological Movements (PPMs), and Passive Accessory Movements (PAMs). Reproduction of the symptoms of the patient’s primary complaint in any of the specific movements is considered the comparable sign and indicates the patient may be a candidate for manual therapy.  

Previous Authors have shown that within sessions changes do appear to predict between session changes in patients who received a manual therapy intervention for Low back pain (Hahne et al 2004) or Cervical pain (Tuttle 2005). Two studies have previously explored between session changes involving patients with sub-acute neck pain (Tuttle et al 2006) and shoulder impingement syndrome (Garrison et al 2011)

We could not find prior studies that evaluated both within and between session changes to manual therapy interventions in the same study.

Thus, our research is the FIRST to explore BOTH within AND between session changes in mechanical Low back pain.

It is also the FIRST article to explore the extent of change that is needed for significant functional improvement.

This article showed that a within/between-session change (Comparable Sign) should be considered a valuable complimentary process along with other examination findings during clinical decision making.

FIRST STUDY to show that within and/or between sessions changes in pain scores have a significant association with pain scores and Oswestry Disability Index (ODI) at discharge.

Our study showed that a significant association exists between a within/between-session change after the second physiotherapy visit and discharge outcomes for pain (VAS) and ODI in this sample (n=100) of mechanical low back pain patients who received a manual therapy intervention.

FIRST STUDY to show that a 2 point change or greater on pain scores (VAS) is associated with functional recovery at discharge.

A within/between-session report of pain reduction of 2 points or greater (on the 11 point VAS) was associated with a 50% or greater reduction in the ODI at discharge.

So what is the take home message?

1) Maitland’s Comparable Sign is a valuable component of the clinical decision making process.

2) Within/between session changes in the Comparable Sign after the 2nd visit have a significant association with outcomes for pain and ODI at discharge.

3) A 2 point change (or better) in the pain is associated with a 50% or greater reduction in ODI at discharge 

Cheers and Enjoy

Chris R Showalter

© Chris R. Showalter and Maitland Australian Physiotherapy Seminars

Not to be reproduced, copied or retransmitted in any manner without author’s express written permission

Directing others to the MAPS website (www.ozpt.com) is permissible.

Where to find the Articles

1) http://www.ncbi.nlm.nih.gov/pubmed/22445052

Cook CE, Showalter C, Kabbaz V, O'Halloran B Can a within/between-session change in pain during reassessment predict outcome using a manual therapy intervention in patients with mechanical low back pain? Man Ther. 2012 Mar 21. [Epub ahead of print]

2) Maitland GD, Manipulation Technique for the Lower Back. Australian Journal of Physiotherapy V3:3, 135-140, 1957. (Authors Personal Library)

3) Maitland GD, Vertebral Manipulation, London, Butterworth-Heinemann, 5th Ed, 1986

4) http://www.ncbi.nlm.nih.gov/pubmed/14987188

Hahne AJ, Keating JL, Wilson SC Do within-session changes in pain intensity and range of motion predict between-session changes in patients with low back pain? Aust J Physiother. 2004;50(1):17-23.

5) http://www.ncbi.nlm.nih.gov/pubmed/15748124

Tuttle N. Do changes within a manual therapy treatment session predict between-session changes for patients with cervical spine pain? Aust J Physiother. 2005;51(1):43-8.

6) http://www.ncbi.nlm.nih.gov/pubmed/17132123

Tuttle n, Laasko L, Barrett R Change in impairments in the first two treatments predicts outcome in impairments, but not in activity limitations, in subacute neck pain: an observational study. Aust J Physiother. 2006;52(4):281-5.

7) http://www.ncbi.nlm.nih.gov/pubmed/20673079

Garrison JC, Shanley E, Thigpen C, Hegedus E, Cook C Between-session changes predict overall perception of improvement but not functional improvement in patients with shoulder impingement syndrome seen for physical therapy: an observational study. Physiother Theory Pract. 2011 Feb;27(2):137-45.

Abstract of Main Article

Man Ther. 2012 Mar 21. [Epub ahead of print]

Can a within/between-session change in pain during reassessment predict outcome using a manual therapy intervention in patients with mechanical low back pain?

Cook CE, Showalter C, Kabbaz V, O'Halloran B.

Source

Division of Physical Therapy, Walsh University, North Canton, OH 44720, USA.

Abstract

The purposes of the study were to determine whether the combined occurrence of within/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 low back pain. A secondary purpose was to determine the extent of change needed for the within/between-session change with association to function. The study involved 100 subjects who were part of a randomized controlled trial that examined manual therapy techniques who demonstrated a positive response to manual therapy during the initial assessment. Within- and between-session findings (within/between session) were defined as a change in pain report from baseline to after the second physiotherapy visit. Within/between-session changes were analyzed for associations between pain change scores at discharge, rate of recovery, and a 50% reduction of the Oswestry disability index (ODI) by discharge. The results suggest there is a significant association between a within/between-session change after the second physiotherapy visit and discharge outcomes for pain and ODI in this sample of patients who received a manual therapy intervention. A 2-point change or greater on an 11-point scale is associated with functional recovery at discharge and accurately described the outcome in 67% of the cases. This is the first study that has shown an association of within/between-session changes with disability scores at discharge and is the first to define the extent of change necessary for prognosis of an outcome. A within/between-session change should be considered as a complimentary artifact along with other examination findings during clinical decision making.

Copyright © 2012 Elsevier Ltd. All rights reserved.


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