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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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Construct validity of Maitland’s “Comparable Sign” is further supported by a new exploratory study in spinal pain patients

January 06, 2015

RESEARCH COMMENTARY

Chris Showalter PT, OCS, COMT, FAAOMPT MAPS Clinical Director


Full Disclosure: This month’s Research Commentary discusses a number of peer reviewed research articles co-authored by MAPS Research Consultant Chad Cook and MAPS Senior Faculty Members including: Ken Learman, Chris Showalter, and Bryan O’Halloran. 


Construct validity of Maitland’s “Comparable Sign” is further supported by a new exploratory study in spinal pain patients


Geoffrey Maitland first described the concept of the Comparable Sign (CS) in 1963 (Maitland 1963) as “Reproduction of the patient’s pain with movement”, which he further refined in 1992 (Maitland 1992) as, “The aim of physical examination is to provoke, with test movements, either an abnormal response in an appropriate (anatomical) site, or, when suited to the disorder, reproduce the symptoms.”  CS is, without question, one of the core tenets of the Maitland approach to manual therapy.  The test movements Maitland referred to include Active Physiological Movements, Passive Physiological Movements, Passive Accessory Movements, and any spontaneous movement the patient can perform to affect their symptoms.


Thus, CS(s) are physical examination findings related to the patient’s chief complaint that are reproduced during examination and treatment.  These findings include observed abnormalities of movement, postures or motor control, abnormal responses to movement, static deformities, and abnormal joint assessment findings. The CS is most commonly accompanied by the patient’s verbal report and confirmation of symptoms of their primary complaint. This is also known as “Symptom Provocation” and is a hallmark of Maitland’s approach as well as other philosophies including those of McKenzie and Cyriax.


Our most recent 2014 Manual Therapy study, currently an “Article in Press”, investigates the relative value of the CS in spinal patients.  The study is entitled, “The relationship between chief complaint and comparable sign in patients with spinal pain: An exploratory study” by Cook C, Learman K, Showalter C, and O’Halloran B.  There is a dearth of information on this relationship, which is the primary reason this exploratory study was undertaken, which included 112 patients with neck and back pain.  Initial results suggest that there may be content validity to the concept of CS, although further research with larger samples sizes is required to explore the extent of such.


The Cook 2014 Manual Therapy study found the following:


  1. There was a high prevalence of CS findings in patients in our study

  2. There was an association between CS during active movements and the patient’s chief complaint

  3. There was a strong relationship between the CS during all examination movements

  4. Reported baseline pain levels were higher in patients without a demonstrable CS

  5. Rate of recovery was slower in patients without a demonstrable CS

  6. The results further suggest the construct validity to the concept of the CS   


Additional details of this study will be available once the full article has been officially published in Manual Therapy.


The value of the CS and within session changes was previously investigated in our 2012 Manual Therapy article (Cook 2012) and described in depth in our May 22, 2012 Research Commentary found here https://www.ozpt.com/research_commentary_item.php?id=18&H=Y


The evaluation of the CS occurs throughout the entire Assessment AND Treatment of the patient’s episode of care.  The evaluation of change in the CS is used to determine the patient’s response to treatment and to guide further intervention and treatment modification if necessary. This is often referred to as “within session” and “between session” changes respectively.


In Cook 2012 we found:


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 PT, OCS, COMT, FAAOMPT 


© 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.


Cook 2014 Article Follows


http://www.manualtherapyjournal.com/article/S1356-689X%2814%2900228-8/abstract


Authors:

Chad Cook, Kenneth Learman, Christopher Showalter, Bryan O'Halloran


The relationship between chief complaint and comparable sign in patients with spinal pain: An exploratory study



Abstract

Many musculoskeletal management philosophies advocate the exploration of the relationship between the patient's chief complaint (CC) and the physical examination findings that reproduce/reduce/change that CC. Geoffrey Maitland developed the concept “comparable sign(s) (CS), which are physical examination findings related to the CC(s) that are reproduced during an examination/treatment. These include observed abnormalities of movement, postures or motor control, abnormal responses to movement, static deformities, and abnormal joint assessment findings. There are no studies that have explored the potential clinical relationships between the patient's CC and a CS, thus this exploratory study evaluated the associations, outcomes, and prevalence of the findings. This cohort study involved 112 subjects age 54.3 years (SD = 13.4 years), with neck (25.9%) or low back pain (74.1%) who were treated with physiotherapy for an average of 42 days. Data analysis revealed 88.4% identified a CC at baseline. There was a moderate statistical association between CC and the active physiological finding of a CS (r = 0.36), and small-moderate associations between all examination phases (r = 0.25–0.37). There were no statistical differences in pain and disability outcomes for those with and without a CC or CS; however, baseline pain levels were higher for those without CC (p = 0.04). Further, rate of recovery was lower in those without a CS during passive physiological examination. The results would suggest that there may be content validity to the concept of CS but further research with larger samples sizes is required to explore the extent of the validity is warranted.


Where to find the Articles  


  1. Maitland, GD The Importance of Examination for Intervertebral Joint Movement.

    Aust J of Physiotherapy 1963, Vol 9 (1) 15-18

     

  2. Neuro/musculo Skeletal Examination and Recording Guide 5th Ed. 1992

    Maitland GD, Lauderdale Press, Adelaide

     

  3. 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 Aug;17(4):325-9 


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