Knee Osteoarthritis

The Facts:

More disability and clinical symptoms result from osteoarthrtits (OA) of the knee than any other joint.  While the exact cause of knee OA is unclear, its prevalence is known to increase with age and in females.²
 
Clinical symptoms of OA include: ¹
• joint pain (specific to the knee and hip are complaints of "deep, aching pain"³
• tenderness
• decreased movement
• a grating sound and/or sensation in the joint
• occasional swelling, and varying degrees of inflammation.
 
OA is distinguished by a progressive loss of articular cartilage, sclerosis/hardening of the subchondral bone, joint space narrowing, and osteophyte (“bone spur”) development.⁴ All of these changes can lead to:
• pain
• loss of muscle strength
• limitation in activities of daily living
• decreased mobility
• overall reduced quality of life

 

Mythbusters:

 

Myth:

Patients with knee osteoarthritis will should simply follow a "cookbook" approach to exercise, because they will achieve the same benefit from doing a few basic exercises as they would seeing a therapist one-on-one.

 

Fact:

A 2006 study compared home-based PT program (consisting of home exercises, and one follow up clinic visit) versus clinic-based treatment (consisting of 8 treatment sessions of supervised exercise, individualized manual therapy, and a home exercise program). 

• After 4 weeks, both groupd did show improvements based on outcome measures, but...
• Clinic-based group: 52% improvement
• Home-based group: 26% improvement
• Clinic-based group also reported great satisfaction with treatment, and less reliance on pain medications

 

Myth:

Aquatic physical therapy is superior to land-based PT in treatment of patients with knee osteoarthritis.

 

Fact:

Systematic reviews have shown both land-based and aquatic therapy programs are beneficial treatment plans for knee OA. 

• Two of the four studies showed greater pain reduction with aquatic therapy
• The other two studies showed greater strength gains with land-based therapy
• No research exists on the long-term benefit of aquatic therapy

With this in mind, patient tolerance may be a guiding factor in choosing the initial plan, but patients will likely benefit more from eventual progression towards a land-based program.
 

Wellness Challenge

For any of you "New Year's Resolution" folks, the therapists at both our Peoria and Washington offices can now sympathize with your pains.  That's right, we just finished up a 10-week Wellness Challenge (beginning at the start of 2013), coordinating with teams all from within the Rock Valley system.  This was a competition based on various wellness categories (not just focused on weight loss), and we know that sometimes all it takes is that competitive edge to get us going!

Although we didn't place too high in the competition, I think it's safe to say that we all got some friendly reminders about things we can do to improve our overall health and well-being.  Even for us, who consider ourselves to be fairly health-conscious, we can admit that there are areas where we were definitely slacking.

I thought it might be nice to share with our readers the type of categories and activities that we tracked during this time period.  Although you don't have to score yourself with a point system, feel free to use these ideas to jumpstart your own personal Wellness Challenge.

 

 

RVPT = Quality Spine Care from Start to Finish

Not all physical therapy treatments are created equal.  Here is an "at-a-glance" look at our background and process:

• Utilization of Clinical Outcome Tools for Assessment
• Treatment-based Classification Systen for Spine Care
• Evidence-based Treatment Approach to Patient Care
• Use of Manual Therapy Including Thrust and Non-thrust Mobilization
• 3 Clinicians Board Certified in Orthopaedic Physical Therapy
• 1 Clinician Board Certified in Sports Physical Therapy

• One Therapist from Start to Finish (Evaluation and Treatments)
• Conveniently Located on the North Side of Peoria and in Washington

We are passionate about continuing the growth of our profession, and how we can more effectively help our patients.  Here are some of the causes we are involved in, related to education:

• Collaborative research with Bradley University for low back pain and hip pain
• Collaborative research with St. Ambrose University on treatment-based classification ssytem for the cervical spine
• Evidence-based clinical updates sent to the referral community quarterly
• Low back pain pilot program with John Deere Medical Group, looking at improving outomes and reducing costs of care
• Partnership with St. Ambrose University for a Manual Orthopaedic Residency Program
  
• Pilot program with University of Iowa for a Post-graduate Extended Clinical Affiliation

Please contact either of our Peoria-area offices for more information on how we may be able to help your spine complaints:

Washington, IL // (309) 444-1030
Amy Johnson, PT, OCS
Kyle Cottone PT, DPT, OCS

Peoria, IL // (309) 243-1989
Luke Acklie, PT, OCS, SCS, CSCS
Rachael Mulch, PT, DPT
Kyle Cottone, PT, DPT, OCS

Snowday!!

After a huge let-down late last week, we did finally get some wintery mix headed our way throughout today!  We still were able to get quite a few patients in the door, and what better way to welcome them in - than our newest staff member and doorman? :-)

 We're glad some of you stayed home and stayed safe from the elements.  Hope you enjoyed curling up with some hot cocoa and and good book!  See you tomorrow!

 

International Pancake Day @ RVPT

How do food and physical therapy go together?  Well, they don't really... that is, unless you're at Rock Valley on a special occasion like this!  In honor of International Pancake Day, we served up a delicious breakfast all day long to our loyal patients.  Homemade buttermilk pancake batter, topped with your choice of fresh strawberries, blueberries, chocolate chips, and of course butter and maple syrup.  Yummmm!

And we even got the boys to sport these lovely aprons!!

Welcome Shannon!

Shannon has joined our Washington team to staff the front desk, and help welcome you to our facility.  She has worked in the medical community for over 12 years, in both a clinic and reception capacity.  Shannon resides in Pekin and enjoys spending time with her husband and two children.  She also spends free time sewing and crafting beautiful gifts and trinkets.  Her warm smiling face is a wonderful addition to our clinic!

 

If you are in Peoria, you may also see her occasionally helping out in our office on Fridays.

Welcome Kyle!

Kyle received his Bachelor of Science degree in Molecular and Integrated Physiology from The University of Illinois in 2003. He received his Doctorate of Physical Therapy from St. Ambrose University 2005 and completed a year-long Orthopedic Residency Program through St. Ambrose and Rock Valley in 2006. He became board certified in Orthopedic Physical Therapy in 2008 and was a primary mentor for the orthopedic residency program through St Ambrose and Rock valley from 2008-2011. Kyle is a member of the Orthopedic section of the American Physical Therapy Association and a member of the American Academy of Orthopedic Manual Physical Therapy.

  
Kyle grew up in Normal Illinois and currently lives there with his wife and daughter. Kyle enjoys football, golf, and spending time with his family.  He will be serving the area by practicing 3 days per week in our Peoria office, and 2 days in Washington.

Covering new ground - Washington, IL

We would like to officially announce the opening of our second central Illinois clinic, just across the river in Washington.  We're excited to be able to continue to help patients in this and surrounding communities.  If you or anyone you know in this area might need our help, please don't hesitate to give us a call!  Thank you for trusting us with your care!

This office will be led by Amy Johnson PT, OCS (formally practicing at our Peoria office), and also staffed by Kyle Cottone PT, DPT, OCS (see separate blog post for his welcome info and credentials).

Washington office phone number: (309) 444-1030

What are we Thankful for?

Greetings again!  It feels like a monthly blog-post aligns well with a "holiday theme" for these last few months of the year.  We'll try to accomplish that without being too cheesy!  First of all, with it being Thanksgiving week, we want to recognize yet again just how thankful we are for you - our patients - and the support and loyalty you have given us the past 2.5 years.  We certainly do not overlook your role in the success of our business (or the fact that we have a business at all!), and we appreciate the positive words you have shared with your friends, loved ones, and physicians.

We hope that this holiday will be a wonderful time for you and your families.  As I (Rachael) anticipate heading to my hometown of Indianapolis, IN, I'm excited about the tradition our family has started, participating in the local "Drumstick Dash" to raise money for hungry families.  It's something my sister and I started doing three years ago, and have since recruited our husbands, dad, and her children to join us.  Thinking about this got my mind spinning on traditions, and how they are formed.

We function like detectives everyday with our patients, and often times look for habits or patterns that contribute to their pain or dysfunction.  I thought about the connection between a habit and a tradition...  the definition of a habit: a settled or regular tendency or practice, especially one that is hard to give up.  And when I got thinking about it, you could say that a tradition is sort of a glorified habit, a fancy habit.  They can be anything from: going out to a certain restaurant every Sunday, to sitting around the turkey table playing cards, to braving the shopping world on Black Friday.

As we love to promote wellness and active lifestyles, I wanted to challenge you to reconsider your family "habits" this holiday.  By all means, eat until your heart's content, enjoy the company and storytelling, but also take a moment and think about the type of traditions you want to feel proud of, what it is that's meaningful to you.  Get outside and play ball (the weather's going to be great this year!), serve local people in need together, go for a walk or hike... remember all traditions started somewhere!

(WebMD has some good new habit-forming ideas for this holiday in this article on "10 Tips for a Thinner Thanksgiving.")

Happy Thanksgiving to all of you!  

Happy Halloween!

Happy Halloween from RVPT!
We hope you all have a safe and fun Halloween this week, whether it's spent tricking or treating!  Please feel free to share photos of your little ghosts, goblins, or princesses with us.  And remember, if you end up getting smashed liked a pumpkin, or stub your toe on a gravestone, come in for a free screening and we'll be glad to see if we can "spook" the pain out of you!

If our patients come in feeling like this...

We hope they leave feeling like this...

------------------------------------------------------------------------------------------------------------------------

And also, just before then end of the month:
October is National Physical Therapy Month!

We are proud to support the American Physical Therapy Association (APTA), as they work to raise awareness of our profession and all that we have to offer.  As members of this organization, we have invested time and resources into protecting, promoting, and growing physical therapy, so that we can continue to help more and more people.  National PT Month is a month dedicated to celebrating our past and our future as a profession, but more importantly celebrating our patients!  We feel so fortunate to be able to play a role in the lives of such wonderful people.

For more information on physical therapy, where we're headed, and how we may be able to help you, visit MoveForwardPT for patient-friendly resources.

Thanks again for your support & we look forward to continuing to serve you!

Vestibular Rehabilitation

Did you know that Rock Valley Physical Therapy now offers evaluation and treatment of vestibular disorders, which may cause symptoms of dizziness, imbalance, or instability?  Our staff is specially trained to assist you in identifying and treating vestibular dysfunction.  Below are some of the common complaints associated with these disorders.  If you or someone you know is experiencing any of these symptoms, we would love to help!

 
Vertigo (dizziness) can be caused by many different bodily structures being in a state of dysfunction.  The most common cause of this symptom is a condition called BPPV (Benign Positional Paroxysmal Vertigo), and involves abnormality of one or more “canals” in your inner ear that sense position change. 

Common aggravating factors involve position changes of the head, such as:

• Rolling over or sitting up/lying down in bed
• Looking up into a cupboard or down towards the floor

 

This condition can be very successfully treated in therapy with specific “repositioning” maneuvers.

Oscillopsia (a bouncing or shaking of your vision) can be a secondary complaint to BPPV or a standalone symptom of vestibular dysfunction.  It is directly caused by a weakening of your vestibular-ocular reflex which normally functions to stabilize your visual field as you do things like walk, jog, or ride in the car.

Physical therapy can help, by applying specific exercises to engage and re-train this reflex.

 

Disequilibrium (light-headedness) and imbalance (unsteadiness) are two related symptoms that can be caused by dysfunction of the vestibular system.   Common causes include: recent infection with resulting neuritis (nerve inflammation), labrynthitis (inflammation of the vestibular organs), impaired circulation, or cervical (neck) misalignment.

These symptoms may come on rapidly or gradually, but will likely come and go with:

• Position changes of the head
• Certain times of day
• General sense of “good” days and “bad” days
• Dark settings or busy environments
• Fatigue

Vestibular rehabilitation, administered by a licensed physical therapist, helps your body compensate for losses within the system, restoring comfortable & confident movement.

Welcome Rachael!

 





As a new addition to the Rock Valley family, I thought I'd better introduce myself in RVPT "blog-world" as well.  I am so excited to join this team of extraordinary professionals, and look forward to meeting and helping many new faces in the Peoria community.



I grew up in Indianapolis, IN where my interest in physical therapy was sparked; this is what drew me west to Peoria to attend Bradley University.  Although I had not intented to stay in this area after obtaining my Doctorate (DPT) degree in 2010, I was blessed to meet my husband while at Bradley, and we have decided to call Peoria "home."  With him growing up in a small town south of Springfield, IL, this is a perfect middle ground for us in many ways.

In our spare time, we enjoy spending as much time as we can outdoors with a variety of recreational activities.  We also love to travel to see friends and family as often as possible.

Professionally speaking, my background is two years practicing in a rural community north of Peoria where I treated a wide variety of diagnoses and age-groups.  I have also developed a niche interest Vestibular Rehabilitation, treating individuals with complaints of dizziness and imbalance, and have advanced training in this area.

Posterior Tibialis Tendon Dysfunction

The posterior tibialis tendon crosses the inside of the ankle joint, and works to control foot position during stance and walking.  Posterior tibialis dysfunction is the major cause of acquired flat foot deformity.^1,2

Nearly 60% of patients with a rupture of the posterior tibialis tendon had 1 or more of the following symptoms: hypertension, obesity, diabetes mellitus, previous surgery or trauma in the medial aspect of the foot, or exposure to steroids.¹

 

There are two main classifications within this disorder process:

Stage I: The tendon is of normal length, pain and swelling at medial foot
Stage II: Elongation of tendon, patient is unable to stand on toes of affected limb

What is the rehab role?

A study by Kulig et al examined the effectiveness of a 12 week program with custom -made orthotics in addition to stretching with or without an exercise program in adults with Stage I or II PTTD.  The study found that all interventions were effective in reducing pain; however the custom made orthotics along with eccentric exercises group had the most improvement in all subscales of foot functional index scores.³

A study by Alvarez et al found treating patients with Stage II PTTD with short articulating orthotics in combination with a high repetition ankle strengthening program showed significant improvements in VAS, single-support heel rise, ambulation distance, and strength.⁴

While being more expensive, custom articulating orthotics have been shown to provide best foot kinematics in gait, when compared to OTC or solid custom AFOs.⁶

Rehabilitation guidelines:^3,4

• Early stage (up to two weeks): Unload the tendon using orthotics, gastroc/soleus stretching, and build ambulation tolerance.

• Middle stage (2-8 weeks): Recruit tibialis posterior, eccentric strengthening

• Late stage (8-12 weeks): Progress toe walking to 150ft, progress ambulation distance to 2 miles, increase reps in HEP.

References:
Geideman WM, Johnson JE. Posterior Tibial Tendond Dysfunction. J Orthop Sports Phys Ther. 2000;30(2):68-77.
Trnka HJ. Dysfunction of the tendon of tibialis posterior.  J Bone Joint Surg [BR]. 2004;86-B:939-46.
Neville C et al. Choosing among 3 ankle-foot orthoses for a patient with Stage II posterior tibial tendon dysfunction. Journal of Ortho and Sports Phy Ther. 2009;39(11):816-824.

Alvarez RG et al. Stage I and II posterior tendon dysfunction treated by a structured nonoperative management protocol: an orthoses and exercises program. Foot & Ankle Internationional. 2006;27(1):2-8.

Kulig K et al. Effect of eccentric exercise program for early tibialis posterior tendinopathy. Foot & Ankle International. 2009;30(9):877-855.

Franettovich M et al. A physiological and psychological basis for anti-pronation taping from a critical review of the literature. Sports Med 2008;38(8):617-631.

ASTYM

The ASTYM system is an evidence-based rehabilitation process designed to effectively treat chronic tendon disorders, scar tissue and fibrosis.


The goal of the ASTYM treatment is to stimulate the body’s healing response, resulting in the resorption and remodeling of scar tissue and the regeneration of degenerative tendons. This effective therapy incorporates a customized program of stretching and exercise, which positively influences the alignment of the new collagen.

For some of you who may have heard of this technique, through personal experience or observation, there are some common misconceptions that we would like to clarify.  Please read-on as we unravel the myths surrounding this effective rehab process:

Myth:  All soft tissue injuries are treated equally regardless of the underlying cause.

Fact:  Chronic, long-standing repetitive injuries must be treated differently than acute injuries.  The absence of cardinal signs of inflammation should necessitate that an alternate approach should be taken.  Interventions used for a tendinosis that attempt to address inflammation where inflammation is absent will be unsuccessful.

Myth:  ASTYM is just “scrapping” people with tools.

Fact:  ASTYM tools are designed and used to promote controlled capillary leakage promoting phagocytosis of inappropriate tissue and stimulation of fibroblasts.  Although to the lay person treatments appear to be scrapping tissue, provider training and testing ensure the  proper tool pressure, direction, and angulation give the sought after effect.

 

Myth:  ASTYM is most effective when done without exercise.

Fact:  Exercise, including strength and flexibility,  in conjunction with ASTYM treatment is necessary to promote proper collagen fiber alignment and alleviate impairments caused by chronic dysfunction.

 

 

References:

Kannus P and Jozsa L. Histopathologic changes preceding spontaneous rupture of a tendon. Journal of Bone and Joint Surgery. 1991; 73-A(10):1507-1525.

Maffulli N, Khan KM, Puddu G. Overuse tendon conditions: time to change a confusing terminology. Arthroscopy. 1998; 14(8):840-843.

Gehlsen GM, Ganion L, Helfst RH. Fibroblast Response to Variation in Soft Tissue Mobilization Pressure. Med Sci Sports Ex 1998; 31(4):531-535.

Wilson JK, Sevier TL, Helfst RH, Honing EW, Thomann A. Comparison of rehabilitation methods in the treatment of patellar tendinitis. J Sports Rehab, 2000;9:304-14.

Walking Speed

There is significant evidence to suggest that people with decreased walking tolerance, strength, and balance are actually dying sooner.  There is also significant evidence that sitting time, alone, increases risk of death.  Walking speed is a powerful indicator of functional status for patients with varying diagnoses; however, it is not routinely assessed by the medical community.

The functional requirements for community-living, aging adults are identified as follows:

·         1203 feet (366.7 meters) to complete an errand in the community

·         Gait speed of 1.2 m/s or 2.68 mph to cross a street safely

·         Need to carry an average of 6.7  lb. package

How do we measure walking speed?

We can time how long it takes a person to travel a 20-meter distance, by using only the middle 10-meters of this area, to allow for acceleration and deceleration.

 

What does the research have to say?

A significant increase in mortality existed among subjects with increased time to perform the 400 meter walk test.  (948 men and women; this was further adjusted for depression, education, smoking, BMI, sedentary, chronic disease.)^2,3  For each additional minute of longer performance time, risk of death increased 35%.⁴

Walking speed, walking less than 400 meters, and decreased lower extremity strength are strong predictors for nursing home placement.  Loss of leg strength is the strongest single predictor for subsequent institutionalization, stronger than disease diagnosis. ^5,6

A change in gait speed by .10 m/s (.22 mph) has been shown to be a meaningful change in community dwelling older adults, hospitalized male veterans, and patients with a hip fracture. A 2011 study in the Journal of American Medical Association found that a change of .10 m/s (.33 mph) increased survival over a 10 year period.⁷

How can we help?

The staff at Rock Valley Physical Therapy can help to identify a decline in function, using this measure along with other special testing.  We will then work with you to establish a program that is consistent with your pace of life & desired activity level, restoring your mobility and independence.

References:

Shumway-Cook A, et al.  Environmental demands associated with community mobility in older adults with and without disabilities.  Phys Ther.  2002;82:670-681.

Chang M, et al.  Incidence of loss of ability to walk 400 meters in a functionally limited older population.  J Am Geriatr Soc.  2004;52:2094-8.

Vestergaard S, et al.  Characteristis of 400-meter walk test performance and subsequent mortality in older adults.  Rejunenation  Res.  2009;12:177-84.

Newman AB, et al.  Association of long-distance corridor walking performance with mortality, cardiovascular disease, mobility limitation, and disability.  JAMA.  2006;295:2018-2026.

Guralnik JM, et al.  Validation and use of performance measures of functioning in a non-disabled older population: MacArthur studies of successful aging.  Aging.  1994;6:410-419.

Judge JO, et al.  Step length reductions in advanced age: the role of ankle and hip kinetics.  J Geritol A Biol Sci Med Sci.  1996;51:M303-M312.

Studenski S, Perera S, Patel K, et al.  Gait speed and survival in older adults.  JAMA.  2011;305(1):50-58.

Fritz S, Lusardi M.  White paper: “Walking speed: the sixth vital sign.”  J Geriatr Phys Ther.  2009;32(2):2-5.

 

Welcome Alicia!

We would like to welcome Alicia Kuhns to the Rock Valley family.  She will be assisting Cheryl at the front desk, by serving as our front line on Fridays. 

Alcia is from Decatur, IL and currently resides in West Peoria.  She enjoys spending time with family and friends, as well as coaching middle school volleyball.

Headache

Headaches originating from the cervical spine are believed to account for approximately 15-20% of all chronic and recurrent headaches.¹  The International Headache Society (IHS) defines cervicogenic headache as “pain referred from a source in the neck and perceived in one or more regions of the head and/or face².”

 
 

Individuals with cervicogenic headache have been shown to exhibit restricted neck motion, palpable upper cervical joint dysfunction, and impaired muscle performance of the deep neck flexors.³
 

Limited upper cervical spine rotation with the neck flexed has been shown to differentiate individuals suffering from cervicogenic headache from those suffering from migraine headache.⁴

 

 

How can we help?

Based on the available current best evidence, the combination of exercise and manual physical therapy has been shown to be beneficial in reducing symptoms of headaches.  Jull et al.⁵ showed that a physical therapy program that combined manipulative interventions with endurance training for deep neck flexor endurance resulted in significantly reduced frequency, intensity, and duration of headaches.  These improvements were maintained at twelve month follow-up.  Hall et al. ⁶ showed that regular performance of a patient self-mobilization exercise resulted in significant improvements in headache symptoms.  These benefits were also maintained at twelve months.

 

Effective Interventions: 

·         Deep neck flexor endurance training

·         Self-mobilization

·         Postural education

·         Manual physical therapy



References:

Nilsson N.  The prevalence of cervicogenic headaches in a random population sample of 20-59 year olds.  Spine 1995;20:1884-1888.

The International Classification of Headache Disorders:  2^nd Edition.  Cephalgia 2004.24:9-160.

Jull et al.  Cervical musculoskeletal impairment in frequent intermittent headache, Part 1:  subjects with single headaches.  Cephalgia  2007.27:793-802.

Zito G, Jull G.  Clinical tests of musculoskeletal dysfunction in the diagnosis of cervicogenic headache. Manual Therapy 2006;11:118-130.

Jull et al.  A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache.  Spine 2002;27(12):1835-1843.

Hall et al.  Efficacy of a C1-C2 self-sustained natural apophyseal glide in the management of cervicogenic headache.  JOSPT  2007;37(3):100-107.

American Gastroenterological Association (2005, January 16). Study Shows Long-term Use Of NSAIDs Causes Severe Intestinal Damage.ScienceDaily. Retrieved January 31, 2011, from http://www.sciencedaily.com­/releases/2005/01/050111123706.htm

Hall  T, Briffa K.  Reliability of manual examination and frequency of symptomatic cervical motionsegment dysfunction in cervicogenic headache.  Man Ther 2010;15:542-546.

Gadotti I, Olivo S, Magee D.  Cervical musculoskeletal impairments in cervicogenic headache: a systematic review and a meta-analysis.  Physical Therapy Reviews  2008;13(3):149-166.

Injury Prevention and Management in the Soccer Athlete

It has been quite some time since we posted on our blog. That means it has been busy at the clinic. We wanted to share with everyone in the Peoria area athletic community that we are hosting a presentation on June 8th entitled, "Injury Prevention and Management in the Soccer Athlete." This will be a joint presentation between us and Joe Terry, PT, CSCS of the Human Performance Lab. Feel free to forward this information to coaches and parents who might be interested. As physical therapists and strength coaches, sports-specific rehabilitation and injury prevention have been a primary focus. We hope to educate the soccer community on injuries most commonly seen in the sport, functional testing, and preventative training.

Date: June 8th, 2011

Time: 7:00 - 8:30 PM

Location: Rock Valley Physical Therapy (9901 N. Knoxville)

Amy Johnson, PT, OCS/ Luke Acklie, PT, OCS, CSCS/ Joe Terry, PT, CSCS

Description: The presentation will consist of two lectures with the first lecture discussing the management of common injuries in the soccer athlete. The second lecture will focus on injury prevention in the soccer athlete from the sports enhancement perspective. There will be time devoted for a question/answer session after each presentation. For more information or questions, please contact the clinic at 309-243-1989.

Low Back Pain

 
 

There is no question that low back pain is a problem for many people.  Annually, low back pain accounts for approximately 40% of all lost workdays and has been estimated to cost $49 billion within the industrial sector.¹

So what do we do about it?
Attempts to identify effective interventions for patients with low back pain (LBP) have been largely unsuccessful.^2,3  One explanation offered for the lack of evidence is the inability to define subgroups of patients most likely to respond to a particular intervention.⁴  Recently, Flynn et al. validated a clinical prediction rule that identifies a subgroup of patients with nonspecific low back who are likely to respond to spinal manipulation.⁵

The predictor variables, based on the history and physical examination, were identified as follows:

• Pain of less than 16 days duration
• No symptoms distal to the knee
• One or both hips with internal rotation < 35°
• One or more hypomobile lumbar segments
• FABQ*-work subscale score of < 19

The presence of four out of five variables in the prediction rule increases the likelihood of success with manipulation from 45% to 95%.

According to a study by Childs et al.⁶, patients who were “positive on the rule” (met 4 or 5 of 5 predictor variables) and did not receive spinal manipulation were 8 times more likely to experience a worsening in disability as compared to those that did. 

*Fear-Avoidance Belief Questionnaire: measure of how beliefs of fear and avoidance are contributing to function.


References:

Leigh J et al.  Occupational injury and illness in the United States.  Arch Int Med 1997;157:1557-1568.

van Tulder MW, Koes BW, Bouter LM. Conservative treatment of acute and chronic nonspecific low back pain: a systematic review of randomized controlled trials of the most common interventions. Spine 1997;22:2128–56.

van Tulder MW, Malmivaara A, Esmail R, et al. Exercise therapy for low back pain: a systematic review within the framework of the Cochrane Collaboration Back Review Group. Spine 2000;25:2784–96.

Bouter LM, van Tulder MW, Koes BW. Methodologic issues in low back pain research in primary care. Spine 1998;23:2014–20.

Flynn T, Fritz J, Whitman J, et al.  A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation.  Spine 2002;27:2835-2843.

Childs J, Flynn T, Fritz J.  A perspective for considering the risks and benefits of spinal manipulation in patients with low back pain.  Man Ther 2006;11:316-320.

Ernst E, Canter P.  A systematic review of systematic reviews of spinal manipulation.  J R Soc Med 2006;99:192–196.

Flynn T, Fritz J, Whitman J, et al.  A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation.  Spine 2002;27:2835-2843.

UK BEAM trial team.  United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: effectiveness of physical treatments for back pain in primary care.  BMJ 2004.10:1-8.