SYNOPSIS: The development of valid classification methods to assist the physical therapy management of patients with low back pain has been recognized as a research priority. There is also growing evidence that the use of a classification approach to physical therapy results in better clinical outcomes than the use of alternative management approaches. In 1995, Delitto and colleagues proposed a classification system intended to inform and direct the physical therapy management of patients with low back pain. The system described 4 classifications of patients with low back pain (manipulation, stabilization, specific exercise, and traction). Each classification could be identified by a unique set of examination criteria, and was associated with an intervention strategy believed to result in the best outcomes for the patient. The system was based on expert opinion and research evidence available at the time. A substantial amount of research has emerged in the years since the introduction of this classification system, including the development of clinical prediction rules, providing new evidence for the examination criteria used to place a patient into a classification, and for the optimal intervention strategies for each classification. New evidence should continually be incorporated into existing classification systems. The purpose of this clinical commentary is to review this classification system, its evolution and current status, and discuss its implications for the classification of patients with low back pain.

J Orthop Sports Phys Ther. 2007;37(6):290-302, Epub 15 March 2007. doi:10.2519/jospt.2007.2498

The original article was corrected in December 2007, and the amended article PDF is provided here. Please see Erratum December 2007. J Orthop Sports Phys Ther. 2007;37(12):769.

KEY WORDS: clinical decision-making, lumbar spine, manipulation, stabilization, traction

STUDY DESIGN: Prospective, multicenter research design. OBJECTIVES: To assess functional and health status outcomes in patients following a physical therapy program after rotator cuff repair surgery, and to determine the impact of selected patient medical comorbidities on rehabilitation outcomes. BACKGROUND: While authors have studied the influence of multiple factors on patient outcomes after rotator cuff repair surgery, little research has been done on the impact of comorbidities, particularly as it relates to establishing an accurate patient prognosis.  METHODS AND MEASURES: One hundred eighteen patients who had recently undergone a rotator cuff repair surgical procedure were recruited at 1 of 30 Physiotherapy Associates, Inc. outpatient clinics located in 13 states. A rehabilitation protocol was implemented and included the following interventions, as indicated: therapeutic exercise, manual therapy, electrotherapeutic modalities, and physical agents. Patient health history factors were documented during the initial examination, including age, race, body mass index, smoking, rotator cuff tear size, type of surgical procedure, and selected medications and comorbidities.  The Disabilities of the Arm, Shoulder, and Hand (DASH), and the Short-Form-36 (SF-36) were completed prior to rehabilitation, at discharge, and 6 months postdischarge. RESULTS: DASH and most SF-36 domain mean scores obtained postrehabilitation were significantly improved from pretherapy scores. Most health status outcomes were maintained at 6-month follow-up, with slight further improvement noted in SF-36 physical dimensions and DASH scores. Having a greater number of comorbidities was associated with worse postrehabilitation SF-36 scores, but not with the DASH shoulder function scores. The mean change scores (difference between prerehabilitation and postrehabilitation status) for the DASH and SF-36 were not significantly different for patients with 0 to 1, 2, or at least 3 or more comorbidities (except for emotional role). In regression analyses, a model with baseline physical function score (P = .0001), age P = .03), and number of comorbidities (P = .003) fitted the data well and explained 38% of the variance in the physical function score at discharge. CONCLUSIONS: A higher number of comorbidities had a negative effect on general health status outcomes but not on shoulder function outcomes at the time of patient discharge following rehabilitation. Despite a negative effect of more comorbidities on health status outcomes, the specific number of medical comorbidities did not affect the overall level of improvement prerehabilitation to postrehabilitation in function and health status. The findings describing the influence of comorbidities on rehabilitation outcomes may assist therapists in establishing accurate patient prognosis.

J Orthop Sports Phys Ther. 2007;37(6):312-319, Epub 16 April 2007. doi:10.2519/jospt.2007.2448 

KEY WORDS: DASH, general health status, prognosis, SF-36, shoulder

STUDY DESIGN: A placebo, control, repeated measures, single-blinded randomized study. OBJECTIVES: To compare the immediate effects on pressure pain threshold (PPT) tested over the lateral elbow region following a single cervical high-velocity low-amplitude (HVLA) thrust manipulation, a sham-manual application (placebo), or a control condition; and to analyze if a different effect was evident on the side ipsilateral to, compared to the side contralateral to the intervention. BACKGROUND: Previous studies investigating the effects of spinal manual therapy used passive mobilization procedures. There is a lack of studies exploring the effect of cervical manipulative interventions. METHODS: Fifteen asymptomatic volunteers (7 male and 8 female; aged 19 to 25 years) participated in this study. Each subject attended 3 experimental sessions on 3 separate days at least 48 hours apart. At each session, subjects received either the manipulation, placebo, or control intervention provided by an experienced therapist. The manipulative intervention was directed at the posterior joint of the C5-6 vertebral level. PPT over the lateral epicondyle of both elbows was assessed preintervention and 5 minutes postintervention by an examiner blinded to the treatment allocation of the subject. A 3-way analysis of covariance (ANCOVA) with intervention, side, and time as factors, and gender as covariate was used to evaluate changes in PPT. RESULTS: The analysis of variance detected a significant effect for intervention (F = 31.46, P<.001) and for time (F = 33.81, P<.001), but not for side (F = 0.303, P>.5). A significant interaction between intervention and time (F = 15.74; P<.001) was also found. Gender did not influence the comparative analysis (F = 0.252; P>.6). Post hoc analysis revealed that the application of a HVLA thrust manipulation produced a greater increase of PPT in both elbows, as compared to placebo or control interventions (P<.001). No significant changes in PPT levels were found after the placebo and control intervention (P>.6). Within group effect sizes were large for PPT levels in both elbows after the manipulative procedure (d>1.0), but small after placebo or control intervention (d<0.1). CONCLUSIONS: The application of a manipulative intervention directed at posterior joint of the C5-6 vertebral level produced an immediate increase in PPT over the lateral epicondyle of both elbows in healthy subjects. Effect sizes for the HVLA thrust manipulation were large, suggesting a strong effect of unknown clinical importance at this stage, whereas effect sizes for both placebo and control procedures were small, suggesting no significant effect.

J Orthop Sports Phys Ther. 2007;37(6):325-329, Epub 29 May 2007. doi:10.2519/jospt.2007.2542

KEY WORDS: hypoalgesia, manual therapy, neck pain, thrust manipulation

STUDY DESIGN: Case report. BACKGROUND: Shoulder pain and disability is a common clinical problem that may be influenced by impairments from a variety of sources. The purpose of this case report is to illustrate a manual physical therapy management approach for a patient with shoulder pain and disability, specifically addressing impairments of the cervical spine and upper limb neural tissue believed to contribute to the patient's symptoms. CASE DESCRIPTION: The patient was a 45-year-old female research scientist with symptoms of anterior shoulder and posterior scapular region pain that limited her ability to use her right upper extremity for normal activities of daily living. An examination and evaluation revealed impairments of the cervical spine and upper limb neural tissue that were believed to contribute to the patient's symptoms. Intervention consisted of joint mobilization directed at the impaired cervical spine segment.  The Shoulder Pain and Disability Index (SPADI) and goniometric measurement of shoulder range of motion (ROM) were used to measure outcomes following the intervention. OUTCOMES: The patient was seen once a week over the course of 5 weeks. The patient's SPADI score improved from 83% to 1.5% over the course of treatment. Active ROM of shoulder flexion improved from 50° to 155° over this period of time. A 6-month follow-up revealed a full return to usual activity and a SPADI score of 0%. DISCUSSION: A manual physical therapy approach addressing impairments of the cervical spine and upper limb neural tissue may lead to improved outcomes in the management of patients with shoulder pain and disability. 

J Orthop Sports Phys Ther. 2007;37(6):342-350, Epub 16 April 2007. doi:10.2519/jospt.2007.2458

KEY WORDS:  cervicobrachial pain, mechanosensitivity, mobilization