STUDY DESIGN: Randomized, controlled trial. OBJECTIVES: To assess the believability of a novel sham intervention for a neurodynamic technique (NDT) in participants with signs and symptoms of carpal tunnel syndrome (CTS). Additionally, we wished to assess a potential mechanism of NDT (hypoalgesia) and to compare outcomes related to clinical pain and upper extremity disability between NDT and a sham intervention. BACKGROUND: Preliminary evidence suggests that NDT is effective in the treatment of CTS. A sham-controlled study is lacking from the literature and could provide insight to the efficacy of NDT, as well as the corresponding mechanisms. METHODS: Participants with signs and symptoms consistent with CTS provided baseline measures of expectation, clinical pain intensity, upper extremity disability, and experimental pain sensitivity. Participants were then randomly assigned to receive either a NDT known to anatomicallystress the median nerve or a sham technique intended to minimize stress to the median nerve. Following brief exposure to the assigned technique, expectation was reassessed to observe for group-dependent changes. Participants received the assigned intervention over 3 weeks. Additionally, all participants received a prefabricated wrist splint for their involved hands, with instructions to sleep in the splint and to wear it during painful activities when awake. Following 3 weeks of the assigned intervention and splint wear, baseline measures were reassessed and participants were asked which intervention they believed they had received. RESULTS: Forty females agreed to participate. Expectations for pain relief and perceived group assignment were similar between the groups. Within-session decreases in clinical pain intensity and pressure pain sensitivity were observed independent of group assignment. Reduction of temporal summation was observed only in participants receiving NDT. Significant improvements in clinical pain intensity and upper extremity disability were observed at 3 weeks, independent of group assignment. CONCLUSION: The sham intervention was successful in blinding the participants. Immediate changes in pain sensitivity and intensity and 3-week changes in clinical pain intensity and upper extremity disability associated with NDT were equivalent to a sham intervention to which the participants were adequately blinded. Conversely, reduction of temporal summation was only observed in participants receiving the NDT, suggesting the potential of a favorable neurophysiological effect. LEVEL OF EVIDENCE: Therapy, level 1b.

J Orthop Sports Phys Ther 2009;39(10):709-723. doi:10.2519/jospt.2009.3117

KEY WORDS: central sensitization, manual therapy, musculoskeletal pain, placebo

For some patients, spinal manipulative therapy is an effective treatment for spine pain, yet we really don't fully understand how or why. The mechanisms of spinal manipulative therapy are not well defined, and common explanations for why spinal manipulative therapy works lack supporting evidence. Traditionally, the decision to incorporate spinal manipulative therapy into a plan of care is based on a seductively plausible biomechanical theory. Examination techniques, sometimes quite elaborate in nature, are used to determine painful structures and associated abnormalities related to alignment and mobility. The appropriately matched spinal manipulative therapy treatment techniques are then implemented to correct "pathological" findings. The underlying implication of these approacheds is that success of spinal manipulative therapy is dependent upon correction of biomechanical faults detected on examination.

J Orthop Sports Phys Ther. 2008;38(6):293-295. doi:10.2519/jospt.2008.0118

KEY WORDS: biomechanics, spine

Letters to the Editor-in-Chief of the JOSPT as follows:

• Regional Interdependence: A Musculoskeletal Examination Model Whose Time Has Come. J Orthop Sports Phys Ther. 2008;38(3):159-161. doi:10.2519/jospt.2008.0201
• Authors' response. J Orthop Sports Phys Ther. 2008;38(3):159-161. doi:10.2519/jospt.2008.0202
• Slipped Capital Femoral Epiphysis in a Patient Referred to Physical Therapy for Knee Pain. J Orthop Sports Phys Ther. 2008;38(3):159-161. doi:10.2519/jospt.2008.0203
• Authors' response. J Orthop Sports Phys Ther. 2008;38(3):159-161. doi:10.2519/jospt.2008.0204

STUDY DESIGN: Cross-sectional. OBJECTIVES: To (1) determine the association between pain severity and pain drawing area for men and women; (2) determine if sex differences exist in pain severity or pain drawing area; (3) determine the relative influence of pain sever­ity, anatomical location of pain, personality, and psychological coping factors on pain drawing area for men and women. BACKGROUND: Pain drawings have been pos­tulated to assist in clinical decision making regard­ing classification and treatment of musculoskeletal pain. Prior studies have been ambiguous on this topic, possibly because they have not considered if sex differences exist for pain drawing area. METHODS AND MEASURES: One hundred twenty-six subjects referred to a multidisciplinary chronic pain clinic with chronic musculoskeletal pain were included in this study. Subjects com­pleted a pain drawing, the Multidimensional Pain Inventory (MPI), the Coping Strategies Question­naire (CSQ), and the Minnesota Multiphasic Per­sonality Inventory (MMPI-2). Pearson correlations investigated the associations of pain severity and pain drawing area, independent t tests investigated sex differences in pain severity and pain drawing area, and multiple regression investigated factors that influenced pain drawing area. RESULTS: Pain severity was positively corre­lated with pain drawing area for men (r = 0.38, P = .003) and women (r = 0.23, P = .052), account­ing for approximately 14% and 5% of the total variance, respectively. There was no significant sex difference in pain severity ratings, but women reported a significantly larger area of symptoms on the pain drawings (effect size, 0.61; P = .002). The sex difference in pain drawing area was consistent across different anatomical locations of pain. In women, the final regression model accounted for 39% (P<.001) of the variance in pain drawing area, with anatomical location of pain (β = .42, P<.001) and hypochondriasis (β = .31, P = .005) as the only unique predictors in the final model. In men, the regression model accounted for 27% (P = .003) of the variance in pain drawing area, with pain severity (β = .32, P = .021) and a coping style of ignoring pain (β = –.32, P = .018) as the only unique predictors in the final model. CONCLUSIONS: Women had larger pain draw­ing area and this area was significantly associated with anatomical location of pain and hypochon­driasis. Men had smaller pain drawing area and this area was associated with pain severity and a coping style of ignoring pain. These findings sug­gest that clinicians interpreting pain diagram area should consider the sex of the individual. 

J Orthop Sports Phys Ther. 2007;37(3):115-121. doi:1.2519/jospt.2007.2399 

KEY WORDS: chronic pain, coping styles, personality style, pain drawing, sex difference, yellow flags

Study Design: Secondary analysis of a prospective cohort of patients with acute low back pain (LBP). Objectives: To determine if the centralization phenomenon and fear-avoidance beliefs predict measurement of pain and disability 6 months after entering the study. Background: The centralization phenomenon and fear-avoidance are predictive of future pain and disability. However, previous prognostic studies have not routinely included both measures in homogenous subgroups of patients with acute LBP. Methods and Measures: Patients completed self-report questionnaires and were evaluated and treated with treatment-based classification guidelines. Only the patients classified for specific exercise were included in this analysis (n = 28). Measures of disability and pain intensity were reassessed at 6 months by mail. Separate hierarchical regression models predicted measures of disability and pain intensity with the centralization phenomenon, fear-avoidance beliefs, and prespecified covariates. Results: There were no significant differences in duration of symptoms, fear-avoidance beliefs, and history of LBP based on the centralization phenomenon (P>.05). Patients reporting the centralization phenomenon were significantly more likely to have leg pain (P<.01). A regression model including initial disability, the centralization phenomenon, and fear-avoidance beliefs about work significantly predicted 6-month disability, explaining 49% of the total variance (P<.001). A regression model that included initial pain intensity and the centralization phenomenon significantly predicted 6-month pain intensity, explaining 29% of the total variance (P<.016). These factors also appeared to be clinically meaningful predictors of outcome, but lacked precision for immediate use in clinical settings. The following covariates were not included in the final regression models: presence of leg pain, history of LBP, and duration of LBP. Conclusions: Baseline elevation in fear-avoidance beliefs about work and lack of centralization phenomenon predicted higher disability. Baseline lack of centralization phenomenon predicted higher pain intensity. These results can only be generalized to patients with acute LBP classified for specific exercise. It will be necessary to independently validate these prediction models before they can be implemented in clinical settings.

J Orthop Sports Phys Ther. 2005;35(9):580-588. doi:10.2519/jospt.2005.2073

Key Words: McKenzie, pain intensity, physical therapy, treatment-based classification