Journal of Orthopaedic & Sports Physical Therapy - Maj John D. Childs, PT, PhD

Development of a Clinical Prediction Rule for Diagnosing Hip Osteoarthritis in Individuals With Unilateral Hip Pain

Thomas G. Sutlive, Heather P. Lopez, Dani E. Schnitker, Sarah E. Yawn, Robert J. Halle, Liem T. Mansfield, Robert E. Boyles, Maj John D. Childs

STUDY DESIGN: Prospective cohort/predictive validity study. OBJECTIVE: To determine the diagnostic accuracy of common clinical examination items and to construct a preliminary clinical prediction rule for diagnosing hip osteoarthritis (OA) in individuals with unilateral hip pain. BACKGROUND: The current gold standard for the diagnosis of hip OA is a standing antero-posterior (AP) radiograph of the pelvis. Other than for Altman's criteria, little research has been done to determine the accuracy of clinical examination findings for diagnosing hip OA. METHODS: Seventy-two subjects completed the study. Each subject received a standardized history, physical examination, and standing AP radiograph of the pelvis. Subjects with a Kellgren and Lawrence score of 2 or higher based on the radiographs were considered to have definitive hip OA. Likelihood ratios (LRs) were computed to determine which clinical examination findings were most diagnostic of hip OA. Potential predictor variables were entered into a logistic regression model to determine the most accurate set of clinical examination items for diagnosing hip OA. RESULTS: Twenty-one (29%) of the 72 subjects had radiographic evidence of hip OA. A clinical prediction rule consisting of 5 examination variables was identified. If at least 4 of 5 variables were present, the positive LR was equal to 24.3 (95% confidence interval=4.4-142.1), increasing the probability of hip OA to 91%. CONCLUSION: The preliminary clinical prediction rule provides the ability to a priori identify patients with hip pain who are likely to have hip OA. A validation study should be done before the rule can be implemented in routine clinical practice.

J Orthop Sports Phys Ther., Epub 14 July 2008. doi:10.2519/jospt.2008.2753

KEYWORDS: arthritis, diagnosis, OA, predictive validity

Manual Physical Therapy: We Speak Gibberish

Timothy W. Flynn, Maj John D. Childs, Stephania Bell, Jake S. Magel, Robert H. Rowe, Haideh Plock

In December of 2006, the American Academy of Orthopaedic Manual Physical Therapists (AAOMPT) convened a task force to create a framework for standardizing manual physical therapy procedures. The impetus came from many years of frustration with our ability to precisely communicate to each other, as well as to stakeholders outside our profession. To this end, a contribution titled "A Model for Standardizing Manipulation Terminology In Physical Therapy Practice" is published in this issue of the Journal.

J Orthop Sports Phys Ther. 2008;38(3):97-98. doi:10.2519/jospt.2008.0103

KEY WORDS: guidelines, manual physical therapy, terminology

Investigation of Elevated Fear-Avoidance Beliefs for Patients With Low Back Pain: A Secondary Analysis Involving Patients Enrolled in Physical Therapy Clinical Trials

Steven Z. George, Julie M. Fritz, Maj John D. Childs

STUDY DESIGN: Secondary analysis. OBJECTIVE: To investigate the Fear-Avoidance Beliefs Questionnaire (FABQ) for its ability to predict 6-month outcomes for patients with low back pain (LBP) participating in physical therapy clinical trials. BACKGROUND: Consistent evidence suggests that fear-avoidance beliefs are predictive of short-term outcomes for patients with LBP. However, proposed cut-off scores have not been widely investigated for longer-term outcomes in samples of patients receiving physical therapy. METHODS AND MEASURES: Subjects (n = 160) were participants in 2 separate randomized trials that used standard methodology and investigated the efficacy of physical therapy interventions for LBP. Subjects completed baseline measures of pain, disability, fear-avoidance beliefs, and physical impairment. They completed 4 weeks of randomly assigned physical therapy and were reassessed at 6 months with standard examination techniques. The accuracy of previously proposed cut-offs for elevated FABQ scores were determined by independent t tests and chi-square analysis on raw 6-month Oswestry Disability Questionnaire (ODQ) scores, 6-month ODQ change scores, and minimally clinical important difference (MCID) in ODQ scores (6 points). Next, a hierarchical regression model determined which FABQ scale better predicted 6-month ODQ scores after controlling for previously reported prognostic factors and relevant treatment parameters. Last, receiver operating characteristic curve analyses were planned to generate a range of FABQ cut-off scores that predicted 6-month MCID in the ODQ. RESULTS: The previously reported cut-off score for the FABQ physical activity scale (>14) resulted in 111 (69.4%) of 160 patients being classified as having elevated baseline scores, while the previously reported cut-off score for the FABQ work scale (>29) resulted in 19 (11.9%) of 160 patients being classified as having elevated baseline scores. Patients with elevated FABQ physical activity scale scores (>14) had no significant differences in 6-month ODQ outcomes. Patients with elevated FABQ work scale (>29) scores reported higher 6-month ODQ scores and were more likely to have reported no improvement in ODQ score. The final regression model explained 24.4% of the variance in 6-month ODQ scores, with only manipulation and exercise and the FABQ work scale as unique predictors. Fifteen of the subjects (12.7%) had a 6-month change in ODQ that indicated no improvement. The area under the receiver operating characteristic curve for the FABQ physical activity scale predicting this outcome was 0.562 (95% CI: 0.415-0.710) and for the FABQ work scale was 0.694 (95% CI: 0.542-0.846). Cut-off scores were explored for the FABQ work scale only, with positive likelihood ratios that ranged from 1.19 to 5.15 and negative likelihood ratios that ranged from 0.30 to 0.83. CONCLUSIONS: The FABQ work scale was the better predictor of self-report of disability in this sample of patients participating in physical therapy clinical trials. Future studies are necessary to further test and refine the FABQ work scale as a screening tool alone, and in combination with other examination findings. LEVEL OF EVIDENCE: Prognosis, Level 2b.

J Orthop Sports Phys Ther. 2008;38(2):50-58, published online 22 January 2008. doi:10.2519/jospt.2008.2647

KEY WORDS: disability, FABQ, Owestry, prognosis

Rehabilitative Ultrasound Imaging: When Is a Picture Necessary?

Deydre S. Teyhen, Maj John D. Childs, Timothy W. Flynn

In this issue of the journal, we explore rehabilitative ultrasound imaging's potential as a tool that physical therapists use in examining low back muscle function. As an assessment tool, RUSI can assist practitioners in recognizing impairments such as a decreased ability to increase muscle thickness (eg, transversus abdominis or multifidus) during specific physical tasks, excessive use of more global muscles (eg, rectus abdominis or erector spinae muscles) during low-level activities, and muscular atrophy. Identifying these impairments can help practitioners formulate a specific exercise program matched to the patient's underlying impairments during early stages of rehabilitation. From a treatment perspective, RUSI can provide feedback to both the physical therapist and patient that may help determine which verbal or tactile cues are most effective to facilitate proper performance of therapeutic exercises during the early phase of rehabilitation. Additionally, it may assist physical therapists in their decision-making process related to exercise prescription and progression. Finally, RUSI may help determine when specific impairments have been sufficiently addressed to permit the exercise progression necessary to achieve maximal pain-free function.

J Orthop Sports Phys Ther. 2007;37(10):579-580. doi:10.2519/jospt.2007.0109

KEY WORDS: rehabilitative ultrasound imaging, low back

Observed Changes in Lateral Abdominal Muscle Thickness After Spinal Manipulation: A Case Series Using Rehabilitative Ultrasound Imaging

Nicole H. Raney, Nicole H. Raney, Deydre S. Teyhen, Deydre S. Teyhen, Maj John D. Childs, Maj John D. Childs
STUDY DESIGN: Case series. BACKGROUND: A clinical prediction rule (CPR) has been developed and validated that accurately identifies a subgroup of patients with low back pain (LBP) likely to benefit from spinal manipulation; however, the mechanism of spinal manipulation remains unclear. The purpose of this case series was to describe changes in lateral abdominal muscle thickness using rehabilitative ultrasound imaging (RUSI) immediately following spinal manipulation in the subgroup of patients positive on the rule. CASE DESCRIPTIONS: Data from 9 patients (5 female, 4 male; 18 to 53 years of age) with a primary complaint of LBP are presented. All patients had symptoms for less than 16 days (range, 3 to 14 days) and did not have symptoms distal to the knee, satisfying the 2-factor rule for predicting successful outcome from spinal manipulation. The Oswestry Disability Index scores ranged from 8% to 52%. Lateral abdominal muscle thickness was assessed with the patient at-rest and while contracted during an abdominal drawing-in maneuver (ADIM) using RUSI. Measurements were taken before and immediately after spinal manipulation. Patients completed a 15-minute training session of the ADIM prior to assessment to mitigate the potential for a learning effect to occur. OUTCOMES: Based on changes that exceeded the threshold for measurement error, 6 of 9 patients demonstrated an improved ability (11.5%-27.9%) to increase transversus abdominis (TrA) muscle thickness during the ADIM post manipulation. Additionally, TrA muscle thickness at-rest post manipulation decreased for 5 patients (11.5%-25.9%), while at-rest internal oblique muscle thickness decreased for 4 patients (6.4%-12.2%). DISCUSSION: This case series describes short-term changes in lateral abdominal muscle thickness post spinal manipulation. Although case series have significant limitations, including the fact that no cause-and-effect claims can be made, the decrease in muscle thickness at-rest and the greater increase in muscle thickness during the ADIM post manipulation observed in some of the patients could suggest an improvement in muscular function. Future research is needed to determine if increased muscle thickness is associated with improvements in pain and disability and to further explore neurophysiologic mechanisms of spinal manipulation.

J Orthop Sports Phys Ther. 2007:37(8):472-479; published online 12 July 2007. doi:10.2519/jospt.2007.2523

KEY WORDS: internal oblique, lumbar stabilization, manual therapy, sonography, transversus abdominis

Subgrouping Patients With Low Back Pain: Evolution of a Classification Approach to Physical Therapy

Joshua A. Cleland, Maj John D. Childs, Julie M. Fritz
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

Clinical Decision Making in the Identification of Patients Likely to Benefit From Spinal Manipulation: A Traditional Versus an Evidence-Based Approach

Maj John D. Childs, Julie M. Fritz, Sara R. Piva, Richard E. Erhard

Growing evidence suggests that spinal manipulation is effective in the management of low back pain (LBP). However, in the absence of evidence of an alternative approach, clinicians have primarily relied on diagnostic tests with questionable reliability and validity in the clinical decision-making process to identify potential candidates for spinal manipulation. These 2 cases highlight the use of a clinical prediction rule (CPR) developed by Flynn et al, which demonstrates that there are a few simple criteria from the history and physical examination that can be used to help clinicians decide if spinal manipulation and a range of motion (ROM) exercise may be helpful in the management of a patient with LBP. Importantly, these results provide clinicians with an easy-to-use procedure to accurately identify patients with LBP who are likely to achieve a dramatic improvement prior to treatment.

We believe this CPR offers clinicians an efficient and practical evidence-based tool that can be applied by even the novice physical therapist who is familiar with the CPR and the technique that was used in its development. This CPR should encourage clinicians who were previously reluctant to incorporate spinal manipulation into their clinical practice to use it more frequently based on a patient’s status with respect to the CPR.

J Orthop Sports Phys Ther. 2003;33(5):259-272.

Key Words: low back pain, spinal manipulation, clinical prediction rule

Case Reports: Can We Improve?

Maj John D. Childs

The purpose of this editorial is to offer several recommendations to improve the overall quality and usefulness of manuscripts submitted as case reports to the JOSPT and other peer-reviewed journals. Specifically, authors should distinguish how publication of their case report adds to the existing body of knowledge in the literature. They should incorporate reliable and valid health-related quality of life (HRQL) instruments specific to the patient's condition and representative of the patient's impairments and level of function/disability, where such instruments exist. Authors of case reports should resist the temptation to assume that what was done to the patient directly caused the observed outcome. And finally, and perhaps most important, authors should subject their case report to a substantive "in-house" peer review prior to submission.

J Orthop Sports Phys Ther. 2004;34(2):44-46. doi:10.2519/jospt.2004.0102

Key Words: case reports, peer review

The Influence of Experience and Specialty Certifications on Clinical Outcomes for Patients With Low Back Pain Treated Within a Standardized Physical Therapy Management Program

Julie M. Whitman, Julie M. Fritz, Maj John D. Childs

Study Design: Secondary analysis of a randomized trial. Objectives: To examine the influence of experience and specialty certification on outcomes for patients with low back pain receiving a standardized manipulation or stabilization exercise intervention program. Background: Little research has examined the impact of therapist-related factors on the outcomes of clinical care for patients with low back pain. It is assumed that therapists with more clinical experience or specialty certification will achieve better clinical outcomes; however, few studies have examined this hypothesis. Methods and Measures:One hundred thirty-one participants in a randomized trial were included (70 randomized to receive manipulation, 61 stabilization). All subjects completed an Oswestry Disability Questionnaire at baseline, and after 1 and 4 weeks of treatment. Therapists were categorized based on total years of experience, years of experience with manual therapy, and specialty certification status. Two-way repeated-measures analyses of covariance were performed within each intervention group to examine the effects of the therapist characteristics on outcomes. Hierarchical linear regression models were used to examine the relative effects of therapist characteristics and intervention on clinical outcomes. Results: Thirteen therapists participated (average 6.0 years of experience [standard deviation, 4.0], 4 (30.8%) with specialty certification). A significant interaction between time and specialty certification status (P = .04) was detected for subjects receiving the manipulation intervention. No significant interactions were detected in the stabilization group. The regression models found that the intervention group significantly contributed to explaining clinical outcomes, but that therapist characteristics did not. Conclusions: With the standardized protocol utilized in this study, it appears that the therapist-related factors of increased experience and specialty certification status do not result in an improvement in patients’ disability associated with low back pain.

Invited Commentary by Linda Resnik

J Orthop Sports Phys Ther. 2004;34(11):662-675. doi:10.2519/jospt.2004.1535

Key Words: experience, expertise, low back pain manipulation, stabilization

Proposal of a Classification System for Patients With Neck Pain

Maj John D. Childs, Julie M. Fritz, Sara R. Piva, Julie M. Whitman

It is likely that patients with neck pain are not a homogeneous group, but, instead, consist of a variety of subgroups, each of which may benefit from a specific intervention matched to the patient’s signs and symptoms. Studies to date have largely failed to account for this possibility, which may compromise the statistical power of research and ultimately fail to provide guidance for clinical decision making. Classification provides a means of breaking down a larger entity into more homogeneous subgroups of patients, based on examination data. Classification can guide the determination of a patient’s prognosis, and the selection of the most appropriate intervention strategy. Classification has received considerable attention in the management of patients with low back pain, and evidence is emerging regarding its benefits. There has been considerably less effort made toward examining classification as it pertains to patients with neck pain. The purpose of this clinical commentary is to examine the current literature and to propose a classification system for patients with neck pain, based on the overall goal of treatment. The approach is based on published evidence when possible and is also informed by clinical experience and expert opinion. Classification decisions are based on the integration of data from a variety of information from the history and physical examination. The end result of the classification process is to determine the treatment approach believed to be most likely to maximize the clinical outcome for an individual patient with neck pain.

Invited Commentary by Michele Sterling

J Orthop Sports Phys Ther. 2004;34(11):686-700. doi:10.2519/jospt.2004.1451

Key Words: conservative treatment, decision making, diagnosis, neck pain, staging