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

STUDY DESIGN: A single-blinded, quasi-experimental, within- and between-sessions assessment. OBJECTIVES: To investigate potential mechanisms of neural mobilization (NM), using tensioning techniques in comparison to sham NM on a group of asymptomatic volunteers between the ages of 18 and 50. BACKGROUND: NM utilizing tensioning techniques is used by physical therapists in the treatment of patients with cervical and/or upper extremity symptoms. The underlying mechanisms of potential benefits associated with NM tensioning techniques are unknown. METHODS AND MEASURES:  Participants (n = 62) received either a NM or sham NM intervention 2 to 3 times a week for a total of 9 sessions, followed by a 1-week period of no intervention to assess carryover effects. A-delta (first pain response) and C-fiber (temporal summation) mediated pain perceptions were tested via thermal quantitative sensory testing procedures. Elbow extension range of motion (ROM) and sensory descriptor ratings were obtained during a neurodynamic test for the median nerve. Data were analyzed with repeated-measures analysis of variance (ANOVA). RESULTS: No group differences were seen for A-delta mediated pain perception at either immediate or carryover times. Group differences were identified for immediate C-fiber mediated pain perception (P = .032), in which hypoalgesia occurred for the NM group but not the sham NM group. This hypoalgesic effect was not maintained at carryover (P = .104). Group differences were also identified for the 3-week and carryover periods for elbow extension ROM (P = .004), and for the participant sensory descriptor ratings (P = .018), in which increased ROM and decreased sensory descriptor ratings were identified in participants in the NM group but not the sham NM group. CONCLUSION: This study provides preliminary evidence that mechanistic effects of tensioning NM differ from sham NM for asymptomatic participants. Specifically, NM resulted in immediate, but not sustained, C-fiber mediated hypoalgesia. Also, NM was associated with increased elbow ROM and a reduction in sensory descriptor ratings at 3-week and carryover assessment times. These differences provide potentially important information on the mechanistic effects of NM, as well as the description of a sham NM for use in future clinical trials. LEVEL OF EVIDENCE: Therapy, level 2b.

J Orthop Sports Phys Ther 2009;39(6):428-438, Epub 19 March 2009. doi:10.2519/jospt.2009.2954

KEY WORDS: manual therapy, neurodynamic testing, temporal summation

SYNOPSIS: The fear-avoidance model of musculoskeletal pain suggests that elevated pain-related fear is a precursor to chronic low back pain. Recent prospective studies support the predictive validity of this model, and treatment approaches based on the model have also been reported in the literature. Graded exercise/activity is one treatment approach that has been well described in the literature, with reports describing physical-therapy-specific application. Graded exposure is another intervention with the potential to reduce pain-related fear, yet physical-therapy-specific application of graded exposure has not been widely described in the literature. The purpose of this clinical commentary was to provide information on the theoretical aspects of graded exposure, to briefly review available evidence for graded exposure, and to describe physical therapy application of graded exposure for 2 patients enrolled in a physical therapy clinical trial. LEVEL OF EVIDENCE: Therapy, level 5.

J Orthop Sport Phys Ther 2009;39(7):496-505, Epub 24 February 2009. doi:10.2519/jospt.2009.2983

KEY WORDS: behavioral intervention, biopsychosocial, disability, fear-avoidance, kinesiophobia, secondary prevention

STUDY DESIGN: Cross-sectional. OBJECTIVES: This study examined the baseline relationship of pain intensity, physical impairment, and pain-related fear to shoulder function. BACKGROUND: There is no consensus regarding the influence psychological variable have on function and recovery in individuals with shoulder pathologies. While pain-related fear has been shown to predict disability for patients with low-back and cervical pain, this relationship has not been consistently reported for patients with shoulder pain. METHODS AND MEASURES: One hundred forty-two subjects (78 male, 64 female; mean age, 41.4 years) with nonoperative unilateralshoulder disorders were identified from a clinical database of impairment and outcome measures.Demographic information, duration of symptoms, mechanism of injury, pain intensity, pain-related
fear, and range-of-motion (ROM) measures were collected. Self-report of function was measured with the Shoulder Pain and Disability Index (SPADI). Hierarchical regression analysis determinedthe proportions of explained variance in function. RESULTS: Demographic variables (durationof symptoms, sex, age, and mechanism of injury) collectively contributed approximately 9% (P = .003) of the variance in function scores. Average pain intensity and flexion ROM contributed an additional 22% (P<.001) of the variance, and Tampa Scale of Kinesiophobia (TSK-11) scores contributed an additional 3% (P<.001). In the final parsimonious model, presence of symptoms longer than 3 months (ß = .23, P = .003), pain intensity (ß = .25, P = .002), shoulder flexion ROM index (ß = –.35, P = .001), and kinesiophobia (ß = .17, P = .026) explained 33% of the variance in SPADI function score (P<.001). CONCLUSIONS: Presence of symptoms longer than 3 months, average pain intensity, flexion ROM index (strongest contributor in multivariate model), and fear-of-pain scores all contributed to baseline shoulder function. The immediate clinical relevance of these findings is unclear but they do provide direction for prospective studies. LEVEL OF EVIDENCE: Prognosis, level 2b.

J Orthop Sports Phys Ther 2009;39(4):270-277, Epub 15 December 2008. doi:10.2519/jospt.2009.2879

KEY WORDS: disability, kinesiophobia, psychological, physical therapy, shoulder flexion

STUDY DESIGN: Cross-sectional. OBJECTIVES: To measure fear of movement/reinjury levels and determine the association with function at different timeframes during anterior cruciate ligament (ACL) reconstruction rehabilitation. We hypothesized that fear of movement/reinjury would decrease during rehabilitation and be inversely related with function. BACKGROUND: Fear of movement/reinjury can prevent return to sports after ACL reconstruction, but it has not been studied during rehabilitation. METHODS AND MEASURES: Demographic data and responses on the shortened version of Tampa Scale for Kinesiophobia (TSK-11), 8-Item Short-Form Health Survey (SF-8), and International Knee Documentation Committee (IKDC) subjective form were extracted from a clinical database for 97 patients in the first year after ACL reconstruction. Three groups were formed: group 1, less than or equal to 90 days; group 2, 91 to 180 days; group 3: 181 to 372 days post-ACL reconstruction. Group differences in TSK-11 score, SF-8 bodily pain rating, and IKDC scores were determined. Hierarchical linear regression models were created for each group, with IKDC score as the dependent variable and demographic factors, SF-8 bodily pain rating, and TSK-11 score as independent variables. RESULTS: TSK-11 score was higher in group 1 than in group 3 (P < .05). Across the groups, SF-8 bodily pain rating decreased (P < .001) and IKDC score increased (P < .001). SF-8 bodily pain rating was a significant factor in the regression model for all groups, whereas TSK-11 score only contributed to the regression model in group 3 (partial correlation, -0.529). CONCLUSIONS: Pain was consistently associated with function across the timeframes studied. Fear of movement/reinjury levels appear to decrease during ACL reconstruction rehabilitation and are associated with function in the timeframe when patients return to sports. LEVEL OF EVIDENCE: Prognosis, level 4.

J Orthop Sports Phys Ther. 2008;38(12):746-753, published online 19 September 2008. doi:10.2519/jospt.2008.2887

KEY WORDS: ACL, knee injury, outcomes, psychosocial

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

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

• Letter regarding the editorial, Risk and Physical Therapy?. J Orthop Sports Phys Ther. 2007:37(9):570-572. doi:10.2519/jospt.2007.0209.
• Authors' Response. J Orthop Sports Phys Ther. 2007:37(9):571-572. doi:10.2519/jospt.2007.0210.

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

The process of differential diagnosis involves the development of working hypotheses concerning dysfunction. These working hypotheses are revised, if necessary, based on the results of a physical examination. Some of the hypotheses to consider for a patient with symptoms involving the posterior thigh include lumbar radiculopathy, hamstring strain or tear, and sciatic nerve irritation. Involvement of the lumbar spine is assessed by evaluating the range and pattern of active lumbar movements. For example, a patient with asymmetrical lumbar sidebending may have facet joint restriction. In addition to range of motion, lumbar movements that centralize or peripheralize lower extremity symptoms are determined. Centralization of symptoms is defined as lumbar spine movements that abolish lower extremity symptoms, or make the symptoms move towards the spine. Peripheralization of symptoms is defined as lumbar spine movements that produce lower extremity symptoms or make the symptoms move farther away from the spine. The purpose of this case problem is to highlight the decision making process involved in determining the treatment of a patient with posterior thigh symptoms. In addition, the method of treatment will be described, and the patient's response to the treatment will be included in this article.

J Orthop Sports Phys Ther. 2000;30(8):468-472.

Key Words: lumbar, posterior thigh symptoms

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

For certain patients, fear of pain can be as disabling as pain itself. Clinicians and researchers interested in reducing the societal impact of chronic musculoskeletal pain must work together to manage relevant psychological influences like fear of pain. Collaborative efforts are necessary to address the following issues in a wide range of musculoskeletal pain conditions: (1) refine current screening techniques to make them more efficient and accurate, and (2) develop and test interventions that effectively reduce pain-related fear. Otherwise, an important contributor to our patients' pain and disability will continue to be mismanaged by the same professionals trying to prevent chronic conditions.

J Orthop Sports Phys Ther. 2006; 36(5):264-266. doi:10.2519/jospt.2006.0106

Study Design: Secondary analysis of pooled data from 3 randomized trials. Objective: This study investigated sex differences in response to physical therapy intervention for acute low back pain. Background: Sex differences in experimental pain sensitivity have been consistently described in the literature. However, clinical consequences of these sex differences have not been widely reported. Methods and Measures: Subjects (n = 165) were participants in 3 randomized trials of physical therapy interventions from outpatient physical therapy clinics in the general and military communities. Subjects were randomly assigned spinal manipulation with range-of-motion exercise, lumbar stabilization exercise, or directional-preference exercise. Outcomes were measured at 4 weeks through self-report of pain intensity and pain-related disability. Sex differences were investigated with independent t tests (baseline data), 2 x 3 analysis of variance (4-week reductions in pain and pain-related disability), and regression models (predictors of outcome). Results: Men and women had similar reductions of pain intensity (raw mean difference, 0.5; 95% CI, -1.4 to 0.4) and pain-related disability (raw mean difference, 5.3; 95% CI, -0.1 to 10.7) over 4 weeks. Baseline pain intensity, duration of symptoms, and baseline pain-related disability significantly predicted change in pain intensity for women (r² = 26%, P<.01). Baseline pain intensity and stabilization exercise predicted change in pain intensity for men (r² = 33%; P<.01). Baseline pain-related disability, duration of pain, and pain intensity predicted change in disability for women (r² = 24%, P<.01). Baseline pain-related disability, fear-avoidance beliefs, stabilization exercise, and leg pain predicted change in disability for men (r² = 32%, P<.01). Conclusion: For patients with acute low back pain, men and women had similar physical therapy outcomes for reductions in pain intensity and pain-related disability. However, men and women had different factors that predicted treatment outcome.

J Orthop Sports Phys Ther. 2006; 36(6):354-363. doi:10.2519/jospt.2006.2270

Key Words: acute pain, gender differences, lumbar spine, rehabilitation, treatment response

Objectives: The purpose of this case series was to describe the criteria used to determine if patients were to receive slump stretch treatment within a treatment-based classification system and to describe selected symptom characteristics associated with these patients.

Background: Previous reports from the literature suggest that the slump test position may be a useful treatment and evaluation technique. However, little information has been presented regarding how to identify patients who are appropriate to treat with slump stretching and the symptom characteristics associated with these patients.

Methods and Measures: Prior to recruitment, criteria were established to identify patients who would be considered appropriate to treat with slump stretching. Consecutive patients referred with low back diagnosis or low–back-related diagnoses were then evaluated using a treatment-based classification system. Selected symptom characteristics were collected from patients treated with slump stretching.

Results: Out of 88 consecutive patients with low back diagnoses or low–back-related diagnoses, 6 met the study’s inclusion criteria and were treated with slump stretching. All pain diagrams were classified as ‘‘organic’’ or ‘‘possibly organic,’’ and the most common symptom descriptor was ‘‘deep ache.’’ At the discharge session of physical therapy, 5 of 6 patients had symptoms that were more proximally located and all patients reported a decrease in symptom intensity.

Conclusion: Favorable changes in symptom intensity and location were observed for this case series, but definitive conclusions cannot be drawn from this study design. Additional research needs to be completed to determine if the slump test position is an effective evaluation and treatment technique.

J Orthop Sports Phys Ther 2002; 32(8):391–398.

Key Words: classification, slump test, symptoms