“We Need to Educate and Interact – With Ourselves and Our Patients“, by Joseph Brence, PT, DPT, FAAOMPT, COMT, DAC
“Utility of the Head Thrust Test to Investigate Vestibular Function: A Clinical Pearl“, by Jeff Walter, PT, DPT, NCS
“Repeated Motions Exam and Treatment: Why You Should Be Using It“, by Chris Fox PT, DPT
“Return to Play After ACL Reconstruction in Preadolescent Athletes“, by Brian Schiff, PT, OCS, CSCS
“The Language of Pain“, by John Barbis, MPT, cert. MDT
“How can resistance-training programs best improve power?“, by Chris Beardsley, PhD
1. Butler RJ, Myers HS, Black D, et al. BILATERAL DIFFERENCES IN THE UPPER QUARTER FUNCTION OF HIGH SCHOOL AGED BASEBALL AND SOFTBALL PLAYERS. International Journal of Sports Physical Therapy. 2014;9(4):518–524.
2. Imai A, Kaneoka K, Okubo Y, Shiraki H. COMPARISON OF THE IMMEDIATE EFFECT OF DIFFERENT TYPES OF TRUNK EXERCISE ON THE STAR EXCURSION BALANCE TEST IN MALE ADOLESCENT SOCCER PLAYERS. International Journal of Sports Physical Therapy. 2014;9(4):428–435.
3. Cook G, Burton L, Hoogenboom BJ, Voight M. FUNCTIONAL MOVEMENT SCREENING: THE USE OF FUNDAMENTAL MOVEMENTS AS AN ASSESSMENT OF FUNCTION – PART 2. International Journal of Sports Physical Therapy. 2014;9(4):549–563.
4. Taylor-Hass JA, Hugentobler JA, DiCesare CA, et al. REDUCED HIP STRENGTH IS ASSOCIATED WITH INCREASED HIP MOTION DURING RUNNING IN YOUNG ADULT AND ADOLESCENT MALE LONG-DISTANCE RUNNERS. International Journal of Sports Physical Therapy. 2014;9(4):456–467.
5. Butler R, Arms J, Reiman M, et al. Sex Differences in Dynamic Closed Kinetic Chain Upper Quarter Function in Collegiate Swimmers. Journal of Athletic Training. 2014;49(3). doi:10.4085/1062-6050-49.3.17.
6. Beynnon BD, Vacek PM, Newell MK, et al. The Effects of Level of Competition, Sport, and Sex on the Incidence of First-Time Noncontact Anterior Cruciate Ligament Injury. Am J Sports Med. 2014;42(8):1806–1812. doi:10.1177/0363546514540862.
7. Haik MN, Alburquerque-Sendín F. Scapular Kinematics Pre– and Post–Thoracic Thrust Manipulation in Individuals With and Without Shoulder Impingement Symptoms: A Randomized Controlled Study. Journal of Orthopaedic & Sports Physical Therapy. 2014;44(7):475–487. doi:10.2519/jospt.2014.4850.
8. Ryan J, DeBurca N, Mc Creesh K. Risk factors for groin/hip injuries in field-based sports: a systematic review. British Journal of Sports Medicine. 2014;48(14):1089–1096. doi:10.1136/bjsports-2013-092263.
9. Kamath GV. Anterior Cruciate Ligament Injury, Return to Play, and Reinjury in the Elite Collegiate Athlete: Analysis of an NCAA Division I Cohort. Am J Sports Med. 2014;42(7):1638–1643. doi:10.1177/0363546514530866.
10. Paterno MV, Rauh MJ, Schmitt LC, Ford KR, Hewett TE. Incidence of Second ACL Injuries 2 Years After Primary ACL Reconstruction and Return to Sport. Am J Sports Med. 2014;42(7):1567–1573. doi:10.1177/0363546514530088.
Patient education and the instruction of a home exercise program (HEP) is of utmost importance to clinicians in order to obtain positive patient outcomes and to improve compliance. Recently, MedBridge Education rolled out their Patient Care Portal, which includes a HEP and Patient Education materials. I have had the opportunity to use this software for the past month or so and have broken my review into the following areas…
With 1,500 exercises (and growing) this HEP is almost all you will ever need with regards to prescribing a patient’s home program. These are not just simple stick figures or awkwardly drawn models either. Each exercise includes simple, modifiable instruction of technique, exercise parameters, and an in-depth video demonstration. Each exercise program can also have a detailed description and 3D video demonstration of the injury and/or disorder that your patient is being treated for. Additionally, if you cannot find the exercise or disorder that you need, both can be easily uploaded to the system. After you finished creating your patient’s program it can then be printed out, e-mailed, or the patient can visit their ‘Patient Portal’ to view their HEP and associated videos.
Ease of Use
MedBridge’s Patient Portal is one of the most user friendly HEPs that I have come across. Finding the correct exercise is simple with the ability to search based on body region, exercise type, or by searching for the specific exercise’s name. We all know that there can be countless names for the same exercise and this can cause significant issues when attempting to find your exercise in most HEPs. MedBridge’s program actually gives you the ability to modify the exercise’s name so that you can keep things straight in your head and so searching for the exercise in the future can be more efficient. Finally, to create a more efficient process, you can create templates for the more common disorders/injuries that you see on a day to day basis.
In my limited use of this program, I have heard nothing but positive feedback. Most patients are used to receiving crude drawing with poorly described exercise techniques and once they get home, all memory of how to perform their exercises is gone. I have noticed improved patient compliance and recall of exercise technique since implementing MedBridge’s HEP. The only negative comment I have received from a few patients/clients is that the pictures on the printouts are rather small and when printing in black & white, they can be difficult to see. Obviously, they could go to the website to watch the associated videos, but many patients don’t want to take that extra step.
Honestly, I have very few negative things to say about this software. It is intuitive, detailed, and a game-changer with regards to home exercise and patient education. The only negative I see is having to log into the online program in order to make a program, but this is a very minimal hassle for such a beneficial component to my patient’s care. After using basic and (mostly) frustrating HEPs in the past, my switch to MedBridge’s Patient Portal has been seamless with a very minimal learning curve. After 15-20 minutes of playing around with the program, I felt comfortable creating, editing, and sending programs to my clients. What’s the best part of this program? The cost. Currently, the Patient Portal is included with MedBridge’s online continuing education product, so for all those therapists already using this great resource, it is absolutely FREE.
For those of you who have not yet subscribed, you can purchase a one-year subscription to the continuing education, patient portal, and reference tools (Orthopedic Exam Videos, Manual Therapy Technique Videos, and 3D Models) for only $200, which is a savings of $225! For the Discounted rate, CLICK HERE or feel free to check out the MedBridge website and use promo code orthomanualPT when you’re ready to buy. This sale is good until 11:59 PM EST on Sunday, August 10th, so don’t wait too long!
The following is another article written for the online, video-based physical therapy continuing education company MedBridge…
Recently, a lot of attention has been paid to re-injury and return to sport following anterior cruciate ligament reconstruction (ACLR) and the results continue to be less than exceptional. A recent case series of elite collegiate athletes who suffered ACL injuries prior to and during their college careers continually found difficulty returning to sports participation (Kamath et al., 2014). Of the 35 athletes who had undergone ACLR prior to enrollment in college, the rate of re-operation on the involved limb was 51.4%, the rate of re-rupture of the ACL graft was 17.4%, and contralateral ACL rupture was 20.0% within this population of athletes. Similarly, those who underwent ACLR during college had a 20.4% re-operation rate, 1.9% suffered re-rupture of the ACL graft, and 11.1% of these athletes underwent ACLR on the contralateral limb. In agreement with these findings, a prospective cohort study of 456 collegiate athletes conducted by Rugg and colleagues found that athletes entering college with a history of ACLR had a 892.9-fold increase in knee surgery compared to those who entered college without undergoing surgery. Unfortunately, these findings are not isolated to collegiate athletes as professional (Busfield et al., 2009) and high school athletes (McCullough et al., 2012) alike have similar statistics. Considering these numbers, it points to inadequate or premature return to athletic participation, which may be because we are overlooking a very important aspect of athletic competition… [Continue Reading]
“What is the Lateral Shift & Why Does It Matter?“, by Trent Nessler, PT, DPT
“Kinesio Taping looks so cool, but is it effective?“, by Leo Costa, PT, PhD
“Assess, Don’t Assume“, by Mike Reinold, PT, DPT, SCS, ATC, CSCS
“Is hip strength a risk factor for patellofemoral pain?“, by Christian Barton, PT, PhD
“How do rest periods affect strength gains?“, by Chris Beardsley, PhD
“Assessing VBI before cervical manipulation: Should we test for it?“, by Chris Fox, PT, DPT
“There is no skill in manual therapy…?“, by Adam Meakins
“Unstable Surface Training: The Good, Bad, and Ugly“, by Eric Cressey, MS, CSCS
“Iliotibial Band Syndrome, Running, and Gender – What you should know“, by Christopher Johnson, PT, MCMT, ITCA
“Common Misconceptions of the Functional Movement Screen“, by Phil Plisky, PT, DSc, OCS, ATC, CSCS
“Screening for Movement Dysfunction: Are We Missing Anything?“, by Greg Lehman, BKin, MSc, DC, MScPT
Kooiker L, Van De Port IGL, Weir A, Moen MH. Effects of Physical Therapist–Guided Quadriceps-Strengthening Exercises for the Treatment of Patellofemoral Pain Syndrome: A Systematic Review. Journal of Orthopaedic & Sports Physical Therapy. 2014; 44(6): 391–B1.
Enseki K, Harris-Hayes M, White DM, et al. Nonarthritic Hip Joint Pain. Journal of Orthopaedic & Sports Physical Therapy. 2014; 44(6): A1–A32.
Cools AM, Borms D, Cottens S, Himpe M, Meersdom S, Cagnie B. Rehabilitation Exercises for Athletes With Biceps Disorders and SLAP Lesions: A Continuum of Exercises With Increasing Loads on the Biceps. American Journal of Sports Medicine. 2014; 42(6): 1315–1322.
Drew BT, Smith TO, Littlewood C, Sturrock B. Do structural changes (eg, collagen/matrix) explain the response to therapeutic exercises in tendinopathy: a systematic review. British Journal of Sports Medicine. 2014; 48(12): 966–972.
Kiesel KB, Butler RJ, Plisky PJ. Prediction of Injury by Limited and Asymmetrical Fundamental Movement Patterns in American Football Players. Journal of Sport Rehabilitation. 2014; 23(2): 88–94.
Powers CM, Ho K-Y, CHEN Y-J, Souza RB, Farrokhi S. Patellofemoral Joint Stress During Weight-Bearing and Non—Weight-Bearing Quadriceps Exercises. Journal of Orthopaedic & Sports Physical Therapy. 2014; 44(5): 320–327.
Nilstad A, Andersen TE, Kristianslund E, et al. Physiotherapists Can Identify Female Football Players With High Knee Valgus Angles During Vertical Drop Jumps Using Real-Time Observational Screening. Journal of Orthopaedic & Sports Physical Therapy. 2014; 44(5): 358–365.
Otsuki R. EFFECT OF INJURY PREVENTION TRAINING ON KNEE MECHANICS IN FEMALE ADOLESCENTS DURING PUBERTY. International Journal of Sports Physical Therapy. 2014; 9(2): 149–156.
Glaws KR. INTRA- AND INTER-RATER RELIABILITY OF THE SELECTIVE FUNCTIONAL MOVEMENT ASSESSMENT (SFMA). International Journal of Sports Physical Therapy. 2014;9(2):195–207.
Rust DA, Giveans MR, Stone RM, Samuelson KM, Larson CM. Functional Outcomes and Return to Sports After Acute Repair, Chronic Repair, and Allograft Reconstruction for Proximal Hamstring Ruptures. American Journal of Sports Medicine. 2014; 42(6): 1377–1383.
The following is another article written for the online, video-based physical therapy continuing education company MedBridge…
A lot has been written and researched with regards to return to sport criteria and testing for injuries of the lower extremity, and more specifically following anterior cruciate ligament reconstruction (ACL-R), however little attention has been given to injuries of the upper extremity. As with ACL-R, return to sport following surgical intervention in the upper extremity is less than stellar. Harris et al conducted a systematic review that found amongst elite pitchers undergoing shoulder surgery (rotator cuff, biceps/labrum, instability, internal impingement, ect.), only 68% returned to play 12 months following surgery. Additionally, they found that 22% of major league baseball pitchers included in their review never returned to sport. In agreement with these findings, Cohen et al evaluated the return to sport of professional baseball players following shoulder and/or elbow surgery and found only 48% of participants returned to the same or higher level of professional baseball following surgery. Why are these numbers so low and what can we do as rehabilitation specialists to improve the rate of return to sport following surgery?
Sometimes, it simply takes correctly identifying those who are at risk of re-injury or those simply not ready to rerun to their chosen sport. When devising an appropriate return to sport test, Phil Plisky, PT, DSc, OCS, ATC, CSCS says in his course, “Return to Sport and Discharge Testing“, that each test should be reliable, predictive of injury, have discriminate validity, and the test must be modifiable with training/rehabilitation. With regards to the upper extremity, there is a significant gap in knowledge/research in comparison to the lower extremity. That being said, the Y-Balance Test has recently been adapted to help fill this gap. Gorman et al investigated to reliability of the Upper Quarter Y Balance Test (UQ-YBT) and found that the test-retest reliability (0.80-0.99) and inter-rater reliability (1.00) ranged from good to excellent. Along with this information, normative data was determined amongst active adults with males generally performing the test superiorly to females and a minimally detectable difference of 8.1 cm in the medial direction, 6.4 cm in the superolateral direction, and 6.1 cm in the inferolateral direction. In addition to these findings, Westrick et al found that there was no significant difference between the dominant and non-dominant limb when young females or males perform the UQ-YBT. This shows that, generally speaking, any significantly asymmetrical findings should be investigated further prior to returning the athlete to his/her sport. While, currently, there are no studies investigating this test’s capacity to predict injury or its ability to be modified with training, the excellent reliability and discriminate validity make this a solid return to sport test.
Similarly, the Closed Kinetic Chain Upper Extremity Stability Test (CKCUEST) offers an additional way to assess upper extremity dynamic stability, albeit in a singular plane. Once again, this test demonstrates excellent reliability with a Test-Retest Reliability of 0.92 (Goldbeck et al), an intersession reliability ranging between 0.87 to 0.96 (Tucci et al), and an intrasession reliability ranging between 0.86 and o.97. Furthermore, Tucci et al also found the CKCUEST to have discriminate validity as those performing the test with diagnosed subacromial impingement performed significantly inferiorly in comparison to asymptomatic participants. Along with this excellent reliability and obvious display of closed kinetic chain dynamic stability, the CKCUEST also has recently been shown to have the capacity to predict injury. Pontillo et al performed a prospective cohort study attempting to identify potentially factors that would be predictive of upper extremity injury in collegiate football players. The only significant factor in predicting future injury in this population of athletes was a CKCUEST in which the athlete completed < 21 touches (Sn= 79%, Sp= 83%, + LR= 4.74, – LR= 0.25, Odds Ratio= 18.75). This is a significant finding and shows the benefit for utilizing this test not only for return to sport, but also in pre-season testing to identify individuals who are at risk for injury.
For a more demanding task, similar to the single-leg hop testing utilized for patients following ACL reconstruction, the One-Arm Hop Test was created to test the athlete’s plyometric, power, and dynamic closed kinetic chain stability. Unfortunately, to this date, there has only been one study investigating this specific return to sport test. Falsone et al found the test to have good Test-Retest Reliability (0.78-0.81) and also found only a 4.4% difference between non-dominant and dominant limbs when performing the test. This once again shows the ability to assess post-operative function based upon the symmetry between limbs. While this may not be a perfect solution, it allows the ability to utilize the test with evidence-based backing until further research is conducted investigating its ability to predict injury and/or be modified with training.
Returning an athlete to sport is a multi-factorial decision that must incorporate that athlete’s psychological readiness to return to play, strength, range of motion, pain level, and ultimately the ability to perform the movement patterns consistent with their sport and/or position. The aforementioned return to sport tests provides a hierarchical (i.e. increasingly demanding) system for testing the individual’s capacity to withstand the rigors of their chosen activity. This allows clinicians something outside of subjective reports, range of motion, and strength measures to assess your patient’s ability to perform dynamic upper extremity tasks prior to returning to sport and in doing so, we may be able to identify some of the deficits our athletes are hiding that are preventing them from ultimately returning to their sport.
The following is another article written for the online, video-based physical therapy continuing education company MedBridge Education…
Think for a minute about what you would do if the following patient walked into your clinic…
A 24-year-old female patient presents with left anterior knee pain, which was exacerbated after beginning a rigorous marathon training program. No other complaints other than pain during her runs and for 4-6 hours thereafter, but no other functional limitations when performing her ADLs.
So, based on this scenario, where would you focus your evaluation? My guess is that the majority of clinicians would focus on the knee and more specifically, the patellofemoral joint. Active and passive range of motion would be taken, gross lower extremity strength would be screened, and special tests would be performed. But, what if the patellofemoral joint was not the issue?
While these tests and measures are often indicated, with regards to musculoskeletal injuries, a joint or muscle group proximal or distal to the involved site can actually be the cause of the patient’s complaints. This concept is known as Regional Interdependence. This can be seen with a variety of orthopedic complaints as hip involvement has been associated with low back pain (Cibulka et al) and knee osteoarthritis (Cliborne et al), and thoracic/rib involvement in neck pain (Cleland et al) and subacromial impingement (Bergman et al). Specifically speaking of patellofemoral pain syndrome (PFPS) and our marathon running patient, proximal and distal impairments have also been shown to be very common in this patient population. A recent study conducted by Khayambashi et al found that following 8 weeks of hip abductor and external rotator strengthening, reduced pain and improved function was reported in women with PFPS in comparison to a control group. Furthermore, Khayambashi et al later conducted a randomized controlled trial comparing quadriceps strengthening to posterolateral hip strengthening in patients with PFPS. This study once again favored the hip-strengthening group with improvements in VAS and WOMAC scores in the posterolateral hip exercise group being superior to those in the quadriceps exercise group post-intervention and at 6-month follow-up. Going along with these findings, a systematic review investigating the utility of proximal stability training in patients with PFPS, which included 8 RCTs and found a consistent reduction of pain and improved function in the treatment of patellofemoral pain (Peters et al). Additionally, looking distally from the knee at the foot/ankle joint, according to a case-control study performed by Barton et al, individuals who present with PFPS, possess a more pronated foot posture and increased foot mobility compared to controls.
So, as the research shows, there is a fairly significant amount of evidence supporting the premise of Regional Interdependence, but how do we evaluate how and where to address the potential proximal or distal impairments? While there are several systems available to therapists to identify and address impairments based on the regional interdependence model, one of the most well-known and widely accepted systems is that of the Selective Functional Movement Assessment (SFMA). This system consists of a series of 7 full-body movement tests designed to assess fundamental patterns of movement, such as bending and squatting, in those with known musculoskeletal pain. From this assessment, interventions can then be applied to the identified impairments. While in comparison to its brother system, the Functional Movement Screen (FMS), which was developed for movement assessment in individuals without a painful condition, the SFMA has significantly less research available. That being said, a reliability study was recently conducted by Glaws et al in the International Journal of Sports Physical Therapy. This study found intra-rater reliability that ranged from Good to Poor and inter-rater reliability ranging from slight to substantial agreement. Those raters with increased experience utilizing the system demonstrated superior performance compared to those who were less experienced. This study provides preliminary evidence with regards to the reliability of the system, but there has yet to be a study conducted to validate the system’s effectiveness. In lieu of this evidence, the system itself still provides a reliable way to assess your patient’s movement impairments and allows the clinician to apply interventions, whether manual therapy techniques or therapeutic exercise, that will improve the patient’s quality of movement. For further information regarding the SFMA and its utility, take the time to understand the intricacies of the system by taking “Movement Dysfunction: An Evidence-Based Overview” by Kyle Kiesel, PT, PhD, ATC. The research indicates that movement relies on a coordinated interaction of multiple joints, muscles, and biological systems (cardiovascular, musculoskeletal, neurological, ect.). Because of these multiple influences, the therapist must look at potential factors that may be predisposing the patient to their painful condition and many times this will take us away from the effected joint.
Orthopedic Manual Physical Therapy was officially named ‘Best Student Blog’ in Therapydia’s PT Blog Awards for the second consecutive year! Thank you so much for the continued support and taking time out of your day to to vote for OMPT! I was honored just to be nominated along with The AAOMPT sSIG, Pitt Physical Therapy, The Student Physical Therapist, and A Cup A Day.
OMPT also came in 3rd place for ‘Best Research Blog’ and it was honestly great just to be named in the same breath as Body in Mind and Forward Thinking PT. Congratulations to Joseph Brence, DPT, FAAOMPT and all those that contribute to Forward Thinking PT!
Thanks again for all of your continued support,
John Snyder, DPT, CSCS
Thanks to all your continued support, OrthopedicManualPT.com was nominated for both ‘Best PT Student Blog’ and ‘Best PT Research Blog’ in Therapydia’s 2014 PT Blog Awards. It’s an honor to be named in the same group as all of the nominees in both categories!
Please continue to support OrthopedicManualPT.com and CAST YOUR VOTE (voting ends in ~ 2 weeks)!
John Snyder, SPT, CSCS
Last chance to save $225.00 on a one-year subscription to MedBridge Education’s online physical therapy continuing education resource! My affiliate discount will expire on April 30th, so if you’re interested in evidence-based continuing education that you can complete at home, don’t miss this opportunity! I do not push many products through my website for various reasons, but I honestly believe every clinician or DPT student can learn a ton from this resource. If you have any questions about my experience with MedBridge, feel free to e-mail me and I can answer any questions you have.
Thanks and enjoy!
John Snyder, SPT, CSCS
Research Review: Validation of a Clinical Prediction Rule to Identify Patients with LBP Likely to Respond to Stabilization Exercises
In the next instalment of my Research Review Series for MedBridge Education, we discuss a recent randomized controlled study investigating the validity of a clinical prediction rule for identifying patients with low back pain likely to respond favoribly to a spinal stabilization program.
Randomized Controlled Trial.
One hundred five patients diagnosed with LBP and referred to physical therapy at 1 of 5 outpatient clinics of Clalit Health Services in the Tel-Aviv metropolitan area, Israel, were recruited for this study. Of these 105 patients, 40 were positive on the Stabilization CPR and 65 were negative. The most evident difference between baseline differences of groups was age, with those in the stabilization group being significantly younger (one of the items of the CPR is < 40 years old).
Inclusion Criteria: 18 to 60 years of age, primary complaint of LBP with or without associated leg symptoms (pain, paresthesia), and had a minimum score of 24% on the Hebrew version of the modified Oswestry Disability Index (MODI) outcome measure.
Exclusion Criteria: History indicating any red flags (malignancy, infection, spine fracture, cauda equina syndrome), 2 or more signs suggesting lumbar nerve root compression (decreased deep tendon reflexes, myotomal weakness, decreased sensation in a dermatomal distribution, or a positive SLR, crossed SLR, or femoral nerve stretch test), history of corticosteroid use, osteoporosis, or rheumatoid arthritis. Additionally, patients were excluded if they were pregnant, received chiropractic or physical therapy care for LBP in the preceding 6 months, could not read or write in the Hebrew language, or had a pending legal proceeding associated with their LBP.
Outcome Measures: Hebrew version of the modified Oswestry Disability Index (MODI) and Numerical Pain Rating Scale (NPRS).
Randomization: Based on a computer-generated list of random numbers, which was then stratified by CPR status to ensure that adequate numbers of patients with a positive and a negative CPR status would be included in each intervention group.
Evaluation: A physical examination was conducted that included a neurological screen to rule out lumbar nerve root compression. Next, lumbar active motion was evaluated, during which the presence of aberrant movement, as defined by Hicks et al, was determined. Bilateral SLR range of motion, segmental mobility of the lumbar spine, and the prone instability testing was then also conducted. The patients’ status on the CPR (positive or negative) was established based on the findings of the physical examination.
Interventions: Patients in both the Lumbar Stabilization Exercise group (LSE Group) and Manual Therapy group (MT) received 11 treatments over an 8 week period and a 12 visit, which consisted of solely a re-evaluation. The LSE group was first educated on the function and common impairments related to the lumbar stabilizing musculature, they were then taught to perform an isolated contraction of the transversus abdominis and lumbar multifidus through an abdominal drawing-in maneuver (ADIM) in the quadruped, standing, and supine positions. Once the patient could successfully perform these actions, the demands on the musculature were increased by the addition of various upper and lower extremity movements. Finally, during the seventh session, functional movements were added to their program. Those patients randomized to the MT group received several thrust and non-thrust mobilization techniques to their lumbar spine in addition to manual stretching of several hip and thigh muscle groups. Each treatment session included up to three manual techniques (one of which had to be a thrust technique). With regards to exercise, those in the MT group performed active range of motion and self-stretching exercises, but did not perform isolated spinal stabilization exercises. All variations and progressions of exercises and manual therapy techniques can be seen in the appendix of the research report.
With regards to MODI, clinical significance could not be determined after 2-way interaction between treatment group and CPR status was calculated (p = 0.17). That being said, individuals who were positive on the CPR did demonstrate less disability at the end of the study compared to those who were negative (p = 0.02). Furthermore, amongst patients who were positive on the CPR, those who received LSE also demonstrated less disability following treatment compared to those who received MT. When the authors introduced a modified CPR, which consisted of positive prone instability test and presence aberrant movement, they did find a significant interaction with treatment for final MODI. Those positive on the modified CPR demonstrated superior outcomes compared to the group as a whole and also showed improved outcomes when receiving LSE compared to MT (p = 0.005).
The most prevalent limitations include an inadequate sample size, which resulted in a limited overall power of the findings as well as the retrospective nature of some of the findings (i.e. modified CPR). Additionally, this study had a high drop-out rate for a study of its size with an overall drop-out rate of 22.8% (33% in the LSE group and 14% in the MT group). The lower dropout rate in the MT group could potentially be due to an attention affect due to the manual contact required for the interventions within this group compared to the LSE group. Additionally, while short-term results are important, understanding the long-term implications of either MT or LSE is of greater importance. This study only included an 8 week follow-up and it would be beneficial to see the long-term implications with a 6 or 12 month follow-up to gauge the overall effectiveness of the CPR and associated interventions. Finally, it should be noted that status on CPR was determined prior to group determination, which introduces an additional level of bias. Future studies should look at results with CPR determination post priori or following allocation to groups.
Manual therapy and spinal stabilization are two very common interventions utilized by physical therapists when treating low back pain. As manual therapy is common amongst clinicians and generally considered an effective treatment option, it provides an excellent reference value in the validation of the stabilization CPR. Unfortunately, the utility of the CPR as it was constructed could not be validated based on the findings of this study. Several factors could have played into this discrepancy including attention effect by those in the MT group, small sample size, and large dropout percentage. While the original CPR could not be validated, retrospectively an abbreviated CPR was identified and ‘validated’ based on the findings of the 2-way interaction between treatment group and modified CPR status. So, while this study seems like a knock to the current lumbar stabilization CPR, the study design and execution of the study cannot allow the CPR to be disregarded as all of the aforementioned limitations may have played a significant role in the study’s results. Additionally, the creation of an abridged CPR may have more value to clinicians long-term as it provided superior results and requires less factors to be evaluated by the clinician. However, the results must be taken with a grain of salt as a prospective evaluation of the modified CPR must be conducted in order to determine its utility. Clinical prediction rules and the effectiveness of spinal stabilization are polarizing issues within the physical therapy community and this study debatably provides support to the use of spinal stabilization and indicates that future research is needed to clear up the murkiness of the current stabilization CPR. When treating the lumbar spine, no treatment should be provided with every patient and Chad Cook, PT, PhD, FAAOMPT goes into great detail in his course, “Evidence-Based Treatment of the Lumbar Spine”, with regards to the use of spinal stabilization within the Treatment-Based Classification system.
Rabin A, Shashua A, Pizem K, Dickstein R, Dar G. A Clinical Prediction Rule to Identify Patients With Low Back Pain Who Are Likely to Experience Short-Term Success Following Lumbar Stabilization Exercises: A Randomized Controlled Validation Study. Journal of Orthopaedic & Sports Physical Therapy. 2014; 44(1): 6–18, B1–13.
Did you enjoy this blog post? If so, please take the time to nominate Orthopedic Manual PT as ‘Best Student Blog’ in Therapydia’s 2014 PT Blog Awards!