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Donaldson M, Petersen S, Cook C, Learman K. A Prescriptively Selected Nonthrust Manipulation Versus a Therapist-Selected Nonthrust Manipulation for Treatment of Individuals With Low Back Pain: A Randomized Clinical Trial. J Orthop Sports Phys Ther. 2016;46(4):243-50.
DOI:10.2519/jospt.2016.6318
Since we were on the topic of manual intervention vs. therapist-patient interaction/therapeutic alliance etc.
The purpose of this randomized controlled trial was to compare objective and subjective outcomes of prescriptively selected (PS) nonthrust manipulation and therapist-selected (TS) nonthrust manipulation in subjects with low back pain with short and long term follow-up periods. Similar studies have been performed previously, however, none of them included long-term outcomes. Subjects (n=63) with mechanically reproducible low back pain received treatments of either two 60 seconds bouts of grade III central posterior-anterior mobilizations (CPAs) to both L4 and L5 (PS), or a variable amount of unilateral posterior-anterior mobilizations (UPAs) and CPAs to the individuals’ comparable spinal segment at grades ranging from I to IV, based on subject response. There was no time limit given for the TS treatment and the study does not specify how much time was spent and what was treated specifically in the TS group. Both groups were seen for 4 visits over a 2-week period. Additionally, both groups received a standardized home exercise program (HEP) consisting of standing hamstring stretches, quadruped cat and camel stretching, prone press-ups and supine Piriformis stretches. During the treatment sessions, these exercises were prescribed 3 times per day at 10 repetitions each. After the treatments, the subjects were urged to continue the HEP until the 1-month follow up, however, the article does not specify whether compliance with the HEP was recorded, or may have factored into the results.
The outcome measures for disability (ODI, NPRS) were collected at baseline, visit 4, 1 month and 6 months, while the PASS and GRoC were collected only at visit 4 and the 1 and 6 months follow up. The subjects were all in chronic stages of low back pain and did not seek out treatment separately, but rather responded to the advertisement for this study. The majority of subjects ranged from low to moderate on disability outcome measures, was not irritable and had low fear of movement (measured with TSK).
The results indicate that there is no statistically significant difference between the groups in regards to short or long term outcomes, except in GRoC scores. These results are similar to the findings in a study by Petersen et al. (JOSPT 3/16) investigating differences between general range of motion exercises and augmentative exercises in combination with manual intervention in subjects with neck pain. The GRoC is used to determine the subjects’ perceived improvement after treatment (health status, pain, disability, function, quality of life).
In the discussion section, the authors state that these results could stem from increased clinician-patient interaction in the TS group, due to the therapist seeking constant feedback in regards to the treatment. The authors suggest possible bias and assignment of greater value to treatment as a result.
There are several limitations to this study, including the lack of a control group and low number of visits, as listed by the authors. The lack of a control group raises the question whether the improvements by both groups should be attributed to the manual intervention, introduction to and performance of HEP, or simply decreases of symptoms over time. From a clinical/practical perspective, 4 visits in 2 weeks do not seem adequate and may be under the therapeutic levels. Furthermore, the inclusion/exclusion criteria were very focused on disability and outcome measures, however, did not specify aggravating or easing factors, or behavior of symptoms. Considering that the TS treatments still consisted of UPAs and CPAs, as compared to CPAs only the PS group, it is questionable how much difference there really was between the treatments received by either group. Although the TS group was not limited in regards to time and the comparable segments were treated, the authors do not specify what the treatments were and how much overlap there was between groups. Considering that CPAs and UPAs do not follow specific mechanical coupling patterns of the facet joints like other techniques (attempt to do), it is often suggested that PAs provide more of a neurophysiological input into an area, rather than treating specific intervertebral joint restrictions. We know that PAs do not isolate a single segment, but rather move adjacent segments above and below, further suggesting that the treatment effects by the two groups may have been more similar than intended, or necessary for the purpose of this study. The lack of information in regards to compliance with HEP, both during treatments and after discharge, is another variable to be considered. It is possible that the majority of improvement made, could mostly be due to introduction of stretching and motor control exercises. As several studies have shown, manual therapy and exercise in combination tend to have the best outcomes, which could explain the steep decrease in ODI and NPRS, as well as plateau and increase respectively, after discharge. However, due to aforementioned lack of information, we are limited to speculation in this regard. Lastly, while decreased symptoms over time are less likely due to the chronicity of symptoms in these patients, it is still a possibility.
Considering the design and results, it seems that the study is more indicative of whether there is a significant difference in outcomes when comparing time and location specific bouts of grade III CPAs (PS) to varying grades of CPAs and/or UPAs to comparable segments and adjusted intensity and location as per patient response to intervention (TS).Questions:
1. Do you consider the findings in this study to be applicable to your practice? If yes, how? If no, why?
2. How do you weigh the importance between perceived improvement (GRoC), likely related to clinician-subject interaction, in comparison to disability and pain outcome measures?
3. How do the subject demographics (chronicity, irritability, function, baseline outcome measure scores etc.) influence your interpretation of the information given?
4. What do you consider to be the most significant limitation in this study? Why? How does it affect your utilization/application of the results? -
Alex, thanks for posting
I think perceived improvement and objective improvement go hand-in-hand and the weight of one or the other is very much dependent on the patient. I think we could all reflect on a particular patient that may perceive they are doing really well but objectively they may not be and may require more specific patient education to avoid recurrent episodes, such as a post-op patient or someone with a reactive tendon or joint pathology for example. In cases of chronic conditions with individuals with fear avoidance and maladaptive movement behavior, patient interaction and education are critical and perceived improvement I feel is more important than their actual pain level. I feel if I can influence this type of patient to be more active, to move more and be more social in their community without an increase in pain, then that’s a win.As for the demographics of the subjects in this study, I think it’s worth analyzing the potential influence of studies that utilize a convenience sample such as this. There will be a big difference in patient perspectives and biopsychosocial factors between someone who is seeking treatment because it’s significantly affecting their life and someone that participates in a study just because someone asked them or sent them an advertisement. I think these individuals may respond very different to the same treatment and our treatment selection should be selected carefully and be based on multiple factors when it comes to chronic LBP (fear, beliefs, perception of PT, past treatment, etc.) and not just on the fact that they have chronic pain with low to moderate disability, etc..
I can’t believe I posted something before Nick
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Thanks for sharing Alex!
I’m having a hard time finding the difference between a prescriptively selected (PS) treatments as compared to a therapist- selected treatment approach. Just to make sure I’m understanding this correctly group 1 (PS) received central PAs or UPAs grade III and the L4/L5 segment. Group 2 was the therapist selected group where they used a grade IV mobilization based on their clinical reasoning on the specified direction needed.
I find myself still struggling to find that specific segment that sometimes I’m lost in my own mind while I could be asking the patient how they’re doing. It seems to me that a PA at the L4/L5 area for patients with mechanical back pain have similar results as compared to the clinical reasoning behind therapist selected mobilizations. Something that stuck out to me was when Kyle shared at our previous conference in Winchester “patients will get better, but if you want them to get that extra 10-15% then that’s where specificity kicks in. Research hasn’t measured that extra benefit for patients. ” (paraphrased but meaningful) I believe confidence and competence of the therapist giving the treatments is pretty important. Maybe that’s what the results don’t know why at 6 months were better for the therapist guided group. For my practice, I want to be confident in what I do. Even if I don’t get that specific segment then I know I’m doing some sort of a difference that’s not contraindicated for the patient.
Subjects where recruited through advertisements, word of mouth, and via e-mail. If patients are taking time for this study, then hopefully they want to be there therefore this may have had a positive influence on the results. I have a patient who has had chronic low back pain, severely depressed, and the only reason he’s here today is because I treated his parents and they’re forcing him. GREAT! Biopsychosocial factors are totally not in my favor. One of the biggest things I’m trying to communicate is finding an activity that he finds some enjoyment doing. He said grappling but he’s afraid. Grappling is pretty aggressive (he liked pinning and throwing people on the floor) so we tried to talk through other less aggressive activities like maybe swimming. Looking back I should have probably said taekwondo? I would love anyones thoughts.
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Oksana – group 1 received CPAs at a set dosage, grade and location. Group 2 received largely either CPAs and/or UPAs with varying dosage, grade, location.
I certainly hope that I apply the findings of all studies to my practice, the question is simply how. I do NOT believe that the appropriate way to apply the results of this study is to forego clinical reasoning in applying manual therapy and instead just press and guess. I simply think there are too many methodological limitations to this study itself that make that conclusion erroneous.
To me the largest “limitation” in the study is the patient’s duration of symptoms, which averaged 5 and 9 years for group 1 and 2 respectively. While I would contend that specificity in our manual treatment is ALWAYS preferable, it is certainly in my judgment less crucial when dealing with chronic vs. acute conditions. That is, it is almost certain that in someone with a 9 year history of back pain central sensitization is a significant driver of their pain, compared to a more acute injury where nociceptive mechanisms are more responsible. In the first instance, manual therapy is likely to exert its effects more generally and globally compared to the latter instance where improved specificity would be more appreciated.
Another large limitation for me is the rather difference in techniques, as you rightly pointed out Alex. A CPA at a given level is different than a UPA at the same or another level; but certainly the difference is less than that between a CPA and a rotational or side bending mobilization in sidelying, joint mobilization vs. soft tissue mobilization, or even manual therapy applied to another region (e.g., hip or thoracic spine) while not directing any specific manual therapy to the lumbar spine. I imagine that a greater difference in pain and disability would be observed if prescribed CPAs were compared to a much broader spectrum of manual therapy vs. targeted CPA’s and UPA’s alone.
Your second question is a hard one to answer Alex. Obviously we work towards an improvement in BOTH categories, but when they begin to diverge what is given greater importance? What is the greater victory – a patient who is really satisfied with the treatment they have received and yet their disability is largely unchanged, or a patient who has significantly reduced disability and yet remains unsatisfied? I am honestly not sure. All I can say is that in clinical practice I feel I work towards the former.
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I think you all make fantastic points about specificity of our manual techniques and I want to contribute to the question about the Global Rating of Change.
There was an interesting article published in 2009 in JMMT on the Global Rating of Change (GROC) scale, including the strengths and weaknesses of using such a scale. One of the points that the authors stress is the ambiguity and the variability in which you can use this scale, and the interpretation that patients can take in regards to answering the question, “Are you better, no change, or worse?”.
“Reliable and accurate function of the GROC places considerable cognitive demand of the patient, and a prominent criticism of the measure is founded in the contention that people are unable to accurately recall prior health states. An ability to recall and quantify status at a previous time-point is necessary for proper function of the measure. If the reliability of the recall is poor, the change score measured by the GROC scales is unduly influenced by the status of the patient at the time of the scale administration.”
The authors of this article don’t make the distinction whether the patients were referencing how they felt in regards to where they were at the beginning of the study, or where they were with the initial onset of their condition. Nick mentioned that the onset of symptoms were averaged between 5 and 9 years, so there is abundant possibilities for what memory constructs these patients are using among the time period of their condition to relate to their change. I think there’s an important distinction here and it would be important to determine this with our patients before we hang our hats on the significant change with GROC results, especially a small difference in treatment such as the specificity of non-thrust joint mobilizations in the same region over 4 visits.
Regardless, I agree that it is crucial and of arguably more importance for the patient to perceive improvement in their condition rather than objective improvement. But, we might have to take these study results with caution.
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Alex – to me, that final point is what is most significant. I completely agree with your hypothesis about T spine mobilization; and that is why I feel this article has limited applicability to the more acutely injured patient.
For those with chronic symptoms, however, maybe this article does indeed make us not stress so hard to get to a segment specific dysfunction (though I would still argue we should try and make SOME effort).
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