Are within/between session changes associated with functional outcomes, pain and recovery?

I recently had the opportunity to participate in a RCT to collect data to deterimine if within and between-session changes of pain and disability are associated with overall outcomes, pain and self-reported recovery in patients with mechanical, nonspecific LBP who are treated with manual therapy.
The study involved 100 subjects who demonstrated a positive response to manual therapy during the initial assessment (ie. had a positive change in symptoms following a mobilization).  This group was then randomized to recieve either a thrust or non-thrust manipulation and outcomes of the numeric pain rating scale, Oswestry and self-report of recovery (0-100%) were taken.  Outcomes were measured at initial evaluation, second visit and discharge. 
The results indicated that a there was a significant association of a within- and between session change at the second physical therapy visit and discharge outcomes for pain and disability.    The type of manual intervetion applied did not matter.  Simply a positive response to an initial session involving manual therapy was predictive of outcomes .  This is the first study to show an association between these variables and is the first to define the extent of change necessary for prognosis of an outcome.
Check it out:
Cook CE, Showalter C, et al. Can a within/between-session change in pain during reassessment predict outcome using a manual therapy intervention in patients with mechanical low back pain?Manual Therapy (2012), doi:10.1016/j.math.2012.02.020

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  • Dear Joseph,
    McKenzie/MDT has allready advised in his book to direct the therapy on symptom behavior. (The Lumbar Spine Mechanical Diagnosis and Therapy Spinal Publications 1981 ISBN 0 473 00064 4). A positive response in a sesion is called centralization when the pain distrubution get less big , returns to the central spine and to finally dissappear. This is typical for the classification category called derangement. Also a directional preference (more (intensity of) symptoms with repeated movements in one direction less in the opposite direction) indicates a derangement. There are lots of research done already and can be found here: Principally this is the same as you decribes Joseph, so to me it is nothing new. Thereby it is mostly not neccesary to apply an manipulation, but can it be achieved by patient generated forces. The same force and exercise can then be used to prevent a recurrence. This hands-of therapy has big advantages for the patiënt, because he can has more frequently therapy and has the ability to make him independent for health care services. So it is principally not right to do the job for the patient, just because we love to do it to earn the credits. Only when the patient force is not enough mobilisations are used. Only when even that is not enough, manipulations can do the job.
    kindest regards, Koen Overdijk, Netherlands

    koenoverdijk May 9, 2012 12:07 pm Reply
  • Koen,
    Thanks for the comment. I agree the we should always take an interactive route to patient care vs. operational. That stated, we should be able to determine clinically who are responders from manual interventions (predictive after 1st session) and this was the first prognostic study to look at this. The individuals who were included did not have radicular symptoms and had relatively nonspecific LBP. I am cool with McKenzie and my graduate program was McKenzie based (in teaching orthopedics of the spine) but there is a significant amount of literature to support the effects of manual therapy in the treatment of LBP. We now can predict who will respond to it favorably.

    josephbrence May 9, 2012 12:50 pm Reply
  • Interesting study what bothers me about it is that there is lots of info/research in addiction and psych fields that show responders usually show initial positive outcomes across a wide spectrum of theraputic skill sets and a simple variable such as tone of voice can be seen to make a positive response.

    Jim May 22, 2012 10:07 am Reply

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