John D. Childs, PhD, PT; Julie M. Fritz, PhD, PT; Timothy W. Flynn, PhD, PT; James J. Irrgang, PhD, PT; Kevin K. Johnson; Guy R. Majkowski; Anthony Delitto, PhD, PT
Childs JD, Fritz JM, Flynn TW, Irrgang JJ, Johnson KK, Majkowski GR, et al. A Clinical Prediction Rule To Identify Patients with Low Back Pain Most Likely To Benefit from Spinal Manipulation: A Validation Study. Ann Intern Med. 2004;141:920-928. doi: 10.7326/0003-4819-141-12-200412210-00008
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Published: Ann Intern Med. 2004;141(12):920-928.
In this randomized, controlled trial, spinal manipulation plus exercise produced outcomes for low back pain similar to those produced by exercise alone. Yet, some patients did respond to spinal manipulation, and it would be helpful for doctors to be able to identify such patients.
Patients were most likely to benefit from spinal manipulation if they met 4 of 5 of the following criteria: symptom duration less than 16 days, no symptoms distal to knee, score less than 19 on a fear-avoidance measure, at least 1 hypomobile lumbar segment, and at least 1 hip with more than 35 degrees of internal rotation.
Clinicians may be able to use these criteria to identify patients with low back pain who are good candidates for spinal manipulation.
See Appendix 2 and Appendix 3 video for details. Reprinted from reference 30: Childs JD, Fritz JM, Piva SR, Erhard RE. Clinical decision making in the identification of patients likely to benefit from spinal manipulation: a traditional versus an evidence-based approach. J Orthop Sports Phys Ther. 2003;33:259-75, with permission of the Orthopaedic and Sports Physical Therapy Sections of the American Physical Therapy Association.
Lower scores represent less disability.
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Myron M. LaBan
William Beaumont Hospital, Royal Oak, MI 48073, Department of PM&R
January 13, 2005
Spinal Pain; A Symptom Not a Diagnosis
Myron M. LaBan, M.D., FACP, FAAPM&R
Department of Physical Medicine & Rehabilitation William Beaumont Hospital 3601 W. Thirteen Mile Road Royal Oak, MI 48073
Phone: 248-898-0162 Fax: 248-642-2483 Email: email@example.com
Key Words: Cervical spine pain, Lumbar spinal pain, Manipulation
The Editor Annals of Internal Medicine 190 N. Independence Mall West Philadelphia, PA 19106-1572, USA
"Spinal Pain"; A Symptom Not a Diagnosis
To the Editor: As a physiatrist honored over 30 years ago by my internist colleague's nomination to the American College of Physicians, I have since looked forward to receiving my monthly issues of the Annals of Internal Medicine. As a past President of the American Academy of Physical Medicine & Rehabilitation and subsequently its liaison to the ACP, I have on a number of occasions privately called attention to the Annal's apparent disturbing editorial policy which continues to treat the issue of spinal pain, i.e., both lumbosacral and cervical, as a generic disease entity rather than more appropriately as a symptomatic complaint. Two articles appearing in the December 2004 issue of the Archives the initial on "neck pain"1 and the later on "low back pain"2 are again but two examples of a continuing cavalier treatment of this complex and challenging entity which in addition to the health issue itself also has significant societal and economic consequences.
The Editors of the Annals would undoubtedly be more discriminating if called upon to publish an article on "stomach pain" and/or "heartburn"! Although the most frequent cause of spinal pain remains that of degenerative disease and its associated osteoarthritic involvement of the zygapophyseal joints, among other significant etiologies are herniated discs, spinal stenosis, occult spinal and paraspinal metastasis3 as well as pathomechanical vascular dysfunction, i.e., aneurysms and cardiomyopathies.4 A failure to discriminate in all treatment series as to the etiology of spinal pain should in this otherwise quality journal preclude publication. To continue to do otherwise, does a disservice to its readers as well as continuing to risk the otherwise well-earned reputation of the Annals. As a caveat after five days of "spinal pain" manipulation has been demonstrated to be no better than conventional physical therapy!5
1.White P, Lewith G, Prescott P, Conway J. Acupuncture versus placebo for the treatment of chronic mechanical neck pain. Ann Intern Med 2004;141:911-919.
2.Childs JD, Fritz JM, Flynn TW, Irrgang JJ, Johnson KK, Majkowski GR, Delitto A. A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study. Ann Intern Med 2004;141:920-28.
3.LaBan MM, Wilkins JCS, Szappanyos B, Shetty AN, Wang A-M. Paravertebral plexus of veins (Batson's) the potential route of paravertebral muscle metastasis as imaged by magnetic venous angiography (MVA). Am J Phys Med Rehabil 1997;76:517-19.
4.LaBan MM, Wilkins JC, Wesolowski DP, Bergeon B, Szappanyos BJ. Paravertebral venous distension (Batson's), an inciting etiological agent in lumbar radiculopathy as observed by venous angiography. Am J Phys Med Rehabil 2001;80:129-33.
5.LaBan MM, Taylor RS. Chiropractic manipulation in low back pain and the recommendations of the Agency for Health Care Policy and Research (HCPR). Letter to the Editor. Ann Internal Med 1999;130:75.
Rheumatology, Back Pain.
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