We hypothesized that patients with pain located below the knee would respond better to MDT than to Back School. Some preliminary studies suggest people with leg pain may respond well to the MDT approach, 30 — 32 and there is little rationale why Back School would specifically help these people.
The MDT approach focuses on achieving centralization of pain from the periphery into the low back. Whether patients had pain extending below the knee was determined using a body chart and patient self-report during the baseline assessment. We hypothesized that patients with higher baseline pain intensity using median split would respond better to MDT than to Back School. This hypothesis was based on clinical experience rather than any strong existing evidence. We hypothesized that patients with younger age using median split would respond better to MDT than to Back School.
The rationale was that they might be able to move further into the range of motion and, therefore, better achieve an end-of-range position. Movement to end of range is proposed to be important to optimize response to MDT in people classified as having a derangement syndrome. We investigated baseline patient characteristics associated with greater effect of MDT versus Back School separately for outcomes of pain and disability. Each of the 4 predictor variables was investigated in separate univariate models. The continuous effect modifiers of pain intensity and age were dichotomized using the median split method, as other methods where optimal thresholds are used have been shown to be substantially biased and are recommended against.
The interaction term was used to quantify size of the effect modification. It has been estimated that the detection of a statistically significant subgroup interaction effect in an RCT requires a sample size approximately 4 times that required to detect a main effect of the same size. If the interaction was greater than 1.
Low back pain: mechanism, diagnosis, and treatment
This was done by calculating the marginal means for the subgroups. Previous work suggests this is influenced by the main treatment effect 18 , 37 as well as the potential harms and benefits of the interventions. The research protocol was published elsewhere. Of these patients, were considered eligible and randomized 74 to each treatment group. All patients received the treatments as allocated. A total of patients were included in the main RCT. However, 8 patients were not classified as having directional preference and were excluded from the analysis of this study.
Therefore, patients were included in this secondary analysis Figure. After dichotomizing, the average age of older patients was The average score for higher pain intensity was 8. The baseline characteristics of both groups, including effect modifiers investigated in this study, were similar. Patients generally had moderate levels of pain and disability Tab.
The results of the linear regression analyses for the outcomes of pain and disability are shown in Tables 2 and 3 , respectively. As expected in this hypothesis-setting study, none of the interaction terms for any findings for these outcomes were statistically significant. However, the direction of effect was opposite to our hypothesis. Interaction terms for the other 3 effect modifiers clear centralization, pain below knee, and high pain intensity were below our thresholds for potential clinical importance. Interaction terms provide the critical information for assessing whether effect modification exists.
Positive interactions mean that the direction of the effect was in favor of the study's hypothesis. Negative interactions mean the effect was in the opposite direction to that hypothesized. Results of Linear Regression Models in Disability a. Negative interactions mean the effect was in the opposite direction to that hypothesized ie, we found an effect modification, but it was opposite to our hypothesis.
Table 4 shows the effect of MDT compared with Back School separately for patients younger and older than 54 years. Older people improved 1. The purpose of this hypothesis-setting, secondary analysis was to investigate whether 4 baseline characteristics presence of clear centralization, pain location, pain intensity, and age of patients with chronic LBP can identify those who respond better to MDT compared with Back School.
However, the direction of effect was opposite to our initial hypothesis, and as expected the effect was not statistically significant, so caution is required when interpreting this finding.
Low back pain: mechanism, diagnosis, and treatment
The presence of clear centralization, pain located below the knee and, pain intensity were not found to be effect modifiers for response to MDT compared with Back School. A strength of our study was that the data were derived from a high-quality RCT. Only 4 potential effect modifiers were selected a priori after consideration of the theoretical rationale and consultation with a specialist musculoskeletal physical therapist who is a credentialed MDT therapist. Another contribution of this study is the interpretation of the actual findings leading to hypotheses that can be tested in future trials.
The main limitation of this study was the lack of statistical power for an ideal subgroup analysis. We used a simple analysis that did not contain any covariates. This approach was chosen to minimize the risk of overfitting the model and because the resulting interaction effect size is exactly equal to the difference between treatment effect in one subgroup eg, older age and treatment effect in the other subgroup eg, younger age , 18 , 35 — 37 which makes the finding easier to interpret.
However, to test potential confounding, we conducted a post hoc analysis for the predictor of age in which we added sex and duration of symptoms to the models. Our study showed that patients who were older than 54 years and received MDT compared with Back School experienced an additional reduction in pain of 1. It is important to note that the interaction does not define the main effect of the interventions, but rather the difference in effect of treatment for older patients compared with young patients.
Similarly, for disability, MDT was statistically more effective for disability in the subgroup of older people 3. We only investigated treatment effects MDT versus Back School within subgroups where the interaction met our criteria for clinical importance to reduce the chance of spurious findings.
We initially hypothesized that MDT would be more effective in younger patients, as they might be able to move further into range of lumbar spine motion and, therefore, gain more benefit. Our findings suggesting that MDT may be more effective in older people raise the question of the potential mechanism underlying this hypothesis. One possibility is that older people were more adherent to the approach that is almost entirely a self-management intervention. Another possibility is that pain has a somewhat different physiological basis in older people and responds better to MDT. However, we do not have data to support these theories.
These results may simply be spurious findings due to lack of statistical power. We recommend the investigation of age as a potential effect modifier in future rehabilitation trials, including but not limited to those investigating MDT for spinal pain.
There are 2 previous studies that tested possible treatment effect modifiers for MDT. The authors found that these potential effect modifiers did not predict a more favorable response to MDT. The second study 18 compared MDT with spinal manipulation in patients with chronic back pain. The authors included 6 predictor variables: centralization, age below 40 years, duration of symptoms more than 1 year, leg pain, pain below the knee, signs of nerve root involvement.
The difference in our findings regarding age as an effect modifier may be due to a different control intervention or population or may simply be a spurious finding. Subgroup effects within trials are always specific to the control group. These studies together suggest that it is difficult to identify powerful effect modifiers for MDT. This difficulty may be due to the fact that the MDT approach already uses a stratified approach to care. Interestingly, the existing studies have not investigated psychosocial characteristics as effect modifiers, and this is an area of future investigation that we would recommend.
In conclusion, we conducted a secondary analysis of an RCT to determine whether potential treatment effect modifiers for MDT could be identified in patients with chronic LBP and with a directional preference. We found that patients who were older appeared to respond better to MDT compared with Back School the direction of effect was opposite to our initial hypothesis.
Clear centralization, pain below the knee, and high pain intensity do not appear to be useful effect modifiers. The results of this hypothesis-setting, secondary analysis have to be interpreted cautiously because of the small sample size. These findings, particularly of the potential effect modification effect of age, need testing in larger trials and with different comparisons. Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide.
Sign In or Create an Account. Sign In. Advanced Search. Article Navigation. Close mobile search navigation Article Navigation. Volume Article Contents. Oxford Academic. Google Scholar. Luciola da Cunha Menezes Costa. Mark Hancock. Leonardo Oliveira Pena Costa. Ms Garcia and Dr Luciola Costa provided data collection, project management, and consultation including review of manuscript before submission.
Dr Hancock and Dr Leonardo Costa provided fund procurement. Dr Leonardo Costa provided participants and institutional liaisons.
Cite Citation. Permissions Icon Permissions. Open in new tab Download slide. The interested reader will learn the intricacies of identifying, diagnosing, and treating spinal stenosis. This chapter classifies the several types of spinal stenosis and delineates the differential diagnostic factors of intermittent claudication. Causes of stenosis are discussed, and a variety of treatments are reviewed.
Several case studies are included in this chapter, which offers the reader a comprehensive overview of the condition. Chapter 5 describes the anatomy, biomechanics, and kinetics of the sacroiliac joint. This most interesting and challenging joint is reviewed from a strong basis of clinical anatomical dissections. Physical examination findings, trigger point pain referral patterns, and treatment procedures are presented.
Chapters 6, 13, and 14 cover facet syndrome, the transitional segment, and spondylolisthesis.
David Wickes, the well-known lecturer on this subject, is the author. Both nonspecific and specific, or focused, laboratory indicators of disease are reviewed. The chapter then continues with an extremely valuable discussion of the laboratory evaluation of specific disorders. Several laboratory tests are suggested as being specifically relevant to particular conditions and especially useful when one is differentially diagnosing nonmusculoskeletal causes of low back pain.
A number of treatments are discussed, some in terms of algorithms of diagnosis and treatment protocols and others with flow charts of treatment procedures. Chapters 8, 9 , and 10 are the cornerstone of the book. They contain extremely detailed protocols for the application of distraction adjustments for the chiropractic physician.
BACK PAIN - East London Chiropractic back pain south woodford
Specific treatments for patients with back pain, sciatica, spondylolisthesis, and scoliosis are but a few of the topics discussed. Electric stimulation, bracing, and drug and nutritional options are included as considerations pertaining to care. A discussion of the physical examination, including diagnostic pearls of disk lesions, is also included these chapters, as are low back examination forms and a discussion of orthopedic test findings.
Case presentations are offered as well; these illustrate concepts that have previously been discussed. This presentation reminds the reader of the close relationship that exists between the mental state and the physical state. Common characteristics and risks of those with back pain are identified.
This chapter offers insights on coping strategies that physicians can use to better serve patients. The topic of chapter 7 is fibromyalgia. The history, incidence, characteristics symptoms, and diagnostic criteria of fibromyalgia are discussed. The chapter offers a variety of management and treatment strategies. This chapter discusses the mechanisms of spinal stability, patient assessment, and postural analysis. Certain exercise prescriptions are recommended; these include progression of difficulty for sensory and motor stimulation exercises. The application of these treatment suggestions will be a welcome addition to clinical practice.
This text is a must-read for everyone interested in addressing the issues of diagnosing and treating patients with low back pain. I found the book to be extremely informative and was particularly impressed with the clinical relevance of the information that it contains.