Manual Therapy xxx (2014) 1e5
Contents lists available at ScienceDirect
Manual Therapy journal homepage: www.elsevier.com/math
Original article
The relationship between chief complaint and comparable sign in patients with spinal pain: An exploratory study Chad Cook a, *, Kenneth Learman b, Chris Showalter c, Bryan O'Halloran d a
Division of Physical Therapy, Duke University, Durham, NC, USA Division of Physical Therapy, Youngstown State University, Youngstown, OH, USA c Maitland Australian Physiotherapy Seminars, Cutchogue, NY, USA d Pain Relief and Physical Therapy, Havertown, PA, USA b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 5 June 2014 Received in revised form 11 November 2014 Accepted 17 November 2014
Many musculoskeletal management philosophies advocate the exploration of the relationship between the patient's chief complaint (CC) and the physical examination findings that reproduce/reduce/change that CC. Geoffrey Maitland developed the concept “comparable sign(s) (CS), which are physical examination findings related to the CC(s) that are reproduced during an examination/treatment. These include observed abnormalities of movement, postures or motor control, abnormal responses to movement, static deformities, and abnormal joint assessment findings. There are no studies that have explored the potential clinical relationships between the patient's CC and a CS, thus this exploratory study evaluated the associations, outcomes, and prevalence of the findings. This cohort study involved 112 subjects age 54.3 years (SD ¼ 13.4 years), with neck (25.9%) or low back pain (74.1%) who were treated with physiotherapy for an average of 42 days. Data analysis revealed 88.4% identified a CC at baseline. There was a moderate statistical association between CC and the active physiological finding of a CS (r ¼ 0.36), and small-moderate associations between all examination phases (r ¼ 0.25e0.37). There were no statistical differences in pain and disability outcomes for those with and without a CC or CS; however, baseline pain levels were higher for those without CC (p ¼ 0.04). Further, rate of recovery was lower in those without a CS during passive physiological examination. The results would suggest that there may be content validity to the concept of CS but further research with larger samples sizes is required to explore the extent of the validity is warranted. © 2014 Elsevier Ltd. All rights reserved.
Keywords: Comparable sign Low back pain Neck pain Manual therapy
1. Introduction Within clinical practice, the term chief complaint (CC) is used to describe reports of symptoms from the patient during the patient history. Many musculoskeletal management philosophies espouse the importance of recognizing the CC of the patient and then identifying elements of the physical examination that influence the chief complaint. These philosophies are well documented in orthopedic/manual therapy textbooks (Stoddard, 1969; Cyriax, 1975; Maitland et al., 2001; Dutton, 2013; Cook et al., 2014). It is believed that establishing primary symptom(s) and the movement patterns
* Corresponding author. Doctor of Physical Therapy Division, Duke University School of Medicine 104002, 2200 West Main Street, Suite B-230, Durham NC, 27708, USA. E-mail addresses: [email protected], [email protected] (C. Cook).
impacting those symptoms initiates the process of determining whether the problem may be amenable to manual therapy care. Cyriax (1975) emphasized the significance of establishing the physical complement to the patient's CC as the “correct symptom”. Maitland developed the concept comparable sign(s) (CS) over many years and presented these ideas in his clinical teaching and publications (Maitland, 1963, 1983). According to Maitland, a CS refers to the “combination of pain, stiffness, motor response or other findings which the examiner discovers on physical examination and considers being comparable with the patient's symptoms as described in the subjective examination”. Clinically, a CS is integrated with the patient's CC and the coordinated identification of both is often used to direct treatment application (Maitland et al., 2001). At present, despite that the introduction of the concept of the CS was over 50 years ago there are no studies that have investigated the relationship of a CS with a chief complaint. This may be related to the complex multifactorial nature of an examination or the fact
http://dx.doi.org/10.1016/j.math.2014.11.007 1356-689X/© 2014 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Cook C, et al., The relationship between chief complaint and comparable sign in patients with spinal pain: An exploratory study, Manual Therapy (2014), http://dx.doi.org/10.1016/j.math.2014.11.007
2
C. Cook et al. / Manual Therapy xxx (2014) 1e5
that the CS is typically evaluated continuously throughout all phases of assessment. The aims of this exploratory study were the following: 1. Identify trends in distinguishing characteristics of those with and without a chief complaint. 2. Explore the relationship of the presence of a CC and CS during selected phases of the examination (during active physiological movements [AP], passive physiological movements [PP] and passive accessory movements [PA].) 3. Evaluate trends in outcomes of those with and without a defined CC or CS to explore differences in pain, recovery, and disability outcomes.
2. Methods 2.1. Study design This study was a prospective cohort design in which data were collected from May of 2011 to April of 2014. The study was exploratory in concept, and was specifically implemented to examine the relationship of CS findings at selected examination phases (e.g., AP, PP, and PA) and the patient's chief complaint. The examination phases of AP, PP, and PA were selected only for repeatability purposes and to streamline data collection and ease of reporting. The design involved no prospective assignment of human participants or groups of humans to one or more healthrelated interventions to evaluate the effects on health outcomes, thus clinical trials registration was not required.
examination and the CC during the patient history, and how these findings influence treatment decision making. All individuals were instructed to enroll individuals as frequently as possible although no formal mechanism was used to evaluate enrollment rates, consecutively of enrollment, or decline rates for study inclusion. Experience ranged from 12 to 24 years and practice settings were either hospital-based or private outpatient orthopedic facilities. 2.3. Examination terminology For the study, the CC was operationally defined during questioning of the patient (during the patient history). Upon initiation of an assessment, the patient was asked to describe their CC and was asked if there was an activity that could provide their familiar pain or dysfunction. If the patient indicated “yes”, the patient was then asked if that was what brought them in to see the physiotherapist. If the CC was elicited it was scored as “yes reproducible” and if a CC could not be elicited with an activity or a response by the patient then it was scored as “no, not reproducible”. The CS was operationally defined as; any assessment-related combination of pain, stiffness, motor response or other findings which the examiner discovers on physical examination (Maitland et al., 2001) that reproduced the familiar pain reported in the patient's CC or if originally not reported, was able to reproduce the subjects newly determined chief complaint. Findings were scored as “present” or “not present”. All CS findings were captured on the initial visit (initial examination) only and required assessment in three different physical examination phases (AP, PP, and PA movements).
2.2. Eligibility criteria
2.4. Examination
2.2.1. Patients Patients were from eight distinct outpatient physical therapy clinics in the United States. Subjects were required to be 18 years of age or older with mechanically producible cervical or lumbar spine pain during clinical examination movements. By definition, mechanically reproducible pain suggests that there is no neoplastic, infectious, or primarily inflammatory cause (Deyo and Weinstein, 2001). All subjects were required to have a primary diagnosis demonstrative of spine related disorder; required care beyond a single visit, and had to speak English. Exclusion criteria involved presence of red flags (tumor, metabolic disease, rheumatoid arthritis, osteoporosis, prolonged history of steroid use) and signs consistent with nerve root compression that resulted in a radiculopathy (i.e., diminished muscle stretch reflex, or diminished or absent sensation to pinprick in any upper or lower extremity dermatome). Because tests and measures used to diagnosis radiculopathy are often specific and not sensitive (Cook and Hegedus, 2013), we allowed the clinicians to exclude patients with negative findings on the examination but who they still suspected may have radicular symptoms. Additionally, any history including prior surgery for a neck or low back related problem or current pregnancy was cause for exclusion. Prior to inclusion, all participants signed an informed consent statement which was approved by a local University Human Ethics committee.
Prior to involvement, all clinicians participated in a standardized, mandatory 30 min educational webinar that explained the purpose of the study, the data collection methods, and the requirements for participation. Once part of the study, all clinicians performed a patient responder-based examination in which feedback was gathered with each targeted passive or active movement. For this study, a standardized examination process was used for all patients and the process involved documenting the presence or absence of a CS and formalization of the physical examination phases of AP, PP, and PA movements. Active physiological movements were osteokinematic movements that were performed by the patient, and generally consisted of plane-based, repeated and sustained active movements (flexion, extension, rotation, side flexion, and combined movements as needed), in a standing or recumbent position. Passive physiological movements were similar to AP movements directionally, except that the examiner moved the patient passively, while assuming different positions, with repeated bouts or sustained positioning. Passive accessory movements were designed to reflect arthrokinematic movements and consisted of central posterior-anterior or unilateral posterior anterior glides, or variations including unilateral anterior-posterior glides and rarely transverse glides.
2.2.2. Clinicians The study included 9 physiotherapists, all of whom had rigorous, extensive training in manual therapy principles, orthopedic manual therapy certification, or were fellows of the American Academy of Orthopedic Manual Physical Therapists. All individuals were educators in the Maitland concept of orthopedic treatment and were familiar with the use of the CS during the physical
Specific interventions were not the purpose of the study thus the components of each were not collected. Nonetheless, treatment interventions were performed pragmatically and almost exclusively consisted of manual therapy, strengthening, and patientspecific education. To ensure ecological validity, clinicians were instructed to treat patients as they normally would, outside the research study.
2.5. Intervention
Please cite this article in press as: Cook C, et al., The relationship between chief complaint and comparable sign in patients with spinal pain: An exploratory study, Manual Therapy (2014), http://dx.doi.org/10.1016/j.math.2014.11.007
C. Cook et al. / Manual Therapy xxx (2014) 1e5
3
2.6. Outcome measures
2.7. Sample size estimation
Outcomes were collected at baseline, week 2, and discharge. Discharge was at the discretion of the physiotherapist and averaged 42.8 days. Clinicians were not masked to the outcomes results or the CC or CS findings of the patients. Primary disability measures included the Oswestry Disability Index (ODI) (Fairbank et al., 1980) which was provided to those with low back pain or the Neck Disability Index (NDI) (Vernon and Mior, 1991) which was provided to those with neck pain, whereas the primary pain measure included the numeric pain rating scale (NPRS). The recovery measure involved the self-report Rate of Recovery (RoR) (Cook et al., 2013).
The study was exploratory and exploratory studies are performed to generate new hypotheses that can then be formally tested. In such experiments, the usual aim is to look for patterns of response, often evaluating many data comparisons (Dell et al., 2002). Data collected in exploratory experiments is normally used to create sample size calculations for future hypotheses generated by the exploration. We targeted a sample size of appropriately 100e125 subjects because we felt that we could identify patterns within the data in a regression model if we elected to use one. 2.8. Data analysis
2.6.1. Oswestry Disability Index The ODI was used to measure patient disability. The ODI is a scale of 10 questions with scoring of 0e5 for each question, and the ODI defines disability as the higher the score, the greater the disability (Fairbank et al., 1980). The ODI is considered a valid and reliable instrument (Ostelo and de Vet, 2005). We used percentage change to determine the change score for each patient. This was calculated as [(baseline ODI score final ODI score)/(baseline ODI score)] 100 (Fritz et al., 2009). 2.6.2. Neck Disability Index The NDI was created to measure pain related disability associated with activities of daily living in people with neck pain (Vernon and Mior, 1991). Content and construct validity and reliability of the NDI has been previously shown in patients with neck pain (Cleland et al., 2008). As with the ODI, we used percentage change to determine the change score for each patient. This was calculated as [(baseline NDI score final NDI score)/(baseline NDI score)] 100. 2.6.3. Numeric pain rating scale The NPRS was used for patient perception of pain intensity using a scale of 0 (“no pain”) to 10 (“worst pain imaginable”). The NPRS has been found to be reliable and responsive (Childs et al., 2005). We also used a percentage change as our outcome measure. This was calculated as: [(baseline NPRS score final NPRS score)/ (baseline NPRS score)] 100. 2.6.4. Rate of recovery The RoR was originally described as the single assessment numeric evaluation (SANE) by Williams et al. (1999) but was modified and called RoR by Cook et al. (2013) in a randomized trial for low back pain. We used the same language used by Cook and colleagues. Patients were asked to rate their recovery at discharge from 0 percent (meaning no recovery at all) to 100 percent (meaning totally recovered). This method has been used and validated with patients with shoulder pain (O'Halloran et al., 2013) and low back pain (Wright and Cook, 2013).
All analyses completed were performed using Statistical Package for the Social Sciences (SPSS), version 21.0 (IBM Corp, Armonk, NY). In the single instance in which missing data was present, the mean of the age of the sample was used. Descriptive statistics were used to describe the full patient sample. The relationship between CC and the CS findings in AP, PP, and PA were evaluated using the phi coefficient/Cramer's V coefficient, both of which are conservative measures of association for nominal variables and provide the same values. Cohen (1988) characterized a correlation of 0.10 as depicting a small relationship, a correlation of 0.30 as a moderate relationship, and a correlation of 0.50 as a large/strong relationship. For conservative identification of differences in outcomes between those with and without a CC/CS were evaluated using a Mann Whitney U. For all analyses, a p value of 0.05 was considered significant. 3. Results The study enrolled 83 (74.1%) patients with low back pain and 29 (25.9%) with neck pain. Of the 112, most were Caucasian (95.5%), the majority were female (N ¼ 64; 57%), and the mean age was 54.3 years (SD ¼ 13.4 years). The baseline ODI was 32.8/100 (SD ¼ 17.8) whereas the baseline NDI was 32.7/100 (SD ¼ 16.8). The baseline pain scores were a mean of 5.76 (SD ¼ 2.1) and individuals were seen for a mean of 10.4 total visits (SD ¼ 8.3). The average duration of symptoms was 11.9 weeks (SD ¼ 19.3). Of the 112, a CC was identified in 99 individuals (88.4%). A CS during the active physiological examination was found in 82.9% of cases, whereas a CS for the passive physiological examination was found in 65.2% of cases. A CS during the passive accessory examination was found in 90.2% of cases. When divided by “yes, reproducible” and “no, not reproducible”, there were significant differences in baseline pain between those with and without a CC with individuals who did not report an activity that could reproduce their CC reporting significantly more pain (p ¼ 0.04). Table 1 outlines the descriptive statistics of the full cohort and the
Table 1 Descriptive statistics of the sample population (N ¼ 112). Variable
Full sample mean/SD I frequency (N ¼ 112)
Patients with CC mean/SD I frequency (N ¼ 99)
Patients without definable CC mean/SD I frequency (N ¼ 13)
P value
Age (years) Gender
54.3 (13.4) 48 ¼ Male 64 ¼ Female 26.4 (4.0) 11.9 (19.3) 32.8 (17.4) 5.8 (2.1) 30 ¼ Yes 79 ¼ No 83 ¼ Low back 29 ¼ Neck
54.2 (13.4) 43 ¼ Male 56 ¼ Female 26.4 (3.9) 10.9 (14.2) 32.7 (17.6) 5.6 (2.0) 25 ¼ Yes 71 ¼ No 75 ¼ Low back 24 ¼ Neck
55.0 (14.5) 5 ¼ Male 8 ¼ Female 26.9 (4.7) 19.4 (41.5) 33.5 (16.6) 6.9 (2.3) 5 ¼ Yes 8 ¼ No 8 ¼ Low back 5 ¼ Neck
0.85 0.73
Body mass index Duration of symptoms (weeks) ODI/NDI at baseline (0e100) Pain score at baseline (0e10) Irritability Neck or back pain
0.64 0.13 0.88 0.04 0.34 0.27
Bold indicates significance at
Contents lists available at ScienceDirect
Manual Therapy journal homepage: www.elsevier.com/math
Original article
The relationship between chief complaint and comparable sign in patients with spinal pain: An exploratory study Chad Cook a, *, Kenneth Learman b, Chris Showalter c, Bryan O'Halloran d a
Division of Physical Therapy, Duke University, Durham, NC, USA Division of Physical Therapy, Youngstown State University, Youngstown, OH, USA c Maitland Australian Physiotherapy Seminars, Cutchogue, NY, USA d Pain Relief and Physical Therapy, Havertown, PA, USA b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 5 June 2014 Received in revised form 11 November 2014 Accepted 17 November 2014
Many musculoskeletal management philosophies advocate the exploration of the relationship between the patient's chief complaint (CC) and the physical examination findings that reproduce/reduce/change that CC. Geoffrey Maitland developed the concept “comparable sign(s) (CS), which are physical examination findings related to the CC(s) that are reproduced during an examination/treatment. These include observed abnormalities of movement, postures or motor control, abnormal responses to movement, static deformities, and abnormal joint assessment findings. There are no studies that have explored the potential clinical relationships between the patient's CC and a CS, thus this exploratory study evaluated the associations, outcomes, and prevalence of the findings. This cohort study involved 112 subjects age 54.3 years (SD ¼ 13.4 years), with neck (25.9%) or low back pain (74.1%) who were treated with physiotherapy for an average of 42 days. Data analysis revealed 88.4% identified a CC at baseline. There was a moderate statistical association between CC and the active physiological finding of a CS (r ¼ 0.36), and small-moderate associations between all examination phases (r ¼ 0.25e0.37). There were no statistical differences in pain and disability outcomes for those with and without a CC or CS; however, baseline pain levels were higher for those without CC (p ¼ 0.04). Further, rate of recovery was lower in those without a CS during passive physiological examination. The results would suggest that there may be content validity to the concept of CS but further research with larger samples sizes is required to explore the extent of the validity is warranted. © 2014 Elsevier Ltd. All rights reserved.
Keywords: Comparable sign Low back pain Neck pain Manual therapy
1. Introduction Within clinical practice, the term chief complaint (CC) is used to describe reports of symptoms from the patient during the patient history. Many musculoskeletal management philosophies espouse the importance of recognizing the CC of the patient and then identifying elements of the physical examination that influence the chief complaint. These philosophies are well documented in orthopedic/manual therapy textbooks (Stoddard, 1969; Cyriax, 1975; Maitland et al., 2001; Dutton, 2013; Cook et al., 2014). It is believed that establishing primary symptom(s) and the movement patterns
* Corresponding author. Doctor of Physical Therapy Division, Duke University School of Medicine 104002, 2200 West Main Street, Suite B-230, Durham NC, 27708, USA. E-mail addresses: [email protected], [email protected] (C. Cook).
impacting those symptoms initiates the process of determining whether the problem may be amenable to manual therapy care. Cyriax (1975) emphasized the significance of establishing the physical complement to the patient's CC as the “correct symptom”. Maitland developed the concept comparable sign(s) (CS) over many years and presented these ideas in his clinical teaching and publications (Maitland, 1963, 1983). According to Maitland, a CS refers to the “combination of pain, stiffness, motor response or other findings which the examiner discovers on physical examination and considers being comparable with the patient's symptoms as described in the subjective examination”. Clinically, a CS is integrated with the patient's CC and the coordinated identification of both is often used to direct treatment application (Maitland et al., 2001). At present, despite that the introduction of the concept of the CS was over 50 years ago there are no studies that have investigated the relationship of a CS with a chief complaint. This may be related to the complex multifactorial nature of an examination or the fact
http://dx.doi.org/10.1016/j.math.2014.11.007 1356-689X/© 2014 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Cook C, et al., The relationship between chief complaint and comparable sign in patients with spinal pain: An exploratory study, Manual Therapy (2014), http://dx.doi.org/10.1016/j.math.2014.11.007
2
C. Cook et al. / Manual Therapy xxx (2014) 1e5
that the CS is typically evaluated continuously throughout all phases of assessment. The aims of this exploratory study were the following: 1. Identify trends in distinguishing characteristics of those with and without a chief complaint. 2. Explore the relationship of the presence of a CC and CS during selected phases of the examination (during active physiological movements [AP], passive physiological movements [PP] and passive accessory movements [PA].) 3. Evaluate trends in outcomes of those with and without a defined CC or CS to explore differences in pain, recovery, and disability outcomes.
2. Methods 2.1. Study design This study was a prospective cohort design in which data were collected from May of 2011 to April of 2014. The study was exploratory in concept, and was specifically implemented to examine the relationship of CS findings at selected examination phases (e.g., AP, PP, and PA) and the patient's chief complaint. The examination phases of AP, PP, and PA were selected only for repeatability purposes and to streamline data collection and ease of reporting. The design involved no prospective assignment of human participants or groups of humans to one or more healthrelated interventions to evaluate the effects on health outcomes, thus clinical trials registration was not required.
examination and the CC during the patient history, and how these findings influence treatment decision making. All individuals were instructed to enroll individuals as frequently as possible although no formal mechanism was used to evaluate enrollment rates, consecutively of enrollment, or decline rates for study inclusion. Experience ranged from 12 to 24 years and practice settings were either hospital-based or private outpatient orthopedic facilities. 2.3. Examination terminology For the study, the CC was operationally defined during questioning of the patient (during the patient history). Upon initiation of an assessment, the patient was asked to describe their CC and was asked if there was an activity that could provide their familiar pain or dysfunction. If the patient indicated “yes”, the patient was then asked if that was what brought them in to see the physiotherapist. If the CC was elicited it was scored as “yes reproducible” and if a CC could not be elicited with an activity or a response by the patient then it was scored as “no, not reproducible”. The CS was operationally defined as; any assessment-related combination of pain, stiffness, motor response or other findings which the examiner discovers on physical examination (Maitland et al., 2001) that reproduced the familiar pain reported in the patient's CC or if originally not reported, was able to reproduce the subjects newly determined chief complaint. Findings were scored as “present” or “not present”. All CS findings were captured on the initial visit (initial examination) only and required assessment in three different physical examination phases (AP, PP, and PA movements).
2.2. Eligibility criteria
2.4. Examination
2.2.1. Patients Patients were from eight distinct outpatient physical therapy clinics in the United States. Subjects were required to be 18 years of age or older with mechanically producible cervical or lumbar spine pain during clinical examination movements. By definition, mechanically reproducible pain suggests that there is no neoplastic, infectious, or primarily inflammatory cause (Deyo and Weinstein, 2001). All subjects were required to have a primary diagnosis demonstrative of spine related disorder; required care beyond a single visit, and had to speak English. Exclusion criteria involved presence of red flags (tumor, metabolic disease, rheumatoid arthritis, osteoporosis, prolonged history of steroid use) and signs consistent with nerve root compression that resulted in a radiculopathy (i.e., diminished muscle stretch reflex, or diminished or absent sensation to pinprick in any upper or lower extremity dermatome). Because tests and measures used to diagnosis radiculopathy are often specific and not sensitive (Cook and Hegedus, 2013), we allowed the clinicians to exclude patients with negative findings on the examination but who they still suspected may have radicular symptoms. Additionally, any history including prior surgery for a neck or low back related problem or current pregnancy was cause for exclusion. Prior to inclusion, all participants signed an informed consent statement which was approved by a local University Human Ethics committee.
Prior to involvement, all clinicians participated in a standardized, mandatory 30 min educational webinar that explained the purpose of the study, the data collection methods, and the requirements for participation. Once part of the study, all clinicians performed a patient responder-based examination in which feedback was gathered with each targeted passive or active movement. For this study, a standardized examination process was used for all patients and the process involved documenting the presence or absence of a CS and formalization of the physical examination phases of AP, PP, and PA movements. Active physiological movements were osteokinematic movements that were performed by the patient, and generally consisted of plane-based, repeated and sustained active movements (flexion, extension, rotation, side flexion, and combined movements as needed), in a standing or recumbent position. Passive physiological movements were similar to AP movements directionally, except that the examiner moved the patient passively, while assuming different positions, with repeated bouts or sustained positioning. Passive accessory movements were designed to reflect arthrokinematic movements and consisted of central posterior-anterior or unilateral posterior anterior glides, or variations including unilateral anterior-posterior glides and rarely transverse glides.
2.2.2. Clinicians The study included 9 physiotherapists, all of whom had rigorous, extensive training in manual therapy principles, orthopedic manual therapy certification, or were fellows of the American Academy of Orthopedic Manual Physical Therapists. All individuals were educators in the Maitland concept of orthopedic treatment and were familiar with the use of the CS during the physical
Specific interventions were not the purpose of the study thus the components of each were not collected. Nonetheless, treatment interventions were performed pragmatically and almost exclusively consisted of manual therapy, strengthening, and patientspecific education. To ensure ecological validity, clinicians were instructed to treat patients as they normally would, outside the research study.
2.5. Intervention
Please cite this article in press as: Cook C, et al., The relationship between chief complaint and comparable sign in patients with spinal pain: An exploratory study, Manual Therapy (2014), http://dx.doi.org/10.1016/j.math.2014.11.007
C. Cook et al. / Manual Therapy xxx (2014) 1e5
3
2.6. Outcome measures
2.7. Sample size estimation
Outcomes were collected at baseline, week 2, and discharge. Discharge was at the discretion of the physiotherapist and averaged 42.8 days. Clinicians were not masked to the outcomes results or the CC or CS findings of the patients. Primary disability measures included the Oswestry Disability Index (ODI) (Fairbank et al., 1980) which was provided to those with low back pain or the Neck Disability Index (NDI) (Vernon and Mior, 1991) which was provided to those with neck pain, whereas the primary pain measure included the numeric pain rating scale (NPRS). The recovery measure involved the self-report Rate of Recovery (RoR) (Cook et al., 2013).
The study was exploratory and exploratory studies are performed to generate new hypotheses that can then be formally tested. In such experiments, the usual aim is to look for patterns of response, often evaluating many data comparisons (Dell et al., 2002). Data collected in exploratory experiments is normally used to create sample size calculations for future hypotheses generated by the exploration. We targeted a sample size of appropriately 100e125 subjects because we felt that we could identify patterns within the data in a regression model if we elected to use one. 2.8. Data analysis
2.6.1. Oswestry Disability Index The ODI was used to measure patient disability. The ODI is a scale of 10 questions with scoring of 0e5 for each question, and the ODI defines disability as the higher the score, the greater the disability (Fairbank et al., 1980). The ODI is considered a valid and reliable instrument (Ostelo and de Vet, 2005). We used percentage change to determine the change score for each patient. This was calculated as [(baseline ODI score final ODI score)/(baseline ODI score)] 100 (Fritz et al., 2009). 2.6.2. Neck Disability Index The NDI was created to measure pain related disability associated with activities of daily living in people with neck pain (Vernon and Mior, 1991). Content and construct validity and reliability of the NDI has been previously shown in patients with neck pain (Cleland et al., 2008). As with the ODI, we used percentage change to determine the change score for each patient. This was calculated as [(baseline NDI score final NDI score)/(baseline NDI score)] 100. 2.6.3. Numeric pain rating scale The NPRS was used for patient perception of pain intensity using a scale of 0 (“no pain”) to 10 (“worst pain imaginable”). The NPRS has been found to be reliable and responsive (Childs et al., 2005). We also used a percentage change as our outcome measure. This was calculated as: [(baseline NPRS score final NPRS score)/ (baseline NPRS score)] 100. 2.6.4. Rate of recovery The RoR was originally described as the single assessment numeric evaluation (SANE) by Williams et al. (1999) but was modified and called RoR by Cook et al. (2013) in a randomized trial for low back pain. We used the same language used by Cook and colleagues. Patients were asked to rate their recovery at discharge from 0 percent (meaning no recovery at all) to 100 percent (meaning totally recovered). This method has been used and validated with patients with shoulder pain (O'Halloran et al., 2013) and low back pain (Wright and Cook, 2013).
All analyses completed were performed using Statistical Package for the Social Sciences (SPSS), version 21.0 (IBM Corp, Armonk, NY). In the single instance in which missing data was present, the mean of the age of the sample was used. Descriptive statistics were used to describe the full patient sample. The relationship between CC and the CS findings in AP, PP, and PA were evaluated using the phi coefficient/Cramer's V coefficient, both of which are conservative measures of association for nominal variables and provide the same values. Cohen (1988) characterized a correlation of 0.10 as depicting a small relationship, a correlation of 0.30 as a moderate relationship, and a correlation of 0.50 as a large/strong relationship. For conservative identification of differences in outcomes between those with and without a CC/CS were evaluated using a Mann Whitney U. For all analyses, a p value of 0.05 was considered significant. 3. Results The study enrolled 83 (74.1%) patients with low back pain and 29 (25.9%) with neck pain. Of the 112, most were Caucasian (95.5%), the majority were female (N ¼ 64; 57%), and the mean age was 54.3 years (SD ¼ 13.4 years). The baseline ODI was 32.8/100 (SD ¼ 17.8) whereas the baseline NDI was 32.7/100 (SD ¼ 16.8). The baseline pain scores were a mean of 5.76 (SD ¼ 2.1) and individuals were seen for a mean of 10.4 total visits (SD ¼ 8.3). The average duration of symptoms was 11.9 weeks (SD ¼ 19.3). Of the 112, a CC was identified in 99 individuals (88.4%). A CS during the active physiological examination was found in 82.9% of cases, whereas a CS for the passive physiological examination was found in 65.2% of cases. A CS during the passive accessory examination was found in 90.2% of cases. When divided by “yes, reproducible” and “no, not reproducible”, there were significant differences in baseline pain between those with and without a CC with individuals who did not report an activity that could reproduce their CC reporting significantly more pain (p ¼ 0.04). Table 1 outlines the descriptive statistics of the full cohort and the
Table 1 Descriptive statistics of the sample population (N ¼ 112). Variable
Full sample mean/SD I frequency (N ¼ 112)
Patients with CC mean/SD I frequency (N ¼ 99)
Patients without definable CC mean/SD I frequency (N ¼ 13)
P value
Age (years) Gender
54.3 (13.4) 48 ¼ Male 64 ¼ Female 26.4 (4.0) 11.9 (19.3) 32.8 (17.4) 5.8 (2.1) 30 ¼ Yes 79 ¼ No 83 ¼ Low back 29 ¼ Neck
54.2 (13.4) 43 ¼ Male 56 ¼ Female 26.4 (3.9) 10.9 (14.2) 32.7 (17.6) 5.6 (2.0) 25 ¼ Yes 71 ¼ No 75 ¼ Low back 24 ¼ Neck
55.0 (14.5) 5 ¼ Male 8 ¼ Female 26.9 (4.7) 19.4 (41.5) 33.5 (16.6) 6.9 (2.3) 5 ¼ Yes 8 ¼ No 8 ¼ Low back 5 ¼ Neck
0.85 0.73
Body mass index Duration of symptoms (weeks) ODI/NDI at baseline (0e100) Pain score at baseline (0e10) Irritability Neck or back pain
0.64 0.13 0.88 0.04 0.34 0.27
Bold indicates significance at
