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Below are 3 sample reviews ...
Category : Chiropractic / Manual Medicine

 Sample 11:
Research Review by Dr. Shawn Thistle©
Date: Oct. 2007
Study Title: The effect of combining manual therapy with exercise on the respiratory function of normal individuals: A randomized control trial
Authors: Engel RM & Vemulpad S
Publication Information: Journal of Manipulative and Physiological Therapeutics 2007; 30: 509-513.
Summary: It is noteworthy that 20% of all deaths worldwide are attributable to dysfunction of the respiratory system, with non-communicable conditions responsible for approximately one third of those. This trend is destined to increase as the population in general ages.

Assessing respiratory function is not normally conducted in a formal (physiological) manner in most manual therapy practices. That being said, many manual therapists are concerned with the musculoskeletal aspects of breathing, and their consequences on human health and performance.

It is generally thought that “normal” respiratory function begins to decline after age 25. In a laboratory setting, respiratory function is often assessed using spirometry – with common measures including forced vital capacity (FVC) and forced expiratory volume in one second (FEV1). Normal ranges for these measures vary depending on age, gender, and height. Studies utilizing these measures estimate that anywhere between 3-8% of people in the USA show signs of COPD. Although somewhat controversial, one factor discussed in older literature and thought to be particularly important in determining the rate of respiratory decline is a history of recurrent respiratory tract infections (RTI) in childhood. It has been suggested that recurrent RTIs in childhood may correlate with future incidence of chronic obstructive pulmonary disease (COPD), which is characterized by progressive, irreversible airflow changes. COPD is usually clinically silent in the early stages, so initial diagnosis is critical to improving prognosis.

In light of the hypothesis that adult decline in respiratory function may stem from childhood – it may be pertinent to explore interventions that may positively impact respiratory function in seemingly normal individuals. It has been suggested that manual therapy aimed at the thoracic spine and rib articulations can improve respiratory function in asymptomatic individuals. This is based on the concept that thoracic cage mobility can influence respiratory function, a tenet generally accepted in the fields of respiratory physiology and functional anatomy.

This study aimed to measure the effect of manual therapy and exercise on the respiratory function of normal individuals. 20 healthy volunteers between the ages of 18-28 who were non-smokers for at least 12 months and who were not taking any respiratory medications were randomized into four groups as follows (n=5 in each group):
  1. Exercise Only Group - underwent a standardized 15 minute treadmill walking program adhering to specific pace, inclination, and duration – 6 sessions over a 4-week period
  2. Manual Therapy Only Group - received (nondescript) soft tissue therapy and spinal and/or rib manipulation (high-velocity, low-amplitude) to the lower cervical and thoracic spines, and associated ribs – 6 sessions over a 4-week period
  3. Manual Therapy and Exercise - a combination of the two interventions (manual therapy followed by the exercise protocol) – 6 sessions over a 4-week period
  4. Control Group - received no intervention
All participants underwent standard spirometry testing (including FVC and FEV1 measurements) at two week intervals starting at study inception.

Spirometry measurements were taken 1 minute before and 1 minute after each intervention (note: for group 3, measures were done before and after manual therapy, and then after the exercise protocol).

Pertinent results of this study include:
  • participants in the “exercise only” group had a statistically significant decrease in FVC and FEV1 – this may be explained by increased exercise-induced respiratory resistance
  • participants in the “manual therapy only” group had a statistically significant increase in FVC and FEV1 after treatment
  • participants in the combination manual therapy/exercise group had a significant increase in FVC and FEV1 after manual therapy, followed by additional gains after exercise (overall, this increase was not statistically significant)
  • the nature and extent of the changes in the two groups receiving manual therapy was similar
  • overall, the control group had lower FVC values, and showed no change in either FCV or FEV1 values throughout the study
Conclusions & Practical Application: This small study provides preliminary evidence that manual therapy in the form of soft tissue therapy and manipulation of the lower cervical/thoracic spinal and rib articulations can have an immediate, positive impact on respiratory function in asymptomatic subjects. It is interesting to note that manual therapy also seemed to reverse the trend for negative effects of exercise on FVC and FEV1, a finding that would be more compelling if reproduced in a larger study. These findings highlight a potential role for manual therapy in treating respiratory dysfunction (ex. manipulating patients before exercise in a pulmonary rehabilitation setting?), and should stimulate more research in this area.

The results of this study should be considered keeping some weaknesses in mind:
  • the sample size was small – limiting the statistical power of this study
  • the intervention groups were not matched to age or gender (although the range of patient ages was small [early 20s]) – this would have been difficult anyway due to the small sample size
  • the exercise protocol was only 15 minutes long – arguably not long enough to create a true exercise adaptation
  • respiratory function was assessed in the very short-term (i.e. immediately post-intervention); hence the long-term effects cannot be elucidated
Further studies are required to replicate and build on these findings, particularly those involving patients with existing respiratory conditions, or those deemed to be at high risk.

Sample 22:
Research Review by Dr. Shawn Thistle©
Date: Aug. 2007
Study Title: Iliotibial band friction syndrome – a systematic review
Authors: Ellis R, Hing W & Reid D
Publication Information: Manual Therapy 2007; 12: 200-208.
Summary: Iliotibial band friction syndrome (ITBFS) is described as lateral knee pain that is aggravated by lower limb activities, primarily running and cycling. As more and more people participate in these two activities in the form of marathon running, mountain biking, spinning classes, and so on, the incidence of this condition will continue to rise. Current estimates in the literature state that the ITBFS is the most common running injury in the lateral knee, with an incidence of 1.6-12%. In cycling, ITBFS may account for up to 15-24% of all overuse injuries. Additional studies indicate that ITBFS is common in military recruits, with an incidence of between 1-5.3%. By contrast, ITBFS seems to be uncommon in inactive people. Little quality data exists identifying predisposing factors to developing ITBFS, prognostic factors for recovery, or what the natural history of the condition is.

The pathoanatomy of this condition is theoretically well known. It is thought that ITBFS is a multi-factorial, non-traumatic, overuse condition in which the distal aspect of the iliotibial band rubs over the lateral femoral epicondyle with repetitive knee flexion and extension. This results in an imbalance between tissue healing and damage, ultimately leading to irritation of the iliotibial band and lateral synovial recess. The posterior, deeper fibres of the ITB would be most vulnerable, in addition to the possibility of periosteal irritation of the lateral femoral epicondyle. Various authors have described a dynamic “impingement zone” at approximately 30° and greater of knee flexion. During this range, the ITB passes over and posterior to the lateral femoral epicondyle. When running, as each leg comes forward before heel strike, the tensor fascia latae (TFL) and gluteus maximus/medius (and of course the hamstring) are contracting eccentrically to decelerate the leg, which can result in a large amount of tissue tension generated in the ITB.

A variety of treatment options for ITBFS have been reported in the literature, with some authors reporting very high success rates. The purpose of this study was to systematically review the literature on conservative treatments to ITBFS, with the goal of guiding evidence-based treatment of this condition.

The authors conducted a well-described and seemingly comprehensive literature search, including all relevant databases, and also including a hand-search of references in retrieved papers. To be included in the review, a study had to have the following:
  • participants aged 18 and over
  • randomized, controlled design involving a conservative treatment for ITBFS (i.e. non-surgical)
  • at least one of the following outcome measures: VAS, function-specific VAS, time from diagnosis until free of symptoms, return to work and/or sport status
Studies were excluded if they were non-controlled, non-randomized, evaluated surgical interventions, or were not written in English (note: only one paper was excluded from review based on this factor).

Methodological quality of each paper was performed using the PEDro Scale, a commonly used, 11-item tool that has been validated for evaluating randomized controlled trials (RCTs). The PEDro scale evaluates various aspects of RCT design including internal and external validity, appropriateness of outcome measures, group similarity at baseline, randomization and concealment, patient and assessor blinding, and statistics.

Surprisingly, only 4 trials met the inclusion criteria (discussed individually below, and fully referenced at the end of this review). Each study investigated different interventions, and hence no pooling of data could be completed. Below is an executive summary of each study.

Bischoff et al. (1995) – phonophoresis versus immobilization
  • PEDro score – 7/11, Internal Validity score 3/7 (limited quality)
  • 26 young, male navy students participated in 2 week treatment period
  • 13 subjects in intervention group – phonophoresis (ultrasound using 10% hydrocortisone cream), rest, ice, stretching, and Ibuprofen over 2 weeks
  • 13 subjects in control group – 2 weeks of knee immobilization, rest, ice, stretching (is this really immobilization?), and Ibuprofen
  • outcome was “number of days until pain free and ability to run on a treadmill at 6.5mph”
  • Results - more patients in the phonophoresis group recovered in ten days compared to control (no report on statistical significance was present)
Gunter & Schwellnus (2004) – corticosteroid injection
  • PEDro score – 9/11, Internal Validity score 4/7 (moderate quality)
  • 18 subjects between the ages of 20-50, duration of symptoms < 14 days
  • 9 subjects in intervention group – corticosteroid injection at lateral knee joint, ice 2x/d for 30 minutes
  • 9 subjects in control group – placebo injection at lateral knee joint, ice 2x/d for 30 minutes
  • Results - there was clinical improvement in both groups, but significant reduction in pain while running (30% on VAS) was observed in the corticosteroid group (p = 0.01)
Schwellnus et al. (1991) – NSAIDs
  • PEDro score 8/11, Internal Validity Score 4/7 (moderate quality)
  • 43 patients (age not given), symptoms > 6 weeks, treatment period of 7 days
  • 14 subjects in intervention group #1 – 50mg Diclofenac, physiotherapy (ultrasound, stretching, friction massage)
  • 16 subjects in intervention group #2 – 400mg Ibuprofen, 500mg Paracetamol, 20mg Codeine, physiotherapy as above
  • 13 subjects in control group – physiotherapy as above
  • Results - the combined analgesic/anti-inflammatory group (#2 above) was the most effective management, and also the only group to show reduced running pain (on VAS); all groups experienced significant reduction in daily pain
Schwellnus et al. (1992) – Deep Transverse Friction Massage (DTFM)
  • PEDro score 7/11, Internal Validity Score 4/7 (moderate quality)
  • 20 subjects over 18 years of age with symptoms > 14 days
  • 9 subjects in intervention group – DTFM daily from days 3-14, daily stretching, 2x/day ice, ultrasound daily from days 3-14
  • 9 subjects in control group – daily stretching, 2x/day ice, ultrasound from days 3-14
  • outcomes – total running pain (VAS)
  • Results - both groups improved significantly (p = 0.0005), but no significant difference was noted between treatment groups, suggesting no additional benefit of adding DTFM
Conclusions & Practical Application: The primary and unfortunate finding of this review is that there is a woeful lack of research in the area of conservative treatment for ITBFS. In most of these studies, a course of physiotherapy accompanied the study intervention, including ice, stretching, ultrasound, and in one case, friction massage. The results of these studies, when viewed as a whole (non-statistically of course) suggest that many of these commonly used interventions lack a firm evidence base for this condition. Results from two of the studies weakly suggest that NSAIDs or corticosteroid injections many be of some benefit, but more research is required to make more conclusive recommendations, even for these two treatment choices.

Future research in this area should improve on the shortcomings of the current literature including:
  • all studies in this review lacked systematic blinding
  • common physiotherapy interventions used for this condition appear to have little benefit – creating the need for an improved standard or control treatment for ITBFS, or more stringent study of those treatment choices (as opposed to being a poorly standardized “throw-in” treatment)
  • the impact of some treatments may be governed by whether they are applied in the acute or chronic phase of this condition – these factors must be further clarified
  • careful assessment of patient factors could provide information on predisposing factors, or prognostic considerations
The pathoanatomical and biomechanical theories surrounding ITBFS are plentiful, and seemingly applicable in a clinical setting. Commonly used interventions for ITBFS at this time, do not have solid evidence to support their use.

References Cited
  1. Bischoff C et al. Comparison of phonophoresis and knee immobilization in treating iliotibial band syndrome. Sports Medicine, Training and Rehabilitation 1995; 6: 1-6.
  2. Gunter P & Schwellnus M. Local corticosteroid injection in iliotibial band friction syndrome in runners: a randomized controlled trial. British Journal of Sports Medicine 2004; 38: 269-272.
  3. Schwellnus M et al. Anti-inflammatory and combined anti-inflammatory/analgesic medication in the early management of iliotibial band friction syndrome. South African Medical Journal 1991; 79: 602-606.
  4. Schwellnus M, Mackintosh L & Mee J. Deep transverse frictions in the treatment of iliotibial band friction syndrome in athletes: a clinical trial. Physiotherapy 1992; 78(8): 564-569.

Sample 33:
Research Review by Dr. Shawn Thistle©
Date: July 2007
Study Title: Subgrouping patients with low back pain: Evolution of a classification approach to physical therapy
Authors: Fritz JM, Cleland JA, Childs JD
Publication Information: Journal of Orthopaedic & Sports Physical Therapy 2007; 37(6): 290-302.
Summary: Low back pain (LBP) is one of the most common reasons people seek healthcare from manual medicine providers and family physicians. Despite its prevalence, LBP remains challenging for all health care providers, a persistent "black box" of musculoskeletal medicine. We know there is some type of dysfunction causing pain, but we are not always sure exactly what that is. In fact, the literature indicates that an exact pathological diagnosis can be achieved in only 10% of cases. Combine this with the questionable relevance of some common imaging findings, and it can be very confusing.

Over 1000 randomized clinical trials exist in the literature, investigating conservative and surgical interventions for LBP. To date, this expansive volume of research has been unable to offer conclusive support for most treatment interventions. One logical explanation for this trend relates to study designs incorporating broad inclusion criteria, resulting in heterogeneous patient samples. It has been advocated that the power of research efforts could be improved by attempting to match subgroups of LBP patients to appropriate treatment interventions they would be most likely to benefit from. This makes sense, as clinical experience dictates that not all patients will respond to one treatment method or approach. This is where a Clinical Prediction Rule (CPR) can help by assisting clinicians to identify clusters of factors (clinical or historical) that can predict patient response to a treatment intervention (ex. manipulation, stabilization exercise etc.).

A CPR does exist for LBP. A substantial volume of published theoretical and experimental research on this topic has been completed by a group of physical therapists (including the three authors of this paper). The existing CPR can now be used for patients with LBP to guide clinical decision making. This paper reviews the development and content of this CPR.

Overview of the Classification System

The original classification system was first published in 1995 (Delitto A et al. Phys Ther 1995; 75: 470-485), and was intended for patients with acute LBP or an acute exacerbation of pre-existing LBP causing substantial pain and limitations in daily activities. Basically, after screening patients for medical red flags, the model used information gathered from the history and examination to place each patient into one of four treatment categories: manipulation, stabilization, specific exercise (flexion, extension, and lateral shift patterns), and traction. These factors vary slightly for each group, but some overlap exists, which makes clinical application more efficient. The treatment groups were initially proposed based on expert opinion, and existing literature on common treatment approaches for LBP. In recent years, numerous studies have added to, and adapted the content of the initial system, resulting in the current CPR (the paper discusses this evolution, but the focus here will be on the practical application based on current evidence). To illustrate the utility of this approach, the research to date on this CPR has demonstrated (references below):
  • the CPR to have high inter-rater reliability (Fritz & George 2000)
  • the CPR to be reliable (Fritz et al. 2006)
  • using the CPR improves clinical outcomes (Brennan et al. 2006)
  • this CPR outperforms existing Clinical Practice Guidelines (Fritz et al. 2003)
  • the CPR can effectively identify those likely to benefit from manipulation (Flynn et al. 2002)
  • there are potential risks of NOT performing manipulation on appropriate patients identified using the CPR (Childs JD et al. 2006)
Content of the Clinical Prediction Rule

The following are revised and updated signs and symptoms associated with each of the four treatment groups. A small description of each category follows:

(1) Manipulation
  • no symptoms distal to the knee
  • recent onset of symptoms (<16 days)
  • low FABQ (Fear Avoidance Beliefs Questionnaire) score (<19)
  • hypomobility of the lumbar spine
  • hip internal rotation > 35° for at least one hip
When 4 of 5 of these factors are present, patients are highly likely to improve with manipulation (positive likelihood ratio of 24!), while the presence of 2 or fewer factors are predictive of failure with manipulation (negative likelihood ratio of 0.009). Factors against this approach include symptoms below the knee, increasing episode frequency (suggests need for stabilization), peripheralization with motion testing (suggests need for specific exercise), and no pain with spring testing.

(2) Stabilization
  • younger age (<40)
  • greater general flexibility (ex. postpartum, SLR > 91°)
  • "instability catch" - (when returning to neutral from a flexed position), or other aberrant movements during lumbar flexion/extension
  • positive prone instability test
  • for patients who are postpartum: 1) positive posterior pelvic pain provocation, active SLR, and Trendelenberg tests, and 2) pain with palpation of the dorsal sacral ligament or pubic symphysis
Not including the last factor listed above, the presence of 3 of the other 4 factors suggests that a patient would benefit from stabilization rehab (Stu McGill's "Big 3" exercises, etc.). Factors against this approach include a SLR discrepancy of > 10° between legs, and a FABQ score < 9. The strength of these associations is not as strong as those for manipulation, so further research is required specific to this category.

(3) Specific Exercise

Extension (more common)
  • symptoms distal to the buttock
  • symptoms centralize with lumbar extension
  • symptoms peripheralize with lumbar flexion
  • directional preference for extension
Flexion
  • older age (>50)
  • directional preference for flexion
  • imaging evidence of lumbar spinal stenosis
Lateral Shift (least common)
  • visible frontal plane deviation of the shoulders relative to the pelvis
  • directional preference for lateral translation movements of the pelvis
For this category, centralization is defined as abolishment of pain or paresthesia with a specific position of the spine (flexion or extension normally), and directional preference is defined as a situation where movement in a certain direction improves pain and ROM limitation, while movement in the opposite direction causes signs and symptoms to worsen. This approach is consistent with what most know as the Mechanical Diagnosis and Therapy (McKenzie) method of assessment and treatment. Factors against this approach include having only LBP (no distal symptoms) and having no change in symptoms with any type of movement.

(4) Traction
  • signs and symptoms of nerve root compression
  • no movement centralizes symptoms
There continues to be a lack of evidence supporting the use of traction for patients with LBP. It is within reason however, that a small subset of LBP patients may benefit from this therapy. More research is required to identify specific factors to support this treatment. For now, the focus of the CPR is generally on the first three categories.
Conclusions & Practical Application: Currently, there is a lack of clarity regarding the treatment of LBP. Systematic reviews and meta-analyses continually paint a dreary picture LBP treatment, citing equivocal results which require further study. This clinical prediction rule has been well developed and researched, and provides a simple model that can assist in classification of LBP patients. By providing appropriate treatment, we can increase our likelihood of success. Further, using this model may guide future research by providing homogenous patient samples, allowing a more fair analysis of certain treatments. The RRS encourages all readers to become familiar with this line of research, as well as the treatment modalities contained within in. Additional references about the CPR are listed below.

Additional References
  • Brennan GP et al. Identifying subgroups of patients with acute/subacute "nonspecific" low back pain: Results of a randomized clinical trial. Spine 2006; 31(6): 623-631.
  • Childs JD, Flynn TW & Fritz JM. A perspective for considering the risks and benefits of spinal manipulation in patients with low back pain. Manual Therapy 2006; 11: 316-320.
  • Cook C et al. Subjective and objective descriptors of clinical lumbar spine instability: A Delphi study. Manual Therapy 2006; 11: 11-21.
  • Flynn T et al. A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine 2002; 27(24): 2835-2843.
  • Fritz JM et al. The use of a classification approach to identify subgroups of patients with acute low back pain: Interrater reliability and short-term treatment outcomes. Spine 2000; 25(1): 106-114.
  • Fritz JM et al. Comparison of classification-based physical therapy with therapy based on clinical practice guidelines for patients with acute low back pain. Spine 2003; 28(13): 1363-1372.
  • Fritz JM et al. An examination of the reliability of a classification algorithm for subgrouping patients with low back pain. Spine 2006; 31(1): 77-82.
 
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