Académique Documents
Professionnel Documents
Culture Documents
inpeoplewithchroniclowbackpain
followingagradedprogrammeof
movementcontrolexercises
LeylaOkyay
Aresearchprojectsubmittedinpartialfulfilmentoftherequirements
forthedegreeofMasterofOsteopathy,UnitecInstituteof
Technology,2010
De
eclaratiion
Nameofcan
ndidate:
LeylaOkyay
ThissResearchP
ProjectentittledPredicctorsoffun
nctionalimp
provementtinpeoplew
with
chro
onic low back
b
pain following a graded programm
me of movement con
ntrol
exercisesissu
ubmittedinpartialfulffilmentforttherequirem
mentsforth
heUnitecdegree
ofM
MasterofOstteopathy.
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ndidatessdeclara
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CandidateSignaature:
Date:
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dentID:112
25187
Acknowledgments
MygreatestthanksgoestoClaireOBrien,forwithoutthecountlessunpaidhoursshe
spentteachingourparticipantstheinsandoutsofmovingaround,thisstudywouldnot
havebeenpossible.
ThankyoutomysupervisorsCatherineBacon,RobMoran,andCraigHilton.Icould
not imagine doing such a project without your help and support. Your belief in my
abilitytocarryoutthisstudywaspivotaltoitssuccess.
I would like to thank all our participants for your enthusiastic participation and hope
yougainedasmuchfromthisstudyaswedid.
Tomyfamilyandfriends,thankyouforencouraging,supportinganddistractingmeand
makingsureIhadalifebeyondmythesis.
Contents
Declaration
Acknowledgments
Contents
Introductiontothethesis
Overview
Section1:LiteratureReview
Introduction
Chroniclowbackpainanddisability
Currentguidelinesandthenatureofresearchandclinicalpractice
11
Subgroupsandclassificationsystems
14
Clinicalpredictionrules
17
Exerciseforchroniclowbackpain
22
Potentialpredictors
26
Conclusions
29
References
30
41
Section2:Manuscript
Abstract
44
Introduction
45
Methods
48
Studysample
48
PreinterventionAssessments
48
OutcomeAssessment
49
Intervention
49
DataAnalysis
50
52
Results
Regressionmodels
52
ClinicalPredictionRules
53
55
Discussion
IndividualPredictors
55
Nonpredictors
58
Limitationsofthestudy
59
Generalizability
60
Furtherresearch
61
Conclusions
62
References
63
TablesandFigures
71
Table1.Participantcharacteristicsatbaselineandtheircorrelationwithchangein
72
PatientSpecificFunctionalScaleforlowbackpainrelateddisability
Table2.PredictorsretainedinthemultiplelinearregressionmodelforPSFS
change
73
Table3.Dichotomisedpredictorsretainedinthelogisticregressionmodels
74
Table4.Clinicalpredictionruleforsuccess
75
Table5.Clinicalpredictionruleforfailure
76
Figure1.TheReformer
77
AppendixA
78
AppendixB
80
AppendixC
82
AppendixD
83
84
Section3:Appendices
AppendixA:EthicsApprovalforthisproject
85
AppendixB:InformationSheetforParticipants
87
AppendixC:TelephoneScreenforEligibility
90
AppendixD:ConsentForm
92
AppendixE:PreinterventionQuestionnaire
94
AppendixF:HistoryandPhysicalExaminationForm
109
AppendixG:PostinterventionQuestionnaire
112
AppendixH:AuthorGuideforSubmissiontotheJournalofBodyworkandMovement
117
Therapies
Introductiontothethesis
Low back pain (LBP) has been, and continues to be extensively researched, without
beingwellunderstood.Inrecentyearstherehasbeenashiftintheresearchontwokey
fronts.Forone,thesearchforpathoanatomicaloriginsofdiseaseanddysfunctionhas
givenwaytomoreneurologicalpsychologicalexplanationsforLBPwithrecognitionof
the complex multifactorial determinants of pain. Secondly, with recognition of the
heterogeneitythatexistsinthepatientpresentationandtreatmentresponse,therehas
beenanincreasedeffortinidentifyingsubgroupsoflowbackpainpatientswithdistinct
featuresthatpredictresponsetoaparticulartreatment.
Howdowedecidewhichtreatmentshavethepotentialtoworkinapersonalizedcare
paradigm, if we have only research that tells us that nothing works on everyone, and
anecdotallythatanytreatmentwillworkforsomeone?Abasic understandingofpain
and disability along with sound theories on potential mechanisms of the effect of
particular treatments might pave the way. Promising treatments can then be
researchedwithinLBPpopulationstoidentifypeoplewhowillbenefit.
Theaimofthestudyreportedinthisthesiswastoinvestigatepredictorsofoutcomefor
one potential treatment for people with chronic LBP. A clinical prediction rule was
developedtoidentifyasubgroupofpeoplewithchronicLBPwhoshowimprovementin
functionfollowingagradedprogrammeofmovementcontrolexercises.Thepreceding
literature review examines the research relating to subgrouping, clinical prediction
rules, and movement control exercises in the treatment of chronic LBP, and provides
justificationsforthechoiceofpotentialpredictorsincluded inthesubsequentresearch
study.
Overview
Thefollowingresearchprojectisdividedintothreesections:
1. Theliteraturereview,withemphasison:
ClassificationSystems
Methodsofsubgroupinglowbackpain
Definitionanduseofclinicalpredictionrulesinlowbackpain
care
Thetreatmentofchroniclowbackpainwithexercise
Predictorsofrehabilitationoutcomeinlowbackpain
2. AmanuscriptintheformatspecifiedforsubmissiontotheJournalofBodyworkand
MovementTherapies.
3. Appendicesthatincludeethicsapproval,participantinformationsheet,screening
questions,consentform,questionnaires,medicalhistoryformandtheguidelinesfor
authorstotheJournalofBodyworkandMovementTherapies.
Section1:LiteratureReview
Introduction
Over the last 20 years there has been a shift in the wider medical literature to
personalize patient care, supported by the research discoveries within genomics
and pharmacogenetics. Groups of people at risk for chronic diseases like cancer
and heart disease can be identified and appropriate individualized preventative
strategiesandearlytreatmentprogrammescanbeinitiated.Lowbackpain(LBP)
is a chronic problem that could also benefit from personalized care that is
supportedbyanevidencebasedframework.
Inthefirstinstance,thisreviewexploressomeoftheproblemsintheresearchand
care of LBP. The concepts of subgrouping and clinical prediction rules are
discussed. This is followed by an overview of research supporting exercise as a
treatment of choice for chronic LBP. Finally, potential predictors of outcome are
discussed.
(Walker, Muller & Grant, 2004). Chronic LBP causes particularly large
socioeconomic problems in the form of longterm disability, work absenteeism,
income compensation, and healthcare costs. Based on a young adult population,
the annual cost of LBP in New Zealand is estimated at almost $500 million
(McBride,Begg,Herbison&Buckingham,2004).
A specific pathology such as an infection, tumour, fracture or nerve root
compressioncanbeidentifiedinlessthan15%ofLBPpatients (Deyo&Phillips,
1996). These patients are labelled as experiencing specific LBP, while the
remaining 85% of patients are classified as having nonspecific LBP. This latter
groupisoftenfurthersubdividedbasedondurationofsymptoms.AcuteLBPlasts
up to 6 weeks, subacute pain is identified as lasting 6 weeks to 3 months, and
chronicpainpersistsforgreaterthan3months.UnfortunatelythecourseofLBPis
not so simple and many patients experience multiple flareups of acute pain
interspersedwithperiodsofremission(Pengeletal.,2003;vonKorff&Saunders,
1996). In light of this, a further patient population group with recurrent non
specificLBPhasbeensuggested(Stanton,Latimer,Maher&Hancock,2009).Most
treatmenttrialsstudyeitheracuteorchronic(persistent)LBPpopulations,anditis
often unclear if the authors have included and acknowledged people who
experience recurrent episodes of pain. Because of the longterm nature of
recurrentLBPitmayperhapsbeclassedasanintermittentformofchronicLBP.A
review that found exercise to be beneficial for subacute, chronic, and recurrent
LBP,butnotforacuteLBP(Henchoz&KaiLikSo,2008),supportsthisassociation.
LBPischaracterisedbythesensationofpainbetweenthelowerribsandbuttock
creases and is usually associated with some level of functional limitations
(disability). Arguably, it is disability that causes the biggest problems in those
experiencing LBP. Disability may range from limitations in leisure activities and
10
decreased productivity at work, to inability to perform basic activities of daily
living, unemployment and adopting an invalid status (Bogduk, 2006). Levels of
disability are only to some extent linked to the amount of physical impairment.
Waddell et al. (1993) have shown that 40% of disability can be explained by
physical impairment, 23% can be explained by psychological distress, and 8% is
explainedbyillnessbehaviour.Itcanbesaidthatdisabilityisarepresentationof
thepatientsresponsetopain,motivatedbythedesiretoavoidaggravationofpain
(Bogduk,2006).
11
disability. Furthermore, whilst some highquality randomized controlled trials of
these treatment modalities confirm a positive effect, the effect size is small and,
whenmorethanonetreatmentis compared,nodifferencebetweeninterventions
hasbeenfound(Critchley,Ratcliffe,Noonan,Jones&Hurley, 2007;vanTulderet
al.,2006).
Intervention trials usually recruit a heterogeneous sample of nonspecific LBP
patients and report the mean effect of the intervention. Thus it is, in effect,
incorrectly treated as an homogenous problem. However, patients with non
specificLBPhavemanydifferentpresentations,andfactorsthatcontributetotheir
experience of pain and disability may vary. Because of this diversity, certain
groups of patients may respond better than others to a particular treatment
(Delitto, 2005). Trials with heterogeneous LBP populations may experience a
dilutioneffectwhereamarkedimprovementinsomepatientsis,ineffect,cancelled
outbylackofimprovementinotherpatients,givingtheoverallimpressionofonly
mild effectiveness (LeboeufYde & Manniche, 2001). It has been argued that
interventions that do not take the heterogeneity of the LBP population into
account,mayfailtoidentifytreatmentsthatareeffectiveforasubgroupofpeople
withLBP(Brennanetal.,2006).
There is evidence that better outcomes are reported when a population of LBP
patients is divided into subgroups and treatment is tailored to the subgroups
comparedtoaonehatfitsallmodel(Fritz,Delitto&Erhard,2003;Hall,McIntosh
&Boyle,2009).Fritzandcoworkers(2003)comparedtheuseofaclassification
system where patients were assigned to one of four treatments
(manipulation/mobilization, directional exercises, traction, or stabilization
exercises)totreatmentbasedonclinicalpracticeguidelinesinvolvingreassurance,
advice to stay active, lowstress aerobic exercise, and general muscle
12
reconditioning exercises after the first 2 weeks. The classification group was
evaluated at the beginning of every session and treated using one of the four
treatment methods, as determined by the clinical prediction rules. After four
weeks, greater percentage improvement in the Oswestry disability Questionnaire
score(difference=10.9,95%CI:1.919.9,P<.05)wasobservedintheclassification
group compared to the guideline group. As can be seen by the large standard
deviations, there was considerable variation in response in both groups, which
could be a reflection of the sample size (n=78). Although the authors state that
theyhadsufficientparticipantstodetectchange,thetotal numberofparticipants
wasperhapsratherlowcomparedtootherstudiesthatassesstheimpactofanew
treatmentapproachonoutcomeinaclinicalsetting.Forexample,Halletal.(2009)
comparedthetreatmentresultsof2223patientswithlowbackandlegpainwho
were either treated as usual using numerous physical therapy modalities
includingexercise,reassurance,andadvicetostayactive,or classifiedintooneof
four subgroups that guided selection and personalization of the same treatment
modalities.Theoddsofcompletepainrelieffollowingtreatmentweretwototen
timesgreater(dependingonthesubgroup)intheclassifiedgroupthaninthenon
classified group. In addition, the odds of a minimal clinically important
improvement in function were all greater in the classified groups, although these
differenceswerenotaslargeasforpainrelief.Classifiedpatientsonaveragealso
had fewer treatments (9.916.5 days) than the comparison group (21.5 days).
Studies such as these two provide strong motivation to find clinically useful
systemsthatcanguidecliniciansintheirtreatmentchoices.
MostprimarycarecliniciansbelievethatnonspecificLBPisnotasinglecondition
(Kent & Keating, 2004). Over 70% also believe that it is possible to identify
subgroups within LBP populations, and they treat patients differently based on
signs and symptoms (Kent & Keating, 2004). However, clinicians tend to rely
13
heavily on physical assessments of impairment, many of which have poor or
uncertain reliability (Essendrop, Maul, Lubli, Riihimki & Schibye, 2003; May,
Littlewood&Bishop,2006;vanTrijffel,Oostendorp,Lindeboom,Bossuyt&Lucas,
2008). Diagnosis is usually made on a pathoanatomical basis, with little and
controversialevidenceofvalidity(Kent&Keating,2005).Allowingcliniciansthe
freedom to choose the type of manual therapy technique they use in a particular
patient has been shown to provide no additional benefit compared to applying a
predetermined technique (Kent, Marks, Pearson & Keating, 2005). Kent et al.
(2005) reviewed randomized controlled trials that compared lumbar spine
manipulations/mobilizations to no intervention/placebo or other interventions.
They determined that studies where practitioners had no choice of technique
reported better outcomes for both pain (difference in effect size = 0.390.37,
P=.02) and activity limitation (difference in effect size = 0.620.47, P<.01). It is
evidentthatdifferentstrategiesinbothresearchandclinicalpracticeareneededto
address these problems and a potential solution is to undertake research into
subgroupidentification.
14
selectedpatients.Throughsubgroups,trendsintheLBPpopulationmaybecome
clearerandshedfurtherlightonunderlyingpainmechanisms.
There are three primary methods of subgrouping LBP patients: diagnostic,
prognostic,andprescriptive(Riddle,1998).Thediagnosticapproachisbasedon
identifyingunderlyingpainmechanismsorsyndromesandisbuiltonthepremise
that there are multiple aetiologies underlying LBP and that it is possible to
accuratelyidentifythese.Prognosticsubgroupingusuallyaimstoidentifygroups
of patients who will become chronic pain sufferers or who have a higher risk of
recurrent LBP episodes (Riddle, 1998). The last method takes a very clinical
approachbyprovidingsuggestionsforthemostappropriatetreatmentmethodfor
specific subgroups and bypasses the need to diagnose elusive pathoanatomy.
Prescriptive subgrouping is based on responsiveness to different treatments,
acknowledging that even people with the same diagnosis may not respond
identicallytothesametreatment.
Subgroupsareoftendevelopedandpresentedintheformofaclassificationsystem.
According to Binkley et al. (1993), a classification system should do three things:
guide clinical decisionmaking, identify homogenous subgroups for effectiveness
studies,and facilitatecommunicationamongclinicians.Anumberofprescriptive
classification systems have been developed to date, including the McKenzie
MechanicalDiagnosisandTherapysystemin1980(Donelson,2004),theSikorski
approach in 1985 (Riddle, 1998), the Delitto system in 1995 (Delitto, Erhard &
Bowling,1995),andmorerecentlytheOSullivanclassificationsystemforchronic
LBP(O'Sullivan,2005).However,notallhavebeenstudiedanddevelopedtothe
sameextent.
TherearetwowaystodevelopclassificationsystemsthatsubgroupLBPpatients
(Riddle, 1998). All the above systems were developed using a judgmental
15
approach, where the developers identified subgroups using traditional customs
(for example, variables appearing repeatedly in the literature), conventional
wisdom (clinicians beliefs), and personal experience (Riddle, 1998). However,
thereisalsoanotherstatisticalapproachthatrequirescollectionofmanyvariables
andapplicationofmultivariatestatisticalmodelslikeclusteranalysisorregression
to identify groups of patients with similar characteristics. The former method is
subjective and may fit with current clinical practices, but may not be accurate or
valid. The latter method can be more objective, and can be used to test and
improveajudgmentalclassificationsystem.TheDelittoclassificationsystemisthe
onlyoneoftheabovementionedsystemsthathasundergonefurtherdevelopment
andrevisionthroughstatisticalmethods(Fritz,Cleland&Childs,2007).
Delitto et al. (1995) originally devised a comprehensive system of classification
using a decision tree approach that served to identify the most appropriate
managementforaparticularpatient.Theoriginalsysteminvolvedinitialscreening
of patients who require referral because of possible underlying spinal pathology.
Those patients who could be managed by physical therapists were staged
according to pain severity and treatment priority (pain reduction, functional
improvement,ortrainingforhighdemandactivities).Patientsintheacutestage,
requiringpainreduction,werethenassignedtooneoffourtreatmentapproaches
(directional movements, traction, mobilization, or immobilization). Examples of
pathoanatomical causes of LBP, and a collection of signs and symptoms were
providedtoassistpractitionersinchoosingoneofthefourapproaches.
ThereareanumberofproblemswiththeoriginalDelittosystem.Ononehand,the
systemofferslittleadviceontreatingchronicpainandthepsychosocialfactorsthat
influencetheexperienceofpainanditsresolution.However,classificationsystems
aredynamic,changeableentitiesthatcancontinuetoevolvewithtimeandfurther
16
research. For example, the original Delitto system was developed purely on a
judgmental basis and relied heavily on conventional diagnostic and treatment
methodsofthetimewithlittlesupportingresearchontheirreliabilityorvalidity.
Theclassificationcriteriahavesincethenbeenupdatedbasedonnewresearchand
improvementshavealsobeenmadetotheinterventionsused(Fritz,2009).Much
ofthis evolution hasoccurredthoroughstatistical methodsin theformofclinical
predictionrules(Flynnetal.,2002;Fritzetal.,2007;Hicks,Fritz,Delitto&McGill,
2005).
17
CPRsareusuallydescribedintermsofsensitivity,specificity,andlikelihoodratios.
The decision on whether to maximise sensitivity or specificity depend on the
situation in which the CPR is used (Laupacis et al., 1997). Likelihood ratios
estimatetheposttestprobabilityofanoutcomewhenusingtherule.Alikelihood
of 1 means that the posttest probability of the outcome occurring, is exactly the
sameasthepretestprobability(Laupacisetal.,1997).Thegreaterthelikelihood
ratio,thegreateristheprobabilityoftheoutcomeoccurring.Likelihoodratiosof2
to5havebeenproposedtoindicatesmallbutpossiblyimportantchanges,ratiosof
5 to 10 suggest moderate changes, and ratios greater than 10 suggest large and
conclusive changes in likelihood of observing the outcome (Beattie & Nelson,
2006).
Derivation of a rule does not provide evidence of usefulness in a clinical setting
(Laupacis et al., 1997). Once a sensible CPR has been developed, a number of
further steps are required to ensure that the CPR can be used with confidence.
McGinn et al. (2000) have offered a hierarchy of evidence that can be used to
determinevalidityofaCPR.Level4evidencemeansthattherulehasbeenderived
in a welldefined population but has not yet been validated and needs further
evaluationbeforeclinicaluse.Level3ruleshavebeenvalidatedinasimilarsample
tothatofthederivationstudyandshouldonlybeusedcautiouslyandwithpatients
that closely resemble the study population. Level 2 rules have demonstrated
accuracyinalargesamplewithavarietyofpatientsandexaminersandcanbeused
with confidence in a variety of settings. Finally Level 1 rules have undergone
impact analyses that have demonstrated change in clinician behaviour and
improvedpopulationoutcomeswiththeiruse.
It is important to note that CPRs are not classification systems. Rather they are
toolsthatmayidentifyadiscretesubgroupthatcouldformpartofaclassification
18
system. They are also not clinical practice guidelines, which address multiple
issues in patients with a particular syndrome (e.g. back pain) (Reilly & Evans,
2006). Simply, a CPR is a statistically derived tool that provides diagnostic or
prognostic probabilities of a particular outcome in a person with a specific
presentationanditonlyexistsbecauseofitsabilitytopredictoutcome.CPRsare
particularly useful when the decision making process is complex, in highrisk
situation,ortoreducecostsduetounnecessarytestsortreatments(McGinnetal.,
2000). In medicine, CPRs have been developed for many scenarios. There are
CPRstopredict:theneedforankleradiography(Stielletal.,1992),riskofactive
TBatthetimeofhospitaladmission(Wisniveskyetal.,2005),complicationsofan
acute ischaemic heart disease (Reilly & Evans, 2006), and more. Recently CPRs
havealsofoundtheirwayintoLBPliterature.
CPRsmaybeparticularlyusefulinrecommendingtreatmentchoiceforLBPasitis
a highly prevalent condition, common diagnostic tests are generally unreliable,
conflicting information exists regarding the effectiveness of interventions, and
thereisabeliefamongresearcherandcliniciansthatsubgroupsexistandwouldbe
useful to research (May & Rosedale, 2008). Numerous studies have developed
prescriptive CPRs for use in LBP populations. However, only two of these have
been subjected to validation: a study examining responders to manipulation
(Flynn et al., 2002), and a study examining stabilization exercise responders
(Hicksetal.,2005).
Flynn et al. (2002) derived a 5variable rule that was successfully able to predict
peoplewithacuteLBPwhoshoweda50%improvementindisabilityfollowingtwo
sessionsofspinalmanipulation.Therulewasabletopredict67%(NagelkerkeR2)
of the variance in outcome (P<.001). Predictors of a successful outcome were:
onsetofLBP<16daysago;atleastonehipinternalrotationrangeofmotion>35;
19
detectionofhypomobilityduringlumbarspinespringtest;FearAvoidanceBeliefs
Questionnaire work subscale score <19; and no symptoms below the knee. If at
leastfourofthesepredictorswerepresent,thepositivelikelihoodratiowas24.4,
indicating high likelihood of improvement in disability. One problem with the
studyisthattheauthorsfailedtoblindtheassessorsofthe predictorvariablesto
theoutcome.
Fourdifferentvalidationstudies(Brennanetal.,2006;Childsetal.,2004;Cleland,
Fritz, Whitman, Childs & Palmer, 2006; Hancock, Maher, Latimer, Herbert &
McAuley, 2008) have been undertaken on the manipulation CPR, with one
independent study failing to support the subgroup characteristic (Hancock et al.,
2008). The latter study showed no significant difference in outcomes between
those who met the CPR criteria and those who did not (P=.80 for pain, P=.60 for
disability),leadingareviewtoconcludethattheevidenceforthisrulewaslimited
andcontradictory(May&Rosedale,2008).However,thisconclusionwasperhaps
alsosomewhatlimited,asthedifferencesbetweenthestudieswerenotdiscussed.
ThestudybyHancocketal.(2008)differedsignificantlyinanumberofwaysfrom
the original derivation study (Flynn et al., 2002) and other validation studies
(Brennan et al., 2006; Childs et al., 2004; Cleland et al., 2006). The study was
conductedinadifferentsetting,whichisappropriatebecauseavarietyofpatients
and clinicians is a requirement for Level 2 validation (Beattie & Nelson, 2006).
However, the researchers also varied the treatment protocol considerably. The
fourcomparisonstudiesallusedhighvelocitythrustmanipulationstargetedtothe
sacroiliacjointsorL45lumbarvertebraljoints,aswellasprescribingsomepelvic
tilting exercises, while Hancock et al. (2008) allowed the clinicians to use any
manipulation or mobilization techniques and prescribed all patients with a mild
analgesic,andaproportionofpatientswithnonsteroidalantiinflammatorydrugs.
CPRvalidationprotocolsdonotindicatethatthetreatmentsgivenshouldbevaried
20
(Beattie&Nelson,2006).Infact,changingthetreatmentcouldpotentiallyalterthe
predictors of success and hence the subgroups indicated for intervention. It is
possiblethatthenonsignificantresultsobservedbyHancocketal.(2008)resulted
fromapplyinganinterventionthatwasdifferentfromthestudiesusedtodevelop
theCPR,ratherthanlackofstabilityoftheCPR.Anotherstudythatvalidatedthe
CPR, albeit in a similar setting to the original study, reported a significant
difference in change in disability score at 4 weeks (Childs et al., 2004). Patients
receiving manipulation who were positive for the CPR had a better percentage
improvement in Oswestry disability score than those who were negative
(difference = 15.2, 95% CI: 7.5 to 23.3, P<.001). The same did not hold true for
participants in the control group (receiving exercise) who were positive or
negativefortherule(difference=6.5,95%CI:1.8to14.8,P=.127).
A clinical prediction rule for stabilization exercises in acute LBP populations has
beendevelopedaswell(Hicksetal.,2005).Thelikelihoodratioofthe4variable
rulewasonly4.00,indicatingsmallchangesinthelikelihoodof50%improvement
ontheOswestryDisabilityQuestionnaire, and no datademonstratingthe models
fit was reported. However, a construct validity study that has shown that spinal
motion characteristics measured using digital fluoroscopic video can identify the
responders to stabilization exercises (Teyhen, Flynn, Childs & Abraham, 2007),
increasesconfidenceintheconstructvalidityofthemodel.
Only one trial has aimed to validate all the clinical prediction rules based on the
Delittosystem.Brennanetal.(2006)randomlyassigned123participantstooneof
three treatments (manipulation, stabilization exercises, and specific directional
exercises; traction was not included). The clinical outcomes for those people
matched and unmatched to their treatment groups (according to the CPRs) was
then compared. Patients receiving treatment matched to their CPR subgroup
21
experienced greater improvement in Oswestry disability score than patients
receiving unmatched treatment, at four weeks (difference = 6.6; 95% CI: 0.70 to
12.5,P<.05)andat1year(difference=8.3,95%CI:2.514.1,P<.01).Inlightofthis
study and the abovementioned trials, subgrouping LBP patients through CPRs
appears promising but considerably more research is needed before they can be
confidentlyemployedinpatientcare.
NumerousotherCPRshavebeendevelopedtoidentifyLBPresponderstotraction,
physical
therapy/chiropractic,
zygapophyseal
joint
injections,
and
multidisciplinary rehabilitation (May & Rosedale, 2008). All of these have not
beenadvancedbeyondthederivationstageandnonewereofhighquality(May&
Rosedale, 2008). One CPR derivation study for chronic LBP (multidisciplinary
treatment)didnotactuallyreportarule,astheresultsoftheregressionmodelsdid
not justify such development (Van Der Hulst, VollenbroekHutten, Groothuis
Oudshoorn & Hermens, 2008). Limitations of the study included too many
outcome variables and a limited range of potential predictors. Unfortunately, all
otherCPRstudieshavefocusedonacuteLBP,anddespitetheperplexityofchronic
LBP,nospecificCPRsexist.Itisplausiblethatsimilartreatmentsmaybeeffective
for chronic LBP, although outcome predictors may differ. In particular the
stabilizationexerciseCPRmayholdgreatvalueasexercisehasalreadybeenshown
tobeapromisingtreatmentforchronicnonspecificLBP.
22
stillsmall:3.00points(95%CI:0.53to6.48)outof100comparedtonotreatment,
and 2.37 points (95% CI: 0.74 to 4.0) out of 100 compared to other conservative
treatments. Interestingly, the authors do not recommend further research on
general exercise therapy for people with chronic LBP. Instead, they recommend
that studies should focus on specific exercise interventions in welldefined LBP
populations. Hayden, van Tulder and Tomlinson (2005) reviewed numerous
exercise programmes, and determined that individualized, supervised programs
and those that include stretching and strengthening can yield the greatest
improvements in pain and disability. However, Paalanne at al (2008) found no
association between trunk muscle strength and LBP, so it is unclear why
strengtheningexerciseswouldimproveoutcome.
OSullivan (2005) has suggested that one subgroup of patients with chronic and
recurrent LBP may have movement control impairments that prevent recovery,
and would thus be likely to benefit from interventions that addressed this
deficiency. Several studies have examined the effects of movement control
exercises(commonlyreferredtoasstabilizationexercisesandrecentlyasmotor
control exercises) on LBP, some reporting improvement in disability and pain
(Harringe, Nordgren, Arvidsson & Werner, 2007; Rydeard, Leger & Smith, 2006)
whereasothersreportnosignificantimprovement(Arokoski,Valta,Kankaanpaa
&Airaksinen,2004).Whilevariationsinthetypeofexercisesmakescomparison
between studies difficult, a number of studies have compared stabilization
exercises to other types of exercise. These studies concluded that exercise was
better than placebo but that the effects of the different exercises are comparable
with each other (Cleland, Schulte & Durall, 2002; Miller, Schenk, Kames &
Rousselle,2005).AreviewbyMayandJohnson(2008)concludesthatstabilization
exercise interventions for people with chronic LBP show superiority to passive
treatments(limitedtherapistinputorlimited/unmonitoredpatientparticipationin
23
management), but perform comparably to other active interventions including
manual therapy and other exercise programmes. However, certain subgroups of
LBP patients could exist that respond better than others to particular active
interventions. For example, Koumantakis, Watson and Oldham (2005) found no
greaterbenefitofcombinedstabilizationexercisesandgeneralexercisecompared
togeneralexercisealone,unlesssubjectshadclinicalsignsofinstability.Another,
more recent study, by RasmussenBarr et al. (2009), showed that graded
stabilization exercises were better than daily walks at improving disability in
peoplewithrecurrentLBP.Whiletheydemonstratedthattherewasnosignificant
difference in the number of people who showed minimal clinically important
change (MCIC) immediately after the intervention (P=0.26), at 12month post
intervention53%ofthoseinthegradedstabilizationexercisegroupshowedMCIC
indisabilitycomparedtoonly26%ofthewalkinggroup(P=0.02).Soperhaps,if
exercise programmes and target patients meet certain criteria, the interventions
canbemoreeffective.
Stabilization exercises are aimed at training activation of deep trunk muscles,
specificallythetransversusabdominisandthedeepfibresofthemultifidi,aswell
as improving coordination between contraction of deep and superficial trunk
muscles,whilegraduallyincreasingthedemandoftheexercisetasks(Richardson,
Hodges&Hides,2004).Thisapproachisbasedonthenotionthatchangesintrunk
muscle coordination have occurred in people suffering from chronic LBP.
Numerous studies give evidence to the presence of motor control impairment in
patientswithchronicandrecurrentLBP,withchangesintrunk muscleactivation
patterns (Hodges & Richardson, 1998; Hodges & Richardson, 1999; Hodges,
Richardson &Jull,1996;HubleyKozey& Vezina,2002) andreorganisationofthe
brainsmotorcortex(Tsao,Galea&Hodges,2008).StudiesonchronicLBPhave
consistentlyobserveddelayedactivityandwastingindeepabdominalmusclesand
24
back muscles and increased activity in superficial abdominal muscles (Ferreira,
Ferreira & Hodges, 2004; Hodges et al., 1996; Hungerford, Gilleard & Hodges,
2003). While it is unknown whether the changes are the cause or result of LBP,
Cholewicki (2005) suggests that these alterations may contribute to the frequent
recurrenceofLBP.
Thereissomeevidencethatrecruitmentpatternsoftrunkmusclescanbechanged
throughspecificexercises(Stevensetal.,2007;Tsao&Hodges,2007;Tsao,Galea
&Hodges,2008).Stevensetal.(2007)demonstratedincreasedabdominalmuscle
activation after stabilization training in healthy people. In addition, Tsao and
Hodges(2007)havereportedthatvoluntarytrunkmuscleactivationcanimprove
activation of trunk stabilizing muscles during trunk perturbation tasks in people
with recurrent LBP. The authors have also demonstrated that these changes can
persist for up to 6months, even after cessation of exercises (Tsao & Hodges,
2008).Itseemsthatspecificexercisescanimprovenotonlyvoluntaryactivationof
deep trunk muscles, but that the learned skills can also improve automatic
contractions.
In addition to physical effects, the graded approach generally used in teaching
stabilizationexercises,mayhelpinreducingfearavoidancebeliefs.Fearavoidance
beliefs are patients beliefs about how physical activity and work affected their
low back pain (Waddell et al., 1993). They have been shown to correlate to the
degreeofdisabilityandmayexplainthevariancebetweenpainanddisabilitythat
is frequently seen in chronic LBP (Crombez, Vlaeyen, Heuts & Lysens, 1999;
Waddell et al., 1993). Macedo et al. (2008) hypothesize that graded activity
exercises may improve disability and reduce fearavoidance beliefs. So, a graded
programme of exercises, that is supervised and includes movement control
25
exercisesandsomestretching,mayprovidethegreatestbenefitforasubgroupof
chronicLBPpatients.
Potential predictors
To develop a clinical prediction rule, potential predictors of outcome need to be
identified. Predictor variables may include: those that are commonly used in
clinicalpractice;thosethatarepopularintheliteratureandinpracticeguidelines;
and variables that are emergent in research and clinic settings and have the
potentialtobeuseful.Forthefollowingstudy,predictorsthatrelatespecificallyto
chronic LBP, movement control impairment, and exercise, will be particularly
pertinent.
Demographicvariablessuchasage,gender,workstatusandlevelofeducation,as
wellasbodymassindexhaveallbeendeemedimportantfactorstoconsiderinthe
transitionfromacutetochronicLBPbyagroupofexperts(Pincus,Santos,Breen,
Burton & Underwood, 2008). Therefore these variables would be valuable to
include as predictors of outcome following an intervention for chronic LBP. For
example,Costaetal.(2009)havedemonstratedthattheprognosisforchronicLBP
patients is worse for those with lower education levels. Pincus and coworkers
(2008) also recommend assessment of pain intensity and disability as baseline
predictorsofchronicLBP.Higherpainintensityatbaselineisapredictorofpoor
prognosisandnoncompletionoftreatmentprogrammes(Barnes,Smith,Gatchel&
Mayer, 1989; Menezes Costa et al., 2009). Prognosis is also worse for those with
highlevelsofdisabilityatbaseline(MenezesCostaetal.,2009).
It is now well recognised that chronic LBP is a multidimensional condition, and
psychosocial factors form a strong part of the pain experience. Fearavoidance
beliefsanddistressareassociatedwithdisabilitylevelsandareparticularlyhighin
26
patientswithchronicLBP(Grotle,Vllestad,Veierd&Brox,2004;Waddelletal.,
1993).Mannionetal.(2001)haveshownthatfearavoidancebeliefsanddistress
each explain almost 10% of the variance in disability following an active therapy
for chronic LBP. Higher levels of depression are seen among patients who fail to
improve following a functional restoration programme (Barnes et al., 1989) and
havebeenshowntobegeneralpredictorsofpoorprognosis(Pincus,Burton,Vogel
& Field 2002). A heightened belief in possible negative consequences
(catastrophizing) has also been associated with poor outcome following active
therapiesforchronicLBPpatients(Mannionetal.,2001).
Thereisevidencethatphysical signsandsymptomsarenotpredictorsofchronic
disability (Hunter, Smith & Gribbin, 2001), but musculoskeletal examination
findings form an important part of clinical decision making. A selection of tests
including lumbar spine segmental mobility assessment, a prone instability test,
passive straight leg raise range of motion, and lumbar flexion range showed
predictivevalueinapreviousCPRforstabilizationexercisesinacuteLBP(Hickset
al.,2005).ThesemayalsopredictoutcomeinachronicLBPpopulationfollowinga
similarexerciseprogramme.
Because movement control exercises aim to improve disability partly by
addressing altered postural adaptations, tests such as those examining aberrant
motions on forward bending (Hicks, Fritz, Delitto & Mishock, 2003), and
movement control tests described by Luomajoki et al. (2007) may be able to
predictoutcome.Hicksetal.(2005)showedthatthepresenceofaberrantmotions
onforwardbendingwasapredictorofsuccessfollowingstabilizationexercisesin
people with acute LBP. Luomajoki et al. (2008), showed that LBP patients had
significantlymorepositive(inabilitytoperformthemovementcorrectly)teststhan
healthy controls (difference 1.8, 95% CI: 1.02 to 1.34, P<.001). Furthermore,
27
chronic LBP patients also had significantly more positive tests than acute LBP
patients(p<.01).Therefore,bothofthesegroupsoftestsmaybeusefulpredictors
ofoutcomeinpeoplewithchronicLBP,followinganexerciseintervention.
Lack of muscle strength and endurance may play a role in the propagation of
chronic LBP. It is recognised that deep spinal muscles play an essential role in
stabilizingthespine,butthesuperficialmusclesmayalsobecomedysfunctionalin
LBP(Barr,Griggs&Cadby,2005).Trunkmusclestrengthandbodyswayhavenot
shownsignificantassociationwithLBP(Paalanneetal.,2008).However,muscle
endurance times are frequently decreased in people with LBP when compared to
healthy individuals (Ito et al., 1996; Latimer, Maher, Refshauge & Colaco, 1999;
McGill,Childs&Liebenson,1999;Schellenberg,Lang,Chan&Burnham,2007).
A multitude of variables exist that could be potential predictors of treatment
outcomeinpeoplewithchronicLBP.Itisunfeasibletotestallpossiblevariables,
and therefore the selection outlined above were deemed most promising
predictorsandchosenforinclusioninthefollowingresearchproject.
28
Conclusions
LBPisverycommon.Chronicpainanddisabilityinparticularlayaheavyburden
on the individual and society as a whole. While current evidence of treatment
effectivenessisregrettable,developmentofsubgroupsthrough clinicalprediction
rules may provide solutions for future management of LBP. There is some
evidence that specific movement control exercises are effective in improving
disability,andnumerousstudiesvariablesmaypredicttreatmentresponse.
For these reasons, a study to identify variables that predict change in disability
rating in people with chronic nonspecific LBP following a graded programme of
movement control exercises, and the development of a clinical prediction rule to
identify asubgroup ofpatientslikelytobenefit fromsuchan interventionisboth
relevantandtimely.
Sectiontwoofthisthesisreportsontheinvestigation.
29
References
1. Airaksinen,O.,Brox,J.I.,Cedraschi,C.,Hildebrandt,J.,KlaberMoffett,J.,Kovacs,
F.,etal.(2006).Chapter4.Europeanguidelinesforthemanagementofchronic
nonspecificlowbackpain.EuropeanSpineJournal,15Suppl2,S192300.
2. Arokoski,J.P.,Valta,T.,Kankaanpaa,M.,&Airaksinen,O.(2004).Activationof
lumbar paraspinal and abdominal muscles during therapeutic exercises in
chroniclowbackpainpatients.ArchivesofPhysicalMedicineandRehabilitation,
85(5),823832.
3. Barnes,D.,Smith,D.,Gatchel,R.J.,&Mayer,T.G.(1989).Psychosocioeconomic
predictors of treatment success/failure in chronic lowback pain patients.
Spine,14(4),427430.
4. Barr,K.P.,Griggs,M.,&Cadby,T.(2005).Lumbarstabilization:Coreconcepts
and current literature, part 1. American Journal of Physical Medicine and
Rehabilitation,84(6),473480.
5. Beattie, P., & Nelson, R. (2006). Clinical prediction rules: What are they and
whatdotheytellus?.AustralianJournalofPhysiotherapy,52(3),157163.
6. Binkley, J., Finch, E., Hall, J., Black, T., & Gowland, C. (1993). Diagnostic
classification of patients with low back pain: Report on a survey of physical
therapyexperts.PhysicalTherapy,73(3),138150.
7. Bogduk, N. (2004). Management of chronic low back pain. MedicalJournalof
Australia,180(2),7983.
8. Bogduk, N. (2006). Psychology and low back pain. International Journal of
OsteopathicMedicine,9(2),4953.
9. Brennan,G.P.,Fritz,J.M.,Hunter,S.J.,Thackeray,A.,Delitto,A.,&Erhard,R.E.
(2006). Identifying subgroups of patients with acute/subacute " nonspecific"
lowbackpain:Resultsofarandomizedclinicaltrial.Spine,31(6),623631.
30
10. Carey,T.S.,Garrett,J.M.,&Jackman,A.M.(2000).Beyondthegoodprognosis.
Examination of an inception cohort of patients with chronic low back pain.
Spine,25(1),115120.
11. Childs, J. D., & Cleland, J. A. (2006). Development and application of clinical
prediction rules to improve decision making in physical therapist practice.
PhysicalTherapy,86(1),122131.
12. Childs,J.D.,Fritz,J.M.,Flynn,T.W.,Irrgang,J.J.,Johnson,K.K.,Majkowski,G.R.,
etal.(2004).Aclinicalpredictionruletoidentifypatients withlowback pain
most likely to benefit from spinal manipulation: A validation study. Annalsof
InternalMedicine,141(12),920928.
13. Cleland,J.A.,Fritz,J.M.,Whitman,J.M.,Childs,J.D.,&Palmer,J.A.(2006).The
useofalumbarspinemanipulationtechniquebyphysicaltherapistsinpatients
whosatisfy aclinicalpredictionrule:Acaseseries. JournalofOrthopaedicand
SportsPhysicalTherapy,36(4),209214.
14. Cleland, J., Schulte, C., & Durall, C. (2002). The role of therapeutic exercise in
treating instabilityrelated lumbar spine pain: A systematic review. Journalof
BackandMusculoskeletalRehabilitation,16(23),105115.
15. CostaLCM,MaherCG,McAuleyJH,HancockMJ,HerbertRD,RefshaugeKM,and
Henschke N. 2009b. Prognosis for patients with chronic low back pain:
Inceptioncohortstudy.BMJ339:b3829.
16. Critchley, D. J., Ratcliffe, J., Noonan, S., Jones, R. H., & Hurley, M. V. (2007).
Effectiveness and costeffectiveness of three types of physiotherapy used to
reduce chronic low back pain disability: A pragmatic randomized trial with
economicevaluation.Spine,32(14),14741481.
17. Crombez,G.,Vlaeyen,J.W.,Heuts,P.H.,&Lysens,R.(1999).Painrelatedfearis
more disabling than pain itself: Evidence on the role of painrelated fear in
chronicbackpaindisability.Pain,80(12),32939.
31
18. Delitto,A.(2005).Researchinlowbackpain:Timetostopseekingtheelusive
"magicbullet".PhysicalTherapy,85(3),206208.
19. Delitto, A., Erhard, R. E., & Bowling, R. W. (1995). A treatmentbased
classificationapproachtolowbacksyndrome:Identifyingandstagingpatients
forconservativetreatment.PhysicalTherapy,75(6),470489.
20. Deyo,R.A.,&Phillips,W.R.(1996).Lowbackpain:Aprimarycarechallenge.
Spine,21(24),28262832.
21. Donelson, R. (2004). EvidenceBased low back pain classification. Improving
careatitsfoundation.EuropaMedicophysia,40(1),3744.
22. Essendrop,M.,Maul,I.,Lubli,T.,Riihimki,H.,&Schibye,B.(2003).Measures
of low back function: A review of reproducibility studies. PhysicalTherapyin
Sport,4(3),137151.
23. Ferreira,P.H.,Ferreira,M.L.,&Hodges,P.W.(2004).Changesinrecruitmentof
theabdominalmusclesinpeoplewithlowbackpain:Ultrasoundmeasurement
ofmuscleactivity.Spine,29(22),25602566.
24. Flynn,T.,Fritz,J.,Whitman,J.,Wainner,R.,Magel,J.,Rendeiro,D.,etal.(2002).
A clinical prediction rule for classifying patients with low back pain who
demonstrateshorttermimprovementwithspinalmanipulation.Spine,27(24),
28352843.
25. Foster,N.E.,Dziedzic,K.S.,VanDerWindt,D.A.W.D.,Fritz,J.M.,&Hay,E.M.
(2009). Research priorities for nonpharmacological therapies for common
musculoskeletal
problems:
Nationally
and
internationally
agreed
recommendations.BMCMusculoskeletalDisorders,10(3).
26. Fritz,J.M.(2009).Clinicalpredictionrulesinphysicaltherapy:Comingofage?.
JournalofOrthopaedic&SportsPhysicalTherapy,39(3),159161.
27. Fritz,J. M.,Cleland,J. A., &Childs,J. D.(2007).Subgrouping patientswithlow
backpain:Evolutionofaclassificationapproachtophysicaltherapy.Journalof
OrthopaedicandSportsPhysicalTherapy,37(6),290302.
32
28. Fritz,J.M.,Delitto,A.,&Erhard,R.E.(2003).Comparisonofclassificationbased
physicaltherapywiththerapybasedonclinicalpracticeguidelinesforpatients
withacutelowbackpain:Arandomizedclinicaltrial.Spine,28(13),13631371.
29. Grotle, M., Vllestad, N. K., Veierd, M. B., & Brox, J. I. (2004). FearAvoidance
beliefsanddistressinrelationtodisabilityinacuteandchroniclowbackpain.
Pain,112(3),343352.
30. Hall, H., McIntosh, G., & Boyle, C. (2009). Effectiveness of a low back pain
classificationsystem.TheSpineJournal,9(8),648657.
31. Hancock,M.J.,Maher,C.G.,Latimer,J.,Herbert,R.D.,&McAuley,J.H.(2008).
Independent evaluation of a clinical prediction rule for spinal manipulative
therapy:Arandomisedcontrolledtrial.EuropeanSpineJournal,17(7),936943.
32. Harringe,M.L.,Nordgren,J.S.,Arvidsson,I.,&Werner,S.(2007).Lowbackpain
in young female gymnasts and the effect of specific segmental muscle control
exercises of the lumbar spine: A prospective controlled intervention study.
KneeSurgery,SportsTraumatology,Arthroscopy,15(10),12641271.
33. Hayden, J. A., van Tulder, M. W., & Tomlinson, G. (2005). Systematic review:
Strategiesforusingexercisetherapytoimproveoutcomesinchroniclowback
pain.AnnalsofInternalMedicine,142(9),776785.
34. Hayden,J.A.,vanTulder,M.W.,Malmivaara,A.,&Koes,B.W.(2005).Exercise
therapy for treatment of nonspecific low back pain. Cochrane Database of
SystematicReviews,(3),CD000335.
35. Henchoz,Y.,&KaiLikSo,A.(2008).Exerciseandnonspecificlowbackpain:A
literaturereview.JointBoneSpine,75(5),533539.
36. Henschke, N., Maher, C. G., Refshauge, K. M., Das, A., & McAuley, J. H. (2007).
Lowbackpainresearchpriorities:Asurveyofprimarycarepractitioners.BMC
FamilyPractice,8(40).
33
37. Henschke, N., Maher, C. G., Refshauge, K. M., Herbert, R. D., Cumming, R. G.,
Bleasel,J.,etal.(2008).Prognosisinpatientswithrecentonsetlowbackpainin
australianprimarycare:Inceptioncohortstudy.BMJ,337,a171.
38. Hicks, G. E., Fritz, J. M., Delitto, A., & McGill, S. M. (2005). Preliminary
development of a clinical prediction rule for determining which patients with
low back pain will respond to a stabilization exercise program. Archives of
PhysicalMedicineandRehabilitation,86(9),17531762.
39. Hicks,G.E.,Fritz,J.M.,Delitto,A.,&Mishock,J.(2003).Interraterreliabilityof
clinical examination measures for identification of lumbar segmental
instability.ArchivesofPhysicalMedicineandRehabilitation,84(12),18581864.
40. Hodges, P. W., & Richardson, C. A. (1998). Delayed postural contraction of
transversusabdominisinlowbackpainassociatedwithmovementofthelower
limb.JournalofSpinalDisorders,11(1),4656.
41. Hodges,P.W.,&Richardson,C.A.(1999).Alteredtrunkmusclerecruitmentin
people with low back pain with upper limb movement at different speeds.
ArchivesofPhysicalMedicineandRehabilitation,80(9),10051012.
42. Hodges, P., Richardson, C., & Jull, G. (1996). Evaluation of the relationship
between laboratory and clinical tests of transversus abdominis function.
PhysiotherapyResearchInternational,1(1),3040.
43. HubleyKozey, C. L., & Vezina, M. J. (2002). Differentiating temporal
electromyographic waveforms between those with chronic low back pain and
healthycontrols.ClinicalBiomechanics,17(910),621629.
44. Hungerford, B., Gilleard, W., & Hodges, P. (2003). Evidence of altered
lumbopelvicmusclerecruitmentinthepresenceofsacroiliacjointpain.Spine,
28(14),15931600.
45. Hunter, J., Smith, B., & Gribbin, M. (2001). Physical symptoms and signs and
chronicpain.ClinicalJournalofPain,17(4suppl).
34
46. Ito, T., Shirado, O., Suzuki, H., Takahashi, M., Kaneda, K., & Strax, T. E. (1996).
Lumbar trunk muscle endurance testing: An inexpensive alternative to a
machine for evaluation. ArchivesofPhysicalMedicineandRehabilitation, 77(1),
7579.
47. Kent, P., & Keating, J. L. (2005). Classification in nonspecific low back pain:
What methods do primary care clinicians currently use?. Spine, 30(12), 1433
1440.
48. Kent,P.,&Keating,J.(2004).Doprimarycarecliniciansthinkthatnonspecific
lowbackpainisonecondition?.Spine,29(9),10221031.
49. Kent, P., Marks, D., Pearson, W., & Keating, J. (2005). Does clinician treatment
choiceimprovetheoutcomesofmanualtherapyfornonspecificlowbackpain?
Ametaanalysis.JManipulativePhysiolTher,28(5),312322.
50. Koes,B.W.,vanTulder,M.W.,Ostelo,R.,KimBurton,A.,&Waddell,G.(2001).
Clinical guidelines for the management of low back pain in primary care: An
internationalcomparison.Spine,26(22),25042513.
51. Koumantakis, G. A., Watson, P. J., & Oldham, J. A. (2005). Supplementation of
general endurance exercise with stabilisation training versus general exercise
only:Physiologicalandfunctionaloutcomesofarandomisedcontrolledtrialof
patientswithrecurrentlowbackpain.ClinicalBiomechanics,20(5),474482.
52. Latimer, J., Maher, C. G., Refshauge, K., & Colaco, I. (1999). The reliability and
validity of the BieringSorensen test in asymptomatic subjects and subjects
reporting current or previous nonspecific low back pain. Spine, 24(20), 2085
2089.
53. Laupacis,A.,Sekar,N.,&Stiell,I.G.(1997).Clinicalpredictionrules:Areview
and suggested modifications of methodological standards. Journal of the
AmericanMedicalAssociation,277(6),488494.
54. LeboeufYde, C., & Manniche, C. (2001). Low back pain: Time to get off the
treadmill.JournalofManipulativeandPhysiologicalTherapeutics,24(1),6366.
35
55. Luomajoki, H., Kool, J., de Bruin, E. D., & Airaksinen, O. (2007). Reliability of
movementcontroltestsinthelumbarspine. BMCMusculoskeletalDisorders,8,
90.
56. Luomajoki, H., Kool, J., de Bruin, E. D., & Airaksinen, O. (2008). Movement
controltestsofthelowback;evaluationofthedifferencebetweenpatientswith
lowbackpainandhealthycontrols.BMCMusculoskeletalDisorders,9,170.
57. Macedo,L.G.,Latimer,J.,Maher,C.G.,Hodges,P.W.,Nicholas,M.,Tonkin,L.,et
al.(2008).Motorcontrolorgradedactivityexercisesforchroniclowbackpain?
Arandomisedcontrolledtrial.BMCMusculoskeletalDisorders,9,65.
58. Mannion, A. F., Junge, A., Taimela, S., Mu?ntener, M., Lorenzo, K., & Dvorak, J.
(2001). Active therapy for chronic low back pain. Part 3. Factors influencing
selfrateddisabilityanditschangefollowingtherapy.Spine,26(8),920929.
59. May, S., & Johnson, R. (2008). Stabilisation exercises for low back pain: A
systematicreview.Physiotherapy,94(3),179189.
60. May,S.,&Rosedale,R.(2008).Prescriptiveclinicalpredictionrulesinbackpain
research: A systematic review. Journal of Manual and Manipulative Therapy,
17(1),3645.
61. May,S.,Littlewood,C.,&Bishop,A.(2006).Reliabilityofproceduresusedinthe
physical examination of nonspecific low back pain: A systematic review.
AustralianJournalofPhysiotherapy,52(2),91102.
62. McBeth, J., & Jones, K. (2007). Epidemiology of chronic musculoskeletal pain.
BestPractice&ResearchClinicalRheumatology,21(3),403425.
63. McBride,D.,Begg,D.,Herbison,P.,&Buckingham,K.(2004).Lowbackpainin
youngNewZealanders.NewZealandMedicalJournal,117(1203),U1099.
64. McGill, S. M., Childs, A., & Liebenson, C. (1999). Endurance times for low back
stabilization exercises: Clinical targets for testing and training from a normal
database.ArchivesofPhysicalMedicineandRehabilitation,80(8),941944.
36
65. McGinn,T.G.,Guyatt,G.H.,Wyer,P.C.,Naylor,C.D.,Stiell,I.G.,&Richardson,
W. S. (2000). Users' guides to the medical literature XXII: How to use articles
about clinical decision rules. Journal of the American Medical Association,
284(1),7984.
66. Menezes Costa, L., Maher, C. G., McAuley, J. H., Hancock, M. J., Herbert, R. D.,
Refshauge, K. M., et al. (2009). Prognosis for patients with chronic low back
pain:Inceptioncohortstudy.BMJ,339,b3829.
67. Miller,E.R.,Schenk,R.J.,Kames,J.L.,&Rousselle,J.G.(2005).Acomparisonof
themckenzieapproachtoaspecificspinestabilizationprogramforchroniclow
backpain.JournalofManualandManipulativeTherapy,13(2),103112.
68. O'Sullivan, P. (2005). Diagnosis and classification of chronic low back pain
disorders: Maladaptive movement and motor control impairments as
underlyingmechanism.ManualTherapy,10(4),242255.
69. Paalanne,N.,Korpelainen,R.,Taimela,S.,Remes,J.,Mutanen,P.,&Karppinen,J.
(2008).Isometrictrunkmusclestrengthandbodyswayinrelationtolowback
paininyoungadults.Spine,33(13),E435441.
70. Pengel,L.H.,Herbert,R.D.,Maher,C.G.,&Refshauge,K.M.(2003).Acutelow
backpain:Systematicreviewofitsprognosis.BMJ,327(7410),323.
71. Pincus,T.,Burton,A.K.,Vogel,S.,&Field,A.P.(2002).Asystematicreviewof
psychological factors as predictors of chronicity disability in prospective
cohortsoflowbackpain.Spine,27(5),E10920
72. Pincus,T.,Santos,R.,Breen,A.,Burton,A.K.,&Underwood,M.(2008).Areview
andproposalforacoresetoffactorsforprospectivecohortsinlowbackpain:
Aconsensusstatement.Arthritis&Rheumatism,59(1),1424.
73. RasmussenBarr,E.,Ang,B.,Arvidsson,I.,&NilssonWikmar,L.(2009).Graded
exercise for recurrent lowback pain: A randomized, controlled trial with 6,
12,and36monthfollowups.Spine,34(3),221228.
37
74. Reilly, B. M., & Evans, A. T. (2006). Translating clinical research into clinical
practice:Impactofusingpredictionrulestomakedecisions. AnnalsofInternal
Medicine.,144(3),201209.
75. Richardson, C., Hodges, P., & Hides, J. (2004). Therapeuticexerciseforlumbo
pelvicstabilisation.Edinburgh:ChurchillLivingstone.
76. Riddle,D.L.(1998).Classificationandlowbackpain:Areviewoftheliterature
andcriticalanalysisofselectedsystems.PhysicalTherapy,78(7),708737.
77. Rydeard, R., Leger, A., & Smith, D. (2006). PilatesBased therapeutic exercise:
Effect on subjects with nonspecific chronic low back pain and functional
disability: A randomized controlled trial. Journal of Orthopaedic & Sports
PhysicalTherapy,36(7),472484.
78. Schellenberg,K.L.,Lang,J.M.,Chan, K.M.,&Burnham,R.S.(2007).Aclinical
tool for office assessment of lumbar spine stabilization endurance: Prone and
supine bridge maneuvers. American Journal of Physical Medicine and
Rehabilitation,86(5),380386.
79. Stanton, T. R., Latimer, J., Maher, C. G., & Hancock, M. J. (2009). How do we
definethecondition'recurrentlowbackpain'?Asystematicreview.European
SpineJournal(inpress).
80. Stevens,V.K.,Coorevits,P.L.,Bouche,K.G.,Mahieu,N.N.,Vanderstraeten,G.G.,
& Danneels, L. A. (2007). The influence of specific training on trunk muscle
recruitmentpatternsinhealthysubjectsduringstabilizationexercises.Manual
Therapy,12(3),271279.
81. Stiell, I. G., Greenberg, G. H., McKnight, R. D., Nair, R. C., McDowell, I., &
Worthington,J.R.(1992).Astudytodevelopclinicaldecisionrulesfortheuse
of radiography in acute ankle injuries. Annals of Emergency Medicine, 21(4),
384390.
38
82. Teyhen, D. S., Flynn, T. W., Childs, J. D., & Abraham, L. D. (2007).
Arthrokinematics in a subgroup of patients likely to benefit from a lumbar
stabilizationexerciseprogram.PhysicalTherapy,87(3),313325.
83. Tsao, H., & Hodges, P. W. (2007). Immediate changes in feedforward postural
adjustments following voluntary motor training. ExperimentalBrainResearch,
181(4),537546.
84. Tsao, H., & Hodges, P. W. (2008). Persistence of improvements in postural
strategies following motor control training in people with recurrent low back
pain.JournalofElectromyographyandKinesiology,18(4),559567.
85. Tsao, H., Galea, M. P., & Hodges, P. W. (2008). Reorganization of the motor
cortex is associated with postural control deficits in recurrent low back pain.
Brain,131(8),21612171.
86. vanderHulst,M.,VollenbroekHutten,M.M.R.,GroothuisOudshoorn,K.G.M.,
&Hermens, H.J.(2008). Multidisciplinaryrehabilitationtreatment ofpatients
withchroniclowbackpain:Aprognosticmodelforitsoutcome.ClinicalJournal
ofPain,24(5),421430.
87. van Trijffel, E., Oostendorp, R. A., Lindeboom, R., Bossuyt, P. M., & Lucas, C.
(2008).Perceptionsanduseofpassiveintervertebralmotionassessmentofthe
spineAsurveyamongphysiotherapistsspecializinginmanualtherapy.Manual
Therapy14(3),243251.
88. vanTulder,M.W.,Koes,B.,&Malmivaara,A.(2006).Outcomeofnoninvasive
treatmentmodalitiesonbackpain:Anevidencebasedreview. EuropeanSpine
Journal,15Suppl1,S6481.
89. vonKorff,M.,&Saunders,K.(1996).Thecourseofbackpaininprimarycare.
Spine,21(24),28332837.
90. Waddell, G., Newton, M., Henderson, I., Somerville, D., & Main, C. J. (1993). A
fearavoidance beliefs questionnaire (FABQ) and the role of fearavoidance
beliefsinchroniclowbackpainanddisability.Pain,52(2),157168.
39
91. Walker,B.F.(2000).Theprevalenceoflowbackpain:Asystematicreviewof
theliteraturefrom1966to1998.JournalofSpinalDisorders,13(3),205217.
92. Walker, B. F., Muller, R., & Grant, W. D. (2004). Low back pain in australian
adults: Prevalence and associated disability. Journal of Manipulative and
PhysiologicalTherapeutics,27(4),238244.
93. Wisnivesky,J.P.,Serebrisky,D.,Moore,C.,Sacks,H.S.,Iannuzzi,M.C.,&McGinn,
T. (2005). Validity of clinical prediction rules for isolating inpatients with
suspected tuberculosis: A systematic review. Journal of General Internal
Medicine,20(10),947952.
40
Section2:Manuscript
Note:Thismanuscripthasbeenpreparedinaccordancewiththeinstructionsfor
authorsfortheJournalofBodyworkandMovementTherapies[seeAppendixH].
41
Predictorsoffunctionalimprovementin
peoplewithchroniclowbackpainfollowinga
gradedprogrammeofmovementcontrol
exercises
42
Predictorsoffunctionalimprovementin
peoplewithchroniclowbackpainfollowinga
gradedprogrammeofmovementcontrol
exercises
Author:
LeylaOkyay
Affiliation:
DepartmentofOsteopathy
UnitecNewZealand
PrivateBag92025
Auckland
NewZealand
Email:leyla.o@gmail.com
Contact:
Tel:+6498154321x8642
Fax:+6498154573
43
Abstract
Objectives.i)Todeterminepredictorsofchangeindisabilityofpeoplewithchronic
low back pain following a graded programme of movement control exercises and
ii) to develop a simple clinical rule that predicts outcome. Methods. Fiftyfive
people from a community sample with nonspecific chronic low back pain were
examined before undergoing a graded 6week programme of movement control
exercises. Predictors of change in disability, as measured by the PatientSpecific
FunctionalScale,wereidentifiedthroughregressionanalysisandusedtodevelopa
clinicalpredictionrule.Results.Clinicallyimportantimprovementindisabilitywas
predicted by four variables that explained 48% of the variance in outcome
(P<.001): gradual rather than sudden onset of low back pain, patientspecific
functionalscore<3.7points,absenceofaberrantmotionsonforwardbending,and
body mass index >24.5. Failure to show clinically meaningful improvement was
predicted by three variables that explained 40% of the variance in outcome
(P<.001):suddenonsetoflowbackpain,patientspecificfunctionalscore3.7,and
difference between left and right active straight leg raise >7. Conclusion. A
combination of five, easily measured variables are able to predict disability
outcome followingagradedprogrammeof movementcontrolexercises inpeople
withchroniclowbackpain.
44
Introduction
Backpainisverycommon.Uptotwothirdsofthepopulationareaffectedbylow
backpain(LBP)ina 1yearperiod(McBeth and Jones 2007).Whilemostpeople
show rapid improvement in pain and disability within the first month of
experiencingLBP,inabout10%ofcasesLBPbecomeschronic,persistingformore
than3months,and manymorewill continueto experiencerecurrent episodesof
painforatleastoneyear(Carey,GarrettandJackman2000;Pengeletal.2003).
45
OSullivan(2005)hasdistinguishedonepotentialsubgroupofchronicLBPpatients
that is characterized as demonstrating signs of motor control impairments.
Numerous studies give evidence to the presence of motor control impairment in
patientswithchronicandrecurrentLBP,withchangesintrunk muscleactivation
patterns(Hodges,RichardsonandJull1996;HodgesandRichardson1998;Hodges
and Richardson 1999; HubleyKozey and Vezina 2002; Tsao, Galea and Hodges
2008) and reorganisation of the brains motor cortex (Tsao et al 2008). There is
alsosomeevidencethatexercisetrainingmayinducechangesinthemotorcortex
(Adkinsetal.2006)andintherecruitmentpatternsoftrunkmuscles(Stevensetal.
2007;TsaoandHodges2008).Anumberofreviewshaveconcludedthatexercise
iseffectiveinreducingLBPrelateddisability(Hayden,vanTulderandTomlinson
2005;SladeandKeating2007;vanTulderetal.2000),butclarificationisneededto
determine which exercises bring the greatest benefits for subgroups of LBP
patients(BellandBurnett2009;HenchozandKaiLikSo2008).Theidentification
ofsubgroupsiscurrentlyanareareceivingconsiderableattentioninthebackpain
literatureandmayshedlightonthisquestion(Billis,McCarthyandOldham2007;
Delitto2005).
OnemethodofsubgroupidentificationthathasbecomepopularinLBPliteratureis
thedevelopmentofclinicalpredictionrules.Aclinicalpredictionrule(CPR)isaset
of variables that, when present, indicate the probability of occurrence of an
outcomeofinterest(Laupacis,SekarandStiell1997).TodevelopaCPR,anumber
of variables that are believed to be potential predictors of the outcome are
identified from the literature and measured before an intervention. Through
regression analysis, predictor variables for the selected outcome (e.g. disability)
areidentified.TheCPRisthengeneratedfromthesetofvariableswiththehighest
predictiveability.
46
The purpose of this study was to identify variables that predict clinically
meaningful changes in disability rating in patients with chronic nonspecific LBP
followingagradedprogrammeofmovementcontrolexercises.Inaddition,CPRsto
identifysubgroupsofpatientslikelytobenefit,ornotbenefitfromsuchanexercise
programmeweredevelopedbydeterminingasubsetofpredictorvariableswhich
maximisespecificityandsensitivityofasuccessfulorunsuccessfuloutcome.
47
Methods
Study sample
Participants were recruited from the local community through convenience
sampling in the form of advertising posters. All participants were required to be
between25and65yearsofagewithcurrentLBPofatleast6monthsdurationor
currentLBPoflessthan6monthsdurationwithrepeatedpainepisodesinthelast
year. Exclusion criteria were: known or suspected pregnancy; osteoporosis; any
signs of spinal pathology (e.g. tumour, infection, fracture); signs of nerve root
compression;historyofspinalorabdominalsurgerywithinthepreviousyear;any
contraindications to exercise; or any previous regular involvement in Pilates or
backexercise classes. Prior to enrolment all participants were informed of the
studyproceduresandgavewritteninformedconsent.Thestudywasapprovedby
theinstitutionalresearchethicscommittee.
Pre-intervention Assessments
One week before the intervention, LBPrelated disability was measured using the
PatientSpecificFunctionalScale(PSFS)(Stratfordetal.1995).ThePSFSrequires
patients to selfnominate three to five activities that are important to them, and
ratethemonan 11pointscale.Thescalehasbeenshowntobe ahighlyreliable
(ICC=.97) (Stratford et al. 1995) and responsive outcome measure (Pengel,
RefshaugeandMaher2004).ThePSFSrangesfrom0(unabletoperformactivity)
to 10 (able to perform activity at preinjury level). An average PSFS score of 6
wasrequiredforinclusioninthestudy.
Intheweekbeforetheinterventioncommenced,participantscompletedabooklet
ofquestionnairesandunderwentaphysicalassessmenttomeasurevariablesthat
were potential predictors of outcome. The measures included demographic and
anthropomorphic variables; characteristics of pain; activity interference, beliefs,
48
andreportedbehaviours;otherpsychosocialfactors;musculoskeletalexamination
findings; flexibility measures; movement control tests; and trunk muscle
endurance tests (see appendices A and B). Physical examination variables were
collected by an independent examiner. The exercise practitioner was blinded to
thescoresofthepredictorandoutcomevariables.
Outcome Assessment
The PSFS was again administered one week after completion of the intervention.
Animprovementof4.3pointsontheaveragescorehasbeenfoundtoequatetoa
large change on the global rating of change scale (a measure of the patients
perceptionofchange)(Stratfordetal.1995)andanimprovementof4pointswas
therefore used as an indicator of clinically important improvement (classified as
success). A change of 0.8 points correlates with a small change on the global
ratingofchangescale(Stratfordetal.1995).Asasmallchangewasnotconsidered
clinicallymeaningful,patientswithimprovementof1pointwereclassedasfailing
to respond (classified as failure). The term improvement is used to identify
participants who showed clinically meaningful improvement but not clinically
importantimprovement(changeinPSFSscoreof<4pointsbut>1point).
Intervention
Theprogrammeconsistedof12exerciseclassesof1hourduration,scheduledover
aperiodofsixweeks.Everyparticipantattendedonematclassandonereformer
classperweek.Thematclassisperformedwhilelyingsupineorsidelyingonthe
ground or in a 4point kneeling position and sometimes includes small props to
supportortochallengetheparticipantduringexercises.Thereformer(seeFigure
1)isaspringloadedcarriageonwhichtheparticipantlies,sitsorstands,thatcan
be used to provide either external resistance or assistance. The classes were
supervised by a trained Pilates instructor and conducted in groups of 27
49
participants for the reformer classes and 516 participants for the mat classes.
Catchup sessions were provided for any missed classes, ensuring a 100%
attendancerateforeveryparticipant.
The exercises were graded and were designed to improve body awareness and
movementcontrol.Theyprogressedfromawarenessofbreathingandcontraction
of pelvic floor and abdominal muscles, through to maintaining control of spinal
movement whilst performing dynamic tasks that involved leg and arm motion.
Other exercises encouraged spinal mobility and stretching of the hip and leg
muscles. More challenging exercises that incorporated control of the spine in
seated and standing positions were also practiced on the reformer in the latter
stages of the intervention. See Appendices C and D for an overview of the
exercises.
Data Analysis
Data were analysed using SPSS version 15 (SPSS Inc., Chicago IL). Potential
predictor variables were grouped into categories in order to assess univariate
relationships with the outcome variables (success, failure or PSFS change) and
with each other using Pearsons productmoment correlations. Variables with
significance levels of P<.10 when correlated with any one of the three outcome
measures were included. When two potential predictors from the same category
werefoundtobecorrelatedwitheachother(r>.30,P<.05),onlythevariablewith
thehigherunivariatecorrelationwithoneoftheoutcomevariableswaschosenfor
furtheranalysis.
Linear and logistic regression models were developed to identify variables that
predicted outcome. A stepwise multiple linear regression model was used to
identify determinants of change in PSFS score. Two logistic regression models
50
were also applied to determine predictors that increased the probability of
successandpredictorsthatincreasedtheprobabilityoffailure.Backwardentry
procedureswereusedfortheinitialregressionmodels(Pout<.05,Pin=.05)andeach
model was confirmed by rerunning the regression procedure with statistically
redundantdeterminantsremoved,usingastepwiseentryprocedure.
51
Results
Outof67participantswhowereinterviewed,55wereeligibleandabletocommit
to the class times. Five people failed to complete the study due to work
commitments(n=2),familyillness(n=1)andbecausetheclassesaggravatedtheir
pain (n=2). A further two data sets were unusable because participants had
significantly altered some questions. Therefore, data from 48 people, 32 (67%)
females and 16 males (33%), were included in the analyses. Their baseline
characteristicsareoutlinedinTable1.TheaveragePSFSscorewas3.51.3(mean
standard deviation) at baseline, and improved to 6.32.0 following the
intervention. According to the participants changes in PSFS score there were 14
successcases,16improvementcases,and18failurecasesclassified.
Regression models
Thepotentialpredictorswereenteredintologisticregression modelsforsuccess
and failure, and into the multiple linear regression model. There was no
interaction between these variables in the regression procedures. Variables
retained in the success model were: age (positive predictor); BMI (positive);
gradual mode of onset of LBP (positive); PSFS score (negative); and presence of
aberrant motions on forward bending (negative). Cumulatively, these explained
45%ofvarianceintheprobabilityofsuccess(P<.001).Variablesretainedinthe
failuremodelwere:age(negative);gradualmodeofonsetofLBP(negative);PSFS
52
score (positive); left/right active SLR difference (positive); and spinal extensor
muscleendurancetime(positive).Thesecumulativelyexplained44%ofvariance
in the probability of failure (P<.001). Five variables were also retained in the
multiple linear regression model: age (positive); gradual mode of onset of LBP
(positive); PSFS score (negative); presence of aberrant motions on forward
bending(negative);and spinalextensormuscleendurancetime(negative)(Table
2). These five variables cumulatively explained 52% of variance in PSFS change
(P<.001).
Using the dichotomized variables, two clinical prediction rules were constructed,
onetopredictsuccess,andonetopredictfailure.Accuracystatistics,likelihood
ratios and probability of outcome were calculated for each rule (Tables 4 and 5).
Theprobabilityofsuccessfortheentiresamplewas29%.Whenatleastthreeof
thefoursuccesspredictorswerepresent,theprobabilityof successincreasedto
53
73%,andwhenparticipantswerepositiveforallfourpredictors,theirprobability
of success was 82%. The probability of failure for the entire sample was 38%,
but when all three failure predictors were present, the probability of failure
increasedto80%.
54
Discussion
Prescriptive clinical prediction rules have received much attention in recent LBP
literatureandtheyarenowemergingforcommontreatmentmodalitiesforacute
LBP (May and Rosedale 2008). However, no equivalent rules yet exist for those
with chronic and recurrent LBP. This preliminary study investigated change in
disability in people with chronic LBP following a 6week movement control
exercise programme and identified five variables that were able to predict
outcome. These are: preintervention functional score; mode of onset of LBP;
aberrantmotionsonforwardbending;BMI;andadifferencebetweenleftandright
activeSLRrangeofmotion.Allofthesevariablesareeasilyandquicklyassessedin
a clinical setting, and in most cases already form part of a standard examination
procedure. High preintervention functional limitations, gradual onset of LBP,
absenceofaberrantmotionsonforwardbending,andhighBMIwerepredictorsof
successinshowingclinicallyimportantimprovementinfunctioning,whilelowpre
interventionfunctionallimitations,suddenonsetofLBP,andmoderatedifference
between the left and right leg active SLR predicted failure to show clinically
meaningful improvement. Participants who met the criteria of either one of the
two CPRs increased their chances of success or failure from less than 40% to
greaterthan80%.
Individual Predictors
ThesinglestrongestpredictorofoutcomewasthepreinterventionPSFSscore.A
low score, meaning high levels of disability, predicted success, while a higher
score, identifying lower levels of disability, predicted failure. This result was
unexpected,asahigherlevelofdisabilitywhenseekingcareisgenerallyseenasa
predictorofpoorprognosisforchronicLBPpatients(Costaetal.2009b).However,
thisisnotthefirsttimesucharesulthasbeenreported.Bendix(1998)determined
55
that patients who had greater limitations in activities of daily living at baseline,
showedgreaterimprovement,ofanunspecifiedmagnitude,followingafunctional
restoration program than those who had lower levels of limitation. A study by
Walshetal.(2002)suggeststhatpatientswhofavourabeliefinorganicconcepts
aboutpain(e.g.painistheresultoftissuedamage),asopposedtopsychological
concepts (e.g. anxiety makes pain worse), report higher levels of disability at
baseline and show a greater reduction in disability following a multidisciplinary
treatment programme. It is plausible that the present study included a similar
group of people with higher baseline disability and belief in organic concepts of
pain,whowerepositivelyinfluencedbytheintervention.Theactiveintervention,
whichemphasisescontrolofmovements,stretchingandstrengthening,islikelyto
be congruent with their belief system that a mechanical problem (e.g. weak
abdominalmuscles,poorposture etc.)canbeimprovedbyspecificexerciseswith
suchaims.
Mode of LBP onset was another consistent predictor of outcome. Gradual onset
predictedsuccess,whilesuddenonsetpredictedfailure.InacuteLBPpatients,a
history of sudden onset of LBP favours rapid recovery with general practitioner
care(Macfarlaneetal.1999).However,thesameconceptcannotbeextrapolated
to patients with chronic LBP. The present data suggest that there may be a
subgroupofpeoplewithsuddenonsetofLBPinwhompainpersistsfollowingan
exercise intervention, possibly as a result of undetected underlying pathology or
cognitivebehavioural factors that prevent recovery. The role of gradual onset of
LBP in predicting success remains unclear. While an association has been
identified between gradual LBP onset and psychological problems (Smedley et al.
2005), the impact of this intervention on psychological factors cannot be
determined.
56
Inthisstudy,theabsenceofaberrantmotionduringforwardbendingwasfoundto
be a predictor of clinically important improvement in disability, and a moderate
difference between the right and left leg active SLR was a predictor of failure.
Both tests have been hypothesised to measure ability to maintain appropriate
lumbopelvic control when performing movements (O'Sullivan 2000; O'Sullivan et
al.2002).AstudybyMoseleyandHodges(2005)concludesthatobservedmotor
control changes are a result of altered postural adjustments in response to pain.
Because the absence of altered lumbopelvic control predicted success and
asymmetrical control predicted failure following this intervention, it is likely that
the exercises did not effect changes in postural adjustment. The relatively brief
(sixweek) exercise programme undertaken here, may have provided insufficient
stimulus for change in a chronic pain population and it is also possible that the
interventiondidnotaddresstheunderlyingcausesofalteredmovementstrategies
like fear of pain (Hodges and Moseley 2003). In acute LBP, alterations in
adjustment have occurred recently and may be more responsive to improvement
byspecificexercise,explainingthecontrastingresultsbyHicksetal.(2005).They
reported that the presence of aberrant motions on forward bending predicted
successandtheirabsencepredictedfailuretoshowimprovementindisabilityinan
acuteLBPpopulationfollowingstabilizationexercises.
Higher BMI was associated with improvement in function following the exercise
interventioninthisstudy.Apreviousstudy(Mangwanietal.2010)examiningthe
influence of BMI on change in disability following an imprecisely described
physiotherapy intervention demonstrated no significant association. However,
obesity and chronic LBP may be comorbid conditions that share similar risk
factors, such as inactivity (Shirei et al. 2010) and low selfefficacy beliefs (Annesi
2010; Main et al 2010). The current intervention may have positively influenced
57
overweight participants by providing manageable amounts of exercise that might
haveimprovedtheirmood,selfefficacy,andselfconcept(Annesi2010).Thesame
factorshavebeenlinkedtorecoveryfromLBP(Mainetal.2010).Annesi(2010)
suggests that people with higher bodyweights show greater benefits from a
manageable lowintensity exercise programme than others, because they begin
withalowerperceptionoftheirselfefficacyandphysicalcompetencies.
Non-predictors
A large number of variables included for analysis were not retained in the final
clinicalpredictionrules.Notablytheseincluded:age;gender;durationofLBP;LBP
intensity; various musculoskeletal examination findings; endurance tests; and
numerous psychological factors. The first four variables as nonpredictors are
consistentwithfindingsbyDenisonetal.(2004),whofoundthatage,genderand
LBP duration were not related to disability, and pain intensity only explained a
small proportion of the variance in disability ratings. Previous investigators
(Ferreira et al. 2009) have also reported that spinal stiffness holds no value in
predictingdisabilityfollowinggeneralormotorcontrolexercises,findingsthatare
consistent with the results of this study. The conclusions of studies investigating
trunk muscle endurance in relation to disability are contradictory. Evans (2005)
foundonesidedlateralmuscleendurancedeficitstobepredictorsofrecurrentLBP
ingolfersandEnthoven(2003)foundthatextensormuscleendurancetimesat4
weeks, but not at baseline, predicted disability at 12 months when no specific
treatmentwasgiven.Ontheotherhand,Mannionetal.(2001)foundthatextensor
muscle endurance times were not predictive of disability levels with one of three
activetherapies,andtheendurancetestsdidnotappearinaCPRforstabilization
exercisesinanacuteLBPpopulation(Hicksetal.2005).Thereforeitappearsthat,
in a normal LBP population, endurance tests at baseline are not predictors of
disabilityfollowingactiveinterventions.
58
On the other hand, psychological factors such as fear of pain and movement,
catastrophizing, distress and depression have been found to play a strong role in
the development and maintenance of LBPrelated disability (Burton et al. 2004;
Leeuw et al. 2007; Main, Foster and Buchbinder 2010; Picavet, Vlaeyen and
Schouten2002).Thereforeitisunexpectedthatnoneofthesevariablespredicted
changeindisabilityfollowinganexerciseintervention.Ifactivetreatmentshavean
effectonfearavoidancebeliefsandpsychologicaldistress,asMannionetal.(2001)
suggest, then it is possible that their status at baseline may not predict outcome
followingtheinterventioniftheychangeinproportiontothechangeindisability.
One consistent shortcoming of CPR development studies for LBP is the small
samplesize.Tenparticipantsperprospectivepredictoraregenerallysuggestedfor
regression procedures (Peduzzi et al. 1996). While these sample size
59
recommendations have been followed for validation studies in LBP research
(Brennan et al. 2006; Childs et al. 2004), derivation studies where a distinct
treatment method was examined, have fallen short of this ratio, with 5471
participants(Flynnetal2002;Fritzetal2004;Fritzetal2007;Hicksetal.2005).
However, these sample size recommendations may be even more important for
derivation studies in order to have sufficient statistical power to identify all
potentiallyrelevantpredictorsandavoidpredictorsenteringtherulebychance,as
well as avoiding association of variables in the wrong direction (Peduzzi et al.
1996).Basedonnineunivariatepredictorsenteredintotheregressionmodels,the
present study with 48 participants fell short of the recommended number of 90
participants. However, a second regression procedure was undertaken with only
five dichotomized variables, which is very close to the recommended ratio of
variablestoparticipant.Thisstepallowsgreaterconfidenceinthepredictorsthat
havebeenincludedintherule.
Generalizability
Participants inthestudy selfselectedtotakepartandonly thosewhocompleted
the intervention were included in the regression analyses. Therefore, the
applicabilityofthederivedCPRsisrestrictedtopatientswhowillactuallycomplete
an exercise programme. Patient preference for a particular treatment may affect
outcome(Main,FosterandBuchbinder2010)andthismayaccountforthegreater
changesinPSFSscoreobservedinthisstudycomparedtoasimilarinterventionby
Costa (2009a). Further, adherence rates are commonly poor in exercise
interventions(Jacketal.2010)anditisimportanttoidentify,inadvance,whether
patients are likely to complete the programme. Questionnaires that can predict
compliance, such as one developed by Howard and Gosling (2008), may allow
practitioners to make informed decisions with regard to recommending exercise
programmes.
60
Further research
It should be noted that the developed clinical prediction rules are not yet
appropriate for use in a clinical setting. Validation studies, and ideally impact
studies, need to be conducted to determine the true value of these rules (Beattie
andNelson2006).Itwouldalsobeusefultoredeveloptherulesbyincludingthe
mostsignificantandsensiblepredictorsfromthisstudy,identifyingandincluding
furtherpotentialpredictors,andthendeterminingwhichpredictorsareusefulina
different population with an intentiontotreat protocol. Medium (312 months)
andlongterm(>12months)outcomesshouldalsobeassessed.
61
Conclusions
Twoclinicalpredictionruleswithmoderatepredictiveabilityweredevelopedfora
chronic LBP population following a graded programme of movement control
exercises.Therulesshowedthatacombinationofhighdisabilitylevels,historyof
gradual onset of low back pain, absence of aberrant motions on forward bending
and higher BMI score is best able to predict clinically important improvement in
disability,whilelowlevelsof disability,historyofsuddenonset oflowbackpain,
anddifferencesbetweenleftandrightactivestraightlegraisemaypredictfailure
to show clinically meaningful improvement. Followup studies are required to
confirmtheseresultsinawiderpopulationandoveralongerfollowupperiod.
62
References
1. AdkinsDAL,BoychukJ,RempleMS,andKleimJA.2006.Motortraininginduces
experiencespecificpatternsofplasticityacrossmotorcortexandspinalcord.J
ApplPhysiol101,17761782.
2. AnnesiJJ.2010.DoseResponseandselfefficacyeffectsofanexerciseprogram
onvigorchangeinobesewomen.AmJMedSci339,127132.
3. BeattiePandNelsonR.2006.Clinicalpredictionrules:Whataretheyandwhat
dotheytellus?AustJPhysiother52,157163.
4. Bell JA and Burnett A. 2009. Exercise for the primary, secondary and tertiary
prevention of low back pain in the workplace: A systematic review. J Occup
Rehabil19,824.
5. BendixAF,BendixT,andHaestrupC.1998.Canitbepredictedwhichpatients
with chronic low back pain should be offered tertiary rehabilitation in a
functionalrestorationprogram?:Asearchfordemographic,socioeconomic,and
physicalpredictors.Spine23,17751784.
6. BillisEV,McCarthyCJ,andOldhamJA.2007.Subclassificationoflowbackpain:
Acrosscountrycomparison.EurSpineJ16,865879.
7. BogdukN.2006.Psychologyandlowbackpain.IntJOsteopathMed9,4953.
8. BogdukN.2004.Managementofchroniclowbackpain.MedJAust180,7983.
9. Bouter LM, van Tulder MW, and Koes BW. 1998. Methodologic issues in low
backpainresearchinprimarycare.Spine23,20142020.
10. BrennanGP,FritzJM,HunterSJ,ThackerayA,DelittoA,andErhardRE.2006.
Identifyingsubgroupsofpatientswithacute/subacute"nonspecific"lowback
pain:Resultsofarandomizedclinicaltrial.Spine31,623631.
63
11. BurtonAK,McCluneTD,ClarkeRD,andMainCJ.2004.LongTermfollowupof
patients with low back pain attending for manipulative care: Outcomes and
predictors.ManTher9,3035.
12. Carey TS, Garrett JM, and Jackman AM. 2000. Beyond the good prognosis.
Examination of an inception cohort of patients with chronic low back pain.
Spine25,115120.
13. ChildsJD,FritzJM,FlynnTW,IrrgangJJ,JohnsonKK,MajkowskiGR,andDelitto
A.2004.Aclinicalpredictionruletoidentifypatientswithlowbackpainmost
likelytobenefitfromspinalmanipulation:Avalidationstudy.AnnInternMed
141,920928.
14. CookCE.2008.Potentialpitfallsofclinicalpredictionrules.JManManipTher
16,6971.
15. Costa LOP, Maher CG, Latimer J, Hodges PW, Herbert RD, Refshauge KM,
McAuley JM, and Jennings MD. 2009a. Motor control exercise for chronic low
backpain:Arandomizedplacebocontrolledtrial.PhysTher89,12751286.
16. CostaLCM,MaherCG,McAuleyJH,HancockMJ,HerbertRD,RefshaugeKM,and
Henschke N. 2009b. Prognosis for patients with chronic low back pain:
Inceptioncohortstudy.BMJ339:b3829.
17. Davidson M and Keating JL. 2002. A comparison of five low back disability
questionnaires:Reliabilityandresponsiveness.PhysTher82,824.
18. Delitto A. 2005. Research in low back pain: Time to stop seeking the elusive
"magicbullet".PhysTher85,206208.
19. Delitto A, Erhard RE, and Bowling RW. 1995. A treatmentbased classification
approach to low back syndrome: Identifying and staging patients for
conservativetreatment.PhysTher75,470489.
20. Denison E, Asenlf P, and Lindberg P. 2004. SelfEfficacy, fear avoidance, and
pain intensity as predictors of disability in subacute and chronic
musculoskeletalpainpatientsinprimaryhealthcare.Pain111,245252.
64
21. EnthovenP,SkargrenE,KjellmanG,andObergB.2003.Courseofbackpainin
primarycare:Aprospectivestudyofphysicalmeasures.JRehabilMed35,168
173.
22. EvansK,RefshaugeKM,AdamsR,andAliprandiL.2005.Predictorsoflowback
paininyoungelitegolfers:Apreliminarystudy.PhysTherSport6,122130.
23. Farrar JT, Young JP, LaMoreaux L, Werth JL, and Poole RM. 2001. Clinical
importance of changes in chronic pain intensity measured on an 11point
numericalpainratingscale.Pain94,149158.
24. Ferreira ML, Ferreira PH, Latimer J, Herbert RD, Maher C, and Refshauge K.
2009. Relationship between spinal stiffness and outcome in patients with
chroniclowbackpain.ManTher14,6167.
25. FlynnT,FritzJ,WhitmanJ,WainnerR,MagelJ,RendeiroD,ButlerB,GarberM,
andAllisonS.2002.Aclinical predictionruleforclassifyingpatientswithlow
backpainwhodemonstrateshorttermimprovementwithspinalmanipulation.
Spine27,28352843.
26. Fritz JM, Childs JD, and Flynn TW. 2005. Pragmatic application of a clinical
predictionruleinprimarycaretoidentifypatients with low back pain with a
good prognosis following a brief spinal manipulation intervention. BMC Fam
Pract6,29.
27. FritzJM,LindsayW,MathesonJW,BrennanGP,HunterSJ,MoffitSD,Swalberg
A, and Rodriquez B. 2007. Is there a subgroup of patients with low back pain
likelytobenefitfrommechanicaltraction?Resultsofarandomizedclinicaltrial
andsubgroupinganalysis.Spine32,E793800.
28. Fritz JM, Whitman JM, Flynn TW, Wainner RS, and Childs JD. 2004. Factors
related to the inability of individuals with low back pain to improve with a
spinalmanipulation.PhysTher84,17390.
65
29. Hayden JA, van Tulder MW, and Tomlinson G. 2005. Systematic review:
Strategiesforusingexercisetherapytoimproveoutcomesinchroniclowback
pain.AnnInternMed142,776785.
30. Henchoz Y and So AKL. 2008. Exercise and nonspecific low back pain: A
literaturereview.JointBoneSpine75,533539.
31. Hicks GE, Fritz JM, Delitto A, and Mishock J. 2003. Interrater reliability of
clinical examination measures for identification of lumbar segmental
instability.ArchPhysMedRehabil84,18581864.
32. HicksGE,FritzJM,DelittoA,andMcGillSM.2005.Preliminarydevelopmentofa
clinicalpredictionrulefordeterminingwhichpatientswithlowbackpainwill
respondtoastabilizationexerciseprogram.ArchPhysMedRehabil86,1753
1762.
33. Hodges PW and Richardson CA. 1998. Delayed postural contraction of
transversusabdominisinlowbackpainassociatedwithmovementofthelower
limb.JSpinalDisord11,4656.
34. Hodges PW and Richardson CA. 1999. Altered trunk muscle recruitment in
peoplewithlowbackpainwithupperlimbmovementatdifferentspeeds.Arch
PhysMedRehabil80,10051012.
35. Hodges PW, Richardson CA, and Jull G. 1996. Evaluation of the relationship
between laboratory and clinical tests of transversus abdominis function.
PhysiotherResInt1,3040.
36. HodgesPWandMoseleyGL.2003.Painandmotorcontrolofthelumbopelvic
region:Effectandpossiblemechanisms.JElectromyogrKinesiol13,361370.
37. Howard DB and Gosling CMR. 2008. A short questionnaire to identify patient
characteristics indicating improved compliance to exercise rehabilitation
programs:Apilotinvestigation.IntJOsteopathMed11,715.
66
38. HubleyKozey CL and Vezina MJ. 2002. Differentiating temporal
electromyographic waveforms between those with chronic low back pain and
healthycontrols.ClinicalBiomechanics17,621629.
39. ItoT,ShiradoO,SuzukiH,TakahashiM,KanedaK,andStraxTE.1996.Lumbar
trunk muscle endurance testing: An inexpensive alternative to a machine for
evaluation.ArchPhysMedRehabil77,7579.
40. Jack K, McLean SM, Moffett JK, and Gardiner E. 2010. Barriers to treatment
adherenceinphysiotherapyoutpatientclinics:Asystematicreview.ManTher
15,220228.
41. Kerns R, Turk D, and Rudy T. 1985. The West HavenYale multidimensional
paininventory(WHYMPI).Pain23,345356.
42. Lam IE, Peters ML, Kessels AG, Van Kleef M, and Patijn J. 2008. TestRetest
stabilityofthepaincatastrophizingscaleandthetampascaleforkinesiophobia
inchronicpainoveralongerperiodoftime.JHealthPsychol13,820826.
43. LaupacisA,SekarN,andStiellIG.1997.Clinicalpredictionrules:Areviewand
suggestedmodificationsofmethodologicalstandards.JAMA277,488494.
44. LeeuwM,HoubenRMA,SevereijnsR,PicavetHSJ,SchoutenEGW,andVlaeyen
JWS. 2007. PainRelated fear in low back pain: A prospective study in the
generalpopulation.EurJPain11,256266.
45. Levangie,PK.1999.Theassociationbetweenstaticpelvicasymmetryandlow
backpain.Spine24,12341242.
46. Luomajoki H, Kool J, de Bruin ED, and Airaksinen O. 2007. Reliability of
movementcontroltestsinthelumbarspine.BMCMusculoskeletDisord8:90.
47. Macfarlane GJ, Thomas E, Croft PR, Papageorgiou AC, Jayson MIV, and Silman
AJ.1999.Predictorsofearlyimprovementinlowbackpainamongstconsulters
to general practice: The influence of premorbid and episoderelated factors.
Pain80,113119.
67
48. MaherC.2006.Clinicalpredictionrules[3].PhysTher86,759.
49. MainCJ,FosterN,andBuchbinderR.2010.Howimportantarebackpainbeliefs
andexpectationsforsatisfactoryrecoveryfrombackpain?BestPractResClin
Rheumatol24,205217.
50. MangwaniJ,GilesC,MullinsM,SalihT,andNataliC.2010.Obesityandrecovery
fromlowbackpain:Aprospectivestudytoinvestigatetheeffectofbodymass
indexonrecoveryfromlowbackpain.AnnRCollSurgEngl92,2326.
51. MannionAF,JungeA,TaimelaS,MuentenerM,LorenzoK,andDvorakJ.2001.
Activetherapyforchroniclowbackpain.Part3.Factorsinfluencingselfrated
disabilityanditschangefollowingtherapy.Spine26,920929.
52. MaySandRosedaleR.2008.Prescriptiveclinicalpredictionrulesinbackpain
research:Asystematicreview..JManManipTher17,3645.
53. McBethJandJonesK.2007.Epidemiologyofchronicmusculoskeletalpain.Best
Practice&ResearchClinicalRheumatology21,403425.
54. McGill SM, Childs A, and Liebenson C. 1999. Endurance times for low back
stabilization exercises: Clinical targets for testing and training from a normal
database.ArchPhysMedRehabil80,941944.
55. Moseley GL and Hodges PW. 2005. Are the changes in postural control
associatedwithlowbackpaincausedbypaininterference?ClinJPain21,323
329.
56. O'Sullivan PB. 2000. Lumbar segmental 'instability': Clinical presentation and
specificstabilizingexercisemanagement.ManTher5,212.
57. O'Sullivan PB, Beales DJ, Beetham JA, Cripps J, Graf F, Lin IB, Tucker B, and
AveryA.2002.Alteredmotorcontrolstrategiesinsubjectswithsacroiliacjoint
painduringtheactivestraightlegraisetest.Spine27,E18.
68
58. O'Sullivan PB. 2005. Diagnosis and classification of chronic low back pain
disorders: Maladaptive movement and motor control impairments as
underlyingmechanism.ManTher10,242255.
59. Parsons S, Carnes D, Pincus T, Foster N, Breen A, Vogel S, and Underwood M.
2006. Measuring troublesomeness of chronic pain by location. BMC
MusculoskeletDisord7,34.
60. Peduzzi P, Concato J, Kemper E, Holford TR, and Feinstein AR. 1996. A
simulation study of the number of events per variable in logistic regression
analysis.JClinEpidemiol49,13731379.
61. Pengel LH, Refshauge KM, and Maher CG. 2004. Responsiveness of pain,
disability, and physical impairment outcomes in patients with low back pain.
Spine29,87983.
62. Pengel LH, Herbert RD, Maher CG, and Refshauge KM. 2003. Acute low back
pain:Systematicreviewofitsprognosis.BMJ327,323.
63. Perret C, Poiraudeau S, Fermanian F, Colau MM, Benhamou MA, and Revel M.
2001.Validity,reliability,andresponsivenessofthefingertiptofloortest.Arch
PhysMedRehabil82,15661570.
64. Picavet HS, Vlaeyen JW, and Schouten J. 2002. Pain catastrophizing and
kinesiophobia:Predictorsofchroniclowbackpain.AmJEpidemiol156,1028
1034.
65. PincusT,SantosR,BreenA,BurtonAK,andUnderwoodM.2008.Areviewand
proposal for a core set of factors for prospective cohorts in low back pain: A
consensusstatement.ArthritisRheum59,1424.
66. RadloffLS.1977.TheCESDscale:Aselfreportdepressionscaleforresearchin
thegeneralpopulation.AppliedPsychologicalMeasurement1,385401.
67. RousselNA,NijsJ,TruijenS,SmeuninxL,andStassijnsG.2007.Lowbackpain:
Clinimetric properties of the Trendelenburg test, active straight leg raise test,
69
andbreathingpatternduringactivestraightlegraising.JManipulativePhysiol
Ther30,270278.
68. ShiriR,KarppinenJ,LeinoArjasP,SolovievaS,andViikariJunturaE.2010.The
association between obesity and low back pain: A metaanalysis. Am J
Epidemiol171,135154.
69. Slade SC and Keating JL. 2007. Unloaded movement facilitation exercise
compared to no exercise or alternative therapy on outcomes for people with
nonspecificchroniclowbackpain:Asystematicreview.JManipulativePhysiol
Ther30,301311.
70. SmedleyJ,InskipH,BuckleP,CooperC,andCoggonD.2005.Epidemiological
differences between back pain of sudden and gradual onset. J Rheumatol 32,
528532.
71. Stevens VK, Coorevits PL, Bouche KG, Mahieu NN, Vanderstraeten GG, and
Danneels LA. 2007. The influence of specific training on trunk muscle
recruitment patterns in healthy subjects during stabilization exercises. Man
Ther12,271279.
72. Stratford P, Gill C, Westaway M, and Binkley J. 1995. Assessing disability and
change on individual patients: A report of a patient specific measure.
PhysiotherCan47,258263.
73. TousignantM,PoulinL,MarchandS,ViauA,andPlaceC.2005. Themodified
modified schober test for range of motion assessment of lumbar flexion in
patientswithlowbackpain:Astudyofcriterionvalidity,intraandinterrater
reliabilityandminimummetricallydetectablechange.DisabilRehabil27,553
559.
74. TsaoH,GaleaMP,andHodgesPW.2008.Reorganizationofthemotorcortexis
associatedwithposturalcontroldeficitsinrecurrentlowbackpain.Brain131,
21612171.
70
75. Tsao H and Hodges PW. 2008. Persistence of improvements in postural
strategies following motor control training in people with recurrent low back
pain.JElectromyogrKinesiol18,559567.
76. Van Dillen LR, Sahrmann SA, Norton BJ, Caldwell CA, Fleming DA, McDonnell
MK,andWoolseyNB.1998.Reliabilityofphysicalexaminationitemsusedfor
classificationofpatientswithlowbackpain.PhysTher78,979988.
77. vanTulderM,MalmivaaraA,EsmailR,andKoesB.2000.Exercisetherapyfor
low back pain: A systematic review within the framework of the cochrane
collaborationbackreviewgroup.Spine25,27842796.
78. van Tulder MW, Koes B, and Malmivaara A. 2006. Outcome of noninvasive
treatmentmodalitiesonbackpain:Anevidencebasedreview.EurSpineJ15,
S6481.
79. Waddell G, Newton M, Henderson I, Somerville D, and Main CJ. 1993. A fear
avoidance beliefs questionnaire (FABQ) and the role of fearavoidance beliefs
inchroniclowbackpainanddisability.Pain52,157168.
80. WalshDAandRadcliffeJC.2002.Painbeliefsandperceivedphysicaldisability
ofpatientswithchroniclowbackpain.Pain97,2331.
81. WobySR,UrmstonM,andWatsonPJ.2007.SelfEfficacymediatestherelation
betweenpainrelatedfearandoutcomeinchroniclowbackpainpatients.EurJ
Pain11,711718.
71
All subjects
(n=48)
Success
with
treatment
(n=14)
Improvement
with
treatment
(n=16)
Failure
with
treatment
(n=18)
P
value
Age
41 11
45 11
42 12
38 8
.27
.07
BMI
26.4 4.7
28.2 5.7
24.9 4.5
26.3 3.8
.25
.09
35%
64%
31%
17%
.38
.01
29%
7%
31%
44%
-.31
.03
Fear-avoidance beliefs
about work
14 12
16 11
18 14
10 8
.31
.03
3.5 1.3
2.9 0.9
3.3 1.3
4.3 1.2
.47
<.01
Increased segmental
mobility (% present)
40%
21%
44%
50%
-.36
.01
42%
21%
62%
39%
-.26
.07
55
44
33
77
-.27
.06
126 61
108 59
125 + 67
141 56
-.31
.03
49 34
38 26
45 34
61 39
-.25
.08
Success = improvement in PSFS score by 4 points; Improvement = improvement in PSFS score by 2-3
72
Table 2. Predictors retained in the multiple linear regression model for PSFS
change
B
SE B
-0.64**
0.20
-.37
1.51**
0.53
.33
-1.14*
0.52
-.25
Age
0.07**
0.02
.33
-0.01*
0.00
-.29
(Constant)
3.42*
1.32
Variable
73
SE B
3.95**
1.40
2.98*
1.23
BMI >24.5
3.09**
1.33
2.02
1.05
-8.15**
2.44
(Constant)
0.83
1.79
0.91
1.73*
0.88
-3.59**
1.09
(Constant)
2.54**
74
Sensitivity
Specificity
Positive
LR
Probability of
success
Variables: Gradual onset of LBP, no aberrant motions on forward bending, PSFS functional score
<3.7, BMI >24.5
All 4 variables present
.31*
.97*
11.25*
82%
At least 3
.79
.88
6.68
73%
At least 2
1.00
.35
1.55
39%
At least 1
1.00
.06
1.06
30%
Note: Probability of success for all participants was 29% *value of 1 added to all cells used to calculate this
value to avoid division by zero error
LR = likelihood ratio; LBP = low back pain; PSFS = Patient-Specific Functional Score; BMI = body mass index
75
Sensitivity
Specificity
Positive
LR
Probability of
Failure
Variables: Sudden onset of LBP, PSFS functional score >3.7, Active SLR difference >7
All 3 variables
.22
.97
6.67
80%
At least 2
.83
.80
4.17
72%
At least 1
1.00
.30
1.43
46%
76
The Reformer is a spring-loaded carriage that can be used to provide assistance or resistance during
exercises.
77
Appendix A
Variable
Explanation
Measurement Tool
Reliability
single question
Gender
male or female
single question
weight(kg)/height(m)2
Education Level
As recommended by
Pincus et al. (2008)
Work Status
As recommended by
Pincus et al. 2008)
LBP intensity
11-point numeric
rating scale (Farrar et
al. 2001)
11-point numeric
rating scale (Farrar et
al. 2001)
Mode of onset of
LBP*
gradual or sudden
verbal history
History of traumatic
onset of LBP*
yes or no
verbal history
Duration of LBP
verbal history
Failure of multiple
treatments
verbal history
Troublesomeness of
LBP
Troublesomeness
Questionnaire
(Parsons et al. 2006)
ICC=.59-.91
Characteristics of pain
Fear-avoidance
Beliefs Questionnaire
(Waddell et al. 1993)
=.74
Fear-avoidance
beliefs about work*
Fear-avoidance
Beliefs Questionnaire
(Waddell et al. 1993)
=.74
Work satisfaction
As recommended by
Pincus et al. (2008)
78
Disability as a result
of LBP
Oswestry Disability
Questionnaire
(Davidson and
Keating 2002)
ICC=.80
Patient-specific
disability rating*
Patient-Specific
Functional Scale
(Stratford et al. 1995)
ICC=.97
Involvement in
leisure activities
West Haven-Yale
Multidimensional Pain
Inventory (WHYMPI)
(Kerns, Turk and
Rudy 1985)
r=.83-.91
Pain interference
WHYMPI (Kerns,
Turk and Rudy 1985)
r=.86
Pain Catastrophizing
Scale (Lam et al.
2008)
ICC=.73
Depression
r=.57
Questionnaire subscale
r=.68
Affective distress
Questionnaire subscale
r=.69
Troublesomeness of
body pains
Troublesomeness
Questionnaire (Parsons
et al. 2006)
ICC=.59-.91
Interpersonal Issues
Questionnaire subscale
r=.62-.91
Note: * Significant (P<0.10) univariate predictor, Predictor in the clinical prediction rules, LBP = low back pain
79
Appendix B
Variable
Explanation
Measurement
Tool
Reliability
Supine leg
length
discrepancy
measurement
(Levangie 1999)
ICC=.71
Lumbar spine
flexion
Modifiedmodified
Schober test
(Tousignant et
al. 2005)
ICC=.91
Increased*
and/or
decreased
mobility on
posterioranterior
segmental
mobility
assessment
PA mobility
testing (Fritz,
Childs and Flynn
2005; Hicks et
al. 2003)
hypermobility
=.30-.48
Lumbar
segmental
instability
Prone Instability
Test (Fritz,
Childs and Flynn
2005; Hicks et
al. 2003)
=.69-.87
Passive straight
leg raise
difference
Digital
inclinometer
(Fritz, Childs
and Flynn 2005)
ICC=.70
Forward
bending
flexibility
Fingertip-to floor
test (Perret et al.
2001)
ICC=.99
General
ligamentous
laxity
Beightons
Ligamentous
Laxity Scale
(Fritz, Childs
and Flynn 2005;
Hicks et al.
2003)
ICC=.72.78
hypomobility
=.18-.38
Flexibility
80
Average
passive straight
leg raise
(Fritz, Childs
and Flynn 2005)
ICC=.70
Aberrant
Motions Test
(Hicks et al.
2003)
=.60
Movement
control
Movement
control tests
(Luomajoki et al.
2007; van Dillen
et al. 1998)
=.43-.78
Active straight
leg raise
difference*
Digital
inclinometer
=.70
Pain on active
straight leg
raise
Modification of
test by Roussel
et al. (2007)
Modified
BieringSorenson Test
(Ito et al. 1996)
r=0.93-.95
Trunk flexor
muscle
endurance
Modified McGill
flexion
endurance test
(McGill, Childs
and Liebenson
1999)
r=.93-.97
Average lateral
trunk muscle
endurance*
r=.96-.99
Lateral
endurance
difference
Ratio of lateral
endurance over
extensor
endurance
Note: * Significant (P<0.10) univariate predictor, Predictor in the clinical prediction rules
81
Appendix C
82
App
pendix D
83
Section3:Appendices
84
85
86
87
INFORM
MATION SH
HEET
88
You have had any of the following in the last 12 months: a spinal fracture, spinal tumour,
spinal infection, surgery to your spine, or abdominal surgery
As many of the questions are of a personal nature we ask that you do not write your name
anywhere on the questionnaire. This is important to protect your anonymity.
You will be given an ID number on enrolment in the study, which is printed on the questionnaires.
This is so that we can compare your pain measurement at the beginning and end of the pilates
programme with your answers to the questions. Your name, or any other information that could
identify you, will be stored separately.
Once the reseach has been completed, your name and your questionnaire number will be deleted
from all records so that you cannot be identified. All computer records will only be accessible by
passwords held by the researchers. All hard copies will be stored in a locked file, accessible only
by the researchers.
Information gathered during this research will be held for 5 years before being destroyed.
You have the right to withdraw your data from this research project at any time within 1 week of
your final data collection (1 week after the final interview). This can be done by contacting one of
the researchers listed below.
A summary of the final report of the study will be available to you if you are interested.
Information and concerns
If you require any further information about the project please contact us by phone or email:
Claire OBrien
Leyla Okyay
Rob Moran
Mob.: 021 55 84 55
pilates.research@gmail.com
pilates.research@gmail.com
rmoran@unitec.ac.nz
Finally, we would like to thank you for your interest in contributing to this research project.
URECREGISTRATIONNUMBER:2009923
ThisstudyhasbeenapprovedbytheUNITECResearchEthicsCommitteefrom3rdApril2009to2nd
April2010.Ifyouhaveanycomplaintsorreservationsabouttheethicalconductofthisresearch,
youmaycontacttheCommitteethroughtheSecretary(ph:098154321ext7248).Anyissuesyou
raisewillbetreatedinconfidenceandinvestigatedfully,andyouwillbeinformedoftheoutcome.
89
90
TELE
EPHONESC
CREENINGQ
QUESTION
NS
Hi, Who
W am I speeaking with? Name
N
A
Age?
Do you
y currently have
h
LBP? Yees go to Q4
2.
3.
How
w long did it laast (duration of
o episode)?
4.
How
w long have yoou had LBP foor? < 6 month
hs - exclude
5.
6.
7.
Women only:
o
Are youu currently preegnant or is there a possibiliity that you m
might be pregnant
or are plaanning on becoming pregnaant during the next 2 monthhs? Yes - excluude
8.
9.
Has there been anny concern aboout your bone density? Yess - exclude
11.
What effe
fect does coughing/ sneezingg/ straining haave on the paiin?
Activve Disc Herniiation
12.
13.
Do you
y have stiffnness or pain inn the morning
g when you waake up?
If yes, duuration?
> 1 houur - exclude
14.
Do you
y have any numbness
n
or tingling
t
in you
ur groin/inside thighs? Yess - exclude
15.
16.
17.
Do you
y have troubble urinating or
o controlling your bowel and
a bladder? Y
Yes exclude
18.
Do you
y have unreelenting pain at
a night? recen
nt unplanned weightloss?
w
Y
Yes - exclude
19.
20.
21.
Yes - exclud
de
Do you have
h
a history of psoriasis, diarrhoea,
d
eyee trouble, or seevere pain in tthe joints of hands
or feet jooints?
Psoriatic arthhritis, Reiters..
Havee you recentlyy been feelingg unwell? Detaails
91
92
P
PARTICIPA
ANT CONS
SENT FORM
M
Pilates Exercise
E
f Chronic Low Baack Pain
for
Thiss research projject examines the effects off a 6-week Pilaates programm
me on chronicc low back pain,
and will
w determinee what indicattors might preedict a successsful outcome. The research is being
condducted by Claiire OBrien annd Leyla Okyaay, Master of Osteopathy sttudents at Uniitec, and will be
b
supeervised by Robb Moran, Assoociate Professsor Andrew Sttewart and Sennior Lecturer Craig Hilton.
Nam
me of Particip
pant:
.
I havve seen the Infformation Sheeet for particippants in the prroject titled P
Pilates Exercisse for Chronicc
Low
w Back Pain. I have had thee opportunity to read the co
ontents of the information
i
shheet and to disscuss
the project
p
with a member of thhe research teaam and I am saatisfied with the
t explanatioons I have been
n
givenn. I understannd that taking part
p in this prooject is volunttary (my choicce) and that I may withdraw
w
from
m the project at
a any time (refer below) andd this will in no
n way affect my access to the services
provvided by the Unitec
U
Osteopaathy Clinic or Unitec NZ.
draw from thee study, for any
a reason, up
p to 1 week aafter the last data
d
I understand thaat I can withd
colleection, but noo later.
I undderstand that my
m participatiion in this projject is confideential and thatt no material thhat could iden
ntify
me will
w be used inn any reports on
o this projectt.
I havve had enoughh time to consider whether I want to take part.
I knoow whom to contact
c
if I havve any questioons or concern
ns about the prroject.
The researchers foor this project are:
Clairre OBrien
Leyla Okkyay
Tel.:: 09 550 3212
Tel.: 09 550
5 3212
Mobb.: 021 55 84 55
5
Mob.: 0221 142 42 61
pilattes.research@gmail.com
pilates.reesearch@gmail.com
Rob Moran
Discipline Leeader - Osteop
pathy
Tel.: 09 815 44321 ext 8642
2
rmoran@unittec.ac.nz
Partticipant Signaature
.(ddate)
Projeect explained by
Reseearcher Signatture
...
...((date)
Theparticipantsshouldretainacopyofthisconsentforrm.
URE
ECREGISTRAT
TIONNUMBE
ER:2009923
Thissstudyhasbeeenapproved bytheUNITE
TECResearch EthicsComm
mitteefrom3rrdApril2009 to2nd
Apriil2010.Ifyo
ouhaveanyccomplaintsorrreservationssabouttheetthicalconducctofthisreseearch,
you maycontact theCommitteeethroughth
heSecretary (ph:098154
4321ext7248
8).Anyissuessyou
me.
raiseewillbetreattedinconfideenceandinvesstigatedfully,,andyouwillbeinformedoftheoutcom
93
94
QUESTIONNA
AIRE
Pilates Exercise
E
f Chron
for
nic Low Back Pain
Welccome and thannk you for parrticipating in this
t study.
Please take time too read the queestions carefullly and answer them truthfuully. If you aree not sure how
w to
answ
wer a questionn, please mark it with a quesstion mark (?)) and we will clarify
c
during the interview
w.
To protect
p
your annonymity pleaase DO NOT write
w
your nam
me anywhere on the questioonnaire.
Secttion 1:
Datee of Birth:
Gen
nder:
Male
1. What
W is the highhest level of education
e
that you have com
mpleted?
No formal schooling
s
Less than primary schooll
Primary schhool completeed
Intermediatte school comppleted
High Schoool (or equivaleent) completedd
Tertiary deggree or diplom
ma completed
Postgraduatte degree com
mpleted
Homeemaker/ caring
g for family
Lookeed but cant fin
nd a job
Doingg unpaid work
k/ voluntary acctivities
Studiees/ training
Retireed/ too old to work
w
Ill heaalth
Other (please state))
95
Fem
male
3. During the last 12 months what has been your main occupation?
Legislator/ Senior official/ Manager.
Professional (engineer, doctor, teacher, clergy, etc).
Technician/ Associate Professional (inspector, finance, dealer, etc).
Clerk (secretary, cashier, etc).
Service/ Sales worker (cook, travel guide, shop salesperson, etc).
Agriculture or Fishery worker (vegetable grower, livestock producer, etc).
Craft or Trades worker (carpenter, painter, jewellery worker, butcher, etc).
Plant /Machine Operator or Assembler (equipment assembler, sewing machine operator, driver,
etc).
Elementary worker (street food vendor, shoe cleaner, etc).
Armed Forces (government military)
2 3 4 5 6 Extremely satisfied
5. Medical History:
Do you currently have or have you ever been diagnosed with any of the following?
Arthritis
Numbness/weakness
Asthma
Epilepsy
Osteoarthritis
Anaemia
Gynaecological problems
Osteoporosis
Bowel/Bladder Changes
Heart Attack
Osteopenia
Balance Problems
Heart Palpitations
Migraines
Bursitis
Heart Disease
Shortness of Breath
Cancer
Hyperglycemia
Stenosis
Diabetes
Hypoglycemia
Thyroid Disorder
Dizziness
Kidney Disorder
Fainting
Visual Disturbances
7. Areyoucurrentlyreceivingprofessionalhealthcareservices?(eg.Osteopathy,Physiotherapy,
Chiropractic,Massage,MedicalTreatment)
Forlowbackpain
No
No
96
Section 2:
1. Do you get leg pain below the knee?
Yes
No
2. In the past week how bothersome have the following symptoms been?
(010, where 0 = no pain, 10 = worst pain imaginable)
a. Lower Back Pain
0
10
10
b. Leg Pain
0
3. I am going to ask you to identify at least three important activities that you are unable to do or are
having difficulty with as a result of your low back pain. Please choose at least three activities and write
them in the chart below, then score each activity from 0-10 according to the scale shown.
Examples of activities: running, playing squash, getting out of bed, vacuuming, sitting for longer than
1 hour, playing soccer with your children, gardening, bending down to tie your shoe laces.
Unable to
perform
activity
10
Able to perform
activity at the same
level as before
injury or problem
Activity
Score
1.
2.
3.
4.
5.
Average Score (we will calculate this)
97
Section 3:
1. During the past week, how troublesome have each of the following symptoms been? (Please put a
cross (x) in the appropriate box on each row for each area that you have pain)
No pain
experienced
Not at all
troublesome
Slightly
troublesome
Moderately
troublesome
Very
troublesome
Extremely
troublesome
Head ache
Neck pain
Shoulder
pain
Elbow pain
Wrist / hand
pain
Chest pain
Abdominal
pain
Upper back
pain
Lower back
pain
Hip/thigh
pain
Knee pain
Ankle/foot
pain
Other pains
98
ooooo
Ache:
ooooo
Numbness:
-----
xxxxx
Pain:
-----
/////
/////
99
xxxxx
Section 4:
This questionnaire is designed to give us information as to how your back pain has affected your ability
to manage in everyday life. Please answer every question by placing a cross in the one box that best
describes your condition today. We realize that you may feel that 2 of the statements may describe your
condition, but please mark only the box that most closely describes your current condition.
Pain Intensity
Standing
Sleeping
Social Life
100
Walking
Travelling
Employment/Homemaking
101
Section 5:
Here are some of the things which other patients have told us about their pain. For each statement
please circle any number from 0 to 6 to say how much physical activities such as bending, lifting,
walking, or driving affect or would affect your back pain.
Completely
disagree
Unsure
Completely
agree
The following statements are about how your normal work affects or would affect you back pain.
Completely
Completely
agree
Unsure
disagree
6. My pain was caused by my work
or by an accident at work
102
Section 6:
Everyone experiences painful situations at some point in their lives. Such experiences may include
headaches, tooth pain, joint or muscle pain. People are often exposed to situations that may cause pain
such as illness, injury, dental procedures or surgery.
We are interested in the types of thoughts and feelings that you have when you are in pain. Listed
below are thirteen statements describing different thoughts and feelings that may be associated with
pain. Using the following scale, please indicate the degree to which you have these thoughts and
feelings when you are experiencing pain.
Not at
all
To a slight
degree
To a moderate
degree
To a great
degree
All the
time
103
Section 7:
Below is a list of the ways you might have felt or behaved. Please tell us how often you have felt this
way during the past week.
Rarely or none
of the time
(less than 1
day)
Most or all
of the time
(5-7 days)
6. I felt depressed.
Section 8:
104
Some of the questions in this questionnaire refer to your significant other. A significant other is a
person with whom you feel closest. This includes anyone that you relate to on a regular or infrequent
basis. It is very important that you identify someone as your significant other. Please indicate below
who your significant other is (check one):
Spouse
Partner/Companion
Housemate/Roommate
Friend
Neighbour
Parent/Child/Other relative
Yes
No
When you answer questions in the following pages about your significant other,
always respond in reference to the specific person you just indicated above.
A.
In the following 20 questions, you will be asked to describe your pain and how it affects your life.
Under each question is a scale to record your answer. Read each question carefully and then circle
a number on the scale under that question to indicate how that specific question applies to you.
1. Rate the level of your pain at the present moment.
No pain 0 1 2 3 4 5 6
Extreme pain
2. In general, how much does your pain problem interfere with your day to day activities?
No interference 0 1 2 3 4 5 6 Extreme interference
3. Since the time you developed a pain problem, how much has your pain changed your ability to
work?
No change 0 1 2 3 4 5 6
Extreme change
Check here, if you have retired for reasons other than your pain problem
4. How much has your pain changed the amount of satisfaction or enjoyment you get from
participating in social and recreational activities?
No change 0 1 2 3 4 5 6
Extreme change
5. How supportive or helpful is your spouse (significant other) to you in relation to your pain?
Not at all supportive 0
2 3 4 5 6 Extremely supportive
7. On the average, how severe has your pain been during the last week?
Not at all severe 0 1 2 3 4 5 6 Extremely severe
8. How much has your pain changed your ability to participate in recreational and other social
activities?
No change 0 1 2 3 4 5 6
Extreme change
9. How much has your pain changed the amount of satisfaction you get from family related
activities?
No change 0 1 2 3 4 5 6
Extreme change
10. How worried is your spouse (significant other) about you in relation to your pain problem?
105
Extremely worried
11. During the past week, how much control do you feel that you have had over your life?
No at all in control
1 2 3 4 5 6
Extremely in control
Extreme suffering
13. How much has your pain changed your marriage and other family relationships?
No change 0 1 2 3 4 5 6
Extreme change
14. How much has your pain changed the amount of satisfaction or enjoyment you get from
work?
No change 0 1 2 3 4 5 6
Extreme change
Extremely attentive
16. During the past week, how much do you feel that youve been able to deal with your
problems?
Not at all 0 1 2 3 4 5 6 Extremely well
17. How much has your pain changed your ability to do household chores?
No change 0 1 2 3 4 5 6
Extreme change
18. During the past week, how irritable have you been?
Not at all irritable 0 1 2 3 4 5 6
Extremely irritable
19. How much has your pain changed your friendships with people other than your family?
No change 0 1 2 3 4 5 6
Extreme change
20. During the past week, how tense or anxious have you been?
Not at all tense or anxious 0 1 2 3 4 5 6 Extremely tense or anxious
B.
In this part, we are interested in knowing how your significant other (this refers to the person you
indicated above) responds to you when he or she knows that you are in pain. On the scale listed
below each question, circle a number to indicate how often your significant other generally
responds to you in that particular way when you are in pain.
Very
often
Never
1. Ignores me
3. Reads to me
Never
Very
106
often
4. Expresses irritation at
me
6. Talks to me about
something else to take
my mind off the pain
7. Expresses frustration
at me
9. Tries to involve me in
some activity
10.Expresses anger at me
12. Encourages me to
work on a hobby
C.
Listed below are 18 common daily activities. Please indicate how often you do each of these
activities by circling a number on the scale listed below each activity. Please complete all 18
questions.
Very
often
Never
1. Wash dishes
3. Go out to eat
5. Go grocery shopping
7. Go to a movie
107
Very
often
Never
8. Visit friends
16. Go to a park or
beach
108
109
HISTORY
Y&PHYSIC
CALEXAMINATION
History of Low
wer Back Pain
P
Modde of onset
T
Gradual / Sudden / Traumatic
Freqquency of episodes
e
How
w has it progreessed?
Durration of sym
mptoms.
How
w long does thee pain
last??
Daily Pattern
Agggravating Faactors
Reliieving Factoors
Ressponse to prrior
treaatments
Asssociated Sym
mptoms
Sadddle anaesthhesia?
Incontinencce?
Height
cm
m
Weiight
kgg
cm
110
Standing
Seated
Painful arc
Painful arc on return
Gowers Sign
Instability catch
Reverse Lumbopelvic Rhythm
Hands flat on floor (LLS)
Left
Right
cm
Supine
Rocking fwd ?E
Right ___________cm
Rotation
Left ____________cm
Prone
SLR
Passive
Active
Pain?
A/P
Right
Left
Reflexes
Patella
Achilles
Myotomes
Hip
Knee
Ankle
Flex
R L
R L
R L
Pain
L1
L2
L3
L4
L5
LS
Endurance Tests
Ext
R L
R L
R L
Dermatomes
Light touch / Sharp touch
111
Norm
Extensor
mins/secs
L Lateral
mins/secs
R Lateral
mins/secs
Flexor
mins/secs
P.I +ve
112
P
POSTPILA
ATESQUEST
TIONNAIRE
E
Pilates Exercise
E
f Chronic Low Baack Pain
for
Please take time too read the queestions carefullly and answer them truthfuully. If you aree not sure how
w to
answ
wer a questionn, please mark it with a quesstion mark (?)) and we will clarify
c
during the interview
w.
To protect
p
your annonymity pleaase DO NOT write
w
your nam
me anywhere on the questioonnaire.
Secttion 1:
1. Do you get leg pain below thhe knee?
No
Yes
ymptoms beenn?
2. Inn the past weeek how botherrsome have thee following sy
(010, where 0 = no pain, 10 = worst painn imaginable)
a. Loower Back Pain
0
10
10
b. Leeg Pain
0
Secction 2:
1.
When we asssessed you iniitially, you tolld us that you had difficultyy with the activvities listed
below. Todaay, do you stilll have difficullty with these activities?
Unnable to
perrform
actiivity
110
A
Able to perforrm
activity at thee same
llevel as before
iinjury or prob
blem
Activity
Scoree
1.
2.
3.
4.
5.
Average Scoore
113
Section 3:
During the past week, how troublesome have each of the following symptoms been? (Please put a cross
(x) in the appropriate box on each row for each area that you have pain)
No pain
experienced
Not at all
troublesome
Slightly
troublesome
Moderately
troublesome
Very
troublesome
Extremely
troublesome
Head ache
Neck pain
Shoulder
pain
Elbow pain
Wrist / hand
pain
Chest pain
Abdominal
pain
Upper back
pain
Lower back
pain
Hip/thigh
pain
Knee pain
Ankle/foot
pain
Other pains
114
Section 4:
This questionnaire is designed to give us information as to how your back pain has affected your ability
to manage in everyday life. Please answer every question by placing a cross in the one box that best
describes your condition today. We realize that you may feel that 2 of the statements may describe your
condition, but please mark only the box that most closely describes your current condition.
Pain Intensity
Standing
Sleeping
Social Life
115
Walking
Travelling
Employment/Homemaking
Section 5:
(We will complete this)
Fingertip to floor _____________cm
Schober Index _______________cm
116
117
Officialjournalofthe:
AssociationofNeuromuscularTherapists
AustralianPilatesMethodAssociation
NationalAssociationofMyofascialTriggerPointTherapists,USA
NowindexedinMedline
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