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Study design Randomized clinical trial. Objective Compare outcomes of patients with low back pain receiving treatments matched or unmatched to their subgrouping based on initial clinical presentation. Summary of background data Patients with "nonspecific" low back pain are often viewed as a homogeneous group, equally likely to respond to any particular intervention. Others have proposed methods for subgrouping patients as a means for determining the treatment most likely to benefit patients with particular characteristics. Methods Patients with low back pain of less than 90 days' duration referred to physical therapy were examined before treatment and classified into one of three subgroups based on the type of treatment believed most likely to benefit the patient (manipulation, stabilization exercise, or specific exercise). Patients were randomly assigned to receive manipulation, stabilization exercises, or specific exercise treatment during a 4-week treatment period. Disability was assessed in the short-term (4 weeks) and long-term (1 year) using the Oswestry. Comparisons were made between patients receiving treatment matched to their subgroup, versus those receiving unmatched treatment. Results A total of 123 patients participated (mean age, 37.7 +/- 10.7 years; 45% female). Patients receiving matched treatments experienced greater short- and long-term reductions in disability than those receiving unmatched treatments. After 4 weeks, the difference favoring the matched treatment group was 6.6 Oswestry points (95% CI, 0.70-12.5), and at long-term follow-up the difference was 8.3 points (95% CI, 2.5-14.1). Compliers-only analysis of long-term outcomes yielded a similar result. Conclusions Nonspecific low back pain should not be viewed as a homogenous condition. Outcomes can be improved when subgrouping is used to guide treatment decision-making.

STUDY DESIGN: A blinded, prospective diagnostic test study was conducted. OBJECTIVES: To assess the reliability and accuracy of individual clinical examination items and self-report instruments for the diagnosis of cervical radiculopathy, and to identify and assess the accuracy of an optimum test-item cluster for the diagnosis of cervical radiculopathy. SUMMARY OF BACKGROUND DATA: Although cervical radiculopathy remains largely a clinical diagnosis, the reliability and diagnostic accuracy of clinical examination items, individually or in combination, for cervical radiculopathy is largely unknown. METHODS: Patients with suspected cervical radiculopathy or carpal tunnel syndrome received standardized electrophysiologic examination of the symptomatic upper quarter followed by a standardized clinical examination by physical therapist examiners blinded to diagnosis. Diagnostic properties were assessed using a neural impairment reference criterion standard. RESULTS: The study involved 82 patients. More than two thirds of 34 clinical examination items had reliability coefficients rated at least fair or better, and 13 items had likelihood ratio point estimates above 2 or below 0.50. A single diagnostic test item cluster of four variables was identified and produced a positive likelihood ratio point estimate of 30.3. The 95% confidence intervals for all likelihood ratio point estimates in this study were wide. CONCLUSIONS: Many items of the clinical examination were found to be reliable and to have acceptable diagnostic properties, but the test item cluster identified was more useful for indicating cervical radiculopathy than any single test item. Upper limb tension Test A was the most useful test for ruling out cervical radiculopathy. Further investigation is required both to validate the test item cluster and to improve point estimate precision.

Study design A randomized clinical trial was conducted. Objective To compare the effectiveness of classification-based physical therapy with that of therapy based on clinical practice guidelines for patients with acute, work-related low back pain. Summary of background data Clinical practice guidelines recommend minimal intervention during the first few weeks after acute low back injury. However, studies supporting this recommendation have not attempted to identify which patients are likely to respond to particular interventions. Methods For this study, 78 subjects with work-related low back pain of less than 3 weeks duration were randomized to receive therapy based on a classification system that attempts to match patients to specific interventions or therapy based on the Agency for Health Care Policy and Research guidelines. The subjects were followed for 1 year. Outcomes included the impairment index, Oswestry scale, SF-36 component scores, satisfaction, medical costs, and return to work status. Results After adjustment for baseline factors, subjects receiving classification-based therapy showed greater change on the Oswestry (P = 0.023) and the SF-36 physical component (P = 0.029) after 4 weeks. Patient satisfaction was greater (P = 0.006) and return to full-duty work status more likely (P = 0.017) after 4 weeks in the classification-based group. After 1 year, there was a trend toward reduced Oswestry scores in the classification-based group (P = 0.063). Median total medical costs for 1 year after injury were 1003.68 dollars for the guideline-based group and 774.00 dollars for the classification-based group (P = 0.13). Conclusions For patients with acute, work-related low back pain, the use of a classification-based approach resulted in improved disability and return to work status after 4 weeks, as compared with therapy based on clinical practice guidelines. Further research is needed on the optimal timing and methods of intervention for patients with acute low back pain.

Study design A cross-sectional study was used to determine whether limited range of motion in the hip was present in 100 patients--one group with unspecified low back pain and another group with signs suggesting sacroiliac joint dysfunction. Objectives To determine whether a characteristic pattern of range of motion in the hip is related to low back pain in patients and to determine whether such a pattern is associated with and without signs of sacroiliac joint dysfunction. Summary of background data The sacroiliac joint is often considered a potential site of low back pain. Problems with the sacroiliac joint, as well as with the low back, have often been related to reduced or asymmetric range of motion in the hip. The correlation between sacroiliac joint dysfunction and hip range of motion, however, has not been thoroughly evaluated with reliable tests in a population of patients with low back pain. Methods Passive hip internal and external rotation goniometric measurements were taken by a blinded examiner, while a separate examiner evaluated the patient for signs of sacroiliac joint dysfunction. Patients with sacroiliac joint dysfunction were further classified as having a left or a right posteriorly tilted innominate. Results The patients with low back pain but without evidence of sacroiliac joint dysfunction had significantly greater external hip rotation than internal rotation bilaterally, whereas those with evidence of sacroiliac joint dysfunction had significantly more external hip rotation than internal rotation unilaterally, specifically on the side of the posterior innominate. Conclusions Clinicians should consider evaluating for unilateral asymmetry in range of motion in the hip in patients with low back pain. The presence of such asymmetry in patients with low back pain may help identify those with sacroiliac joint dysfunction.

The purpose of this investigation was to assess the reliability of isokinetic trunk muscle performance. Sixty-one volunteers participated (29 men, 32 women; age range, 20-60 years). All subjects were without low-back symptoms at the time of testing. All testing was performed with the subject initially standing, using speeds of 60, 120, and 180 degrees per second. Ten repetitions of flexion and extension were performed reciprocally at each speed, with a 3-minute rest period between speeds. Test-retest intervals were 1 and 3 weeks from the initial test. Peak torque-to-body-weight ratios, extension-to-flexion ratios, and average work per repetition were calculated for each speed for flexion and extension. Data were analyzed with analysis of variance, intraclass correlation coefficients, and Pearson correlation coefficients. Intraclass correlation coefficient values ranged from .74 to .88 for measurements derived from peak torque, and from .88-.93 for measurements derived from work (with the exception of .69 for men at 180 degrees/sec). Standard error of measurements ranged from 8 to 32 ft-lb, with a tendency to increase with increasing speeds. It was concluded that, when using this protocol, isokinetic measurements of muscle function offer the clinician sensitive and reliable measurements of trunk muscle performance and that incorporating increased practice with women and longer rest periods with men may further decrease error associated with these isokinetic trunk strength measurements.

Study Design. This study evaluated performance differences between patients with chronic low back pain and a control group during their performance of a novel functional capacity task. Objective. To 1) evaluate strength and endurance differences between patients and control subjects, 2) test for movement pattern differences between these groups, and 3) evaluate how these patterns changed with repetitive performance of the wheel-turning task. Summary of Background Data. Despite increased emphasis on quantifying functional capacities, few well-controlled studies comparing the performances of patients with low back pain with those of control subjects have appeared in the literature, particularly for movement patterns. Methods. Forty patients with low back pain and 40 control subjects performed a sustained isodynamic wheel turning task. This task was selected because it simultaneously combined several common pain-related movements. A set of kinematic measures to characterize the basic movement patterns during this task were developed. Results. Control subjects produced significantly higher levels of static torque and completed significantly more wheel-turning repetitions. Patients with low back pain exhibited significantly less upper torso and pelvic motion, upper torso rotation, and lateral trunk flexion than those in the control group. Conclusion. The dissimilar movement strategies found between the patient and control groups suggests that factors beyond more global physical explanations (e.g., deconditioning) may be important in accounting for the large discrepancy between these groups regarding the amount of work performed. These findings, along with the basic kinematic patterns developed in this study, may have important implications for determining the efficacy of instruction in body mechanics and treatment outcome for patients with chronic low back pain.