Faculty Bibliography

Study Design Retrospective cohort. Objectives In subjects with neck pain, the present study aimed (1) to describe the prevalence of centralization (CEN), noncentralization (non-CEN), directional preference (DP), and no directional preference (no DP); (2) to determine if age, sex, fear-avoidance beliefs about physical activity, number of comorbid conditions, or symptom duration varies among subjects who demonstrate CEN versus non-CEN and DP versus no DP; and (3) to determine if CEN and/or DP are associated with changes in function and pain. Background CEN and DP are prevalent among patients with low back pain and should be considered when determining treatment strategies and predicting outcomes; however, these findings are not well investigated in patients with neck pain. Methods Three hundred four subjects contributed data. CEN and DP prevalence were calculated, as was the association between CEN and DP, and age, sex, number of comorbid conditions, fear-avoidance beliefs, and symptom duration. Multivariate models assessed whether CEN and DP predicted change in function and pain. Results CEN and DP prevalence were 0.4 and 0.7, respectively. Younger subjects and those with fewer comorbid conditions were more likely to centralize; however, subjects who demonstrated DP were more likely to have acute symptoms. Subjects who centralized experienced, on average, a 3.6-point (95% confidence interval: -0.3, 7.4) improvement in function scores, whereas subjects with a DP averaged a 5.4-point (95% confidence interval: 0.8, 10.0) improvement. Neither CEN nor DP was associated with pain outcomes. Conclusion DP and, to a lesser extent, CEN represent evaluation categories that are associated with improvements in functional outcomes. J Orthop Sports Phys Ther 2014;44(2):68-75. Epub 21 November 2013. doi:10.2519/jospt.2014.4632.

STUDY DESIGN: Prospective, longitudinal, observational cohort. OBJECTIVES: Primary aims were to determine (1) baseline prevalence of directional preference (DP) or no directional preference (no-DP) observed for patients with low back pain whose symptoms centralized (CEN), did not centralize (non-CEN), or could not be classified (NC), and (2) to determine if classifying patients at intake by DP or no-DP combined with CEN, non-CEN, or NC predicted functional status and pain intensity at discharge from rehabilitation. BACKGROUND: Although evidence suggests that patient response classification criteria DP or CEN improve outcomes, previous studies did not delineate relations between DP and CEN findings and outcomes. METHODS: Eight therapists classified patients using standardized definitions for DP and CEN. Prevalence rates for DP and no-DP and CEN,non-CEN, and NC were calculated. Ordinary least-squares multivariate regression models assessed whether multilevel classification combining DP and CEN (DP/CEN, DP/non-CEN, DP/NC, no-DP/non-CEN, and no-DP/NC categories) predicted discharge functional status (scale range, 0 to 100, with higher values representing better function) or pain intensity (scale range, 0 to 10, with higher values representing more pain). RESULTS: Overall prevalence of DP and CEN was 60% and 41%, respectively. For those with DP, prevalence rates for DP/CEN, DP/non-CEN, and DP/NC were 65%, 27%, and 8%, respectively. The amount of variance explained (R2 values) for function and pain models was 0.50 and 0.39, respectively. Compared to patients classified as DP/CEN, patients classified as DP/non-CEN or no-DP/non-CEN reported 7.7 and 11.6 functional status units less at discharge (P<.001), respectively, and patients classified as no-DP/non-CEN reported 1.7 pain units more at discharge (P<.001). CONCLUSIONS: Findings suggest that classification by pain pattern and DP can improve a therapist's ability to provide a short-term prognosis for function and pain outcomes. LEVEL OF EVIDENCE: Prognosis, level 1b-.

OBJECTIVES: Aims were (1) to determine the proportion of patients with lumbar impairments who could be classified at intake by McKenzie syndromes (McK) and pain pattern classification (PPCs) using Mechanical Diagnosis and Therapy (MDT) assessment methods, manipulation, and stabilization clinical prediction rules (CPRs) and (2) for each Man CPR or Stab CPR category, determine classification prevalence rates using McK and PPC. METHODS: Eight physical therapists practicing in eight diverse clinical settings classified patients typically referred to rehabilitation by McKenzie syndromes (i.e. derangement, dysfunction, posture, or other), pain pattern classification [i.e. centralization (CEN), not centralization (Non CEN), and not classified (NC)], Manipulation CPR (positive, negative), and stabilization CPR (positive, negative). Prevalence rates with 95% confidence intervals (CI) were calculated for each classification category by McK, PPC, and manipulation and stabilization CPRs. Prevalence rates (95% CIs) for McK and PPC were calculated for each CPR category separately. RESULTS: Data from 628 adults [mean age: 52+/-17 years, 56% female] were analyzed. Prevalence rates were: McK - derangement 67%, dysfunction 5%, posture 0%, other 28%; P

BACKGROUND: Trigger point (TrPs) identification has become the mainstay of diagnosis for the treatment of Myofascial Pain Syndrome; however, manual pressure (MP) to identify TrPs by determining low-pressure pain threshold has low interrater reliability and may lack validity since it is done on inactive muscles. To elicit contractions and mimic an active muscle or movement that 'causes' pain, a Muscle Pain Detection Device (MPDD) has been developed. A selected muscle is stimulated and painful muscles are precisely detected, allowing distinctions between primary and referred muscle pain as well as distinguishing other functional muscle pain thought to cause MPS. METHODS: An IRB approved randomized controlled study is presented of MP (20 patients) control vs MPDD (20 patients) to identify which muscle(s) was the source of pain in subjects presenting to the NYU Pain Management Center with a minimum 3 months history of back pain. Patients were unaware of their diagnostic method. Subjects were injected in 1-3 sites identified via MP or MPDD by a separate, blinded physician. Prior to, and following treatment at one week and one month, the patients were administered Oswestry and visual analog scale pain questionnaires by a blinded evaluator, and their range of motion was measured by a blinded physical therapist. RESULTS: The MPDD group reported significantly larger improvements in pain, mood and Oswestry scores compared with the control (P < 0.05). Moreover, the MPDD group reported 82.5% pain relief at 1 month, compared with 53.2% in the control (P < 0.001). The range of motion measurements failed to reveal any significant difference between the groups. CONCLUSIONS: Using the MPDD appears to be more valid and potentially more reliable than palpation to identify muscles causing regional pain that could benefit from injections

Trigger Point (TrPs) identification has become the mainstay of diagnosis for the treatment of Myofascial Pain Syndrome; however manual pressure (MP) to identify TrPs by determining low pressure pain threshold has low inter-rater reliability and may lack validity since it is done on inactive muscles. To elicit contractions and mimic an active muscle or movement that “causes” pain, a Muscle Pain Detection Device (MPDD) has been developed. A selected muscle is stimulated and painful muscles are precisely detected, allowing distinctions between primary and referred muscle pain as well as distinguishing other functional muscle pain thought to cause MPS. An IRB approved double-blind, randomized controlled study is presented of MP (20 patients) control vs. MPDD (20 patients) to identify which muscle(s) was the source of pain in subjects presenting to the NYU Pain Management Center with a minimum 3 month history of back pain. Patients were unaware of their diagnostic method. Subjects were injected in 1-3 sites identified via MP or MPDD by a separate, blinded physician. Prior to, and following treatment at one week and one month, the patients were administered Oswestry and VAS pain questionnaires by a blinded evaluator, and their range of motion was measured by a blinded physical therapist. The MPDD group reported significantly larger improvements in pain, mood and Oswestry scores compared to the control (P < 0.05). Moreover, the MPDD group reported 82.5% pain relief at 1 month, compared to 53.2% in the control (P < 0.001). The range of motion measurements failed to reveal any significant difference between the groups. In conclusion, using the MPDD appears to be more valid and potentially more reliable than palpation to identify muscles causing regional pain that could benefit from injections