Research Review By Dr. Ceara Higgins©


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Date Posted:

August 2020

Study Title:

Evaluation is treatment for low back pain


Louw A, Goldrick S, Bernstetter A, et al.

Author's Affiliations:

International Spine and Pain Institute, Story City, IA; St Ambrose University, Davenport, IA; Kitsap Physical Therapy, Silverdale, WA; Outpatient Physical Therapy, Kent, WA; Dynamic Principles LLC, Grand Rapids, MI; ProActive Physical Therapy, Tucson, AZ; University of South Dakota; Southwest Baptist University, Bolivar, MO – all in the USA

Publication Information:

Journal of Manual & Manipulative Therapy 2020; Feb 24; 1-10. doi: 10.1080/10669817.2020.1730056.

Background Information:

Low back pain (LBP) is the most widely reported musculoskeletal disorder worldwide (1), accounting for 25% of outpatient physical therapy (PT) visits in the US (3). Generally speaking, most initial healthcare visits include history taking, a physical examination and treatment, all of which have been shown to align well with patient expectation studies (9). Interestingly, both patients and health care providers (of all disciplines) tend to attribute reduction in primary complaints to the treatment provided (13). However, little thought is given to the influence history taking and/or the physical examination have on the outcomes (16).

More recently, there has been a shift toward the biopsychosocial model, including increased attention on the therapeutic alliance (TA), which is defined as the working rapport or positive social connection between the patient and the clinician (19). This includes a complex blend of the clinician’s technical skills, verbal and non-verbal communication, sense of warmth, collaboration, and trust (19). This, importantly (and logically?) has been shown to have a powerful effect on pain and outcomes (8). Strategies such as active listening, being present in the moment, acknowledging the patient’s individual experience, eye contact, empathy, etc. employed during history taking have all been shown to help build trust and foster the TA (22). As well, the physicality of touch during the examination may further build that trust and TA through the release of the neuropeptide oxytocin, which is involved in pain relief (21). Some of the tests utilized during the physical examination may also serve the same function as treatment.

This study investigated if the ritual of the examination might result in a meaningful change in pain and function for patients presenting with LBP, before implementing any treatment interventions. Specifically, the study aimed to test any therapeutic effects of the history taking and physical examination.

Pertinent Results:

The 34 subjects included in this study (18 female, average age 57.7  18.7) showed an average duration of LBP of 113.7 months and average disability (ODI) of 28.2% (moderate disability).

The NPRS for LBP significantly decreased following the physical exam and showed a moderate effect size, however, improvements did not meet minimally clinically important difference (MCID). Leg pain showed a significant change after history taking but again, failed to reach MCID. Upon completion of the history, 23.5% of patients showed reductions of  2 points in LBP and 26.5% of patients showed reductions of  2 points in leg pain, while an additional 11.7% of patients showed a reduction of  2 points in LBP after the physical examination, all of which reached MCID. No further reduction in leg pain was noted after the physical examination.

At baseline, 13 patients showed scores of > 14 on the FABQ-PA (physical activity) subscale, indicating increased disability. After the history, that number reduced to 9, and further reduced to 7 after the physical examination (a 50% reduction!). However, these improvements (somehow?) fail to reach statistical significance. Only 2 patients exceeded the cut-off score of > 34 points on the FABQ-WS (work) subscale at baseline, with one dropping below cut-off after the history and physical exam. Again, statistical significance was not reached. Pain catastrophization (PCS) showed significant improvement after history taking with 12 patients classified as high (> 30 points) as baseline, and only 6 patients classified as high after the history. This improvement was maintained after the physical exam, but no further improvement was seen.

Active lumbar flexion improved by 2.27cm following the history and a further 1.86cm after the physical exam, for an overall increase of 4.14cm. However, this did not meet MCID. PPT measurements of the hand, upper trapezius, and low back all showed improvements exceeding the MCID of 15% immediately after the history and physical exam.

The average duration of the history was 20.5 minutes and the physical examination was 18.4 minutes. There were no statistically significant correlations between the duration of the history and the pre-to-post changes seen in any outcome measures. However, the duration of the physical exam showed positive correlations with regard to PPT at the low back and hand, but negative correlations for the PCS.

The therapists reported an average score of 7.15 for perceived connection to the patient during the history taking. PPT at the upper trapezius at intake was the only factor positively correlated with perceived connection by the PT.

Clinical Application & Conclusions:

In this small but interesting study, a significant therapeutic effect on pain, fear-avoidance, pain catastrophization, movement, and sensitivity of the nervous system was seen after history taking and physical examination. Only some of these met or exceeded the minimal clinically important differences (MCID) and none correlated to the duration of the exam or perceived connection to the clinician.

After the history taking, significant improvements were seen in the NPRS (leg pain), PCS, trunk flexion, and PPT. With the addition of the completed physical examination, all of these measures, as well as the NPRS for LBP, showed significant improvements. However, only active trunk flexion and PPT for the low back showed significant improvements after the physical examination when compared to the measurements after the history taking, indicating that the history taking had the largest impact. This may be a result of the history taking being the first contact with the patient, allowing an immediate chance to connect, alleviate fears, and establish a therapeutic alliance (TA), thus setting the tone for the remainder of the clinical encounter. The physical exam may then enhance confidence and reduce fear of movement, accounting for the additional improvements noted. Based on this, the physical exam should not be disconnected from the history.

A further, perhaps paradoxical finding from this study was that more time spent on the evaluation actually resulted in an increase in pain catastrophization (measured with the PCS). This may be a result of the patient becoming worried that the extended examination time is an indication that there is something more seriously wrong with them. Thus, being focused and present during the examination and getting to know the patient may be more important than the amount of time spent of the examination (63).

Further, the clinician’s perceived connection with the patient showed no correlation with changes in pain or function. This may be a result of the authors only evaluating perceived connection from the therapist’s perspective. How the patient feels about this may be a more important indicator that requires further study.

Overall, this study showed that the evaluation process alone plays a large role in patient improvement in a LBP population, with the history taking specifically having the largest effect.

Study Methods:

40 patients with LBP with/without leg pain who attended four different outpatient physical therapy (PT) clinics over a 3-month period were asked to participate in the observational cohort study. At each site, one PT performed the history and physical exam and another PT took all outcome measurements. Inclusion criteria were as follows:
  • Patients presenting for treatment of LBP
  • Age greater than 18 years
  • Ability to read and understand English
  • Willingness to participate in the study
Exclusion criteria included:
  • Inability to forward flex the lumbar spine due to some medical complication or contraindication
  • Skin lesions in areas to be tested with pressure pain threshold
  • Red flags indicating that PT was not appropriate
34 participants were ultimately included in the study.

Patients were all asked to complete a demographic survey including age, gender, ethnicity, socioeconomic status, duration of LBP, past LBP, and lumbar surgical history. As well, they were asked to complete the Oswestry Disability Index (ODI) (28) to assess their level of disability. Patients also completed a number of outcome measures before the history and immediately after the history and physical examination. These included:
  1. Numeric Pain Rating Scale (NPRS) for low back and leg pain;
  2. Fear-Avoidance Beliefs Questionnaire (FABQ), a 16-item questionnaire with subscales for physical activity (PA) and work (W), each scored from 0-6 with higher scores indicating an increase in fear-avoidance beliefs;
  3. Pain Catastrophization Scale (PCS), a self-report questionnaire to assess inappropriate coping strategies and catastrophic thinking about pain and injury, with higher scores indicating elevated levels of catastrophizing;
  4. lumbar flexion, active forward flexion with knees kept straight, measured from the tip of the longest finger on the dominant hand to the floor in centimeters;
  5. Pressure pain thresholds (PPT) measured in lbs/in2 using a digital pressure algometer over three points on the dominant side. These included the first and second interosseous web space of the hand, the upper trapezius, and adjacent to the L3 spinous process. Three consecutive PPT measurements were taken at each point with 20 seconds rest between measurements, and the mean calculated for each point.
All measurements were taken by a non-attending PT.

The attending PT next performed a pragmatic history based on the patient’s clinical presentation. History taking included gathering information on the chief complaint, mechanisms of injury, medical history, functional limitations, prior level of function, and social and environmental factors. The duration of the history taking episode was recorded. The attending PT was asked to indicate how well they believed they connected with the patient from 0 (not connected) to 10 (very connected). The non-attending PT then repeated the outcome measures before the attending PT returned to conduct the physical examination. The physical exam was conducted at the discretion of the attending PT, but could not include any treatment interventions. Physical examinations included systems review, functional movement, range of motion, neurologic screening, palpation, joint and soft tissue mobility, and special tests as needed. As with the history, the duration of the physical exam was recorded. Next, all outcome measurements were repeated by the non-attending PT. The study was considered complete at this point and the remainder of the session and any further treatment was performed at the discretion of the attending PT.

Study Strengths / Weaknesses:

By repeating outcome measurements after the history taking and again after the physical examination, it was possible to identify which aspect of the clinical encounter had the larger impact on outcomes.

  • The use of a cohort, observational study design does not allow for the identification of direct causal relationships.
  • No specific controls were placed on the history taking or examination, making them non-standardized components within this study. Reviewer’s note: However, this does make the history and physical examination more similar to the clinical experience and may make the results of the study more generalizable to clinical practice.
  • Ratings of perceived connection were only collected from the practitioner, making it unclear if patient perceptions of connection may have had any correlation with outcomes.
  • The study only included patients with LBP, making it more difficult to generalize these findings to other patient populations.
  • The short duration of the follow-up does not provide any indication of whether changes in outcome measures are sustained over time.

Additional References:

  1. Deyo RA, Mirza SK, Turner JA, et al. Overtreating chronic back pain: time to back off? J Am Board Fam Med 2009; 22(1): 62–68.
  2. Jette DU, Jette AM. Physical therapy and health outcomes in patients with spinal impairments. Phys Ther 1996; 76(9): 930–941. discussion 942–935.
  3. Benedetti F, Amanzio M. The placebo response: how words and rituals change the patient’s brain. Patient Educ Couns 2011; 84(3): 413–419.
  4. Verbeek J, Sengers MJ, Riemens L, et al. Patient expectations of treatment for back pain: a systematic review of qualitative and quantitative studies. Spine 2004; 29(20): 2309–2318.
  5. Puentedura EJ, Landers MR, Hurt K, et al. Immediate effects of lumbar spine manipulation on the resting and contraction thickness of transversus abdominis in asymptomatic individuals. J Orthop Sports Phys Ther 2011; 41(1): 13–21.
  6. Diener I, Kargela M, Louw A. Listening is therapy: patient interviewing from a pain science perspective. Physiother Theory Pract 2016; 32(5): 356–367.
  7. Crepeau EB, Garren KR. I looked to her as a guide: the therapeutic relationship in hand therapy. Disabil Rehabil 2011; 33(10): 872–881.
  8. Rash JA, Aguirre-Camacho A, Campbell TS. Oxytocin and pain: a systematic review and synthesis of findings. Clin J Pain 2014; 30(5): 453–462.
  9. Grant S. Are there blueprints for building a strong patient-physician relationship? Am Med Assoc J Ethics 2009; 11: 3.
  10. Deyo RA, Battie M, Beurskens AJ, et al. Outcome measures for low back pain research. A proposal for standardized use. Spine 1998; 23(18): 2003–2013.
  11. Sullivan MJL, Bishop SR, Pivik J. The pain catastrophizing scale: development and validation. Psychol Assess 1995; 7(4): 524–532.
  12. Moss P, Sluka K, Wright A. The initial effects of knee joint mobilization on osteoarthritic hyperalgesia. Manual Ther 2007; 12(2): 109–118.
  13. Walton DM, Levesque L, Payne M, et al. Clinical pressure pain threshold testing in neck pain: comparing protocols, responsiveness, and association with psychological variables. Phys Ther 2014; 94(6): 827.
  14. Merel SE, McKinney CM, Ufkes P, et al. Sitting at patients’ bedsides may improve patients’ perceptions of physician communication skills. J Hosp Med 2016; 11(12): 865–868.