Fritz
Fritz
Fritz
Preliminary Examination of a
Proposed Treatment-Based
Classification System for Patients
Receiving Physical Therapy
Results
A total of 274 patients were included in this study (74% women; age
[X⫾SD]⫽44.4⫾16.0 years). The most common classification was centralization
(34.7%); next were exercise and conditioning (32.8%) and mobility (17.5%). The
interrater reliability for classification decisions was high (kappa⫽.95, 95% confidence
interval [CI]⫽0.87–1.0). A total of 113 patients (41.2%) received interventions
matched to the classification. Receiving matched interventions was associated with
greater improvements in the NDI (mean difference⫽5.6 points, 95% CI⫽2.6 – 8.6)
and in pain ratings (mean difference⫽0.74 point, 95% CI⫽0.21–1.3) than receiving
nonmatched interventions.
N
eck pain is a common condi- but little work on validation has been ting this subgroup recommends mo-
tion, with an annual incidence performed. We recently proposed a bilization,37 neck active range-of-
estimated at about 15%.1 Pa- treatment-based classification ap- motion (ROM) exercises, and
tients with neck pain frequently are proach that seeks to use information avoidance of immobilization (eg, cer-
treated without surgery by primary from the history and physical exam- vical collar).38,39 Finally, the head-
care and physical therapy provid- ination to place patients into 1 of 5 ache classification includes patients
ers.2– 4 Within physical therapy, separate subgroups that provide a di- with a chief complaint of headache
there appears to be a great deal of rection for the initial physical ther- presumed to originate from struc-
variation in choices of interven- apy treatment approach.22 tures in the cervical spine.40 The ev-
tions,5 indicating a degree of uncer- idence for physical therapy interven-
tainty about optimal strategies for The classification strategy was devel- tions for patients with cervicogenic
Method Table 1.
Procedures Variables Standardized for Collection at the Baseline Examination for All Patients
Data for this study were collected Variables Measurement Method
from 4 outpatient physical therapy
Duration of symptoms (d) Patient self-report
clinics of Intermountain Health Care,
a private, nonprofit health care sys- Mode of onset of symptoms (gradual, sudden, Patient self-report
tem. In each participating clinic, traumatic, other)
clinical outcomes are routinely Symptom location (neck, head, scapula, shoulder, arm, Patient self-report
tracked for all patients receiving hand) and most bothersome symptom location
physical therapy interventions. Each Aggravating or relieving factors Patient self-report
new patient is entered into an elec-
iarize the therapists with the stan- straints were placed on the content aware of the interventions and out-
dardized forms. The procedures or duration of treatment. After the comes and unaware of the judgments
used for examination items and the completion of therapy, examination of the first reviewer, classified a ran-
operational definitions of the inter- and intervention data were col- domly selected subset of 50 patients
ventions were reviewed. Interven- lected. For each patient, initial and to examine the interrater reliability
tions were discussed, but no explicit final scores on the NDI and pain rat- of the classification algorithm.
instruction in the classification pro- ings and the number of physical ther-
cess or clinical decision making was apy visits were obtained from the Interventions
provided. The purpose of the train- database. Prior to data collection, we defined
ing was to standardize data collec- the intervention components matched
tion procedures, not to standardize Patient Classification to each classification in the proposed
treatment decision making. Using the proposed classification sys- system on the basis of current evi-
tem, we developed an algorithm to dence when possible and standard
Data collection was conducted from prioritize the findings and place practice when necessary (Tab. 2). For
January to December 2004. During each patient into a classification cat- the mobility classification, evidence
this period, all new patients who egory on the basis of variables from supported defining the matched com-
were determined by the physical the baseline examination (Figure). A ponents as manual therapy (manipula-
therapists to have a primary com- classification category was assigned tion or mobilization of the cervical or
plaint of neck pain were evaluated for each patient by a reviewer who thoracic spine) and strengthening ex-
with the standardized form, and in- was unaware of the interventions ercises for the deep neck flexor mus-
terventions were recorded with the used and the patient’s clinical out- cles.26,27,49 Because we anticipated
standardized categories. No con- comes. A second reviewer, also un- rapid improvement in this classifica-
tion, these interventions had to be re- Data Analysis compared the numbers of sessions
ceived within the first 3 sessions. High- To permit the evaluation of clinical for patients receiving matched treat-
quality evidence is lacking in the outcomes, the analysis included only ments and those receiving non-
literature for the centralization clas- patients with at least 2 physical ther- matched treatments by using inde-
sification. Common practice includes apy visits. The interrater reliabilities pendent t tests. We compared
either cervical traction or neck re- of the classification algorithm and clinical outcomes (changes in NDI
traction exercises to promote cen- the treatment-matching criteria were and pain rating scores) by using sep-
tralization24,50 –54; therefore, these in- examined by calculating percentage arate analysis of covariance proce-
terventions were considered matched agreement and kappa coefficients dures with covariates of age, sex, du-
components. More specifically, trac- with 95% confidence intervals (CIs) ration of symptoms, classification
tion (manual or mechanical) had to between the judgments of the first category, and baseline score for the
Table 3.
Comparison of Baseline Characteristics Among Classification Categories
Characteristica All Subjects Mobility Centralization Exercise and Pain Control Headache
(nⴝ274) (nⴝ48) (nⴝ95) Conditioning (nⴝ16) (nⴝ25)
(nⴝ90)
Age, y, X (SD) 44.4 (16.0) 37.0 (11.6)b 43.9 (13.7)b 50.5 (18.6)c,d 39.3 (16.2) 41.2 (14.2)
% Women 73.7 70.8 73.7 70.0 87.5 84.0
b,d,e c,f c,e,f b,d,e
Symptom duration, 48 d (1 d–24 y) 14 d (4–30 d) 78 d (7 d–20 y) 120 d (7 d–24 y) 11.5 d (1–21 d) 45 db (6 d–3 y)
median (range)
% of subjects with prior 45.4 39.6 45.3 42.7 37.5 72.0
Table 4.
Comparison of Clinical Outcomes Among Classification Categoriesa
Physical Therapy
Characteristic Mobility Centralization Exercise and Pain Control Headache
of Outcome Conditioning
Matched Nonmatched Matched Nonmatched Matched Nonmatched Matched Nonmatched Matched Nonmatched
No. of patients 18 30 56 39 26 64 10 6 3 22
Volume 87
Age, y, X (SD) 38.8 (10.9) 35.9 (12.1) 44.6 (13.0) 43.0 (14.9) 53.0 (17.1) 49.5 (18.9) 38.4 (19.5) 40.8 (9.6) 33.0 (6.0) 40.4 (13.5)
% women 72.2 70.0 67.9 82.1 76.9 67.2 100 66.7 100 81.8
No. of therapy 4.9 (2.3) 5.0 (4.0) 6.0 (3.3) 5.4 (3.8) 6.0 (3.3) 5.4 (3.8) 9.6 (5.9) 5.8 (5.3) 5.0 (1.7) 4.8 (2.7)
Number 5
visits
NDI (initial) 34.1 (10.9) 32.2 (15.4) 37.7 (17.9) 37.4 (14.1) 29.7 (16.0) 31.3 (15.4) 65.0 (11.1) 61.8 (17.7) 33.0 (23.6) 34.0 (13.7)
Pain rating 5.1 (2.0) 4.7 (2.3) 5.0 (2.4) 5.7 (2.6) 4.1 (2.2) 5.0 (2.3) 8.2 (1.8) 7.3 (0.82) 5.3 (4.4) 5.3 (2.4)
(initial)
NDI (final) 15.9 (11.7) 19.5 (15.5) 24.8 (18.0) 30.0 (17.2) 15.6 (12.4) 21.1 (14.0) 28.2 (18.0) 45.0 (22.6) 18.0 (17.4) 25.3 (16.1)
Pain rating 2.1 (1.8) 2.9 (2.2) 3.2 (2.4) 4.2 (2.7) 2.7 (2.4) 3.3 (2.2) 2.9 (1.4) 5.0 (3.0) 2.0 (2.0) 4.1 (2.8)
(final)
Change in NDIb 18.6 (13.1, 24.1) 12.8 (8.5, 17.0) 13.5 (10.3, 16.6) 7.4 (3.4, 11.0) 15.0 (10.7, 19.2) 9.8 (7.1, 12.5) 36.9 (23.0, 50.9) 17.3 (⫺1.6, 36.2) 22.3 (6.2, 38.3) 8.8 (3.3, 14.4)
(95% CI)
Change in pain 3.0 (2.1, 3.9) 1.9 (1.2, 2.5) 2.0 (1.4, 2.5) 1.3 (0.66, 2.0) 2.0 (1.1, 2.8) 1.5 (1.0, 2.1) 5.3 (3.7, 6.9) 2.4 (0.23, 4.5) 4.2 (0.55, 7.8) 1.2 (⫺0.10, 2.4)
Treatment-Based Classification System for Patients With Neck Pain
ratingb
(95% CI)
% of subjects 66.7 66.7 71.4 43.6 61.5 54.7 90.0 66.7 100 50.0
achieving
minimum
detectable
change
in NDI
a
Data are reported as mean (SD) unless otherwise indicated. CI⫽confidence interval, NDI⫽Neck Disabaility Index.
b
Change scores were adjusted for age, sex, duration of symptoms, and baseline pain and disability scores.
May 2007
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Treatment-Based Classification System for Patients With Neck Pain
egory, had longer symptom dura- for patients receiving matched and next. The results of the present study
tions. Patients in the pain control cat- nonmatched interventions within showed that the decision-making al-
egory had less ROM and were more each classification category is shown gorithm could be applied consis-
likely to experience symptom aggra- in Table 6. tently by different examiners consid-
vation with ROM. Patients in the cen- ering the same patient data (kappa
tralization category were most likely Discussion value for interrater agreement⫽.95),
to experience peripheralization with Physical therapists working in out- but only additional research can eval-
ROM. Patients in the pain control patient settings frequently treat pa- uate and refine the algorithm so that
category had higher baseline NDI tients with neck pain.59 The progno- it results in the best outcomes for
and pain rating scores (Tab. 4). Pa- sis for neck pain is not consistently patients. Additional research is also
tients in the centralization category good, with many people experienc- necessary to further examine the
ability to improve patient outcomes The most common classification not to emphasize strengthening in-
when it is used for treatment deci- among the patients in the present terventions. As expected, patients in
sion making in clinical practice. Re- study was centralization. This classi- the pain control classification re-
search must demonstrate that out- fication was identified by the pres- ported more pain and disability and
comes are better when patients ence of signs of nerve root com- greater ROM restrictions, were more
receive interventions matched to pression or symptoms distal to the likely to report aggravation of symp-
their classifications than when they elbow. Patients in this classifica- toms with various movements than
receive nonmatched interventions. tion also were more likely to show patients in other classifications at
The design of the present study does peripheralization with active ROM at baseline, and reported the most
not permit any conclusions about the baseline examination, a finding change in pain and disability with
the effectiveness of this system for that may be useful to consider as a treatment.
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