Within Session Changes, Manual Therapy, and Outcomes

Cook CE et al. Can a within/between session change in pain during reassessment predict outcome using a manual therapy intervention in patients with mechanical low back pain? Manual Therapy 2012
  • Within manual therapy interventions, there are within-session changes (improvement in pain and/or ROM that occurs within the same treatment visit), and between-session changes (changes that carry over to subsequent visits).
  • the extent of change that is necessary for clinical relevance, specifically with association to long-term improvement in report of function in pts who demonstrate a concurrent within/between-session change has yet to be investigated.
  • The first objective was to determine if within/between session changes were significantly associated with functional outcomes, pain, and self-report of recovery in pts treated for low back pain. The second objective was to determine the extent of change needed for a within/between session change with association to function.
  • The RCT employed investigated the use of both thrust and non-thrust manipulation on a population of pts w/ LBP. Both groups received a standard evaluation and then one of the two forms of manual therapy. The treatments used were meant to reflect a "real world" treatment environment in order to enhance external validity.
  • Participants in the study were from 14 different outpatient physical therapy clinics aged 18 yrs or older with mechanically reproducible LBP. Inclusion criteria included a within-session change in pain or ROM during the manual therapy assessment phase, specifically, passive accessory mobility testing.
  • All pts were treated by 14 physical therapists all with extensive manual therapy training and experience who had also undergone standardized training specific for this RCT. The standardized manual therapy evaluation required a comparable response by the pt of their chief complaint of symptoms with either central or unilateral p-a mobilization.
  • Pts were then randomized to receive either only thrust or non-thrust manipulation for the first two visits along with a standardized home exercise program. In order to replicate actual clinical practice, the treating clinician was able to select the technique for either thrust or non-thrust manipulation that they felt would most benefit the pt. The technique was not directed to a pre-selected level, but rather to the level identified by the therapist as producing the pts symptoms.
  • Within/between session findings were significantly associated with pain change but not perceived rate of recovery. A within/between session report of pain reduction of 2 points or greater was associated with a > 50% reduction on the ODI.
  • The findings in this study suggest that within/between session changes is significantly associated with improvement in function is is different to that of prior research in this area. One reason for this may be that this study employed a consecutive within/between session change model whereas other studies have only used either one or the other.