STUDIES IN SPORT, PHYSICAL EDUCATION AND HEALTH 173 MJaernknki uK Pualmateallma a Orthopedic Manual Therapy on Low Back Pain with Working Adults (cid:2)(cid:3)(cid:4)(cid:5)(cid:4)(cid:6)(cid:7)(cid:3)(cid:8)(cid:9)(cid:10)(cid:11)(cid:12)(cid:11)(cid:13)(cid:8)(cid:14)(cid:15)(cid:16)(cid:6)(cid:3)(cid:7)(cid:11)(cid:11)(cid:4)(cid:17)(cid:6)(cid:7)(cid:12)(cid:4)(cid:18)(cid:5)(cid:8)(cid:7)(cid:5)(cid:19)(cid:8) Clinical Trial of Low Back Pain STUDIES IN SPORT, PHYSICAL EDUCATION AND HEALTH 173 Markku Paatelma Orthopedic Manual Therapy on Low Back Pain with Working Adults Clinical Tests, Subclassification and Clinical Trial of Low Back Pain Esitetään Jyväskylän yliopiston liikunta- ja terveystieteiden tiedekunnan suostumuksella julkisesti tarkastettavaksi yliopiston Agora-rakennuksen auditoriossa 1 lokakuun 1. päivänä 2011 kello 12. Academic dissertation to be publicly discussed, by permission of the Faculty of Sport and Health Sciences of the University of Jyväskylä, in Agora-building, Auditorium 1, on October 1, 2011 at 12 o'clock noon. UNIVERSITY OF JYVÄSKYLÄ JYVÄSKYLÄ 2011 Orthopedic Manual Therapy on Low Back Pain with Working Adults Clinical Tests, Subclassification and Clinical Trial of Low Back Pain STUDIES IN SPORT, PHYSICAL EDUCATION AND HEALTH 173 Markku Paatelma Orthopedic Manual Therapy on Low Back Pain with Working Adults Clinical Tests, Subclassification and Clinical Trial of Low Back Pain UNIVERSITY OF JYVÄSKYLÄ JYVÄSKYLÄ 2011 Editors Harri Suominen Department of Health Sciences, University of Jyväskylä Pekka Olsbo, Ville Korkiakangas Publishing Unit, University Library of Jyväskylä Cover picture: Carelian Maid by Terho Grönlund, 2005 URN:ISBN:978-951-39-4436-0 ISBN 978-951-39-4436-0 (PDF) ISBN 978-951-39-4428-5 (nid.) ISSN 0356-1070 Copyright © 2 0 1 1 , by University of Jyväskylä Jyväskylä University Printing House, Jyväskylä 2011 Dedicated to my grandchildren Arttu and Leo “Let us spend more time together.” - Markku - ABSTRACT Paatelma, Markku Orthopedic manual therapy on low back pain with working adults; clinical tests, subclassification and clinical trial of low back pain Jyväskylä: University of Jyväskylä, 2011, 98 p. (Studies in Sport, Physical Education and Health ISSN 0356-1070; 173) ISBN 978-951-39-4428-5 (nid.) ISBN 978-951-39-4436-0 (PDF) Although the natural history of low back pain (LBP) is considered to be good, most sufferers have further episodes during the first year. Debate continues on the comparative effectiveness of advice on bed rest and staying active as part of the primary care management to avoid a vicious circle, preventing LBP from becoming chronic in its early phase (of < 12-week duration). LBP in its early phase is also a common reason to consult a physiotherapist (PT). The objective of this dissertation was to evaluate the intertester and intratester reliability of selected clinical tests between PTs to assess LBP patients in the early phase, and to discover the sensitivity and specificity of these tests in acute/subacute and chronic LBP patients, and in a group of no “patient status” subjects. A further objective was to evaluate the intertester reliability of a pathoanatomical/pathophysiological classification by general practitioners in primary care physiotherapy compared to findings classified by a specialist in orthopedic manual therapy (OMT) and the findings of two OMT specialists when examining patients with early-phase LBP using selected clinical tests. The objective was also to compare effectiveness against low back and leg pain, disability, and sick leave of OMT physiotherapy using a pathoanatomical/pathophysiological classification to the effectiveness of the McKenzie method and “Advice” only to stay active. The inter- and intratester reliability of clinical tests seemed to be at an acceptable level globally, although tests had both high and low reliability among test categories. Intratester reliability was slightly better than intertester reliability. Of all the selected clinical tests, few tests were moderately sufficient in sorting the chronic low back pain patients (CLBP) from subacute low back pain patients (SLBP), and distinguishing patient groups from controls. These 31 clinical tests quite poorly sorted the CLBP or SLBP patients from the controls. It may be possible that a combination of tests may enhance the sensitivity and specificity in sorting the CLBP or SLBP patients from the controls. Subclassification into clinical subgroups is reliable in the two most common subgroups also with PTs without specialization in OMT after a short post-graduate training. No further conclusion could be drawn from other subgroups because of the low number of subjects in these categories. The OMT and McKenzie methods, compared to Advice-only to stay active for low back and leg pain, and disability showed no significant difference in effectiveness during a one-year follow-up of working adults. However, the OMT and McKenzie groups showed positive treatment effects compared to the Advice-only group in form of the smaller number of days of sick leave because of LBP. Regarding sick leave days, there was also a statistically significant difference between OMT and McKenzie groups in favor of OMT- physiotherapy. Keywords: orthopedic manual therapy, McKenzie method, clinical tests, sub-classification, low back pain in early phase, randomized controlled trial Author`s address Markku Paatelma Department of Health Sciences University of Jyväskylä P.O. Box 35 40014 Jyväskylä, Finland [email protected] Supervisors Professor Ari Heinonen Department of Health Sciences University of Jyväskylä P.O. Box 35 40014 Jyväskylä, Finland Professor Tapio Videman Faculty of Rehabilitation Medicine University of Alberta Edmonton, Canada Reviewers Docent Jari Ylinen Physical Medicine and Rehabilitation Central Hospital of Central Finland Jyväskylä, Finland Professor Jenny Keating Faculty of Medicine Nursing Department of Physiotherapy Victoria, Australia Opponent Docent Markku Kankaanpää Physical Medicine and Rehabilitation Tampere University Hospital Tampere, Finland ACKNOWLEDGEMENTS This dissertation was carried out in the Department of Health Sciences, University of Jyväskylä during the years 1998-2011. A large number of people have contributed to this work in many different ways and I wish to express my sincere gratitude to all of them. I first like to thank my teachers in Norway, physiotherapists Freddy Kaltenborn and Olaf Evjenth, founders and creators of Orthopedic Manipulative Therapy. They showed me a way in physiotherapy already in early 80th and inspired me to start this thesis. Without their support, Orthopedic Manipulative Therapy would have raised the head much later. I would like to thank my supervisors, professors Ari Heinonen, PT, PhD, Tapio Videman, MD, PhD. I am deeply grateful to my principal supervisor Ari Heinonen for his constant encouragement and advice during the course of this project, being available almost always. I want to express my gratitude to official reviewers of this thesis, Docent Jari Ylinen, MD, PhD, and professor Jenny Keating, PT, PhD. They have had very clear comments and constructive criticism. I am truly indebted and thankful for Jari Ylinen for his time to go through the thesis from page by page. Through his advice this thesis improved a lot. I owe sincere and earnest thankfulness to my co-authors Markku Alèn, MD, PhD, Riitta Simonen, PT, PhD, and especially to Sinikka Kilpikoski, PT, PhD, who finished her thesis last year, for her tireless input for preparing the fourth article. In the second article, Jouko Heiskanen, PT, MD, was a strong generator not only in that paper, but during this whole process, putting a theory to practice. The dissertation would not have been possible without my beloved wife Eira Karvonen, PT, MSc, who was not only one of the co-authors in I-III articles, but far more. She has helped me professionally and intellectualmentally, supported me not to stop, she has helped my financially, and she has taken care of our house, children and grandchildren for these years. My special thanks go to my very good friend Kari Koskikare, Orthopedic Surgeon, MD, who has trained me physically every week in squash court, and given me extra knowledge of low back pain, how to examine, how to treat, and especially when to consult. I am obliged to many of colleagues, especially to Martti Palo, Keijo Pitkämäki, and Mikael Falck, who supported me with taking my tasks, helped me with patients, and divided supervision with me in OMT class. I would like to show my gratitude also to physiotherapists in Palokka Health Care center, who participate in study III, and Jari Rautiainen, PT, for making possible to carry out the study I in his premises. I would like to thank Jukka-Pekka Kesonen, MSc, and Hannu Kautiainen, MSc, for analyzing data statistically. I also thank the Physiotherapist Association in Finland for funding part of my statistical analysis in study IV, and travel costs to WCPT Congress in Vancouver to present one of the articles, and also to Finnish Association for Manual Therapy for sharing several travel costs for international seminars. Thanks go to Finnish Work Environment Fund, whose support helped me to take some weeks free to prepare these articles. Further, I warmly thank my children Liisa and Vesa and their spouses for never-ending support, and grandchildren Arttu and Leo for their understanding of their grand-father’s travels and the time spent in front of computer during week-ends. I feel also sorry that my mother, who had so long awaited the final input, passed away last November, not having possibility to shear my happiness. Last but not least my grate gratitude goes to Carolyn Norris, PhD, for checking the content and author-editing my language, and for given me extra- ordinary important tips for 20 years on how to write. Lahti 11th July 2011 Markku Paatelma