Systematic Review
Are within and/or between session improvements in pain and function prognostic of medium and long-term improvements in musculoskeletal problems? A systematic review

https://doi.org/10.1016/j.msksp.2019.102102Get rights and content

Highlights

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    Within and between session changes are thought to be good prognostic factors.

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    This systematic review identified 13 studies that investigated this association.

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    The evidence for changes in pain location as a prognostic factor was inconclusive.

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    No evidence for within session changes in pain intensity as prognostic factor.

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    Very limited evidence for prognostic value of between-session changes on disability.

Abstract

Background

Initial or between session improvements in pain and/or function are often considered to be predictive of ultimate outcomes in musculoskeletal problems.

Objective

To determine the long-term prognostic value of within and between session improvements to pain and function.

Design

Systematic review of relevant literature.

Method

A search was made of multiple databases (Pubmed/Medline, Cochrane, Cinahl, and AMed) using relevant search terms. Titles, abstracts, and then full texts were filtered to find articles that met the strict inclusion/exclusion criteria. Searching, data extraction, and quality assessment, using GRADE, were done independently by two authors. Disagreements were resolved by consensus.

Results

Only 13 articles met the criteria for inclusion. For the effect of pain location or pain intensity changes in the first treatment session on medium or long-term pain, disability, return-to-work, or global outcomes nine outcomes were available. Findings were mostly inconclusive (5) or negative (3). There was only one study evaluating between session improvements with ambiguous results. There were no studies evaluating the prognostic value of early improvements in function.

Conclusions

There is no conclusive evidence to support the concept that early changes in pain location or pain intensity offer a good longer-term prognosis on a variety of outcomes; and no evidence relating to early improvements in function. The idea that patients who appear to improve in the first treatment session will do well longer term is not supported by the literature.

Introduction

There have been several ways that researchers have used to try to identify those who respond better to an intervention, such as secondary analyses, which attempt to distinguish between those who responded and those who did not. Clinical prediction rules and classification-based treatments attempt to be more selective about who receives a particular intervention, thus more akin to real clinical practice, as opposed to ‘all-comers' receiving the same intervention as in a standard RCT (May et al., 2008).

In clinical practice, one of the main approaches used to guide management is a systematic approach that continues treatment if it leads to improvement, but discards an intervention when there is no change (Tuttle, 2009). Changes are commonly used as day-to-day indicators of a patient's progress, monitored through neurological symptoms, pain, active range of movement; or clinician's impression of passive mobility (Tuttle, 2009). In this context, different therapy approaches such as Maitland, Mulligan, McKenzie, and the shoulder symptom modification procedure use immediate changes in symptoms to guide treatment (Maitland et al., 2005; McKenzie and May 2003; Meakins et al., 2018; Mulligan, 2003).

In all these approaches, an apparently initial positive response is used as an indicator for on-going management, which it is hoped will lead to an overall improvement in the patients' signs and symptoms. So within and/or between session improvements in these parameters are being used to predict a persistent positive prognosis. Obviously, a corollary of this is that these 'responders' do better overall than ‘non-responders.'

However, it is currently unclear if immediate or very short-term changes have any longer-term prognostic value (Tuttle, 2009). Therefore, the aim of this systematic review was to address the question, if within and/or between session improvements in pain and/or function are prognostic of medium and/or long-term improvements in musculoskeletal problems?

Section snippets

Study selection and reporting

Any full-text study that reported some aspect of within or between session change in either pain or function, and reported follow-up at some later date was included. PRISMA guidelines for reporting systematic reviews were followed (Moher et al., 2009). The protocol for the systematic review was registered on PROSPERO (CRD42018109766).

Inclusion/exclusion criteria

Inclusion criteria:

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    Any musculoskeletal condition

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    Any study design with follow-up, such as RCT or cohort, published as a full article

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    Outcome measures that included

Study selection and characteristics of studies

Fifty-five full text papers were initially thought relevant to this review, but only 13 were finally included (Fig. 1). The most common reasons for exclusion were: lack of within or between-session changes, lack of medium or long-term follow-up, or that follow-up timings were not clearly defined. The thirteen studies dealt predominantly with patients with low back pain (10), and one each with neck, shoulder or hip pain. Seven were prospective cohort studies and six were secondary analyses of

Findings of the review

This review set out to explore the common concept that early changes to pain and function are able to predict patients who will respond well to the interventions used at medium or long-term. Surprisingly few studies could be included (n = 13). All studies reported within session changes, and only one between sessions changes. The identified studies have allowed investigation of 10 different outcomes of which seven were in the medium-term and three in the long-term. The overall quality of

Conclusion

In this systematic review we included 13 studies that explored whether within session improvements in pain location, pain severity and function were prognostic of medium and/or long-term pain and/or functional outcomes. The findings did not support the concept that initial changes in pain severity predicted later outcomes, and the evidence for changes in pain location was mostly inconclusive. No studies investigated if early changes in function predicted later outcomes. Only one study

Ethical approval

Not applicable.

Funding

None declared.

Declaration of competing interest

None declared.

References (44)

  • C.E. Cook et al.

    Can experienced physiotherapists identify which patients are likely to succeed with physical therapy treatment?

    Arch. Physiother.

    (2015)
  • C. Cook et al.

    Does early change predict long-term (6 months) improvements in subjects who receive manual therapy for low back pain?

    Physiother. Theory Pract.

    (2017)
  • R.A. Coronado et al.

    The temporal effect of a single session of high velocity, low-amplitude thrust manipulation on subjects with spinal pain

    Phys. Ther. Rev.

    (2010)
  • S.L. Edmond et al.

    Association between centralization, depression, somatization, and disability among patients with nonspecific low back pain

    J. Orthop. Sport. Phys. Ther.

    (2010)
  • A.D. Furlan et al.

    Editorial board Cochrane back review group

    Spine

    (2009)
  • J.C. Garrison et al.

    Between-session changes predict overall perception of improvement but nut functional improvement in patients with shoulder impingement syndrome seen in physical therapy: an observational study

    Physiother. Pract.

    (2011)
  • S.Z. George et al.

    The centralization phenomenon and fear-avoidance beliefs as prognostic factors for acute low back pain: a preliminary investigation involving patients classified for specific exercise

    J. Orthop. Sport. Phys. Ther.

    (2005)
  • L. Hartvigsen et al.

    Clinical examination findings as prognostic factors in low back pain: a systematic review of the literature

    Chiropr. Man. Ther.

    (2015)
  • J.A. Hayden et al.

    Evaluation of the quality of prognosis studies in systematic reviews

    Ann. Intern. Med.

    (2006)
  • J.A. Hayden et al.

    Assessing bias in studies of prognostic factors

    Ann. Intern. Med.

    (2013)
  • E.J. Hegedus et al.

    Systematic review. The neurophysiological effects of a single session of spinal joint mobilization: does the effect last

    J. Man. Manip. Ther.

    (2011)
  • A. Huguet et al.

    Judging the quality of evidence in reviews of prognostic factor research: adapting the GRADE framework

    Syst. Rev.

    (2013)

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