Synopsis Manual therapy interventions are popular among individual health care providers and their patients; however, systematic reviews do not strongly support their effectiveness. Small treatment effect sizes of manual therapy interventions may result from a "one-size-fits-all" approach to treatment. Mechanistic-based treatment approaches to manual therapy offer an intriguing alternative for identifying patients likely to respond to manual therapy. However, the current lack of knowledge of the mechanisms through which manual therapy interventions inhibit pain limits such an approach. The nature of manual therapy interventions further confounds such an approach, as the related mechanisms are likely a complex interaction of factors related to the patient, the provider, and the environment in which the intervention occurs. Therefore, a model to guide both study design and the interpretation of findings is necessary. We have previously proposed a model suggesting that the mechanical force from a manual therapy intervention results in systemic neurophysiological responses leading to pain inhibition. In this clinical commentary, we provide a narrative appraisal of the model and recommendations to advance the study of manual therapy mechanisms. J Orthop Sports Phys Ther 2018;48(1):8-18. doi:10.2519/jospt.2018.7476.

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Prediction of clinical outcomes by psychology-based measures was dependent upon the clinical outcome domain of interest. Similar to studies from the primary care setting, initial screening with the SBT provided additional prognostic information for 6-month disability and changes in SBT overall scores may provide important clinical decision-making information for treatment monitoring.

about their care, even when faced with a serious diagnosis. Shared decision making is essential to ensure that individuals are supported to make decisions that are right for them. Using a collaborative process, the clinician should highlight the treatment options, evidence, risks, and benefits and, together with the person, seek to understand how these fit with that person's circumstances, goals, values, and beliefs. 56

Key Points Question Is the transition from acute to chronic low back pain (LBP) associated with risk strata, defined by a standardized prognostic tool, and/or with early exposure to guideline nonconcordant care? Findings In this cohort study of 5233 patients with acute LBP from 77 primary care practices, nearly half the patients were exposed to at least 1 guideline nonconcordant recommendation within the first 21 days after the index visit. Patients were significantly more likely to transition to chronic LBP as their risk on the prognostic tool increased and as they were exposed to more nonconcordant recommendations. Meaning In this study, the transition rate to chronic LBP was substantial and increased correspondingly with risk strata and early exposure to guideline nonconcordant care.

Study Design Clinical measurement, cross-sectional. Background Pain-associated psychological distress adversely influences outcomes for patients with musculoskeletal pain. However, assessment of pain-associated psychological distress (ie, yellow flags) is not routinely performed in orthopaedic physical therapy practice. A standardized yellow flag assessment tool will better inform treatment decision making related to psychologically informed practice. Objectives To describe the development of a concise, multidimensional yellow flag assessment tool for application in orthopaedic physical therapy clinical practice. Methods A 136-item yellow flag item bank was developed from validated psychological questionnaires across domains related to pain vulnerability (negative mood, fear avoidance) and resilience (positive affect/coping). Patients seeking physical therapy with neck, back, knee, or shoulder pain completed the item bank. Iterative statistical analyses determined minimal item sets meeting thresholds for identifying elevated vulnerability or low resilience (ie, upper or lower quartile, as indicated). Further item reduction yielded a concise yellow flag assessment tool to assess 11 psychological constructs measuring pain-associated psychological distress. Correlations between the assessment tool and individual psychological questionnaires were measured and compared between anatomical regions. Concurrent validity was assessed by determining variance explained in pain and disability scores by the assessment tool. Results Subjects with elevated vulnerability and decreased resilience were identified with a high degree of accuracy (minimum of 85%) using a 17-item tool. Correlations were moderate to high between the 17-item tool and individual psychological questionnaires, with no significant differences in correlations between different anatomical regions. Shorter 10- and 7-item versions of the assessment tool allow clinicians the flexibility to assess for yellow flags quickly with acceptable trade-offs in accuracy (81% and 75%, respectively). All versions of the tool explained significant additional variance in pain and disability scores (range, 19.3%-36.7%) after accounting for demographics, historical variables, and anatomical region of pain. Conclusion Concise assessment of yellow flags is feasible in outpatient physical therapy settings. This multidimensional tool advances assessment of pain-associated psychological distress through the addition of positive affect/coping constructs and estimation of full questionnaire scores. Further study is warranted to determine how this tool complements established risk-assessment tools by providing the option for efficient treatment monitoring. J Orthop Sports Phys Ther 2016;46(5):327-345. Epub 21 Mar 2016. doi:10.2519/jospt.2016.6487.

t he fear-avoidance model of musculoskeletal pain (FAM) has been highlighted as a psychological model of potential importance for rehabilitation. 33 The FAM proposes that during a musculoskeletal pain episode, anxiety, pain-related fear, and pain catastrophizing interact to determine whether an individual will resume normal activities (low psychological distress) or will avoid normal activities due to anticipation of increased pain and/or reinjury (high psychological distress). 33,35,60 The FAM suggests that high psychological distress will be associated with poor clinical outcomes, potentially resulting in depressive symptoms, elevated pain intensity, greater physical impairments, and continued disability. 33,35,60 Evidence supporting validity of the FAM can be found in the clinical studies of low back pain (LBP). Longitudinal studies have indicated that elevated FAM measures were predictive of poor outcomes for individuals with LBP. 2,12,14,44,46,52 Furthermore, effective FAM treatment strategies have been reported, including patient education, 3,5 graded exercise, 13,36 and graded exposure. 6,20,21,37,58,59 While portions of the FAM are well supported in the literature, there are unresolved questions and issues affecting its application in clinical settings. 33One unresolved issue is related to measurement of FAM constructs in outpatient physical therapy settings, which is the focus of this particular study. The FAM is associated with multiple psychological constructs, and there are several available measurement tools. Examples include the Fear-Avoidance Beliefs Questionnaire (FABQ), 61 Fear of Pain Questionnaire (FPQ), 40 Tampa �ca-Tampa �ca-le for Kinesiophobia (T�K), 64 and Pain Catastrophizing �cale (PC�). 49 Typically, psychometric studies incorporate 1 or 2 t sTuDY DesiGn: Validity and test-retest reliability of questionnaires related to the fear-avoidance model (FAM).t oBJeCTiVe: To investigate test-retest reliability, construct redundancy, and criterion validity for 4 commonly used FAM measures.t BaCkGrounD: Few studies have reported psychometric properties for more than 2 FAM measures within the same cohort, making it difficult to determine which specific measures should be implemented in outpatient physical therapy settings.t MeTHoDs: Fifty-three consecutive patients (mean age, 44.3  18.5 years) with chronic low back pain participated in this study. Data were collected with validated measures for FAM constructs, including the Fear-Avoidance Beliefs Questionnaire (FABQ), Fear of Pain Questionnaire (FPQ), Tampa Scale for Kinesiophobia, and Pain Catastrophizing Scale. Validated measures were used to investigate criterion validity of the FAM measures, including the Patient Health Questionnaire for depression, the numerical rating scale for pain intensity, the Physical Impairment Scale for physical impairment, and the Oswestry Disability Questionnaire for self-report of disability. Test-retest reliability of the FAM measures was determined with intraclass correlation coefficients (ICC 2,1 ) for total ...

The SBT may provide important prognostic information for physical therapists.