Manual Therapy xxx (2014) 1e5

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Manual Therapy
journal homepage: www.elsevier.com/math

Original article

The relationship between chief complaint and comparable sign in

patients with spinal pain: An exploratory study
Chad Cook a, *, Kenneth Learman b, Chris Showalter c, Bryan O'Halloran d
a
Division of Physical Therapy, Duke University, Durham, NC, USA
b
Division of Physical Therapy, Youngstown State University, Youngstown, OH, USA
c
Maitland Australian Physiotherapy Seminars, Cutchogue, NY, USA
d
Pain Relief and Physical Therapy, Havertown, PA, USA

a r t i c l e i n f o a b s t r a c t

Article history: Many musculoskeletal management philosophies advocate the exploration of the relationship between
Received 5 June 2014 the patient's chief complaint (CC) and the physical examination findings that reproduce/reduce/change
Received in revised form that CC. Geoffrey Maitland developed the concept “comparable sign(s) (CS), which are physical exami-
11 November 2014
nation findings related to the CC(s) that are reproduced during an examination/treatment. These include
Accepted 17 November 2014
observed abnormalities of movement, postures or motor control, abnormal responses to movement,
static deformities, and abnormal joint assessment findings. There are no studies that have explored the
Keywords:
potential clinical relationships between the patient's CC and a CS, thus this exploratory study evaluated
Comparable sign
Low back pain
the associations, outcomes, and prevalence of the findings. This cohort study involved 112 subjects age
Neck pain 54.3 years (SD ¼ 13.4 years), with neck (25.9%) or low back pain (74.1%) who were treated with phys-
Manual therapy iotherapy for an average of 42 days. Data analysis revealed 88.4% identified a CC at baseline. There was a
moderate statistical association between CC and the active physiological finding of a CS (r ¼ 0.36), and
small-moderate associations between all examination phases (r ¼ 0.25e0.37). There were no statistical
differences in pain and disability outcomes for those with and without a CC or CS; however, baseline pain
levels were higher for those without CC (p ¼ 0.04). Further, rate of recovery was lower in those without a
CS during passive physiological examination. The results would suggest that there may be content val-
idity to the concept of CS but further research with larger samples sizes is required to explore the extent
of the validity is warranted.
© 2014 Elsevier Ltd. All rights reserved.

1. Introduction impacting those symptoms initiates the process of determining

Within clinical practice, the term chief complaint (CC) is used to
describe reports of symptoms from the patient during the patient
history. Many musculoskeletal management philosophies espouse
the importance of recognizing the CC of the patient and then
identifying elements of the physical examination that influence the
chief complaint. These philosophies are well documented in or-
thopedic/manual therapy textbooks (Stoddard, 1969; Cyriax, 1975;
Maitland et al., 2001; Dutton, 2013; Cook et al., 2014). It is believed
that establishing primary symptom(s) and the movement patterns
* Corresponding author. Doctor of Physical Therapy Division, Duke University
School of Medicine 104002, 2200 West Main Street, Suite B-230, Durham NC,
27708, USA.
E-mail addresses: chadedwardcook@gmail.com, chad.cook@duke.edu (C. Cook).
whether the problem may be amenable to manual therapy care.
Cyriax (1975) emphasized the significance of establishing the
physical complement to the patient's CC as the “correct symptom”.
Maitland developed the concept comparable sign(s) (CS) over many
years and presented these ideas in his clinical teaching and publi-
cations (Maitland, 1963, 1983). According to Maitland, a CS refers to
the “combination of pain, stiffness, motor response or other findings
which the examiner discovers on physical examination and considers
being comparable with the patient's symptoms as described in the
subjective examination”. Clinically, a CS is integrated with the pa-
tient's CC and the coordinated identification of both is often used to
direct treatment application (Maitland et al., 2001).
At present, despite that the introduction of the concept of the CS
was over 50 years ago there are no studies that have investigated
the relationship of a CS with a chief complaint. This may be related
to the complex multifactorial nature of an examination or the fact

http://dx.doi.org/10.1016/j.math.2014.11.007
1356-689X/© 2014 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Cook C, et al., The relationship between chief complaint and comparable sign in patients with spinal pain: An
exploratory study, Manual Therapy (2014), http://dx.doi.org/10.1016/j.math.2014.11.007
2 C. Cook et al. / Manual Therapy xxx (2014) 1e5
that the CS is typically evaluated continuously throughout all
phases of assessment. The aims of this exploratory study were the
following:
1. Identify trends in distinguishing characteristics of those with
and without a chief complaint.
2. Explore the relationship of the presence of a CC and CS during
selected phases of the examination (during active physiological
movements [AP], passive physiological movements [PP] and
passive accessory movements [PA].)
3. Evaluate trends in outcomes of those with and without a
defined CC or CS to explore differences in pain, recovery, and
disability outcomes.
2. Methods
2.1. Study design
This study was a prospective cohort design in which data were
collected from May of 2011 to April of 2014. The study was
exploratory in concept, and was specifically implemented to
examine the relationship of CS findings at selected examination
phases (e.g., AP, PP, and PA) and the patient's chief complaint. The
examination phases of AP, PP, and PA were selected only for
repeatability purposes and to streamline data collection and ease of
reporting. The design involved no prospective assignment of hu-
man participants or groups of humans to one or more health-
related interventions to evaluate the effects on health outcomes,
thus clinical trials registration was not required.
2.2. Eligibility criteria
2.2.1. Patients
Patients were from eight distinct outpatient physical therapy
clinics in the United States. Subjects were required to be 18 years of
age or older with mechanically producible cervical or lumbar spine
pain during clinical examination movements. By definition, me-
chanically reproducible pain suggests that there is no neoplastic,
infectious, or primarily inflammatory cause (Deyo and Weinstein,
2001). All subjects were required to have a primary diagnosis
demonstrative of spine related disorder; required care beyond a
single visit, and had to speak English.
Exclusion criteria involved presence of red flags (tumor, meta-
bolic disease, rheumatoid arthritis, osteoporosis, prolonged history
of steroid use) and signs consistent with nerve root compression
that resulted in a radiculopathy (i.e., diminished muscle stretch
reflex, or diminished or absent sensation to pinprick in any upper or
lower extremity dermatome). Because tests and measures used to
diagnosis radiculopathy are often specific and not sensitive (Cook
and Hegedus, 2013), we allowed the clinicians to exclude patients
with negative findings on the examination but who they still sus-
pected may have radicular symptoms. Additionally, any history
including prior surgery for a neck or low back related problem or
current pregnancy was cause for exclusion. Prior to inclusion, all
participants signed an informed consent statement which was
approved by a local University Human Ethics committee.
2.2.2. Clinicians
The study included 9 physiotherapists, all of whom had
rigorous, extensive training in manual therapy principles, ortho-
pedic manual therapy certification, or were fellows of the American
Academy of Orthopedic Manual Physical Therapists. All individuals
were educators in the Maitland concept of orthopedic treatment
and were familiar with the use of the CS during the physical
Please cite this article in press as: Cook C, et al., The relationship between chief complaint and comparable sign in patients with spinal pain: An
exploratory study, Manual Therapy (2014), http://dx.doi.org/10.1016/j.math.2014.11.007
examination and the CC during the patient history, and how these
findings influence treatment decision making. All individuals were
instructed to enroll individuals as frequently as possible although
no formal mechanism was used to evaluate enrollment rates,
consecutively of enrollment, or decline rates for study inclusion.
Experience ranged from 12 to 24 years and practice settings were
either hospital-based or private outpatient orthopedic facilities.
2.3. Examination terminology
For the study, the CC was operationally defined during ques-
tioning of the patient (during the patient history). Upon initiation of
an assessment, the patient was asked to describe their CC and was
asked if there was an activity that could provide their familiar pain
or dysfunction. If the patient indicated “yes”, the patient was then
asked if that was what brought them in to see the physiotherapist.
If the CC was elicited it was scored as “yes reproducible” and if a CC
could not be elicited with an activity or a response by the patient
then it was scored as “no, not reproducible”.
The CS was operationally defined as; any assessment-related
combination of pain, stiffness, motor response or other findings
which the examiner discovers on physical examination (Maitland
et al., 2001) that reproduced the familiar pain reported in the pa-
tient's CC or if originally not reported, was able to reproduce the
subjects newly determined chief complaint. Findings were scored as
“present” or “not present”. All CS findings were captured on the
initial visit (initial examination) only and required assessment in
three different physical examination phases (AP, PP, and PA
movements).
2.4. Examination
Prior to involvement, all clinicians participated in a standard-
ized, mandatory 30 min educational webinar that explained the
purpose of the study, the data collection methods, and the re-
quirements for participation. Once part of the study, all clinicians
performed a patient responder-based examination in which feed-
back was gathered with each targeted passive or active movement.
For this study, a standardized examination process was used for all
patients and the process involved documenting the presence or
absence of a CS and formalization of the physical examination
phases of AP, PP, and PA movements.
Active physiological movements were osteokinematic move-
ments that were performed by the patient, and generally consisted
of plane-based, repeated and sustained active movements (flexion,
extension, rotation, side flexion, and combined movements as
needed), in a standing or recumbent position. Passive physiological
movements were similar to AP movements directionally, except
that the examiner moved the patient passively, while assuming
different positions, with repeated bouts or sustained positioning.
Passive accessory movements were designed to reflect arthroki-
nematic movements and consisted of central posterior-anterior or
unilateral posterior anterior glides, or variations including unilat-
eral anterior-posterior glides and rarely transverse glides.
2.5. Intervention
Specific interventions were not the purpose of the study thus
the components of each were not collected. Nonetheless, treatment
interventions were performed pragmatically and almost exclu-
sively consisted of manual therapy, strengthening, and patient-
specific education. To ensure ecological validity, clinicians were
instructed to treat patients as they normally would, outside the
research study.
 C. Cook et al. / Manual Therapy xxx (2014) 1e5
2.6. Outcome measures
Outcomes were collected at baseline, week 2, and discharge.
Discharge was at the discretion of the physiotherapist and averaged
42.8 days. Clinicians were not masked to the outcomes results or the
CC or CS findings of the patients. Primary disability measures
included the Oswestry Disability Index (ODI) (Fairbank et al., 1980)
which was provided to those with low back pain or the Neck
Disability Index (NDI) (Vernon and Mior, 1991) which was provided
to those with neck pain, whereas the primary pain measure included
the numeric pain rating scale (NPRS). The recovery measure
involved the self-report Rate of Recovery (RoR) (Cook et al., 2013).
2.6.1. Oswestry Disability Index
The ODI was used to measure patient disability. The ODI is a
scale of 10 questions with scoring of 0e5 for each question, and the
ODI defines disability as the higher the score, the greater the
disability (Fairbank et al., 1980). The ODI is considered a valid and
reliable instrument (Ostelo and de Vet, 2005). We used percentage
change to determine the change score for each patient. This was
calculated as [(baseline ODI score  final ODI score)/(baseline ODI
score)]  100 (Fritz et al., 2009).
2.6.2. Neck Disability Index
The NDI was created to measure pain related disability associ-
ated with activities of daily living in people with neck pain (Vernon
and Mior, 1991). Content and construct validity and reliability of the
NDI has been previously shown in patients with neck pain (Cleland
et al., 2008). As with the ODI, we used percentage change to
determine the change score for each patient. This was calculated as
[(baseline NDI score  final NDI score)/(baseline NDI score)]  100.
2.6.3. Numeric pain rating scale
The NPRS was used for patient perception of pain intensity using
a scale of 0 (“no pain”) to 10 (“worst pain imaginable”). The NPRS
has been found to be reliable and responsive (Childs et al., 2005).
We also used a percentage change as our outcome measure. This
was calculated as: [(baseline NPRS score  final NPRS score)/
(baseline NPRS score)]  100.
2.6.4. Rate of recovery
The RoR was originally described as the single assessment
numeric evaluation (SANE) by Williams et al. (1999) but was
modified and called RoR by Cook et al. (2013) in a randomized trial
for low back pain. We used the same language used by Cook and
colleagues. Patients were asked to rate their recovery at discharge
from 0 percent (meaning no recovery at all) to 100 percent
(meaning totally recovered). This method has been used and vali-
dated with patients with shoulder pain (O'Halloran et al., 2013) and
low back pain (Wright and Cook, 2013).
Table 1
Descriptive statistics of the sample population (N ¼ 112).
Variable Full sample mean/SD I
frequency (N ¼ 112)
Age (years) 54.3 (13.4)
Gender 48 ¼ Male
64 ¼ Female
Body mass index 26.4 (4.0)
Duration of symptoms (weeks) 11.9 (19.3)
ODI/NDI at baseline (0e100) 32.8 (17.4)
Pain score at baseline (0e10) 5.8 (2.1)
Irritability 30 ¼ Yes
79 ¼ No
Neck or back pain 83 ¼ Low back
29 ¼ Neck
Bold indicates significance at <0.05.
Please cite this article in press as: Cook C, et al., The relationship between chief complaint and comparable sign in patients with spinal pain: An
exploratory study, Manual Therapy (2014), http://dx.doi.org/10.1016/j.math.2014.11.007
3
2.7. Sample size estimation
The study was exploratory and exploratory studies are per-
formed to generate new hypotheses that can then be formally
tested. In such experiments, the usual aim is to look for patterns of
response, often evaluating many data comparisons (Dell et al.,
2002). Data collected in exploratory experiments is normally used
to create sample size calculations for future hypotheses generated
by the exploration. We targeted a sample size of appropriately
100e125 subjects because we felt that we could identify patterns
within the data in a regression model if we elected to use one.
2.8. Data analysis
All analyses completed were performed using Statistical Pack-
age for the Social Sciences (SPSS), version 21.0 (IBM Corp, Armonk,
NY). In the single instance in which missing data was present, the
mean of the age of the sample was used. Descriptive statistics were
used to describe the full patient sample. The relationship between
CC and the CS findings in AP, PP, and PA were evaluated using the
phi coefficient/Cramer's V coefficient, both of which are conserva-
tive measures of association for nominal variables and provide the
same values. Cohen (1988) characterized a correlation of 0.10 as
depicting a small relationship, a correlation of 0.30 as a moderate
relationship, and a correlation of 0.50 as a large/strong relationship.
For conservative identification of differences in outcomes between
those with and without a CC/CS were evaluated using a Mann
Whitney U. For all analyses, a p value of 0.05 was considered
significant.
3. Results
The study enrolled 83 (74.1%) patients with low back pain and
29 (25.9%) with neck pain. Of the 112, most were Caucasian (95.5%),
the majority were female (N ¼ 64; 57%), and the mean age was 54.3
years (SD ¼ 13.4 years). The baseline ODI was 32.8/100 (SD ¼ 17.8)
whereas the baseline NDI was 32.7/100 (SD ¼ 16.8). The baseline
pain scores were a mean of 5.76 (SD ¼ 2.1) and individuals were
seen for a mean of 10.4 total visits (SD ¼ 8.3). The average duration
of symptoms was 11.9 weeks (SD ¼ 19.3).
Of the 112, a CC was identified in 99 individuals (88.4%). A CS
during the active physiological examination was found in 82.9% of
cases, whereas a CS for the passive physiological examination was
found in 65.2% of cases. A CS during the passive accessory exami-
nation was found in 90.2% of cases. When divided by “yes, repro-
ducible” and “no, not reproducible”, there were significant
differences in baseline pain between those with and without a CC
with individuals who did not report an activity that could repro-
duce their CC reporting significantly more pain (p ¼ 0.04). Table 1
outlines the descriptive statistics of the full cohort and the
Patients with CC mean/SD Patients without definable P value
I frequency (N ¼ 99) CC mean/SD I frequency (N ¼ 13)
54.2 (13.4) 55.0 (14.5) 0.85
43 ¼ Male 5 ¼ Male 0.73
56 ¼ Female 8 ¼ Female
26.4 (3.9) 26.9 (4.7) 0.64
10.9 (14.2) 19.4 (41.5) 0.13
32.7 (17.6) 33.5 (16.6) 0.88
5.6 (2.0) 6.9 (2.3) 0.04
25 ¼ Yes 5 ¼ Yes 0.34
71 ¼ No 8 ¼ No
75 ¼ Low back 8 ¼ Low back 0.27
24 ¼ Neck 5 ¼ Neck
4 C. Cook et al. / Manual Therapy xxx (2014) 1e5

distinguishing characteristics of those with and without a chief Table 3

complaint. Percent change scores and rate of recovery in those with and without comparable
signs and symptoms at baseline.
Statistically significant, small and moderate relationships were
present among occurrences of the CS among all the physical ex- Movement Present at Not present at P value
amination components (AP, PP, and PA). The strongest relationship baseline baseline

present was between AP and PP (0.37; p < 0.01). The association of CC patient history (present in)
CC with CS was significant only during AP movements (0.36; Pain change score 69.5 (31.1) 67.9 (31.3) 0.07
ODI/NDI change score 66.1 (36.2) 52.7 (35.4) 0.68
p < 0.01) and that relationship was moderate (see Table 2).
Rate of recovery 83.0 (20.8) 79.6 (20.5) 0.33
Average ODI percentage change scores for patient with LBP were CS active physiological examination
64.6% (SD ¼ 35.9), average NDI percentage change score for those Pain change score 71.8 (29.3) 59.0 (36.3) 0.19
with neck pain were 64.1% (SD ¼ 37.8), and average pain percentage ODI/NDI change score 67.7 (32.8) 55.6 (40.0) 0.23
Rate of recovery 83.8 (19.8) 76.7 (24.9) 0.26
change scores were 71.2% (SD ¼ 28.8) for those with LBP and 63.4%
CS passive physiological examination
(SD ¼ 36.6) for those with neck pain. Rate of recovery percentages Pain change score 73.3 (26.0) 61.7 (37.9) 0.23
were 83.5% (SD ¼ 19.6) for low back pain and 79.7% (SD ¼ 23.9) for ODI/NDI change score 69.1 (35.1) 55.8 (37.3) 0.07
neck pain. Descriptively, outcome scores were almost always lower Rate of recovery 87.2 (15.2) 74.4 (26.3) 0.02
in subjects without an identified CC/CS at baseline. Rate of recovery CS passive accessory examination
Pain change score 71.5 (28.8) 48.9 (42.3) 0.10
was significantly lower in those without a CS during PP (74.4%
ODI/NDI change score 66.6 (34.8) 45.9 (44.8) 0.15
versus 87.2%, p ¼ 0.02) (Table 3). Rate of recovery 83.7 (19.8) 72.8 (27.3) 0.10

CC ¼ Chief compliant; CS ¼ Comparable sign; ODI ¼ Oswestry Disability Index;

4. Discussion NDI ¼ Neck Disability Index.
Bold indicates significance at <0.05.

The aims of this study were to explore the relationship of the

occurrences of CC and CS (identified during AP, PP, and PA move-
ments), and to evaluate the presences of differences in pain, re-
covery, and disability outcomes. As stated, there is an implied
clinical value in the philosophical concept of identifying the CS and
its relationship to the CC of the patient (Stoddard, 1969; Cyriax,
1975; Maitland et al., 1997; Dutton, 2013; Cook et al., 2014). We
found that the identification of a CC/CS during the patient history
and clinical examination in our sample is very common and that
the AP, PP, and PA findings were moderately statistically associated
with one another. We did not find notable differences in outcomes
in those with and without CS findings, with the exception of rate of
recovery during the PP examination.
Interestingly, the only significant relationship found between
the CC and any of the physical examination boundaries was with AP
examination; which demonstrated a moderate statistical relation-
ship. There are two possible reasons for this finding. First, patients
may be more cognizant of active movements that reproduce their
CC, since by definition a CC included an activity that reproduced
their primary symptoms. Second, within the Maitland concept
adopted by the physiotherapists, gentle overpressures are used to
“rule out” an AP movement as a contributor to the CC of the patient.
It may be that the comprehensiveness associated with the over-
pressures was what assisted the patient in identifying the rela-
tionship between the two clinical findings. Worth noting is that the
Mechanical Diagnosis and Treatment concept commonly uses active
movements to link findings with the patient's CC; a concept that
has been used in a number of clinical trials (Hefford, 2008; Rosedale
et al., 2014).
We found significant associations between all three of the
physical examination phases (AP, PP, and PA). This is a unique
finding which complements the importance of examining all three
phases (Maitland, 1963, 1983) during clinical assessment. To our
knowledge, it's the first time a study has explored the relationships
of phases of the examination. The small to moderate relationships
also suggests that varying clinical patterns may emerge during the
physical assessment process.
Although there were very similar frequencies, the CS finding
within the PA examination boundary was the most frequent among
the 3 sub-groups. Interestingly, patient's reported a higher per-
centage of reproduction of their symptoms (90.2%) than when
queried regarding a CC (88.4%). This suggests that clinicians were
able to reproduce the patient's CC at a slightly higher percentage
than the patient was able to identify themselves. It also reflects the
highly sensitive nature of PA movements such as the posterior-
anterior glide, which have been used in clinical practice to accu-
rately implicate selected concordant spinal levels (Jull et al., 1988;
Phillips and Twomey, 1996; Schnieder et al., 2014).
There was only one statistically significant finding that sug-
gested that those without a CC or CS finding during the initial ex-
amination had poorer overall outcomes; although descriptively, the
outcomes for those without a CC or CS were lower in every single
category. Rate of recovery was lower in those without a CS during
PP (74.4% versus 87.2%, p ¼ 0.02). In this trial in order to achieve
ecological validity, clinicians were instructed to treat patients as
they normally would, outside the research study. Specific inter-
vention types were not captured thus it is unknown if clinicians
used treatment approaches that are more commonly associated
with use of a CC or CS (e.g., manual therapy) or treatment methods
that were more guideline-oriented (i.e., exercise) or those that were
designed to reduce pain only (i.e., modalities).
Lastly, it is quite intuitive that this clinical reasoning process that
incorporates the assessment and relationship between CC and CS
has face validity; however, this philosophy is not without criticism.
In chronic conditions, an emerging philosophy contends that there

Table 2
Relationship the occurrences of CC and CS (identified during active physiological movements, passive physiological movements and passive accessory movements) using phi
coefficient and Cramer's V coefficient.

CC (patient history) CS (active physiological) CS (passive physiological) CS (passive accessory)

CC (patient history)
CS (active physiological) 0.36 (p < 0.01)
CS (passive physiological) 0.03 (p ¼ 0.74) 0.37 (p < 0.01)
CS (passive accessory) 0.07 (p ¼ 0.47) 0.25 (p < 0.01) 0.26 (p < 0.01)

CC ¼ Chief compliant; CS ¼ Comparable sign.

Bold indicates significance at <0.05.

Please cite this article in press as: Cook C, et al., The relationship between chief complaint and comparable sign in patients with spinal pain: An
exploratory study, Manual Therapy (2014), http://dx.doi.org/10.1016/j.math.2014.11.007
 C. Cook et al. / Manual Therapy xxx (2014) 1e5
is limited correlation between specific tissues and movement pat-
terns. The mind-body syndrome philosophy advocated by Nijs and
colleagues (2013), espouses the belief that most chronic pain states
are mediated and fundamentally provoked by unconscious nega-
tive emotional states and that the beginning of the management for
mind-body syndrome is to accept this underlying fact and cease
searching for a cure for a non-existent pathoanatomic cause for
pain. If this philosophy were true, identifying the CC would be
necessary in the treatment but the psychosocial attributes should
be considered in addition to the patient's CC and CS. There are likely
numerous conditions that may not be amenable to identification of
a specific CS that changes the patient's chief complaint, including
non-mechanical pain, inflammatory mediated pain, centrally
mediated pain or other mechanisms or pathology (e.g., fibromyal-
gia, complex regional pain syndrome, chronic pain syndrome)
acting within the patient, whereby the CC is not restricted to
particular spinal segments or regions. Further, it is entirely possible
that patients not expressing clear CC may better fit these pathol-
ogies. Future studies are needed to better understand if sub-
categories of CC exist.
4.1. Limitations
This study has several limitations. The sample size is relatively
small for between group comparisons of those with and without a
CS, thus risking a type II error. The small percentage of subjects did
not report CC required a more conservative nonparametric statis-
tical analysis. Other demographic or clinical variables that may
impact the interpretation of CC and CS were not collected such as
fear avoidance measures, or other psychosocial components such
as depression, anxiety or coping. Our sample was mostly acute/sub-
acute, thus we were underrepresented by patients with central
mediated symptoms or chronic pain. We did not evaluate whether
patients were consecutively enrolled thus some bias may be pre-
sent in the inclusion of the sample.
5. Conclusion
Within our limited sample both CC and CS findings were com-
mon examination findings. The moderate relationship between a
patient's CC and a CS found during an AP examination may be
reflective of the way CC is conceptualized by the patient. Future
studies should evaluate whether different treatment methods are
needed when CC or CS is or isn't found during an examination.
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