ndi university award center san marcos tx

Comments

Transcription

ndi university award center san marcos tx
[
research report
]
Robert E. Boyles, PT, DSc1 • Michael J. Walker, PT, DSc2 • Brian A. Young, PT, DSc3
Joseph B. Strunce, PT, DSc4 • Robert S. Wainner, PT, PhD5
The Addition of Cervical Thrust
Manipulations to a Manual Physical Therapy
Approach in Patients Treated for Mechanical
Neck Pain: A Secondary Analysis
M
echanical neck pain is
defined as pain that
can be provoked by
neck movements or
provocative tests.2 Neck pain
is a common musculoskeletal
complaint, with a reported
lifetime prevalence of 22% to
67%10 and a point prevalence
of 13% to 22%.34 Up to 41% of
patients with neck pain seek care
from a general practitioner and
33% from a physical therapist.31
The Guide to Physical Therapist Practice1 outlines several physical therapy
interventions suitable for the management of patients with mechanical neck
pain. These interventions include manual physical therapy, exercise, traction,
physical agents, and mechanical and
electrotherapeutic modalities.1 Despite
their common use, existing research has
produced insufficient evidence regarding
the effectiveness of these interventions
and the clinical decision-making strategies to guide their use.15-18 Current best
evidence supports the multimodal use of
manual physical therapy (MPT), includ-
ing cervical thrust and/or nonthrust manipulation, and exercise
for patients with cervicogenic
SUPPLEMENTAL
VIDEO ONLINE
t STUDY DESIGN: Secondary analysis of a
randomized clinical trial (RCT).
t OBJECTIVES: To perform a secondary analysis
on the treatment arm of a larger RCT to determine
differences in treatment outcomes, adverse reactions, and effect sizes between patients who received cervical thrust manipulation and those who
received only nonthrust manipulation as part of an
impairment-based, multimodal treatment program
of manual physical therapy (MPT) and exercise for
patients with mechanical neck pain.
t BACKGROUND: A treatment regimen of MPT
and exercise has been effective in patients with
mechanical neck pain. Limited research has compared the effectiveness of cervical thrust manipulations and nonthrust mobilizations for this patient
population, and no studies have investigated the
added benefit of cervical thrust manipulations as
part of an overall MPT treatment plan.
t METHODS: Treatment outcomes from 47
patients in the treatment arm of a larger RCT, with
a primary complaint of mechanical neck pain, were
analyzed. Twenty-three patients (49%) received
cervical thrust manipulations as part of their MPT
treatment, and 24 patients (51%) received only cervical nonthrust mobilizations. All patients received
up to 6 clinic sessions, twice weekly for 3 weeks,
and a home exercise program. Primary outcome
measures were the Neck Disability Index (NDI), 2
headache and mechanical neck
pain.5,17,18 Hoving et al21,22 and
Korthals-de Bos et al28 reported
visual analog scales for cervical and upper extremity
pain, and a 15-point global rating of change scale.
Blinded outcome measurements were collected at
baseline and at 3-, 6- and 52-week follow-ups.
t RESULTS: Consistent with the larger RCT, both
subgroups in this secondary analysis demonstrated improvement in short- and long-term pain and
disability scores. Low statistical power (β.28)
and the resultant small effect size indices (–0.21 to
0.17) preclude the identification of any betweengroup differences. No serious adverse reactions
were reported by patients in either subgroup.
t CONCLUSIONS: Clinically meaningful and
statistically significant improvements in both subgroups of patients over time suggest that cervical
thrust manipulation, as part of the MPT treatment
plan, did not influence the results of the treatment
arm of the larger RCT from which this study was
drawn. Although no between-group differences can
be identified, the small observed effect sizes in this
study may benefit future studies with sample size
estimation for larger RCTs and indicate the need
to incorporate clinical prediction rule criteria as a
means to improve statistical power.
t LEVEL OF EVIDENCE: Therapy, level 4. J
Orthop Sports Phys Ther 2010;40(3):133-140.
doi:10.2519/jospt.2010.3106
t KEY WORDS: cervical spine, manual therapy,
mobilization
Associate Professor, University of Puget Sound, School of Physical Therapy, Tacoma, WA. 2Assistant Professor, US Army-Baylor University Doctoral Program in Physical Therapy,
Fort Sam Houston, TX. 3Physical Therapy Element Chief, United States Air Force, Sheppard Air Force Base, TX. 4Director of Rehabilitation Department, Northern Navajo Medical
Center, Shiprock, NM. 5Associate Professor, Department of Physical Therapy, Texas State University, San Marcos, TX. This study was approved by The Institutional Review Boards
of Brooke Army Medical Center and Wilford Hall Medical Center. The opinions or assertions contained herein are the private views of the authors and are not to be construed as
official or as reflecting the views of the Departments of the Army, Air Force, or Defense. Address correspondence to Dr Robert E. Boyles, Associate Professor, University of Puget
Sound, School of Physical Therapy, 1500 N Warner St, #1070, Tacoma, WA 98416. E-mail: [email protected]
1
journal of orthopaedic & sports physical therapy | volume 40 | number 3 | march 2010 |
40-03 Boyles.indd 133
133
2/17/10 2:49:30 PM
[
superior patient perceived recovery and
cost effectiveness when using cervical
nonthrust manipulations as compared
to general practitioner care or physical
therapy that did not include nonthrust
manipulations for patients with neck
pain greater than 2 weeks in duration.
Cervical thrust manipulation and exercise
resulted in better patient outcomes and
satisfaction levels when compared to the
use of manipulation or exercise alone.3,12
In a recent randomized controlled trial,
Walker et al38 compared the effectiveness
of MPT and exercise to a minimal intervention approach in 94 patients with
acute, subacute, or chronic mechanical
neck pain with or without upper extremity symptoms. Unlike previous studies,
the MPT techniques included both thrust
and nonthrust manipulations applied to
the cervical spine, thoracic spine, and adjacent ribs. Walker et al33 demonstrated
significant short-term (3- and 6-week)
and long-term (1-year) improvements
in pain, disability, and patient perceived
recovery following up to 6 treatment sessions consisting of a multimodal use of
MPT and exercise.
Three studies4,23,37 have directly compared the effectiveness of cervical thrust
manipulation versus nonthrust manipulation for the treatment of patients with
acute, subacute, and chronic neck pain.
No differences in short- and long-term
pain relief and disability were reported in
these trials when comparing these MPT
interventions.18 Despite these similar results, Hurwitz et al24 reported that adverse
reactions were more common in patients
following cervical thrust manipulation,
and that these adverse reactions negatively
affected patient satisfaction, perceived improvement, and pain and disability scores
at subsequent follow-up visits.
The purpose of this study was to perform a secondary analysis on the treatment arm of a larger RCT38 to determine
differences in treatment outcomes, adverse reactions, and effect sizes between
patients who received cervical thrust
manipulation and those who received
only nonthrust manipulation, as part of
research report
FIGURE 1. Cervical thrust gapping manipulation in
flexion for left C4-5 opening restriction (ONLINE VIDEO).
an impairment-based, multimodal treatment program of MPT and exercise for
patients with mechanical neck pain.
METHODS
Subjects
N
inety-four patients referred
to 3 outpatient military treatment
facilities with a primary complaint
of neck pain were included in the initial
multicenter RCT.38 Inclusion criteria for
this RCT were the following: a primary
complaint of neck pain, with or without
unilateral upper extremity symptoms;
age greater than 18 years; a Neck Disability Index (NDI) score equal to or greater
than 10 points; and a composite visual
analog scale (VAS) pain score equal to or
greater than 30 mm, as derived from 3
separate 100-mm pain scales measuring
the patient’s cervical, upper extremity,
and average 24-hour pain scores. Patients
were excluded if they had a whiplash injury within the past 6 weeks, a history of
spinal tumors, spinal infection, cervical
spine fracture, or previous neck surgery, a
pending legal action regarding their neck
pain, a diagnosis of central cervical spinal
stenosis, bilateral upper extremity symptoms, or 2 positive neurological findings
at the same nerve root level.
Eligible patients were randomly assigned to 2 treatment groups: MPT and
exercise (n = 47) or minimal intervention (n = 47). Each patient underwent
a standardized history and physical
]
FIGURE 2. Cervical thrust manipulation in extension
for right C4-5 closing restriction (ONLINE VIDEO).
examination of the cervical spine and
upper quarter prior to randomization,
where demographic information, selfreport measures, and physical exam
measurements (ie, cervical range of motion, passive accessory mobility and pain
provocation testing, cervical special testing, etc) were collected. The self-report
scores from the 47 patients (31% female;
mean  SD age, 48.8  14.1 years) assigned to the MPT and exercise group of
the RCT were analyzed for the purposes
of this secondary analysis.
Interventions
Patients within the treatment arm received MPT and exercise directed at impairments of the cervical spine, thoracic
spine, and adjacent ribs, as identified by
the treating physical therapist. The specific manual interventions applied (which
included the use of thrust and nonthrust
techniques) and the intervention parameters used (grade, duration, and repetitions) were solely based on the clinical
reasoning and decision making of the
treating therapists. Although numerous
cervical manipulative techniques exist,
2 techniques were predominantly used.
Spinal stiffness in flexion, described as
“opening restrictions,” was treated in
flexion with a translatory thrust gapping
manipulation applied to the contralateral side of the restricted motion segment
(FIGURE 1 , ONLINE VIDEO). Spinal stiffness in
extension, described as “closing restrictions,” was treated in extension with a
caudally and slightly medially directed
134 | march 2010 | volume 40 | number 3 | journal of orthopaedic & sports physical therapy
40-03 Boyles.indd 134
2/17/10 2:49:31 PM
FIGURE 3. Cervical thrust manipulation using
nonphysiologic (upslope) techniques to right C4-5
(ONLINE VIDEO).
thrust to the ipsilateral dysfunctional segment (FIGURE 2, ONLINE VIDEO). Additionally,
and to a lesser extent, a nonphysiologic,
or upslope, thrust manipulation technique was used at the treating therapist’s
discretion (FIGURE 3, ONLINE VIDEO).
In addition to MPT, all patients received 3 basic clinic and home exercises:
cervical rotation range of motion, cervical retraction (chin tucks), and deep neck
flexor strengthening. The therapist could
add additional exercises as needed to target specific impairments or reinforce the
manual interventions. Patients received
up to 6 sessions, twice weekly for 3 weeks.
Treatment sessions were limited to 1 hour
for the initial examination and treatment
and to 30 minutes for subsequent followup sessions. The 8 physical therapists
providing treatment were either faculty or
fellows in the US Army-Baylor University
Post-Professional Doctoral Program for
Orthopaedic Manual Physical Therapy.
For this secondary analysis, patient
outcome data from these 47 patients were
separated into 2 groups based on the type
of cervical MPT provided: (1) patients
who received cervical thrust manipulation as part of their treatment (thrust
group, n = 23 [49%]) and (2) patients
who received only cervical nonthrust
manipulations (nonthrust group, n = 24
[51%]). Patients within this treatment
arm were not randomized with respect
to the inclusion or exclusion of cervical
thrust manipulations. All patients receiving cervical thrust manipulation also received cervical nonthrust manipulations
during their treatment duration.
Baseline comparisons (TABLE 1) of clinical and demographic characteristics revealed statistically significant differences
between the 2 groups in age (nonthrust
group being older [P =.02]) and baseline NDI scores. The difference in NDI
scores was statistically significant but not
clinically meaningful (thrust group having a higher NDI score [P =.05]). The
difference in symptom duration (mean
difference, 1166 days), while clinically
significant, was not statistically significant. Although the distribution of patients with acute, subacute, and chronic
neck pain was similar between groups,
the nonthrust group had 6 patients with
symptoms greater than 5 years in duration as compared to 1 patient in the
thrust group.
TABLE 1
Baseline Demographic and Clinical Variables*
Demographic and Clinical VariablesAll Patients (n = 47)Thrust (n = 23)Nonthrust Only (n = 24)Significance (P Value)
Age (y)
48.8  14.1
44.0  11.1
53.5  15.3
31
15
16
.92
1082.4  2256.7
487.0  447.2
1653.0  3049.5
.08
Acute, 30 d (n)
7
3
4
.73
Subacute, 30-90 d (n)
9
5
4
.66
Gender, female (n)
Symptom duration (d)
.02†
Chronic, 90 d (n)
31
15
16
.92
Imaging performed (n)
31
13
18
.18
Headaches (n)
27
14
13
.64
UE symptoms (n)
31
13
18
.18
Cumulative ROM (deg)
255.3  56.8
263.6  59.2
247.3  54.5
.35
Flexion
44.9  14.1
46.3  13.9
43.6  14.5
.51
Extension
42.7  14.3
45.1  16.7
40.3  11.5
.26
Right rotation
53.0  14.2
55.8  12.7
50.4  15.3
.20
Left rotation
48.8  14.8
50.6  15.6
47.1  14.1
.42
Right sidebending
32.7  12.8
32.8  13.3
32.6  12.5
.95
Left sidebending
33.1  12.5
33.0  13.6
33.3  11.7
.93
Initial NDI (0-50 points)
15.6  4.5
16.9  5.2
14.4  3.3
.05†
Cervical VAS (0-100 mm)
53.5  20.7
57.4  23.1
49.7  17.7
.21
UE VAS (0-100 mm)
25.3  24.9
23.4  27.1
27.2  23.0
.61
Abbreviations: NDI, neck disability index; ROM, range of motion; UE, upper extremity; VAS, visual analog scale.
* Values expressed as mean  SD unless otherwise noted.
†
Indicates significant (P.05) difference between groups using independent t tests.
journal of orthopaedic & sports physical therapy | volume 40 | number 3 | march 2010 |
40-03 Boyles.indd 135
135
2/17/10 2:49:32 PM
[
TABLE 2
research report
]
Adjusted Mean Scores, Mean Differences, and
Effect Size Indices for Primary Outcome Measures*
Measure/Follow-upThrust MeanNonthrust-Only Mean
Mean Difference (95% CI)Effect Size† (95% CI)
NDI (0-50)
Baseline
17.1 (15.2 to 19.0)
14.1 (12.3 to 16.0)
3.0 (0.3 to 5.6)
0.66 (0.06 to 1.23)
3 wk
6.2 (4.0 to 8.5)
6.4 (4.2 to 8.6)
–0.2 (–3.3 to 3.0)
–0.04 (–0.61 to 0.54)
6 wk
6.3 (4.3 to 8.4)
5.5 (3.5 to 7.5)
0.8 (–2.1 to 3.7)
0.17 (–0.41 to 0.74)
1 y
5.2 (2.8 to 7.6)
6.4 (4.1 to 8.8)
–1.2 (–4.6 to 2.2)
–0.21 (–0.78 to 0.37)
Cervical VAS (0-100 mm)
Baseline
56.5 (47.3 to 65.6)
50.6 (41.7 to 59.5)
5.9 (–6.9 to 18.6)
3 wk
14.7 (6.4 to 22.9)
13.7 (5.7 to 21.8)
0.9 (–10.6 to 12.5)
0.27 (–0.31 to 0.84)
0.05 (–0.52 to 0.62)
6 wk
16.3 (8.6 to 24.1)
15.2 (7.6 to 22.8)
1.1 (–9.7 to 12.0)
0.06 (–0.51 to 0.63)
1 y
17.2 (7.9 to 26.6)
19.8 (10.6 to 28.9)
–2.5 (–15.6 to 10.5)
–0.11 (–0.68 to 0.46)
UE VAS (0-100 mm)
Baseline
21.5 (10.5 to 32.5)
29.0 (18.2 to 39.8)
3 wk
6.9 (0.9 to 12.8)
7.6 (1.8 to 13.4)
–7.5 (–22.9 to 7.9)
–0.29 (–0.86 to 0.29)
–0.7 (–9.0 to 7.6)
–0.05 (–0.62 to 0.52)
6 wk
8.5 (1.7 to 15.4)
6.7 (0.1 to 13.6)
1.7 (–7.9 to 11.3)
0.10 (–0.47 to 0.67)
1 y
8.6 (–0.4 to 17.6)
11.5 (2.7 to 20.3)
–2.9 (–15.5 to 9.7)
–0.14 (–0.71 to 0.44)
Abbreviations: CI, confidence interval; NDI, neck disability index; UE, upper extremity; VAS, visual analog scale.
* Values are means (95% CIs) unless otherwise noted. Adjusted values based on covariates of age, symptom duration, and baseline NDI scores.
†
Effect sizes of 0.2, 0.5, and 0.8 correspond to small, medium, and large differences, respectively. Positive mean differences and effect sizes denote an advantage
towards the thrust group.
Outcome Measures
Primary outcome measures consisted of
the NDI, a VAS for cervical pain, a VAS
for upper extremity pain, and the patientperceived global rating of change (GRC).
The NDI and VAS measures were completed at baseline, upon treatment completion at 3 weeks, and at 6-week and
1-year follow-ups. The GRC was completed at the 3 follow-up periods. Recent
clinical trials22,28 and a systematic review18
have used these 3 common outcome measures to assess pain intensity, disability,
and perceived recovery in patients with
mechanical neck pain.
The NDI was selected to assess the patient’s self-reported disability due to mechanical neck pain.29,36 The NDI has been
found to have high test-retest reliability,
internal consistency,32,3629 and good concurrent validity with the McGill Pain
Questionnaire and patient-perceived improvement.36 Stratford et al32 analyzed the
NDI in relation to patient decision making and found both the minimal clinically
important difference (MCID), the smallest change in a scale that is meaningful
to patients, and the minimal detectable
change (MDC), the smallest amount of
change that represents a change beyond
measurement error, to be 5 raw points
or 10 percentage points. Cleland et al8
compared the psychometric properties
of the NDI and the Numeric Pain Rating
Scale (NPRS) in patients with mechanical neck pain and found them both to be
responsive and to display fair to moderate test-retest reliability. They also found
the NDI to have a higher MDC score than
previously reported (19%). Young et al40
reported similar results to Cleland et al,8
with the MDC found to be 10 raw score
points on the NDI.
The 100-mm VAS, where 0 represented “no pain” and 100 represented “worst
pain imaginable,” was used to assess cervical and upper extremity pain intensities. The VAS has reported test-retest
reliability between 0.95 to 0.9730 and an
MCID of 12 mm (3 mm at a 95% CI),27
regardless of the severity of pain initially
reported.
The patient-perceived GRC25,26 was
used to assess the patient’s perception
of change in their condition. The GRC
is a 15-point scale ranging from –7 to +7,
where 0 represents no change, –7 indicates that the patient is “a very great deal
worse,” and +7 indicates that the patient
is “a very great deal better.” Juniper et
al26 proposed the following classifications
based on a patient’s GRC score: 0, 1, or –1
had no change; 2 to 3 had minimal
change; 4 to 5 had moderate change;
and 6 to 7 had a large change in their
condition.
Data Analysis
Based on the manual interventions used,
patients were divided into 2 groups for
data analysis. Twenty-three patients
received cervical high-velocity thrust
(thrust group) as part of their treatment,
and 24 patients received only nonthrust
techniques (nonthrust group). NDI and
VAS variables were analyzed using a 2-by4 mixed-model multivariate analysis of
covariance (MANCOVA) and univariate
analyses of covariance (ANCOVA), with
covariates of age and duration of symptoms (α = .05). A separate 2-by-3 mixedmodel MANCOVA and ANCOVA were
performed to include baseline NDI scores
as an additional covariate in the model.
136 | march 2010 | volume 40 | number 3 | journal of orthopaedic & sports physical therapy
40-03 Boyles.indd 136
2/17/10 2:49:32 PM
70.0
Cervical VAS Pain Scores (mm)
Dichotomized GRC scores were used
to classify patients as a success or nonsuccess at each follow-up interval. Patients
that rated their improvement at or above
6 (“a great deal better”) were considered
a success, while patients that rated their
change at 5 (“quite a bit better”) or below
were a nonsuccess. These success rates
were compared using the chi-square statistic (α = .05).
60.0
57.4
49.7
50.0
40.0
30.0
20.0
14.0
3 wk
Thrust
DISCUSSION
his study is a secondary analysis of the treatment arm of a larger
RCT,38 in which patients with mechanical neck pain achieved significant
short- and long-term improvements in
1 yr
6 wk
Nonthrust only
FIGURE 4. Cervical visual analog scale (VAS) pain scores. Values expressed in millimeters (scale, 0-100 mm).
Nonsignificant interaction effect with analysis of covariance ANCOVA (P = .73). Significant main effect for time
(P.05) demonstrates improvement in cervical pain for both groups.
80
70
Treatment Success (%)
T
22.6
14.2
0.0
RESULTS
here were no significant interactions for either the multivariate or univariate analyses, but there
was a significant main effect with respect
to time for all variables in both analyses
(P.05). None of the covariate variables
was significant (α = .05), indicating that
these variables did not significantly add
to the model and resulted in similar adjusted and unadjusted means (differences
of 0.5 points for NDI means and 2.5
mm for VAS scores). Adjusted mean differences are listed in TABLE 2, along with
the effect size index for all between-group
comparisons, which was small. Observed
power was low for both the MANCOVA
(β.28) and ANCOVA (β.44) procedures. FIGURE 4 depicts the improvement
in cervical pain over time for both intervention groups and the nonsignificant
interaction effect between groups. This
graph is representative of the changes
observed in the NDI and upper extremity VAS pain scores.
There were no significant differences
between the 2 groups for treatment success rates based on patient-perceived
GRC scores (P.28) (FIGURE 5).
Patients reported no adverse treatment effects, regardless of which manual
physical therapy technique was used.
13.7
17.8
10.0
Baseline
T
14.4
60
50
40
30
20
10
0
6 wk
3 wk
Thrust
1 yr
Nonthrust only
FIGURE 5. Global rating of change treatment success rates (where GRC 6). *Values expressed as a percentage.
†
No observed differences with chi-square analysis (P.28) for all time intervals.
pain and disability following treatment
with MPT and exercise. Consistent with
these findings, both the thrust and nonthrust subgroups in this analysis demonstrated similar improvements over
time in short- and long-term clinical
outcomes, with no statistical or clinically significant differences between the
groups (TABLE 2). At first glance, a similar
outcome between the 2 groups might indicate that there was a lack of influence
by a subset of patients for whom thrust
manipulation was indicated, or that, if
such a subgroup existed, the influence
was minimal. However, an equally plausible explanation is that the nonsignificant results were due to a relatively small,
heterogeneous sample.
The mean differences between groups
at each follow-up interval (TABLE 2) are
smaller than the established MCID for
each outcome measure (12 mm for the
VAS and 5 points for the NDI). Additionally, the observed effect size indices
were small (–0.21 to 0.17), with large
95% confidence intervals that include
null values for each outcome measure
and time interval. Effect size indices less
than 0.2 typically indicate small clinical
differences that are neither clinically nor
statistically significant.
Caution, however, must be exercised
when interpreting these data based on
study limitations. This is an underpowered secondary analysis (β.28 and
β.44) that prohibits any definitive state-
journal of orthopaedic & sports physical therapy | volume 40 | number 3 | march 2010 |
40-03 Boyles.indd 137
137
2/17/10 2:49:34 PM
[
ment regarding the presence or absence
of a treatment advantage of one approach
over the other. Given the results of previous studies demonstrating the effectiveness of both thrust3,12 and nonthrust21,22
procedures, a small effect size is not to be
unexpected when comparing differences
between cervical thrust and nonthrust
manipulation as part of a larger treatment
plan. If this is indeed the case, a larger and
possibly more homogenous sample would
be necessary to determine the clinical
and statistical relevance in observed differences between these interventions. For
example, Hurwitz et al23 compared thrust
versus nonthrust manipulation in a large
RCT involving 336 patients with neck
pain. Even with this larger sample size,
they were unable to detect clinical and
statistically meaningful differences between the 2 interventions. Their findings
are consistent with our own, including
similar mean differences and confidence
intervals for pain and disability. Taken
collectively, these trials underscore the
need for future studies to incorporate
criteria associating thrust manipulation
with successful outcomes6,34 rather than
simply increasing sample size. Due to the
rare but potentially serious complications
that have been reported following cervical
thrust manipulation, as well as perceived
harm,19,20 a stronger case might be made
for the use of nonthrust procedures if they
are shown to be equally effective, even
though nonthrust procedures are still not
without associated complications.11
In a recent RCT, Gonzalez-Iglesias
et al14 reported that patients with neck
pain who received thoracic spine thrust
manipulations had significantly greater improvements in pain, motion, and
disability than a control group up to 4
weeks following treatment. Cleland et al9
reported that thrust manipulation of the
thoracic spine was significantly more effective than nonthrust manipulation for
reducing pain and disability in patients
with mechanical neck pain. Although
similar to our study in sample size (n =
60) and patient presentation (mean age,
43.3 years; 55% female), Cleland et al7
research report
had sufficient power and effect sizes to
detect these between-group differences.
High-velocity, low-amplitude thrust
techniques appear to be more effective
than low-velocity, variable-amplitude
nonthrust manipulation techniques in
overcoming the relative stiffness/immobility found in the thoracic spine. In
contrast, cervical thrust and nonthrust
manipulation techniques appear to have
similar treatment effects when applied
as part of an ongoing treatment program
to the smaller, more mobile facet joints
within the cervical spine.23 However,
when used as a single-session intervention, Vernon et al35 concluded in a recent
systematic review that thrust manipulation, as compared to nonthrust manual
therapy, demonstrates superior changes
in 100-mm VAS change scores and larger
effect sizes in patients with nonradicular
chronic neck pain.
Clinical decision making regarding
the use of thrust manipulation is of interest. Another significant limitation of
this study is the inherent selection bias
in this nonrandomized post hoc analysis.
Although subjects were randomly assigned to the MPT and exercise group in
the larger RCT,38 the inclusion of cervical
thrust manipulation was at the discretion
of the treating physical therapist. Physical therapists in our study chose to manipulate patients who were younger (P
= .02) and had more reported disability
(P = .05) and less symptom chronicity (P
= .08) than patients receiving only nonthrust manipulations. Although adjusting
for these covariates (age, duration, and
baseline NDI scores) did not add to our
statistical model, observed differences
in these variables suggest that they were
considered as part of the physical therapist’s clinical decision-making process
for when to administer cervical thrust
manipulation. It may be that physical
therapists in this study performed cervical thrust techniques on patients whom
they perceived to be more responsive or
presented with less relative risk (“safer”)
towards this intervention.
Clinical prediction rules (CPR) have
]
been developed to assist in the clinical
decision making associated with the diagnosis and treatment of several musculoskeletal conditions. A CPR consisting
of clinical examination items has been
reported to identify patients with LBP
who are more likely to respond to lumbar manipulation.6,13 Similarly, Cleland
and colleagues7 have reported a developmental CPR for patients with neck pain
who benefit from thrust manipulation to
the thoracic spine. Tseng and colleagues33
reported on predicted responders to cervical manipulation, but this has yet to
be validated. Identifying a relevant subgroup of patients with neck pain who respond to cervical thrust manipulation, if
one exists, would not only be useful for
clinical decision making but would also
help adequately plan future clinical trials.
Future studies that compare the relative
effectiveness of cervical thrust manipulation to nonthrust manipulation to treat
patients with neck pain must consider
the lack of significance and small effect
sizes reported to date.23 Incorporating existing7,39 and future developmental CPR
criteria that identify a subset of patients
who would benefit from cervical thrust
manipulation would not only help determine the validity of developmental CPRs
but may help determine if there is a clinically meaningful difference between the 2
interventions for a subgroup of patients.
CONCLUSION
T
his secondary analysis of 2
subgroups of patients with mechanical neck pain demonstrated
short- and long-term improvements in
pain and disability following a treatment
regimen of MPT and exercise. The inclusion or exclusion of cervical thrust manipulation into the MPT treatment plan
did not influence the results of the treatment arm of the larger RCT from which
this study was drawn. While the methods
used in this study limits our conclusions,
our small observed effect sizes may benefit future researchers with sample size
estimation for larger RCTs and suggest
138 | march 2010 | volume 40 | number 3 | journal of orthopaedic & sports physical therapy
40-03 Boyles.indd 138
2/17/10 2:49:35 PM
the need to incorporate developmental
CPR criteria as a means to improve statistical power. t
9.
KEY POINTS
FINDINGS: Patients who received thrust
manipulation to the cervical spine had
similar short- and long-term results in
all outcome scores of NDI, VAS, and
GRC compared to those patients who
received cervical nonthrust manipulations. Neither group reported adverse
effects from either thrust or nonthrust
cervical manipulations.
IMPLICATIONS: Both approaches appear to
be equally effective and safe in this patient population.
CAUTION: This is a secondary analysis
performed on a relatively small number
of patients from a larger RCT.
10.
11.
12.
13.
references
1. G
uide to Physical Therapist Practice. Second
Edition. American Physical Therapy Association.
Phys Ther. 2001;81:9-746.
2. Bogduk N. Neck pain. Aust Fam Physician.
1984;13:26-30.
3. Bronfort G, Evans R, Nelson B, Aker PD, Goldsmith CH, Vernon H. A randomized clinical trial
of exercise and spinal manipulation for patients
with chronic neck pain. Spine (Phila Pa 1976).
2001;26:788-797; discussion 798-789.
4. Cassidy JD, Lopes AA, Yong-Hing K. The immediate effect of manipulation versus mobilization
on pain and range of motion in the cervical
spine: a randomized controlled trial. J Manipulative Physiol Ther. 1992;15:570-575.
5. Childs JD, Cleland JA, Elliott JM, et al. Neck
pain: Clinical practice guidelines linked to the
International Classification of Functioning, Disability, and Health from the Orthopedic Section
of the American Physical Therapy Association. J
Orthop Sports Phys Ther. 2008;38:A1-A34.
6. Childs JD, Fritz JM, Flynn TW, et al. A clinical
prediction rule to identify patients with low
back pain most likely to benefit from spinal manipulation: a validation study. Ann Intern Med.
2004;141:920-928.
7. Cleland JA, Childs JD, Fritz JM, Whitman JM,
Eberhart SL. Development of a clinical prediction rule for guiding treatment of a subgroup of
patients with neck pain: use of thoracic spine
manipulation, exercise, and patient education. Phys Ther. 2007;87:9-23. http://dx.doi.
org/10.2522/ptj.20060155
8. Cleland JA, Childs JD, Whitman JM. Psychometric properties of the Neck Disability Index
14.
15.
16.
17.
18.
19.
20.
21.
and Numeric Pain Rating Scale in patients with
mechanical neck pain. Arch Phys Med Rehabil.
2008;89:69-74. http://dx.doi.org/10.1016/j.
apmr.2007.08.126
Cleland JA, Glynn P, Whitman JM, Eberhart
SL, MacDonald C, Childs JD. Short-term effects of thrust versus nonthrust mobilization/
manipulation directed at the thoracic spine in
patients with neck pain: a randomized clinical
trial. Phys Ther. 2007;87:431-440. http://dx.doi.
org/10.2522/ptj.20060217
Cote P, Cassidy JD, Carroll L. The Saskatchewan
Health and Back Pain Survey. The prevalence of
neck pain and related disability in Saskatchewan
adults. Spine (Phila Pa 1976). 1998;23:16891698.
Di Fabio RP. Manipulation of the cervical spine:
risks and benefits. Phys Ther. 1999;79:50-65.
Evans R, Bronfort G, Nelson B, Goldsmith CH.
Two-year follow-up of a randomized clinical trial
of spinal manipulation and two types of exercise
for patients with chronic neck pain. Spine (Phila
Pa 1976). 2002;27:2383-2389. http://dx.doi.
org/10.1097/01.BRS.0000030192.39326.FF
Flynn T, Fritz J, Whitman J, et al. A clinical
prediction rule for classifying patients with low
back pain who demonstrate short-term improvement with spinal manipulation. Spine (Phila
Pa 1976). 2002;27:2835-2843. http://dx.doi.
org/10.1097/01.BRS.0000035681.33747.8D
Gonzalez-Iglesias J, Fernandez-de-las-Penas
C, Cleland JA, Gutierrez-Vega Mdel R. Thoracic
spine manipulation for the management of patients with neck pain: a randomized clinical trial.
J Orthop Sports Phys Ther. 2009;39:20-27.
Gross AR, Aker PD, Goldsmith CH, Peloso P. Patient education for mechanical neck disorders.
Cochrane Database Syst Rev. 2000;CD000962.
http://dx.doi.org/10.1002/14651858.CD000962
Gross AR, Aker PD, Goldsmith CH, Peloso
P. Physical medicine modalities for mechanical neck disorders. Cochrane Database
Syst Rev. 2000;CD000961. http://dx.doi.
org/10.1002/14651858.CD000961
Gross AR, Goldsmith C, Hoving JL, et al. Conservative management of mechanical neck
disorders: a systematic review. J Rheumatol.
2007;34:1083-1102.
Gross AR, Hoving JL, Haines TA, et al. A Cochrane review of manipulation and mobilization
for mechanical neck disorders. Spine (Phila Pa
1976). 2004;29:1541-1548.
Haldeman S, Kohlbeck FJ, McGregor M. Risk factors and precipitating neck movements causing
vertebrobasilar artery dissection after cervical
trauma and spinal manipulation. Spine (Phila Pa
1976). 1999;24:785-794.
Haldeman S, Kohlbeck FJ, McGregor M. Unpredictability of cerebrovascular ischemia
associated with cervical spine manipulation
therapy: a review of sixty-four cases after cervical spine manipulation. Spine (Phila Pa 1976).
2002;27:49-55.
Hoving JL, de Vet HC, Koes BW, et al. Manual
therapy, physical therapy, or continued care
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
by the general practitioner for patients with
neck pain: long-term results from a pragmatic randomized clinical trial. Clin J Pain.
2006;22:370-377. http://dx.doi.org/10.1097/01.
ajp.0000180185.79382.3f
Hoving JL, Koes BW, de Vet HC, et al. Manual
therapy, physical therapy, or continued care by a
general practitioner for patients with neck pain.
A randomized, controlled trial. Ann Intern Med.
2002;136:713-722.
Hurwitz EL, Morgenstern H, Harber P, Kominski GF, Yu F, Adams AH. A randomized trial of
chiropractic manipulation and mobilization for
patients with neck pain: clinical outcomes from
the UCLA neck-pain study. Am J Public Health.
2002;92:1634-1641.
Hurwitz EL, Morgenstern H, Vassilaki M, Chiang
LM. Adverse reactions to chiropractic treatment
and their effects on satisfaction and clinical
outcomes among patients enrolled in the UCLA
Neck Pain Study. J Manipulative Physiol Ther.
2004;27:16-25. http://dx.doi.org/10.1016/j.
jmpt.2003.11.002
Jaeschke R, Singer J, Guyatt GH. Measurement
of health status. Ascertaining the minimal clinically important difference. Control Clin Trials.
1989;10:407-415.
Juniper EF, Guyatt GH, Willan A, Griffith LE.
Determining a minimal important change in a
disease-specific Quality of Life Questionnaire. J
Clin Epidemiol. 1994;47:81-87.
Kelly AM. The minimum clinically significant
difference in visual analogue scale pain score
does not differ with severity of pain. Emerg Med
J. 2001;18:205-207.
Korthals-de Bos IB, Hoving JL, van Tulder MW,
et al. Cost effectiveness of physiotherapy,
manual therapy, and general practitioner care
for neck pain: economic evaluation alongside a
randomised controlled trial. Bmj. 2003;326:911.
http://dx.doi.org/10.1136/bmj.326.7395.911
MacDermid JC, Walton DM, Avery S, et al. Measurement properties of the neck disability index:
a systematic review. J Orthop Sports Phys Ther.
2009;39:400-417. http://dx.doi.org/10.2519/
jospt.2009.2930
McCormack HM, Horne DJ, Sheather S. Clinical
applications of visual analogue scales: a critical
review. Psychol Med. 1988;18:1007-1019.
Picavet HS, Schouten JS. Musculoskeletal pain
in the Netherlands: prevalences, consequences
and risk groups, the DMC(3)-study. Pain.
2003;102:167-178.
Stratford PW, Riddle DL, Binkley JM, Spadoni
G, Westaway MD, Padfield B. Using the Neck
Disability Index to make decisions concerning individual patients. Physiother Canada.
1999;51:107-112.
Tseng YL, Wang WT, Chen WY, Hou TJ, Chen TC,
Lieu FK. Predictors for the immediate responders to cervical manipulation in patients with
neck pain. Man Ther. 2006;11:306-315. http://
dx.doi.org/10.1016/j.math.2005.08.009
v an der Donk J, Schouten JS, Passchier J, van
Romunde LK, Valkenburg HA. The associations
journal of orthopaedic & sports physical therapy | volume 40 | number 3 | march 2010 |
40-03 Boyles.indd 139
139
2/17/10 2:49:36 PM
[
of neck pain with radiological abnormalities of
the cervical spine and personality traits in a general population. J Rheumatol. 1991;18:1884-1889.
35. Vernon H, Humphreys BK. Chronic mechanical
neck pain in adults treated by manual therapy: a
systematic review of change scores in randomized controlled trials of a single session. J Man
Manip Ther. 2008;16:E42-52.
36. Vernon H, Mior S. The Neck Disability Index: a
study of reliability and validity. J Manipulative
Physiol Ther. 1991;14:409-415.
37. Vernon HT, Aker P, Burns S, Viljakaanen S, Short
L. Pressure pain threshold evaluation of the ef-
research report
fect of spinal manipulation in the treatment of
chronic neck pain: a pilot study. J Manipulative
Physiol Ther. 1990;13:13-16.
38. Walker MJ, Boyles RE, Young BA, et al. The
effectiveness of manual physical therapy and
exercise for mechanical neck pain: a randomized clinical trial. Spine (Phila Pa 1976).
2008;33:2371-2378. http://dx.doi.org/10.1097/
BRS.0b013e318183391e
39. Wang WT, Olson SL, Campbell AH, Hanten WP,
Gleeson PB. Effectiveness of physical therapy
for patients with neck pain: an individualized
approach using a clinical decision-making al-
]
gorithm. Am J Phys Med Rehabil. 2003;82:203218; quiz 219-221. http://dx.doi.org/10.1097/01.
PHM.0000052700.48757.CF
40. Young BA, Walker MJ, Strunce JB, Boyles RE,
Whitman JM, Childs JD. Responsiveness of the
Neck Disability Index in patients with mechanical neck disorders. Spine J. 2009;9:802-808.
http://dx.doi.org/10.1016/j.spinee.2009.06.002
@
more information
www.jospt.org
EARN CEUs With JOSPT’s Read for Credit Program
JOSPT’s Read for Credit (RFC) program invites Journal readers to study and
analyze selected JOSPT articles and successfully complete online quizzes
about them for continuing education credit. To participate in the
program:
1. Go to www.jospt.org and click on “Read for Credit” in the left-hand
navigation column that runs throughout the site or on the link in the
“Read for Credit” box in the right-hand column of the home page.
2. Choose an article to study and when ready, click “Take Exam” for
that article.
3. Login and pay for the quiz by credit card.
4. Take the quiz.
5. Evaluate the RFC experience and receive a personalized certificate of
continuing education credits.
The RFC program offers you 2 opportunities to pass the quiz. You may
review all of your answers—including the questions you missed. You
receive 0.2 CEUs, or 2 contact hours, for each quiz passed. The Journal
website maintains a history of the quizzes you have taken and the credits
and certificates you have been awarded in the “My CEUs” section of your
“My JOSPT” account.
140 | march 2010 | volume 40 | number 3 | journal of orthopaedic & sports physical therapy
40-03 Boyles.indd 140
2/17/10 2:49:38 PM

Similar documents