Thrust joint manipulation utilization by U.S. physical therapists

Effectiveness of thoracic spine manipulation for upper quadrant musculoskeletal disorders: protocol for a systematic review

INTRODUCTION

Upper quadrant musculoskeletal disorders (UQMD), comprising of cranial, cervical, shoulder and upper extremity disorders, are among the most frequently reported disorders in clinical practice. Thoracic high velocity low amplitude thrust (Tx-HVLAT) manipulation is a form of conservative management recommended in systematic reviews as an effective treatment option for aspects of UQMD disorders such headache, shoulder pain and lateral elbow pain. However, no recent systematic reviews have assessed the effectiveness across UQMD. Therefore, this systematic review aims to update the current evidence on the effectiveness of Tx-HVLAT for patients with UQMD on (1) patient-reported outcomes, (2) performance measures or (3) psychosocial outcomes.

METHODS AND ANALYSIS

The Cochrane Controlled Trials Register, MEDLINE, EMBASE, CINAHL, PEDro and Index to Chiropractic Literature will be searched from inception using Medical Subject Headings (MeSH), Thesaurus and/or free-text words. Combinations will be made based on localisation, disorder, intervention and design. Following guidelines as advised by the Cochrane Back Review Group, published randomised controlled trials will be included. Two review authors will independently assess the risk of bias (ROB) using the Cochrane Back Review Group's recommended ROB2 tool and will independently extract the data using a standardised data extraction form. Overall quality of the evidence will be evaluated using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) method. For continuous data, we will calculate standardised mean differences with 95% CIs. For dichotomous outcomes, relative risks and 95% CIs will be calculated. Where possible we will present a subgroup analysis by disorder. For pooling, a random-effects model will be used.

ETHICS AND DISSEMINATION

Ethics approval is not required for this systematic review. The study findings will be submitted to a relevant peer-reviewed journal for dissemination and presented at relevant conferences.

PROSPERO REGISTRATION NUMBER

CRD42023429996.

Knowledge, beliefs, and attitudes of spinal manipulation: a cross-sectional survey of Italian physiotherapists

Background and Objective

High-velocity low-amplitude thrust spinal manipulation (SM) is a recommended and commonly used manual therapy intervention in physiotherapy. Beliefs surrounding the safety and effectiveness of SM have challenged its use, and even advocated for its abandonment. Our study aimed to investigate the knowledge and beliefs surrounding SM by Italian physiotherapists compared with similar practitioners in other countries.

Methods

An online survey with 41 questions was adapted from previous surveys and was distributed via a mailing list of the Italian Physiotherapists Association (March 22–26, 2020). The questionnaire was divided into 4 sections to capture information on participant demographics, utilization, potential barriers, and knowledge about SM. Questions were differentiated between spinal regions. Attitudes towards different spinal regions, attributes associated with beliefs, and the influence of previous educational background were each evaluated.

Results

Of the 7398 registered physiotherapists, 575 (7.8%) completed the survey and were included for analysis. The majority of respondents perceived SM as safe and effective when applied to the thoracic (74.1%) and lumbar (72.2%) spines; whereas, a smaller proportion viewed SM to the upper cervical spine (56.8%) as safe and effective. Respondents reported they were less likely to provide and feel comfortable with upper cervical SM (respectively, 27.5% and 48.5%) compared to the thoracic (respectively, 52.2% and 74.8%) and lumbar spines (respectively, 46.3% and 74.3%). Most physiotherapists (70.4%) agreed they would perform additional screening prior to upper cervical SM compared to other spinal regions. Respondents who were aware of clinical prediction rules were more likely to report being comfortable with SM (OR 2.38–3.69) and to perceive it as safe (OR 1.75–3.12). Finally, physiotherapists without musculoskeletal specialization, especially those with a traditional manual therapy background, were more likely to perform additional screening prior to SM, use SM less frequently, report being less comfortable performing SM, and report upper cervical SM as less safe (p < 0.001).

Discussion

The beliefs and attitudes of physiotherapists surrounding the use of SM are significantly different when comparing the upper cervical spine to other spinal regions. An educational background in traditional manual therapy significantly influences beliefs and attitudes. We propose an updated framework on evidence-based SM.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12998-022-00449-x.

Assessing Cranial Nerves in Physical Therapy Practice: Findings from a Cross-Sectional Survey and Implication for Clinical Practice

BACKGROUND AND OBJECTIVE

Serious pathologies of the neck can potentially result in cranial nerve palsy. Knowledge about cranial nerve examination (CNE) seems sparse, and its use is still unknown. We aim to investigate the knowledge, skills, and utilization of CNE of Italian physiotherapists.

MATERIALS AND METHODS

An online cross-sectional survey.

RESULTS

396 completed the survey, reaching the required sample size. Although Italian physiotherapists consider CNE relevant (mean ± SD = 7.6/10 ± 2.0), over half of all responders (n = 229 (57.8%)) were not trained in the fundamentals and around a third did not use it in their daily practice (n = 138 (34.8%)). Additionally, participants were unconfident and insecure in conducting (n = 152 (38.4%) and n = 147 (37.1%)), interpreting (n = 140 (35.4%) and n = 164 (41.4%)), and managing the CNE (n = 141 (35.6%) and n = 154 (38.9%)). Possessing a musculoskeletal specialization was associated with an increased value attributed to clinical practice guidelines and reduced the lack of confidence in conducting, interpreting, and managing the CNE (respectively, n = 35 (25.5%), p = 0.0001; n = 32 (23.4%) p = 0.0002; n = 32 (23.4%) p = 0.0002). Working in a direct access setting significantly increased the considered relevance of guidelines and the concerns about arterial (p = 0.004) and other serious pathologies (p = 0.021). Pain and visual disturbances were considered the main indicators to CNE, demonstrating limited knowledge of signs and symptoms' indicating CNE. Participants considered specific training in CNE as relevant (mean ± SD = 7.6/10 = 2.1).

CONCLUSIONS

a substantial proportion of Italian physiotherapists are not schooled in the fundamentals of cranial nerve examination. Given the number of physiotherapists who work in first contact roles, this is a professional concern.

Thoracic thrust joint manipulation: An international survey of current practice and knowledge in IFOMPT member countries

BACKGROUND

The perceived relative safety of thoracic thrust joint manipulation (TTJM) has contributed to a growth in evidence supporting use in practice. Yet adverse events (AE) have been documented following TTJM. Knowledge of current practice is therefore required to support further research.

PURPOSE

To investigate TTJM knowledge and pre-TTJM examination across IFOMPT Member Organisations (MO) and Registered Interest Groups (RIG).

METHODS

An e-survey was designed based on existing evidence and piloted. Eligibility criteria: physiotherapists from member countries of the International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) who use TTJM. Recruitment was through IFOMPT networks (May 2018-March 2019). Data analyses included descriptive analyses and content analysis for free text data.

RESULTS

Respondents (n = 363) from 20 countries. Pre-TTJM examination included patient history (22%, n = 81) and physical examination (69%, n = 248). Across presentations (>80% threshold of agreement) contraindications included osteomyelitis, fracture and metastatic disease. Spinal deformity, respiratory disease, serious joint disease and hypermobility achieved >60% agreement as precautions. Consent was obtained by 93% respondents (n = 250). Preferred technique was PA/AP thrust (61%, n = 144). Perception of primary effect was neurophysiological (52%, n = 134), biomechanical (42%, n = 109) and placebo (3%, n = 8). From those who reported AE (n = 100), these included fractures (36%, n = 42) and cord signs/symptoms (6%, n = 7).

CONCLUSION

Pre-TTJM examination is common, although bias towards physical examination. Differential testing for upper versus lower thoracic spine is limited. Inconsistencies across knowledge of contraindications and precautions, and beliefs for biomechanical effect were found. Findings highlight the importance of high levels of clinical reasoning during patient history for TTJM.

Thoracic adverse events following spinal manipulative therapy: a systematic review and narrative synthesis

Objectives: Spinal manipulative therapy (SMT) is widely used by manual therapists to manage spinal complaints. Notwithstanding the perceived relative safety of SMT, instances of severe thoracic adverse events (AE) have been documented. An evidence synthesis is required to understand the nature, severity and characteristics of thoracic AE following all SMT. The primary objective of this study was to report thoracic AE following SMT and secondly to report patient characteristics to inform further research for safe practice. Methods: A systematic review and data synthesis were conducted according to a registered protocol (PROSPERO CRD42019123140). A sensitive topic-based search strategy for key databases, gray literature and registers used study population terms and keywords, to search to 12/6/19. Two reviewers were involved at each stage. Using the Oxford Center for Evidence-based Medicine (CEBM) the level evidence was evaluated with grade presented for each AE. Results were reported in the context of overall quality. Results: From 1013 studies identified from searches, 19 studies (15 single case studies and 4 case series) reporting 21 unique thoracic AE involving the spinal cord tissues [nonvascular (n = 7), vascular (n = 6)], pneumothorax or hemothorax (n = 3), fracture (n = 3), esophageal rupture (n = 1), rupture of thoracic aorta (n = 1), partial pancreatic transection (n = 1). Reported outcomes included fully recovery (n = 8), permanent neurological deficit (n = 5), and death (n = 4). Conclusion: Although causality cannot be confirmed, serious thoracic AE to include permanent neurological deficit and death have been reported following SMT. Findings highlight the importance of clinical reasoning, including pre-thrust examination, as part of best and safe practice for SMT.

Use of thrust joint manipulation by student physical therapists in the United States during clinical education experiences

Introduction: Thrust joint manipulation (TJM) is used in physical therapy practice and taught in entry-level curricula in the United States (US); however, research regarding implementation by student physical therapists (SPT)s is scarce. Objectives: To explore the use of TJM in SPT clinical education and factors influencing implementation. Methods: In a cross-sectional exploratory study, accredited physical therapy (PT) programs in the US (n = 227) were invited to participate in an electronic survey. SPTs were queried about TJM use and their clinical instructor's (CI) credentials during their final musculoskeletal clinical experience. Results: Forty-five programs participated in the study, consisting of 2,147 SPTs. Of those, 414 (19.3%) responses were used for analysis and 69% reported using TJM. SPTs who utilized TJM were more likely to have a CI who used TJM (p < 0.001) and/or had advanced certification/training in manual therapy (p < .001). A majority of students agreed or strongly agreed that their academic preparation provided them with clinical reasoning tools (84%) and psychomotor skills (69%) necessary to perform TJM. SPT use of TJM was facilitated by CI clinical practice, SPT competence in psychomotor skill, confidence in clinical reasoning, and practice setting. A main barrier to student use of TJM was CI lack of TJM use. Conclusions: Clinical practice of the CI appears to be a key factor in determining student use of TJM. Level of evidence: 2b.

Factors associated with cervical arterial dysfunction: a survey of physical therapist educators in the United States

Objectives: The purpose of this study was to identify the key constructs associated with symptom description and behavior, natural history of complaints, and previous medical history of cervical arterial dysfunction (CAD) according to a panel of physical therapist (PT) educators. Methods: An electronic survey was conducted of licensed PT educators currently involved in musculoskeletal physical therapy education within a credentialed program. Survey prompts queried educators to list the subjective and objective items associated with CAD, in open-text format. Responses were coded to identify unique themes (constructs). Principal axis factor analysis with Varimax rotation was performed to identify underlying constructs associated with CAD according to the panel of educators. Results: Seventy-two educators completed the survey (24.2% response rate) resulting in 50 identified unique items through thematic coding. Factor analysis (Kaiser-Meyer-Olkin measure of sampling adequacy = .679, Bartlett's test of sphericity (x ²(351) = 1129.06. p < .001), resulted in a four-factor solution: '5Ds and 3 Ns,' 'Other Neurological Findings,' 'Signs & Symptoms in Rotation and/or Extension,' and 'General Health.' Discussion: According to the PT educators in this study, the factors associated with CAD appear to reflect the IFOMPT guidelines. The responses and subsequent factor analysis demonstrate the lack of any one clinical finding for the identification of CAD in a patient with neck pain. Level of Evidence: V.

Thoracic spine manipulation for the management of mechanical neck pain: A systematic review and meta-analysis

Objective

To investigate the role of thoracic spine manipulation (TSM) on pain and disability in the management of mechanical neck pain (MNP).

Data sources

Electronic databases PubMed, CINAHL, Pedro, Embase, AMED, the Cochrane Library, and clinicaltrials.gov were searched in January 2018.

Study selection

Eligible studies were completed RCTs, written in English, had at least 2 groups with one group receiving TSM, had at least one measure of pain or disability, and included patients with MNP of any duration. The search identified 1717 potential articles, with 14 studies meeting inclusion criteria.

Study appraisal and synthesis methods

Methodological quality was evaluated independently by two authors using the guidelines published by the Cochrane Collaboration. Pooled analyses were analyzed using a random-effects model with inverse variance methods to calculate mean differences (MD) and 95% confidence intervals for pain (VAS 0-100mm, NPRS 0-10pts; 0 = no pain) and disability (NDI and NPQ 0–100%; 0 = no disability).

Results

Across the included studies, there was increased risk of bias for inadequate provider and participant blinding. The GRADE approach demonstrated an overall level of evidence ranging from very low to moderate. Meta-analysis that compared TSM to thoracic or cervical mobilization revealed a significant effect favoring the TSM group for pain (MD -13.63; 95% CI: -21.79, -5.46) and disability (MD -9.93; 95% CI: -14.38, -5.48). Meta-analysis that compared TSM to standard care revealed a significant effect favoring the TSM group for pain (MD -13.21; 95% CI: -21.87, -4.55) and disability (MD -11.36; 95% CI: -18.93, -3.78) at short-term follow-up, and a significant effect for disability (MD -4.75; 95% CI: -6.54, -2.95) at long-term follow-up. Meta-analysis that compared TSM to cervical spine manipulation revealed a non-significant effect (MD 3.43; 95% CI: -7.26, 14.11) for pain without a distinction between immediate and short-term follow-up.

Limitations

The greatest limitation in this systematic review was the heterogeneity among the studies making it difficult to assess the true clinical benefit, as well as the overall level of quality of evidence.

Conclusions

TSM has been shown to be more beneficial than thoracic mobilization, cervical mobilization, and standard care in the short-term, but no better than cervical manipulation or placebo thoracic spine manipulation to improve pain and disability.

Trial registration

PROSPERO CRD42017068287

Knowledge and pre-thoracic spinal thrust manipulation examination: a survey of current practice in the UK

OBJECTIVES

The perceived relative safety of thoracic thrust joint manipulation (TTJM) has contributed to evidence supporting its use. Yet, TTJM is not without risk, where transient side effects (SE) and severe adverse events (AE) have been documented. With evidence supporting the importance of prethrust examination in reducing AE in other spinal regions this study investigated TTJM knowledge and pre-TTJM examination. Method: An e-survey, informed by existing evidence and expertise was designed and piloted. Eligibility criteria: UK-trained physiotherapists who use TTJM. Recruitment via professional networks and social media from December 2016 to February 2017. Data analysis included descriptive analyses (means, standard deviation and frequencies/central tendencies), and content analysis (themes and frequencies) for free text data. Results: From 306 responses, the sample comprised 146 (53%) males, mean (SD) age 36.37(8.68) years, with 12.88(8.67) years in practice, 11.07(8.14) years specialization, working in National Health Service/private practice (81%) and performing 0-5 TTJM/week (86%).

EXAMINATION

40% (n = 83) utilized pre-TTJM examination with 45% (n = 139) adapting the examination for different regions. Technique selection and effect: preferred technique was prone rotational TTJM (67%). Perception of the primary underlying effect was neurophysiological (54%), biomechanical (45%) or placebo (1%). Knowledge: Levels of agreement were found for contraindications (85%), precautions (75%), and red flags (86%) with more variability for risks including AE and SE (61%).

DISCUSSION

UK physiotherapists demonstrated good knowledge and agreement of contraindications, precautions, and red flags to TTJM. With <50% respondents utilizing pre-TTJM examination, variable knowledge of TTJM risks, and therapeutic effects of TTJM further research is required.