Cervical arterial dysfunction: knowledge and reasoning for manual physical therapists

Cervical manipulation versus thoracic or cervicothoracic manipulations for the management of neck pain. A systematic review and meta-analysis

BACKGROUND

Cervical and thoracic thrust or non-thrust manipulations have shown to be effective in patients with neck pain, but there is a lack of studies comparing both interventions in patients with neck pain.

OBJECTIVE

To investigate the effects of cervical thrust or non-thrust manipulations compared to thoracic or cervicothoracic manipulations for improving pain, disability, and range of motion in patients with neck pain.

DESIGN

Systematic review and meta-analysis.

METHOD

Searches were performed in PubMed, PEDro, Cochrane Library, CINHAL, and Web of Science databases from inception to May 22, 2023. Randomized clinical trials comparing cervical thrust or non-thrust manipulations to thoracic or cervicothoracic manipulations were included. Methodological quality was assessed with PEDro scale, and the certainty of evidence was evaluated using GRADE guidelines.

RESULTS

Six studies were included. Meta-analyses revealed no differences between cervical thrust or non-thrust manipulations and thoracic or cervicothoracic manipulations in pain intensity, disability, or cervical range of motion in any plane. The certainty of evidence was downgraded to very low for pain intensity, to moderate or very low for disability and to low or very low for cervical range of motion.

CONCLUSION

There is moderate to very low certainty evidence that there is no difference in effectiveness between cervical thrust or non-thrust manipulations and thoracic or cervicothoracic manipulations for improving pain, disability, and range of motion in patients with neck pain.

PROSPERO REGISTRATION

CRD42023429933.

Physiotherapy Screening for Referral of a Patient with Patent Foramen Ovale Presenting with Neck Pain as Primary Complaint: A Case Report

Neck pain is a common musculoskeletal disorder encountered by physiotherapists. However, it may be the early manifestation of more alarming conditions, such as cardiovascular diseases mimicking musculoskeletal pain. Patent foramen ovale (PFO) is a congenital heart defect consisting of a small opening between the right and the left atrium. A 56-year-old male presented with neck pain and head heaviness as primary complaints. The cardiovascular profile and the behavioral symptoms led the physiotherapist to find an exaggerated blood pressure response during exercise; in addition to subtle neurological signs, this prompted the physiotherapist to make an urgent referral. At the emergency department a PFO was diagnosed. To the best of the authors' knowledge, this is the first case to describe a rare clinical presentation of a PFO presenting neck pain as primary complaint. This case report emphasizes the importance for physiotherapists to be able to triage patients for conditions outside their scope suggestive of further medical investigation.

Pre-manipulative cervical spine testing and sustained rotation do not influence intracranial hemodynamics: an observational study with transcranial Doppler ultrasound

INTRODUCTION

Manual joint mobilization and manipulation are recommended therapeutic interventions for people with neck pain. High-velocity thrust and sustained techniques have an uncertain association with serious arterial trauma. The validity of pre-manipulative tests of the cervical spine is often questioned, and the understanding of the effect of head/neck position on blood flow is still incomplete. Most of the evidence concerning hemodynamics in this area relates to extracranial flow (vertebral and carotid artery). Less is understood about the effects on intracranial flow while performing pre-manipulative tests and sustained positions like end of range cervical rotation mobilization. The aim of the study was to assess the influence of commonly used evaluation and treatment positions on intracranial hemodynamic parameters.

METHOD

A randomized, cross-over observational study using ultrasonography on healthy subjects (n = 19) was conducted to measure hemodynamic parameters (peak systolic velocity and end diastolic maximum) of intracranial arterial systems. Two test positions (sustained pre-manipulative thrust C0-1 and sustained cervical end of range rotation) were compared with a sham position for each test position.

RESULTS

:Neither the sequence of tests performed nor an independent variable (the two positions) had a significant effect (p < 0.05) on peak systolic velocity (PSV) or end diastolic maximum (EDM).

DISCUSSION

No effects from commonly used assessment and treatment of neck positions on hemodynamic parameters were found. This is consistent with previous studies. Further study is indicated on people with symptoms and known pathologies.

Imaging and Clinical Findings after Auto-mobilization in a Cervical Disk Herniation Patient with Prolonged Neck Pain: A 7-year Follow-up Case Report

Background

Auto-mobilization (AM) is a treatment method that patients can use by themselves for pain relief. We report the case of a patient diagnosed with cervical disk herniation (CDH), with frequent recurrences of upper limb numbness and neck pain. The patient experienced a favorable outcome after cervical spine AM, as evidenced by the immediate and long-term relief of his symptoms as well as changes observed through imaging.

Case

A 33-year-old-man diagnosed with CDH presented with frequent recurrences of upper limb numbness and neck pain. Radiographic and T2-weighted magnetic resonance imaging scans revealed cervical spine kyphosis and a left paracentral to intraforaminal lesion with disk herniation of protrusion type at C4-5. He was started on AM to elicit physiological lordosis of the cervical spine. This treatment was painless and did not cause withdrawal on discontinuation. AM improved the mobility of his cervical lower facet joints, reduced dysesthesia, and eliminated pain. Improvement in neck pain and cervical kyphosis and reduction of disk herniation were observed 2 years after initiating the intervention.

Discussion

Appropriate physical therapy evaluation and cervical AM for this patient resulted in symptomatic relief and indirect disk herniation regression. By adding imaging findings to clinical findings, the effect of AM could be visualized, and the reliability of the therapeutic effect was further enhanced.

Is Altered Oculomotor Control during Smooth Pursuit Neck Torsion Test Related to Subjective Visual Complaints in Patients with Neck Pain Disorders?

Subjective visual complaints are commonly reported in patients with neck pain, but their relation to objectively measured oculomotor functions during smooth pursuit neck torsion tests (SPNTs) has not yet been investigated. The aim of the study was to analyse classification accuracy of visual symptom intensity and frequency based on SPNT results. Forty-three patients with neck pain were referred by orthopaedic outpatient clinics where they were required to fill out 16-item proformas of visual complaints. Infrared video-oculography was used to measure smooth pursuit eye movements during neutral and neck torsion positions. Parameters of gain and SPNT difference (SPNTdiff) were taken into the Naïve Bayes model as classifiers, while intensity and frequency of visual symptoms were taken as predicted class. Intensity and, to a lesser degree, frequency of visual symptoms previously associated with neck pain or focal vision disorders (computer vision syndrome) showed better classification accuracy using gain at neck torsion position, indicating cervical driven visual disturbances. Moreover, SPNTdiff presented with slightly lower classification accuracy as compared to gain at neck torsion position. Our study confirmed the relationship between cervical driven oculomotor deficits and some visual complaints (concentrating to read, words moving on page, blurred vision, difficulty judging distance, sore eyes, heavy eyes, red eyes, and eyes strain).

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.

Identifying vascular pathologies or flow limitations: Important aspects in the clinical reasoning process

Cervical spine manipulation and mobilisation are frequently used in the management of neck pain and headache. Although very rare, serious adverse events (SAEs) following cervical spine manipulation and mobilisation have been described. Recently, a revised version of the International IFOMPT Cervical Framework was published, to provide guidance for the assessment of the cervical spine region for potential vascular pathologies of the neck in advance of planned Orthopaedic Manual Physical Therapy (OMPT) interventions. Clinicians should realise that following the Framework does not guarantee that vascular pathologies or flow limitations will be identified. To illustrate this, in this Professional Issue, we use a case description of a SAE that occurred in the Netherlands during a mobilisation technique used by a physiotherapist and discuss this case using the IFOMPT Cervical Framework and highlight some important aspects in the clinical reasoning process.

Proposing a new algorithm for premanipulative testing in physical therapy practice

In the field of physical therapy, there is debate as to the clinical utility of premanipulative vascular assessments. Cervical artery dysfunction (CAD) risk assessment involves a multi-system approach to differentiate between spontaneous versus mechanical events. The purposes of this inductive analysis of the literature are to discuss the link between cervical spine manipulation (CSM) and CAD, to examine the literature on premanipulative vascular tests, and to suggest an optimal sequence of premanipulative testing based on the differentiation of a spontaneous versus mechanical vascular event. Knowing what premanipulative vascular tests assess and the associated clinical application facilitates an evidence-informed decision for clinical application of vascular assessment before CSM.

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.

Uniaxial Tensile Properties of Atherosclerotic Carotid Artery After Mobilization of Pushing on Qiao-Gong: A Safety Study Using an Animal Model of Carotid Atherosclerosis

OBJECTIVES

This study aimed to preliminarily explore the effects of the soft tissue mobilization of pushing on Qiao-Gong (MPQ) on biomechanical properties of the carotid artery using an animal model of carotid atherosclerosis (CAS).

METHODS

Fifty rabbits were randomly divided into 4 groups: animals with CAS treated with MPQ (CAS-MPQ [n = 15]); animals with CAS treated without MPQ (CAS [n = 15]); normal animals treated with MPQ (normal-MPQ [n = 10]); and a blank control group (n = 10). The MPQ procedure consisted of soft tissue mobilization of the Qiao-Gong acupoint on the front edge of the sternocleidomastoid muscle applied from top to bottom, by flat pushing with the thumb repeatedly for 20 times. Disease in the CAS models was induced by carotid artery balloon injury combined with a high-fat diet for 12 weeks. At the end of modeling, carotid color Doppler ultrasonography examination was performed to confirm which animal models were successfully induced with CAS, excluding model rabbits without typical CAS at the same time. Then, MPQ was applied on rabbits in the CAS-MPQ and the normal-MPQ groups for 3 weeks. By contrast, rabbits in the other 2 groups were fed normally without MPQ. Uniaxial failure tests were later performed on carotid arteries in all 4 groups, and at the end of the study, a 2-way factorial analysis of variance of the results was conducted.

RESULTS

(1) At the end of modeling, 10 rabbits in the CAS-MPQ group and 9 in the CAS group were included with typical carotid atherosclerotic characteristics. (2) Young's elastic modulus of the rabbit carotid artery increased more significantly in the CAS-MPQ group than the CAS group. (3) Compared with normal rabbit carotid arteries, atherosclerotic carotid arteries had lower levels of ultimate stress and ultimate strain but higher levels of ultimate load.

CONCLUSIONS

The uniaxial tensile mechanical properties of the rabbit atherosclerotic carotid artery were impaired after MPQ.

Effects of Cervical Rotatory Manipulation on Internal Carotid Artery in Hemodynamics Using an Animal Model of Carotid Atherosclerosis: A Safety Study

BACKGROUND Spinal manipulation, particularly in cervical rotatory manipulation (CRM), has become increasingly popular in physical therapies, with satisfying effect. However, it is still unclear whether CRM affects internal carotid arteries (ICA) with mild carotid atherosclerosis (CAS), especially in hemodynamics. MATERIAL AND METHODS Nine cynomolgus monkeys were randomly divided into 3 groups: the CAS-CRM, the CAS, and the blank control groups. CAS models were developed in the left ICA in the CAS-CRM and the CAS groups. The monkeys in the CAS-CRM group underwent CRM intervention for 3 weeks. Histology and hemodynamics were measured, including peak systolic velocity (PSV), end-diastolic velocity (EDV), time average velocity (TAV), resistance index (RI), and pulsatility index (PI). Measurements were made separately at 3 different rotation angles (0°, 45°, and 90°). RESULTS In the 3 groups, with the increase of rotation angle, the decreasing tendency of PSV, EDV, and TAV and the increasing tendency of RI and PI were statistically significant. At each angle, the monkeys in the CAS-CRM and the CAS groups had lower levels of PSV, EDV, and TAV and higher levels of RI and PI compared with the blank control group. No significant difference in hemodynamics was found between the CAS-CRM and the CAS groups. CONCLUSIONS Both the rotational angle and the atherosclerotic disease can affect the blood flow of the ICA. However, CRM does not cause adverse effects on hemodynamics in cynomolgus monkeys with mild CAS, and appears to be a relatively safe technique.

What are the risks of manual treatment of the spine? A scoping review for clinicians

Background

Communicating to patients the risks of manual treatment to the spine is an important, but challenging element of informed consent. This scoping review aimed to characterise and summarise the available literature on risks and to describe implications for clinical practice and research.

Method

A methodological framework for scoping reviews was followed. Systematic searches were conducted during June 2017. The quantity, nature and sources of literature were described. Findings of included studies were narratively summarised, highlighting key clinical points.

Results

Two hundred and fifty articles were included. Cases of serious adverse events were reported. Observational studies, randomised studies and systematic reviews were also identified, reporting both benign and serious adverse events.Benign adverse events were reported to occur commonly in adults and children. Predictive factors for risk are unclear, but for neck pain patients might include higher levels of neck disability or cervical manipulation. In neck pain patients benign adverse events may result in poorer short term, but not long term outcomes.Serious adverse event incidence estimates ranged from 1 per 2 million manipulations to 13 per 10,000 patients. Cases are reported in adults and children, including spinal or neurological problems as well as cervical arterial strokes. Case-control studies indicate some association, in the under 45 years age group, between manual interventions and cervical arterial stroke, however it is unclear whether this is causal. Elderly patients have no greater risk of traumatic injury compared with visiting a medical practitioner for neuro-musculoskeletal problems, however some underlying conditions may increase risk.

Conclusion

Existing literature indicates that benign adverse events following manual treatments to the spine are common, while serious adverse events are rare. The incidence and causal relationships with serious adverse events are challenging to establish, with gaps in the literature and inherent methodological limitations of studies. Clinicians should ensure that patients are informed of risks during the consent process. Since serious adverse events could result from pre-existing pathologies, assessment for signs or symptoms of these is important. Clinicians may also contribute to furthering understanding by utilising patient safety incident reporting and learning systems where adverse events have occurred.

Validity of a new assessment rubric for a short-answer test of clinical reasoning

BACKGROUND

The validity of high-stakes decisions derived from assessment results is of primary concern to candidates and certifying institutions in the health professions. In the field of orthopaedic manual physical therapy (OMPT), there is a dearth of documented validity evidence to support the certification process particularly for short-answer tests. To address this need, we examined the internal structure of the Case History Assessment Tool (CHAT); this is a new assessment rubric developed to appraise written responses to a short-answer test of clinical reasoning in post-graduate OMPT certification in Canada.

METHODS

Fourteen physical therapy students (novices) and 16 physical therapists (PT) with minimal and substantial OMPT training respectively completed a mock examination. Four pairs of examiners (n = 8) participated in appraising written responses using the CHAT. We conducted separate generalizability studies (G studies) for all participants and also by level of OMPT training. Internal consistency was calculated for test questions with more than 2 assessment items. Decision studies were also conducted to determine optimal application of the CHAT for OMPT certification.

RESULTS

The overall reliability of CHAT scores was found to be moderate; however, reliability estimates for the novice group suggest that the scale was incapable of accommodating for scores of novices. Internal consistency estimates indicate item redundancies for several test questions which will require further investigation.

CONCLUSION

Future validity studies should consider discriminating the clinical reasoning competence of OMPT trainees strictly at the post-graduate level. Although rater variance was low, the large variance attributed to error sources not incorporated in our G studies warrant further investigations into other threats to validity. Future examination of examiner stringency is also warranted.

Establishing assessment criteria for clinical reasoning in orthopedic manual physical therapy: a consensus-building study

OBJECTIVES

Clinical reasoning (CR) represents one of the core components of clinical competence in Orthopaedic Manual Physical Therapy (OMPT). While education standards have been developed to guide curricular design, assessment of CR has not yet been standardized. Without theory-informed and rigorously developed measures, the certification of OMPTs lacks credibility and is less defensible. The purpose of this study was to use a theory-informed approach to generate assessment criteria for developing new assessment tools to evaluate CR in OMPT.

METHODS

A list of assessment criteria was generated based on international education standards and multiple theoretical perspectives. A modified Delphi method was used to gain expert consensus on the importance of these assessment criteria for the assessment of CR in OMPT. The OMPTs from 22 countries with experience in assessing CR were invited to participate in three rounds of online questionnaires to rate their level of agreement with these criteria. Responses were tabulated to analyze degree of consensus and internal consistency.

RESULTS

Representatives from almost half of the OMPT member organizations (MO) participated in three rounds of the Delphi. High levels of agreement were found among respondents regarding the importance and feasibility of most assessment criteria. There was high internal consistency among items within the proposed item subgroupings.

DISCUSSION

A list of assessment criteria has been established that will serve as a framework for developing new assessment tools for CR assessment in OMPT. These criteria will be important for guiding the design of certification processes in OMPT as well as other episodes of CR assessment throughout OMPT training.

Beliefs and practice patterns in spinal manipulation and spinal motion palpation reported by canadian manipulative physiotherapists

PURPOSE

This practice survey describes how Fellows of the Canadian Academy of Manipulative Physiotherapy (FCAMPT) use spinal manipulation and mobilization and how they perceive their competence in performing spinal assessment; it also quantifies relationships between clinical experience and use of spinal manipulation.

METHODS

A cross-sectional survey was designed based on input from experts and the literature was administered to a random sample of the FCAMPT mailing list. Descriptive (including frequencies) and inferential statistical analyses (including linear regression) were performed.

RESULTS

The response rate was 82% (278/338 eligible FCAMPTs). Most (99%) used spinal manipulation. Two-thirds (62%) used clinical presentation as a factor when deciding to mobilize or manipulate. The least frequently manipulated spinal region was the cervical spine (2% of patients); 60% felt that cervical manipulation generated more adverse events. Increased experience was associated with increased use of upper cervical manipulation among male respondents (14% more often for every 10 years after certification; β, 95% CI=1.37, 0.89-1.85, p<0.001) but not among female respondents. Confidence in palpation accuracy decreased in lower regions of the spine.

CONCLUSION

The use of spinal manipulation/mobilization is prevalent among FCAMPTs, but is less commonly used in the neck because of a perceived association with adverse events.

Determining adverse events in patients with neck pain receiving orthopaedic manual physiotherapy: a pilot and feasibility study

PURPOSE

To pilot and determine the feasibility of estimating adverse events in patients with neck pain treated with cervical manipulation/mobilization by Canadian orthopaedic manual physiotherapists (OMPTs) using an online data-collection system to provide estimates for a future larger multi-centre international study.

METHODS

In a prospective multi-site two-group cohort study, participants received usual care and either (a) combined manipulation and mobilization or (b) mobilization only. Study feasibility objectives and criteria for success were set a priori. Data were analyzed using descriptive statistics.

RESULTS

A total of 20 patients were recruited from 6 of 16 participating centres, 17 to the mobilization group and 3 to the combined group. Barriers to data collection included low recruitment, difficulties in using the online data-collection system, and clinicians' and patients' being too busy to participate. Missing data for the primary outcome averaged 28.5%. A total of 69 symptom occurrences were reported during the treatment phase, all benign and transient. Most began within 0-12 hours after treatment (66/69, 95.6%) and lasted for 0-2 days (56/69, 81.2%). Kappa estimates of agreement between therapists and patients on reporting of adverse symptoms across visits 1-5 was substantial (κ=0.68; 95% CI, 0.52-0.84; p<0.01).

CONCLUSIONS

This pilot study demonstrates substantial challenges in conducting a large multi-centre trial. Brief, benign, and transient adverse events were common; no substantial adverse events were observed.

International framework for examination of the cervical region for potential of Cervical Arterial Dysfunction prior to Orthopaedic Manual Therapy intervention

A consensus clinical reasoning framework for best practice for the examination of the cervical spine region has been developed through an iterative consultative process with experts and manual physical therapy organisations. The framework was approved by the 22 member countries of the International Federation of Orthopaedic Manipulative Physical Therapists (October 2012). The purpose of the framework is to provide guidance to clinicians for the assessment of the cervical region for potential of Cervical Arterial Dysfunction in advance of planned management (inclusive of manual therapy and exercise interventions). The best, most recent scientific evidence is combined with international expert opinion, and is presented with the intention to be informative, but not prescriptive; and therefore as an aid to the clinician's clinical reasoning. Important underlying principles of the framework are that 1] although presentations and adverse events of Cervical Arterial Dysfunction are rare, it is a potentially serious condition and needs to be considered in musculoskeletal assessment; 2] manual therapists cannot rely on the results of one clinical test to draw conclusions as to the presence or risk of Cervical Arterial Dysfunction; and 3] a clinically reasoned understanding of the patient's presentation, including a risk:benefit analysis, following an informed, planned and individualised assessment, is essential for recognition of this condition and for safe manual therapy practice in the cervical region. Clinicians should also be cognisant of jurisdictionally specific requirements and obligations, particularly related to patient informed consent, when intending to use manual therapy in the cervical region.

Immediate changes in widespread pressure pain sensitivity, neck pain, and cervical range of motion after cervical or thoracic thrust manipulation in patients with bilateral chronic mechanical neck pain: a randomized clinical trial

STUDY DESIGN

Randomized clinical trial.

OBJECTIVES

To compare the effects of cervical versus thoracic thrust manipulation in patients with bilateral chronic mechanical neck pain on pressure pain sensitivity, neck pain, and cervical range of motion (CROM).

BACKGROUND

Evidence suggests that spinal interventions can stimulate descending inhibitory pain pathways. To our knowledge, no study has investigated the neurophysiological effects of thoracic thrust manipulation in individuals with bilateral chronic mechanical neck pain, including widespread changes on pressure sensitivity.

METHODS

Ninety patients (51% female) were randomly assigned to 1 of 3 groups: cervical thrust manipulation on the right, cervical thrust manipulation on the left, or thoracic thrust manipulation. Pressure pain thresholds (PPTs) over the C5-6 zygapophyseal joint, lateral epicondyle, and tibialis anterior muscle, neck pain (11-point numeric pain rating scale), and cervical spine range of motion (CROM) were collected at baseline and 10 minutes after the intervention by an assessor blinded to the treatment allocation of the patients. Mixed-model analyses of covariance were used to examine the effects of the treatment on each outcome variable, with group as the between-subjects variable, time and side as the within-subject variables, and gender as the covariate. The primary analysis was the group-by-time interaction.

RESULTS

No significant interactions were found with the mixed-model analyses of covariance for PPT level (C5-6, P>.210; lateral epicondyle, P>.186; tibialis anterior muscle, P>.268), neck pain intensity (P = .923), or CROM (flexion, P = .700; extension, P = .387; lateral flexion, P>.672; rotation, P>.192) as dependent variables. All groups exhibited similar changes in PPT, neck pain, and CROM (all, P<.001). Gender did not influence the main effects or the interaction effects in the analyses of the outcomes (P>.10).

CONCLUSION

The results of the current randomized clinical trial suggest that cervical and thoracic thrust manipulation induce similar changes in PPT, neck pain intensity, and CROM in individuals with bilateral chronic mechanical neck pain. However, changes in PPT and CROM were small and did not surpass their respective minimal detectable change values. Further, because we did not include a control group, we cannot rule out a placebo effect of the thrust interventions on the outcomes.

LEVEL OF EVIDENCE

Therapy, level 1b.J Orthop Sports Phys Ther 2012;42(9):806-814, Epub 18 June 2012. doi:10.2519/jospt.2012.4151.

Development of a clinical prediction rule to identify patients with neck pain likely to benefit from thrust joint manipulation to the cervical spine

STUDY DESIGN

Prospective cohort/predictive validity study.

OBJECTIVE

To determine the predictive validity of selected clinical examination items and to develop a clinical prediction rule to determine which patients with neck pain may benefit from cervical thrust joint manipulation (TJM) and exercise.

BACKGROUND

TJM to the cervical spine has been shown to be effective in patients presenting with a primary report of neck pain. It would be useful for clinicians to have a decision-making tool, such as a clinical prediction rule, that could accurately identify which subgroup of patients would respond positively to cervical TJM.

METHODS

Consecutive patients who presented to physical therapy with a primary complaint of neck pain completed a series of self-report measures, then received a detailed standardized history and physical examination. After the clinical examination, all patients received a standardized treatment regimen consisting of cervical TJM and range-of-motion exercise. Depending on response to treatment, patients were treated for 1 or 2 sessions over approximately 1 week. At the end of their participation in the study, patients were classified as having experienced a successful outcome based on a score of +5 ("quite a bit better") or higher on the global rating of change scale. Sensitivity, specificity, and positive and negative likelihood ratios were calculated for all potential predictor variables. Univariate techniques and stepwise logistic regression were used to determine the most parsimonious set of variables for prediction of treatment success. Variables retained in the regression model were used to develop a multivariate clinical prediction rule.

RESULTS

Eighty-two patients were included in data analysis, of whom 32 (39%) achieved a successful outcome. A clinical prediction rule with 4 attributes (symptom duration less than 38 days, positive expectation that manipulation will help, side-to-side difference in cervical rotation range of motion of 10° or greater, and pain with posteroanterior spring testing of the middle cervical spine) was identified. If 3 or more of the 4 attributes (positive likelihood ratio of 13.5) were present, the probability of experiencing a successful outcome improved from 39% to 90%.

CONCLUSION

The clinical prediction rule may improve decision making by providing the ability to a priori identify patients with neck pain who are likely to benefit from cervical TJM and range-of-motion exercise. However, this is only the first step in the process of developing and testing a clinical prediction rule, as future studies are necessary to validate the results and should include long-term follow-up and a comparison group.

LEVEL OF EVIDENCE

Prognosis, level 2b.

The pearls and pitfalls of magnetic resonance imaging for the spine

Musculoskeletal imaging of the spine can be an invaluable tool to inform clinical decision making in patients with spinal pain. An understanding of the technology involved in producing and interpreting high-resolution images produced from magnetic resonance imaging (MRI) of the human spine is necessary to better appreciate which sequences can be used for, or tailored to, individual patients and their conditions. However, there is substantial variability in the clinical meaningfulness of some MRI findings of spinal tissues. For example, normal variants can often mimic significant musculoskeletal pathology, which could increase the risk of misinformed clinical decisions and, even worse, poor or adverse outcomes. This clinical commentary will highlight some of the pearls and pitfalls of MRI for the cervical, thoracic, and lumbar regions, and include cases to illustrate some of the common imaging artifacts and normal variants for MRI of the spine.

Thoracic spine thrust manipulation improves pain, range of motion, and self-reported function in patients with mechanical neck pain: a systematic review

STUDY DESIGN

Systematic review.

BACKGROUND

Neck pain is a common diagnosis in the physical therapy setting, yet there is no gold standard for treatment. This study is part of a growing body of literature on the use of thoracic spine thrust manipulation for the treatment of individuals with mechanical neck pain.

OBJECTIVE

The purpose of this systematic review was to determine the effects of thoracic spine thrust manipulation on pain, range of motion, and self-reported function in patients with mechanical neck pain.

METHODS

Six online databases were comprehensively searched from their respective inception to October 2010. The primary search terms included "thoracic mobilization," "thoracic spine mobilization," "thoracic manipulation," and "thoracic spine manipulation." Of the 44 studies assessed for inclusion, 6 randomized controlled trials were retained. Between-group mean differences and effect sizes for pretreatment-to-posttreatment change scores, using Cohen's d formula, were calculated for pain, range of motion, and subjective function at all stated time intervals.

RESULTS

Effect size point estimates for the pain change scores were significant for global assessment across all studies (range, 0.38-4.03) but not conclusively significant at the end range of active rotation (range, 0.02-1.79). Effect size point estimates were large among all range-of-motion change measures (range, 1.40-3.52), and the effect size point estimates of the change scores among the functional questionnaires (range, 0.47-3.64) also indicated a significant treatment effect.

CONCLUSIONS

Thoracic spine thrust manipulation may provide short-term improvement in patients with acute or subacute mechanical neck pain. However, the body of literature is weak, and these results may not be generalizable.

LEVEL OF EVIDENCE

Therapy, level 1b-.

A patient with internal carotid artery dissection

BACKGROUND AND PURPOSE

The purpose of this case report is to raise physical therapist awareness of Horner syndrome as a "red flag" for immediate medical referral.

CASE DESCRIPTION

A 45-year-old man sought physical therapy for examination and treatment of neck pain and headache symptoms 5 days after experiencing a whiplash-type injury while waterskiing. His complaints were similar to a prior condition diagnosed as occipital neuralgia that had successfully responded to education, cervical and thoracic joint mobilization, and exercise provided by a physical therapist. The initial examination findings also were similar to those of the previous episode. However, signs consistent with Horner syndrome were noted on the second visit. This finding raised immediate concern on the part of the treating clinician and resulted in prompt physician referral, medical diagnosis, and intervention.

OUTCOMES

A magnetic resonance imaging angiogram revealed an internal carotid artery dissection. A successful outcome was achieved over the course of 6 months through medical intervention, which consisted of anticoagulant therapy and modification of activity levels.

DISCUSSION

In this case, the patient's sudden onset of signs of Horner syndrome was indicative of a medical emergency-internal carotid artery dissection.

Occult hypermobility of the craniocervical junction: a case report and review

STUDY DESIGN

Resident's case problem.

BACKGROUND

Patients often present to physical therapists with chief complaints of neck pain, occipital headache, and dizziness associated with a past history of cervical spine injury. These symptoms may be associated with various cervical spine conditions, including craniocervical junction (CCJ) hypermobility.

DIAGNOSIS

This report reviews the history, physical exam, and diagnostic imaging findings of a patient with the above symptoms. This patient, who had a history of multiple cervical spine injuries, was examined with 2 manual therapy provocative tests: the Sharp-Purser test, which is intended to stress the transverse ligament and odontoid, and the modified lateral shear test, which is intended to stress the alar ligaments. The lateral shear test was perceived as demonstrating excessive mobility and a soft end feel, with a "shift" of C1 on C2. Stress cervical radiographs, obtained using open-mouth projections in neutral, left, and right cervical lateral flexion, revealed a 3-mm lateral offset of the right lateral mass of C1 on C2. MRI evaluation of the lower cervical spine did not reveal any significant disc derangement; however, images of the soft tissues of the craniocervical junction were not obtained. Based on the examination and imaging studies, the patient was determined to have a previously undiagnosed hypermobility of the atlantoaxial joint.

DISCUSSION

The patient was advised to avoid rotational manipulation and end range lateral flexion stretching exercises. Axial traction manipulation techniques, midrange stabilization exercises, and postural advice appeared to provide good relief of symptoms. Physical therapists should consider the possibility of CCJ hypermobility in the frontal plane when examining the cervical spine in patients with chronic neck pain, headache, and a past history of trauma. The lateral shear test and stress radiography may provide simple screening tests for occult CCJ hypermobility; however, the reliability and validity of these tests is lacking. Further research on diagnosis and management of CCJ hypermobility is warranted.

LEVEL OF EVIDENCE

Differential diagnosis, level 4.

Manipulative practice in the cervical spine: a survey of IFOMPT member countries

The International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) aims to achieve worldwide promotion of excellence and unity in clinical and academic standards for manual and musculoskeletal physical therapists. To this end, IFOMPT has sponsored several conference panel sessions and a survey of Member Organizations (MOs) and Registered Interest Groups (RIGs) regarding current cervical spine manipulation and pre-manipulative screening practice in each country. The purpose of this study was to determine common elements of cervical spine manipulative practice and pre-manipulative screening between countries. In late 2007, a questionnaire investigating recommended pre-manipulative screening protocol/guideline use, informed consent regarding risks, screening procedures, and treatment/manipulation technique was sent to all twenty MOs and five RIGs. The response rate was 88%. The main findings of the survey included: 77% of respondent organizations use pre-manipulative guidelines, with Australian guidelines the most frequently adopted internationally (36%); recommendations concerning the provision of information about the possibility of serious adverse events is not standard practice in all countries (50%); positional tests for vertebrobasilar insufficiency are used by all respondent organizations; craniovertebral ligament testing is sometimes taught as a pre-manipulative screening tool (36%); the use of upper cervical spine manipulation has declined in some countries (41%); and of the respondent organizations that continue to teach upper cervical manipulation, most (70%) minimize the rotation component. The findings of this research will inform an IFOMPT international standard for screening the cervical region prior to orthopaedic manual therapy intervention. The development of an IFOMPT endorsed document will be of assistance to manual therapy clinicians worldwide in safely managing disorders of the cervical spine.