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

Combined Effects of Glenohumeral Mobilization, Stretching, and Thoracic Manipulation on Shoulder Internal Rotation Range of Motion

Background/purpose

Interventions including posterior glenohumeral mobilizations (PGM), sleeper stretches, and thoracic manipulation are commonly used to address posterior shoulder tightness. The purpose of this study was to assess the effects of adding thoracic manipulation to PGM and sleeper stretches on passive range of motion (PROM), joint mobility, and infraspinatus electromyographic (EMG) activity in shoulders with decreased internal rotation (IR) PROM.

Design

Randomized Sequential Intervention Laboratory Study.

Methods

Forty individuals with clinically significant IR loss attended two study sessions. Participants were randomized to receive five 30 seconds bouts of either grade III PGM or sleeper stretching. Following a seven-day washout period, all participants attended a second session and received a prescriptive supine HVLA manipulation targeting the T3-4 segment, followed by the previously randomized intervention. Outcome measures included internal rotation PROM, horizontal adduction PROM, posterior glenohumeral joint translation assessed via ultrasound imaging, and EMG activity of the infraspinatus during a PGM. All outcome measures were assessed pre- and immediately post-intervention and compared statistically.

Results

There were significant within-group, but not between-group, differences for IR and horizontal adduction PROM following a single session of PGM or sleeper stretch. When combined with thoracic manipulation, significantly smaller within session changes of IR PROM were observed for both PGM (mean difference 4.4, p=0.017) and sleeper stretches (mean difference 6.4, p=0.0005). There were no significant between group differences for horizontal adduction PROM, humeral head translation, or EMG activity across all time points.

Discussion

Both GH posterior mobilizations and sleeper stretches improved IR and horizontal adduction PROM in a single session. The addition of thoracic manipulation prior to local shoulder interventions resulted in smaller gains of both IR and horizontal adduction ROM.

Level of evidence

Level 2.

The majority of clinical trials assessing mobilization and manipulation for neck pain lack a pragmatic approach: a systematic review of 174 trials

BACKGROUND

Disorders of the cervical spine are some of the costliest musculoskeletal conditions to manage globally. Joint mobilization and manipulation have been shown to be an effective treatment for neck pain. However, the generalizability and clinical translation depends on the nature of the trial designs that inform its use. The extent to which randomized control trials (RCTs) assessing manual therapy treatments for cervical spine disorders fall on the efficacy (explanatory) -effectiveness (pragmatic) spectrum often informs how the findings are translated into clinical practice.

OBJECTIVE

The aim of this systematic review was to determine where RCTs of manual therapy for neck disorders fall on the efficacy-effectiveness spectrum.

METHODS

A search of three electronic databases including PubMed, CINAHL, and CENTRAL were completed for trials published from inception to May 2023. RCTs in which joint mobilization or manipulation were used to treat cervical spine disorders were assessed on the effectiveness-efficacy spectrum using the Rating of Included Trials on the Efficacy-Effectiveness Spectrum (RITES) tool and risk of bias using the Revised Cochrane Risk of Bias tool.

RESULTS

A total of 174 trials met eligibility. RITES domain two trial setting (71.3% vs 16.1%), domain three flexibility of intervention(s) (62.1% vs 23%), and domain four clinical relevance of experimental and comparison intervention(s) (51.7% vs 29.3%) all favored efficacy over effectiveness. Domain one participant characteristic(s) had a slightly greater emphasis on effectiveness compared to efficacy (36.8% vs 44.8%). Most studies (96%) had at least some risk of bias.

CONCLUSION

Over half of the RCTs assessing the treatment effect of joint mobilization and manipulation for neck pain favor efficacy (explanatory) over effectiveness (pragmatic) designs. Future RCTs on this topic should consider a greater emphasis on pragmatic trial design components in order to better reflect real-world translation to clinical practice.

Stretching and muscle-performance exercises for chronic nonspecific neck pain: who may benefit most?

BACKGROUND

Although exercise is the mainstay of treatment for neck pain (NP), uncertainty remains over optimal decision-making concerning who may benefit most from such, particularly in the long term.

OBJECTIVE

To identify the subgroup of patients with nonspecific NP most likely to benefit from stretching and muscle-performance exercises.

METHODS

This was a secondary analysis of treatment outcomes of 70 patients (10 of whom dropped out) with a primary complaint of nonspecific NP in one treatment arm of a prospective, randomized, controlled trial. All patients performed the exercises, twice weekly for 6 weeks, and a home exercise program. Blinded outcome measurements were collected at baseline, after the 6-week program, and at a 6-month follow-up. Patients rated their perceived recovery on a 15-point global rating of change scale; a rating of "quite a bit better" (+5) or higher was defined as a successful outcome. Clinical predictor variables were developed via logistic regression analysis to classify patients with NP that may benefit from exercise-based treatment.

RESULTS

NP duration since onset≤6 months, no cervicogenic headache, and shoulder protraction were independent predictor variables. The pretest probability of success was 47% after the 6-week intervention and 40% at the 6-month follow-up. The corresponding posttest probabilities of success for participants with all three variables were 86% and 71%, respectively; such participants were likely to recover.

CONCLUSION

The clinical predictor variables developed in this study may identify patients with nonspecific NP likely to benefit most from stretching and muscle-performance exercises in the short and long terms.

The validity of the cervical rotation lateral flexion test in predicting benefit after manipulation treatment to the first and second rib

STUDY DESIGN

Prospective cohort study.

BACKGROUND

The cervical rotation lateral flexion (CRLF) test is frequently used in clinical practice to determine whether a thrust manipulation targeting the first rib should be performed.

OBJECTIVES

To evaluate the predictive validity of the CRLF test and manual examination in determining whether patients with neck pain are likely to benefit from manipulative treatment to the first and second rib.

METHODS

A physical examination incorporating the CRLF test was performed on 50 participants with neck pain followed by manipulation treatment to the first and second ribs. Clinical improvement was assessed immediately and one week after treatment. Participants who experienced at least a 30% improvement in their Neck Disability Index (NDI) score were considered "improved." Predictive validity was assessed by calculating sensitivity, specificity, and negative and positive likelihood ratios.

RESULTS

Neither the CRLF test nor manual examination were predictive of clinical improvement after manipulative treatment to the first and second rib. However, being male, of older age, and exhibiting T1 and/or T2 restricted end-feel were associated with improved neck related-disability at one-week follow-up.

CONCLUSION

The CRLF test does not appear to be helpful in determining whether patients with neck pain are likely to benefit from manipulative treatment to the first and second rib. Other factors from the history and clinical examination may be more helpful when selecting manipulative treatment including age and gender and possibly the presence of T1/T2 restricted end-feel.

Complexity theory in the management of patients with musculoskeletal pain

Nonlinear systems are not susceptible to research with a reductionist approach. In this sense, the complexity theory provides an alternative approach to quantify the importance of contextual factors in patients with musculoskeletal pain. The use of positive (placebo) or negative (nocebo) contextual factors in the therapeutic setting could largely account for the non-specific component of treatment efficacy, directly affecting the quality of patients’ health-related outcomes (e.g., pain, disability, or satisfaction). In recent years, there has been a better understanding of the effects of contextual factors. However, the knowledge and awareness of them is limited and heterogeneous among physical therapists, reducing their translational value in the field of physiotherapy. The purpose of this essay is to describe the management of patients with musculoskeletal pain from the complexity theory perspective.

Predictors of pain reduction following a program of manual therapies for patients with temporomandibular disorders: A prospective observational study

BACKGROUND

Clinical guidelines recommend conservative treatment for the management of temporomandibular disorders (TMD), and manual therapy (MT) is commonly applied to reduce pain and improve function.

OBJECTIVES

To identify predictors of pain reduction and functional improvement following a program of manual therapies (MTP) in patients with TMD and develop a first screening tool that could be used in clinical practice to facilitate decision-making.

DESIGN

A cohort of 102 adults with a diagnosis of TMD were treated with four weekly sessions within a MTP applied to craniomandibular structures. Candidate predictors were demographic variables, general health variables, psychosocial features, TMD characteristics and related clinical tests. A reduction of pain intensity by at least 30% after the MTP was considered a good outcome. Logistic regression was adopted to develop the predictive model and its performance was assessed considering the explained variance, calibration, and discrimination. Internal validation of the prediction models was further evaluated in 500 bootstrapped samples.

RESULTS

Patients experiencing pain intensity greater than 2/10 during mouth opening, positive expectations of outcome following a MTP, pain localized in the craniocervical region, and a low Central Sensitization Inventory score obtained a good outcome following the MTP. Predictive performance of the identified physical and psychological variables was characterized by high explained variance (R2 = 58%) and discrimination (AUC = 89%) after internal validation. A preliminary screening clinical tool was developed and presented as a nomogram.

CONCLUSIONS

The high discrimination of the prediction model revealed promising findings, although these need to be externally validated in future research.

TRIAL REGISTRATION NUMBER

NCT03990662.

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.

Immediate Effects of Adding Dry Needling to Thoracic Manipulation and Exercise in Cervical Range of Motion for Adults With Neck Pain: A Randomized Clinical Trial

OBJECTIVE

The purpose of this study was to determine the immediate effects of adding dry needling (DN) to thoracic spine manipulation and neck-specific exercise in individuals with neck pain.

METHODS

Forty-two participants with neck pain were randomized to either the true (n = 21) or sham (n = 21) DN groups, receiving treatment on the initial visit and 2 to 3 days later. Outcomes were assessed on day 1, both at baseline and immediately after the initial treatment, at the second treatment 2 to 3 days later, and at the final visit 5 to 7 days after visit 2. Primary outcomes were Neck Disability Index (NDI) (0-50) and current pain via numeric pain rating scale (0-10). Secondary outcomes were cervical range of motion, pain pressure threshold, and global rating of change.

RESULTS

Repeated measures analysis of covariance with baseline value as covariate revealed no significant difference in NDI scores at either follow-up time point with adjusted mean differences (95% confidence interval) of -0.11 (-2.70 to 2.48) and 0.31 (-1.96 to 2.57). There were no between-group differences in pain at any time point via Independent-Samples Median Test (P value range of .54-1.0). Secondary outcome measures were similarly not statistically different between groups except for immediate improvements in rotation to the side opposite of pain, which favored DN, with an adjusted mean difference (95% confidence interval) of 7.85 (3.54-12.15) degrees.

CONCLUSION

The addition of DN to thoracic spinal manipulation and neck-specific exercise did not affect improvements in NDI score or numeric pain rating scale but showed an increase in cervical range of motion.

The clinical impact of pain neuroscience continuing education on physical therapy outcomes for patients with low back and neck pain

Objectives

Research suggests that attendance by physical therapists at continuing education (CE) targeting the management of low back pain (LBP) and neck pain does not result in positive impacts on clinical outcomes. The aim of this study was to determine if therapists attending a self-paced 3-hour online Pain Neuroscience Education (PNE) program was associated with any observed changes to patient outcomes and also clinical practice.

Methods

Participants were 25 different physical therapists who treated 3,705 patients with low back pain (LBP) or neck pain before and after they had completed an online PNE CE course. Change in outcomes measures of pain and disability at discharge were compared for the patients treated before and after the therapist training. Clinical practice patterns of the therapists, including total treatment visits, duration of care, total units billed, average units billed per visit, percentage of ‘active’ billing units and percentage of ‘active and manual’ billing units, were also compared for the patient care episodes before and after the therapist training.

Results

There was no significant difference for change in pain scores at discharge for patients treated after therapist CE training compared to those treated before regardless of the condition (LBP or neck pain). However, patients with LBP who were treated after therapist CE training did report greater improvement in their disability scores. Also after CE training, for each episode of care, therapists tended to use less total visits, billed fewer units per visit, and billed a greater percentage of more ‘active’ and ‘active and manual’ billing units.

Discussion

Attending an online 3-hour CE course on PNE resulted in improved disability scores for patients with LBP, but not for those with neck pain. Changes in clinical behavior by the therapists included using less visits, billing fewer total units, and shifting to more active and manual therapy interventions. Further prospective studies with control groups should investigate the effect of therapist CE on patient outcomes and clinical practice.

Impact of contextual factors on patient outcomes following conservative low back pain treatment: systematic review

Background and objective

Chronic low back pain is pervasive, societally impactful, and current treatments only provide moderate relief. Exploring whether therapeutic elements, either unrecognised or perceived as implicit within clinical encounters, are acknowledged and deliberately targeted may improve treatment efficacy. Contextual factors (specifically, patient’s and practitioner’s beliefs/characteristics; patient-practitioner relationships; the therapeutic setting/environment; and treatment characteristics) could be important, but there is limited evidence regarding their influence. This research aims to review the impact of interventions modifying contextual factors during conservative care on patient’s pain and physical functioning.

Databases and data treatment

Four electronic databases (Medline, CINAHL, PsycINFO and AMED) were searched from 2009 until 15th February 2022, using tailored search strategies, and resulted in 3476 unique citations. After initial screening, 170 full-text records were potentially eligible and assessed against the inclusion–exclusion criteria. Thereafter, studies were assessed for methodological quality using a modified Downs and Black scale, data extracted, and synthesised using a narrative approach.

Results

Twenty-one primary studies (N = 3075 participants), were included in this review. Eight studies reported significant improvements in pain intensity, and seven in physical functioning, in favour of the contextual factor intervention(s). Notable contextual factors included: addressing maladaptive illness beliefs; verbal suggestions to influence symptom change expectations; visual or physical cues to suggest pain-relieving treatment properties; and positive communication such as empathy to enhance the therapeutic alliance.

Conclusion

This review identified influential contextual factors which may augment conservative chronic low back pain care. The heterogeneity of interventions suggests modifying more than one contextual factor may be more impactful on patients’ clinical outcomes, although these findings require judicious interpretation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12998-022-00430-8.

Limited prognostic value of pain duration in non-specific neck pain patients seeking chiropractic care

BACKGROUND

Pain chronicity is considered an important prognostic factor for outcome. Here, it was investigated whether pain duration influences outcome when only chronic patients (pain > three months) are considered. Secondary aims were to determine, in patients of any pain duration, how much variance in outcome is explained by pain duration and whether pain duration truly predicts outcomes, i.e. out-of-sample prediction in independent data.

METHODS

Secondary analysis of a cohort study of neck pain patients. Patients were assessed before start of treatment and at one week, one, three, six- and 12-months follow-up. Outcomes were Patient Global Impression of Change (PGIC) and percent change of patients' perceived pain intensity, rated on a numerical rating scale (NRS). Regression analyses (linear and logistic) and supervised machine learning were used to test the influence of pain duration on PGIC and percent NRS change at one week, one, three, six- and 12-months follow-up within sample and out-of-sample. Separate analyses were performed for the full sample (n=720) and for chronic patients (n=238) only.

RESULTS

No relationship between pain duration and outcome was found for chronic patients only. For the full sample, statistical relationships between pain duration and outcomes were observed at all tested follow-up time points. However, the amount of variance in outcome explained by pain duration was low and no out-of-sample prediction was possible.

CONCLUSIONS

Pain duration did not emerge as an important predictor of outcome in this database of 720 neck pain patients receiving chiropractic treatment.

Neck Pain Clinical Prediction Rule to Prescribe Combined Aerobic and Neck-Specific Exercises: Secondary Analysis of a Randomized Controlled Trial

OBJECTIVE

A previous randomized controlled trial revealed that combined aerobic and neck-specific exercises yielded greater improvement than neck-specific exercises alone after a 6-month intervention in outpatients with nonspecific neck pain (NP). The aim of this secondary analysis was to identify subgroups of patients in the combined exercises group most likely to benefit from the intervention.

METHODS

Sixty-nine patients were included. The original trial was conducted in multiple physical therapy outpatient clinics twice a week for 6 weeks; follow-up was 6 months after assignment. The primary outcome was the therapeutic success rate (Global Rating of Change Score ≥ +5, "quite a bit better") after 6 weeks of training and at the 6-month follow-up. Candidate predictors from patients' medical history and physical examination were selected for univariable regression analysis to determine their association with treatment response status. Multivariable logistic regression analysis was used to derive preliminary clinical prediction rules.

RESULTS

The clinical prediction rule contained 3 predictor variables: (1) symptom duration ≤6 months, (2) neck flexor endurance ≥18 seconds, and (3) absence of referred pain (Nagelkerke R2 = .40 and -2 log likelihood = 60.30). The pre-test probability of success was 61.0% in the short term and 77.0% in the long term. The post-test probability of success for patients with at least 2 of the 3 predictor variables was 84.0% in the short term and 87.0% in the long term; such patients will likely benefit from this program.

CONCLUSION

A simple 3-item assessment, derived from easily obtainable baseline data, can identify patients with NP who may respond best to combined aerobic and neck-specific exercises. Validation is required before clinical recommendation.

IMPACT

Patients experiencing NP symptoms ≤6 months who have no referred pain and exhibit neck flexor endurance ≥18 seconds may benefit from a simple self-training program of combined aerobic and neck-specific exercises.

Exercise Effects on Neck Function Among F-15E Aircrew

BACKGROUND: Neck pain (NP) is common among high performance aircrew, yet evidence remains insufficient to guide examination, treatment, and prevention. The purpose of this randomized pilot study was to collect baseline data for neck function for F-15E aircrew and determine efficacy and feasibility of two separate exercise protocols in measuring short-term outcomes of subjective and objective neck function in order to inform future study design. METHODS: Randomized to either progressive (PRO) or general (GEN) exercise groups were 41 F-15E aircrew. Data collection occurred at baseline, 3 wk, and 3 mo. RESULTS: At baseline, 39% of the subjects reported current NP, 79.5% reported a history of NP attributed to flying, 12.8% reported being removed from flying duties due to NP, and 10% reported receiving medical care for NP. PRO and GEN group randomization showed similar baseline assessment data. Blinding was successful and exercise logs showed 31.6% compliance with prescribed exercise regimens. There were small but statistically significant increases in neck range of motion in both groups over the course of the study. Aircrew with current NP had significantly higher F-15E flight hours. DISCUSSION: This study supports the high prevalence of NP in aircrew, yet low frequency of seeking care for NP. Future studies to assess NP prevention and treatment in aircrew require an integrated approach that includes operational exercise policy and long-term data collection in flying units with dedicated resources for assessment and analysis. Lee MS, Briggs R, Scheirer V, Kearby G, Young BA. Exercise effects on neck function among F-15E aircrew. Aerosp Med Hum Perform. 2021; 92(10):815824.

Influence of pain duration on pain outcomes following palliative radiotherapy for painful tumors: the sooner the irradiation, the better?

PURPOSE

The influence of pre-radiotherapy pain duration on post-treatment outcomes was assessed.

METHODS

Patients that received palliative radiotherapy were analyzed in a prospective observational study investigating curative and palliative radiotherapy. Brief Pain Inventory data were acquired at baseline and 1, 2, and 3 months after commencing irradiation. The pain response in terms of the index pain (i.e., pain caused by the irradiated tumors) was assessed using the International Consensus Endpoint. Patients were diagnosed with predominance of other pain (POP) if non-index pain of malignant or unknown origin was present and showed a higher pain score than the index pain. Competing risk analyses were performed in which deaths without the pain endpoints were considered as competing events.

RESULTS

Of 229 patients analyzed, 123 (54%) experienced a pain response and 43 (19%) experienced POP. Multivariable analyses using the Fine-Gray model revealed that patients with shorter pain duration (< 1 month) had higher cumulative incidence of pain response (subdistribution hazard ratio, 2.43; 95% confidence interval [CI], 1.35-4.38) and POP (subdistribution hazard ratio, 4.22; 95% CI, 1.30-13.70) compared with patients with longer pain duration (≥ 4 months). For patients with a pain duration of less than 1 month, cumulative incidence of pain response was estimated to be 69% (95% CI, 53-85%) and cumulative incidence of POP was estimated to be 15% (95% CI, 3-28%) at 1‑month follow-up.

CONCLUSION

Commencing palliative radiotherapy earlier may improve the probability of patients achieving a pain response, although POP may be more frequent.

Recovery expectations of neck pain patients do not predict treatments outcome in manual therapy

Patient recovery expectations can predict treatment outcome. Little is known about the association of patient recovery expectations on treatment outcome in patients with neck pain consulting a manual therapist. This study evaluates the predictive value of recovery expectations in neck pain patients consulting manual therapists in the Netherlands. The primary outcome measure 'recovery' is defined as 'reduction in pain and perceived improvement'. A prospective cohort study a total of 1195 neck pain patients. Patients completed the Patient Expectancies List (PEL) at baseline (3 item questionnaire, score range from 3 to 12), functional status (NDI), the Global Perceived Effect (GPE) for recovery (7-points Likert scale) post treatment and pain scores (NRS) at baseline and post treatment. The relationship between recovery expectancy and recovery (dichotomized GPE scores) was assessed by logistic regression analysis. Patients generally reported high recovery expectations on all three questions of the PEL (mean sumscores ranging from 11.3 to 11.6). When adjusted for covariates the PEL sum-score did not predict recovery (explained variance was 0.10 for the total PEL). Separately, the first question of the PEL showed predictive potential (OR 3.7; 95%CI 0.19-73.74) for recovery, but failed to reach statistical significance. In this study patient recovery expectations did not predict treatment outcome. Variables predicting recovery were recurrence and duration of pain. The precise relationship between patient recovery expectations and outcome is complex and still inconclusive. Research on patient expectancy would benefit from more consistent use of theoretical expectancy and outcome models.

Effectiveness of Cervical Spine High-Velocity, Low-Amplitude Thrust Added to Behavioral Education, Soft Tissue Mobilization, and Exercise for People With Temporomandibular Disorder With Myalgia: A Randomized Clinical Trial

OBJECTIVE

To determine the immediate and short-term effects of adding cervical spine high-velocity, low-amplitude thrust (HVLAT) to behavioral education, soft tissue mobilization, and a home exercise program on pain and dysfunction for people with a primary complaint of temporomandibular disorder (TMD) with myalgia.

DESIGN

Randomized clinical trial.

METHODS

Fifty individuals with TMD were randomly assigned to receive cervical HVLAT or sham manipulation for 4 visits over 4 weeks. Participants in both groups received other treatments, including standardized behavioral education, soft tissue mobilization, and a home exercise program. Primary outcomes included maximal mouth opening, the numeric pain-rating scale, the Jaw Functional Limitation Scale (JFLS), the Tampa Scale of Kinesiophobia for TMD (TSK-TMD), and a global rating of change (GROC). Self-report and objective measurements were taken at baseline, immediately after initial treatment, and follow-ups of 1 week and 4 weeks. A 2-by-4 mixed-model analysis of variance was used, with intervention group as the between-subjects factor and time as the within-subject factor. Separate analyses of variance were performed for dependent variables, and the hypothesis of interest was the group-by-time interaction.

RESULTS

There was no significant interaction for maximal mouth opening, the numeric pain-rating scale, or secondary measures. There were significant 2-way interactions for the JFLS (d = 0.60) and TSK-TMD (d = 0.80). The HVLAT group had lower fear at 4 weeks and improved jaw function earlier (1 week). The GROC favored the HVLAT group, with significant differences in successful outcomes noted immediately after baseline treatment (thrust, 6/25; sham, 0/25) and at 4 weeks (thrust, 17/25; sham, 10/25).

CONCLUSION

Both groups improved over time; however, differences between groups were small. There were significant differences between groups for the JFLS, TSK-TMD, and GROC. The additive clinical effect of cervical HVLAT to standard care remains unclear for treating TMD. J Orthop Sports Phys Ther 2020;50(8):455-465. Epub 6 Jan 2020. doi:10.2519/jospt.2020.9175.

The Effects of Thrust Joint Manipulation on the Resting and Contraction Thickness of Transversus Abdominis in Patients With Low Back Pain: A Randomized Control Trial

OBJECTIVE

To investigate the immediate changes in resting and contracted thickness of the transversus abdominis (TrA) muscle after application of thrust joint manipulation (TJM) vs sham manipulation in participants with low back pain.

METHODS

A pretest-posttest randomized controlled trial design was performed. Consecutive subjects satisfying eligibility criteria completed patient-report outcome baseline measures, pretreatment rehabilitative ultrasound imaging (RUSI) measurements, followed by the randomly assigned intervention then, post-treatment RUSI measurements, and post-treatment & final patient-reported outcome measures. To compare the outcomes of TJM and sham manipulation on the TrA muscle thickness, a 2-by-2 analysis of variance (treatment [TJM and sham manipulation]) by time (pretreatment and post-treatment) was completed for both the TrA muscle thickness at rest and muscle thickness during contraction. Descriptive statistics including independent-sample t tests for continuous variables and χ² tests for categorical variables were used to analyze differences in patient-reported outcome measures between groups.

RESULTS

Sixty-seven eligible participants agreed to participate. No significant interactions were identified for either muscle thickness at rest or contraction.

CONCLUSION

This study did not support the hypothesis that manipulation would result in greater changes in TrA thickness at rest or during contraction in participants with low back pain. Based on prior research that identified subgroups of participants likely to respond to manipulation, future research should include participants more likely to respond favorably to TJM. This study was a priori registered with clinicaltrails.gov (NCT02558855).

Treatment based classification systems for patients with non-specific neck pain. A systematic review

OBJECTIVE

We aimed to identify published classification systems with a targeted treatment approach (treatment-based classification systems (TBCSs)) for patients with non-specific neck pain, and assess their quality and effectiveness.

DESIGN

Systematic review.

DATA SOURCES

MEDLINE, CINAHL, EMBASE, PEDro and the grey literature were systematically searched from inception to December 2019.

STUDY APPRAISAL AND SYNTHESIS

The main selection criterium was a TBCS for patients with non-specific neck pain with physiotherapeutic interventions. For data extraction of descriptive data and quality assessment we used the framework developed by Buchbinder et al. We considered as score of ≤3 as low quality, a score between 3 and 5 as moderate quality and a score ≥5 as good quality. To assess the risk of bias of studies concerning the effectiveness of TBCSs (only randomized clinical trials (RCTs) were included) we used the PEDro scale. We considered a score of ≥ six points on this scale as low risk of bias.

RESULTS

Out of 7664 initial references we included 13 studies. The overall quality of the TBCSs ranged from low to moderate. We found two RCTs, both with low risk of bias, evaluating the effectiveness of two TBCSs compared to alternative treatments. The results showed that both TBCSs were not superior to alternative treatments.

CONCLUSION

Existing TBCSs are, at best, of moderate quality. In addition, TBCSs were not shown to be more effective than alternatives. Therefore using these TBCSs in daily practice is not recommended.

Physiological Responses Induced by Manual Therapy in Animal Models: A Scoping Review

Background: Physiological responses related to manual therapy (MT) treatment have been investigated over decades using various animal models. However, these studies have not been compiled and their collective findings appraised. The purpose of this scoping review was to assess current scientific knowledge on the physiological responses related to MT and/or simulated MT procedures in animal models so as to act as a resource to better inform future mechanistic and clinical research incorporating these therapeutic interventions.

Methods: PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane, Embase, and Index of Chiropractic Literature (ICL) were searched from database inception to August 2019. Eligible studies were: (a) published in English; (b) non-cadaveric animal-based; (c) original data studies; (d) included a form of MT or simulated MT as treatment; (e) included quantification of at least one delivery parameter of MT treatment; (f) quantification of at least one physiological measure that could potentially contribute to therapeutic mechanisms of action of the MT. MT studies were categorized according to three main intervention types: (1) mobilization; (2) manipulation; and (3) massage. Two-phase screening procedures were conducted by a pair of independent reviewers, data were extracted from eligible studies and qualitatively reported.

Results: The literature search resulted in 231 articles of which 78 met inclusion criteria and were sorted by intervention type. Joint mobilization induced changes in nociceptive response and inflammatory profile, gene expression, receptor activation, neurotransmitter release and enzymatic activity. Spinal manipulation produced changes in muscle spindle response, nocifensive reflex response and neuronal activity, electromyography, and immunologic response. Physiological changes associated with massage therapy included autonomic, circulatory, lymphatic and immunologic functions, visceral response, gene expression, neuroanatomy, function and pathology, and cellular response to in vitro simulated massage.

Conclusion: Pre-clinical research supports an association between MT physiological response and multiple potential short-term MT therapeutic mechanisms. Optimization of MT delivery and/or treatment efficacy will require additional preclinical investigation in which MT delivery parameters are controlled and reported using pathological and/or chronic pain models that mimic neuromusculoskeletal conditions for which MT has demonstrated clinical benefit.

The effectiveness of an aerobic exercise training on patients with neck pain during a short- and long-term follow-up: a prospective double-blind randomized controlled trial

Objective:

To examine the effect of adding aerobic exercise (AE) to neck-specific exercise treatment for patients with neck pain (NP) to reduce pain and disability.

Design:

A prospective multicentre randomized controlled trial.

Setting:

Physiotherapy outpatient clinics.

Subjects:

Patients with nonspecific NP.

Intervention:

Patients with NP were randomly assigned to six weeks of neck-specific exercise with and without the addition of AE.

Measures:

Patients were classified as having a successful or non-successful outcome according to the Global Rating of Change (GROC). Outcome measures included Visual Analogue Scale (VAS), Neck Disability Index (NDI), Fear Avoidance Beliefs Questionnaire (FABQ) and cervicogenic headache. Assessments were performed at six-week, and three- and six-month follow-ups.

Results:

A total of 139 participants (mean age: 54.6 ± 10.5 years) were recruited ( n = 69 AE, n = 70 control). According to GROC, 77.4% of the AE group reported a successful outcome at six months vs. 40% in the control group ( P < 0.001). There was a significant reduction in VAS from baseline to six months in the AE vs. control group 6.73 (±1.69) to 1.89 (±1.37) vs. 6.65 (±1.67) to 3.32 (±1.82), respectively ( P  < 0.001). Significant improvements were also obtained for NDI and FABQ from baseline to six weeks in the AE group: NDI from 16.10 (±4.53) to 7.78 (±4.78) vs. 17.01 (±4.84) to 11.09 (±5.64) in the control group ( P = 0.003); FABQ from 33.53 (±9.31) to 20.94 (±841) in the AE vs. 33.45 (±10.20) to 26.83 (±10.79) in the control group ( P < 0.001). The AE group also demonstrated significant reduction in cervicogenic headache from baseline to six months ( P = 0.003).

Conclusion:

Adding AE to long-term neck-specific exercises is an effective treatment for reducing NP and headache in patients with NP.

Predictors of pain reduction following manual therapy in patients with temporomandibular disorders: a protocol for a prospective observational study

INTRODUCTION

Temporomandibular disorders (TMDs) are principally characterised by pain in the craniomandibular area and probable limitations of jaw opening. Manual therapy, like other recommended conservative treatments included in clinical guidelines, is commonly used to treat patients with TMD to reduce pain and improve function. However, outcomes may be variable. The aim of this study is to identify predictors associated with pain reduction in patients with TMD following manual therapy by analysing a combination of patient-reported outcome measures and clinical tests. Such knowledge will support a more personalised management approach by facilitating clinical decision-making.

METHODS/ANALYSIS

An observational prospective design will recruit a cohort of 100 adults with a diagnosis of TMD (according to Axis I of the Diagnostic Criteria for TMD) at a Dental Hospital in Italy. Patients will be treated with four weekly sessions of manual therapy applied to craniomandibular structures. An array of predictors has been chosen based on previous research on prognostic factors for TMD and altered pain modulation in musculoskeletal disorders. Candidate predictors including demographic variables, general health variables, psychosocial features, TMD characteristics and clinical tests of the temporomandibular joint and masticatory muscles will be collected at baseline. Definition of good outcome is a clinically significant reduction of pain intensity over the last week (≥30% reduction Visual Analogue Scale) immediately following the four week intervention. Exploratory factor analysis will be applied to analyse factor loading of candidate predictors for good outcome at four weeks. Subsequently, a logistic multivariable regression model will be performed to calculate low and high risk of good outcome.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the 'Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico' and University of Birmingham Ethics Committee. The results will be submitted for publication in a peer-reviewed journal and presented at conferences.

TRIAL REGISTRATION NUMBER

NCT03990662; Pre-results.

Systematic review of the diagnostic accuracy, reliability, and safety of the sharp-purser test

Introduction: The Sharp-Purser Test (SPT) is used to assess for atlantoaxial instability (AI) in patients with rheumatoid arthritis (RA). The test is commonly used by clinicians; however, many experts argue it lacks reliability and validity along with concerns of safety. The primary purpose of this review is to determine the diagnostic accuracy of the SPT to detect AI.Methods: A search of five databases was performed from inception to 19 December 2018 using search terms related to the SPT. Studies were eligible for inclusion if the SPT was used on a patient/participant. Methodological quality assessment of diagnostic studies was performed with the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) for studies that reported data to calculate sensitivity (SN), specificity (SP), positive likelihood ratio (+LR), and negative likelihood ratio (-LR).Results: The search yielded 1009 articles, and 32 studies met the inclusion criteria for analysis. Meta-analysis on diagnostic accuracy studies assessing the SPT was not possible due to statistical heterogeneity. Six diagnostic accuracy studies assessed the SN of the SPT ranging from 0.19 to 1.00. Four of the studies assessed SP of the SPT ranging from 0.71 to 0.98. The +LR was identified in 4 studies was 0.655, 1.73, 22, and 17.25. The -LR was 1.14, 0.799, 0.571, and 0.323. Seven RCTs utilized the SPT to screen for AI, and the SPT was used in 18 case reports.Conclusion: The SPT may be inappropriate to use due to inconsistent validity, poor inter-rater reliability, and potential to cause harm.Level of evidence: 1.

Association between sympathoexcitatory changes and symptomatic improvement following cervical mobilisations in participants with neck pain. A double blind placebo controlled trial

BACKGROUND

sympathoexcitation observed with passive cervical mobilisations may imply activation of an endogenous pain inhibition system resulting in hypoalgesia. However, research is mostly in asymptomatic participants and there is very limited evidence of a relationship between sympathoexcitation and symptomatic improvement in people with clinical pain.

OBJECTIVE

to investigate the effects of cervical mobilisations on the sympathetic nervous system in participants with neck pain, and to explore the relationship between symptomatic improvement and sympathoexcitation.

DESIGN

double-blind randomised controlled trial.

METHOD

40 participants with neck pain (aged 20-69 years, 25 female) were randomly allocated to either cervical mobilisations or motionless placebo. Skin conductance was measured before, during, and after intervention. After interventions were completed, their credibility was assessed. Participants were classified as responders or non-responders according to global symptom change.

RESULTS

participants receiving mobilisations were more likely to be classified as responders (odds ratio: 4.33, p = 0.03) and demonstrated greater change in most outcome measures of sympathoexcitation from baseline to during the intervention but not from during to after the intervention. There was no association between sympathoexcitation and symptomatic improvement. Mobilisations and placebo were equally credible.

CONCLUSIONS

These findings suggest sympathoexcitatory changes may be caused by an orienting response unrelated to the activation of an endogenous pain inhibition system Alternatively, the observed lack of an association may be explained by the existence of various mechanisms for pain relief. This study used single outcome measures of sympathoexcitation and symptomatic improvement and other measures may reveal different things. CLINICALTRIALS.

GOV NUMBER

M10/2016/095.

Can short-term effectiveness of anti-pronation taping predict the long-term outcomes of customized foot orthoses: developing predictors to identify characteristics of patients with plantar heel pain likely to benefit from customized foot orthoses

BACKGROUND

Foot orthoses are widely used to manage plantar heel pain (PHP). However, the evidence concerning the effect of foot orthoses on PHP is not conclusive. The study aims to identify the characteristics of patients with PHP likely to achieve a positive outcome after customized foot orthoses and to verify the concept that patients who respond positively to anti-pronation taping would achieve a positive prognosis after wearing foot orthoses for six months.

METHODS

This is a prospective observational cohort study. Seventy-four patients with PHP underwent a baseline examination and received anti-pronation taping to their painful feet. The taping effects on pain and function were assessed at the 7-day follow-up visit. Then, all patients received an intervention for their PHP with customized foot orthoses for six months. Outcome was assessed with a numeric pain rating scale, the patient-specific functional scale, the foot function index, and the global rating of perceived change. Significant reduction of pain, increase of function, and perception of a meaningful improvement were considered a positive response.

RESULTS

Of 74 patients, 49 had a positive response to the customized foot orthosis treatment. Five predictors were identified: (1) the average pain intensity decreased by over 1.5 points with taping, (2) the range of ankle plantarflexion > 54 degrees, (3) the strength of ankle plantarflexors on the symptomatic side was equal to or stronger than that on the other side, (4) the range of hip internal rotation < 39 degrees, and (5) the range of hip external rotation > 45 degrees. The presence of three or more predictors increased the rate of achieving positive outcome from 66 to 89%.

CONCLUSIONS

The predictors of customized foot orthosis outcome in patients with PHP are related to several physical measures of a lower extremity. Findings of the study can be used to screen and select patients with PHP for foot orthosis intervention. Moreover, patients who respond positively to anti-pronation taping would also benefit from the customized foot orthoses. However, since there was no control group in the current study, it is inappropriate to draw conclusions about the effectiveness of the foot orthoses treatment.

TRIAL REGISTRATION

The trial was retrospectively registered with the Australian and New Zealand Clinical Trials Registry (ACTRN 12617000119392 ).

Immediate effects of cervical mobilisations on global perceived effect, movement associated pain and neck kinematics in patients with non-specific neck pain. A double blind placebo randomised controlled trial

BACKGROUND

Neck pain is prevalent, costly and disabling. Cervical mobilisations are frequently used to treat it but their effectiveness has been questioned by several systematic reviews. Evidence suggests that better outcomes are achieved with mobilisations when they are applied to specific patient subgroups. A criteria for patients suitable for neck mobilisations has been proposed, but the effectiveness on this patient subgroup has not been tested.

OBJECTIVE

To assess the effectiveness of cervical mobilisations applied to a subgroup of patients with neck pain who fulfil specific criteria.

DESIGN

Randomised controlled trial.

METHOD

40 patients with neck pain attending a Physiotherapy clinic were recruited and randomised to a single session of either cervical mobilisations or motionless manual contact placebo. The immediate effects on global perceived effect, range of movement (ROM), movement velocity and movement associated pain were assessed.

RESULTS

mobilisation participants reported significantly better global perceived effect (p˂0.001) and improvements in movement associated pain (p = 0.041). Mobilisations produced a significant increase in ROM in side flexion (p = 0.006) and rotation (p = 0.044) when compared with placebo, but only in patients with pre-intervention ROM restriction. 29-47% of all movement associated pains were resolved following mobilisations and 11-27% following placebo. Patients in both groups showed a significant (p < 0.05) increase in movement velocity, but only in those who had a velocity restriction pre-intervention.

CONCLUSIONS

Cervical mobilisations are effective in improving movement-associated pain, increasing ROM and velocity, and patient perceived improvement when applied to patients with neck pain that fulfil a criteria. Their use should be advocated.

The Association between Patient Characteristics and Opioid Treatment Response in Neuropathic and Nociceptive Pain due to Cancer

BACKGROUND

Cancer pain remains a difficult problem, for which opioids are often necessary. At present it is difficult to predict the effectiveness of opioid therapy.

OBJECTIVES

We aim to assess the association between patient characteristics and opioid treatment response in cancer patients, and develop a model to predict probability of response.

SUBJECTS

We used data from two previously published randomized clinical trials, in which patients with head and neck cancer were treated with fentanyl or methadone (total N = 134).

MEASUREMENTS

Treatment success was defined as ≥50% pain reduction at one and five weeks. We analyzed patient characteristics (age, sex, depression, and anxiety), treatment characteristics (having had chemotherapy, radiotherapy, surgery, methadone, or fentanyl) and pain characteristics (neuropathic and nociceptive).

DESIGN

Based on univariable and multivariable regression analyses determinants of therapy success were assessed. Based on these analyses a prediction model was developed.

RESULTS

Our analyses show that one-week therapy success was associated with methadone (odds ratio [OR] = 5.21), duration of pain in months (OR = 1.12), neuropathic pain (OR = 3.36), and age of the patient in years (OR = 0.95). Inclusion of these four characteristics into our prediction model resulted in an area under the curve of 81.6%.

CONCLUSIONS

Careful analyses of patient attributes, treatment, and pain type of patients with head and neck cancer resulted in a prediction model that allowed to predict short-term pain relief and the opioid treatment response in neuropathic and nociceptive pain owing to cancer.

Functional Magnetic Resonance Imaging of Cerebral Hemodynamic Responses to Pain Following Thoracic Thrust Manipulation in Individuals With Neck Pain: A Randomized Trial

OBJECTIVE

The purpose of this study was to examine whether cerebral activation in response to noxious mechanical stimuli varies with thrust manipulation (TM) when compared with sham manipulation (SM) as measured by blood oxygenation level-dependent functional magnetic resonance imaging.

METHODS

Twenty-four volunteers (67% female) with complaints of acute or subacute mechanical (nontraumatic) neck pain satisfied eligibility requirements and agreed to participate. Participants were randomized to receive TM to the thoracic spine or SM, and then underwent functional magnetic resonance scanning while receiving noxious stimuli before and after TM or SM. An 11-point numeric pain rating scale was administered pre- and postmanipulation for neck pain and to determine perceptions of pain intensity with respect to neck pain and mechanical stimuli. Blood oxygenation level-dependent functional magnetic resonance imaging recorded the cerebral hemodynamic response to the mechanical stimuli.

RESULTS

Imaging revealed significant group differences, with those individuals in the manipulation group exhibiting increased areas of activation (postmanipulation) in the insular and somatosensory cortices and individuals in the sham group exhibiting greater areas of activation in the precentral gyrus, supplementary motor area, and cingulate cortices (P < .05). However, between-group differences on the numeric pain rating scale for mechanical stimuli and for self-reported neck pain were not statistically significant.

CONCLUSIONS

This study provides preliminary level 2b evidence suggesting cortical responses in patients with nontraumatic neck pain may vary between thoracic TM and a sham comparator.

Development of a clinical prediction rule to identify patients with plantar heel pain likely to benefit from biomechanical anti-pronation taping: A prospective cohort study

OBJECTIVES

To develop a clinical prediction rule (CPR) to identify patients with plantar heel pain (PHP) likely to benefit from biomechanical anti-pronation taping (BAPT).

DESIGN

A prospective cohort study.

SETTING

An outpatient rehabilitation department in a general hospital.

PARTICIPANTS

Seventy-five patients with PHP.

MAIN OUTCOME MEASURES

After completing a series of physical examinations, all patients received BAPT and were evaluated with a numeric rating scale for pain intensity, the patient-specific functional scale and foot function index (FFI) for function, and the global rating of change for perceived improvement.

RESULTS

Twenty-eight patients achieved a successful outcome. A CPR with 6 significant variables was identified by a multivariate logistic regression: FFI score less than 33.3, hip adduction angle of the most affected side was greater than the contralateral side, ankle plantarflexors and hip abductors on the most affected side were not weaker than those on the contralateral side, ankle invertors on the most affected side were weaker than the contralateral side, and having more than 2 painful sites in the low back and lower extremity regions. If 5 or more of the 6 predictors were presented, the probability of success increased from 37% to 80%.

CONCLUSIONS

A CPR has been developed to identify patients with PHP likely to benefit from BAPT.

Unraveling the Mechanisms of Manual Therapy: Modeling an Approach

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

Few promising multivariable prognostic models exist for recovery of people with non-specific neck pain in musculoskeletal primary care: a systematic review

QUESTION

Which multivariable prognostic model(s) for recovery in people with neck pain can be used in primary care?

DESIGN

Systematic review of studies evaluating multivariable prognostic models.

PARTICIPANTS

People with non-specific neck pain presenting at primary care.

DETERMINANTS

Baseline characteristics of the participants.

OUTCOME MEASURES

Recovery measured as pain reduction, reduced disability, or perceived recovery at short-term and long-term follow-up.

RESULTS

Fifty-three publications were included, of which 46 were derivation studies, four were validation studies, and three concerned combined studies. The derivation studies presented 99 multivariate models, all of which were at high risk of bias. Three externally validated models generated usable models in low risk of bias studies. One predicted recovery in non-specific neck pain, while two concerned participants with whiplash-associated disorders (WAD). Discriminative ability of the non-specific neck pain model was area under the curve (AUC) 0.65 (95% CI 0.59 to 0.71). For the first WAD model, discriminative ability was AUC 0.85 (95% CI 0.79 to 0.91). For the second WAD model, specificity was 99% (95% CI 93 to 100) and sensitivity was 44% (95% CI 23 to 65) for prediction of non-recovery, and 86% (95% CI 73 to 94) and 55% (95% CI 41 to 69) for prediction of recovery, respectively. Initial Neck Disability Index scores and age were identified as consistent prognostic factors in these three models.

CONCLUSION

Three externally validated models were found to be usable and to have low risk of bias, of which two showed acceptable discriminative properties for predicting recovery in people with neck pain. These three models need further validation and evaluation of their clinical impact before their broad clinical use can be advocated.

REGISTRATION

PROSPERO CRD42016042204. [Wingbermühle RW, van Trijffel E, Nelissen PM, Koes B, Verhagen AP (2018) Few promising multivariable prognostic models exist for recovery of people with non-specific neck pain in musculoskeletal primary care: a systematic review. Journal of Physiotherapy 64: 16-23].

The immediate effects of manual stretching and cervicothoracic junction manipulation on cervical range of motion and upper trapezius pressure pain thresholds

INTRODUCTION

Myofascial pain is a common impairment treated with various manual interventions including spinal thrust manipulation and stretching; however, the comparative efficacy of each intervention is uncertain. Therefore, the purpose of this investigation was to evaluate thrust manipulation targeting the cervicothoracic junction compared to a manual stretch of the upper trapezius muscle on cervical range of motion and upper trapezius pressure pain thresholds (PPTs).

METHODS

Healthy participants with no significant history of neck pain were randomized into a thrust manipulation group, a stretching group, or a control group. Within group differences were evaluated via a dependent t-test, and group by time interactions were evaluated by a two-way repeated measures ANOVA.

RESULTS

One hundred and two participants were recruited to participate. Baseline demographics revealed no significant differences between groups. Significant group by time interactions were found for changes in PPTs for both the right and left upper trapezius. Also, significant differences were found for changes in cervical extension, as well as right and left cervical side bending favoring the treatment groups.

DISCUSSION

This study demonstrates the potential independent effectiveness of spinal thrust manipulation or stretching for reducing PPTs at the upper trapezius. Future research should further evaluate the limitation of PPTs as a measure of muscle sensitivity as well as factors that may contribute to variability in the measurements among individuals seeking care.

Acute electromyographic responses of deep thoracic paraspinal muscles to spinal manual therapy interventions. An experimental, randomized cross-over study

This single group, randomized, cross-over study explored whether manual therapy alters motor tone of deep thoracic back muscles by examining resting electromyographic activity (EMG) after 2 types of manual therapy and a sham control intervention. Twenty-two participants with thoracic spinal pain (15 females, 7 males, mean age 28.1 ± 6.4 years) had dual fine-wire, intramuscular electrodes inserted into deep transversospinalis muscles at a thoracic level where tissues appeared abnormal to palpation (AbP) and at 2 sites above and below normal and non-tender to palpation (NT). A surface electrode was on the contralateral paraspinal mass at the level of AbP. EMG signals were recorded for resting prone, two 3-s free neck extension efforts, two 3-s resisted maximal voluntary isometric contractions (MVIC), and resting prone before the intervention. Randomized spinal manipulation, counterstrain, or sham manipulation was delivered and EMG re-measured. Participants returned 1 and 2 weeks later for the remaining 2 treatments. Reductions in resting EMG followed counterstrain in AbP (median decrease 3.3%, P = 0.01) and NT sites (median decrease 1.0%, P = 0.05) and for the surface electrode site (median decrease 2.0%, P = 0.009). Reduction in EMG following counterstrain during free neck extension was found for the surface electrode site (median decrease 2.7%, P < 0.01). Spinal manipulation produced no change in EMG, whereas counterstrain technique produced small significant reductions in paraspinal muscle activity during prone resting and free neck extension conditions. The clinical relevance of these changes is unclear.

The influence of clinical equipoise and patient preferences on outcomes of conservative manual interventions for spinal pain: an experimental study

Background

Expected pain relief from treatment is associated with positive clinical outcomes in patients with musculoskeletal pain. Less studied is the influence on outcomes related to the preference of patients and providers for a specific treatment.

Objectives

We sought to determine how provider and patient preferences for a manual therapy intervention influenced outcomes in individuals with acutely induced low back pain (LBP).

Participants and methods

Pain-free participants were randomly assigned to one of two manual therapies (joint biased [JB] or constant touch [CT]) 48 hours after completing an exercise protocol to induce LBP. Expectations for pain relief and preferences for treatment were collected at baseline, prior to randomization. Pain relief was assessed using a 100 mm visual analog scale. All study procedures were conducted in a private testing laboratory at the University of Florida campus.

Results

Sixty participants were included in this study. After controlling for preintervention pain intensity, the multivariate model included only preintervention pain (B=0.12, p=0.07) and provider preference (B=3.05, p<0.0001) and explained 35.8% of the variance in postintervention pain. When determining whether a participant met his or her expected pain relief, receiving an intervention from a provider with a strong preference for that intervention increased the odds of meeting a participant’s expected pain relief 68.3 times (p=0.013) compared to receiving any intervention from a provider with no preference. Receiving JB intervention from any provider increased the odds of meeting expected relief 29.7 times (p=0.023). The effect of a participant receiving an intervention they preferred was retained in the model but did not meet the criteria for a significant contribution.

Conclusion

Our primary findings were that participant and provider preferences for treatment positively influence pain outcomes in individuals with acutely induced LBP, and joint-biased interventions resulted in a greater chance of meeting participants’ expected outcomes. This is contrary to our hypothesis that the interaction of receiving an intervention for which a participant had a preference would result in the best outcome.

Complaints of Upper Extremity Numbness and Tingling Relieved With Dry Needling of the Teres Minor and Infraspinatus: A Case Report

Study Design Case report. Background Abnormal sensation, such as numbness or tingling, is traditionally thought to originate from neural compression. There is limited evidence to support reports of abnormal sensation arising from a trigger point. Case Description The patient was a 60-year-old woman with a primary complaint of right shoulder pain and secondary complaints of neck pain and right upper extremity numbness. Cervical spine neurological examination was unremarkable, and manual examination did not reproduce the patient's arm numbness or tingling symptoms. Compression of a trigger point in the infraspinatus and teres minor reproduced the patient's primary complaint of shoulder pain. The initial intervention included dry needling, which reproduced her upper extremity numbness. Subsequent treatment included manual therapy and exercise. Outcomes The patient was seen for a total of 3 visits, including the evaluation. Dry needling was utilized in 2 of her 3 visits. At discharge, she reported complete resolution of pain and altered sensation. Additionally, her scores on the Neck Disability Index, numeric pain-rating scale, and global rating of change exceeded the minimal clinically important difference. These outcomes were maintained at 2- and 12-month follow-up phone calls. Discussion This case report described the examination and use of dry needling in a case where the diagnosis was unclear. Clinicians may consider trigger point referral when examining patients with reports of abnormal sensation, especially when a more common cause cannot be identified. Level of Evidence Therapy, level 5. J Orthop Sports Phys Ther 2017;47(4):287-292. Epub 3 Mar 2017. doi:10.2519/jospt.2017.7055.

Eccentric Exercise Versus Eccentric Exercise and Soft Tissue Treatment (Astym) in the Management of Insertional Achilles Tendinopathy

Background:

Eccentric exercise is commonly used in the management of Achilles tendinopathy (AT) but its effectiveness for insertional AT has been questioned. Soft tissue treatment (Astym) combined with eccentric exercise could result in better outcomes than eccentric exercise alone.

Hypothesis:

Soft tissue treatment (Astym) plus eccentric exercise will be more effective than eccentric exercise alone for subjects with insertional AT.

Study Design:

Prospective randomized controlled trial.

Level of Evidence:

Level 2.

Methods:

Sixteen subjects were randomly assigned to either a soft tissue treatment (Astym) and eccentric exercise group or an eccentric exercise–only group. Intervention was completed over a 12-week period, with outcomes assessed at baseline, 4, 8, 12, 26, and 52 weeks. Outcomes included the Victorian Institute of Sport Assessment Achilles-Specific Questionnaire (VISA-A), the numeric pain rating scale (NPRS), and the global rating of change (GROC).

Results:

Significantly greater improvements on the VISA-A were noted in the soft tissue treatment (Astym) group over the 12-week intervention period, and these differences were maintained at the 26- and 52-week follow-ups. Both groups experienced a similar statistically significant improvement in pain over the short and long term. A significantly greater number of subjects in the soft tissue treatment (Astym) group achieved a successful outcome at 12 weeks.

Conclusion:

Soft tissue treatment (Astym) plus eccentric exercise was more effective than eccentric exercise only at improving function during both short- and long-term follow-up periods.

Clinical Relevance:

Soft tissue treatment (Astym) plus eccentric exercise appears to be a beneficial treatment program that clinicians should consider incorporating into the management of their patients with insertional AT.

Clinical prediction rules for prognosis and treatment prescription in neck pain: A systematic review

Clinical prediction rules (CPRs) developed to identify sub-groups of people with neck pain for different prognoses (i.e. prognostic) or response to treatments (i.e. prescriptive) have been recommended as a research priority to improve health outcomes for these conditions. A systematic review was undertaken to identify prognostic and prescriptive CPRs relevant to the conservative management of adults with neck pain and to appraise stage of development, quality and readiness for clinical application. Six databases were systematically searched from inception until 4th July 2016. Two independent reviewers assessed eligibility, risk of bias (PEDro and QUIPS), methodological quality and stage of development. 9840 records were retrieved and screened for eligibility. Thirty-two studies reporting on 26 CPRs were included in this review. Methodological quality of included studies varied considerably. Most prognostic CPR development studies employed appropriate designs. However, many prescriptive CPR studies (n = 12/13) used single group designs and/or analysed controlled trials using methods that were inadequate for identifying treatment effect moderators. Most prognostic (n = 11/15) and all prescriptive (n = 11) CPRs have not progressed beyond the derivation stage of development. Four prognostic CPRs relating to acute whiplash (n = 3) or non-traumatic neck pain (n = 1) have undergone preliminary validation. No CPRs have undergone impact analysis. Most prognostic and prescriptive CPRs for neck pain are at the initial stage of development and therefore routine clinical use is not yet supported. Further validation and impact analyses of all CPRs are required before confident conclusions can be made regarding clinical utility.

Clinical Decision Support Tools for Selecting Interventions for Patients with Disabling Musculoskeletal Disorders: A Scoping Review

Purpose We aimed to identify and inventory clinical decision support (CDS) tools for helping front-line staff select interventions for patients with musculoskeletal (MSK) disorders. Methods We used Arksey and O'Malley's scoping review framework which progresses through five stages: (1) identifying the research question; (2) identifying relevant studies; (3) selecting studies for analysis; (4) charting the data; and (5) collating, summarizing and reporting results. We considered computer-based, and other available tools, such as algorithms, care pathways, rules and models. Since this research crosses multiple disciplines, we searched health care, computing science and business databases. Results Our search resulted in 4605 manuscripts. Titles and abstracts were screened for relevance. The reliability of the screening process was high with an average percentage of agreement of 92.3 %. Of the located articles, 123 were considered relevant. Within this literature, there were 43 CDS tools located. These were classified into 3 main areas: computer-based tools/questionnaires (n = 8, 19 %), treatment algorithms/models (n = 14, 33 %), and clinical prediction rules/classification systems (n = 21, 49 %). Each of these areas and the associated evidence are described. The state of evidentiary support for CDS tools is still preliminary and lacks external validation, head-to-head comparisons, or evidence of generalizability across different populations and settings. Conclusions CDS tools, especially those employing rapidly advancing computer technologies, are under development and of potential interest to health care providers, case management organizations and funders of care. Based on the results of this scoping review, we conclude that these tools, models and systems should be subjected to further validation before they can be recommended for large-scale implementation for managing patients with MSK disorders.

Combining manual therapy with pain neuroscience education in the treatment of chronic low back pain: A narrative review of the literature

Teaching people with chronic low back pain (CLBP) about the neurobiology and neurophysiology of their pain is referred to as pain neuroscience education (PNE). There is growing evidence that when PNE is provided to patients with chronic musculoskeletal pain, it can result in decreased pain, pain catastrophization, disability, and improved physical performance. Because the aim of PNE is to shift the patient's focus from the tissues in the low back as the source of their pain to the brain's interpretation of inputs, many clinicians could mistakenly believe that PNE should be a "hands-off," education-only approach. An argument can be made that by providing manual therapy or exercise to address local tissue pathology, the patient's focus could be brought back to the low back tissues as the source of their problem. In this narrative literature review, we present the case for a balanced approach that combines PNE with manual therapy and exercise by considering how manual therapy can also be incorporated for interventions with patients with CLBP. We propose that as well as producing local mechanical effects, providing manual therapy within a PNE context can be seen as meeting or perhaps enhancing patient expectations, and also refreshing or sharpening body schema maps within the brain. Ideally, all of this should lead to better outcomes in patients with CLBP.

Thrust joint manipulation utilization by U.S. physical therapists

STUDY DESIGN

Online survey study.

OBJECTIVE

To determine physical therapists' utilization of thrust joint manipulation (TJM) and their comfort level in using TJM between the cervical, thoracic, and lumbar regions of the spine. We hypothesized that physical therapists who use TJM would report regular use and comfort providing it to the thoracic and lumbar spines, but not so much for the cervical spine.

BACKGROUND

Recent surveys of first professional physical therapy degree programs have found that TJM to the cervical spine is not taught to the same degree as to the thoracic and lumbar spines.

METHODS

We developed a survey to capture the required information and had a Delphi panel of 15 expert orthopedic physical therapists review it and provide constructive feedback. A revised version of the survey was sent to the same Delphi panel and consensus was obtained on the final survey instrument. The revised survey was made available to any licensed physical therapists in the U.S.A. using an online survey system, from October 2014 through June 2015.

RESULTS

Of 1014 responses collected, 1000 completed surveys were included for analysis. There were 478 (48%) males; the mean age of respondents was 39.7 ± 10.81 years (range 24-92); and mean years of clinical experience was 13.6 ± 10.62. A majority of respondents felt that TJM was safe and effective when applied to lumbar (90.5%) and thoracic (91.1%) spines; however, a smaller percentage (68.9%) felt that about the cervical spine. More therapists reported they would perform additional screening prior to providing TJM to the cervical spine than they would for the lumbar and thoracic spines. Therapists agreed they were less likely to provide and feel comfortable with TJM in the cervical spine compared to the thoracic and lumbar spines. Finally, therapists who are male; practice in orthopedic spine setting; are aware of manipulation clinical prediction rules; and have manual therapy certification, are more likely to use TJM and be comfortable with it in all three regions.

CONCLUSION

Results indicate that respondents do not believe TJM for the cervical spine to be as safe and efficacious as that for the lumbar and thoracic spines. Further, they are more likely to perform additional screening, abstain from and do not feel comfortable performing TJM for the cervical spine.

CLINICAL RELEVANCE

Our research reveals there is a discrepancy between utilization of TJM at different spinal levels. This research provides an opportunity to address variability in clinical practice among physical therapists utilizing TJM.

Enhance placebo, avoid nocebo: How contextual factors affect physiotherapy outcomes

INTRODUCTION

Placebo and nocebo represent complex and distinct psychoneurobiological phenomena in which behavioural and neurophysiological modifications occur together with the application of a treatment. Despite a better understanding of this topic in the medical field, little is known about their role in physiotherapy.

PURPOSE

The aim of this review is: a) to elucidate the neurobiology behind placebo and nocebo effects, b) to describe the role of the contextual factors as modulators of the clinical outcomes in rehabilitation and c) to provide clinical and research guidelines on their uses.

IMPLICATIONS

The physiotherapist's features, the patient's features, the patient-physiotherapist relationship, the characteristics of the treatment and the overall healthcare setting are all contextual factors influencing clinical outcomes. Since every physiotherapy treatment determines a specific and a contextual effect, physiotherapists should manage the contextual factors as a boosting element of any manual therapy to improve placebo effects and avoid detrimental nocebo effects.

Cervical zygapophysial (facet) joint pain: effectiveness of interventional management strategies

Diagnostic facet joint nerve blocks have been utilized in the diagnosis of cervical facet joint pain in patients without disk herniation or radicular pain due to a lack of reliable noninvasive diagnostic measures. Therapeutic interventions include intra-articular injections, facet joint nerve blocks and radiofrequency neurotomy. The diagnostic accuracy and effectiveness of facet joint interventions have been assessed in multiple diagnostic accuracy studies, randomized controlled trials (RCTs), and systematic reviews in managing chronic neck pain. This assessment shows there is Level II evidence based on a total of 11 controlled diagnostic accuracy studies for diagnosing cervical facet joint pain in patients without disk herniation or radicular pain utilizing controlled diagnostic blocks. Due to significant variability and internal inconsistency regarding prevalence in a heterogenous population; despite 11 studies, evidence is determined as Level II. Prevalence ranged from 36% to 67% with at least 80% pain relief as the criterion standard with a false-positive rate ranging from 27% to 63%. The evidence is Level II for the long-term effectiveness of radiofrequency neurotomy and facet joint nerve blocks in managing cervical facet joint pain. There is Level III evidence for cervical intra-articular injections.

Manipulation and mobilisation for neck pain contrasted against an inactive control or another active treatment

BACKGROUND

Manipulation and mobilisation are commonly used to treat neck pain. This is an update of a Cochrane review first published in 2003, and previously updated in 2010.

OBJECTIVES

To assess the effects of manipulation or mobilisation alone compared wiith those of an inactive control or another active treatment on pain, function, disability, patient satisfaction, quality of life and global perceived effect in adults experiencing neck pain with or without radicular symptoms and cervicogenic headache (CGH) at immediate- to long-term follow-up. When appropriate, to assess the influence of treatment characteristics (i.e. technique, dosage), methodological quality, symptom duration and subtypes of neck disorder on treatment outcomes.

SEARCH METHODS

Review authors searched the following computerised databases to November 2014 to identify additional studies: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and the Cumulative Index to Nursing and Allied Health Literature (CINAHL). We also searched ClinicalTrials.gov, checked references, searched citations and contacted study authors to find relevant studies. We updated this search in June 2015, but these results have not yet been incorporated.

SELECTION CRITERIA

Randomised controlled trials (RCTs) undertaken to assess whether manipulation or mobilisation improves clinical outcomes for adults with acute/subacute/chronic neck pain.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, abstracted data, assessed risk of bias and applied Grades of Recommendation, Assessment, Development and Evaluation (GRADE) methods (very low, low, moderate, high quality). We calculated pooled risk ratios (RRs) and standardised mean differences (SMDs).

MAIN RESULTS

We included 51 trials (2920 participants, 18 trials of manipulation/mobilisation versus control; 34 trials of manipulation/mobilisation versus another treatment, 1 trial had two comparisons). Cervical manipulation versus inactive control: For subacute and chronic neck pain, a single manipulation (three trials, no meta-analysis, 154 participants, ranged from very low to low quality) relieved pain at immediate- but not short-term follow-up. Cervical manipulation versus another active treatment: For acute and chronic neck pain, multiple sessions of cervical manipulation (two trials, 446 participants, ranged from moderate to high quality) produced similar changes in pain, function, quality of life (QoL), global perceived effect (GPE) and patient satisfaction when compared with multiple sessions of cervical mobilisation at immediate-, short- and intermediate-term follow-up. For acute and subacute neck pain, multiple sessions of cervical manipulation were more effective than certain medications in improving pain and function at immediate- (one trial, 182 participants, moderate quality) and long-term follow-up (one trial, 181 participants, moderate quality). These findings are consistent for function at intermediate-term follow-up (one trial, 182 participants, moderate quality). For chronic CGH, multiple sessions of cervical manipulation (two trials, 125 participants, low quality) may be more effective than massage in improving pain and function at short/intermediate-term follow-up. Multiple sessions of cervical manipulation (one trial, 65 participants, very low quality) may be favoured over transcutaneous electrical nerve stimulation (TENS) for pain reduction at short-term follow-up. For acute neck pain, multiple sessions of cervical manipulation (one trial, 20 participants, very low quality) may be more effective than thoracic manipulation in improving pain and function at short/intermediate-term follow-up. Thoracic manipulation versus inactive control: Three trials (150 participants) using a single session were assessed at immediate-, short- and intermediate-term follow-up. At short-term follow-up, manipulation improved pain in participants with acute and subacute neck pain (five trials, 346 participants, moderate quality, pooled SMD -1.26, 95% confidence interval (CI) -1.86 to -0.66) and improved function (four trials, 258 participants, moderate quality, pooled SMD -1.40, 95% CI -2.24 to -0.55) in participants with acute and chronic neck pain. A funnel plot of these data suggests publication bias. These findings were consistent at intermediate follow-up for pain/function/quality of life (one trial, 111 participants, low quality). Thoracic manipulation versus another active treatment: No studies provided sufficient data for statistical analyses. A single session of thoracic manipulation (one trial, 100 participants, moderate quality) was comparable with thoracic mobilisation for pain relief at immediate-term follow-up for chronic neck pain. Mobilisation versus inactive control: Mobilisation as a stand-alone intervention (two trials, 57 participants, ranged from very low to low quality) may not reduce pain more than an inactive control. Mobilisation versus another active treatment: For acute and subacute neck pain, anterior-posterior mobilisation (one trial, 95 participants, very low quality) may favour pain reduction over rotatory or transverse mobilisations at immediate-term follow-up. For chronic CGH with temporomandibular joint (TMJ) dysfunction, multiple sessions of TMJ manual therapy (one trial, 38 participants, very low quality) may be more effective than cervical mobilisation in improving pain/function at immediate- and intermediate-term follow-up. For subacute and chronic neck pain, cervical mobilisation alone (four trials, 165 participants, ranged from low to very low quality) may not be different from ultrasound, TENS, acupuncture and massage in improving pain, function, QoL and participant satisfaction at immediate- and intermediate-term follow-up. Additionally, combining laser with manipulation may be superior to using manipulation or laser alone (one trial, 56 participants, very low quality).

AUTHORS' CONCLUSIONS

Although support can be found for use of thoracic manipulation versus control for neck pain, function and QoL, results for cervical manipulation and mobilisation versus control are few and diverse. Publication bias cannot be ruled out. Research designed to protect against various biases is needed. Findings suggest that manipulation and mobilisation present similar results for every outcome at immediate/short/intermediate-term follow-up. Multiple cervical manipulation sessions may provide better pain relief and functional improvement than certain medications at immediate/intermediate/long-term follow-up. Since the risk of rare but serious adverse events for manipulation exists, further high-quality research focusing on mobilisation and comparing mobilisation or manipulation versus other treatment options is needed to guide clinicians in their optimal treatment choices.

Baseline Examination Factors Associated With Clinical Improvement After Dry Needling in Individuals With Low Back Pain

STUDY DESIGN

Quasi-experimental.

OBJECTIVES

To explore for associations between demographic, patient history, and physical examination variables and short-term improvement in self-reported disability following dry needling therapy performed on individuals with low back pain (LBP).

BACKGROUND

Dry needling is an intervention used with increasing frequency in patients with LBP; however, the characteristics of patients who are most likely to respond are not known.

METHODS

Seventy-two volunteers with mechanical LBP participated in the study. Potential prognostic factors were collected from baseline questionnaires, patient history, and physical examination tests. Treatment consisted of dry needling to the lumbar multifidus muscles bilaterally, administered during a single treatment session. Improvement was based on percent change on the Oswestry Disability Index at 1 week. The univariate and multivariate associations between 33 potential prognostic factors and improved disability were assessed with correlation coefficients and multivariate linear regression.

RESULTS

Increased LBP with the multifidus lift test (rpb = 0.31, P = .01) or during passive hip flexion performed with the patient supine (rpb = 0.23, P = .06), as well as positive beliefs about acupuncture/dry needling (rho = 0.22, P = .07), demonstrated univariate associations with Oswestry Disability Index improvement. Aggravation of LBP with standing (rpb = -0.27, P = .03), presence of leg pain (rpb = -0.29, P = .02), and any perception of hypermobility in the lumbar spine (rpb = -0.21, P = .09) were associated with less improvement. The multivariate model identified 2 predictors of improved disability with dry needling: pain with the multifidus lift test and no aggravation with standing (R(2) = 0.16, P = .01).

CONCLUSION

Increased LBP with the multifidus lift test was the strongest predictor of improved disability after dry needling, suggesting that the finding of pain during muscle contraction should be studied in future dry needling studies.

LEVEL OF EVIDENCE

Prognosis, level 1b.

Description of Common Clinical Presentations and Associated Short-Term Physical Therapy Clinical Outcomes in Patients With Neck Pain

OBJECTIVE

To determine the effect of clinical presentations of neck pain on short-term physical therapy outcomes.

DESIGN

Retrospective analysis of pair-matched groups from a clinical cohort.

SETTING

Thirteen outpatient physical therapy clinics in 1 health care system.

PARTICIPANTS

Patients (N=1069) grouped by common clinical presentations of neck pain: nonspecific neck pain (NSNP) with duration <4 weeks; NSNP with duration >4 weeks; neck pain with arm pain; neck pain with headache; and neck pain from whiplash.

INTERVENTION

Conservative interventions provided by physical therapists.

MAIN OUTCOME MEASURES

Neck Disability Index (NDI) and numerical pain rating scale (NPRS) recorded at the initial and last visits. The main outcome of interest was achieving recovery status on the NDI. Changes in NDI and NPRS were compared between clinical presentation groups.

RESULTS

Compared with patients presenting with NSNP >4 weeks, patients with NSNP <4 weeks had increased odds of achieving recovery status on the NDI (P<.0001) and demonstrated the greatest changes in clinical outcomes of pain (P≤.0001) and disability (P≤.0001). Patients with neck pain and arm pain demonstrated an increased odds of achieving recovery status on the NDI (P=.04) compared with patients presenting with NSNP >4 weeks.

CONCLUSIONS

Treating patients with NSNP within <4 weeks of onset of symptoms may lead to improved clinical outcomes from physical therapy compared with other common clinical presentations.

Thrust joint manipulation curricula in first-professional physical therapy education: 2012 update

STUDY DESIGN

Descriptive online observational survey.

OBJECTIVES

To identify the extent of thrust joint manipulation (TJM) integration into first-professional physical therapy program curricula.

BACKGROUND

The most recent survey of TJM curricula was published in 2004, with a wide variation in faculty responses noted. Since that time, faculty resources have been developed and TJM language in "A Normative Model of Physical Therapist Professional Education" from the American Physical Therapy Association has been updated, leaving the current status of TJM education in curricula unknown.

METHODS

Faculty from 205 accredited physical therapy programs were invited to participate in an anonymous 35-item electronic survey during the summer of 2012.

RESULTS

Seventy-two percent of programs responded to the survey, with 99% of programs teaching TJM and 97% of faculty believing TJM to be an entry-level skill. Cervical spine TJM is still being taught at a lower rate than techniques for other body regions. Faculty deemed 91% and 77% of students, respectively, at or above entry-level competency for implementing TJM in their clinical practice upon graduation. Most respondents indicated that increased utilization of TJM during clinical affiliations (78%) and lab hours (78%) would be beneficial to the student's knowledge/application of TJM.

CONCLUSION

The utilization of TJM and faculty perceptions in first-professional physical therapy programs in the United States have evolved over the past decade. With TJM content more fully integrated into educational curricula, programs can now look to refine teaching strategies that enhance learning outcomes.

External validation of a clinical prediction rule to predict full recovery and ongoing moderate/severe disability following acute whiplash injury

STUDY DESIGN

Retrospective secondary analysis of data.

OBJECTIVES

To investigate the external validity of the whiplash clinical prediction rule (CPR).

BACKGROUND

We recently derived a whiplash CPR to consolidate previously established prognostic factors for poor recovery from a whiplash injury and predicted 2 recovery pathways. Prognostic factors for full recovery were being less than 35 years of age and having an initial Neck Disability Index (NDI) score of 32% or less. Prognostic factors for ongoing moderate/severe pain and disability were being 35 years of age or older, having an initial NDI score of 40% or more, and the presence of hyperarousal symptoms. Validation is required to confirm the reproducibility and accuracy of this CPR. Clinician feedback on the usefulness of the CPR is also important to gauge acceptability.

METHODS

A secondary analysis of data from 101 individuals with acute whiplash-associated disorder who had previously participated in either a randomized controlled clinical trial or prospective cohort study was performed using accuracy statistics. Full recovery was defined as NDI score at 6 months of 10% or less, and ongoing moderate/severe pain and disability were defined as an NDI score at 6 months of 30% or greater. In addition, a small sample of physical therapists completed an anonymous survey on the clinical acceptability and usability of the tool. Results The positive predictive value of ongoing moderate/severe pain and disability was 90.9% in the validation cohort, and the positive predictive value of full recovery was 80.0%. Surveyed physical therapists reported that the whiplash CPR was simple, understandable, would be easy to use, and was an acceptable prognostic tool.

CONCLUSION

External validation of the whiplash CPR confirmed the reproducibility and accuracy of this dual-pathway tool for individuals with acute whiplash-associated disorder. Further research is needed to assess prospective validation, the impact of inclusion on practice, and to examine the efficacy of linking treatment strategies with predicted prognosis.

LEVEL OF EVIDENCE

Prognosis, level 1b.