May Journal Club

[lacarroll]

Please view the attached document and article, then briefly discuss the following questions.

1. Do feel like my search strategy was too narrow to start with? Why or why not?

2. What are some strengths/weaknesses of this article?

3. Do you feel like this article impacts or changes your clinical practice for an individual that “fits” into this category?

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[helenrshep]

1) No, I think it was perfectly acceptable and it gave you a good number of results which I think is always a good indicator. If it’s too broad, you’ll get a million results and if it’s too narrow you may only get a couple. I think your terms were specific to your PICO question and 14 results seems reasonable.

2) Strengths:
– Good to compare one manipulation to another (vs manipulation compared to inactive ultrasound) because it controls more variables, such as the general effect of being manipulation, therapist touching the patient, etc
– I like their outcome measures (pain, disability, ROM) because they seem to include all the important things – something subjective, something functional, and something objective

Weaknesses:
– Done in Spain (do they practice the same as us?)
– It doesn’t sound like they did “both side” for the cervical manipulation group. Based on knowing that we usually do “both sides” for cervical manipulation since it’s not super specific and that they did that for the CTJ manipulation, that may be something they could have done differently.

3) As always, it’s “the more you know”, right? I think this along with all the other articles about manipulation help me make a better clinical decision. As we discussed before, journal reputation, impact factor, etc all play a role. I think this is good information that may lead me to do multiple manipulations (as opposed to just one) on patients similar to those in this study, however I’d like to see some more research with a bigger sample size.

[awilson12]

1) I don’t think that is a particularly narrow search strategy but just playing around with wording and the terms you use could be useful to get more results.

2) Strengths: decent sample size, no differences in baseline characteristics, randomization and allocation to groups by researcher not involved in treatment or assessment, specific explanation of techniques used
Weakness: between group for NDI statistically significant but results didn’t meet MCID, recruitment from single clinic, only looks at 1 week time frame

3) To me this article shows that there may be some improvement in self perceived disability in the short term with the addition of manipulation to adjacent areas, but overall the addition of thoracic and CTJ to c-spine manipulation didn’t seem to be better. I don’t know that this specific article justifies a significant benefit of doing this all in combination, but I also think that there is other research out there that does identify the benefit of thoracic manipulation in patients with neck pain.

[Taylor Blattenberger]

1) I see no problem with this. If you attempted to broaden your search with a generic “manipulation” AND “neck pain” you would have drowned in 700 some results. This search is specific and gave you some fair choices.

2) Strengths: Fair exclusion criteria, randomization, fair sample size (although they looked at a lot of outcomes so this may not be very strong?), I think the f/u time fits the goals of the intervention provided

Weaknesses: Lots of outcome measures, A vs. A+B model (more care vs. less care)

3) The results of this study were not overwhelming, but I feel it was a well done study. The within group improvements were fair showing that manipulation definitely has a place in these patient cases, but it may not provide much benefit to spend more time on more manipulations. My take away from this is: manipulate where you feel they need it and move on.

[Michael McMurray]

1. Do you feel like my search strategy was too narrow to start with? Why or why not?

I don’t believe so, I think having a more narrow focus and then being able to broaden your “net” if need be is more efficient than having a huge amount of articles to choose from and have to try and narrow your focus.

2. What are some strengths/weaknesses of this article?

Strengths
-RCT
-blinded and concealment of allocation of participants
-Methodology/consistency of treatment performed

Weakness
-relatively low sample size from one clinic
-No formal inclusion criteria (aside from not being excluded) such as their definition of chronic or their minimum time frame for chronicity
-Lower bound estimates of 95% CI did not meet MCID for pain, so it may not be as significant as the paper states.

3. Do you feel like this article impacts or changes your clinical practice for an individual that “fits” into this category?
-I prefer to utilize CTJ and thoracic manipulation over cervical manipulation in this population, so I think this paper helps to strengthen my bias. There isn’t anything that I read that makes me sway from one intervention to the other though.

Do you feel as though this article answered your PICO question? Your PICO is querying thoracic manipulation vs CTJ manipulation, whereas this article is comparing isolated cervical manipulation to a combination of cervical, CTJ, and thoracic manipulation.

[Steven Lagasse]

1. Do you feel like my search strategy was too narrow to start with? Why or why not?

Your search strategy looks fine. The fact that you managed to only come up with 14 articles likely reflects that.

2. What are some strengths/weaknesses of this article?

For strengths, having some of the more revered researchers such as César Fernández-de-las-Peñas, and Emilio Puentedura is certainly a strength. The methodology of this RCT is strong. Further, the authors do not extrapolate their findings or make wild claims.

A primary weakness of this study is that the authors used a sample of convenience and only two treating therapists. As stated in the article, this can limit the clinical applicability and/or generalizability of the findings. Also, although it may not be a weakness, I did find it interesting that the authors excluded those individuals who had received prior manipulation. It has been my experience that patients with cervical spine symptoms have already seen a chiropractor before seeing physical therapy. Thus, the majority of my patients have already received some form of manipulation before seeing me. I am curious to know the authors’ rationale.

3. Do you feel like this article impacts or changes your clinical practice for an individual that “fits” into this category?

My take away from this article is that, if a clinician is going to go for the throat with cervical manipulation (pun intended), then they may as well back that up with those thoracic manipulations that have been proven safer. Although this may not more readily improve their perceived pain, the article did show for it to improve their perceived level of disability. I believe reframing a patient’s beliefs regarding disability to be quite impactful, especially on a biopsychosocial level. The less disabled the patient feels, the more they will likely do. Changing the patient’s beliefs may create an upward spiral and expedite their rehab. This also leaves me reflecting on the idea of treating manipulation as “input to the system” rather than treating a biomechanical issue.

[lacarroll]

These are all great points. We’re definitely going to talk about a few of these things and some other questions that came up with my case in the presentation during the discussion today.

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