October Journal Club Case

[Nick Law]

Referral: Neck pain, traction, gentle ROM and strengthening

NDI – 16/40 (40%) Items 8 and 10 not completed, “I don’t have a car,” “No rec any way”

NPRS: Best 7/10 Worst 7/10 Now 7/10

Subjective Exam:
– Imprisoned July 2008, fell and hit his head after being intentionally given hallucinogenic medication by prison staff in December.
– Sought medical attention in prison, however reports he was not given substantial treatment and has simply endured pain since.
– Recently released from prison in February, actively seeking lawsuit against prison staff for cruel and unusual punishment, expresses personal bitterness towards prison staff
– Chief complaint: central, non radiating, posterior neck pain at approximately C4. Described as a “pull.”
– Aggravating factors: sleeping with head flat (1 pillow), quick rotational movements both directions
– Relieving factors: doubling pillow up at night to promote cervical flexion
– Recent X rays negative for pathology with exception of ventral cervical osteophytes

Objective examination:
– Forward head, rounded shoulders posture
– Limited SB ROM (50%) bilaterally, pain with overpressure bilaterally
-Rotation 75% bilaterally, pain with overpressure to the left
– Very limited cervical extension (25%), pain with overpressure, flexion WNL and pain free
– Pain before end range right posterior quadrant 1st no attempt, no pain 2nd attempt, left posterior quadrant negative for pain.
– Distraction/compression negative in seated, distraction positive for pain in supine
– Left flexion/rotation + pain 1st attempt, negative 2nd attempt
– Throughout the examination, it was apparent that faster movements exacerbated pain greater than slower motions
– Significantly and globally limited upper/mid cervical and thoracic accessory mobility; inconsistent pain with PA provocation, most consistent over C4 CPA
– Mild weakness, cervical pain with GH IR/ER resistance testing

Hypothesis after objective examination (and reflective discussion): mid cervical motor control impairment, painful spinous process encroachment in extension secondary to longstanding untreated traumatic injury

[Michael McMurray]

Full text for the journal club article is attached

[Laura Thornton]

In response to Nick’s discussion questions, here’s an interesting article I found and will refer to during Journal Club this afternoon. Focusing more on clinical and personal equipoise with RCT’s in manual therapy interventions and treatment groups.

[omikutin]

We learned in school 5 criterias for spinal manipulation when it comes to clinical prediction rules: <16 days for the duration of the current episode of low back pain, no symptoms distal to knee, < 19 on FABQ, > 1 hypomoile segment in the lumbar spine, > 1 hip with > 35 degrees of internal rotation (1). We also know contraindications such as: VBI, RA, fracture, osteomyelitis, bone tumors; however, osteoporosis is not a contraindication. I researched “thrust manipulation osteopenia”, “thrust manipulation osteoporosis “ , “HVLA with osteopenia”, “HVLA with osteoporosis” and found 0 hits on pub med. I think that would be an interesting study, but honestly how many sweet old ladies who have osteoporosis would be thrilled to join this study? I’m already speculating a small pull of patients.

I ran into a narrative review done by the American College of Physicians in 2014 and they concluded that if all contraindications and red flags were ruled out then clinicians can prevent up to 44.8% of adverse effects. An adverse effect was defined as “the sequelae following a CSM that are medium to long term in duration, with moderate to severe symptoms, and of a nature that was serious, distressing, and unacceptable to the patient and required further treatment” (2) Absolute contraindications were found to be: acute fracture, Acute soft tissue injury, Dislocation , Osteoporosis, Ligamentous rupture, Ankylosing spondylitis, Instability, Rheumatoid arthritis, Tumor Vascular disease, Infection, Vertebral artery abnormalities, Acute myelopathy, Connective tissue disease, Recent surgery, Anticoagulant therapy. These were found by Dr. Kathryn Refshauge, dean faculty of Health Sciences and Professor of Physiotherapy at the University of Sydney, who quotes “with subsequent research, manipulation may ultimately prove to be effective in the hands of particularly skilled practitioners for a sub-group of patients” (3) Of those 44.8% of AE cases were not screened for contraindicated signs. A thorough examination needs to be done to rule out contraindications and red flags. I would say as a novice therapist, it’s important to abide strictly to these contraindications. I do know a few experienced physical therapist who have done thoracic HVLA on patients with osteoporosis and have received great results.
Mark Jones brought up a great discussion when he compared novice to experts. When do you think it is appropriate to go off of clinical judgement and use HVLA even if a patient has osteoporosis/ penia? If you can’t use a thrust technique what’s another technique to consider? Dunning et al reports non thrust techniques have a statistical significance of improvement (thank you Nick). What other techniques compared to thrust manipulation could we use to help decrease neck pain?

Reference:
1. Childs JD, Fritz JM, Flynn TW, Irrgang JJ, Johnson KK, Majkowski GR, et al. A Clinical Prediction Rule To Identify Patients with Low Back Pain Most Likely To Benefit from Spinal Manipulation: A Validation Study. Ann Intern Med. 2004;141:920-928. doi:10.7326/0003-4819-141-12-200412210-00008

2. Puentedura EJ1, March J, Anders J, Perez A, Landers MR, Wallmann HW, Cleland JA:Safety of cervical spine manipulation: are adverse events preventable and are manipulations being performed appropriately? A review of 134 case reports. J Man Manip Ther. 2012 May;20(2):66-74. doi: 10.1179/2042618611Y.0000000022.

3. Refshauge KM, Parry S, Shirley D, Larsen D, Rivett DA, Boland R. Professional responsibility in relation to cervical spine manipulation. Aust J Physiother. 2002;48:171–9

[omikutin]

I actually looked into another pubmed search of thrust manipulation and neck pain and found an article comparing KT to thrust. I think patients who are contraindicated for thrust might benefit from this. Has anyone done this type of KT?

[Laura Thornton]

Great job today Nick. I’d like to share some feedback from the presentation to provide some post-hoc discussion. I want to also apologize to you for misunderstanding the forum we were to have before the Journal Club today.

You picked a really interesting article and topic. It was a nice change of pace to look outside of just the contents of the article and into personal biases and potential lack of equipoise in certain RCT’s.

Despite the potential problems that arise with this study, it encourages me to increase my confidence in adding cervical manipulation into my toolbox to use when appropriate.

I will be curious to see if you are considering either thrust manipulation with your current patient. There was a lack of segmental assessment in the current study and yet significant results with pain relief. This weekend, there was still some uncertainty of what is causing his pain (spinous process encroachment, facet joint, segmental instability). Is this treatment on your radar for him?

[Nick Law]

Oksana and Laura,

Thank you both for the post-hoc discussion! I am sure that as we get comfortable with the discussion board format that it will be a great way for us to collaboratively think and learn together.

Oksana, with regard to your post, one thing I would want to make clear is the distinction between osteoporosis. As the article you attached mentioned, OSTEOPOROSIS IS a contra-indication to thrust manipulation. I see no reason why the benefit of thrust manipulation would ever outweigh the inherent risk of such a technique in a person with osteoporosis. However, OSTEOPENIA is NOT a contra-indication, though it is a precaution. I think this is where the benefit-risk analysis can become much more even and when we would really need to use sound clinical reasoning in determining whether or not to use the technique. I would be curious as to know your guys thoughts on what would help you decide whether or not to thrust in a patient with osteopenia. Personally, I would think that factors such as age, medication use (history of corticosteroids or other medications that might decrease bone strength/tissue integrity), history of fracture (especially less traumatic fractures), the patient’s activity level, or any history of recent immobilization would all be important to consider. Even the specific osteopenic score should be considered (e.g., – 1.1 vs.- 2.4) As Eric mentioned, the technique and region would also need to be considered. I probably would not be thrusting the thoracolumbar junction with a high degree of flexion. Using the least amount of force to achieve the desired result would also be paramount.

I wish I could speak more experientially with regard to the kinesiotape, however I have no training with it. Certainly could be a viable option in our osteoporosis patients.

I agree with you Laura that the results of the study certainly encourage me to grow in my confidence and abilities to manipulate the cervical spine. I certainly know that I won’t get where I desire to be without a lot of practice and feedback.

I think there are several things to consider with regard to manipulation in the patient I presented on during the weekend. To be sure, one is a personal lack of confidence in my abilities to achieve the desired therapeutic effect in my patient. My patient presents with intense pain when his cervical spine is taken passively beyond a certain range, and though I do not think that his C1-2 is a pain generator for him in any significant way, I do not think that I could localize the forces to that segment while sufficiently protecting other segments. To be sure his aggressive pursuit of legal action makes me a little nervous with something like attempting a thrust technique. However, this study showed improved deep cervical flexor performance following thrust manipulation, and therefore it ought lead us consider this technique in patients with motor control deficits. This is similar to at least one study showing improved TrA activation following manipulation to the lumbar spine, though this is contradicted by other evidence.

http://www.ncbi.nlm.nih.gov/pubmed/17877283

http://www.ncbi.nlm.nih.gov/pubmed/21765224

[Laura Thornton]

In terms of thrust manipulations in patients with osteopenia, one of the consistent factors I have looked at is how recent their bone scan was. I would feel more comfortable if it was more recent than say, 5 years ago. The specific osteopenia score is an important distinction as well and something I need to ask in more detail (and if they don’t know their osteopenia score, I think it’d be worth finding out before considering further).

Glad you mentioned the legal action, that’s something that would make me pause as well especially with an aggressive pursuit as his is. I’d like to look into this further.

Thanks for posting those articles. Looks like this has been investigated a number of times over the years, but conflicting results just like you said.

[Michael McMurray]

Great discussion, so far.

Oksana – just wanted to clarify that those are CPR guidelines for LUMBAR manipulation, not spinal manipulation.

Also – Try using some strategies that we discussed this weekend to search the evidence like MESH terms and post your findings in trying to find specific information – formulate a searchable PICO question, and use some of the suggestions/resources to see if you can get more clinically relevant evidence for decision making.

[omikutin]

Sorry for the confusion from my previous comment. I did a pub med search “clinical prediction rules for cervical manipulation” and couldn’t find a good search. The reason I listed the Lumbar CPRs is because that’s the only CPR that I know prior to a thrust technique. I would think that osteoporosis would be a contraindication for any region thrust technique.

These clinicians should have determined the safety of the technique based on the following contraindications: acute fracture, Acute soft tissue injury, Dislocation , Osteoporosis, Ligamentous rupture, Ankylosing spondylitis, Instability, Rheumatoid arthritis, Tumor Vascular disease, Infection, Vertebral artery abnormalities, Acute myelopathy, Connective tissue disease, Recent surgery, Anticoagulant therapy. The purpose of this narrative review was to retrospectively analyze documented case reports in the literature describing patients who had experienced severe adverse effects after receiving CSM to determine if the CSM was used appropriately, and if these adverse effects could have been prevented using sound clinical reasoning. The statistic shared earlier of 44.8% corresponds to the number of adverse effects that could have been prevented when contraindications or red flags should have stopped the care provider from performing a CSM. These results imply that determining a CSM is indicated in not sufficient to prevent adverse effects. A thorough examination to rule out all contraindications is necessary. Interestingly, the most common adverse effect was found to be arterial dissection.

In conclusion, it is vital to take a thorough history and rule out a VBI, cervical arterial dysfunction. Clinical prediction rules maybe important as listed for the lumbar spine; however, I think it is most important to rule out potential risk factors before implementing a CSM. We learned from our first weekend courses a few CPR for t-spine manipulation for cervical spine dysfunctions. Do you guys think we need clinical prediction rules for cervical manipulations to treat neck pain as well?

Nick- thank you for your reply. Osteoporosis was indicated as a contraindication, and frankly I don’t think my skills are up to par with cervical manipulations. As for activating deep cervical flexors post manipulation sounds like a great idea especially due to the presentation of your patients “forward head”. I can only imagine how shortened those muscles are. Have you tried the deep cervical flexion endurance test?

[Michael McMurray]

Here are some cervical CPR development studies: (I think Nick pulled most of these in his literature review, before being encouraged to choose the Dunning article he reviewed.

Again these “Rules” have not been validated, so maybe “clinical decision assisting tools” .

Development of a clinical prediction rule to identify patients with neck pain likely to benefit from thrust joint manipulation to the cervical spine.
Puentedura EJ, Cleland JA, Landers MR, Mintken PE, Louw A, Fernández-de-Las-Peñas C.J Orthop Sports Phys Ther. 2012 Jul;42(7):577-92. doi: 10.2519/jospt.2012.4243.
PMID: 22585595

Development of a clinical prediction rule to identify patients with neck pain likely to benefit from cervical traction and exercise.
Raney NH, Petersen EJ, Smith TA, Cowan JE, Rendeiro DG, Deyle GD, Childs JD.
Eur Spine J. 2009 Mar;18(3):382-91.
PMID: 19142674

Development of a clinical prediction rule for guiding treatment of a subgroup of patients with neck pain: use of thoracic spine manipulation, exercise, and patient education.
Cleland JA, Childs JD, Fritz JM, Whitman JM, Eberhart SL.
Phys Ther. 2007 Jan;87(1):9-23.

[Nick Law]

Just a quick follow up point on the thoracic spine CPR; and this study was cited in Cervical Case 1 at the course series but might be worth repeated. A group looked at outcomes in patients who fulfilled the THORACIC CPR when they received either CERVICAL or THORACIC manipulation. The group that received cervical manipulation had better outcomes on the NDI and NPRS with fewwer side effects. The decreased side effects is particularly interesting to me – it seems natural to think that the farther away I am from the patients primary complaint of pain, the less likely I am to generate side effects, however that was not discovered in this study.

Thoracic spine thrust manipulation versus cervical spine thrust manipulation in patients with acute neck pain: a randomized clinical trial. Puentedura EJ1, Landers MR, Cleland JA, Mintken PE, Huijbregts P, Fernández-de-Las-Peñas C.J Orthop Sports Phys Ther. 2011 Apr;41(4):208-20

Also, we talked about the potential neurophysiological effects explaining the rapid improvement in patients who received thrust manipulation in our journal club this past week. We speculated that widespread improvements in pressure pain threshold might have given us an insight as to whether central mechanisms were responsible. Here is a relatively recent study that looked at PPT in patients who received either cervical or thoracic manip. PPT was improved globally (lateral epicondyle and tibialis anterior), however it was not enough to meet the MDC. Would need to do another intensive review on this article itself to appreciate its findings, however it was certainly surprising to me that they do not see a greater change.

Immediate changes in widespread pressure pain sensitivity, neck pain, and cervical range of motion after cervical or thoracic thrust manipulation in patients with bilateral chronic mechanical neck pain: a randomized clinical trial. Martínez-Segura R1, De-la-Llave-Rincón AI, Ortega-Santiago R, Cleland JA, Fernández-de-Las-Peñas C.J Orthop Sports Phys Ther. 2012 Sep;42(9):806-14

Also, is it me, or is Josh Cleland a co-author in almost 50% of orthopedic PT studies published?

[ABengtsson]

Great discussion! Sorry for not contributing sooner!

One thing I noticed in the Puentedura T-Spine vs C-spine thrust study was the following combination of symptoms:

“Finally, patients had to satisfy at least 4 out of the following 6 criteria: symptom duration less than 30 days, no symptoms distal to the shoulder, no aggravation of symptoms by looking up, Fear-Avoidance Beliefs Questionnaire Physical Activity (FABQPA) subscale score of less than 12, decreased upper thoracic spine kyphosis (T3-T5), and cervical extension range of motion (ROM) less than 30°.”

In my rather limited experience, I must say I haven’t seen a single patient who’d satisfy 4/6 here. Most of my patients with mechanical neck pain (or in general) have an increase in upper T-spine kyphosis. Also, from what I’ve seen so far (again, not that much) is that pts who have <30 deg cervical extension, usually have aggravation of symptoms looking up.
Also, just two sentences above the author states that pts with unliateral UE symptoms would be included, but one of the 6 factors is no symptoms below shoulder level. If there’s UE involvement, say coming from stenosis, wouldn’t there be a good chance that ext would aggravate that?

Have you guys seen pts that would satisfy 4 out of those 6 and if so, what kind of presentation did they have and how did you treat them? If not, how would you take the findings in that study into consideration with other patients?

Didn’t mean to pick on this article, but reading through that I just felt like I was really missing something. If anybody has had experiences that fit here, please do share!

Nick – any new developments with your cervical case since your last post? Also, I think considering his legal action status is a great clinical decision regarding thrust techniques.

Reg. Osteopenia: I had one CI who’d use the supine t-sp thrust set up with an open hand as a mobilization technique, just not perform the thrust and just based on how I saw the pts progress, he appeared to have pretty good outcomes overall. Also, the pts tolerated this technique really well, which kind of surprised me at the time.

[omikutin]

The lack of evidence for “premanipulative screening has caused some authors to suggest that identifying patients for whom there may be risks associated with TJM in the cervical spine is virtually impossible and that perhaps the potential benefits may not outweigh the inherent risks. This may explain why physical therapists will report utilizing TJM in the thoracic spine more frequently than in the cervical spine in patients with neck pain,1despite evidence that many of these potential negative outcomes may be prevented through careful examination”. Do you think the reason why many therapist don’t use cervical manips due to potential adverse effects or lack of technique? I mean there are benefits from a T-spine manip. Have you guys seen a case where only a cervical manip was indicated that you couldn’t use the thoracic one?

Puentedura did a study comparing thrust manipulation to the cervical spine as compared to a thoracic manipulation in patients with neck pain. She found “that patients with acute neck pain (less than 30 days in duration) who received TJM to their cervical spine had greater improvements in neck disability (P⩽.001) and pain (P➭.003) at all follow-up times than those who received TJM to the thoracic spine”.

Nick- you bring up an interesting point, I think Cleland is the co-author of a majority of orthopedic studies. I also appreciate what Salmon- Moreno mentions “spinal thrust manipulation to act through the stimulation of descending inhibitory mechanisms, particularly the periaqueductal gray matter. This assumption is mainly based on the premise that spinal thrust manipulation exerts a mechanical hypoalgesic effect, thereby increasing pressure pain thresholds.” I feel as though there is a plethora of articles support thrust manipulations, as long as we clear red flags/ contraindications. Why not? Granit cervical CPRs lack validity but maybe an algorithm is something we should focus on more.

Alex- Great idea on the flat hand technique! We talked about that here in the clinic. I’ve never been able to get the flat hand technique but practice with practice maybe?

[Nick Law]

Alex,

Perhaps we are both in the dark on this one, however I must say that I am a little confused by the thoracic CPR as well. My main purpose for citing the study was simply to take note of the fact that when it was being tested, cervical manip did better and had less side effects than thoracic manip when patients met the criteria for the thoracic manip CPR. The criteria itself is definitely a little puzzling to me, especially the factors that you pointed out. It doesn’t make too much sense to me that patients with less than 30 degrees of extension would not have exacerbation of symptoms by looking up, that is, by moving into extension. With regards to the upper thoracic kyphosis, I certainly think that in my experience most patients have an increased upper thoracic kyphosis. However, I have definitely treated more than a few patients with a diminished upper thoracic kyphosis – almost all females (not sure why). I must admit I am not sure I have a handle on what to do with their T spine, if anything at all, in those patients. It is certainly interesting that the reduced, not increased, upper thoracic kyphosis filtered out into the CPR.

With regards to my case, I have seen him for an additional few visits since the presentation. We have been primarily working on cervical stabilization, motor control. We have been working rotation in supine over a wedge and prone on elbows with suboccipital neutral maintained (which he is very poor at achieving); he has poor control and if he rotates too far or too fast he gets pain. His compliance is very poor; he hardly performs HEP and I had to waken him up from sleeping on the table today 3x (Carl Zovko as witness). I have given him advice on correct sleeping posture (avoidance of extreme ranges of motion, slight flexion), which he has yet to employ. He told me that he fell asleep last night looking at YouTube sitting up in bed. When I queried him regarding overall progression in today’s therapy session, he stated that nothing had changed and that he doesn’t believe anything is going to get better due to protracted period of time between his injury and receiving treatment. I continue to think that he has motor control issues in his C spine, however there is certainly a very large behavioral/psychosocial component to his pain that I am still trying to figure out how to properly manage.

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