Full text for the journal club article is attached

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.

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

• This reply was modified 8 years, 9 months ago by 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?

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?

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.

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.

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?

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.

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.

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?