Post 74

I’ll readily admit that I didn’t have time to write this week. It’s been a hard month for me, avoiding death twice. Therefore, I borrowed from some of my previous research writings from the ladt year. Enjoy. 

Cleland JA, Childs JD, Fritz JM, et al. 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. Phys Ther. 2007;87(1):9-23.
Inherently lower risk of serious complications, thoracic spine thrust manipulation might be a suitable alternative, or supplement, to cervical spine thrust manipulation.

To develop a CPR to identify patients with neck pain who are likely to benefit from

thoracic spine thrust manipulation based on a reference standard of patient-reported improvement
prospective cohort study of consecutive patients with mechanical neck pain

Inclusion criteria

b/t 18 and 60

primary complaint of neck pain

with or without unilateral upper-extremity symptoms

baseline NDI of at least 10%

Exclusion criteria

identification of red flags

h/o whiplash within 6 weeks of the examination

diagnosis of cervical spinal stenosis,

evidence of any central nervous system involvement

s/s of nerve root compression (at least 2 of the following)




4 PT’s underwent standardized training regimen with a mean of 12.3 y/o experience

Self-report measures

body diagram





mode of onset, nature and location of symptoms, aggravating and relieving

factors, prior history of neck pain
Neuro screen

Postural assessment

Cervical ROM

symptom response

length and strength of muscles of the upper quarter and endurance of the

deep neck flexors
Special tests





all treatment standardized

Each subject received 3 different thrust techniques to the T/S twice per session

seated distraction

supine upper thoracic spine manipulation

Middle thoracic spine manipulation

Cervical ROM exercise

10 reps 3-4x/day

fingers on chest and chin on fingers (rotation bilaterally)

GROC with a score of +5 categorized as a successful outcome

high threshold was authors’ way of attempting to isolate the treatment for

improvement (VG: there still may be rapid responders without treatment
or with a separate treatment)
Those without a +5 GROC score were treated for a second session with thrust

manipulations as in the first treatment, with a f/u in 2-4 days.
Those that didn’t reach +5 were then seen as unsuccessful. At this point, the

study was complete and treatment was administered as per their PT.
Sensitivity, Specificity, and positive likelihood ratios (LR’s) were calculated for

those variables that reached significance at a P<.10.
80 subjects recruited and 2 subjects dropped out of the study

23 subjects reported “successful” outcome based on GROC after the first session.

19 after session 2 (42/78)

“successful” outcome group was significantly better with both pain and

disability than the “unsuccessful” group.
6 potential variables based on data analysis are as follows:

No symptoms distal to the shoulder

looking up does not aggravate symptoms

<30 days since onset of injury

<30 degrees of cervical extension


diminished upper thoracic spine kyphosis

14/15 subjects + on 4/6 criteria and 32/37 subjects + on 3/6

all had successful outcomes

+LR for 4/6 + variables is 12.0 and post-test probability of success is 93%

+ LR for 3/6 + variables is 5.5 with post-test probability of success at 86%

Clinicians should look for at least 3/6 variables in order to guide the utilization of

the CPR.
CPR is able to a priori determine who may benefit most from T/S thrust

fulfilled the purpose of creating a CPR and the authors note that additional studies

should be performed to validate the study with a long-term analysis and utilizing an RCT comparison group.
Clinician perspective: This was a well-run initial study. Without validation, I would utilize the CPR should the patient not respond to an assessment/treatment approach that was not demonstrating improvement. In hindsight, this CPR was not validated. Many patients rapidly responded to the manipulation. As a clinician, I would still keep this in mind when treating patients that were not responding to a preset treatment paradigm. There are some questionable actions in this study, for instance, I can’t remember ever using a Roo’s test for someone with cervical complaints, as this is a test for TOS.

Categories: Physical therapy

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