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.

 
PURPOSE:
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
 
MATERIALS AND METHODS
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)

myotomal

dermatomal

reflexes

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

 
EXAM PROCEDURES
Self-report measures

body diagram

NPRS

NDI

FAQ

Evaluation

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

Spurling

Distraction

Roos

ULTT

TREATMENT:
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.
 
DATA ANALYSIS:
Sensitivity, Specificity, and positive likelihood ratios (LR’s) were calculated for

those variables that reached significance at a P<.10.
 
RESULTS:
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

FABQPA < 12

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%

 
DISCUSSION:
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

manipulations
 
 
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.
 

Author: Dr. Vince Gutierrez, PT, cert. MDT

After having dedicated 8 years to growing my knowledge regarding the profession of physical therapy, it seems only fitting that I join the social media world in order to spread a little of the knowledge that I have gained over the years. This by no means is meant to act in place of a one-one medical consultation, but only to supplement your baseline knowledge in which to choose a practitioner for your problem. Having completed a Master of Physical Therapy degree, the MDT (Mechanical Diagnosis and Therapy) certification and currently finishing a post-graduate doctorate degree, I have spent the previous 12 years in some sort of post-baccalalaureate study. Hopefully the reader finds the information insightful and uses the information in order to make more informed healthcare decisions. MISSION STATEMENT: My personal mission statement is as follows: As a professional, I will provide a thorough assessment of your clinical presentation and symptoms in order to determine both the provocative and relieving positions and movements. The assessment process and ensuing treatment will be based on current and relevant evidence. Furthermore, I will educate the patients regarding their symptoms and their likelihood of improving with either skilled therapy, an independent exercise program, spontaneous recovery or if the patient should be referred to a separate specialist to possibly provide a more rapid resolution of symptoms. Respecting the patient’s limited resources is important and I will provide an accurate overview of the prognosis within 7 visits, again based on current research. My goal is to empower the patient in order to take charge of both the symptomatic resolution and return to full function with as little dependence on the therapist as possible. Personally, I strive to be an example for family and friends. My goal is to demonstrate that success is not a byproduct of situations, but a series of choices and actions. I will mentor those, in any way possible, that are having difficulty with the choices and actions for success. I will continue to honor my family’s “blue-collar” roots by working to excel at my chosen career and life situations. I choose to be a leader of example, and not words, all the while reducing negativity in my life. I began working towards the professional aspect of the mission statement while still in physical therapy school. By choosing an internship that emphasized patient care and empowering the patient, instead of the internship that was either closest to home or where I knew that I would have the easiest road to graduation, I took the first step towards learning how to utilize the evidence to teach patients how to reduce their symptoms. I continued this process by completing Mechanical Diagnosis and Therapy courses A-D and passing the credentialing exam. I will continue to pursue my clinical education through CEU’s on MDT and my goal is to obtain the status of Diplomat of MDT. Returning back to school for the t-DPT was a major decision for me, as resources (i.e. time and money) are limited. My choice was between saving money for the Dip MDT course (about 15,000 dollars) and continuing on with the Fellowship of American Academy of Orthopedic Manual Physical Therapists (FAAOMPT) (about 5,000 dollars), as these courses are paired through the MDT curriculum or returning to school to work towards a Doctorate of Physical Therapy degree. I initially planned on saving for the Dip MDT and FAAOMPT, but life changes forced me to re-evaluate my situation. The decision then changed to return for the tDPT, as my employer paid for a portion of the DPT program. My goal for applying to and finishing the Dip MDT and FAAOMPT is 10 years. This is how long I anticipate that it will take to finish paying student loans and save for both programs, based on the current rate of payment. I don’t know if I will ever accomplish what I set forth in the mission statement, but I do know that it will be a forever struggle to maintain this standard that I set for myself.

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