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PubMed2004

The influence of experience and specialty certifications on clinical outcomes for patients with low back pain treated within a standardized physical therapy management program.

STUDY DESIGN: Secondary analysis of a randomized trial. OBJECTIVES: To examine the influence of experience and specialty certification on outcomes for patients with low back pain receiving a standardized manipulation or stabilization exercise intervention program. BACKGROUND: Little research has examined the impact of therapist-related factors on the outcomes of clinical care for patients with low back pain. It is assumed that therapists with more clinical experience or specialty certification will achieve better clinical outcomes; however, few studies have examined this hypothesis. METHODS AND MEASURES: One hundred thirty-one participants in a randomized trial were included (70 randomized to receive manipulation, 61 stabilization). All subjects completed an Oswestry Disability Questionnaire at baseline, and after 1 and 4 weeks of treatment. Therapists were categorized based on total years of experience, years of experience with manual therapy, and specialty certification status. Two-way repeated-measures analyses of covariance were performed within each intervention group to examine the effects of the therapist characteristics on outcomes. Hierarchical linear regression models were used to examine the relative effects of therapist characteristics and intervention on clinical outcomes. RESULTS: Thirteen therapists participated (average 6.0 years of experience [standard deviation, 4.01, 4 (30.8%) with specialty certification). A significant interaction between time and specialty certification status (P = .04) was detected for subjects receiving the manipulation intervention. No significant interactions were detected in the stabilization group. The regression models found that the intervention group significantly contributed to explaining clinical outcomes, but that therapist characteristics did not. CONCLUSIONS: With the standardized protocol utilized in this study, it appears that the therapist-related factors of increased experience and specialty certification status do not result in an improvement in patients' disability associated with low back pain.

Adult↗
PubMed2004

Intermittent cervical traction and thoracic manipulation for management of mild cervical compressive myelopathy attributed to cervical herniated disc: a case series.

STUDY DESIGN: Case series. OBJECTIVE: To describe the management of 7 patients with grade 1 cervical compressive myelopathy attributed to herniated disc using intermittent cervical traction and manipulation of the thoracic spine. BACKGROUND: Intermittent cervical traction has been indicated for the treatment of patients with herniated disc and has been suggested to be helpful for patients with cervical compressive myelopathy. Manipulation of the thoracic spine has been utilized to safely improve active range of motion and decrease pain in patients with neck pain. METHODS AND MEASURES: Seven women with neck pain, 35 to 45 years of age, were identified as having signs and symptoms consistent with grade 1 cervical compressive myelopathy. Symptom duration ranged from less than 1 week to 52 weeks. All patients were treated with intermittent cervical traction and thoracic manipulation for a median of 9 sessions (range, 2-12 sessions) over a median of 56 days (range, 14-146 days). Numeric Pain Rating Scale and Functional Rating Index scores served as the primary outcome measures. RESULTS: The median decrease in pain scores was 5 (range, 2-8) from a baseline of 6 (range, 4-8), and median improvement in Functional Rating Index scores was 26% (range, 10%-50%) from a baseline of 44% (range, 35%-71%). Dizziness was eliminated in 3 out of 4 patients and chronic headache symptoms were improved in 3 out of 3 patients. There were no adverse events or outcomes. CONCLUSIONS: Intermittent cervical traction and manipulation of the thoracic spine seem useful for the reduction of pain scores and level of disability in patients with mild cervical compressive myelopathy attributed to herniated disc. A thorough neurological screening exam is recommended prior to mechanical treatment of the cervical spine.

Adult↗
PubMed2004

Effectiveness of manual physical therapy to the cervical spine in the management of lateral epicondylalgia: a retrospective analysis.

DESIGN: Retrospective ex-post facto design. OBJECTIVES: To retrospectively review the management of patients with lateral epicondylalgia, and to compare self-reported outcomes to assess the potential benefit of manual physical therapy to the cervical spine. BACKGROUND: It has been postulated that dysfunction of the cervical spine may contribute to the symptoms associated with lateral epicondylalgia; however, the literature assessing the effectiveness of manual physical therapy to the cervicothoracic region in this patient population has been inconclusive. Documentation and analysis of outcomes of management strategies focusing on the cervical spine may lead to determining the most effective and efficient clinical practices. METHODS AND MEASURES: Of the 213 charts reviewed, 112 satisfied inclusion-exclusion criteria and were divided into 2 groups: those who received treatment solely directed at the elbow (local management [LM]), or those who received treatment directed at the elbow and cervical manual therapy (LM+C). Telephone follow-up interviews were used to determine the number of successful outcomes. Percentages of successful outcomes in each group were compared using chi-square analysis. An independent samples t test was used to compare the total number of visits per group. RESULTS: Sixty-one of the 112 patients were in the LM group, while 51 received LM+C. Seventy five percent of the patients available for follow-up in the LM group and 80% in the LM+C group reported a successful outcome. Patients in the LM group received a greater number of visits (mean, 9.7; SD, 2.4) than patients in the LM+C group (mean, 5.6; SD, 1.7; P<.01). CONCLUSIONS: The results of this retrospective review suggest that most patients had successful outcomes regardless of the inclusion of manual therapy interventions to the cervical spine. The LM+C group achieved the successful long-term outcome in significantly fewer visits.

Adult↗
PubMed2004

Assessment of lumbar spine kinematics using dynamic MRI: a proposed mechanism of sagittal plane motion induced by manual posterior-to-anterior mobilization.

STUDY DESIGN: Descriptive study. OBJECTIVE: The purpose of this study was to describe the segmental motion of the lumbar spine during a posterior-to-anterior (PA) mobilization procedure using dynamic magnetic resonance imaging and to propose a mechanism of the lumbar spine's motion as a result of a PA force to a lumbar spinous process. BACKGROUND: Studies reporting kinematic descriptions of PA mobilization are in agreement that motion takes place at all lumbar vertebrae. However, these studies differ in the reported direction of motion. METHODS AND MEASURES: Twenty asymptomatic subjects (mean age +/- SD, 31.1 +/- 7.0 years) participated in this study. For each subject, a PA mobilization force was manually applied at each lumbar spinous process while sagittal plane magnetic resonance images were simultaneously obtained. Intervertebral motion was defined as the change in the intervertebral angle between the resting and end range vertebral positions imparted by the PA pressure. RESULTS: PA force applied at 1 spinous process caused motion at the target vertebra and this motion was propagated caudally and cranially. Motion at the target segment was always into extension. CONCLUSIONS: A PA force applied at a single lumbar spinous process caused motion of the entire lumbar region. The magnitude and direction of intervertebral motions varied with the segment at which the PA force was applied. We postulated that the intervertebral motion induced by a PA force on a spinous process could be in part explained by the morphology of the lumbar spine.

Adult↗
PubMed2006

Clinical outcomes following manual physical therapy and exercise for hip osteoarthritis: A case series.

STUDY DESIGN: Case series describing the outcomes of individual patients with hip osteoarthritis treated with manual physical therapy and exercise. CASE DESCRIPTION: Seven patients referred to physical therapy with hip osteoarthritis and/or hip pain were included in this case series. All patients were treated with manual physical therapy followed by exercises to maximize strength and range of motion. Six of 7 patients completed a Harris Hip Score at initial examination and discharge from physical therapy, and 1 patient completed a Global Rating of Change Scale at discharge. OUTCOMES: Three males and 4 females with a median age of 62 years (range, 52-80 years) and median duration of symptoms of 9 months (range, 2-60 months) participated in this case series. The median number of physical therapy sessions attended was 5 (range, 4-12). The median increase in total passive range of motion of the hip was 82 degrees (range, 70 degrees-86 degrees). The median improvement on the Harris Hip Score was 25 points (range, 15-38 points). The single patient who completed the Global Rating of Change Scale at discharge reported being "a great deal better." Numeric pain rating scores decreased by a mean of 5 points (range, 2-7 points) on 0-to-10-point scale. DISCUSSION: All patients exhibited reductions in pain and increases in passive range of motion, as well as a clinically meaningful improvement in function. Although we can not infer a cause and effect relationship from a case series, the outcomes with these patients are similar to others reported in the literature that have demonstrated superior clinical outcomes associated with manual physical therapy and exercise for hip osteoarthritis compared to exercise alone.

Aged↗
PubMed2006

Diagnosis and treatment of cervical radiculopathy using a clinical prediction rule and a multimodal intervention approach: a case series.

STUDY DESIGN: Case series. OBJECTIVES: To describe an established method of diagnosing cervical radiculopathy (CR) using a clinical prediction rule (CPR), and to describe the management of 6 patients using intermittent cervical traction (ICT), thoracic thrust joint manipulation (TJM), and exercise. BACKGROUND: Many patients present with unilateral arm pain without having undergone magnetic resonance imaging (MRI) of the cervical spine. Using a CPR has demonstrated high levels of specificity to rule in cervical radiculopathy. ICT and manual therapy (including thoracic TJM) are widely used in clinical settings to treat cervical radiculopathy. CASE DESCRIPTION: Six patients (3 men, 3 women) were diagnosed with cervical radiculopathy using the CPR. All patients were treated with ICT, thoracic TJM, and exercise. The Northwick Park Neck Questionnaire served as the outcome measure. OUTCOMES: The CPR accurately identified CR (secondary to a disc herniation) in 4 out of 4 patients when compared to the results of a reference standard (MRI). Six patients were seen from 5 to 18 sessions over a 19- to 56-day period. Reduction in Northwick Park Neck Questionnaire scores ranged from 13% to 88%. One patient did not improve significantly and underwent neck surgery. DISCUSSION: Using the CPR may be beneficial in diagnosing CR, so the clinician can devise a plan of care and assess treatment outcomes in a relatively homogenous group of patients. It is possible that a treatment regimen of ICT, thoracic TJM, and exercise will aid in centralizing radicular symptoms and improving functional outcomes in patients with CR.

Adult↗
PubMed2006

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.

BACKGROUND AND PURPOSE: To date, no studies have investigated the predictive validity of variables from the initial examination to identify patients with neck pain who are likely to benefit from thoracic spine thrust manipulation. The purpose of this study was to develop a clinical prediction rule (CPR) to identify patients with neck pain who are likely to experience early success from thoracic spine thrust manipulation. SUBJECTS: This was a prospective, cohort study of patients with mechanical neck pain who were referred for physical therapy. METHODS: Subjects underwent a standardized examination and then a series of thoracic spine thrust manipulation techniques. They were classified as having experienced a successful outcome at the second and third sessions based on their perceived recovery. Potential predictor variables were entered into a stepwise logistic regression model to determine the most accurate set of variables for prediction of treatment success. RESULTS: Data for 78 subjects were included in the data analysis, of which 42 had a successful outcome. A CPR with 6 variables was identified. If 3 of the 6 variables (positive likelihood ratio=5.5) were present, the chance of experiencing a successful outcome improved from 54% to 86%. DISCUSSION AND CONCLUSION: The CPR provides the ability to a priori identify patients with neck pain who are likely to experience early success with thoracic spine thrust manipulation. However, future studies are necessary to validate the rule.

Adult↗
PubMed2000

Transpedicular approach for thoracic disc herniations.

OBJECT: Patients with symptomatic herniated thoracic discs may require operation for intractable radiculopathy or functionally disabling myelopathy. In the past, laminectomy was the procedure of choice for the treatment of thoracic herniations, but it was found that the approach was associated with an unacceptably high rate of neurological morbidity. Several strategies have been developed to excise the disc without manipulating the spinal cord. The focus of this paper is the transpedicular approach. METHODS: The author retrospectively reviewed the cases of 20 consecutive patients presenting with herniated thoracic discs in whom surgery was performed via a transpedicular approach. Fourteen patients presented with acute myelopathy and six with radiculopathy. Of those with myelopathy six of six regained ambulation and six of seven regained normal bladder function. No patient with myelopathy experienced neurological worsening. In four patients presenting with radiculopathy postoperative pain resolved, and in two it remained unchanged. Three minor complications (15%) occurred. No patient suffered postoperative spinal instability-related pain or delayed kyphosis. CONCLUSIONS: As experience accumulates in the use of multiple approaches for the treatment of thoracic disc herniations, the role of each is becoming more clearly defined. The transpedicular approach is most applicable to lateral or centrolateral calcified or soft discs. The more anterior (transthoracic or thoracoscopic) and lateral (costotransversectomy or lateral extracavitary) approaches may be more useful for excision of central calcified discs.

Adult↗
PubMed2004

Nonsurgical treatment of a C6-7 unilateral locked facet joint in an infant. Case report.

Cervical spine injuries in the pediatric population typically affect the upper cervical region. The authors present the first reported case of a subaxial C6-7 unilateral locked facet joint in a neurologically intact 10-month-old infant. To date, this patient's nonoperative treatment has been successful. The proposed biomechanical mechanism of this injury and the treatment paradigm are discussed.

Cervical Vertebrae↗
PubMed2003

[Pathogenic factors of blood circulation disturbance in lumbar intervertebral disc herniation and mechanism of Tuina manipulation in promoting circulation].

Tuina manipulation has long been used in the treatment of lumbar intervertebral disc herniation, although its therapeutic mechanisms remain uncertain. The specific characteristic syndrome of this disease is lumbocrural pain in varying degrees, which is due to mechanical compression, aseptic inflammation, blood circulation disturbance and dystrophy. These factors can act on the involved nerve roots and give rise to nerve conduction disturbance. Since the blood circulation disturbance and nerve roots dystrophy are the most important pathogenic aspects of this disease, the therapeutic effect of Tuina manipulation on lumbar intervertebral disc herniation is related to them directly or indirectly.

Decompression, Surgical↗
PubMed2003

[Influence of cervical curvature change on the nerve root and vertebral artery of patients with cervical spondylosis and clinical observation of manipulation treatment].

OBJECTIVE: To observe the influence of the change of cervical curvature on the nerve root and the vertebral artery of the patients with cervical spondylosis and the curative effect of therapeutic manipulations. METHODS: Sixty cases of cervical spondylosis with the change of cervical curvature, 60 cases of cervical spondylosis without the change of cervical curvature and 60 normal people were chosen. They were clinically observed and the cervical spondylosis was treated by manipulations and the data was processed according to the principle of statistics. RESULTS: The change of cervical curvature affected the nerve root and the vertebral artery and therapeutic manipulations produced a satisfactory curative effect. CONCLUSION: Cervical spondylosis with change of cervical curvature has special characteristics in the etiology, course and state of the disease. The change of cervical curvature produces an effect on the nerve root and the vertebral artery. Selected therapeutic manipulations produce a better curative effect.

Adult↗
PubMed2003

[An transcranial Doppler ultrasonography and X-ray study of cervical vertigo patients treated by manipulation in supine position].

OBJECTIVE: To observe the transcranial Doppler ultrasonography and X-ray changes of cervical vertigo patients caused by cervical instability before and after the manipulation treatment in supine position. METHODS: Sixteen cervical vertigo patients who underwent supine manipulation treatment were reviewed retrospectively. After the treatment, the changes of transcranial Doppler ultrasonography of cervical vertebral artery and X-ray of cervical spine were observed. RESULTS: Before the treatment, the mean blood flow velocity of vertebral artery was (48.6+/-3.1) cm/s, much higher than that of the normal group (P<0.05), the means of the horizontal displacement of C3,4 and C4,5 were (3.18+/-0.42) mm and (3.46+/-0.26) mm respectively. After the treatment, the blood flow velocity and the C3,4 horizontal displacement decreased significantly (P<0.05). The effective rate of the manipulation treatment was 100%. CONCLUSION: The manipulation treatment is an effective method for cervical vertigo patients caused by cervical instability, and the effect is correlated with the improvement of the blood flow of cervical artery and the restoration of cervical stability.

Adult↗
PubMed1999

Nonoperative treatment of low back pain.

Low back pain is a common problem with substantial social and economic issues. Physicians continue to have difficulty managing this condition despite an increased awareness of its magnitude. In addition, there is a misperception about the outcome of patients affected with low back pain; most continue to suffer from pain. We present a nonoperative approach and review various diagnostic and treatment strategies with respect to both scientific and clinical merit. Although many treatment strategies have not been well proved in the scientific literature, thoughtful review of the available information provides a basis for the use of these treatment methods in the patient with refractory pain. This approach can be used in conjunction with existing information to assist clinicians in the management of patients with acute low back pain.

Bed Rest↗