Treatment preferences amongst physical therapists and chiropractors for the management of neck pain: results of an international survey

Diagnosing and treating upper back pain: insights from New Zealand's manipulative physiotherapists and osteopaths

BACKGROUND

Manual therapy is routinely used in the management of upper back pain (UBP), a disabling condition. However, the approach to diagnosis and treatment techniques used by manipulative physiotherapists and osteopaths is largely unknown.

OBJECTIVES

To explore knowledge about UBP, including diagnosis and treatment, by New Zealand (NZ) osteopaths and manipulative physiotherapists and to investigate differences (if any) in the self-reported approaches to diagnosis and management of UBP between the professions.

DESIGN

A cross-sectional survey administered through an online platform (Qualtrics) between September 2023 and January 2024.

PARTICIPANTS

One hundred and ten NZ osteopaths and manipulative physiotherapists completed the survey.

RESULTS

Forty-eight percent (n = 53) of respondents identified their profession as physiotherapists and 52% (n = 57) as osteopaths. Over three-quarters of respondents (77%) 'strongly agreed' that a multimodal approach is essential for effective UBP management. Osteopaths were significantly more likely to often proffer 'wear and tear/degeneration' (p < 0.01) and 'visceral referred pain' (p = 0.02) as the cause of a patient's UBP. In terms of management, osteopaths were significantly more likely to use soft tissue techniques (p < 0.01), spinal manipulations (p < 0.01), rib manipulations (p < 0.01), rib mobilizations (p < 0.01), and visceral techniques (p < 0.01), compared to physiotherapists.

CONCLUSIONS

The survey highlights a strong consensus among respondents that a multimodal approach is essential for effective UBP management. The survey also identified profession-specific approaches to the diagnosis and management of UBP. Future research using qualitative methods is required to further explore these profession-specific differences and explore outcomes of care.

Unraveling the Mechanisms Behind the Short-Term Effects of Dry Needling: New Insights From a Mediation Analysis With Repeatedly Measured Mediators and Outcomes

OBJECTIVE

To explore the causal pathways underlying the short-term effects of deep dry needling (DDN) in people with chronic neck pain.

DESIGN

Explanatory longitudinal mediation analysis with repeatedly measured mediators and outcomes.

SETTING

Primary care setting.

PARTICIPANTS

Patients (N=128) with chronic neck pain.

INTERVENTIONS

Participants were randomized into 2 groups; DDN of the neck muscles combined with stretching (n=64) and stretching alone (n=64).

MAIN OUTCOME MEASURES

Two outcomes (pain intensity and neck pain-related disability) and 3 candidate mediators (local pressure pain thresholds [PPTs], cervical range of motion [ROM], and neck muscle strength) were included. Pain intensity was also included as a competing mediator in the mediation analysis for disability. Mediators and outcomes were measured at 3 time points: after intervention and at 2- and 4-week follow-up. Age, sex, and the baseline values of the outcome and mediators were included as pretreatment mediator-outcome confounders.

RESULTS

Reductions in pain intensity strongly mediated the short-term effects of DDN on disability, from after intervention to 4-week follow-up. In addition, the attenuation of local hypersensitivity (via increasing PPTs) moderately mediated reductions in pain intensity at each time point. On the other hand, gains in cervical ROM contributed to reducing neck pain-related disability. Changes in muscle strength did not lead to better outcomes.

CONCLUSIONS

This novel study demonstrated that DDN effect on neck pain-related disability is strongly driven by the analgesic effects of this physical therapy modality. Increasing PPTs and cervical ROM seem to be also part of the mechanisms behind DDN's effect.

Patient experience and barriers of using a mHealth exercise app in musculoskeletal (MSK) Physiotherapy

Digital transformation has led to an abundance of digital health technologies (DHTs) readily available for Physiotherapists. In July 2020, the Physiotherapy department at a London NHS Trust implemented a mobile health (mHealth) exercise application (app), Physitrack. This service evaluation aims to evaluate patient experience and identify any barriers to using Physitrack/PhysiApp in musculoskeletal (MSK) Physiotherapy. An online experience survey was sent to 10,287 MSK Physiotherapy patients who had appointments between January 17th and April 9th 2022.The survey received 1,447 responses (response rate: 14.07%), with 954 (65.93%) respondents previously provided PhysiApp as part of their Physiotherapy management. Most participants used PhysiApp (83.06%), found it easy to use (82.20%) and had positive perceptions on how it added value to their Physiotherapy treatment through its functionality. However, negative impacts on patient-centred care and practical exercise demonstration were apparent in the qualitative results. Key barriers to use included suboptimal explanation, digital exclusion, registration/ login issues and opinion that PhysiApp was superfluous to Physiotherapy treatment. These differed to the main barriers of why participants stopped using/ used PhysiApp less: if they were confident exercising without it, their condition improved/ resolved, loss of motivation, their exercise programme ended or if they found their exercise programme was unsuitable. Despite multiple interdependent factors influencing patient experience and barriers of using PhysiApp, the survey results revealed the significant influence that is exerted by MSK Physiotherapists. The patient-physiotherapist interaction can positively or negatively impact upon many barriers of use and the subsequent potential added value of PhysiApp to MSK Physiotherapy treatment. Future research should focus on those at most risk of digital exclusion and health inequalities, exploring their barriers to using mHealth apps and other DHTs.

Use of cervical traction for managing neck pain: A cross-sectional survey of physiotherapists in India

BACKGROUND

Neck pain remains the fourth leading cause of disability and work loss, and a multimodal treatment approach is effective in reducing neck pain and disability.

PURPOSE

The purpose of this study is to examine the use of cervical traction for managing neck pain by Physiotherapists in India, including how and when the traction is used, the modes and parameters of traction, any additional interventions given with traction, and the influence of professional demographic characteristics in decision making in traction usage.

STUDY DESIGN

A cross-sectional survey.

METHODOLOGY

A random sample of approximately 2500 musculoskeletal physiotherapists was surveyed, and the data was presented in a descriptive form. Chi-square analyses were used to identify the association between responders' qualifications and traction usage.

RESULTS

From the total physiotherapist approached 18.52% (n = 463) responses were obtained, and 62% (n = 287) respondents reported that they would use traction in their clinical practice. Out of 92.3% of responders indicated using traction for radiculopathy, 78.7% of respondents used traction for patients with neck pain without radiculopathy. It is used as a combination therapy by 58.8% for radiculopathy and 52.2% for stiffness. There was no association between the responder's qualification and traction usage (χ2 = 0.707, p = 0.40). Traction is used in combination with other physiotherapeutic techniques.

CONCLUSION

Traction use was consistent with the proposed criteria identifying patients likely to benefit. However, disregarding current guidelines, physiotherapists also use traction for non-radicular neck pain. Various traction delivery modes and parameters were used within a comprehensive plan of care incorporating multiple interventions.

CPM-Related Mechanisms Could Play a Key Role in the Effects on Pain Sensitivity Induced by Manual Therapy: Three Crossover Trials Investigating the Effects of Manual Pressure

Objective: The aim of this study is to assess whether pain-inducing manual pressure (PIMP) leads to effects on pressure pain threshold (PPT) mediated by conditioned pain modulation (CPM) and whether these effects are influenced by the intensity and repetition of the stimulus. Additionally, the influence of psychological factors and physical activity on the response to PIMP was explored. Methods: A total of 72 pain-free students were randomly assigned to three crossover trials. Trial 1 compared the effects of PIMP with the cold pressor task and pain-inducing electrostimulation. Trial 2 compared the effects of manual pressure that elicited moderate pain, mild pain, and no pain. Trial 3 compared a single PIMP stimulation with four stimuli applied at the same site or at different sites. Results: PIMP produced a lower increase in PPT than cold pressor task and no difference with electrostimulation. Manual pressure that caused moderate pain led to a greater increase in PPT compared to mild pain and pain-free application. Repetition of PIMP stimulus, whether at the same or different sites, did not significantly increase PPT compared to a single stimulation. No association with psychological factors or physical activity was found. Conclusions: PIMP produces an increase in PPT, suggesting the involvement of CPM-related mechanisms.

Association between myofascial trigger point therapy and conditioned pain modulation

INTRODUCTION

Myofascial trigger point therapy (MTrP) is a widely used therapeutic approach, although the underlying mechanisms remain unclear. Mechanisms discussed include peripheral involvement of muscles as well as central pain modulating processes such as the conditioned pain modulation (CPM). The aim of this study was to investigate whether the analgesic response of MTrP and the analgesic response of CPM correlate in asymptomatic participants in order to identify shared underlying mechanisms of MTrP and CPM.

METHOD

Both, CPM and MTrP protocols consisted of heat-based test stimuli (heat pain thresholds before and after the intervention) and pressure-based (conditioning) stimuli. Asymptomatic participants (n = 94) were randomly assigned to receive either mild, intense or no pressure stimuli (between-group design) to both the fingernail and the MTrP of the infraspinatus muscle (within-group design). Pressure stimuli at both locations (fingernail, MTrP) were applied with a pressure algometer for 120 s and continuously adjusted to maintain a constant pain intensity of mild or intense pain. All thermal stimuli were applied on the lower leg with a thermal stimulator.

RESULTS

A significant correlation was shown between the analgesic effect of CPM and MTrP therapy for mild (r = 0.53, p = 0.002) and intensive stimuli (r = 0.73, p < 0.001). 17.3% of the variance of the MTrP effect were explained by CPM after mild stimulation, and 47.1% after intense stimulation. Pain-related characteristics did not explain the variance within the analgesic response using a regression analysis.

CONCLUSIONS

Between the analgesic responses following MTrP and CPM paradigms, a moderate to strong correlation was observed, suggesting shared underlying mechanisms.

Effects of scapular treatment on chronic neck pain: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Chronic neck pain (CNP) is a common public health problem that affects daily living activities and quality of life. There is biomechanical interdependence between the neck and scapula. Studies have shown that shoulder blade function might be related to chronic neck pain. We therefore evaluated the effects of scapular targeted therapy on neck pain and function in patients with CNP.

METHODS

Databases, including MEDLINE (via PubMed), EMBASE (via Ovid), Ovid, Web of Science, and Scopus, were systematically searched for randomized controlled trials published in English investigating treatment of the scapula for CNP before July 16, 2023.

RESULTS

A total of 313 participants were included from 8 RCTs. Compared with those in the control group, the intervention in the scapular treatment group exhibited greater improvement in pain intensity (standardized mean difference (SMD) = 2.55; 95% CI = 0.97 to 4.13; P = 0.002), with moderate evidence. Subgroup analysis for pain intensity revealed a significant difference between the sexes, with only the female population (SMD = 6.23, 95% CI = 4.80 to 7.65) showing better outcomes than those with both sexes (SMD = 1.07, 95% CI = 0.57 to 1.56) (p < 0.00001). However, moderate evidence demonstrated no improvement in neck disability after scapular treatment (SMD of 0.24[-0.14, 0.62] of Neck Disability Index or Northwick Park Neck Pain Questionnaire). No effect of scapular treatment was shown on the pressure pain threshold (PPT). The cervical range of motion (CROM) and electromyographic activity of neck muscles could not be conclusively evaluated due to limited support in the articles, and further study was needed. However, the patient's head forward posture appeared to be corrected after scapular treatment.

CONCLUSION

Scapular therapy was beneficial for relieving pain intensity in patients with CNP, especially in women. Head forward posture might also be corrected with scapular therapy. However, scapular therapy may have no effect on the PPT or neck disability. However, whether scapular therapy could improve CROM and cervical muscle activation in patients with CNPs had not been determined and needed further study.

The knowledge, attitudes and perceptions of physiotherapists and chiropractors in South Africa

Background

Effective healthcare delivery occurs when health professionals collaborate and provide holistic, patient-centred care. Physiotherapists and chiropractors treat a common range of patients with an overlap in their scope of practice and modalities because of typical healthcare roles that could lead to 'perceived' animosity.

Objectives

To assess the knowledge, attitudes, and perceptions of qualified chiropractors and physiotherapists regarding each other's practice.

Method

A cross-sectional survey using an online questionnaire and analysed descriptively.

Results

Participants were chiropractors (n = 116) and physiotherapists (n = 190). Chiropractors achieved a mean knowledge score of 75.7%, with physiotherapists at 59.7% on the assessments of each other's patients; an average score of 85.3% and 72.0% respectively, on knowledge of treatment modalities; knowledge score of 82.4% and 77.3% respectively, on the conditions treated by the other professional. A total of 82.8% (n = 96) of chiropractors and 70.0% (n = 133) of physiotherapists indicated the other professionals' competence in treating neuromusculoskeletal conditions. Inter-professional referrals occurred between 81.9% of chiropractors (n = 95) and 55.3% of physiotherapists (n = 105). Chiropractors (69.0%, n = 80) and physiotherapists (55.3%, n = 105) wanted to collaborate to manage patients.

Conclusion

In the surveyed population in South Africa, chiropractors and physiotherapists had good knowledge, positive attitudes and perceptions of each other's practices, especially in the private sector.

Clinical implications

Inter-professional collaboration between chiropractors and physiotherapists should be encouraged so that healthcare delivery can be holistic and patient-centred for better clinical outcomes.

Rotation-traction manipulation induced intradiskal pressure changes in cervical spine-an in vitro study

Objective: Evaluate the effect of rotation-traction manipulation on intradiskal pressure in human cervical spine specimen with different force and duration parameters, and compare the intradiskal pressure changes between rotation-traction manipulation and traction. Methods: Seven human cervical spine specimens were included in this study. The intradiskal pressure was measured by miniature pressure sensor implanting in the nucleus pulposus. rotation-traction manipulation and cervical spine traction were simulated using the MTS biomechanical machine. Varied thrust forces (50N, 150N, and 250N) and durations (0.05 s, 0.1 s, and 0.15 s) were applied during rotation-traction manipulation with Intradiscal pressure recorded in the neutral position, rotation-anteflexion position, preloading, and thrusting phases. Futuremore, we documented changes in intradiscal pressure during cervical spine traction with different loading forces (50N, 150N, and 250N). And a comparative analysis was performed to discern the impact on intradiscal pressure between manipulation and traction. Results: Manipulation application induced a significant reduction in intradiscal pressure during preloading and thrusting phases for each cervical intervertebral disc (p < 0.05). When adjusting thrust parameters, a discernible decrease in intradiscal pressure was observed with increasing thrust force, and the variations between different thrust forces were statistically significant (p < 0.05). Conversely, changes in duration did not yield a significant impact on intradiscal pressure (p > 0.05). Additionally, after traction with varying loading forces (50N, 150N, 250N), a noteworthy decrease in intradiscal pressure was observed (p < 0.05). And a comparative analysis revealed that rotation-traction manipulation more markedly reduced intradiscal pressure compared to traction alone (p < 0.05). Conclusion: Both rotation-traction manipulation and cervical spine traction can reduce intradiscal pressure, exhibiting a positive correlation with force. Notably, manipulation elicits more pronounced and immediate decompression effect, contributing a potential biomechanical rationale for its therapeutic efficacy.

Profession-based manual therapy nomenclature: exploring history, limitations, and opportunities

OBJECTIVE

The International Consortium on Manual Therapies (ICMT) is a grassroots interprofessional association open to any formally trained practitioner of manual therapy (MT) and basic scientists promoting research related to the practice of MT. Currently, MT research is impeded by professions' lack of communication with other MT professions, biases, and vernacular. Current ICMT goals are to minimize these barriers, compare MT techniques, and establish an interprofessional MT glossary.

METHODS

Practitioners from all professions with training in manual therapies were encouraged by e-mail and website to participate (www.ICMTConferene.org). Video conferences were conducted at least bimonthly for 2.5 years by profession-specific and interprofessional focus groups (FGs). Members summarized scopes of practice, technique descriptions, associated mechanisms of action (MOA), and glossary terms. Each profession presented their work to the interprofessional FG to promote dialogue, understanding and consensus. Outcomes were reported and refined at numerous public events.

RESULTS

Focus groups with representatives from 5 MT professions, chiropractic, massage therapy, osteopathic, physical therapy and structural integration identified 17 targeting osseous structures and 49 targeting nonosseous structures. Thirty-two techniques appeared distinct to a specific profession, and 13 were used by more than 1. Comparing descriptions identified additional commonalities. All professions agreed on 4 MOA categories for MT. A glossary of 280 terms and definitions was consolidated, representing key concepts in MT. Twenty-one terms were used by all MT professions and basic scientists. Five terms were used by MT professions exclusive of basic scientists.

CONCLUSION

Outcomes suggested a third to a half of techniques used in MT are similar across professions. Additional research is needed to better define the extent of similarity and how to consistently identify those approaches. Ongoing expansion and refinement of the glossary is necessary to promote descriptive clarity and facilitate communication between practitioners and basic scientists.

Dry needling perceptions and experiences: A survey of Australian physiotherapists

BACKGROUND

There is a lack of information on the use of dry needling in Australian physiotherapy practice.

OBJECTIVES

Our primary aim was to enhance the understanding of why Australian physiotherapists use dry needling in clinical practice. The secondary aim was to explore Australian physiotherapists experiences with adverse events caused by dry needling.

DESIGN

Cross-sectional online survey.

METHOD

We developed a survey and disseminated it through email to physiotherapists from all states and territories in Australia. Participant demographics and responses were reported as frequencies and percentages.

RESULTS/FINDINGS

We invited 1006 Australian physiotherapists, of which 232 (23%) viewed the online survey and 203 (20%) consented to participate, of which nearly all completed the survey (n = 198, 98%). Most respondents worked in private practice (n = 164, 83%), with 127 (64%) reporting using dry needling as an intervention within the previous 12 months. Physiotherapists typically used dry needling to decrease pain intensity (n = 105, 85%) and reduce muscle tension (n = 100, 81%). Reports of minor adverse events were common and included discomfort during the treatment (n = 77, 62%) and bruising (n = 69, 56%). Some respondents reported experiencing major adverse events including prolonged aggravation of symptoms (n = 10, 8%) and syncope (n = 16, 13%).

CONCLUSIONS

We found that many Australian physiotherapists in private practice use dry needling, usually to decrease pain intensity and muscle tension. Minor adverse events were experienced by more than half the respondents and between 8 and 13% of the Australian physiotherapists surveyed reported experiencing a major adverse event due to dry needling.

Effects of muscle specific as compared to movement specific muscle energy technique in mechanical neck pain: A randomized controlled trial

BACKGROUND

Muscle energy technique (MET) is found to be effective for the management of neck pain and in addition to the muscle specific approach, clinicians may also adopt movement specific approach for METs. However, the literature is deficient in terms of comparison of muscle specific and movement specific METs in the management of mechanical neck pain.

OBJECTIVE

To compare the effects of muscle specific and movement specific METs in the management of mechanical neck pain.

METHODS

A single blind parallel design randomized controlled trial was conducted on 66 participants with mechanical neck pain ranging from 40-80 mm on visual analogue scale (VAS), aged between 19-44 years with pain and limitation on cervical motion. Once included, the participants were randomly allocated to two groups, namely the muscle specific MET group and the movement specific MET group. Outcome measures included VAS, Neck Disability Index (NDI) and cervical range of motion (ROM).

RESULTS

No significant differences (p> 0.05) were observed, neither immediately nor after 5 days, between muscle specific and movement specific MET in terms of VAS, NDI and ROM. However, a significant difference (p< 0.05) was observed in both groups in terms of pre- and post-analysis for all outcome variables.

CONCLUSIONS

Both muscle specific and movement specific METs are effective in the management of mechanical neck pain, with no significant differences between the two treatment techniques.

Effects of Two Exercise Programs on Neck Proprioception in Patients with Chronic Neck Pain: A Preliminary Randomized Clinical Trial

BACKGROUND

The purpose of this study was to compare the effects of specific neck muscle training and general neck-shoulder exercises on neck proprioception, pain, and disability in patients with chronic non-specific neck pain.

METHODS

Twenty-five patients with chronic non-specific neck pain were recruited into this preliminary single-blinded randomized clinical trial. They were randomly assigned to either a specific neck exercise (n = 13, mean aged 24 years) or a general neck exercise group (n = 12, mean aged 25 years). Specific neck exercises included eye-head coordination and isometric deep neck muscle exercises. General neck exercises included neck and shoulder free range of motion and shoulder shrug. Pain, disability, and neck proprioception, which was determined using the joint repositioning error, were measured at baseline and after eight weeks of training in both groups.

RESULTS

Both training groups showed significant improvements in joint repositioning error (p < 0.001, F = 24.144, ES = 0.8), pain (p < 0.001, F = 61.118, ES = 0.31), and disability (p = 0.015, F = 6.937, ES = 0.60). However, the specific neck exercise group showed larger variability in joint repositioning error (p = 0.006, F = 0.20, F critical = 0.36).

CONCLUSIONS

Either specific neck exercise or a general neck-shoulder range of motion exercise could be effective in improving neck proprioception. Therefore, exercises could be recommended based on patient comfort and patients' specific limitations.

Predictors of high-cost patients with acute whiplash-associated disorder in Japan

INTRODUCTION

The proportion of neck injuries due to traffic accidents is increasing. Little is known about high-cost patients with acute whiplash-associated disorder (WAD). The present study aimed to investigate whether time to first visit for conventional medicine, multiple doctor visits, or alternative medicine could predict high-cost patients with acute WAD in Japan.

METHODS

Data from a compulsory, no-fault, government automobile liability insurance agency in Japan between 2014 and 2019 were used. The primary economic outcome was the total cost of healthcare per person. Treatment-related variables were assessed based on the time to first visit for conventional and alternative medicine, multiple doctor visits, and visits for alternative medicine. Patients were categorized according to total healthcare cost (low, medium, and high cost). The variables were subjected to univariate and multivariate analysis to compare high-cost and low-cost patients.

RESULTS

A total of 104,911 participants with a median age of 42 years were analyzed. The median total healthcare cost per person was 67,366 yen. The cost for consecutive medicine, for consecutive and alternative medicine, and total healthcare costs were significantly associated with all clinical outcomes. Female sex, being a homemaker, a history of WAD claim, residential area, patient responsibility in a traffic accident, multiple doctor visits, and visits for alternative medicine were identified as independent predictive factors for a high cost in multivariate analysis. Multiple doctor visits and visits for alternative medicine showed large differences between groups (odds ratios 2673 and 694, respectively). Patients with multiple doctor visits and visits for alternative medicine showed a significantly high total healthcare cost per person (292,346 yen) compared to those without (53,587 yen).

CONCLUSIONS

A high total healthcare cost is strongly associated with multiple doctor visits and visits for alternative medicine in patients with acute WAD in Japan.

Manual Therapy Effects on Nonspecific Neck Pain Are Not Mediated by Mechanisms Related to Conditioned Pain Modulation: A Randomized Clinical Trial

BACKGROUND

Manual therapy (MT) is a treatment recommended by clinical practice guidelines in the management of patients with neck pain. However, the mechanisms through which MT works remain unknown. The aim of the present study is to investigate if MT is mediated by mechanisms related to conditioned pain modulation (CPM), comparing the effects of painful with a pain-free MT treatment.

METHODS

A two-arm, parallel, randomized controlled clinical trial with concealed allocation and blinding of the outcome assessor was conducted in university students with chronic or recurrent nonspecific neck pain (NSNP). Participants received either a painful or pain-free MT session. Psychophysical variables including pressure pain thresholds, CPM, temporal summation of pain and cold pain intensity were assessed before and immediately after treatment. In addition, changes in neck pain intensity over the following 7 days and self-perceived improvement immediately and 7 days after treatment were assessed.

RESULTS

No significant differences were found between groups in any of the psychophysical variables or in patients' self-perceived improvement. Only a significantly greater decrease in neck pain intensity immediately after treatment was found in the pain-free MT group compared to the painful MT group.

CONCLUSION

The results suggest that the immediate and short-term effects of MT on NSNP are not mediated by CPM-related mechanisms.

Factors Associated With Compliance With Self-Management Home Therapies for Spine Pain: A Survey of Participants Attending a Chiropractic Teaching Clinic in South Africa

Objective

The purpose of this study was to determine factors that affect compliance with various prescribed home therapies based on reported feedback from participants with spine pain.

Methods

This was a descriptive, quantitative, cross-sectional survey. A purposive sampling method was used to recruit 121 participants with neck and back pain attending the Durban University of Technology Chiropractic Day Clinic located in KwaZulu-Natal, South Africa. Data were collected using a self-administered questionnaire. Descriptive statistics, including frequencies and percentages, were used to summarize the data, and odds ratios (ORs) were calculated.

Results

Most participants presented with chronic pain, reporting an average severity of 6 out of 10 and little disability from the pain. Home therapy included stretches (92.2%), heat therapy (49.1%), and ice therapy (38.8%). Almost two-thirds (62.1%) of participants reported being fully compliant with the prescribed home therapy, while 32.8% reported partial compliance. The main factors that potentially affected compliance were laziness and forgetfulness. Participants who reported having depression were less compliant (OR, 0.181), while those with chronic pain were more compliant (OR, 3.74). Those who believed that home therapy would alleviate their pain were also more compliant (OR, 3.83).

Conclusion

The study found that a majority of participants with spine pain were compliant with prescribed chiropractic home treatment. Key factors that potentially influenced compliance were identified.

Periosteal Needling to the Cervical Articular Pillars as an Adjunct Intervention for Treatment of Chronic Neck Pain and Headache: A Case Report

(1) Background: Periosteal dry needling (PDN) involves clinicians using a solid filiform needle to stimulate bone for analgesic purposes. This case report presents the use of PDN to the cervical articular pillars (CAPs) in an 85-year-old female with chronic neck pain and headache. (2) Case description: PDN was applied to the right C2–C3 articular pillars, following trigger point dry needling (TrPDN) and manual therapy, in order to provide a direct sensory stimulus to the corresponding sclerotomes. PDN added over two treatments led to improved cervical range of motion and eliminated the patient’s neck pain and headache at 1 week follow-up. (3) Outcomes: At discharge, clinically relevant improvements were demonstrated on the numeric pain rating scale (NPRS), which improved from an 8/10 on intake to a 0/10 at rest and with all movements. In addition, the patient exceeded the risk adjusted predicted four-point score improvement and the minimal clinically important improvement (MCII) value of four points on the Focus on Therapeutic Outcomes (FOTO) Neck Functional Status (Neck FS). At one month post-discharge, the patient remained symptom-free. (4) Discussion: In the context of an evidence-informed approach for neck pain and headache, PDN led to marked improvements in pain and function. Patient outcomes exceeded predictive analytic expectations for functional gains and efficient utilization of visits and time in days. Combined with other interventions, PDN to the CAPs could be a viable technique to treat chronic neck pain with headache.

"Doing our best for patient safety": An international and interprofessional qualitative study with spinal manipulative therapy providers in community-based settings

BACKGROUND

Patient safety research is expanding from hospitals to community-based healthcare settings. Knowledge gaps persist among manual therapy professions that may impede patient safety initiatives within musculoskeletal care settings.

OBJECTIVES

To describe perceptions of patient safety among chiropractors and physiotherapists who provide spinal manipulation therapy (SMT).

DESIGN

Qualitative descriptive study.

METHOD

Cross-sectional data were collected using the SafetyNET Survey to Support Quality Improvement. SMT providers (n = 705) in 3 countries completed surveys, with 84 providing written responses to an open-ended question about patient safety. Qualitative thematic analysis described providers' perceptions about patient safety within their practice.

RESULTS

SMT providers' perceptions were influenced by professional, patient, and practice setting factors. Five themes and 10 supporting categories were developed. Doing Our Best for Patient Safety concerned Avoiding Mistakes and Prioritizing Safety.Putting Patients First focused on Developing Relationships and Individualizing Care.Working and Learning Together advocated for Interprofessional Communication and Collaborative Learning. Organizing Practice Processes emphasized Standardizing Procedures and Benchmarking Progress.Considering Practitioner Identity highlighted how Recognizing Difference among SMT providers and Challenging Fears of other healthcare professionals and patients about SMT were important for enhancing patient safety.

CONCLUSION

Findings align with World Health Organization guiding principles that the nature of healthcare settings influence patient safety strategies. Most responses focused on individual strategies to prevent adverse events. However, this approach may overlook the benefits of identifying and documenting adverse events, setting time to discuss adverse events with clinic members, standardizing clinical practices, and building transparent patient safety cultures across healthcare professions and settings.

Localised manual therapy treatment has a preferential effect on the kinematics of the targeted motion segment

AIM

An observational cohort study to determine whether localised manual therapy results in a preferential increase in mobility of the targeted motion segment.

METHOD

Eighteen participants with mechanical neck pain had three MRIs of their cervical spine. The first two were taken prior to treatment in neutral and at the end of active rotation in their more limited rotation. Participants received localised manual therapy targeting a motion segment deemed to be relevant to their presentation until either their range increased by > 10° or 8 min, whichever came first. A third MRI was performed immediately after treatment with their head in the same rotated position as pre-treatment. In the images, each vertebra was segmented using a semi-automated process. Movement between neutral and rotated positions was calculated as Euler angles and distance of facet translations for each motion segment.

RESULTS

Rotation and lateral flexion at the targeted location increased by 40% (mean 0.86° (CI: 0.24-1.48) and 15% (mean 0.52° (CI: 0.17-1.21) respectively with only the CIs for rotation not containing zero. The mean changes for the non-targeted locations were less than 0.1° for each axis and all CIs contained zero. Facet translations at the targeted location increased by 25% (0.419 mm) and decreased by >4% (>0.01 mm) at the untreated locations but the wide CIs both contained zero.

CONCLUSION

Localised manual therapy seems to have a preferential effect on mobility of the targeted motion segment. The findings support considering segmental dysfunction in clinical reasoning and the use of specifically targeted manual therapy interventions.

Use of Soft Cervical Collar among Whiplash Patients in Two Italian Emergency Departments Is Associated with Persistence of Symptoms: A Propensity Score Matching Analysis

Purpose: Although the use of soft cervical collars in the emergency department (ED), for whiplash-associated disorders (WAD), is controversial, it is still widely adopted. The purpose of our study was to investigate the impact of the early use of soft cervical collars on the return to the ED, within three months of a road traffic collision. Methods: We conducted a retrospective observational study on WAD patients from two EDs in Verona (Italy). Patients in the earlier acute phase of WAD (within 48 h from the trauma) were included; those with serious conditions (WAD IV) were excluded. As an end point, we considered patients who returned to the ED complaining of WAD symptoms within three months as positive outcome for WAD persistence. Results: 2162 patients were included; of those, 85.4% (n = 1847/2162) received a soft cervical collar prescription. Further, 8.4% (n = 156/1847) of those with a soft cervical collar prescription, and 2.5% (n = 8/315) of those without a soft cervical collar (p < 0.001) returned to the ED within three months. The use of the soft cervical collar was an independent risk factor for ED return within three months, with an OR, adjusted for possible clinical confounders, equal to 3.418 (95% CI 1.653–7.069; p < 0.001). After the propensity score matching, 25.5% of the patients (n = 25/98) using the soft cervical collar returned to the ED at three months, compared to the 6.1% (n = 6/98) that did not adopt the soft cervical collar. The use of a soft cervical collar was associated with ED return with an OR = 4.314 (95% CI 2.066–11.668; p = 0.001). Conclusions: Our study shows that the positioning of the soft collar in a cohort of patients with acute WAD, following a rear-end car collision, is an independent potential risk factor to the return to the ED. Clinically, the use of the collar is a non-recommended practice and seems to be related to an increased risk of delayed recovery. There is a need to inform healthcare providers involved in the ED of the aim to limit the use of the soft cervical collar. A closer collaboration between clinicians (e.g., physicians, physical therapists, nurses) is suggested in the ED. Future primary studies should determine differences between having used or not having used the collar, and compare early physical therapy in the ED compared with the utilization of the collar.

Are Findings From a Pragmatic Dry Needling Trial Always Applicable in the Real World?

Letter to the Editor-in-Chief in response to JOSPT article "Dry needling adds no benefit to the treatment of neck pain: a sham-controlled randomized clinical trial with 1-year follow-up" by Gattie et al.J Orthop Sports Phys Ther 2021;51(9):470-471. doi:10.2519/jospt.2021.0202.

Author Response to "Are Findings From a Pragmatic Dry Needling Trial Always Applicable in the Real World?"

Author response to the JOSPT Letter to the Editor-in-Chief "Are Findings From a Pragmatic Dry Needling Trial Always Applicable in the Real World?" J Orthop Sports Phys Ther 2021;51(9):471-472. doi:10.2519/jospt.2021.0202-R.

A survey of American physical therapists' current practice of dry needling: Practice patterns and adverse events

OBJECTIVES

To estimate the proportion of physical therapists currently performing dry needling and report current practices patterns. Secondary aims were to report the numbers of minor and major adverse events and determine if these adverse events were related to therapist characteristics.

METHODS

An anonymous electronic survey was distributed through special interest groups within the United States to physical therapists. Participant demographics and responses were analyzed using descriptive statistics. Associations between variables were examined using chi-square.

RESULTS

The estimated response rate was 14.4% (n = 865, mean age 39.89, SD 11.73 years). More than half (55.0%, n = 461) of respondents perform dry needling; levels of training varied. Most (78.8%, n = 337) performed 0-3 needling sessions per day, usually lasting < 15 min (67.3% of respondents, n = 288). Therapists commonly performed 3-6 sessions over a patient's course of care (82.0% of respondents, n = 350). Minor adverse events were common; respondents estimated this occurred in 39.6% (SD 31.5) of treatments. Major adverse events were rare, typically not requiring emergency care. Being male (X² = 8.197, P = 0.004), experienced (>4 years; X² = 34.635, P < 0.001), and having more training (>61 h; X² = 8.503, P = 0.004) were associated with reporting a major adverse event occurred during their career.

CONCLUSIONS

Half of physical therapists surveyed performed dry needling. Practice patterns were consistent with expert opinion. The number of adverse events reported suggests further research is needed to quantify the risks of dry needling. Participant characteristics associated with a major adverse event appear to be related to the number of exposures.

Medical and allied health service use during acute and chronic post-injury periods in whiplash injured individuals

BACKGROUND

Individuals with whiplash associated disorder (WAD) frequently experience neck pain in addition to other physical, psychological and social symptoms. Consequently, treatment is sought from a variety of health professionals. The limited data available about health services use in this population are conflicting. This study aimed to characterise health service use in individuals with WAD from a motor vehicle crash.

METHODS

Medical (general practitioner (GP), medical specialist, emergency services (ED), radiology - x-ray, computed tomography, magnetic resonance imaging, ultrasound) and allied health service (physiotherapy, chiropractor, psychologist, osteopath, occupational therapy) use during acute (< 12 weeks) and chronic (12 weeks to 2 years) post-injury periods were analysed in adults claiming compensation for WAD in the no-fault jurisdiction of Victoria, Australia (n = 37,315).

RESULTS

Most WAD claimants had an acute post-injury health service payment (95%, n = 35,348), and approximately one-third (29%, n = 10,871) had a chronic post-injury health service payment. During an acute post-injury period, the most frequently compensated services were for: ED (82% of acute claimants), radiology (56%), and medical specialist (38%). Whereas, physiotherapy (64.4% of chronic claimants), GP (48.1%), and radiology (34.6%) were the most frequently paid services during the chronic period. Females received significantly more payments from physiotherapists (F = 23.4%, M = 18%, z = - 11.3, p < .001, r = 0.13), chiropractors (F = 7.4%, M = 5.6%, z = - 6.3, p < .001, r = 0.13), and psychologists (F = 4.2%, M = 2.8%, z = - 6.7, p < .001, r = 0.18); whereas, males received significantly more medical services payments from medical specialists (F = 41.8%, M = 43.8%, z = - 3.7, p < .001, r = 0.03), ED (F = 74.0%, M = 76.3%, z = - 4.9, p < .001, r = 0.03) and radiology (F = 58.3%, M = 60.1%, z = - 3.4, p < .001, r = 0.02).

CONCLUSIONS

Individuals with WAD claimed for a range of health services. Radiology imaging use during the acute post-injury period, and physiotherapy and chiropractor service use during the chronic post-injury period appeared concordant with current WAD management guidelines. Conversely, low physiotherapy and chiropractic use during an acute post-injury period, and high radiology and medical specialists use during the chronic post-injury period appeared discordant with current guidelines. Strategies are needed to help inform medical health professionals of the current guidelines to promote early access to health professionals likely to provide an active approach to treatment, and to address unnecessary referral to radiology and medical specialists in individuals with on-going WAD.

Effects of joint mobilisation on clinical manifestations of sympathetic nervous system activity: a systematic review and meta-analysis

BACKGROUND

A potential mechanism of action of manual therapy is the activation of a sympathetic-excitatory response.

OBJECTIVE

To evaluate the effects of joint mobilisation on changes in clinical manifestations of sympathetic nervous system activity.

DATA SOURCES

MEDLINE, EMBASE, AMED, CINAHL, EBSCO, PubMed, PEDro, Cochrane Collaboration Trials Register, Cochrane Database of Systematic Reviews and SCOPUS databases.

STUDY SELECTION

Randomised controlled trials that compared a mobilisation technique applied to the spine or the extremities with a control or placebo.

DATA EXTRACTION AND DATA SYNTHESIS

Human studies collecting data on skin conductance or skin temperature were used. Data were extracted by two reviewers. Risk of bias was assessed using the Cochrane guidelines, and quality of evidence was assessed using the GRADE approach. Standardised mean differences (SMD) and random effects were calculated.

RESULTS

Eighteen studies were included in the review and 17 were included in the meta-analysis. The meta-analysis found a significant increase in skin conductance [SMD 1.21, 95% confidence interval (CI) 0.88 to 1.53, n=269] and a decrease in temperature (SMD 0.92, 95% CI -1.47 to -0.37, n=128) after mobilisation compared with the control group. An increase in skin conductance (SMD 0.73, 95% CI 0.51 to 0.96, n=293) and a decrease in temperature (SMD -0.50, 95% CI -0.82 to -0.18, n=134) were seen after mobilisation compared with placebo. The risk of bias was generally low, but the heterogenicity of the results downgraded the level of evidence.

LIMITATIONS

Most trials (14/18) were conducted on asymptomatic healthy subjects.

CONCLUSION

There is moderate evidence suggesting a sympatho-excitatory effect of joint mobilisation. Systematic Review Registration Number PROSPERO CRD42018089991.

Factors associated with cervical arterial dysfunction: a survey of physical therapist educators in the United States

Objectives: The purpose of this study was to identify the key constructs associated with symptom description and behavior, natural history of complaints, and previous medical history of cervical arterial dysfunction (CAD) according to a panel of physical therapist (PT) educators. Methods: An electronic survey was conducted of licensed PT educators currently involved in musculoskeletal physical therapy education within a credentialed program. Survey prompts queried educators to list the subjective and objective items associated with CAD, in open-text format. Responses were coded to identify unique themes (constructs). Principal axis factor analysis with Varimax rotation was performed to identify underlying constructs associated with CAD according to the panel of educators. Results: Seventy-two educators completed the survey (24.2% response rate) resulting in 50 identified unique items through thematic coding. Factor analysis (Kaiser-Meyer-Olkin measure of sampling adequacy = .679, Bartlett's test of sphericity (x ²(351) = 1129.06. p < .001), resulted in a four-factor solution: '5Ds and 3 Ns,' 'Other Neurological Findings,' 'Signs & Symptoms in Rotation and/or Extension,' and 'General Health.' Discussion: According to the PT educators in this study, the factors associated with CAD appear to reflect the IFOMPT guidelines. The responses and subsequent factor analysis demonstrate the lack of any one clinical finding for the identification of CAD in a patient with neck pain. Level of Evidence: V.

Do physical therapists follow evidence-based guidelines when managing musculoskeletal conditions? Systematic review

OBJECTIVES

Physicians often refer patients with musculoskeletal conditions to physical therapy. However, it is unclear to what extent physical therapists' treatment choices align with the evidence. The aim of this systematic review was to determine what percentage of physical therapy treatment choices for musculoskeletal conditions agree with management recommendations in evidence-based guidelines and systematic reviews.

DESIGN

Systematic review.

SETTING

We performed searches in Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, Allied and Complementary Medicine, Scopus and Web of Science combining terms synonymous with 'practice patterns' and 'physical therapy' from the earliest record to April 2018.

PARTICIPANTS

Studies that quantified physical therapy treatment choices for musculoskeletal conditions through surveys of physical therapists, audits of clinical notes and other methods (eg, audits of billing codes, clinical observation) were eligible for inclusion.

PRIMARY AND SECONDARY OUTCOMES

Using medians and IQRs, we summarised the percentage of physical therapists who chose treatments that were recommended, not recommended and had no recommendation, and summarised the percentage of physical therapy treatments provided for various musculoskeletal conditions within the categories of recommended, not recommended and no recommendation. Results were stratified by condition and how treatment choices were assessed (surveys of physical therapists vs audits of clinical notes).

RESULTS

We included 94 studies. For musculoskeletal conditions, the median percentage of physical therapists who chose recommended treatments was 54% (n=23 studies; surveys completed by physical therapists) and the median percentage of patients that received recommended physical therapy-delivered treatments was 63% (n=8 studies; audits of clinical notes). For treatments not recommended, these percentages were 43% (n=37; surveys) and 27% (n=20; audits). For treatments with no recommendation, these percentages were 81% (n=37; surveys) and 45% (n=31; audits).

CONCLUSIONS

Many physical therapists seem not to follow evidence-based guidelines when managing musculoskeletal conditions. There is considerable scope to increase use of recommended treatments and reduce use of treatments that are not recommended.

PROSPERO REGISTRATION NUMBER

CRD42018094979.

An exploration of psychosocial practice within private practice musculoskeletal physiotherapy: A cross-sectional survey

BACKGROUND

Patients with pain associated with musculoskeletal disorders often seek treatment from physiotherapists, necessitating these practitioners' competence to practice within the biopsychosocial framework. Qualitative research suggests musculoskeletal physiotherapists may not have adequate proficiency in psychosocial practice to assess and address psychosocial factors effectively.

OBJECTIVE

To collect quantitative self-report data via an online survey from a large cross section of Australian musculoskeletal physiotherapists regarding their psychosocial practice.

METHODS

The study involved an iterative survey development process followed by the conduct of this survey. A provisional survey named the 'Triple P Questionnaire' was developed, informed by the knowledge and experience of the research team. This Questionnaire was piloted by experts (n = 6) to provide feedback on the instrument. Changes were made to the survey based on this feedback. The finalised Triple P Questionnaire was distributed to Australian musculoskeletal physiotherapists.

RESULTS

181 participants completed the full survey. Not all demographic characteristics were representative of the population. Most participants indicated that they 'agree' to most statements posed in the questionnaire including confidence, routine practice of specific psychosocial skills and barriers. Some questions presented a majority response of 'disagree' or a spread of responses, indicating some evidence-practice gaps, including the use of questionnaires, and explicit assessment of psychological factors. Inferential statistics revealed no significant correlations between demographic characteristics and psychosocial practice.

CONCLUSION

The Triple P Questionnaire identified musculoskeletal physiotherapists' general confidence in their psychosocial practice but highlights some apparent inconsistencies in reported practice and areas where confidence is not as strong, reflecting possible evidence practice gaps.

Association between sympathoexcitatory changes and symptomatic improvement following cervical mobilisations in participants with neck pain. A double blind placebo controlled trial

BACKGROUND

sympathoexcitation observed with passive cervical mobilisations may imply activation of an endogenous pain inhibition system resulting in hypoalgesia. However, research is mostly in asymptomatic participants and there is very limited evidence of a relationship between sympathoexcitation and symptomatic improvement in people with clinical pain.

OBJECTIVE

to investigate the effects of cervical mobilisations on the sympathetic nervous system in participants with neck pain, and to explore the relationship between symptomatic improvement and sympathoexcitation.

DESIGN

double-blind randomised controlled trial.

METHOD

40 participants with neck pain (aged 20-69 years, 25 female) were randomly allocated to either cervical mobilisations or motionless placebo. Skin conductance was measured before, during, and after intervention. After interventions were completed, their credibility was assessed. Participants were classified as responders or non-responders according to global symptom change.

RESULTS

participants receiving mobilisations were more likely to be classified as responders (odds ratio: 4.33, p = 0.03) and demonstrated greater change in most outcome measures of sympathoexcitation from baseline to during the intervention but not from during to after the intervention. There was no association between sympathoexcitation and symptomatic improvement. Mobilisations and placebo were equally credible.

CONCLUSIONS

These findings suggest sympathoexcitatory changes may be caused by an orienting response unrelated to the activation of an endogenous pain inhibition system Alternatively, the observed lack of an association may be explained by the existence of various mechanisms for pain relief. This study used single outcome measures of sympathoexcitation and symptomatic improvement and other measures may reveal different things. CLINICALTRIALS.

GOV NUMBER

M10/2016/095.

Cervical isometric exercises improve dysphagia and cervical spine malalignment following stroke with hemiparesis: a randomized controlled trial

BACKGROUND

Hemiparesis following stroke can cause cervical spine scoliosis, kyphosis or hyperlordosis. These abnormal cervical alignments can contribute to dysphagia. The benefit of cervical isometric exercises to improve swallowing has not been previously studied.

AIM

To evaluate the use of cervical isometric exercises in dysphagic adult patients with cervical spine alignment disorders due to hemiparesis after stroke.

DESIGN

A randomized controlled trial.

SETTING

University Hospital, PMR Department.

POPULATION

Dysphagic adult patients with hemiparesis after stroke in the rehabilitation phase.

METHODS

In addition to the standard physical and speech therapy therapeutic approach for 12 weeks, cervical isometric exercises were conducted by a group of patients (experimental group). Patients had cervical spine radiographs in erect (sitting or standing) position coronal and sagittal C2-C7 Cobb angle and a videofluoroscopic swallowing study to evaluate deglutition (0=normal, 1=penetration, 2=aspiration) at 2 time points (at the beginning and at the end of the therapeutic program).

RESULTS

Seventy consecutive patients with hemiparesis of a mean (SD) age of 52±15 years were included in the study and were randomized in 2 groups. Thirty-seven of them (experimental group) conducted cervical isometric exercises in addition to their therapeutic program. At the last follow-up, patients had improved (P<0.001) cervical alignment, in both coronal and sagittal plane, and deglutition. Patients who conducted cervical isometric exercises (experimental group) had more pronounced correction (P<0.001) of cervical alignment in both planes and achieved greater improvement (P<0.05) of deglutition too, than patients who did not conduct such exercises (control group).

CONCLUSIONS

Dysphagic adult patients with hemiparesis after stroke in the rehabilitation phase who underwent cervical isometric strengthening exercises showed more significant correction of cervical alignment and more pronounced improvement in deglutition compared to patients who did not include cervical isometric exercises in their therapeutic program.

CLINICAL REHABILITATION IMPACT

The additional use of cervical isometric exercises in hemiparetic stroke patients with dysphagic symptoms lead to more pronounced improvement of their swallowing function compared to such patients who are subjected to speech therapy only. Furthermore, these exercises are shown to be beneficial for cervical spine alignment too.

Effectiveness and adequacy of blinding in the moderation of pain outcomes: Systematic review and meta-analyses of dry needling trials

BACKGROUND

Blinding is critical to clinical trials because it allows for separation of specific intervention effects from bias, by equalising all factors between groups except for the proposed mechanism of action. Absent or inadequate blinding in clinical trials has consistently been shown in large meta-analyses to result in overestimation of intervention effects. Blinding in dry needling trials, particularly blinding of participants and therapists, is a practical challenge; therefore, specific effects of dry needling have yet to be determined. Despite this, dry needling is widely used by health practitioners internationally for the treatment of pain. This review presents the first empirical account of the influence of blinding on intervention effect estimates in dry needling trials. The aim of this systematic review was to determine whether participant beliefs about group allocation relative to actual allocation (blinding effectiveness), and/or adequacy of blinding procedures, moderated pain outcomes in dry needling trials.

METHODS

Twelve databases (MEDLINE, EMBASE, AMED, Scopus, CINAHL, PEDro, The Cochrane Library, Trove, ProQuest, trial registries) were searched from inception to February 2016. Trials that compared active dry needling with a sham that simulated dry needling were included. Two independent reviewers performed screening, data extraction, and critical appraisal. Available blinding effectiveness data were converted to a blinding index, a quantitative measurement of blinding, and meta-regression was used to investigate the influence of the blinding index on pain. Adequacy of blinding procedures was based on critical appraisal, and subgroup meta-analyses were used to investigate the influence of blinding adequacy on pain. Meta-analytical techniques used inverse-variance random-effects models.

RESULTS

The search identified 4,894 individual publications with 24 eligible for inclusion in the quantitative syntheses. In 19 trials risk of methodological bias was high or unclear. Five trials were adequately blinded, and blinding was assessed and sufficiently reported to compute the blinding index in 10 trials. There was no evidence of a moderating effect of blinding index on pain. For short-term and long-term pain assessments pooled effects for inadequately blinded trials were statistically significant in favour of active dry needling, whereas there was no evidence of a difference between active and sham groups for adequately blinded trials.

DISCUSSION

The small number and size of included trials meant there was insufficient evidence to conclusively determine if a moderating effect of blinding effectiveness or adequacy existed. However, with the caveats of small sample size, generally unclear risk of bias, statistical heterogeneity, potential publication bias, and the limitations of subgroup analyses, the available evidence suggests that inadequate blinding procedures could lead to exaggerated intervention effects in dry needling trials.

Effectiveness of median nerve neural mobilization versus oral ibuprofen treatment in subjects who suffer from cervicobrachial pain: a randomized clinical trial

INTRODUCTION

Oral ibuprofen (OI) and median nerve neural mobilization (MNNM) are first line treatments for patients who suffer cervicobrachial pain (CP). OI may produce side effects which are not tolerated by all subjects who suffer CP, whereas MNNM has no known side effects. Therefore, the aim of this study was to assess the effectiveness of both treatments (OI vs. MNNM) in CP.

MATERIAL AND METHODS

This investigation was a blinded parallel randomized clinical trial (NCT02593721). Sixty-two participants diagnosed with CP were recruited and randomly assigned to 2 groups (n = 31), which received MNNM or 1200 mg/day OI treatment for 6 weeks. The numeric rating scale for pain intensity was the primary outcome. The cervical rotation range of motion (CROM) and the upper limb function were the secondary outcomes.

RESULTS

The results showed that OI treatment (η2 = 0.612-0.755) was clearly superior to MNNM (η2 = 0.816-0.821) in all assessments (p < 0.05) except for the CROM device results, which were equivalent to those of the MNNM group (p > 0.05). Three subjects were discharged because of OI side effects.

CONCLUSIONS

Oral ibuprofen may be superior to MNNM for pain reduction and upper limb function increase of subjects with CP. Nevertheless, both treatments were effective. Median nerve neural mobilization may be considered an effective non-pharmaceutical treatment option in subjects with CP. Regarding OI adverse effects, our findings challenge the role of pharmacologic versus manual therapy as possible treatments that may improve pain intensity and upper limb functionality in subjects with CP.

Is pharmacologic treatment better than neural mobilization for cervicobrachial pain? A randomized clinical trial

Purpose: This study aim was to compare the effectiveness of the median nerve neural mobilization (MNNM) and cervical lateral glide (CLG) intervention versus oral ibuprofen (OI) in subjects who suffer cervicobrachial pain (CP). Methods: This investigation was a, multicenter, blinded, randomized controlled clinical trial (NCT02595294; NCT02593721). A number of 105 individuals diagnosed with CP were enrolled in the study and treated in 2 different medical facilities from July to November 2015. Participants were recruited and randomly assigned into 3 groups of 35 subjects. Intervention groups received MNNM or CLG neurodynamic treatments, and the (active treatment) control group received an OI treatment for 6 weeks. Primary outcome was pain intensity reported through the Numeric Rating Scale for Pain (NRSP). Secondary outcomes were physical function involving the affected upper limb using the Quick DASH scale, and ipsilateral cervical rotation (ICR) using a cervical range of motion (CROM) device. Assessments were performed before and 1 hour after treatment for NRSP (baseline, 3 and 6 weeks) and CROM (baseline and 6 weeks), as well as only 1 assessment for Quick DASH (baseline and 6 weeks). Results: Repeated-measures ANOVA intergroup statistically significant differences were shown for CP intensity (F(2,72) = 22.343; P < .001; Eta2 = 0.383) and Quick DASH (F(2,72) = 15.338; P < .001; Eta2 = 0.299), although not for CROM (F(2,72) = 1.434; P = .245; Eta2 = 0.038). Indeed, Bonferroni´s correction showed statistically significant differences for CP intensity (P < .01; 95% CI = 0.22 - 3.26) and Quick DASH reduction (P < .01; 95% CI = 8.48 - 24.67) in favor of the OI treatment at all measurement moments after baseline. Conclusions: OI pharmacologic treatment may reduce pain intensity and disability with respect to neural mobilization (MNNM and CLG) in patients with CP during six weeks. Nevertheless, the non-existence of between-groups ROM differences and possible OI adverse effects should be considered.

A Regional Analysis of U.S. Insurance Reimbursement Guidelines for Massage Therapy

INTRODUCTION

Massage techniques fall within the scope of many different health care providers. Physical therapists, occupational therapists, and chiropractors receive insurance reimbursement for health care services, including massage. Although many patients pay out of pocket for massage services, it is unclear how the insurance company reimbursement policies factor provider qualifications into coverage. This project examined regional insurance reimbursement guidelines for massage therapy in relation to the role of the provider of massage services.

METHODS

A qualitative content analysis was used to explore guidelines for 26 health insurance policies across seven US companies providing coverage in the northeastern United States. Publicly available information relevant to massage was obtained from insurance company websites and extracted into a dataset for thematic analysis. Data obtained included practice guidelines, techniques, and provider requirements. Information from the dataset was coded and analyzed using descriptive statistics.

RESULTS

Of the policies reviewed, 23% explicitly stated massage treatments were limited to 15-minute increments, 19% covered massage as one part of a comprehensive rehabilitation plan, and 27% required physician prescription. Massage techniques mentioned as qualifying for reimbursement included: Swedish, manual lymphatic drainage, mobilization/manipulation, myofascial release, and traction. Chiropractors, physical therapists, and occupational therapists could directly bill for massage. Massage therapists were specifically excluded as covered providers for seven (27%) policies.

CONCLUSION

Although research supports massage for the treatment of a variety of conditions, the provider type has not been separately addressed. The reviewed policies that served the Northeastern states explicitly stated massage therapists could not bill insurance companies directly. The same insurance companies examined reimbursement for massage therapists in their western U.S. state policies. Other health care providers were able to bill directly for massage services to companies that did not accept direct billing by massage therapists. The specific exclusion of massage therapists as eligible providers violates the Affordable Care Act's non-discriminatory provision. Massage therapists should continue to advocate for reimbursement privileges to spur wider acceptance of massage therapy in health care.

Unraveling the Mechanisms of Manual Therapy: Modeling an Approach

Synopsis Manual therapy interventions are popular among individual health care providers and their patients; however, systematic reviews do not strongly support their effectiveness. Small treatment effect sizes of manual therapy interventions may result from a "one-size-fits-all" approach to treatment. Mechanistic-based treatment approaches to manual therapy offer an intriguing alternative for identifying patients likely to respond to manual therapy. However, the current lack of knowledge of the mechanisms through which manual therapy interventions inhibit pain limits such an approach. The nature of manual therapy interventions further confounds such an approach, as the related mechanisms are likely a complex interaction of factors related to the patient, the provider, and the environment in which the intervention occurs. Therefore, a model to guide both study design and the interpretation of findings is necessary. We have previously proposed a model suggesting that the mechanical force from a manual therapy intervention results in systemic neurophysiological responses leading to pain inhibition. In this clinical commentary, we provide a narrative appraisal of the model and recommendations to advance the study of manual therapy mechanisms. J Orthop Sports Phys Ther 2018;48(1):8-18. doi:10.2519/jospt.2018.7476.

The treatment of migraine patients within chiropractic: analysis of a nationally representative survey of 1869 chiropractors

BACKGROUND

While the clinical role of manual therapies in migraine management is unclear, the use of chiropractors for this condition is considerable. The aim of this study is to evaluate the prevalence and characteristics of chiropractors who frequently manage patients with migraine.

METHODS

A national cross-sectional survey of chiropractors collected information on practitioner characteristics, clinical management characteristics and practice settings. A secondary analysis was conducted on 1869 respondents who reported on their migraine caseload to determine the predictors associated with the frequent management of patients with migraine.

RESULTS

A large proportion of chiropractors report having a high migraine caseload (HMC) (n = 990; 53.0%). The strongest factors predicting a chiropractor having a HMC include the frequent treatment of patients with axial neck pain (OR = 2.89; 95%CI: 1.18, 7.07), thoracic pain (referred/radicular) (OR = 2.52; 95%CI: 1.58, 3.21) and non-musculoskeletal disorders (OR = 3.06; 95%CI: 2.13, 4.39).

CONCLUSIONS

Several practice-setting and clinical management characteristics are associated with chiropractors managing a HMC. These findings raise key questions about the therapeutic approach to chiropractic migraine management that deserves further examination. There is a need for more primary research to assess the approach to headache and migraine management provided by chiropractors and to understand the prevalence, burden and comorbidities associated with migraine found within chiropractic patient populations. This information is vital in helping to inform safe, effective and coordinated care for migraine sufferers within the wider health system.

Effects of Median Nerve Neural Mobilization in Treating Cervicobrachial Pain: A Randomized Waiting List-Controlled Clinical Trial

BACKGROUND

There is a current lack of sufficiently high-quality randomized controlled clinical trials that measure the effectiveness of neural tissue mobilization techniques such as median nerve neural mobilization (MNNM) and their specific effects on cervicobrachial pain (CP). The aim of this study was to compare the effectiveness of MNNM in subjects with CP vs. a waiting list control group (WLCG).

METHODS

A single-blinded, parallel, randomized controlled clinical trial was performed (NCT02596815). Subjects were recruited with a medical diagnosis of CP corroborated by magnetic resonance imaging. In total, 156 individuals were screened, 60 subjects were recruited, and 51 completed the trial. Pain intensity reported using the Numeric Rating Scale for Pain (NRSP; primary outcome), cervical range of motion (CROM), and functionality using the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) scale were the outcome measurements. Assessments were conducted at baseline and 1 hour after treatment (intervention days 1, 15, and 30). Therefore, MNNM was implemented with 30 days of follow-up.

RESULTS

The NRSP values of the MNNM group were significantly (P < 0.0001; 95% confidence interval [CI]) superior to those obtained in the WLCG. Subjects treated with MNNM reported an NRSP decrease of 3.08 points at discharge. CROM and QuickDASH outcome values were significantly (P ˂ 0.0001; 95% CI) improved only in the MNNM group. Hedges' g showed a very large effect of the MNNM intervention.

CONCLUSION

MNNM may be superior to no treatment in reducing pain and increasing function in the affected upper limbs of subjects with CP.

Utilization of Manipulative Treatment for Spine and Shoulder Conditions Between Different Medical Providers in a Large Military Hospital

OBJECTIVE

To describe the use of manipulative treatment for shoulder and spine conditions among various provider types.

DESIGN

Retrospective observational cohort.

SETTING

Single military hospital.

PARTICIPANTS

Consecutive sample of patients (N=7566) seeking care for an initial spine or shoulder condition from January 1 to December 31, 2009.

INTERVENTIONS

Manipulative treatment (eg, manual therapy, spinal and joint manipulation).

MAIN OUTCOME MEASURE

Manipulation treatment was identified with procedure billing codes in the medical records. Spine and shoulder conditions were identified by using the International Classification of Diseases, 9th Revision codes. All data were abstracted from the Department of Defense Military Health System Management and Analysis Tool.

RESULTS

Of 7566 total patients seeking care, 2014 (26.6%) received manipulative treatment at least once, and 1883 of those received this treatment in a military facility (24.7%). Manipulative treatment was used most often for thoracic conditions and least often for shoulder conditions (50.8% and 24.2% of all patients). There was a total of 6706 unique medical visits with a manipulative treatment procedure (average of 3.3 manipulative treatment procedure visits per patient).

CONCLUSIONS

Manipulative treatment utilization rates for shoulder and spine conditions ranged from 26.6% to 50.2%. Chiropractors used manipulation the most and physical therapists the least.

Managing patients with acute and chronic non-specific neck pain: are Danish chiropractors compliant with guidelines?

Background

Non-specific neck pain represents a quarter of all chiropractic patient visits in Denmark. Evidence informed practice can help ensure providers use best available treatment, speed up patient recovery rate and reduce healthcare utilization. It is generally believed that Danish chiropractors treat according to best practice, but we do not know if this is true for management of neck-pain. The objective of this study was to investigate how Danish chiropractors treat patients with acute and chronic non-specific neck pain and determine if management is compliant with recent Canadian guideline recommendations.

Methods

An online survey was sent to 554 members of the Danish chiropractic association. A three-part questionnaire was administered asking participants to: 1) rank the frequency of use of a list of treatment modalities; 2) rank treatment modalities they normally use for acute and chronic non-specific neck pain cases; and 3) provide demographic data. Treatment modalities ranked as “used often” were considered in further analysis and compared to the Canadian Guideline recommendations for neck pain. Chi-squared test was used to investigate differences between treatment and guideline compliance for chronic and acute patients.

Results

A 65% (362/544) response rate was achieved. The sample demographics were representative of a recent Danish study of the entire chiropractic profession. Danish chiropractors use a wide range of treatment modalities, including spinal manipulation, manual therapy, exercises and information/patient education on most of their acute neck pain patients. The use of other treatment modalities and especially exercises was more commonly used with chronic cases. Guideline compliance was 10% for recommendations for acute patients and 43% for chronic patients.

Conclusions

Danish chiropractors use a wide range of treatment options for managing adult patients with acute and chronic non-specific neck-pain. However, there were important differences in treatments chiropractors offered for acute and chronic patients, particularly for the use of exercise therapy, which was mainly reserved for chronic patients. Danish chiropractors’ compliance with guidelines for neck-pain patients was low, but is neither worse nor better than what is seen for other complaints or health disciplines. Our findings suggest a need for active knowledge translation strategies and robust implementation research.

Electronic supplementary material

The online version of this article (doi:10.1186/s12998-017-0148-9) contains supplementary material, which is available to authorized users.

Toward Improving Outcomes in Whiplash: Implementing New Directions of Care

This special issue of JOSPT is the second of a 2-part series on whiplash-associated disorders (WADs). Part 1 was published in the October 2016 issue of the Journal. The articles in these 2 special issues highlight that, while we know a great deal about WAD, there are profound gaps in our understanding of how to more effectively work with patients to limit the consequences of this disorder. The information provided in the special-issue articles can help move physical therapy practice and research toward pragmatic and effective solutions for the perplexing condition of WAD. J Orthop Sports Phys Ther 2017;47(7):447-448. doi:10.2519/jospt.2017.0107.

Cervical Traction for Managing Neck Pain: A Survey of Physical Therapists in the United States

Study Design Cross-sectional survey. Objective To examine the use of traction by physical therapists for patients with neck pain, including how and when traction is used, the delivery modes and parameters, supplemental interventions, and influence of professional demographics on usage. Background Systematic reviews provide little support for traction in managing neck pain. While traction usage among physical therapists in other countries has been described, usage in the United States has not been examined. Methods A random sample of 4000 Orthopaedic Section members of the American Physical Therapy Association were surveyed. Associations among respondents' professional demographics and survey responses were explored with chi-square analyses (α = .05). Results The response rate was 25.5% (n = 1001); 76.6% (n = 767) of respondents reported using traction, and 93.1% reported that they would use traction for a patient presenting with signs of nerve root compression. Common delivery modes included manual methods (92.3%) and mechanical traction tables (88.3%). Using traction is often supplemented with other interventions (exercise, postural education, joint mobilization). A higher proportion of physical therapists with American Board of Physical Therapy Specialties orthopaedic certification reported using traction (88.6%) than did those without specialty certification (73.0%). Conclusion Most respondents reported that their use of cervical traction was consistent with proposed criteria that identify patients who are likely to benefit. They use various traction delivery modes/parameters within comprehensive plans of care incorporating multiple interventions. Professional demographics (clinical specialist credentialing) were associated with traction usage. J Orthop Sports Phys Ther 2017;47(3):200-208. Epub 30 Oct 2016. doi:10.2519/jospt.2017.6914.

Spinal manipulation does not affect pressure pain thresholds in the absence of neuromodulators: a randomized controlled trial

BACKGROUND

Measurement of pressure pain threshold (PPT) is a way to determine one of the many potential treatment effects of spinal manipulative therapy.

OBJECTIVE

To determine how multiple spinal manipulations administered in a single-session affected PPTs at local and distal sites in asymptomatic individuals.

METHODS

Participants were randomly assigned into one of three groups: Group one (n = 18) received a lumbar manipulation followed by a cervical manipulation. Group two (n = 17) received a cervical manipulation followed by a lumbar manipulation. The control group (n = 19) received two bouts of five minutes of rest. At baseline and after each intervention or rest period, each participant's PPTs were obtained using a handheld algometer. The PPTs were tested bilaterally over the lateral epicondyles of the humerus and over the mid-bellies of the upper trapezius, lumbar paraspinal, and the tibialis anterior muscles. This study was registered with ClinicalTrials.gov, and its Identifier is NCT02828501.

RESULTS

Repeated-measures ANOVAs and Kruskal-Wallis tests showed no significant within- or between-group differences in PPT. Within-group effect sizes in the changes of PPT ranged from -.48 at the left paraspinal muscles to .24 at the left lateral humeral epicondyle. Statistical power to detect significant differences at α of 0.05 was calculated to be 0.94.

CONCLUSIONS

This study suggests that in young adults who do not have current or recent symptoms of spinal pain, multiple within-session treatments of cervical and lumbar spinal manipulation fail to influence PPTs. Changes in PPT that are observed in symptomatic individuals are likely to be primarily influenced by pain-related neuromodulators rather than by an isolated, mechanical effect of spinal manipulation.

Evidence-based practice, research utilization, and knowledge translation in chiropractic: a scoping review

BACKGROUND

Evidence-based practice (EBP) gaps are widespread across health disciplines. Understanding factors supporting the uptake of evidence can inform the design of strategies to narrow these EBP gaps. Although research utilization (RU) and the factors associated with EBP have been reported in several health disciplines, to date this area has not been reviewed comprehensively in the chiropractic profession. The purpose of this review was to report on the current state of knowledge on EBP, RU, and knowledge translation (KT) in chiropractic.

METHODS

A scoping review using the Arksey and O'Malley framework was used to systematically select and summarize existing literature. Searches were conducted using a combination of keywords and MeSH terms from the earliest date available in each database to May 2015. Quantitative and thematic analyses of the selected literature were conducted.

RESULTS

Nearly 85 % (56/67) of the included studies were conducted in Canada, USA, UK or Australia. Thematic analysis for the three categories (EBP, RU, KT) revealed two themes related to EBP (attitudes and beliefs of chiropractors; implementation of EBP), three related to RU (guideline adherence; frequency and sources of information accessed; and perceived value of websites and search engines), and three related to KT (knowledge practice gaps; barriers and facilitators to knowledge use; and selection, tailoring, and implementation of interventions). EBP gaps were noted in the areas of assessment of activity limitation, determination of psychosocial factors influencing pain, general health indicators, establishing a prognosis, and exercise prescription. While most practitioners believed EBP and research to be important and a few studies suggested that traditional and online educational strategies could improve patient care, use of EBP and guideline adherence varied widely.

CONCLUSION

Findings suggest that the majority of chiropractors hold favourable attitudes and beliefs toward EBP. However, much remains to be done for chiropractors to routinely apply evidence into clinical practice. Educational strategies aimed at practicing chiropractors can lead to more EBP and improved patient care. The chiropractic profession requires more robust dissemination and implementation research to improve guideline adherence and patient health outcomes.

A value proposition for early physical therapist management of neck pain: a retrospective cohort analysis

BACKGROUND

Neck pain is one of the most common reasons for entry into the healthcare system. Recent increases in healthcare utilization and medical costs have not correlated with improvements in health. Therefore there is a need to identify management strategies for neck pain that are effective for the patient, cost efficient for the payer and provided at the optimal time during an episode of neck pain.

METHODS

One thousand five hundred thirty-one patients who underwent physical therapist management with a primary complaint of non-specific neck pain from January 1, 2008 to December 31, 2012 were identified from the Rehabilitation Outcomes Management System (ROMS) database at Intermountain Healthcare. Patients reporting duration of symptoms less than 4 weeks were designated as undergoing "early" management and patients with duration of symptoms greater than 4 weeks were designated as receiving "delayed" management. These groups were compared using binary logistic regression to examine odds of achieving Minimal Clinically Important Difference (MCID) on the Neck Disability Index (NDI) and Numerical Pain Rating Scale (NPRS). Separate generalized linear modeling examined the effect of timing of physical therapist management on the metrics of value and efficiency.

RESULTS

Patients who received early physical therapist management had increased odds of achieving MCID on the NDI (aOR = 2.01, 95 % CI 1.57, 2.56) and MCID on the NPRS (aOR = 1.82, 95 % CI 1.42, 2.38), when compared to patients receiving delayed management. Patients who received early management demonstrated the greatest value in decreasing disability with a 2.27 percentage point change in NDI score per 100 dollars, best value in decreasing pain with a 0.38 point change on the NPRS per 100 dollars. Finally, patients receiving early management were managed more efficiently with a 3.44 percentage point change in NDI score per visit and 0.57 point change in NPRS score per visit.

CONCLUSIONS

These findings suggest that healthcare systems that provide pathways for patients to receive early physical therapist management of neck pain may realize improved patient outcomes, greater value and higher efficiency in decreasing disability and pain compared to delayed management. Further research is needed to confirm this assertion.

Clinical Outcomes, Utilization, and Charges in Persons With Neck Pain Receiving Guideline Adherent Physical Therapy

In efforts to decrease practice variation, clinical practice guidelines for neck pain have been published. The purpose of this study was to determine the effect of receiving guideline adherent physical therapy (PT) on clinical outcomes, health care utilization, and charges for health care services in patients with neck pain. A retrospective review of 298 patients with neck pain receiving PT from 2008 to 2011 was performed. Clinical outcomes, utilization, and charges were compared between patients who received guideline adherent care and nonadherent care. Patients in the adherent care group experienced a lower percentage improvement in pain score compared to nonadherent care group ( p = .01), but groups did not significantly differ on percentage improvement in disability ( p = .32). However, patients receiving adherent care had an average 3.6 fewer PT visits ( p < .001) and less charges for PT ( p < .001). Additionally, patients receiving adherent care had 7.3 fewer visits to other health care providers ( p < .001), one less prescription medication ( p = .02) and 43% fewer diagnostic images ( p = .02) but did not differ in their charges to other health care providers ( p = .68) during the calendar year of undergoing PT. Although receiving guideline adherent care demonstrated positive effects on health care utilization and financial outcomes, there appears to be a trade-off with clinical outcomes.

Manual and Instrument Applied Cervical Manipulation for Mechanical Neck Pain: A Randomized Controlled Trial

OBJECTIVE

The purpose of this study was to compare the effects of 2 different cervical manipulation techniques for mechanical neck pain (MNP).

METHODS

Participants with MNP of at least 1 month's duration (n = 65) were randomly allocated to 3 groups: (1) stretching (control), (2) stretching plus manually applied manipulation (MAM), and (3) stretching plus instrument-applied manipulation (IAM). MAM consisted of a single high-velocity, low-amplitude cervical chiropractic manipulation, whereas IAM involved the application of a single cervical manipulation using an (Activator IV) adjusting instrument. Preintervention and postintervention measurements were taken of all outcomes measures. Pain was the primary outcome and was measured using visual analogue scale and pressure pain thresholds. Secondary outcomes included cervical range of motion, hand grip-strength, and wrist blood pressure. Follow-up subjective pain scores were obtained via telephone text message 7 days postintervention.

RESULTS

Subjective pain scores decreased at 7-day follow-up in the MAM group compared with control (P = .015). Cervical rotation bilaterally (ipsilateral: P = .002; contralateral: P = .015) and lateral flexion on the contralateral side to manipulation (P = .001) increased following MAM. Hand grip-strength on the contralateral side to manipulation (P = .013) increased following IAM. No moderate or severe adverse events were reported. Mild adverse events were reported on 6 occasions (control, 4; MAM, 1; IAM, 1).

CONCLUSION

This study demonstrates that a single cervical manipulation is capable of producing immediate and short-term benefits for MNP. The study also demonstrates that not all manipulative techniques have the same effect and that the differences may be mediated by neurological or biomechanical factors inherent to each technique.