Predictors for Identifying Patients With Mechanical
Neck Pain Who Are Likely to Achieve Short-Term
Success With Manipulative Interventions
Directed at the Cervical and Thoracic SpineThis section was compiled by Frank M. Painter, D.C.
Send all comments or additions to: Frankp@chiro.org
FROM: J Manipulative Physiol Ther. 2011 (Mar); 34 (3): 144–152 ~ FULL TEXT
Manuel Ssavedra-Hernández, PT, Adelaida M. Castro-Sánchez, PT, PhD,
César Fernández-de-las-Peñas, PT, DO, PhD, Joshua A. Cleland, PT, PhD,
Ricardo Ortega-Santiago, PT, MS, Manuel Arroyo-Morales, MD, PT, PhD
Professor, Department of Nursing and Physical Therapy,
Universidad de Almería, Spain.
This newly published JMPT study attempted to identify those prognostic clinical factors that may potentially identify, a priori, patients with mechanical neck pain who are likely to experience a rapid and successful response to spinal manipulation of the cervical and thoracic spine.
Data from 81 subjects were included in the analysis, of which 50 had experienced a successful outcome (61.7%). Five variables were found to be associated with a positive response:Interestingly, if 4 of 5 variables were present in a particular individual, the likelihood of success increased from the average success rate of 61.7% to a whopping 75.4%.
- Initial pain intensity greater than 4.5 points
- Cervical extension less than 46°
- Hypomobility at T1 vertebra
- A negative upper limb tension test [1] ... please read this study!
- Female sex
Although there are several limitations within this study, including the limited group size, and the lack of a comparative control group, this study is a sound first step towards developing a clinical prediction formula associated with a rapid and positive response to care.
Guidelines, and the more recent evidence-based care pathways were originally conceived as a method to inform clinicians and improve patient outcomes. There is no question that the excessive cost of American medical care needs to be reined in. There is also no question that third party payers in managed care have been ruthless in establishing rules and procedures based on financial targets, rather than reasonable patient care. Money that should be going to patient care is going to their bloated administration and the managed care owners. Crucial differences in the quality and success of care are being ignored.
In the field of spinal manipulation for example, there are fundamentally different levels of education and skill for different health professions utilizing spinal adjusting. This is apparent from trials such as:Meade et al., where chiropractors received significantly superior results for back pain patients than did physical therapists, and
Carey et al., where medical doctors, given postgraduate training in spinal manipulation, proved unable to assess and treat back pain patients successfully.
Our website has published extensively about the vast gap between medical and chiropractic skill sets. That is especially evident in the management of low back pain.
You may also want to review our original Practice Guidelines Page and the newer, evidence-based “Best Practice” Initiative Page, because they both reflect the evolution in thinking about improving patient care outcomes.
REFERENCES:
Upper Limb Neural Tension and Seated Slump Tests: The False Positive Rate among Healthy Young Adults without Cervical or Lumbar Symptoms
J Man Manip Ther. 2009; 17 (3): e104–105A recent trial, involving healthy young adults with no history of cervical, lumbar, or peripheral symptoms, revealed a false-positive response of 86.9% in the ULNTT test at some point in the available range of elbow extension. Because of this finding, the JMPT study under discussion may have inadvertently ruled out some candidates who would have responded positively to manipulative care.
The Abstract:
OBJECTIVE: The purpose of this study was to identify the prognostic factors for individuals with mechanical neck pain likely to experience improvements in both pain and disability after the application of an intervention including cervical and thoracic spine thrust manipulations.
METHODS: Patients presenting with mechanical neck pain participated in a prospective single-arm trial. Participants underwent a standardized examination and then received a series of thrust manipulations directed toward the cervical, cervicothoracic, and thoracic spine. Participants were classified as having achieved a successful outcome at the second and third sessions based on their perceived recovery. Potential prognostic variables were entered into a stepwise logistic regression model to determine the most accurate set of variables for the prediction of treatment success.
RESULTS: Data from 81 subjects were included in the analysis, of which 50 experienced a successful outcome (61.7%). Five variables including pain intensity greater than 4.5 points; cervical extension less than 46°; presence of hypomobility at T1; a negative upper limb tension test and female sex were identified. If 4 of 5 variables were present (likelihood ratio, +1.9), the likelihood of success increased from 61.7% to 75.4%.
CONCLUSIONS: This study identified several prognostic clinical factors that can potentially identify, a priori, patients with neck pain who are likely to experience a rapid response to the application of an intervention including both cervical and thoracic spine manipulations. However, no combination of the variables was able to dramatically increase the posttest probability.
From the Full-Text Article:
Discussion
We have attempted to identify prognostic clinical factors that may potentially identify, a priori, patients with mechanical neck pain who are likely to experience a rapid response after the application of a therapy intervention including cervical and thoracic spine thrust manipulations. Five variables including pain intensity greater than 4.5 points, cervical extension less than 46°, hypomobility at T1 vertebra, a negative ULTT, and female sex were identified. If 4 of 5 variables were present (LR+, 1.9), the likelihood of success increased from 61.7% to 75.4%. If all the variables were present, the +LR was 1.9 and the posttest probability remained consistent at 75.4%. Although we identified variables that may have plausibly been predicted, no parsimonious subset of them could substantially raise the posttest probability of success.
The identified variables posed at least a degree of face validity. The high pain score may have fallen out as a predictor because it could plausibly be that those folks who have a more severe pain may have room for quicker improvements with the appropriate intervention or spontaneous recovery, or it could simply be that patients with a higher intensity of pain are more likely to recover. [40] Restricted cervical extension would theoretically make sense as patients with neck pain often exhibit impaired biomechanics of the cervicothoracic (C7–T1) region. [41–43] This would also lend credibility for the hypomobility identified at T1, which has historically been used as a method to identify patients who should receive thrust manipulation. [31] In addition, we cannot exclude the neurophysiologic mechanisms of spinal manipulation. [44] In fact, it has been reported that C7–T1 manipulation induced hypoalgesic effects, that is, an increase in pressure pain thresholds in the cervical spine in healthy subjects. [45]
A negative ULTT suggests that the patients in this study likely present without neurogenic symptoms, which may render them more likely to recover rapidly then a group with neck and arm pain. This coincides with the study by Tseng et al, [16] who found that patients without cervical radiculopathy had a better outcome with cervical spine thrust manipulation. The reason why the female sex was identified as a prognostic variable remains a bit elusive. It has been demonstrated that sex in itself is not a predictive factor of outcome [46]; however, it has been also shown in other studies in patients with whiplash associated disorders that male sex was a predictor of poor expectations for recovery. [47]
We did not identify a subset of factors likely to identify prognosis in this study; it might be that this subgroup of patients cannot easily be identified. This would be in agreement with the study of Cleland et al [19] that demonstrated that the previously identified predictor variables could not be identified. Given the rapid improvement associated with manipulative techniques in the management of patients with neck pain, we also agree that given the minute risks and the obvious benefit, manual techniques are likely beneficial for most patients with neck pain. [19]
Limitations
There are some limitations to the current study. First, the absence of a control group does not allow for inferences to be made regarding cause and effect, so it cannot be determined if the rule predicted response to treatment or simply identified patients with a good prognosis. Future randomized clinical trials are required to validate the variables in the rule before it can be suggested for widespread clinical application. In fact, it has been stated that single-arm clinical prediction rules are vulnerable to a regression effect, where the variables entered into the logistic regression may have resulted in overfitting of the model, which can lead to spurious findings). [48] However, in the development stages of a possible clinical prediction rule, it is important and necessary to include all potential predictor variables. Nevertheless, as is the case with all statistical modeling, the results presented here will require validation, which can include performing the study on an independent sample of patients. [49] Therefore, these results should be considered as a temporary and exploratory first analysis.
Second, we should recognize that we collected only data for short-term outcomes and after 1 or 2 sessions of treatment. Therefore, we do not know whether the patients classified as responders were still doing well at a longer-term follow-up, and if some patients classified as nonresponders can be classified as having a successful outcome with consecutive treatment sessions. Finally, it is possible that our sample was small. Methods for calculating sample size for multivariate analyses suggest that studies need at least 50 subjects for the first independent variable and 8 for each of the subsequent ones, which would give a greater sample size of that one included in the current study. Future studies are now needed to elucidate these questions
Conclusions
We have identified several potential prognostic clinical factors including pain intensity greater than 4.5 points, cervical extension less than 46°, hypomobility of T1 vertebra, a negative ULTT, and female sex that may potentially identify, a priori, patients with mechanical neck pain who are likely to have an overall good prognosis. However, no combination of the variables was able to dramatically increase the posttest probability. Therefore, we would recommend the use of manual therapy techniques in this pain patient population considering the small inherent risks and likelihood of benefit. Future studies should compare the effects of thoracic and cervical spine manipulation in a patient population with mechanical neck pain.
Practical Applications
The current study identified several prognostic clinical factors including pain intensity greater than 4.5 points, cervical extension less than 46°, hypomobility of T1 vertebra, a negative ULTT, and female sex that may potentially identify patients with mechanical neck pain who are likely to experience a rapid and positive response to the application of cervical and thoracic spine thrust manipulations.
If 4 of 5 variables were present (LR+, 1.9), the likelihood of success increased from 61.7% to 86.3%.
Future studies are necessary to examine the validity of the predictive value of the prognostic factors identified in this study.
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