This will be the first in a series of monthly posts that I will be contributing to MedBridge Education, who is an online continuing education resource for physical and occupation therapists…
According to Sipes et al, 30% of athletes suffer a shoulder injury during their career. Of those injuries, subacromial impingement syndrome and rotator cuff tendonitis were the most common shoulder injuries for each individual sport and accounted for 27% and 24% of total shoulder injuries, respectively. More specifically, over-head throwing athletes are especially susceptible to shoulder pathology as 28% of all injuries in professional baseball have been shown to occur at the shoulder (Cante et al).
Additionally, van der Windt et al conducted a prospective evaluation of over 300 patients. This analysis found that approximately 48% of shoulder injuries in a general population were diagnosed as subacromial impingement. Stability at the glenohumeral joint is dependent upon the passive stabilization of the ligamentous tissues and the dynamic stability provided by the rotator cuff musculature, as well as indirectly by the stability of the scapula and the muscles that support it. The rotator cuff’s primary role is to center the humeral head in the glenoid fossa, which requires adequate muscular strength and endurance. Because the rotator cuff muscles all originate from the scapula, appropriate functional control of the scapula is also an important rehab target.
As weakness of the rotator cuff and scapular stabilizing musculature can predispose individuals to subsequent pathological conditions, understanding what exercises are most effective in training these muscles is of utmost importance to the practicing clinician and student alike. Evidence supports the use of appropriate exercises and manual therapy to improve the strength and function of these muscles. For example, in a clinical trial (Bang et al) comparing an exercise program to the same program with the addition of manual therapy, strength of patients in the manual therapy program improved significantly whereas the exercise-only group did not. In addition, based on the unique ROM, capsular laxity, strength, proprioception, and osseous anomalies specific to the over-head athlete, they too require the creation of a rehabilitation program specific to the demands of their sport/position (see: “Rehabilitation of the Overhead Throwing Athlete”). This review will touch on strength training interventions targeting the rotator cuff, but please remember this is only the tip of the iceberg in terms of rehabilitative principles.
The supraspinatus originates from the supraspinous fossa and inserts laterally to the superior facet of the greater tubercle of the humerus. Based on this muscle’s line of pull, its primary responsibility involves concentric abduction of the humerus. In addition to this primary action, the supraspinatus also drives the superior roll of the humeral head and compresses the humeral head firmly against the glenoid fossa during shoulder abduction. Secondarily, this muscle contributes a small external rotation torque. Based on these biomechanical and anatomical considerations, Reinold et al investigated the electromographic (EMG) activity of the supraspinatus through three common therapeutic exercises, which also serve as diagnostic tests for shoulder impingement when performed isometrically (Full Can, Empty Can , and Prone Full Can). All three of these exercises had nearly identical EMG data ranging between 62% (Full Can) and 67% Maximal Voluntary Isometric Contraction (MVIC) (Prone Full Can). It should also be noted that there was significantly greater middle and posterior deltoid EMG activity during the empty can exercise, which can contribute to superior humeral head migration and a predisposition to subacromial impingement. Biomechanically speaking, when the humerus is elevated in a position of internal rotation, it does not allow the greater tuberosity to clear from under the acromion as it does in a neutral or externally rotated position. Based on these findings, why are we still using the more provocative Empty Can when the better tolerated full can exercise is just as effective?The answer for this is still unclear.
Earlier in 2004, Reinold et al conducted a similar study looking at a broader range of exercises and muscular contributions of the supraspinatus, infraspinatus, teres minor, and posterior & middle deltoid. It was determined that the top three exercises based on %MVIC were Prone Horizontal Abduction at 100° with full external rotation (82% MVIC), Prone External Rotation at 90° of abduction (68% MVIC), and Standing External Rotation at 90° of abduction (57% MVIC). As previously stated, selecting exercises that activate the supraspinatus while minimizing the activity of the deltoid musculature is of importance in the rehabilitation of most shoulder pathologies. This information could make utilizing the Prone Horizontal Abduction at 100° with Full External Rotation and Prone External Rotation at 90° of abduction detrimental to proper rehabilitation as substantial deltoid activity was recorded at 82% and 79% MVIC, respectively.
In lieu of this additional consideration, the most appropriate exercises for isolated strengthening of the supraspinatus are the Full Can, Prone Full Can, and Side-lying ER (51% MVIC). Once progressing to a more functional program targeting scapular and glenohumeral stability, it must be noted that this does not necessarily warrant the discharge of more targeted rotator cuff exercises in favor of seemingly more difficult weight-bearing exercises. Uhl et al evaluated several common weight-bearing exercises and of the exercises evaluated, the most intensely the supraspinatus was engaged was only 29% MVIC during a single-arm push-up.
The infraspinatus originates distally to the supraspinatus at the infraspinous fossa of the scapula and attaches laterally at the middle facet of greater tubercle of the humerus. Based on this muscle’s origin and insertion, its primary action involves external rotation of the humerus. The secondary actions of the infraspinatus include horizontal abduction, glenohumeral compression at the glenoid fossa, and resistance to superior and anterior humeral head translation. This is why many diagnostic special tests for impingement or rotator cuff integrity will also assess the strength of the infraspinatus (e.g. the Resisted Isometric External Rotation Test). The previously mentioned study conducted by Reinold and colleagues also evaluated the %MVIC of the infraspinatus musculature during the same exercises. The three most demanding exercises for the infraspinatus included Sidelying External Rotation at 0° of abduction (62% MVIC), Standing External Rotation in the scapular plane (53% MVIC), and Prone External Rotation at 90° of abduction (50% MVIC). Based on the line of pull and perceived action of the infraspinatus, this data seems to make reasonable sense. Additionally, when having your patient perform side-lying external rotation, consider having them place a rolled towel between their arm and their torso. By making this simple adjustment, it is postulated that the muscles controlling adduction and those performing external rotation are more appropriately balanced. The data from these two exercises agree with this theory as %MVIC of the infraspinatus increased from 20% to 25% MVIC with the addition of a rolled towel. When progressing to more functional weight bearing exercises, Uhl et al determined that infraspinatus activity was substantially more active than the other rotator cuff musculature measured. They found the Push-up with feet elevated (52% MVIC) and One-armed Push-up (82% MVIC) to be especially challenging. Obviously, these are more challenging activities and are not appropriate for every patient, but may be beneficial adjunctive exercises for the more advanced clientele.
The smaller, but still important, teres minor attaches inferior to the infraspinatus at the lateral border of the scapula and inserts onto the inferior facet of the greater tubercle of the humerus. The teres minor’s primary role is external rotation and stabilization of the humeral head within the glenoid fossa. Secondary actions include adduction and horizontal abduction of the humerus. While, in general, teres minor performs similar actions to the infraspinatus. It provides drastically less activity during flexion, abduction, and scapular abduction than the infraspinatus. It may be isolated with the Dropping Sign Test, which has been shown to have poor sensitivity, but good specificity (Hertel et al). With regards to exercise prescription, the three most demanding exercises (as determined by Reinold and colleagues) are Sidelying External Rotation at 0° of abduction (67% MVIC), Standing External Rotation in the scapular plane (55% MVIC), and Prone External Rotation at 90° of abduction (48% MVIC). Once again, given this muscle’s line of pull, the data with regards to these exercises make both biomechanical and anatomical sense. Horizontal abduction was also evaluated as it was shown to have substantial activation (74% MVIC) in a previous study conducted by Townsend et al. However, Reinold’s more recent study showed a relatively small contraction of both the infraspinatus (39% MVIC) and teres minor (44% MVIC). As both the infraspinatus and teres minor are the primary external rotators at the glenohumeral joint, it is important to understand which exercisesimultaneously activates both muscles. Reinold has determined the exercises that elicite the highest combined EMG activation are shoulder ER in side-lying, standing ER in the scapular plane at 45° of abduction, and prone ER in 90° of abduction.
The subscapularis is the only rotator cuff muscle that is located on the anterior surface of the scapula. With an origin at the subscapular fossa and insertion laterally onto the lesser tubercle of the humerus, its primary action is internal rotation of the humerus. Secondary actions include humeral adduction, production of an abduction torque during arm elevation, glenohumeral compression, and anterior stabilization of the glenohumeral joint. As with the supraspinatus, the subscapularis can produce its maximal force when the humerus is positioned at 0° of abduction. As the abduction angle increases, the moment arms of the inferior and middle heads stay relatively constant.However, the moment arm of the superior head progressively decreases until approximately 60° abduction, which translates into diminished torque production. There have been many studies with conflicting results in terms of optimal abduction angle for subscapularis force production. In place of definitive EMG conclusions, potential for compensation should be taken into consideration. With the arm positioned at 0° of abduction, Decker et al found increased activation of the pectoralis major, latissimus dorsi, and teres major, which indicates a greater potential for substitution and masking of subscapularis weakness. In contrast, it was determined that pectoralis major activity decreased substantially when internal rotation was performed at 90° of abduction.
While this study did not clear up any of the murkiness in regards to subscapularis activation, it did offer assistance in avoiding or detecting compensatory muscular substitution. Decker et al also determined three more complex movements that created substantial subscapularis activity. The Push-up Plus (135.5% MVIC), Diagonal (99.7% MVIC), and Dynamic Hug (94.1% MVIC) exercises all created subscapularis activity that exceeded performance during isolated internal rotation exercises. Although these values are much greater than those reported for isolated internal rotation exercises, the potential for muscular substitution is likely with these more dynamic and functional exercises. Based on these considerations, isolated internal rotation should not be dismissed, but rather used in conjunction with these more demanding activities.
Movement at the glenohumeral joint is complex and dependent on many different muscular actions as well as the contributions of several other joints. While strengthening of the rotator cuff and scapular stabilizers is often directed for patients with shoulder pathology, other regions and joints must also be evaluated. Contributions of the cervical spine, thoracic spine , scapulothoracic joint, acromioclavicular joint , sternoclavicular joint, and passive ligamenous structures can affect the underlying pathology and subsequent rehabilitation process. This is why manual therapy is often directed at these areas. Not only can it increase mobility, but it can also improve the quality and strength of the exercise (Bang et al).
Additionally, scapulothoracic and pectoral musculature is also necessary for optimal shoulder biomechanics and must be addressed when appropriate. A recent continuing education course taught by Lenny Macrina, MSPT, SCS, CSCS provides a solid evidence-based explanation of the various factors involved in a successful rotator cuff and/or subacromial impingement program (“Glenohumeral Joint Biomechanics and Rehabilitation Implementation”). A comprehensive impairment-based program focused on muscular strengthening, neuromuscular control, endurance, joint hypo/hypermobility, and surgical precautions must be implemented to treat pathologies related to the glenohumeral joint.
According to Swenson et al, the third most common knee injury in high school aged athletes is pathology associated with the anterior cruciate ligament (ACL) at 25.4%. Additionally, Griffin et al estimated that the total number of ACL ruptures per year approaches nearly 250,000 and a subsequent surgical reconstrucaton is perfromed in nearly 125,000 patients (Kim et al). This injury and the following surgical/rehabilitative principles have been given substantial attention in the literature over the years, however there is one factor that is often overlooked.
Articular cartilage defects, while not as prevalent as meniscal pathology, have been found in 30% of knees that recently underwent ACL reconstruction according to the findings of a recent systematic review published by Flanigan et al. Additionally, Maffulli et al found similar results in an arthroscopic evaluation of 378 knees following acute rupture of the ACL where 163 patients (43%) had evidence of a concomitant full-thickness articular cartilage lesion. Once again, in a similar study, Tandogen et al determined that 146/663 (19.1%) patients showed evidence of at least one chondral lesion with the majority being localized to the medial femoral condyle (41%). Of the patients who presented with a chondral lesion, 80% had a meniscal lesion in addition to the primary ACL rupture in the same compartment. Also, they found that the odds of having a serious chondral lesion (grade III/IV) were 2.7 times higher at 2 to 5 years post-injury and 12.6 times more likely at > 5 years. In a retrospective analysis of over 25,000 knee arthroscopies, Widuchowski et al found that a concomitant chondral lesion was present in 36% of ACL ruptures documented. In a much smaller, albeit similar, study Hjelle et al found an associated ACL rupture in 26% of chondral defects after conducting a retrospective analysis of 1,000 knee arthroscopies. While ACL reconstruction failure and the following revisions are typically rare at an incidence of only 2-6% of all surgeries (Spindler et al), it appears that this revision leads to an increase in articular cartilage damage. Borchers et al evaluated the presence of cartilage defects in patients during primary and revision ACL reconstruction. They found an increased odds ratio of grade III and IV chondral lesions in revision compared with primary ACL reconstruction in the lateral and patellar-trochlear compartments. Based on this data, there does seem to be a higher incidence of chondral injuries in individuals who have undergone ACL reconstruction and especially in those who have undergone a revision, but does this underlying concomitant pathology effect the patient’s outcomes or their eventual return to sport?
While there has not been a great deal of research devoted to this question, there is substantial preliminary evidence that chondral damage does lead to inferior patient outcomes. Røtterud et al evaluated the varying patient-reported outcomes following ACL reconstruction between patients with no additional defects and those with concommitent full-thickness chondral defects or meniscal pathology. After evaluating the Knee Injury and Osteoarthritis Outcome Score (KOOS) of 3,674 patients, those with full-thickness cartilage lesions reported lower crude mean values for all of the KOOS subscales compared with those patients without cartilage lesions at the 2-year follow-up. There were also worse outcomes in those patients with lesions ≥ 2 cm2 in diameter, but these differences were small and did not reach statistical significance. Also, somewhat surprisingly, meniscal pathology and less substantial chondral lesions (grades I/II) did not yield inferior patient-perceived outcomes compared to those without additional intra-articular lesions. Based on these findings, patients with full-thickness cartilage damage reported more pain and symptoms, impaired function in activities of daily living, sports, recreation, and reduced knee-related quality of life compared to those without concomitant chondral damage. Heir et al completed a cross-sectional study that further identified the extreme patient-perceived deficits of individuals presenting with focal cartilage damage. They found that complaints are worse than those of ACL-deficient patients, and quality of life is affected to the same extent as in patients scheduled for total knee replacement. This body of evidence demonstrates that while full-thickness chondral lesions are not nearly as common as meniscal pathology, they still must be considered in patients recovering from ACL reconstruction based on their detrimental impact on the patient’s perceived therapeutic outcome.
Another very important and under appreciated factor must also be considered in rehabilitation status-post ACL reconstruction. Campbell et al conducted a very important study with concerning results. They attempted to determine the ability of radiologists to accurately estimate the size of chondral defects of the knee via pre-operative MRI evaluation. Of the 92 total cartilage defects imaged, the radiological findings indicated lesions that were approximately 1.04 cm2 smaller in diameter than what was found intra-operatively. Areas of specific concern were the medial femoral condyle and femoral trochlea, which were underestimated by 92.0% and 82.8%, respectively. This is especially concerning since the majority of chondral defects associated with ACL reconstruction are localized to the medial femoral condyle. Further, when all compartments were averaged together, MRI imaging underestimated chondral defects by 70%… And this is in high grade defects. This leads us to believe that significant chondral defects are potentially underestimated or missed altogether secondary to unreliable pre-operative imaging. While this study was not focused primarily on patients undergoing treatment for ACL pathology, it does give us information on the underestimation of cartilage defects. To further support the potential for under-reported chondral lesions, Figueroa et al reported specificity of only 45% when MRI was utilized to rule in a chondral lesion. This information should give caution to therapists and orthopedic surgeons alike. Just because imaging is negative, does not mean that a chondral lesion can be definitively ruled out as a differential diagnosis or contributory factor.
These findings indicate the need to take potential cartilage damage into consideration when planning you patient’s return to sport. Van Ginckel et al evaluated fifteen patients treated with isolated ACL reconstruction compared with 15 matched controls. Each patient received a 3-T MRI cartilage evaluation (3-D volume/thickness documented), biochemical composition (T2/T2* mapping), and functional assessment. Patient function was determined by recording in vivo deformation (including recovery) after a 30 minute run. Patients recovering from an isolated ACL reconstruction demonstrated diminished quality and in vivo cartilaginous resiliency compared with controls. In a similar study, Frobell et al performed diagnostic 1.5-T MRI evaluation at baseline, three, six, twelve, and twenty-four months post-injury. At twenty-four months, significant cartilage thinning occurred in the femoral trochlea compared to thickening localized to the central medial aspect of the femur. The morphological changes to the articular cartilage found in these two studies shows the need to understand the biomechanical and neurophysiological changes associated with return to sport following ACL reconstruction. Both short-term (6 months) and long-term (24 months) changes have been identified and must be in the back of the treating clinician’s mind. Specific attention should be paid to the short-term cartilaginous thinning that can be seen in these patients despite the lack of radiological and/or arthroscopic evidence of chondral lesions. While there are typically continual pressures from the athlete and coaching staff, return to sport must be handled delicately to avoid the potential for long-term osteoarthritic changes down the road.
A randomized clinical trial recently published in the Journal of Orthopaedic & Sports Physical Therapy by Masaracchio et al evaluated the effectiveness of adding thoracic spine thrust manipulation to a program consisting of cervical spine non-thrust mobilization and cervical ROM exercises in the treatment of mechanical neck pain. While this study only looked into the short-term impact of this intervention strategy, it does provide some very important data that should help to guide our selection of manual techniques when treating these patients… [Continue Reading]
The University of Pittsburgh is hosting several excellent educational opportunities in the coming months. Proceeds will go directly toward the Foundation for Physical Therapy via the Pitt-Marquette Challenge. So come out and learn from some of our profession’s leaders and help provide much needed funding towards physical therapy research!
Examination and Treatment of Running Injuries
Bryan Heiderscheit, PT, PhD
April 6-7, 2013
Successful treatment of running injuries has remained somewhat elusive to orthopedic and sports medicine clinicians. Through a greater understanding of the associated mechanics, advances in prevention and rehabilitation strategies can be made that will reduce the incidence rate of these common injuries. This advanced 2-day course will provide a thorough review of the most recent scientific findings related to the examination, diagnosis and treatment of running injuries. Discussion will focus on the current literature pertaining to running mechanics and injury, and the clinical decision making needed to achieve superior outcomes. The use of video analysis as part of the running gait examination will be emphasized, and novel strategies to modify running mechanics will be presented as part of a comprehensive approach to treatment. Multiple case studies will be integrated to illustrate concepts and promote idea application. The overall objective is to provide each participant with an understanding of the current knowledge pertaining to the management of runningrelated injuries, with techniques that can be immediately applied in clinical practice.
Continuing Education Credits:
Direct Access CEUs : 2
General Access CEUs: 9.5
Course Level: Intermediate
A Classification Based Approach to Evaluation and Treatment of Cervical Spine Disorders
Louie Puentedura, PT, DPT, PhD, OCS, FAAOMPT
April 13, 2013
Neck pain is a fairly common source of disability and a frequent reason for referral to outpatient physical therapy clinics. Often, patients with neck pain cannot be given a definitive structural diagnosis, which makes it difficult for physical therapists to determine which treatments are most likely to benefit an individual patient. An alternative approach to structural diagnosis is the classification process. Classification seeks to group patients based on clusters of history and examination findings instead of proposed structural pathology. Each group, or classification, is then associated with a particular management approach that is believed to be most effective for patients in that classification.
This 1 day, 8 hour course, offers a comprehensive investigation into the proposed classification-based approach to the management of patients with neck pain and dysfunction. The course is designed to provide the clinician with skills to carefully use a combination of clinical prediction rules (where available) and sound clinical reasoning in order to determine the most effective management of patients with neck pain.
New and updated research will be presented on the 5 proposed classifications within the system, and participants will have the opportunity to explore, in detail, each of the sub-groups within the classification system. The evidence for, and appropriate use of each classification group will be presented, and the most appropriate (and evidence-based) examination and treatment interventions will be outlined and demonstrated. Treatment interventions will include thrust manipulation techniques for the cervical and thoracic spines, non-thrust mobilization techniques for the cervical spine, motor control exercises for the cervical spine, traction, patient education and more.
Research has shown improved outcomes for patients with low back pain when treatments are based on a classification method, and therefore the development of a classification system for patients with neck pain may help to improve outcomes in these patients as well. This course will bring course participants up to date on the classification system for patients with neck pain
Continuing Education Units:
General Access CEUs: 7
Course Level: Intermediate
In an effort to raise money for the Foundation for Physical Therapy, the faculty from the University of Pittsburgh’s Department of Physical Therapy will be traveling to the Cleveland Clinic to offer exceptional programming in many specialty areas including Orthopedics, Neurology, Geriatrics and Cardiopulmonary PT.
Interactive Vestibular Case Studies
Sue Whitney, PT, DPT, PhD, NCS, ATC, FAPTA
Evaluation and Treatment Considerations for Knee Osteoarthritis Examination and Treatment of the Stiff Shoulder
G. Kelley Fitzgerald, PT, DPT, PhD, FAPTA
Jay Irrgang, PT, DPT, PhD, ATC, FAPTA
Motor Skill in Walking: An Energy Cost Savings Approach to Mobility Limitations
Jessie VanSwearingen, PhD, PT, FAPTA
Jennifer Brach, PhD, PT, GCS
Assessment of Exercise Tolerance Across the Continuum: Cardiovascular, Pulmonary and Metabolic Implications
Andrea L. Hergenroeder, PhD, PT, CCS
Victoria Hornyak, PT, DPT, GCS
Low Back Pain: A Case-Based Approach to Orthopaedic Section ICF Guidelines and their Implementation
Tony Delitto, PhD, PT, FAPTA
Michael Timko, PT, MS, FAAOMPT
Chris Bise, PT, MS, DPT, OCS
Continuing Education Units:
General Access CEUs: 3
Course Level: Intermediate
Questions regarding any of the courses listed?
The use of Dry-needling by physical therapists has been a common place for discussion both inside and outside our profession. One of the most prevalent reason for this discussion stems from a lack of understanding as to what Dry-needling actual is and what benefits it provides for our patients… [Continue Reading]
As many of you know, OMPT was recently nominated for ‘Best Student Blog’ by Therapydia along with the AAOMPT Student SIG, Pitt Physical Therapy (Matt Debole), PT to Be in ’15 (Jasmine Marcus), and The Student Physical Therapist (James Heafner, Chris Fox, Brian Schwabe). Last night, thanks to all of your support, I was informed that OMPT was officially named Best Student Blog!
Thank you so much for all of your votes and continued support!
John Snyder, SPT, CSCS
University of Pittsburgh
Class of 2014
To start, Therapydia’s Blog Awards end this Tuesday, February 26th at 5 PM PST / 8 PM EST. Immediately following the end of voting, the winners will be announced live on Therapydia’s PT-TV. So, please take the time to vote for Orthopedic Manual PT as the ‘Best Student Blog’, I appreciate your continued support! VOTE HERE!
This month’s blog posts come from Forward Thinking PT, In Touch Physical Therapy, The Sports Physio, My New Joints, and The Manual Therapist.
Joseph Brence, DPT wrote a great post detailing the brain’s influence on human movement in an article titled, “The Beauty of Movement…Part 1“. This is a topic that I think many therapists disregard, but the importance is paramount to a successful rehabilitation.
Harrison Vaughn, DPT over at In Touch PT has been busy this month with a number of great, informative posts. The first (“By the Numbers: 3.57 vs 2.46“) is an overview of a recent article published by Dr. James Dunning and the differing amount of cavitations versus a similar study conducted in 1996 by Reggars et al. Differing techniques may have contributed, but does this translate to improved outcomes? Current research in the lumbar spine says no, but the cervical spine is a much different animal. The next post, “PT Tests for Dx Achilles Tendon Rupture“, that details the Matles Test (sp = 0.85, sn = 0.88), which is a lesser known diagnostic test for achilles tendon rupture. Finally, “Hoffman’s Test and Inverted Supinator Sign” explains the clinical utility of these tests in the screening for cervical myelopathy (especially when used within the cluster described by Cook et al). The videos of ‘positive’ findings were very useful, especially for current students or new grads.
In a post titled “Shoulder pain, GIRDs and Sleeper Stretches…“, Adam Meakins, PT discusses the probable causes, diagnosis, and treatment of GIRD. Well worth a read!
“Non-operative Management for Patients after ACL Rupture” written by Joseph Zeni, MSPT, PhD details the current research and qualifying criteria for individuals who may be able to forgo ACL reconstruction in favor of conservative treatment. Research has begun to mount in favor of conservative physical therapy for a certain sub-set of patients with this injury and this is information that all patients should know prior to going under the knife.
Finally, at The Manual Therapist, Erson Religioso, DPT, FAAOMPT has posted several articles about IASTM, SIJ Dysfunction, and Patient Evaluation… Check them out:
Anneli P, et al. Physical Function Outcome in Cervical Radiculopathy Patients After Physiotherapy Alone Compared With Anterior Surgery Followed by Physiotherapy: A Prospective Randomized Study With a 2-Year Follow-up. Spine. 2013; 38(4): 300–307.
Collins NJ, et al. Prognostic factors for patellofemoral pain: a multicentre observational analysis. British Journal of Sports Medicine. 2013; 47(4): 227-233.
Oliveira VC, et al. Multimodal physiotherapy is effective for anterior knee pain relief. British Journal of Sports Medicine. 2013; 47(4): 245-246.
Selkowitz DM, et al. Which Exercises Target the Gluteal Muscles While Minimizing Activation of the Tensor Fascia Lata? Electromyographic Assessment Using Fine-Wire Electrodes. Journal of Orthopaedic & Sports Physical Therapy. 2013; 43(2): 54-65.
Swensen DM, et al. Epidemiology of Knee Injuries among U.S. High School Athletes, 2005/2006–2010/2011. Medicine & Science in Sports & Exercise. 2013; 45(3): 462–469.
Walton DM, et al. Risk Factors for Persistent Problems Following Acute Whiplash Injury: Update of a Systematic Review and Meta-analysis. Journal of Orthopaedic & Sports Physical Therapy. 2013; 43(2): 31-43.
Additionally, if you are a physical therapy student and you are interested in interacting with other students from around the world, consider joining the WWPTSN’s Facebook Group!
In Part 1, the relative risks and important screening areas prior to cervical manipulation were discussed. In this second installment, the effectiveness and a theoretical framework for utilizing cervical manipulation will be laid out.
According to the Neck Pain Guidelines published by Cleland et al, manual therapy (mobilization and manipulation) was graded both an ‘A’ (strong evidence) and a ’1′ (evidence from high-quality RCT, prospective, or diagnostic studies) in the treatment of neck pain. These guidelines advocate both manipulative and lower grade mobilization in reducing neck pain and cervicogenic headache symptoms. Published in the same year as the clinical guidelines, Walker et al conducted a RCT looking into the effectiveness of manual therapy and exercise in the management of mechanical neck pain. Those randomized to the manual therapy and exercise group (MTE) received treatments that ranged from cervical manipulation to soft-tissue mobilization and every technique in between. The intervention period lasted for 3 weeks with a total of 6 treatment sessions during this timeframe. At the conclusion of the study, those patients in the MTE group demonstrated statistically superior improvements in NDI scores at all 3 follow-ups, pain reduction at 3 and 6 weeks, perceived patient improvement on the GRC at all follow-ups, and overall treatment success rates were almost two-times as large for the MTE group in comparison to the minimal intervention group. These results bode well for a comprehensive manual therapy approach, but is there evidence to support the use of cervical manipulation in isolation?
Saavedra-Hernández et al recently published a RCT investigating the short-term effects of spinal manipulation in individuals suffering from chronic neck pain. In this study, patients were either randomized to an isolated cervical manipulation program (CMP) or a comprehensive manipulation program (cervical spine, cervicothoracic junction, and thoracic spine). After treatment (7 day follow-up), those in the CMP program demonstrated a decrease in pain from 4.8 to 2.7, NDI from 23.7 to 16.8, and increased ROM in all planes. While these values did reach statistical significance and this does lend evidence in support of cervical manipulation, those in the comprehensive program did achieve a greater reduction in disability than the CMP group. This lends support to a thorough manual therapy approach, but does not necessarily discredit the use of manipulation. With so many options available to the treating clinician, how do we know when to use manipulation?
Tseng et al investigated what predictors helped to identify those patients who would demonstrate immediate reduction in pain intensity, significant perceived improvement, and/or a high satisfaction level following cervical manipulation. After analyzing the outcomes of the 100 patients included and grouping them into either the ‘responder’ or ‘non-responder’ group, 6 variables were determined to be predictors of a positive response. These variables included initial scores on Neck Disability Index < 11.5, having a bilateral involvement pattern, not performing sedentary work greater than 5 h/day, feeling better while moving the neck, did not feel worse when extending the neck, and the diagnosis of spondylosis without radiculopathy. If 4 of these variables were present, the probability of success increased from 60% to 89% following manipulation. More recently, Puentedura et al conducted a similar study attempting to develop a clinical prediction rule identifying those who would respond favorably to cervical manipulation. Eighty-two consecutive patients presenting to an outpatient physical therapy clinic received manipulation of the cervical spine. Of the patients in this study, only 32/82 (39%) reported a favorable outcome. However, of those 32 who met the criteria for a favorable response, there were 4 variables that proved to be predictive. These items included symptom duration less than 38 days, positive expectation that manipulation will help, side-to-side difference in cervical rotation range of motion of 10° or greater, and pain with posteroanterior spring testing of the middle cervical spine. When > 3 of the 4 variables were present, the likelihood of a positive response increased from 39% to 90%. These are overwhelmingly positive findings, but it must be noted that these are merely preliminary findings and further supplemental research needs to be conducted in order to validate Puentedura and colleagues’ findings.
Many clinicians will argue that cervical manipulation should be abandoned in favor of less ‘dangerous’ interventions. The justification is primarily due to a lack of overwhelmingly superior outcomes compared to thoracic manipulation and/or cervical mobilization. While theoretically, these may be considered more conservative, are the outcomes really the same? Puentedura et al evaluated the outcomes of cervical manipulation versus those of thoracic manipulation in a small RCT. At the conclusion of the study, patients randomized to the cervical manipulation + exercise (CME) group demonstrated superior improvement in pain and disability in comparison to the thoracic manipulation + exercise group (TME). Additionally, there were no serious adverse events reported for either group, however the TME group reported significantly more side effects than the CME group (8 side effects versus 1). So, can we honestly say thoracic manipulation is safer and equally effective? This study seems to disagree. While this was a very small study (n = 24) and all subjects were treated by one clinician, it still offers sufficient evidence to compare the two interventions.
The second intervention that is typically used in place of manipulation is a lower grade joint mobilization (grades I-IV). Dunning et al set out to determine whether a combination of thoracic and cervical thrust manipulation was more effective than non-thrust techniques. At follow-up (48 hours post intervention), those in the manipulation group demonstrated superior improvements in disability, pain, atlatoaxial ROM, and motor performance of the deep neck flexor musculature. While this study only included data immediately following treatment, the benefits of manipulation seem to outweigh those of joint mobilization (in the short-term at least). This study is in agreement with an older study (Cassidy et al) that directly compared the short-term effects of cervical manipulation to mobilization. Both groups demonstrated similar improvements in ROM, but the manipulation group yielded superior improvements in pain intensity. However, contrary to the findings of these two studies, there have also been several studies that have found a lack of significant improvements between manipulation and mobilization. Hurwitz et al, Boyles et al, and Leaver et al all found a lack of discernible improvement in patient outcomes between manipulation and mobilization. Additionally, Saavedra-Hernández et al conducted a RCT comparing the effects of cervical manipulation to those of Kinesiotape in patients with mechanical neck pain. Both groups had similar reductions in neck pain and cervical ROM… This does not lend supporting evidence to Kinesiotape, rather it provides evidence against manipulation. Understandably, it is easy to use the findings of these studies as evidence to support the avoidance of manipulation, but what key concept are all of these studies lacking?
Cervical manipulation, actually manipulation in general, is not an intervention that should be used with every patient presenting with a particular diagnosis. There are specific sub-groups where manipulation is highly beneficial and then there are patients that will show no improvement with its use. Look at the Cochrane Review published on spinal manipulation for low back pain (LBP)… It was determined that, when analyzing all of the data, manipulation was no better than other inert interventions. However, based on the most recent developments in sub-grouping and treatment-based classification, matched treatment with regards to manipulation results in a positive likelihood ratio of 13.2. This is why one of the caveats included within the Cochrane Review is that more research needs to be done looking into the benefits of sub-grouping within this patient population. This is the route that cervical manipulation and its subsequent research needs to take (recent studies by Puentedura et al are a step in the right direction). As seen by the early results (improving probability of benefit from 39% to 90%), those patients who are likely to respond deserve to be provided the appropriate intervention. Not all patients need manipulated. In fact, not very many will need cervical manipulation at all, but to eliminate the intervention from those who will likely benefit seems counterproductive to me.
Based on the risk (albeit very minimal) and similar therapeutic effects from other seemingly less provocative interventions, I propose that cervical manipulation should be a potential intervention, but only for specific patient presentations. In general, I believe if you have exhausted other typical treatment approaches and the patient has not responded adequately, it may be time to consider more aggressive methods. My treatments are determined based on patient presentation and response to treatment, but if possible I try to progress from distal to proximal and from low grade to high velocity low amplitude in terms of manual therapy interventions. In addition, motor control, stabilization, and direction preference exercises must not be left out. As seen in several studies throughout this article, benefits are far superior when coupled with appropriate therapeutic exercise… This is further supported by a systematic review conducted by Gross et al who found combined treatment (manual therapy + exercise) to be superior to any treatment in isolation. It is our job as clinicians to develop and implement a comprehensive program utilizing manual therapy, exercise, pain modulation, and our patient’s beliefs and experiences. Use best evidence and clinical reasoning to determine an appropriate plan of care and your patient will demonstrate far superior outcomes compared to any intervention in isolation.
Thoracic Manipulation → Cervicothoracic Manipulation → Cervical Mobilization (Grade III/IV) → Meet CPR? → Cervical Manipulation (Grade V)
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Research Review: Effectiveness of Physical Therapist Administered Spinal Manipulation for the Treatment of Low Back Pain
In the December issue of the International Journal of Sports Physical Therapy, Chad Cook, PT, PhD, MBA, FAAOMPT and 5 students from Walsh University conducted the first-ever systematic review investigating the effectiveness of spinal manipulation performed by physical therapists on the treatment of low back pain (LBP). In addition to analyzing effectiveness, they also investigated the prevalence of adverse effects following manipulative interventions… [Continue Reading]
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Neck pain is a debilitating and all too common issue worldwide. According to a systematic review published by Cote et al, the annual prevalence of neck pain in Quebec City is 48%, 27% in Norway, and 34% in the UK. Subsequently, a limitation in activities of daily living was found in between 11-14% of individuals. An additionally alarming statistic is that 50% of these individuals who suffer from neck pain still have symptoms 12 months after onset. Silverstein et al looked at workers compensation claims in the state of Washington between the years of 1990 and 1998. According to their data, 40.1/10,000 full-time equivalents (FTEs) reported claims for soft-tissue neck pain. This same study found that 19.1/10,000 FTEs missed 4 or more days of work secondary to neck pain. This tells us that neck pain is anything but a ‘self limiting’ disorder, but what are we doing to treat these patients?
Treatment approaches differ between clinicians and professions, but many include various forms of exercise, pain modulation, soft-tissue mobilization, joint mobilization, and the ever controversial cervical manipulation…
Cervical manipulation is the staple of the chiropractic profession, but is also utilized by physical therapists, osteopathic physicians, and other healthcare professions. As beneficial as these manipulative techniques appear to be, they are constantly the focus of media and medical scrutiny, but is it warranted? According to Di Fabio et al, between the years of 1925 and 1997, there were 177 cases of serious injury and 32 mortalities associated with cervical spine manipulation (CSM). The most publicized and discussed adverse events come in the forms of Cervical Artery Dissection (CAD) or Vertebral Artery Dissection (VAD). Lee et al performed an epidemiological study attempting to determine the incidence and prognosis of CAD and VAD. The general incidence of VAD is only 0.97 per 100,000 and CAD was only slightly more common at 2.6 per 100,000 people. With such a low incidence, what is the general risk of causing a severe adverse event as a result of manipulation? There have been a few studies published in recent years with reported incidences of <1/5,000,000 manipulations (Jaskoviak et al), 1/50,000 (Gutmann et al), 1/383,750 (Dvorak et al), <1/518,886 (Patijn et al), 1/3,800,000 (Carey et al), and 1/200,000 (Haynes et al). In addition to these older studies, Gouveia et al conducted a systematic review of the literature from 1966 to 2007 and after review of 46 studies, they concluded the frequency of serious adverse events varied between 5 strokes/100,000 manipulations to 1.46 serious adverse events/10,000,000 manipulations and 2.68 deaths/10,000,000 manipulations. Just to clarify, these statistics do not mean that cervical manipulation CAUSED the adverse event, only that the adverse event was associated with a recent manipulation.
Common symptoms associated with VAD include headache and neck pain, so isn’t it reasonable to assume that these strokes are not caused by the aforementioned interventions, but that these patients are just more likely to seek care for their presumed musculoskeletal symptoms? Cassidy et al investigated just that hypothesis. They found that VAD in those < 45 years old was 3 times more likely when recently visiting a chiropractor OR primary care physician (PCP). In those patients > 45 years old, there was no association between a chiropractic visit and VAD, however there was an association between PCP visits and VAD. So are PCPs somehow causing their patients to have cerebrovascular events? Common sense would dictate that these associations are simply due to ‘at risk’ patients seeking help from those qualified to treat them, regardless of intervention. All this being said, could these adverse events be prevented or predicted?
In a thorough review of 134 case reports of adverse events following cervical manipulation, Puentadura et al tried to determine how many cases could have been prevented and under what circumstances the events typically occurred. Of the cases reported, chiropractors were the practitioners in 93 cases, osteopaths in 11 cases, non-clinicians in 9 cases, physical therapists in 5 cases, a naturopath in 1 case, and unknown practitioners in 15 cases. Chiropractors were involved in the vast majority of cases, but this is likely secondary to their increased utilization of CSM compared to other professions. After evaluation of each case, the investigators determined whether CSM was indicated or unnecessary and whether the event was preventable based on presence of contraindications and/or red flags. According to their data, 44.8% of cases could have been prevented had a thorough examination and history been taken. Additionally, of the 7 deaths included, 4 could have been prevented, 1 was unpreventable, and 2 were unknown (lack of adequate information within case report). At the most recent IFOMPT Conference in Quebec City, a document written by Rushton et al was created to provide a framework for pre-manipulative evaluation. The following lists are typical historical findings in those patients that should be contraindicated from manipulation or are at risk for disorders that may become worse following manipulation:
- Multi-level nerve root pathology
- Worsening neurological function
- Unremitting, severe, non-mechanical pain
- Unremitting night pain (preventing patient from falling asleep)
- Relevant recent trauma
- Upper motor neuron lesions
- Spinal cord damage
Risk Factors of CAD:
- Past history of trauma to cervical spine / cervical vessels
- History of migraine-type headache
- Hypercholesterolemia / hyperlipidemia
- Cardiac disease, vascular disease, previous cerebrovascular accident or transient ischaemic attack
- Diabetes mellitus
- Blood clotting disorders / alterations in blood properties (e.g. hyperhomocysteinemia)
- Anticoagulant therapy
- Long-term use of steroids
- History of smoking
- Recent infection
- Immediately post partum
- Trivial head or neck trauma
- Absence of a plausible mechanical explanation for the patient’s symptoms
Risk Factors of Upper Cervical Instability:
- History of trauma (e.g. whiplash, rugby neck injury)
- Throat infection
- Congenital collagenous compromise (e.g. syndromes: Down’s, Ehlers-Danlos, Grisel, Morquio)
- Inflammatory arthritides (e.g. rheumatoid arthritis, ankylosing spondylitis)
- Recent neck/head/dental surgery
Outside of the identification of contraindications and red flags through patient history and subjective interview, is there evidence to support the use of pre-manipulation physical evaluation in identifying or reducing the prevalence of adverse events? Carlesso et al conducted a survey of Member Groups and Registered Special Interest Groups within the IFOMPT trying to identify how often clinicians performed pre-manipulation Vertibrobasilar Insufficiency (VBI) testing. Of the surveys that were returned, 77% of respondents did perform pre-manipulative screening for VBI. Unfortunately, despite the prevalence of pre-manipulation physical examination, there may not be evidence to support its efficacy. According to Mitchell et al, the most provocative and reliable positional test for VBI is sustained end-range rotation. This test may be of benefit, however research is lacking regarding how predictive or how reliable this test actually is. This examination is meant to maximize the occlusion of the vertebral artery, but is this too intense for those ‘at risk’ patients? In my opinion, this test puts patients into a much more dangerous position than most manipulative techniques ever will. This test alone may stress the vertebral artery beyond its limit and may predispose patients to the condition we are attempting to screen for. In fact, a biomechanical study conducted by Herzog et al determined that vertebral artery strain was significantly higher during diagnostic and range of motion testing compared to high velocity, low amplitude cervical manipulation.
Cervical manipulation is an effective means to decrease pain and improve function in patients suffering from mechanical neck pain and, based on the current evidence, is a generally safe intervention. The incidence of adverse events is minimal and, through adequate screening and evaluation, most adverse events can be prevented. There is still an inherent risk, as 10.4% of adverse events were unpreventable (Puentadura et al), but as previously mentioned, these are only associations. Many of these cases may have simply been a case of individuals presenting with seemingly mechanical symptoms (neck pain and headache), but were truly demonstrated preliminary symptoms associated with CAD. The well-informed clinician will take into consideration the patient’s prior medical history, current symptomology, comorbid conditions, and physical examination findings prior to performing any intervention aimed at the cervical spine. Through the use of sound clinical reasoning and after taking adequate precautions, I do believe the juice is worth the squeeze and my next post will delve a little more into why.
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