1. Manual therapy for the Cervicothoracic Spine

2. Objectives Research that supports manual therapy for neck pain
Mobilization versus manipulation
Thoracic manipulation for neck pain
Examination Considerations

3. Evidence Based Practice
The integration of best RESEARCH EVIDENCE with CLINICAL EXPERTISE and PATIENT VALUES
Best research evidence
Clinical expertise
Patient values
Sackett 2000

4. Neck Pain Clinical Practice Guidelines: Manual Therapy to the Cervical Spine

5. Manual Therapy and Exercise for Neck Pain
Systematic review findings (Miller 2010)
1) Mobilization/manipulation = short-term pain relief
2) Exercise improves long-term pain levels and disability
3) Effects mobilization = to manipulation

6. What do we call it? Manipulation
High velocity, low amplitude thrust manipulation
Adjustments
Grade V mobilization

7. Mechanisms of Manipulation
How does it work?

8. Mechanisms of Manipulation
Biomechanical
Neurophysiologic
Psychological

9. Mechanisms of Manipulation (Bialosky, 2009)

10. Biomechanical Mechanisms (Cleland, 2012)
Evidence exists that manual therapy causes:
Vertebral movement
Gapping of facets
Increased intervertebral motion
However…
Only short term changes
Changes are not site specific
No changes in alignment

11. Neurophysiologic Mechanisms
The peripheral nervous system
Decreases inflammatory mediators (Teodorczyk-Injeyan, 2006)
Spinal cord
Effects afferent discharge (Maliza, 2003)
Promotes hypoalgesia (Mohammadian, 2004)
Supraspinal
Autonomic response
Endocrine response
Dry needling has eerily similar responses…

12. Effects of Manipulation on the Brain (Sparks, 2013)
Functional MRI on healthy subjects to measure blood flow to areas of the brain responsible for pain perception pre- and post-manipulation of the thoracic spine
Anterior cingulate, frontal and somatosensory cortices

13. Effects of Manipulation on the Brain (Sparks, 2013)
Manipulation to the thoracic spine decreased blood flow to the brain’s areas of pain perception and was associated with decreased pain and the numeric pain rating scale with pain threshold testing. WHOA!

14. Psychological effect?
Patients who are given positive expectation for manipulation had the highest change in pain level following treatment

15. Patient Expectations of Common Interventions for Neck Pain
Bishop 2013

16. Placebo effect
General placebo response rate 42.6% in a recent meta-analysis (Dorn, 2007)
Appropriate placebo in manual therapy studies is controversial

17. “If a patient’s expectation could cause harm (e. g
“If a patient’s expectation could cause harm (e.g., and early magnetic resonance imaging scan the patient doesn’t need), the onus is then on each of us to reshape the patient’s beliefs to be consistent with best practice.”
- Laurence Benz and Timothy Flynn

18. Mechanisms Summary
Biomechanical, neurophysiologic, psychological factors (expectations) and placebo response all likely contribute to effects of manual therapy
Encourage patient with positive expectations of evidence-based treatments
Embrace the placebo effect!

19. CERVICAL MANIPULATION VS MOBILIZATION

20. Cervical Mobilization vs. Manipulation (Boyles 2010)
Secondary analysis of a randomized, controlled trial
47 patients with mechanical neck pain, all given home program
One group received cervical mobilization, the other cervical manipulation
No significant difference in outcomes pain and disability
BOTH GROUPS IMPROVED!

21. Cervical Mobilization vs. Manipulation (Boyles 2010)

22. Cervical Mobilization vs. Manipulation (Boyles 2010)

23. Cervical Mobilization vs. Manipulation (Leaver 2010)
182 patients with non-specific neck pain < 3 months duration
Randomly assigned into a neck mobilization or manipulation group
Outcome measure: number of days required to recover from neck pain

24. Cervical Mobilization vs. Manipulation (Leaver 2010)
Days to recovery
Manipulation group = 47 days
Mobilization group = 43 days
NOT statistically significant

25. 107 with neck pain (any duration) patients randomized into 2 groups
Upper cervical and upper thoracic manipulation
Upper cervical and upper thoracic mobilization
Outcome measures: NDI, pain, passive mobility, DNF strength
110 with neck pain (any duration) patients randomized into 2 groups
Upper cervical and upper thoracic manipulation
Upper cervical and upper thoracic mobilization combined with exercise

26. Cervical Mobilization vs. Manipulation (Dunning 2012 and 2016)

27. Cervical Mobilization vs. Manipulation (Dunning 2012)

28. Manipulation wins (in the short-term) for neck pain Dunning 2012
Manipulation group had decreased at 48 HOUR follow-up
Pain
Disability (NDI)
Range of motion restriction (cervical flexion and rotation test)
Impairment of the upper cervical spine

29. Manipulation wins for Cervicogenic HA Dunning 2016
50% reduction in HA intensity 74% vs 38% 75% reduction in HA intensity 48% vs 13% 100% reduction in HA intensity 29% vs 4% Similar number for NDI score

30. Thoracic Manipulation for Neck Pain

31. Neck Pain Clinical Practice Guidelines: Manual Therapy to the Thoracic Spine

32. TM may provide improvement for pain and disability in acute and subacute mechanical neck pain
Dry needling/ acupuncture for chronic pain?

33. Clinical Prediction Rule: Thoracic Manipulation for Mechanical Neck Pain
Cleland 2007

34. Validation of the CPR for Thoracic Manipulation and Neck Pain
Cleland 2010

35. No surprise
Cleland 2009

36. RCT of 120 patients with chronic symptoms Outcome measures: NPRS, NDI and self reported function Conclusions: TM was effective in decreasing pain and increasing function up to 6 months post intervention

37. Why does TM work for patients with neck pain?
Tsang (2013) concluded that the upper thoracic spine contributes significantly to neck movement Highest involvement of the thoracic spine with cervical flexion and extension, lowest with rotation

38. Cervical vs. Thoracic Manipulation for Neck Pain

39. Cervical vs Thoracic Manipulation for Neck Pain Puentedura (2011)
Selected patients with neck pain who met the CPR for thoracic manipulation (24 of 96 patients)
Randomized into 2 groups
Thoracic manipulation
Cervical manipulation

40. Puentedura 2011

41. Cervical vs Thoracic Manipulation for Neck Pain Puentedura (2011)

42. Examination: A Manual Therapy Perspective

44. Examination (Childs 2008)
Outcome measures Neck disability index Patient specific functional scale

45. Examination – Screening
Kerry (2009) proposed individuals who have a serious adverse events related to cervical manipulation may be those who actually present with undiagnosed vascular conditions

46. Examination – Screening
Upper ligamentous testing
Alar ligament stress test
Transverse ligament stress test
Sharp-Purser test
Mintken 2008

47. Examination – Screening
Upper ligamentous testing
Alar ligament stress test
Transverse ligament stress test
Sharp-Purser test
Mintken 2008

48. Examination – Screening
Upper ligamentous testing
Alar ligament stress test
Transverse ligament stress test
Sharp-Purser test
Mintken 2008

49. Mintken 2008

50. Sharp-purser, alar ligament, transverse ligament test
Tests showed acceptable specificity
Clinical value is limited
SENSITIVITY is most important for screening tests, preventing false-negatives

51. Examination – Cervical Radiculopathy
Clinical prediction rule for cervical radiculopathy (Wainner 2003)
Positive Spurling’s test
Positive distraction test
<60 degrees of cervical rotation to one side
+ upper limb tension test in the median distribution

52. Examination – Mobility Testing
Active range of motion
Passive range of motion
Upper cervical rotation testing
Passive intervertebral mobility testing
Cervical spine – prone
Thoracic spine – prone
Upper cervical rotation test (figure from The Cervical Spine: Current Concepts of Orthopedic Physical Therapy, 3rd Edition) – assesses quantity of upper cervical rotation

53. OA Joint Passive Testing

54. Upper Cervical Rotation Test
Patient is supine
Neck is passively and maximally flexed
Neck is rotated passively to end range
Assess pain and ROM

55. Upper Cervical Rotation Test
Reliability
Kappa: 0.81 (good kappa scores are between 0.4 and 0.6)
Diagnostic accuracy
Sensitivity: 91%
Specificity: 90%
Normal range of motion
39-45°
Ogness 2007

56. Cervical Rotation, Lateral Flexion Test (CRLT)
Patient is seated
Neck is maximally rotated followed by lateral flexion toward the chest
End feel and range of motion is assessed
Positive test may indicate elevated or hypomobile 1st rib

57. 2 physiotherapists independently judged general and intersegmental mobility C0-T2 of 32 patients with non-specific neck pain
Only 2 of the 29 measures achieved acceptable reliability
Patient were not able to consistently report pain levels at same vertebral level after 15 minute break
So…can we base our manual therapy decision- making on mobility testing?

58. Is Cervical Manipulation Worth the Risk?

59. Why the heck are we so worried?

60. Adverse Events Associated with Cervical Spine Manipulation
Puentedura (2012) review 134 documented cases of serious adverse events 44% of the documented cases were reviewed and deemed “preventable” 10% of cases were deemed “unpreventable” Conclusion: some inherent risk to cervical spine manipulation

61. Adverse Events Associated with Cervical Spine Manipulation
Holdeman (1999) and Hurwitz (1996) report the risk of serious adverse events ranges between 1 and 400,000 to 3-6 in 10,000,000 manipulations

62. Its all about perspective http://www. pbs

63. Puentedura et al (2012)

64. Thomas 2015

65. Pain distribution of cervical artery dissection

67. Summary of the Thomas Study
“…minor mechanial trauma or strain to the head or neck may be associated with dissection”
General cardiovascular risk factors (except migraine) were not important risk factors
67% of patients with a CAD reported ischemic neurological features in the month prior to dissection
Dizziness, imbalance, limb weakness, ptosis

68. Blood flow to the brain was NOT compromised in positions commonly used in manual therapy

69. Thomas 2013

70. The Aim
“guide clinical reasoning for the assessment of the cervical region for potential of CAD prior to planned OMT interventions…”

71. Patient history
Red flags worsening neurologic function unremitting, severe, non-mechanical pain history of trauma congenital collagenous disorders

72. 5 Screening Recommendations for CAD
Evaluate blood pressure – acute arterial trauma?
Upper cervical instability testing
Peripheral and Cranial nerve testing – neuroexam.com
Provocative testing – low sensitivity, high specificity (Hutting 2013)
Palpation of the carotid artery

73. Risk:Benefit Analysis
Risk:benefit analysis and balance of probabilities
Risk:Benefit Analysis

74. 465 patients
60% reported at least 1 side effect
Began an average of 4 hours following treatment, disappeared within 24 hours
Headache had a higher association with upper cervical manipulation

75. Who’s cervical spine do we manipulate?

76. Pretest Probability of Success with Manipulation
Lumbar – 49%
Thoracic – 54%
Cervical – 39%
What is pretest probability?
Why the differences?

77. Variables that met the CPR
Symptom duration <38 days
Positive expectation that manipulation will help
Side-to-side difference in cervical rotation ROM 10⁰ or greater
Pain with PA spring testing of the middle cervical spine
Which is the strongest predictor?

78. Posttest probability of success
3 or 4 out of 4 variables present = 90%
+ LR ratio 13.5
2 out of 4 variables present = 68%
1 out of 4 variables = 43%

79. Cervicothoracic Technique Considerations

80. Joint Cavitation during Manipulation: Necessary for optimal outcomes?

81. No pop
Cleland (2007): no relationship between the number of audible pops and outcomes during thoracic TM for patient with neck pain

82. Pro Pop
Greater hypoalgesia present in the LE following lumbar HVLA with cavitation (Bialosky 2010) Greater placebo effect? 2 of the 3 pillar of EBP achieved – clinician experience and patient values

83. What is the pop? The Bubble Theory Bubble forms
(Unsworth, 1971)
joint space with force
pressure in joint
CO2 changes from liquid to gas
Bubble forms
Bubble pops and makes noise!

84. The Inception Theory What is the pop?
(Kawchuck, 2015)
As traction force increases, cavity inception occurs
Liquids change to gas rapidly and create sound
No collapsing of a pre-existing bubble

85. Tribonucleation!

86. High vs. Low Mobilization Forces
Snodgrass (2014) compared high (90 N force) and low (30 N force) mobilization forces in patient with neck pain
Measured pain pressure threshold, pain levels, stiffness and cervical ROM at baseline, immediately after treatment and 4 days after treatment
No difference immediately following treatment with increased soreness in the high force group

87. High vs. Low Mobilization Forces
Lower pain levels in the high force group
Lower stiffness in the high force group

88. Joint mobilization reduces pain at rest and with most painful movement
Specific or non-specific mobilization? It depends!
The cervical spine may need more specific mobilization
The lumbar spine will benefit from non-specific mobilization

89. Summary of Clinical Research
Cervical mobilization and manipulation are both effective for treating acute, subacute, and chronic mechanical neck pain
Cervical mobilization and manipulation have similar effects on pain, ROM, and disability
Thoracic manipulation may be effective for short-term improvements in pain, range of motion and disability for those with mechanical neck pain
Serious adverse side effects are VERY RARE with cervical manipulation
Side effects with cervical manipulation are typically mild and of short duration

90. Don’t forget the exercise!

91. References – Cervical Spine
Bialosky J, Bishop MD, Robinson ME, George SZ. The relationship of the audible pop to hypoalgesia associated with high-velocity, low-amplitude thrust manipulation: a secondary analysis of an experimental study in pain-free participants. Jour Man and Manip Ther ; (33):
Cleland J. The cervical spine. Current concepts of orthopaedic physical therapy
Cleland J. The audible pop from thoracic spine TM and its relationship to short-term outcomes in patients with neck pain. JMMT. 2007;15(3):
Childs J, et al. Neck Pain Clinical Practice Guidelines. JOSPT. 2008;38:A1-34.
Cross et al. Thoracic spine manipulation improves pain, range of motion, and self reported function in patients with mechanical neck pain: a systematic review. JOSPT ;41:
Dunning JR, et al. Upper cervical and upper thoracic thrust manipulation versus nonthrust mobilization in patients with mechanical neck pain: a multicenter randomized clinical trial. JOSPT. 2012;42:5-14.
Holdeman S, Kohlbeck FJ, McGregor M. Risk factors and precipitating neck movements causing vertebrobasilar artery dissection after cervical trauma and spinal manipulation. Spine.1999;24(8):
Hurwitz EL, Aker PD, Adams AH, Meeker WC, Shekelle PG. Manipulation and mobilization of the cervical spine: a systematic review of the literature. Spine ;21(15):
Jette AM, Smith K, Haley SM, Davis KD. Physical therapy episodes of care for patients with low back pain. Phys Ther. 1994;74: ; discussion
Kerry R, Taylor AJ. Cervical arterial dysfunction: knowledge and reasoning for manual therapists. JOSPT. 2009;39:
Leaver AM, et al. A randomized controlled trial comparing manipulation with mobilization for recent onset neck pain. Arch Phys Med Rehab. 2010;91:
Miller. Physical therapy patient management utilizing current evidence. Current concepts of Orthopaedic Physical Therapy
Thomas LC, et al. Effect of selected manual therapy interventions for mechanical neck pain on vertebral and internal carotid arterial blood flow and cerebral inflow. Phys Ther. 2013; 93:

92. Manual Therapy for the Lumbar Spine

93. Deliberate practice
Its designed to improve performance It can be repeated A LOT Feedback of results is continuously available Its highly demanding mentally It isn’t much fun

94. Blow our minds talking about segmental mobility testing
Objectives
Review red and yellow flags – identifying who’s lumbar spine not to manipulate
Blow our minds talking about segmental mobility testing

95. Red Flags
Examination findings that may warrant referral for further evaluation and testing
Non-mechanical causes of low back pain are infrequent in the primary care setting (Flynn, 2011)
0.7% cancer
4% fracture
0.01% spinal infection

96. Cancer as a Cause of Back Pain, Deyo, J. Internal Med, 1988
Red Flags
History Sn Sp
+LR
-LR
Age >50
.77
.71
2.7
0.3
Unexplained weight loss
.15
.94
0.9
Previous history of cancer
.31
.98
14.7
0.7
No relief with treatment over the past month
.90 3
0.8
Cancer as a Cause of Back Pain, Deyo, J. Internal Med, 1988

97. Red Flags: Compression Fracture
Subjective report
+ LR LR
History of major trauma
12.8
0.37
Age over 50
2.2
0.34
Age over 75
0.59
0.84
Prolonged use of corticosteroids NR
Point tenderness over fracture site
Increased pain with weight bearing

98. Red Flags: Other Conditions
Cauda equina syndrome
Urinary retention has a +LR of 18.0
Back-related infection
Suspect with presence of a fever, recent infection
Abdominal aneurysm
High sensitivity with palpation of abdominal aortic pulse

99. Yellow Flags
“…factors that increase the risk of developing, or perpetuating long term disability and work loss associated with low back pain.”
- Kendall et al, 2002

100. Yellow Flags
Emotional distress Hypervigilance - preoccupation with pain Pain catastrophizing - overestimating negative impact of pain Elevated fear-avoidance Low self efficacy - belief that one has no control over pain Misunderstanding about the nature and impact of pain Belief condition is more serious than is actually the case Misunderstanding the best strategies for long-term success
Beattie (2012)

101. Yellow Flags 2-Item Depression Screening Questions
1) During the past month have you been feeling down, depressed, or hopeless?
2) During the past month have you been bothered by having little interest or pleasure in doing things?
- Is this something you would like help with?

102. Fear Avoidance Beliefs Questionnaire (FABQ)
Measures patients fear-avoidance beliefs regarding low back pain
Work (scores range from 0-42) and physical activity (scores range 0- 24) subscales
Cut-off scores
>29 on the work subscale is an indicator of poor return to work
>14 on the physical activity subscale is an indicator of poor outcomes with treatment

103. Dermatomes
Facet Joint Referral
SI Joint Referral

104. Trigger Point Referral Patterns

105. Oswestry Disability Index (ODI)
10-item scale with questions regarding pain and function
Total score out of 50 and reported as a percentage
MCID 4-6 points
Beurskens AJ, de Vet HC, Koke AJ. Responsiveness of functional status in low back pain: a comparison of different instruments. Pain. 1996;65:71–76.

106. Lumbar Segmental Mobility Testing
The wonder and mystery of
Lumbar Segmental Mobility Testing

107. Segmental Mobility Testing
Reliability for individual segments is poor
ICC of 0.25 (Hicks 2003)
Reliability improves when making general assessment of spinal motion
Kappa 0.38 – 0.48 (Fritz 2005)
Reliability of pain provocation (painful segment) is moderate to good (Hicks 2003)
Kappa 0.25 – 0.55

108. Hicks (2003)

109. Agreement on painful segment is higher than hypomobile segment
Childs (2005)
Agreement on painful segment is higher than hypomobile segment

110. Fritz (2005)
General hypomobility has better agreement than specific segmental testing

111. Binkley (1995) Fair to poor intertester reliability for:
Locating a specific segment
average between raters is within 1.4 levels
Rating a specific segment as hypomobile

112. Downey (1999)
3 sets of manipulative physiotherapists assessed L1-5 and marked each level on 20 patients
κ = 0.69, weighted = 0.91
Conclusion: spinal level CAN be palpated accurately

113. Kulig (2004)
PA testing performed under functional MRI on asymptomatic individuals
Individual mobility assessment may not be possible
Treatment of a painful segment may be possible without direct mobilization

114. Kulig et al.(2005)
Performed lumbar PA testing within an MRI and outside of an MRI
Measured amount of motion at each level with MRI
Pain does not necessarily correlate with amount of mobility

115. Segmental Mobility Testing
MONDAY MORNING MESSAGE
Classify the lumbar spine as:
Normal
Hypomobile
Hypermobile
Note specific painful segments
This will be important later…
Consider treating painful segments with mobilization of adjacent segments

116. Who’s lumbar spine do we manipulate?

117. Manipulation Subgroup Criteria
No symptoms below the knee
Recent Symptoms (<16 days)
Lumbar Hypomobility
Low Fear-Avoidance
>35 degrees of hip internal rotation (at least 1 hip)
Childs 2007

118. Manipulation Subgroup Criteria
No symptoms below the knee
Recent Symptoms (<16 days)
Lumbar Hypomobility
Low Fear-Avoidance
>35 degrees of hip internal rotation (at least 1 hip)
Fritz (2005) found that these 2 subjective evaluation factors have a moderate to strong shift in likelihood that the patient will benefit from manipulation (+LR 7.2)

119. Lumbar Mobility Testing
Classify the lumbar spine as hypomobile, hypermobile, or normal
Segmental mobility testing has poor inter- rater reliability

120. Assessment of Hip Mobility
Measured in prone
> 35 degrees on at least one side fits prediction rule
Childs’ theory: lack of lumbar mobility compensated with hip mobility

121. Performing high velocity, low amplitude thrust manipulation to the lumbar spine

122. Do I need to hear a “pop”? Occurs in ~70-80% of manipulations
Flynn (2003) “The audible pop is not necessary for successful outcome with high velocity thrust manipulation in individuals with low back pain”
Results: no difference in outcomes for low back pain

123. Audible Pop and Hypoalgesia in a Healthy Population (Bialosky, 2011)
Hypoalgesia occurred regardless of audible pop Trend toward greater reduction in pain perception in the lower extremity with an audible pop

124. Does localization of a segment dictate successful manipulation?
Beffa and Mathews (2004) “Does the adjustment cavitate the targeted joint? An investigation into the location of cavitation sounds”
Technique targeted at L5 or S1 caused cavitation ranging from L3 to the PSIS

125. Does localization of a segment dictate successful manipulation?

126. Joint mobilization reduces pain at rest and with most painful movement
Specific or non-specific mobilization? It depends!
The cervical spine may need more specific mobilization
The lumbar spine will benefit from non-specific mobilization

127. Regional vs. Non-regional Manipulation (Fernando de Oliveira 2013)
Measured immediate effects of a single manipulation in 148 patients with chronic low back pain
Group 1
Group 2

128. So… does technique selection matter?
Reliability of biomechanical assessment
Reliability of spinal accessory mobility testing
General mobility testing more reliable than specific segmental testing
Identifying painful segment more reliable than “hypo-” or “hypermobile” segment
Regional vs. Non-regional manipulation effects
Location of cavitation
Does not necessarily occur at targeted level

129. References – Lumbar Spine
Beattie PF. Current concepts of orthopedic physical therapy, 3rd edition: The lumbar spine: physical therapy patient management utilizing current evidence. APTA, 2012.
Downey B, Taylor N, Niere K. Manipulative physiotherapists can reliably palpate nominated lumbar spinal levels. Man Ther ; 4:
Fritz JM, Whitman JM, Childs JD. Lumbar spine segmental mobility assessment: an examination of validity for determining intervention strategies in patients with low back pain. Arch Phys Med Rehabil. 2005;86(9): Epub 2005/09/27. doi: /j.apmr PubMed PMID:
Fukui S. Distribution of referred pain from the lumbar zygapophyseal joints and dorsal rami. Clin J Pain. 1997; 13:
Hicks GE, Fritz JM, Delitto A, Mishock J. Interrater reliability of clinical examination measures for identification of lumbar segmental instability. Arch Phys Med Rehabil ;84(12): Epub 2003/12/12. PubMed PMID:
Jaeschke R, Singer J, Guyatt GH. Ascertaining the minimal clinically important difference. Cont Clin Trials. 1989;10:407–415.
Kulig K, et al. Assessment of the lumbar spine kinematics using dynamic MRI: a proposed mechanism of sagittal plane motion induced by manual posterior to anterior mobilization. J Orthop Sports Phys Ther. 2004; 34(2):
Kulig K, et al. The relationship between lumbar segmental motion and pain response by a posterior to anterior force in persons with non-specific low back pain. J Orthop Sports Phys Ther. 2005;35(4): doi: /jospt
Majlesi J, et al. The sensitivity and specificity of the slump and straight leg raise tests in patients with lumbar disc herniation. Journal of Clinical Rheumatology ; (2):