Development of a Clinical Prediction Rule to Identify Patients With Neck Pain Likely to Benefit From Thrust Joint Manipulation to the Cervical Spine

Abstract

Study Design Prospective cohort/predictive validity study. Objective To determine the predictive validity of selected clinical examination items and to develop a clinical prediction rule to determine which patients with neck pain may benefit from cervical thrust joint manipulation (TJM) and exercise. Background TJM to the cervical spine has been shown to be effective in patients presenting with a primary report of neck pain. It would be useful for clinicians to have a decision-making tool, such as a clinical prediction rule, that could accurately identify which subgroup of patients would respond positively to cervical TJM. Methods Consecutive patients who presented to physical therapy with a primary complaint of neck pain completed a series of self-report measures, then received a detailed standardized history and physical examination. After the clinical examination, all patients received a standardized treatment regimen consisting of cervical TJM and range-of-motion exercise. Depending on response to treatment, patients were treated for 1 or 2 sessions over approximately 1 week. At the end of their participation in the study, patients were classified as having experienced a successful outcome based on a score of +5 (“quite a bit better”) or higher on the global rating of change scale. Sensitivity, specificity, and positive and negative likelihood ratios were calculated for all potential predictor variables. Univariate techniques and stepwise logistic regression were used to determine the most parsimonious set of variables for prediction of treatment success. Variables retained in the regression model were used to develop a multivariate clinical prediction rule. Results Eighty-two patients were included in data analysis, of whom 32 (39%) achieved a successful outcome. A clinical prediction rule with 4 attributes (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) was identified. If 3 or more of the 4 attributes (positive likelihood ratio of 13.5) were present, the probability of experiencing a successful outcome improved from 39% to 90%. Conclusion The clinical prediction rule may improve decision making by providing the ability to a priori identify patients with neck pain who are likely to benefit from cervical TJM and range-of-motion exercise. However, this is only the first step in the process of developing and testing a clinical prediction rule, as future studies are necessary to validate the results and should include long-term follow-up and a comparison group. Level of Evidence Prognosis, level 2b. J Orthop Sports Phys Ther 2012;42(7):577–592, Epub 14 May 2012. doi:10.2519/jospt.2012.4243

Placebo, Nocebo, and Expectations: Leveraging Positive Outcomes

“…The outcomes of this study are consistent with the findings of the study by Puentedura et al 12 that positive expectations are of prognostic value for predicting favorable outcomes. The authors note that patients will prefer particular treatments because of an expectation of benefit from that treatment.…”

Immediate Changes in Widespread Pressure Pain Sensitivity, Neck Pain, and Cervical Range of Motion After Cervical or Thoracic Thrust Manipulation in Patients With Bilateral Chronic Mechanical Neck Pain: A Randomized Clinical Trial

“…Finally, we assessed potential adverse effects of the spine thrust manipulation at short-term follow-up (1 week). 37 Few patients (3%) reported adverse effects after the cervical spine thrust manipulation, which is a lower percentage than that of a previous study 44 but similar to others. 37,38 This may be related to the restrictive inclusion criteria of the current study or the fact that we only included a short-term follow-up period for adverse effects, as it has been suggested that adverse events can occur up to 1 month after treatment.…”

Evidence-Based Physical Medicine and Rehabilitation Strategies for Patients with Cervical Radiculopathy Due to Disc Herniation

“…As a useful base for making decisions whether to apply or for which individuals to consider thrust manipulation, an attempt has been performed to identify those who would potentially benefit from manipulation. Among the four clinical criteria, duration of symptoms less than 38 days, expectation of the helpfulness of manipulation, a 10° or more difference of cervical rotation range of motion between sides, and provocation of pain with posteroanterior spring test, the presence of three or four criteria was found to improve the probability of success of thrust manipulation from 39% to 90% in patients with neck pain complaints without the exclusion of discogenic neck pain, but with the exclusion of them with two or more positive nerve root compression signs (60). Regarding safety of cervical manipulation, which is also a very important issue, a systematic review reported no serious adverse events resulting from the use of cervical manipulation except for minor ones, including transient neurological deficits and an increase in neck pain.…”