Evidence Based Rehab

New Study Shows Manual Physical Therapy and Exercise ProducesSignificant Improvements in Neck Pain

ALEXANDRIA, VA, December 12, 2008 — The American Physical Therapy Association (APTA) is urging patients with musculoskeletal pain to consider treatment by a physical therapist, in light of a new federal survey showing that more than one-third of American adults and nearly 12 percent of children use alternative medicine - with back and neck pain being the top reasons for treatment. Results of the 2007 survey of more than 32,000 Americans were released December 11 by the National Institutes of Health's National Center for Complementary and Alternative Medicine.

According to APTA, physical therapy offers an evidence-based, time-tested solution to these common conditions in comparison to alternative treatments.
For neck pain, for example, a recent study published in the medical journal Spine found that when patients received up to six treatments of manual physical therapy and exercise, they not only experienced pain relief, but were also less likely to seek additional medical care up to one year following treatment.

"This study, demonstrating the efficacy of physical therapy for a condition as widespread as neck pain, is particularly relevant in today's challenging economic environment," according to the study's lead researcher and APTA spokesman Michael Walker, PT, DSc, OCS, CSCS, FAAOMPT. "The Kaiser Foundation, for instance, recently found that more than half of all Americans are not taking prescribed medication and postponing needed medical care in an effort to save money. It is important for consumers to know that there are effective, conservative solutions such as physical therapy available.1"

Walker's study compared the effectiveness of a three-week program of manual physical therapy and exercise to a minimal intervention treatment approach for patients with neck pain.
Study participants consisted of 94 patients with a primary complaint of neck pain, 58 (62%) of whom also had radiating arm pain. Patients randomized to the manual physical therapy and exercise group received joint and soft-tissue mobilizations and manipulations to restore motion and decrease pain, followed by a standard home exercise program of chin tucks, neck strengthening, and range-of-motion exercises. Patients in the minimal intervention group received treatment consistent with the current guidelines of advice, range-of-motion exercise, and any medication use prescribed by their general practitioner. Patients did not have to complete all six visits if their symptoms were fully resolved.
Sample exercises to relieve neck pain can be found on the APTA Web site, www.apta.org/consumer.

Results show that manual physical therapy and exercise was significantly more effective in reducing mechanical neck pain and disability and increasing patient-perceived improvements during short- and long-term follow-ups. These results are comparable with previous studies that found manual physical therapy and exercise provided greater treatment effectiveness (Hoving et al, 2002)2 and cost effectiveness (Kothals-de Bos et al, 2003)3 than general practitioner care.
"Physical therapist intervention can be an effective, high-value, conservative solution for treatment of musculoskeletal pain," said Walker.

"Physical therapists can help individuals improve mobility and quality of life without expensive surgery or the side effects of pain medication. We give patients the tools they need, such as the home program we used in the study, to help them prevent or manage a condition in order to achieve long-term health benefits."

Physical therapists are highly-educated, licensed health care professionals who can help patients reduce pain and improve or restore mobility — without expensive surgery or the side effects of medications. APTA represents more than 70,000 physical therapists, physical therapist assistants, and students of physical therapy nationwide. Its purpose is to improve the health and quality of life of individuals through the advancement of physical therapist practice. Learn more about conditions physical therapists can treat at www.apta.org/consumer, and find a physical therapist in your area at www.findapt.us.

1 http://www.kff.org/kaiserpolls/h08_posr102108pkg.cfm
2 Hoving JL, Koes BW, de Vet HC, van der Windt DA, et al. Manual Therapy, Physical Therapy, Or Continued Care by a General Practitioner for Patients with Neck Pain. Ann Intern Med 2002;136 (10):713-722
3 Korthals-de Bos IB, Hoving JL, van Tulder MW, et al. Cost effectiveness of physiotherapy, manual therapy, and general practitioner care for neck pain: economic evaluation alongside a randomised controlled trial. BMJ 2003;326 (7395):911

Labels: APTA, evidence based medicine, manipulation, Mobilization, neck pain

Seattle, Washington, October 30, 2008- Physical therapists from around the world are converging on Seattle this week for the annual conference of the American Academy of Orthopaedic Manual Physical Therapists (AAOMPT). Pain: From Science to Solutions, the conference theme, speaks to the unique role physical therapists have in combating pain. Pain from musculoskeletal problems such as back and neck pain is a leading cause of healthcare utilization. Manual physical therapy techniques such as spinal manipulation play an important role in pain relief for patients throughout the United States. Manual physical therapy includes the use of hands-on techniques including joint and soft-tissue mobilization designed to restore motion and reduce pain. AAOMPT members will be discussing emerging research suggesting that spinal manipulation has the ability to positively affect the brain’s processing of pain signals. Keynote speaker and distinguished researcher, Richard Deyo, MD, MPH, will open the conference. Dr. Deyo is the Kaiser-Permanente Endowed Professor in Evidence-Based Medicine, Oregon Health Science University Department of Family Medicine.

AAOMPT president, Tim Flynn, PT, PhD, said about the conference, “This is an exciting time for physical therapy and for health care. On one side, we have a tremendous amount of research emerging in support of manual physical therapy for pain relief, and on the other side we see the stars aligning for great change in the health care industry.” Flynn continued, “As a patient, your choices come down to drugs, surgery, or physical therapists. Physical therapists can offer a low-cost solution for patients with pain and high-quality research supports what we do.”

For more on the benefits physical therapists can provide in the management of back and neck problems, contact your nearest physical therapist or visit the American Academy of Orthopaedic Manual Physical Therapists website at www.aaompt.org. AAOMPT represents physical therapists by promoting excellence in orthopaedic manual physical therapy practice, education and research.

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Jason L. Harris

Labels: AAOMPT, evidence based medicine, manipulation, physical therapy

Tallahassee, Florida, October 20, 2008 – Neck pain is one of the top 10 reasons for a patient to visit a doctor. The lead article in the most recent issue Spine reports on the results of a randomized clinical trial which demonstrated that patients who received manual physical therapy and exercise had twice the improvement in symptoms compared to the current guideline group. The subjects in the study experienced both short and long term improvements in their neck pain. The study compared the use of manual therapy and exercise compared to the current guidelines of advice, rest, and range of motion. The results of this study are comparable to those reported by Hoving et al in 2002, which also demonstrated that manual physical therapy and exercise resulted in excellent clinical results in the treatment of neck pain while also providing a significant cost savings compared to usual physician care (Kothals-de Bos et al 2003). Manual physical therapy includes the use of hands-on techniques including joint and soft-tissue mobilization, designed to restore motion and reduce pain. Hurwitz et al (2008) concluded in a systematic review on neck pain also in the journal Spine, “Our best evidence synthesis suggests that therapies involving manual therapy and exercise are more effective than alternative strategies for patients with neck pain.”

Tim Flynn, PT, PhD, president of the American Academy of Orthopaedic Manual Physical Therapy, expressed confidence that, “This study broadens the base and depth of evidence that manual physical therapy is the first line treatment for patients suffering from neck and arm pain.” He continued, “Year after year the physical therapy profession continues to produce high quality randomized, controlled trials that demonstrate conclusively that our profession provides better outcomes for less money, while also being substantially safer than other medical interventions. Wake up America, to a new day without pain.” If you have neck or back pain or the aches and pains of musculoskeletal problems contact your local physical therapist today.

Jason L. Harris

Labels: AAOMPT, Direct access, evidence based medicine, manipulation, Mobilization

The APTA recently released an article on the benefits of seeing a Physical Therapist (PT) for back pain. They point out that despite a recent article in the Journal of the American Medical Association (JAMA) that even with rising costs associated with back pain there has been no improvements in care, PT's have an excellent track record with the public, and more importantly, in the literature showing our effectiveness in treating back pain with out surgery or drugs.

Consumers need to know that physical therapist management is a low-cost, high-value alternative to drugs and surgery to deal with musculoskeletal pain," said APTA President R Scott Ward, PT, PhD. "The judicious use of appropriate physical therapist treatment based on best evidence can improve the function of people who struggle with back and neck conditions." Ward added, "Because patients with chronic, disabling low back pain account for a disproportionate share of health care expenditures and workers' compensation costs, the potential cost savings of an early, effective intervention to prevent individuals from progressing to chronic disability may be considerable.

Here is the link to the press release.

Labels: AMA, APTA, evidence based medicine, LBP, Low back pain, manipulation, outcomes, physical therapist, physical therapy

I recently came across a paper entitled "A Case of a Potential Manipulation Responder Whose Back Pain Resolved with Flexion Exercises" by Stephen May, MSc and Richard Rosedal, PT, Dip MDT. They present a single patient case study of a LBP patient that met 4 of 5 of the manipulation CPR that drastically improved with flexion exercises but did not receive spinal manipulation.

The authors conclusion(s):

We have presented a case study that was positive for 4 of 5 items of the clinical prediction rule for manipulation responders, but this patient was successfully treated with flexion exercises. The clinical prediction rule may not represent a discrete subgroup but may include patients who can be defectively managed in other ways.

I think the authors are presenting an important point. CPR's must be, for the most part, discreet from other classification, or subgroups of patients. However, this single patient case study is very weak data to lead us to abandon the Manipulation CPR.

Now there is no escaping that this single patient got better. However, one could do a case study in which a person met 4 out 5 of the manipulation CPR and the DID NOT get better at all. That's why larger randomized studies are done and then replicated.

Speaking of replication. The authors suggest that the results of the CPR studies may not work in general as all studies, including the replication study, were done on US military personnel. Specifically -

..this is why once a CPR has been derived in one population it must be validated in a different patient population with different clinicians. The manipulation CPR ahs been so validated, but both derivation and validation studies were performed by specially trained clinicians on US military personnel in military facilities, and the applicability of the results to other patient groups and clinicians is unknown.

In truth, the validation study was done 8 clinics in different regions of the US where "Most participating sites were health care facilities within the U.S. Air Force". Therefore, like in my setting near an Air Force Base, not only military servicemen, but also their families and dependents are treated. Secondly, in the US at least, spinal manipulation is a core skill and intervention taught in physical therapy schools.

In my opinion, the authors true colors about the manipulation CPR are shown with this quote:

If this patient had been treated with manipulation by itself, as she appeared to fit the CPR criteria, this management may have failed to provide the patient with her own ability to control and abolish her symptoms when they returned.

And..

Although it has been directly stated that CPRs are not meant to replace clinical judgment and should be used to complement clinical reasoning, it may also be argued that the use of CPRs minimizes the clinical reasoning process, reducing decision making to a "tick-box" activity to bypass more complex and high-level reasoning that is often required in clinical practice.

The first is a direct dogma held by many "McKenzie" therapist who usually proudly boast not needing to touch a patient to get them better. It's also a Red Herring. To imply that the use of manipulation precludes a competent PT from educating and providing the same means to "self control" their pain is almost pretentious.

The second passage is a classic "Guru" based argument. You can't be providing good results if it's easy or straight forward. One must complete expensive Con Ed after Con Ed to get additional letters after their name and finally portray to the patient the complexity of their pain.
I'm almost saddened as, I feel, McKenzie approach works very well specifically because of it's attempt to subgroup patients, which is what this CPR is striving for. Not because it has a complex model that only those with the money and time (not just access to a well done RCT) can achieve.

Finally, CPRs are used all over in medicine with great results. The Ottawa ankle rule, Canadian C-spine rules, Acute Heart failure index, Short term risk after after a PE, Deep Vein Thrombosis, etc. They are there to help us choose the most appropriate treatment for a patient, which leads to improved outcomes, lower costs, and increased patient satisfaction.

I encourage Mr.'s may and Rosedale to continue with their hypothesis and hopefully tease out what type a subgrouping is more appropriate. I know we've already got authors looking at a potential extension oriented subgroup of LBP patients.

Labels: clinical prediction rules, CPR, manipulation

While I try to stear clear of blogging on the US vs. Them, PT vs. Chiro debate (although my look at the use of the DRX9000 seems to be viewed by chiros as an assault on them), the underhanded way that profession is trying to "claim" manipulation in my state has brought this post out of me.

I want to first comment on how the Chiro profession is handling itself in Nebraska in regards to the PT profession updating our practice act (which dated back to the 1960's IIRC). Their must be respected powerful lobby was threatening to hold up this new legislation because the new act included language about the use of mobilization and manipulation (these are one in the same to the PT profession). "Oh no you don't" the Chiros exclaimed. They pulled out the old very false but effective crap about no having the training or skill to do (hmm, what was that I was learning in PT school then???) High Velocity Low Amplitude (HVLA) manual therapy. And, like PT's always do, we repented and asked the Chiros what we need to do to fix it. "We'll compromise" they offer.

So manipulation was crossed out and "Grade V mobilization" was added (again, in PT, manipulation and mobilization are one in the same). So, the bill is passed (will hold off on the commentary about Orthos objections to the use of "Physical Therapy Diagnosis"; Orthos and Chiros objections to "direct access" even though we've always had it by omission and no one has died - GASP!; and the school systems wanting to bill the government for PT despite providing care with untrained aides). Fast forward a year, and as the new practice act proceeds through it's many steps to fruition - A practice act is just a guideline, and specific rules and regulations need then to be developed from it - Chiros are back shouting "hold on!". We changed our minds, we object to "Grad V mobilization" cuz we say you can't do it. So it's back to expending money, time, energy, and sweat to again fight for what we've already attained. So, the Chiros back off with a knowing smirk of "we'll be back again".

The second item that brought me to write this was a great post by Panda Bear, MD entitled "Stealth Medicine and Other Topics" railing on Chiro's attempt at backdooring into becoming pediatric primary care providers. As Panda Bear quotes them:

“The doctor of chiropractic does not treat conditions or diseases.” Says so right in their mission statement. But then a little further down it ascribes complaints in every system to our old friend the subluxation and promises, by judicious adjustment of the pediatric spine, to allow the body to express a better state of health and well-being.

Imagine that. Promising one thing and practicing the opposite. Sounds familiar to me. Orac at Respectful Insolence and Eric at Evidence In Motion have both commented on a visited this particular post (Damn, I am slow on the uptake I guess). I'll quote Eric as a nice summary to all of this:

For those non-physical therapists reading this, it may be timely to point out that what IS in our scope of practice is all sorts of manipulative therapy. That's right, the specialization area of Orthopaedic Manual Physical Therapy is one where the physical therapist is equipped with both the tools to manipulate the spine or peripheral joints AND develop a comprehensive, integrated program of neuromuscular modalities for orthopaedic conditions.

For an excellent comprehensive look at the history of PT vs Chiro, the arguments analysed and what is most likely behind Chiro's fighting PT's over manipulation (hint: it's not really patient safety. Ok Hint #2: It starts with "M" and ends in "oney") click here.

Labels: APTA, Direct access, DRX 9000, education, manipulation

Ihave been meaning to blog on the results of a Lancet article finding neither spinal manipulation or NSAIDs are effective on low back pain. However, Eric from NPAThinktank beat me to it with a post on Evidence in Motion's blog. It is very well done and thought out.

The key point we must all understand, is that the population tested was a heterogeneous group of low back pain sufferers. Despite the mounting evidence, no sub-grouping of patient's was done. Predictably, then, to significant results were found. I don't care how many low back pain studies are done, if no treatment based classification is used, you will not find significant results.

Eric quotes Dr. K. Shepard using a great analogy for this. I post it here for your convenience:

A study that randomly assigns patients with low back pain to various conservative treatment protocols will produce the same results as a study that randomly assigns patients with abdominal pain to undergo appendectomy, cholecystectomy, or exploratory laparotomy. Neither study makes any sense.

Our hope in the rehab world is that the referral sources also have the great evidence of treatment based classification and the dramatic effects of lumbar manipulation on the right sub group of low back pain patients. Please read Eric's great post.

Labels: clinical prediction rules, EBM, Evidence, Low back pain, manipulation, physical therapy

Students from the University of Regis attempt to spread the knowledge regarding the Clinical Prediction Rule for SI manipulation. Fairly corny, but it gets the point across. Appears aimed at the clinician more than a prospective patient.

Are you manipulating your patients that fit the CPR? Change is difficult, but must be made to continue evolving as clinicians and providing the best care known (friggin state of Iowa and their collusion with "Palmerville")

Labels: clinical prediction rules, EBM, Low back pain, manipulation, Mobilization, physical therapy