1. No category

Case Series Report
Evaluation of outcomes in patients with neck pain treated with
thoracic spine manipulation and exercise: a case series
Kristin J Carpenter, PT, DPT
Doctor of Physical Therapy, University of Colorado Denver, School of Medicine, Department of Physical Therapy,
Denver, CO.
Paul E Mintken PT, DPT
Assistant Professor, University of Colorado Denver, School of Medicine, Department of Physical Therapy, Denver, CO;
Fellow in the Regis University Manual Physical Therapy Fellowship, Regis University, Denver, CO.
Joshua A Cleland PT, PhD
Associate Professor, Department of Physical Therapy, Franklin Pierce University, Concord; Physiotherapist,
Rehabilitation Services, Concord Hospital, Concord, NH; and Faculty, Manual Physical Therapy Fellowship Program,
Regis University, Denver, CO.
ABSTRACT
Many approaches for physical therapy management of neck pain have been
reported; little evidence exists to guide practitioners in selecting the most
appropriate intervention for patients with varied clinical presentations. A preliminary
clinical prediction rule (CPR) for treatment of neck pain with thoracic spine thrust
manipulation has recently been published. This case series describes the outcomes of
three patients with neck pain treated with thoracic spine manipulation and exercise
with reference to their status on the CPR. Three patients referred to outpatient physical
therapy underwent a standardised history and physical examination at baseline
and completed self-report questionnaires. The patients subsequently received five
physical therapy visits, which included two sessions of thoracic manipulation and
an exercise program. The patients again completed the questionnaires at 1-week
and 4-weeks follow-up, and were classified as having experienced a successful or
unsuccessful outcome. Two of three patients satisfied the CPR for thoracic spine
thrust manipulation and experienced successful outcomes at 1-week (following
manipulation and ROM exercise alone) which were maintained at the 4-week follow
up visit. The patient that did not meet the CPR did not experience a successful
outcome at 1-week, but following participation in the exercise program (weeks
2-4) experienced a successful outcome at 4-weeks. The findings in this case series
are consistent with the suggestions of the preliminary CPR for selecting patients with
neck pain likely to benefit from thoracic spine thrust manipulation. We suggest that
patients who do not meet the CPR may benefit from participation in an exercise
program. Carpenter KJ, Mintken PE, Cleland JA (2009): Evaluation of outcomes in
patients with neck pain treated with thoracic spine manipulation and exercise: a
case series. New Zealand Journal of Physiotherapy 37(2): 75-84.
Key words: neck pain, thoracic spine, conservative treatment, manipulation,
exercise, clinical prediction rule, clinical decision rule.
BACKGROUND
It has been reported that more than one in five
people are currently experiencing neck pain, over
50% of the population has had neck pain in the
last 6 months and the lifetime prevalence has been
reported to range from 22%-70% (Cote et al 1998,
2000, Palmer et al 2001). Once a person develops
neck pain, there is a 1 in 3 chance that they will
develop chronic symptoms lasting greater than 6
months, resulting in a tremendous burden on the
health care system (Cote et al 2004, Picavet and
Schouten 2003). It has also been reported that
the incidence of neck pain is increasing (Nygren
et al 1995). In the United States, The Guide to
Physical Therapist Practice (2001) indicates that
manual therapy techniques including mobilisation/
manipulation are appropriate treatment strategies
for the management of neck pain, as are modalities
and therapeutic exercise. While the Guide uses the
terms mobilisation and manipulation synonymously,
for the remainder of this paper we will refer to
NZ Journal of Physiotherapy – July 2009, Vol. 37 (2)
manual therapy techniques as either thrust or
non thrust manipulation. A recent systematic
review reports that mobilisation/manipulation,
strengthening exercises and stretching have strong
evidence to support their use in the conservative
management of patients with neck pain (Gross et
al 2007). Despite evidence supporting the use of
these interventions, little evidence exists to guide
the practitioner in selecting the most appropriate
intervention for patients with varied clinical
presentations (2001b).
Recently, a clinical prediction rule (CPR) for
guiding treatment of a subgroup of patients with
neck pain was published (Cleland et al 2007). Clinical
prediction rules and clinical decision rules quantify
the individual contributions that components of
the history, physical examination and self-report
measures make toward establishing a diagnosis,
prognosis, or likely response to treatment in an
individual patient (McGinn et al 2000). Clinical
prediction rules can assist practitioners in selecting
75
the most appropriate intervention for a particular
patient by predicting likelihood of a successful
outcome following a specific intervention, according
to history, physical examination and self-report
measures findings. Developing and testing a CPR
involves 3 steps: (1) creating or deriving the rule,
(2) testing or validating the rule, and (3) assessing
the impact of the rule on clinical behavior (impact
analysis) (McGinn et al 2000).
The CPR derived by Cleland et al identifies 6
potential predictor variables for likelihood of favorable
outcomes in patients with neck pain treated with
thoracic spine thrust manipulation (Cleland et al
2007). These 6 variables include: symptom duration
<30 days, no symptoms distal to the shoulder, patient
reports that looking up does not aggravate symptoms,
FABQPA score <12, diminished upper thoracic spine
kyphosis (T3-T5), and cervical extension range of
motion (ROM) of <30 degrees (Table 1) (Cleland et al
2007). The authors reported that patients presenting
with 3 of the 6 variables at initial examination were
likely to exhibit a rapid and dramatic response to
thoracic spine thrust manipulation, as evidenced by
a global rating of change in which the patient rated
themselves “quite a bit better,” “a great deal better” or
“a very great deal better” in 7 days or less (Jaeschke
et al 1989). When 3 of the 6 variables were present,
the positive likelihood ratio was 5.5, indicating that a
patient positive on 3 of the 6 variables would be 5.5
times more likely to respond positively than would
an average, unselected patient. This resulted in the
probability that a patient would respond favorably to
thoracic spine thrust manipulation for treatment of
neck pain increased from 54% (pre-test probability)
to 86% (post-test probability). In cases where only
1 or 2 predictor variables were present on initial
examination, the probability of a successful outcome
was 58% and 71%, respectively (Table 1) (Cleland
et al 2007). These values suggest that the post-test
probability of these patients achieving a successful
outcome with thoracic spine thrust manipulation
is only marginally better than chance. Positive
likelihood ratios for the presence of 1 or 2 predictor
variables are 1.2 and 2.09, respectively (Cleland et
al 2007). Positive likelihood ratios greater than 5
generate moderate shifts in probability, and should
be considered in clinical practice (Fritz and Wainner
2001).
Table 1: Combination of Predictor Variables and Likelihood
of Success from the Clinical Prediction Rule of Cleland et al
(2007).
Number of
variables
6
5+
4+
3+
2+
1+
Sensitivity Specificity
+LR
.05
1.0
Infinite
Probability of
Success
100%
.12
.33
.76
.93
1.0
1.0
.97
.86
.56
.17
Infinite
12
5.5
2.1
1.2
100%
93%
86%
71%
58%
The purpose of this case series is to compare
the clinical outcomes of 3 patients referred to
76
physiotherapy with neck pain with reference to
their status on the CPR for thoracic spine thrust
manipulation. This case series design is not able to
provide evidence supporting the utilisation of the
preliminary CPR for selecting patients with neck
pain that are favorable candidates for thoracic
spine thrust manipulation, however other ongoing
research is in the process of investigating the
validity of the CPR among a large population of
patients with mechanical neck pain.
Patient Characteristics
Patients referred for physiotherapy with a primary
report of neck pain were examined for eligibility
to participate in this case series. The patients in
this case series were concurrently participating
in a randomised clinical trial (RCT) designed as
a validation study following the preliminary CPR
of Cleland et al (2007). The inclusion criteria
required patients to be between the ages of 18-65
years, with a primary report of neck pain with or
without unilateral upper extremity symptoms, and
a baseline Neck Disability Index (NDI) score of at
least 10%.
Patient demographics, baseline self-report
variables and baseline characteristics are described
in Table 2. The Institutional Review Board at
Concord Hospital, Concord, New Hampshire, USA
approved this study and all patients provided
informed consent.
Table 2: Patient Demographics, Self-report Variables, and
Baseline Characteristics
Age
Gender
Duration of symptoms
FABQ-PA
FABQ-W
Status on the CPR
Baseline NDI
3rd Visit NDI
Discharge NDI
Baseline NPRS
3rd visit NPRS
Discharge NPRS
Patient 1
Patient 2
Patient 3
42
Male
7 mos, 26 d
5
23
4/6
50/100
18/100
8/100
5
1
0
61
Female
7 mos, 25 d
0
0
3/6
24/100
6/100
0/100
5
1
1
27
Female
15 d
14
14
1/6
24/100
26/100
6/100
5
7
1
FABQ-PA=Fear Avoidance Beliefs Questionnaire Physical Activity
Subscale
FABQ-W= Fear Avoidance Beliefs Questionnaire Work Subscale
CPR=Clinical prediction rule
NDI=Neck Disability Index
NPRS=Numerical Pain Rating Scale
Examination
Self Report Measures
Patients completed a variety of self-report
questionnaires before undergoing a standardised
history and physical examination conducted by
a physiotherapist. Self-report measures included
a pain diagram and Numeric Pain Rating Scale
(NPRS) to determine the distribution of symptoms
and intensity of current, best and worst levels of
NZ Journal of Physiotherapy – July 2009, Vol. 37 (2)
pain, the Neck Disability Index (NDI), and the FearAvoidance Beliefs Questionnaire (FABQ) (Cleland et
al 2008), (Lee et al 2006). The NDI is widely accepted
as a condition-specific disability scale for patients
with neck pain and has proven to be a reliable and
valid outcome measure (Cleland et al 2008, Vernon
and Mior 1991). The NDI consists of ten questions
relating to different areas of function that are scored
from 0-5, with a maximum score of 50 points. To
achieve a percentage of patient-perceived disability,
the total score is doubled, with higher scores
representing increasing levels of disability up to
100%. Fear-avoidance beliefs were assessed using
the fear avoidance beliefs questionnaire (FABQ),
which is a 16-item questionnaire that was designed
to quantify fear and avoidance beliefs in patients
with low back pain (Waddell et al 1993). The FABQ
has two sub-scales, a 4-item scale to measure fearavoidance beliefs about physical activity (FABQPA) and a 7-item scale to measure fear-avoidance
beliefs about work (FABQ-W). Each item is scored
from 0-6 with possible scores ranging between 0-24
for the physical activity sub-scale and 0-42 for the
work sub-scale. The FABQ has been shown to be
a valid and reliable tool in patients with neck pain,
and has been shown to be an important variable in
predicting future disability level and return to work
capacity in these patients (Lee et al 2007, Lee et al
2006) The FABQ-PA is also a clinical predictor for
patients with neck pain that are likely to respond
to thoracic spine thrust manipulation and exercise
(Cleland et al 2007).
History and Physical Examination
The history included demographic information,
past medical history, mechanism of injury, location
and nature of the patient’s symptoms, number of
days since onset, number of previous episodes of
neck pain and treatment for previous episodes.
The physical examination began with a neurologic
screening examination to rule out nerve root
compression, sensory deficits, and upper motor
neuron lesions. The screening included assessment
of the Hoffmann’s and Babinski pathological
reflexes, myotomal testing from C5-T1, dermatomal
pinprick sensation from C5-T1, and upper extremity
deep tendon reflexes (Viikari-Juntura 1987, ViikariJuntura et al 1989). The patient’s posture was then
assessed in standing and sitting according to the
procedures described by Kendall (Kendall FP et al
1993). Postural observation was included because
it is commonly used among therapists for patients
with neck pain and is one of the predictors in the
CPR (Cleland et al 2007). Cervical/thoracic spine
active range of motion (AROM) and its effect on
symptoms was assessed. Cervical flexion, extension
and unilateral side bending were measured using
a single bubble inclinometer (Hole et al 1995).
Unilateral rotation was assessed using a long
arm goniometer (Youdas et al 1991). Intraclass
correlation coefficients (ICC) for measuring cervical
NZ Journal of Physiotherapy – July 2009, Vol. 37 (2)
spine ROM with a single bubble inclinometer and
long arm goniometer range from .81-.94 and 0.540.90 respectively (Hole et al 1995). Thoracic AROM
was assessed qualitatively, having the patient
rotate with arms crossed over the chest in a seated
position; applying overpressure into the direction of
rotation and determining the effect on the patient’s
symptoms.
Special tests, including Spurling’s test, the
distraction test and the upper limb neurodynamic
test were performed to evaluate the presence
of cervical radiculopathy (Wainner et al 2003).
Vertebral artery and cervical ligament screening
tests were performed to determine whether the
patient’s symptoms resulted from vertebral artery
compromise or cervical ligament instability (2001a,
Uitvlugt and Indenbaum 1988). Spring testing of
the cervical and thoracic spine was tested with
the patient prone and the neck in neutral rotation
(Maitland G et al 2001, Smedmark et al 2000). The
mobility at each segment was judged as normal,
hypomobile, or hypermobile. The reliability of
spring testing has been shown to be poor in the
cervical spine and fair to moderate in the thoracic
spine (Cleland JA 2005, Smedmark et al 2000).
Strength testing of the serratus anterior, middle
and lower trapezius were assessed according to
Kendall, as these muscles have been reported
to be frequently impaired in patients with neck
pain (Kendall FP et al 1993), (Falla et al 2004a,
Jull et al 2004b). Finally, the endurance of the
deep neck flexors was assessed as described
by Harris et al (Harris et al 2005). We chose to
use this method rather than the craniocervical
flexion test (CCFT) described by Jull et al (Jull
et al 1999, Jull et al 2004a) because the CCFT is
time consuming, requires the use of additional
equipment and is difficult to use as described in
a clinical setting. Although the reliability of the
CCFT has been reported as excellent, ranging
from 0.994 to 0.998, Harris et al (Harris et al
2005) and Cleland et al (Cleland JA 2005) have
reported adequate intertester reliability (ICC = 0.67
and 0.57 respectively) using the deep neck flexor
endurance test in patients with neck pain.
Clinical Impression
Patients in this case series presented with
signs and symptoms consistent with mechanical
neck pain. Impairments present in these patients
that indicated mechanical neck pain included:
postural abnormalities, hypomobility of the cervical
and/or thoracic spine, weakness of periscapular
musculature and tightness of cervicothoracic
musculature (Falla et al 2007, Griegel-Morris et
al 1992, Jull et al 2004a, Norlander et al 1996,
Norlander et al 1997, O’Leary et al 2007, Zito et
al 2006). Interventions targeting the impairments
listed above may result in favorable outcomes in
patients presenting with mechanical neck pain.
77
Intervention
All patients in this case series attended
physiotherapy twice weekly during the first week
and then once weekly for the following 3 weeks for a
total of 5 sessions of physiotherapy. Each treatment
session lasted for a total of 30 minutes. During the
first two sessions, patients received thoracic spine
thrust manipulation and a general range of motion
(ROM) exercise only. Beginning at the third session,
patients began participating in a stretching and
strengthening program and continued participation
in this program once a week for 3 sessions until the
4-week follow-up visit.
Figure 2: Upper Thoracic/Cervicothoracic Junction
Manipulation
!
Manual Therapy Interventions
For the first 2 sessions, all patients received 3
different thrust manipulations. We will use the
model for describing thrust manipulations as
recently proposed by Mintken et al (Mintken P et
al 2008a, 2008b):
1. A high-velocity, mid-range, distraction force
to the midthoracic spine on the lower thoracic
spine in a sitting position (Figure 1)
2. A high-velocity, end-range, anterior-posterior
force through the elbows to the upper thoracic
spine on the midthoracic spine in a supine
position, in cervicothoracic flexion (Figure 2)
3. A high-velocity, end-range, anterior-posterior
force through the elbows to the middle
thoracic spine on the lower thoracic spine in
a supine position, in cervicothoracic flexion
(Figure 3)
!
For the supine upper thoracic/cervicothoracic thrust manipulation
(above) the patient clasped his or her hands across the base of
the neck. The patient’s arms were pulled downward to create
spinal flexion down to the level the therapist attempted to
manipulate. The therapist’s manipulative hand was used to
stabilise the inferior vertebra of the motion segment and his/
her body was used to push down through the patient’s arms to
perform a high velocity, low amplitude thrust.
Figure 3: Middle Thoracic Spine Manipulation in Supine
!
Figure 1: Seated Thoracic Distraction Manipulation
!
!
For the supine middle thoracic thrust manipulation (above), the
patient clasped his or her opposite shoulders with both hands.
The patient’s arms were pulled downward to create spinal flexion
down to the level the therapist attempted to manipulate. The
therapist’s manipulative hand was used to stabilise the inferior
vertebra of the motion segment and his/her body was used to
push down through the patient’s arms to perform a high velocity,
low amplitude thrust.
For the seated thoracic distraction manipulation (above), the
therapist placed his or her upper chest at the levels of the spine
to be manipulated and grasped the patient, pulling the elbows
towards the therapist until the spine was firmly positioned against
the therapist’s upper chest. Next, the therapist attempted to
localise the force by adjusting the patient position, therapist
position, and the vector of the arm pull. A high velocity distraction
thrust was then performed in an upward direction.
Each thrust manipulation was performed
twice.
Following the manipulative interventions, all
patients were instructed in the “three-finger ROM
78
exercise” which is a general cervical mobility
exercise developed by Erhard (Erhard 1998). The
exercise is described in Figure 4. This exercise was
performed alternately to both sides within the limits
of pain tolerance. Patients performed this exercise
for 10 repetitions to each side, 3-4 times per day
each day during participation in the study. Patients
also received instruction to maintain usual activity
level within the limits of pain. Advice to maintain
usual activity has been found to assist in recovery
from neck pain (Bergstrom et al 2007, Chiu et al
2005a). Patients were instructed to participate in
all activities that do not increase symptoms, and
avoid all activities that aggravate symptoms.
Beginning on the third session, patients were
instructed in a stretching and strengthening
NZ Journal of Physiotherapy – July 2009, Vol. 37 (2)
Figure 4: General Cervical Mobility Exercise (“Three-Finger
ROM Exercise”)
Figure 6: Disability assessed using the Neck Disability Index
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For the “Three-Finger ROM Exercise” (above), the patient was
instructed to place the fingers over the manubrium. The patient
began the exercise with the chin resting on the fingers, rotating to
one side as far as possible and returning to neutral. The exercise
was progressed by reducing the number of fingers resting on
the manubrium, which increased the amount of cervical flexion.
(Erhard 1998).
program. Recent guidelines and reviews have
supported the use of exercise to decrease pain,
improve function and reduce disability in a
patient population with neck pain (Brosseau et al
2001, Sarig-Bahat 2003). The strengthening and
flexibility program used in this study can be found
in Appendices 1 and 2.
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Figure 7: Patient perception of change assessed using the
Global Rating of Change (GROC)
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Follow-up Measurements
All patients completed the NDI, Pain Diagram
and NPRS and the Patient Global Rating of
Change (GROC) at 1-week (3rd visit) and 4 weeks
(5th visit) after the initial examination. We defined
a successful outcome as a score of +5 (quite a bit
better), +6 (a great deal better) or +7 (a very great
deal better) on the GROC.
Patients reporting GROC scores of +4 or lower
were considered unsuccessful outcomes.
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Outcomes
This case series compares the clinical outcomes
of three patients with mechanical neck pain
who were treated with thoracic spine thrust
manipulation and exercise. All patients received
identical treatments, but we observed considerable
variations in outcomes (Figures 5-7). Of the three
patients in this case series, two (patients 1 and
Figure 5: Pain perception assessed using the Numerical Pain
! Rating Scale
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NZ Journal of Physiotherapy – July 2009, Vol. 37 (2)
!
2) met the CPR for thoracic manipulation (Table
3). At short-term follow up (1-week), both of these
patients had achieved a successful outcome with
GROC scores of +6. Patient 3, who did not meet
the CPR, reported no change in her symptoms at
1-week (Figure 7). Similarly, patients 1 and 2 had
significant short-term improvements in the NDI and
NPRS, while patient 3 actually worsened in regard
to NDI and NPRS scores (Figures 5 and 6). At the
Table 3: Patient Status on Predictor Variables
Variable
Patient 1
Patient 2
Patient 3
Symptoms <30d
No
No
Yes
No symptoms distal to the
shoulder
Looking up does not
aggravate symptoms
FABQ-PA score <12
Diminished upper thoracic
spine kyphosis
Cervical extension
ROM <30n
Total number predictor
variables met
Yes
Yes
No
Yes
No
No
Yes (5)
Yes
Yes (0)
Yes
No (14)
No
No
No
No
4/6
3/6
1/6
FABQ-PA=Fear Avoidance Beliefs Questionnaire Physical Activity
Subscale
ROM=Range of motion
79
4-week follow up, patients 1 and 2 maintained the
benefits of treatment reflected at 1-week. Unlike the
1-week follow up, patient 3 displayed significant
improvements in NDI and NPRS scores and attained
a successful outcome based on her GROC score
of +7 following the exercise intervention. Patients
1 and 2 achieved successful outcomes following
treatment with thoracic spine thrust manipulation
and a general cervical mobility exercise alone,
whereas patient 3 did not display significant
improvement until after the initiation of the specific
exercise program.
DISCUSSION
Previous research has derived a CPR that is
purported to identify patients with neck pain that
are likely to respond favorably to thoracic spine
thrust manipulation (Cleland et al 2007). Prior to the
publication of that preliminary CPR, the literature
contained no research evidence specifically to guide
selection of treatment technique for individual
patients with neck pain. All of the patients in this
case series received the same treatment, regardless
of clinical presentation or status on the CPR. We
found that patients 1 and 2 were positive on the rule,
and had favorable short-term (1-week) responses
to thoracic spine thrust manipulation which were
maintained at the 4-week follow up. Patient number
3 was not positive on the rule, did not improve with
thoracic spine thrust manipulation, and actually
worsened in the short-term (1-week). In fact, patient
number 3 only began to improve after the exercise
program was initiated. This is consistent with the
suggestion that the CPR may correctly identify
patients who are likely to exhibit a favorable response
to the thoracic spine thrust manipulations.
Although the underlying effects and mechanism of
spinal manipulation are not widely understood, recent
research suggests that that spinal manipulation
is associated with a neurophysiological response
that may result in measureable therapeutic effects
(Pickar 2002). Spinal manipulation has been shown
to change intradiscal pressure, relax paraspinal
musculature, induce hypoalgesia, increase the
production of B-endorphins, and downregulate the
production of inflammatory proteins (George et al
2006, Maigne and Vautravers 2003, TeodorczykInjeyan et al 2006). Determining the physiological
mechanisms that may have been responsible for the
improvements in our patients is beyond the scope
of this case series.
Impairments in muscle performance and motor
control are common in patients with neck pain
(Chiu et al 2005b, Falla et al 2004a, Falla et al
2004b, Falla et al 2004c, Falla et al 2004d, Falla
et al 2004e, O’Leary et al), Jull 2004). Neck pain
patients frequently have underlying neuromuscular
problems including altered coordination between
superficial and deep neck flexors, greater fatigue
of cervical musculature under low load, and
deficits in kinesthetic sense (O’Leary et al 2003).
Although changes have been found in patterns of
80
cervical muscle activation in cognitive, functional
and automatic tasks, patients with neck pain
also frequently present with impairments in the
postural control system which may implicate the
musculature and joints of the cervicothoracic
and periscapular regions (Jull 2004). In a recent
systematic review Kay et al (2005) recommended
that exercise programs for acute or chronic
mechanical neck pain consist of stretching and
strengthening exercises targeting the musculature
of the cervical region, shoulder-thoracic region or
both. This review revealed that exercise programs
consisting of stretching and strengthening exercises
for the cervical or cervical and shoulder-thoracic
region resulted in benefits in pain and function in
patients with mechanical neck disorders (Kay et
al 2005).
As pathoanatomic models for examining and
managing patients with spinal pain have been largely
unsuccessful, there has been a recent trend towards
utilising treatment-based classifications in an attempt
to improve clinical outcomes (Waddell 1987, Waddell
1999, Waddell et al 1993)(Childs et al 2004, Delitto et
al 1995). The treatment-based classification system
proposed by Delitto et al (1995) has been shown to be
reliable, valid and result in improved clinical outcomes
in patients with mechanical low back pain (Brennan
et al 2006, Fritz and George 2000, George and Delitto
2005). A treatment based classification system
for patients with neck pain has been proposed by
Childs et al (Childs et al 2004). Subsequent research
by Fritz and Brennan demonstrated that patients
receiving interventions matched to the classification
system had better outcomes than patients receiving
unmatched interventions (Fritz and Brennan 2007).
The recent CPR may help further guide clinicians by
identifying a subgroup that responds dramatically
to a specific intervention (Cleland et al 2007). It is
important to note that classification is not the same as
a pathoanatomic diagnosis: indeed, in our experience,
patients with apparently very similar ‘pathoanatomy’
may respond differently to the same intervention.
Therefore, it is useful to have clinical predictors that
may be useful in identifying which patients need
which treatment based on clinical presentation.
If the CPR is validated by subsequent research,
it will be extremely useful for clinicians to know, a
priori, which patients have a significantly greater
likelihood of responding to thoracic spine thrust
manipulation (Cleland et al 2007). If a patient is
not positive on the CPR, as occurred with patient
number 3, the CPR and the results of this case series
would suggest that thoracic manipulation may be of
limited value, and the therapist and patient’s time
would be better spent utilising other evidence-based
interventions, however this must be confirmed in a
validation study of the preliminary CPR.
CONCLUSION
This case series illustrates the potential utility of
the CPR rule in identifying patients with mechanical
neck pain who may experience dramatic shortNZ Journal of Physiotherapy – July 2009, Vol. 37 (2)
term improvements with thoracic spine thrust
manipulation. Three patients were evaluated in this
case series, two of whom were positive on the rule,
and one who did not satisfy the criteria outlined
by the CPR. Although a case series design is not
capable of providing evidence able to support or
refute the preliminary CPR of Cleland et al (2007),
the results presented here are consistent with the
CPR findings. The CPR correctly predicted which
patients may benefit from a particular intervention,
thus increasing a practitioner’s probability of
appropriately and efficiently treating patients with
neck pain. Future research is necessary to validate
the use of the CPR on a large sample of patients
to determine whether the trends observed in this
case series persist.
Key Points
! It appears that some patients with neck pain
do well with thoracic manipulation while others
may require different interventions. Previous
research has derived a preliminary clinical
prediction rule (CPR) that is purported to identify
patients with neck pain that would benefit from
thoracic manipulation.
! Two of the patients in this case series were
positive on the CPR and had excellent short-term
outcomes following manipulation while the third
patient did not meet the CPR, failed to improve
following manipulation, and did well only when
therapeutic exercises were introduced.
! Further research is needed to validate the
preliminary CPR in a randomised clinical trial
design.
ACKNOWLEDGEMENTS
The patients in this case series were treated at Concord
Hospital, Concord, New Hampshire, USA. All patients signed a
consent form as part of a research project investigating the effects
of thoracic manipulation in people with neck pain. This study
had ethical approval by the Human Investigations committee at
Concord Hospital, Concord, New Hampshire, USA. No external
funding was used in this case series. The authors affirm that they
have no financial affiliation (including research funding) or
involvement with any commercial organisation that has a direct
financial interest in any matter included in this manuscript.
ADDRESS FOR CORRESPONDENCE
Dr Paul Mintken, University of Colorado Denver, School of
Medicine, Physical Therapy Program, Mail Stop C244, 13121 E
17th Avenue Aurora, Colorado, USA zip code 80045. Telephone
+ (303) 881-1569, fax + (303) 724-9016. Email: Paul.mintken@
ucdenver.edu
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Appendix 1: Stretching Exercises
Name of Stretching Exercise
Instructions to Patient
Upper Trapezius Stretch
In order to stretch the right upper trapezius, the patient was
instructed to grasp the chair with the right hand and slowly
lean the body slightly forward and to the left. The patient
was instructed to bend the head forward and to the left, then
rotate the head to look right. The patient was permitted to
support the head with the left hand without pulling on the
head. The patient was instructed to hold this position for 30
seconds x 2 repetitions and to repeat on the opposite side.
!!
!
Right Scalene /Sternocleidomastoid Stretch
1
2
In order to stretch the right scalenes and sternocleidomastoid,
the patient was instructed to sit upright in a chair and to use a
sheet (1) or the left hand (2) to hold the right shoulder down.
The patient was then instructed to bend the head to the left,
followed by rotating to look to the right. Finally, the patient
was instructed to tuck the chin (make a “double chin”)
until a stretch was felt along the right side of the neck. The
patient was instructed to hold this position for 30 seconds x 2
repetitions and to repeat twice on the opposite side.
!!
!
!
Levator Scapulae
Stretch
!
!
!!
Pectoralis Major and Minor Stretch
!
In order to stretch the right levator scapulae, the patient was
instructed to grasp the chair with the right hand and slowly
lean the body slightly forward and to the left. The patient
was instructed to bend the head forward and to the left, then
rotate the head to the left until a stretch was felt along the
right side of the neck. The patient was permitted to support
the head with the left hand without pulling on the head. The
patient was instructed to hold this position for 30 seconds x 2
repetitions and to repeat twice on the opposite side.
In order to stretch the right pectoralis major and minor, the
patient was instructed to stand and face a wall with the arm
outstretched against the wall. The patient was instructed
to bend the right elbow slightly and to hold the shoulder
blade down and in towards the spine as the body was slowly
rotated to the left until a stretch was felt along the chest. The
patient was instructed to hold this position for 30 seconds x 2
repetitions and to repeat twice on the opposite side.
!!
!
NZ Journal of Physiotherapy – July 2009, Vol. 37 (2)
83
!
!
!
Appendix 2: Strengthening Exercises
!
Name of Exercise
!
Deep Neck Flexor Training
Instructions to Patient
!
!
!
!
!
!
!
!
!
Neck Isometric Strengthening
In a seated position, the patient was instructed to place the
fingers against the forehead while maintaining a neutral position
of the neck. The patient was instructed to perform an isometric
contraction by pushing the head forward against the fingers.
The patient was instructed to repeat this exercise while pushing
the head backwards and to both sides against the resistance
of the fingers. The patient was instructed to hold each position
for 10 seconds, relax, and to repeat the exercise 10 times in
each direction.
!
!
!
!
!
!
!
!
! Strengthening
Middle Trapezius
!
!
!
!
!
!
!
!
!
! Push-Ups
Serratus Wall
!
!
!
!
!
!
!
!
!
!
!
84
In the prone position, the patient was instructed to raise both
arms towards the ceiling with the arms in line with the shoulders
and the thumbs pointing up. The patient was instructed to hold
this position for 10 seconds, relax, and to repeat the exercise
10 times.
!
!
! Strengthening
Lower Trapezius
!
The patient was instructed to lie on his back with the knees bent
without a pillow under the head/neck. The patient was then
instructed to locate a spot on the wall just above the knees
and to nod the head as if indicating “yes” and to hold this
position for 10 seconds. The patient was instructed to perform
10 repetitions of this exercise. While performing this exercise,
the patient was instructed to place his hand gently on the front
of the neck to feel the superficial muscles to ensure that these
muscles stayed soft and relaxed while performing this exercise.
The patient was instructed to stop the exercise at the point that
he sensed hardening of the superficial muscles.
In the prone position with the arms overhead, the patient was
instructed to raise the arms towards the ceiling with the thumbs
pointing up. The patient was instructed to hold this position for
10 seconds, relax, and to repeat the exercise 10 times.
!
!
!
!
!
!
!
!
While standing at the wall with the arms approximately shoulder
width apart and shoulder height, the patient was instructed
to perform a “push-up with a plus” exercise by pushing away
from the wall until the elbows were fully extended and the
shoulder blades were pulled away from the spine. The patient
was instructed to hold this position for 10 seconds, relax, and to
repeat the exercise 10 times.
!
!
!
!
NZ Journal of Physiotherapy – July 2009, Vol. 37 (2)