July 13, 2013
In my opinion, most Minnesota private practice clinics are not utilized for direct access, although they should be. Therefore, in general, I see people after they have obtained imaging, and or been cleared by an orthopedic MD for PT. This does not decrease thoroughness of a physical examination, although it does mean most patients have already obtained imaging prior to therapy. As opposed to my background with treating in Colorado, where physical therapists are utilized as a first line of defense in acute cervical spine pain and management. As we all know, this delay to treatment negatively affects prognosis. Regardless the state, I utilize the Canadian C-Spine Rules as they have excellent supporting evidence as it was shown to have a sensitivity of 99.4%, with only 1 missed cervical spine fracture, out of almost 9,000 people in an ER setting1. Detection of a fracture and differential diagnosis are pivotal before initiating therapy, and it is my belief that skilled physical therapists are qualified to make these judgments to effectively treat neck pain.
After an examination is performed, the next step should be discussion of my clinical exam findings, and setting expectations for therapy. An excellent article that caught my eye this month is from the most recent issue of JOSPT that discussed patient expectations2. If you haven’t read this article, do so, it is a fun read. It has a few clinical pearls embedded in it where it looks at patient expectations to therapy treatments. Patients overall thought physical therapy would be helpful when compared to surgery which fares well in our favor for not only management, but their outcomes. This article discusses that general perception was that manual therapy and exercise would benefit their neck pain. It states that people with positive expectations for the use of these interventions had improved short term outcomes independent of treatment2. This article spurts the never-ending discussion of what is our affect with manual treatment really is, fixing a dysfunction or tapping into patient expectations? An interesting thought!
Use of physical therapists in a direct access market, would improve early initiation of therapy. As we know, thoracic spine manipulation (TSM) and cervical spine manipulation both have markedly better outcomes if administered within first 30 days of onset of symptoms3. Manipulation may have more added benefit with modulating pain when compared to mobilization. An interesting study published in JOSPT earlier this year showed that patients experienced a reduced activation of insular cortex and decreased subjective pain after a TSM4. Applying this to today’s discussion on cervical pain, a TSM combined with cervical spine mobilization and an exercise program had reduced pain and improvement on NDI after two sessions.
The research is out there, we have excellent resources to rule out patients who not PT appropriate, along with a research based examination and interventions that have been shown to improve prognosis and pain. Manual therapy is at the forefront of our evidence based options. If we are tapping into the nervous system, meeting patient expectations, or achieving end range pain modulation – it really doesn’t matter in my eyes as long as patients meet their goals, and feel better. In conclusion, our role in this problem really should be leaders as we have the tools and knowledge to treat cervical spine pain effectively and are relatively cost friendly.
1) Hogg-Johnson, S., Van der Velde, G., Carroll, L. J., Holm, L. W., Cassidy, J. D., Guzman, J., Côté, P., et al. (2009). The burden and determinants of neck pain in the general population: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Journal of manipulative and physiological therapeutics, 32(2 Suppl), S46–60. doi:10.1016/
2) Bishop, M. D., Mintken, P. E., Bialosky, J. E., & Cleland, J. a. (2013). Patient expectations of benefit from interventions for neck pain and resulting influence on outcomes. The Journal of orthopaedic and sports physical therapy, 43(7), 457–65. doi:10.2519/
3) Childs, J. D. (2008). Neck Pain. Journal of Orthopaedic and Sports Physical Therapy. doi:10.2519/
4) Sparks, C., Cleland, J. a, Elliott, J. M., Zagardo, M., & Liu, W.-C. (2013). Using Functional Magnetic Resonance Imaging to Determine if Cerebral Hemodynamic Responses to Pain Change Following Thoracic Spine Thrust Manipulation in Healthy Individuals. The Journal of orthopaedic and sports physical therapy, 43(5), 340–8. doi:10.2519/