STUDY DESIGN: Secondary analysis of a randomized clinical trial (RCT). OBJECTIVES: To perform a secondary analysis on the treatment arm of a larger RCT to determine differences in treatment outcomes, adverse reactions, and effect sizes between patients who received cervical thrust manipulation and those who received only nonthrust manipulation as part of an impairment-based, multimodal treatment program of manual physical therapy (MPT) and exercise for patients with mechanical neck pain. BACKGROUND: A treatment regimen of MPT and exercise has been effective in patients with mechanical neck pain. Limited research has compared the effectiveness of cervical thrust manipulations and nonthrust mobilizations for this patient population, and no studies have investigated the added benefit of cervical thrust manipulations as part of an overall MPT treatment plan. METHODS: Treatment outcomes from 47 patients in the treatment arm of a larger RCT, with a primary complaint of mechanical neck pain, were analyzed. Twenty-three patients (49%) received cervical thrust manipulations as part of their MPT treatment, and 24 patients (51%) received only cervical nonthrust mobilizations. All patients received up to 6 clinic sessions, twice weekly for 3 weeks, and a home exercise program. Primary outcome measures were the Neck Disability Index (NDI), 2 visual analog scales for cervical and upper extremity pain, and a 15-point global rating of change scale. Blinded outcome measurements were collected at baseline and at 3-, 6- and 52-week follow-ups. RESULTS: Consistent with the larger RCT, both subgroups in this secondary analysis demonstrated improvement in short- and long-term pain and disability scores. Low statistical power (β≤.28) and the resultant small effect size indices (–0.21 to 0.17) preclude the identification of any between-group differences. No serious adverse reactions were reported by patients in either subgroup. CONCLUSIONS: Clinically meaningful and statistically significant improvements in both subgroups of patients over time suggest that cervical thrust manipulation, as part of the MPT treatment plan, did not influence the results of the treatment arm of the larger RCT from which this study was drawn. Although no between-group differences can be identified, the small observed effect sizes in this study may benefit future studies with sample size estimation for larger RCTs and indicate the need to incorporate clinical prediction rule criteria as a means to improve statistical power. LEVEL OF EVIDENCE: Therapy, level 4.

J Orthop Sports Phys Ther 2010;40(3):133-140, Epub 5 February 2010. doi:10.2519/jospt.2010.3106

The patient was a 64-year-old woman who reported a sudden onset of neck pain and headaches following a fall 2.5 months prior to her initial physical therapy visit. Cervical spine radiographs, which were ordered by the referring physician, revealed extensive degenerative disc disease of the lower cervical spine. At her initial physical therapy evaluation, cervical spine range of motion was within functional limits except for bilateral rotation, which was limited to 45° due to pain and stiffness. The patient's headache symptoms were abolished with the Sharp-Purser test. Although assessment of symptoms was not the intent of the Sharp-Purser test, a reduction of symptoms during the test would warrant further evaluation. Therefore, the physical therapist ordered cervical spine flexion-extension radiographic views to assess for atlantoaxial instability. The radiologist's report noted a stable atlantodens interval that did not change with cervical flexion and extension and a course of physical therapy was initiated. At the time of discharge from physical therapy, the patient reported no neck pain and only very mild occasional headaches, which she believed she could manage on her own. 

J Orthop Sports Phys Ther 2009;39(5):418. doi:10.2519/jospt.2009.0405

KEY WORDS: atlantoaxial instability, cervical spine, radiographs

Study Design: Case series. Objective: To describe an impairment-based physical therapy treatment approach for 4 patients with plantar heel pain. Background: There is limited evidence from clinical trials on which to base treatment decision making for plantar heel pain. Methods and Measures: Four patients completed a course of physical therapy based on an impairment-based model. All patients received manual physical therapy and stretching. Two patients were also treated with custom orthoses, and 1 patient received an additional strengthening program. Outcome measures included a numeric pain rating scale (NPRS) and self-reported functional status. Results: Symptom duration ranged from 6 to 52 weeks (mean duration ± SD, 33 ± 19 weeks). Treatment duration ranged from 8 to 49 days (mean duration ± SD, 23 ± 18 days), with number of treatment sessions ranging from 2 to 7 (mode, 3). All 4 patients reported a decrease in NPRS scores from an average (± SD) of 5.8 ± 2.2 to 0 (out of 10) during previously painful activities. Additionally, all patients returned to prior activity levels. Conclusion: In this case series, patients with plantar heel pain treated with an impairment-based physical therapy approach emphasizing manual therapy demonstrated complete pain relief and full return to activities. Further research is necessary to determine the effectiveness of impairment-based physical therapy interventions for patients with plantar heel pain/plantar fasciitis.

J Orthop Sports Phys Ther. 2004;34(11):725-733. doi:10.2519/jospt.2004.1506

Key Words: ankle, manipulation, mobilization, plantar fasciitis

Clinical prediction rules have been developed, which can aid the practitioners in assessing the risk a patient has for developing pulmonary embolism. The present clinical commentary discusses the existing evidence for screening patients for pulmonary embolism. To illustrate the importance of the screening examination, a patient is presented who was referred to physical therapy 5 days after cervical discectomy and fusion. This patient was subsequently referred for medical evaluation and a confirmatory diagnosis of pulmonary embolism.

J Orthop Sports Phys Ther. 2005;35(10):637-644. doi:10.2519/jospt.2005.2109

Key Words: chest pain, dyspnea, lungs, screening, thromboembolism