Thrust Joint Manipulation Utilization by Us Physical Therapists

Study Design: Online survey study. Objective: To determine physical therapists’ utilization of thrust joint manipulation (TJM) and their comfort level in using TJM between the cervical, thoracic, and lumbar regions of the spine. We hypothesized that physical therapists who use TJM would report regular use and comfort providing it to the thoracic and lumbar spines, but not so much for the cervical spine. Background: Recent surveys of first professional physical therapy degree programs have found that TJM to the cervical spine is not taught to the same degree as to the thoracic and lumbar spines. Methods: We developed a survey to capture the required information and had a Delphi panel of 15 expert orthopedic physical therapists reviewed it and provide constructive feedback. A revised version of the survey was sent to the same Delphi panel and consensus was obtained on the final survey instrument. The revised survey was made available to any licensed physical therapists in the USA using an online survey system, from October 2014 through June 2015. Results: Of 1014 responses collected, 1000 completed surveys were included for analysis. There were 478 (48%) males; the mean age of respondents was 39.7 ± 10.81 years (range 24 – 92); and mean years of clinical experience was 13.6 ± 10.62. A majority of respondents felt that TJM was safe and effective when applied to lumbar (90.5%) and thoracic (91.1%) spines; however, a smaller percentage (68.9%) felt that about the cervical spine. More therapists reported they would perform additional screening prior to providing TJM to the cervical spine than they would for the lumbar and thoracic spine. Therapists agreed they were less likely to provide and feel comfortable with TJM in the cervical spine compared to the thoracic and lumbar spine. Finally, therapists who are male; practice in orthopedic spine setting; are aware of manipulation clinical prediction rules; and have manual therapy certification, are more likely to use TJM and be comfortable with it in all 3 regions. Conclusion: Results indicate that respondents do not believe TJM for the cervical spine to be as safe and efficacious as that for the lumbar and thoracic spines. Further, they are more likely to perform additional screening, abstain from and do not feel comfortable performing TJM for the cervical spine. Clinical Relevance: Our research reveals there is a discrepancy between utilization of TJM at different spinal levels. This research provides an opportunity to address variability in clinical practice among physical therapists utilizing TJM

Does inter-vertebral range of motion increase after spinal manipulation? A prospective cohort study.

Background: Spinal manipulation for nonspecific neck pain is thought to work in part by improving inter-vertebral range of motion (IV-RoM), but it is difficult to measure this or determine whether it is related to clinical outcomes. Objectives: This study undertook to determine whether cervical spine flexion and extension IV-RoM increases after a course of spinal manipulation, to explore relationships between any IV-RoM increases and clinical outcomes and to compare palpation with objective measurement in the detection of hypo-mobile segments. Method: Thirty patients with nonspecific neck pain and 30 healthy controls matched for age and gender received quantitative fluoroscopy (QF) screenings to measure flexion and extension IV-RoM (C1-C6) at baseline and 4-week follow-up between September 2012-13. Patients received up to 12 neck manipulations and completed NRS, NDI and Euroqol 5D-5L at baseline, plus PGIC and satisfaction questionnaires at follow-up. IV-RoM accuracy, repeatability and hypo-mobility cut-offs were determined. Minimal detectable changes (MDC) over 4 weeks were calculated from controls. Patients and control IV-RoMs were compared at baseline as well as changes in patients over 4 weeks. Correlations between outcomes and the number of manipulations received and the agreement (Kappa) between palpated and QF-detected of hypo-mobile segments were calculated. Results: QF had high accuracy (worst RMS error 0.5o) and repeatability (highest SEM 1.1o, lowest ICC 0.90) for IV-RoM measurement. Hypo-mobility cut offs ranged from 0.8o to 3.5o. No outcome was significantly correlated with increased IV-RoM above MDC and there was no significant difference between the number of hypo-mobile segments in patients and controls at baseline or significant increases in IV-RoMs in patients. However, there was a modest and significant correlation between the number of manipulations received and the number of levels and directions whose IV-RoM increased beyond MDC (Rho=0.39, p=0.043). There was also no agreement between palpation and QF in identifying hypo-mobile segments (Kappa 0.04-0.06). Conclusions: This study found no differences in cervical sagittal IV-RoM between patients with non-specific neck pain and matched controls. There was a modest dose-response relationship between the number of manipulations given and number of levels increasing IV-RoM - providing evidence that neck manipulation has a mechanical effect at segmental levels. However, patient-reported outcomes were not related to this

Clinical reasoning in canine spinal disease: what combination of clinical information is useful?

Spinal disease in dogs is commonly encountered in veterinary practice. Numerous diseases may cause similar clinical signs and presenting histories. The study objective was to use statistical models to identify combinations of discrete parameters from the patient signalment, history and neurological examination that could suggest the most likely diagnoses with statistical significance. A retrospective study of 500 dogs referred to the Queen Mother Hospital for Animals before June 2012 for the investigation of spinal disease was performed. Details regarding signalment, history, physical and neurological examinations, neuroanatomical localisation and imaging data were obtained. Univariate analyses of variables (breed, age, weight, onset, deterioration, pain, asymmetry, neuroanatomical localisation) were performed, and variables were retained in a multivariate logistic regression model if P<0.05. Leading diagnoses were intervertebral disc extrusion (IVDE, n=149), intervertebral disc protrusion (n=149), ischaemic myelopathy (IM, n=48) and neoplasms (n=44). Multivariate logistic regression characterised IM and acute non-compressive nucleus pulposus extrusions as the only peracute onset, non-progressive, non-painful and asymmetrical T3-L3 myelopathies. IVDE was most commonly characterised as acute onset, often deteriorating, painful and largely symmetrical T3-L3 myelopathy. This study suggests that most spinal diseases cause distinctive combinations of presenting clinical parameters (signalment, onset, deterioration, pain, asymmetry, neuroanatomical localisation). Taking particular account of these parameters may aid decision making in a clinical setting

Physiotherapy students\u27 perceptions and experiences of clinical prediction rules

Objectives: Clinical reasoning can be difficult to teach to pre-professional physiotherapy students due to their lack of clinical experience. It may be that tools such as clinical prediction rules (CPRs) could aid the process, but there has been little investigation into their use in physiotherapy clinical education. This study aimed to determine the perceptions and experiences of physiotherapy students regarding CPRs, and whether they are learning about CPRs on clinical placement. Design: Cross-sectional survey using a paper-based questionnaire. Participants: Final year pre-professional physiotherapy students (n=371, response rate 77%) from five universities across five states of Australia. Results: Sixty percent of respondents had not heard of CPRs, and a further 19% had not clinically used CPRs. Only 21% reported using CPRs, and of these nearly three-quarters were rarely, if ever, learning about CPRs in the clinical setting. However most of those who used CPRs (78%) believed CPRs assisted in the development of clinical reasoning skills and none (0%) was opposed to the teaching of CPRs to students. The CPRs most commonly recognised and used by students were those for determining the need for an X-ray following injuries to the ankle and foot (67%), and for identifying deep venous thrombosis (63%). Conclusions: The large majority of students in this sample knew little, if anything, about CPRs and few had learned about, experienced or practiced them on clinical placement. However, students who were aware of CPRs found them helpful for their clinical reasoning and were in favour of learning more about them

The Application of Airtraq (fibreoptic intubation device) to Otolaryngology

The anaesthetic laryngoscope Airtraq is designed for the difficult airway. This disposable laryngoscope requires minimal cervical manipulation and unlike other common anaesthetic larynmgoscopes contains a channel for the guidance of an endotracheal tube. This could also be used for diagnosis and biopsy under a general anaesthetic or potentially under a local anaesthetic in an outpatient setting for biopsies or the removal of hypopharyngeal foreign bodies via flexible biopsy forceps obviating the need for a general anaesthetic. Thus Airtraq could be included in the armoury of pre-existing direct laryngoscopes because of its virtue of minimal airway manipulation

Clinical and surgical management of holocervical spinal cord ependymomas.

Background:Spinal ependymomas are rare tumors of the central nervous system, and those spanning the entire cervical spine are atypical. Here, we present two unusual cases of holocervical (C1-C7) spinal ependymomas. Case Description:Two patients, a 32-year-old female and a 24-year-old male presented with neck pain, motor, and sensory deficits. Sagittal MRI confirmed hypointense lesions on T1 and hyperintense regions on T2 spanning the entire cervical spine. These were accompanied by cystic cavities extending caudally into the thoracic spine and rostrally to the cervicomedullary junction. Both patients underwent gross total resection of these lesions and sustained excellent recoveries. Conclusion:Two holocervical cord intramedullary ependymomas were safely and effectively surgically resected without incurring significant perioperative morbidity

Letter to the editor

Comment on the article Melikyan G, Kamran S, Akhtar N, Deleu D, Miyares FR. Cortex-sparing infarction in triple cervical artery dissection following chiropractic neck manipulation. Qatar Med J. 2015; (2):1

Somatosensory tinnitus: current evidence and future perspectives

In some individuals, tinnitus can be modulated by specific maneuvers of the temporomandibular joint, head and neck, eyes, and limbs. Neuroplasticity seems to play a central role in this capacity for modulation, suggesting that abnormal interactions between the sensory modalities, sensorimotor systems, and neurocognitive and neuroemotional networks may contribute to the development of somatosensory tinnitus. Current evidence supports a link between somatic disorders and higher modulation of tinnitus, especially in patients with a normal hearing threshold. Patients with tinnitus who have somatic disorders seems to have a higher chance of modulating their tinnitus with somatic maneuvers; consistent improvements in tinnitus symptoms have been observed in patients with temporomandibular joint disease following targeted therapy for temporomandibular disorders. Somatosensory tinnitus is often overlooked by otolaryngologists and not fully investigated during the diagnostic process. Somatic disorders, when identified and treated, can be a valid therapeutic target for tinnitus; however, somatic screening of subjects for somatosensory tinnitus is imperative for correct selection of patients who would benefit from a multidisciplinary somatic approach

Nausea, Vomiting and Retching of Patients with Cervical Cancer Undergoing Chemotherapy in Bali, Indonesia

Background: Nausea, vomiting and retching (NVR) was the frequently reported and troublesome adverse effect for patients receiving chemotherapy. Purpose: This study is a part of a larger study which aims to describe the NVR symptom experience in cervical cancer patients undergoing chemotherapy in Bali, Indonesia, and examine relationships with individual's risk factors. Method: Sixty-six patients with stage II and III cervical cancer receiving Paxus (Paclitaxel)-Cisplatin at the second or the third cycle were enrolled. NVR was measured by the Index of Nausea, Vomiting and Retching (INVR) at the second day of their chemotherapy. This current study included only patients with age ranged between 32 to 65 years (M = 47.15, SD = 9.64, min-max age 35 – 65 years). Result: The result showed that the NVR score was at a moderate level. Younger subjects (age 32-50 years old) reported significantly higher NVR scores than that of older subjects (age 51-65 years old) (t = 2.76, p = .007). The subjects with higher anxiety scores reported significantly higher NVR scores than those with lower anxiety scores (t = -2.41, p = .019). Subjects who had experience in motion sickness had significantly higher NVR scores (M = 12.69, SD = 2.60) than those who did not (M = 9.23, SD = 2.86) and the difference was statistically significant (t = 4.98, p <.01). Meanwhile, no significant difference was found between subjects who reported their expectation to have nausea and those who did not (t = 0.08, p = .94). Conclusion: The findings provide valuable information regarding NVR and the individual risk factors among patients with cervical cancer undergoing chemotherapy. Nurses should assess the anxiety level and a history of motion sickness of patients planned for chemotherapy and offer preventive interventions to prevent and control NVR occurrence and its distress