Mnp ppt jw


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If you have neck pain, check out this presentation of how physical therapy can help you avoid surgery and drugs.

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Mnp ppt jw

  1. 1. Neck Pain with/without Headache<br />Evidence validates that PTs can help your patients….<br />WITHOUT NARCOTICS OR SURGERY!<br />
  2. 2. Problem: Neck Pain with/without Headache<br />Neck pain, without symptoms or signs of serious medical or psychological conditions, associated with <br />motion limitations in the cervical and upper thoracic regions, <br />headaches, and <br />referred or radiating pain into an upper extremity <br /> (Childs et al, 2008)<br />
  3. 3. Intervention<br /><ul><li>Manual Therapy for Thoracic and Cervical Spine
  4. 4. Specific Exercise for the Upper Quarter
  5. 5. Intermittent Cervical Traction
  6. 6. Patient Education and Counseling </li></ul> <br />
  7. 7. Intervention: Manual Therapy<br />Thrust and non-thrust techniques at the Thoracic and Cervical Spine1-7<br />1. Cleland et al. Phys Ther. 2007;87(4):431-440.<br />2. Gonzalez-Iglesias et al.  J Orthop Sports Phys Ther. 2009;39(1):20-27.<br />3. Cleland et al.  Phys Ther.  2010;90(9):1239-1250.<br />4. Lau et al.  Man Ther.  2011;16:141-147.<br />5. Walker et al.  Spine. 2008;33(22):2371-2378.<br />6. Jull et al. Spine. 2002;27(17):1835-1843.<br />7.Childs et al. J Orthop Sports Phys Ther. 2008;38(9):A1-A34 <br />8. Wainner RS, Flynn T. With permission, Copyright Evidence In Motion, LLC. <br />, all rights reserved .<br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />
  8. 8. Intervention: Manual Therapy<br />Cervical Spine Mobilization with Upper Limb Neurodynamics Positioning1, 2<br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />1. Cleland JA et al. J Orthop Sports Phys Ther. 2005.<br />2. Childs et al. J Orthop Sports Phys Ther. 2008.<br /> <br />
  9. 9. Intervention: Specific Exercise<br />Deep Neck Flexor Retraining and Endurance1, 2<br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />1. Jull et al. Spine. 2002.<br />2. Childs et al. J Orthop Sports Phys Ther. 2008.<br />3. Wainner RS, Flynn T. With permission, Copyright Evidence In Motion, LLC., all rights reserved .<br />
  10. 10. Intervention: Specific Exercise<br />Scapular Stabilizer Strengthening1,2<br />1. Jull et al. Spine. 2002.<br />2. Childs et al. J Orthop Sports Phys Ther. 2008.<br />3.Wainner RS, Flynn T. With permission, Copyright Evidence In Motion, LLC., all rights reserved .<br />
  11. 11. Intervention: Specific Exercise<br />Stretching as indicated1,2<br /> <br /> <br /> <br />1. Jull et al. Spine. 2002.<br />2. Childs et al. J Orthop Sports Phys Ther. 2008.<br />3. Wainner RS, Flynn T. With permission, Copyright Evidence In Motion, LLC. <br />, all rights reserved .<br />
  12. 12. Evidence - Manual Therapy + Exercise<br />A. Manual therapy & exercise - indicated for patients with neck pain, +/- headache, & +/- arm pain.<br /> <br />B. Mobilization and/or manipulation and exercise is more effective than either alone. (Level 1 evidence, systematic review, Gross et al. Spine. 2004)<br /> <br />NNT = 2 with Manual Therapy and Exercise to achieve one additional successful outcome than would have occurred with an alternative treatment approach<br />
  13. 13. Evidence - Manual Therapy + ExerciseLong-Term Results<br />A. Walker et al, Spine, 2008 – RCT, MTE vs MIN intervention<br /><ul><li>Disability, UE pain, & patient perceived recovery significantly better at 3 week, 6 week, and 1 year follow-up in the MTE group.</li></ul>B. Bronfort et al, Spine, 2001 – RCT, Manip+ low tech TEX, high tech TEX, Manip alone<br /><ul><li>1 year follow-up: Manip + low tech TEX group demonstrated significantly greater satisfaction with care
  14. 14. Pain better in both exercise groups vs. manip alone</li></ul>  <br />C. Evans et al, Spine, 2002 – 2 yr f/u of Bronfort et al<br /><ul><li>Satisfaction maintained @ 2 yrs; Imp pain with both exercise groups maintained</li></ul> <br />
  15. 15. Evidence: Manual Therapy + ExerciseHoving et al, Ann Intern Med, 2002<br />A. RCT – Man Ther (no thrust, 6 visits) vs Ex/Stretch (12 visits) vs Meds/Advice (1 visit, more optional)<br />    <br />B. Outcomes @ 7 week follow-up<br />    1. Patient Perceived Recovery (defined a priori)<br />        Man Ther 68%; Ex/Stretching 51%; Meds/Advice 36%<br />    2. Pain - Manual Therapy > Ex/Stretch > Meds/Advice<br /> <br />C. Other Noteworthy Items<br />    1. Man Ther & Ex/Stretching took less analgesics<br />    2. Man Ther - missed less work<br />    3. NNT with Manual Therapy is 3<br /> <br /> <br />
  16. 16. Evidence - Manual Therapy + Exercise<br />Cost Effectiveness<br />A. Korthals-de Bos, BMJ, 2003<br /><ul><li>Cost effectiveness analysis of Hoving et al RCT
  17. 17. Over 1 yr, patients with neck pain treated with 6 visits of Manual Physical Therapy and Exercise incurred an average cost of $402, compared to exercise alone ($1,167) or Meds/Advice group ($1241)</li></li></ul><li>Evidence - Manual Therapy + Exercise Cervicogenic Headache (CGHA)<br />A. Cervicogenic Headache Criteria - Sjstaad et al, Headache, 1998<br /><ul><li>Unilateral or unilateral dominant side-consistent headache associated with neck pain and aggravated by neck postures or movement
  18. 18. Tenderness with palpation in at least one of the upper 3 cervical segments
  19. 19. Headache frequency of at least one per week over a period of 2 months to 10 years</li></ul> B. Results of Jull et al, Spine, 2002<br /><ul><li> Man Ther & Exercise - most effective in treating CGHA , outcomes lasting up to 1 yr
  20. 20. Patients :less additional care sought, reduction in headache duration, neck pain, headache intensity, & frequency, reduction on medication intake (93% decrease in MT with Ex,100% decrease in Ex/MT only)
  21. 21. Average length of headaches was 6.1 years with moderate intensity headaches; Jull et al did not find chronicity to be a prognostic factor
  22. 22. 10% better chance of having a good to excellent outcome with combined therapies</li></li></ul><li>Intervention: Traction<br />I. Types of traction<br />   A. Manual vs. Mechanical<br />   B. Continuous vs. Intermittent<br />1. Kisner, 1996.<br />II. Effects of traction may include:<br />   A. Separation of vertebral bodies<br />   B. Distraction/Gliding of facet joints<br />   C. Widening of the intervertebral foramen<br />   D. Straightening of spinal curves<br />   E. Stretching of spinal musculature<br />2. Graham N, 2006.<br />
  23. 23. Evidence: Traction<br />A. Mechanical traction for the cervical spine involves a tractive force applied to the neck via a mechanical system<br />    - Intermittent or Continuous<br />B. Indications: radicularsxs,  sx with distraction test, fit CPR by Raney et al<br />C. Systematic review, mod evidence of benefit for intermittent traction for acute @ chronic neck pain (Level 1 Evidence) (Graham, J Rehabil Med. 2006.)<br />
  24. 24. Evidence: Traction CPR                                                                           Raney et al, Eur Spine J, 2009<br />A. Developed CPR to determine who would respond to traction<br />68 patients/30 positive outcomes included in analysis<br />B. 5 variable CPR identified<br />Age >55<br />Positive shoulder abduction test<br />Positive ULTT A<br />Symptom peripheralization with central posterior–anterior motion testing at lower cervical (C4–7) spine<br />Positive neck distraction test<br />C. 3/5 variables present= +LR of 4.8<br />D. 4/5 variables present= +LR of 11.7 and post-test probability of     90.2% of having improvement <br />
  25. 25. Intervention: Patient Education and Counseling<br /><ul><li>Early return to pain-free activity, active role in recovery1 
  26. 26. Yellow Flags - Psychosocial factors that indicate risk for chronicity, potential work loss
  27. 27. Pain Neurophysiology Education in presence of yellow flags2
  28. 28. Multidisciplinary Approach: Referral to appropriate discipline (psychologist, vocational specialist, pharmaceutical) as indicated by presence of yellow flags1,3</li></ul> <br />1. Childs et al. J Orthop Sports Phys Ther. 2008.<br />2. Nijs et al.  Man Ther. 2011. Available at:<br />3. Sterling M. Man Ther. 2009.<br />
  29. 29. Evidence: Patient Education and Counseling<br />RCT for patients with whiplash<br />Encouragement to exercise/move vs collar<br />Exercise/move advice -  outcomes/  pain vs collar (Crawford 2004)<br />B. RCT for patients with whiplash<br />Early PT/education vs collar<br />PT/education -  long term outcomes vs collar <br /> (Rosenfeld 2003))<br />
  30. 30. Refer: Who, Why and How to Refer<br />- High quality evidence supports manual physical therapy and exercise for neck pain of gradual or sudden onset (ie trauma) that is provoked by movement, +/- associated headaches. <br /><ul><li>Send to PT with“Evaluate and Treat” option checked.
  31. 31. You will receive a copy of your patient’s initial note as well as a copy of the discharge note summarizing their outcome.</li></li></ul><li>References <br /><ul><li>Bovim G, Schrader H, Sand T. Neck pain in the general population. Spine. 1994;19:1307–1309.
  32. 32. Bronfort G, Evans R, Nelson B, et al.  A randomized clinical trial of exercise and spinal manipulation for patients with chronic neck pain.  Spine.  2001;26(7):788-799.
  33. 33. Childs JD, Cleland JA, Elliott JM, et al. Neck pain: Clinical practice guidelines linked to the International Classification of Functioning, Disability, and Health from the Orthopedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther. 2008;38(9):A1-A34.
  34. 34. Cleland JA, Whitman JM, Fritz JM, Palmer JA. Manual physical therapy, cervical traction, and strengthening exercises in patients with cervical radiculopathy: a case series. J Orthop Sports Phys Ther. 2005;35(12):802-811.
  35. 35. Cleland JA, Glynn P, Whitman JM, et al. Short-term effects of thrust versus nonthrust mobilization/manipulation directed at the thoracic spine in patients with neck pain: a randomized clinical trial. Phys Ther. 2007;87(4):431-440.
  36. 36. Cleland JA, Mintken PE, Carpenter K, et al. Examination of a clinical prediction rule to identify patients with neck pain likely to benefit from thoracic spine thrust manipulation and a general cervical range of motion exercise: multi-center randomized clinical trial. Phys Ther. 2010;90(9):1239-1250.
  37. 37. Cote P, Cassidy JD, Carroll L. The epidemiology of neck pain: what we have learned from our population-based studies. J Can Chiropract Assoc. 2003;47:284–290.
  38. 38. Crawford et al. Early management and outcome following soft tissue injuries of the neck - a randomised controlled trial. Injury. 2004;35(9):891-5.
  39. 39. Evans R, Bronfort G, Nelson B, Goldsmith CH.  Two-year follow-up of a randomized clinical trial of spinal manipulation and two types of exercise for patients with chronic neck pain.  Spine.  2002;27(21):2383-2389.
  40. 40. Gonzalez-Iglesias J, Fernandez-de-las-Penas C, Cleland JA, Gutierrez-Vega Mdel R. Thoracic spine manipulation for the management of patients with neck pain: a randomized clinical trial. J Orthop Sports Phys Ther.  2009;39(1):20-7.
  41. 41. Graham N, Gross AR, Goldsmith C.  Mechanical traction for mechanical neck disorders: a systematic review. J Rehabil Med 2006;38(3):145-152. </li></li></ul><li>References<br /><ul><li>Gross AR, et al.  A Cochrane Review of Manipulation and Mobilization for Mechanical Neck Disorders.  Spine.  2004;29(14):1541-1548.oving JL, Koes BW, de Vet HCW, et al.  Manual therapy, physical therapy, or continued care by general practitioner for patients with neck pain: a randomized controlled trial.  Ann Intern Med.  2002;136:713-722.
  42. 42. Jull G, Trott P, Potter H, et al. A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine. 2002;27(17):1835-1843; discussion 1843.
  43. 43. Kisner C, Colby LA. The spine: traction procedures. In: Therapeutic exercise: foundations and techniques 3rd edn. Philadelphia: FA Davis Co.; 1996, p. 575-591.
  44. 44. Korthals-de Bos IBC, 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;326:911.
  45. 45. Lau HMC, Chiu TTW, Lam TH.  The effectiveness of thoracic manipulation on patients with chronic mechanical neck pain - a randomized controlled trial.  Man Ther.  2011;16:141-147.
  46. 46. Linton SJ, Hellsing AL, Hallden K. A population-based study of spinal pain among 35-45-year-old individuals. Prevalence, sick leave, and health care use. Spine 1998;23(13):1457-6.
  47. 47. Nijs J, Paul van Wilgen C, Van Oosterwijck J, van Ittersum M, Meeus M. How to explain central sensitization to patients with “unexplained” chronic musculoskeletal pain: Practice guidelines. Man Ther. 2011. Available at: Accessed August 11, 2011.
  48. 48. Raney NH, Petersen EJ, Smith TA, et al. Development of a clinical prediction rule to identify patients with neck pain likely to benefit from cervical traction and exercise. Eur Spine J. 2009; 18(3):382.
  49. 49. Rosenfeld et al. Active intervention in patients with whiplash-associated disorders improves long-term prognosis: a randomized controlled clinical trial. Spine. 2003;28(22):2491-8.
  50. 50. Sjaastad O, Fredriksen TA, Pfaffenrath V. Cervicogenic headache: Diagnostic criteria. Headache. 1998;38:442-445.</li></ul> <br />
  51. 51. References<br /><ul><li>Sterling M. Physical and psychological aspects of whiplash: important considerations for primary care assessment, part 2--case studies. Man Ther. 2009;14(1):e8-12.
  52. 52. Walker MJ, Boyles RE, Young BA, et al.  The effectiveness of manual physical therapy and exercise for mechanical neck pain.  Spine.  2008;22:2371-2378.
  53. 53. Wright A, Mayer T, Gatchel R. Outcomes of disabling cervical spine disorders in compensation injuries: a prospective comparison to tertiary rehabilitation response for chronic lumbar disorders. Spine. 1999; 24:178–183.</li>