Is Physical Therapy a Go To???
By: Charmine Kay Bartlett
What goes on with a PT each day? Example: patient with cervical or neck pain diagnosis…just one of the many….
Neck pain is a common complaint in my practice setting i.e.geriatrics as observed, but has not been commonly and directly addressed with any intervention unless specified by the referring MD. Which most of the time is inclined to that of commonly used interventions similar to MIN approach: postural advice, encouragement to maintain neck motion and daily activities, cervical ROM exercise, medication maintenance as prescribed, use of cervical collar and of course, therapeutic ultrasound, that was utilized in RCT by Walker et al 2008. Headache is a common occurrence but is readily provided with pain medication either prescribed/ OTC. It is not directly differentiated unless the patient manifested high blood pressure with nausea and vomiting. EMS is the lifeline. Manual therapy: mobilization or manipulation is not a popular intervention at all! Resistance exercises, stretching and functional activities: transfers and gait training are resorted to instead. For CMS/third party payers, these are quantified and considered objective findings reimbursable. The goal is always to return to function in order for patients to go back home or be able to take care of themselves with least assistance. It is ironic because most patients are referred to PT primarily due to pain limiting functional activity and participation but pain is never directly intended to be resolved. Why? I surmise because of multifactorial barriers:
- reimbursement driven culture of these settings or limitations with third party payers particularly CMS.
- Multiple chronic comorbidities of patients treated e.g.CA, dementia, osteoporosis, CHF, DM, COPD, ESRD with hemodialysis, CVA etc., which manual therapy as to mobilization or manipulation is/may be contraindicated.
- Limited physical therapists’ skills set as to manual therapy or EBP practice in general.
- Physical therapist’s personal/professional bias in regards to cervical region and pain
- Patient’s preference.
Due to their ages, PT would be lucky to move an extremity, leave alone the neck with complaints of pain. Exercise is the best tool there is, which improves the patient’s function overtime. With a patient population age range of 60 and above, sarcopenia is the main concern. This condition occurring at a rate of 1% to 5% annually from age 30 (Avers et al), thus decreased strength, (Frontera et al 1988) which contributes to decrease in physical function and eventually, loss of independence (Taaffe et al 2000). After age 60, power decreases even more rapidly at a rate of 3% to 5% annually affecting ability to move and react quickly. (Avers et al). More so, to expect from patients with concomitant comorbidities. Adherence of the patient is another barrier, which I would not dwell into as this would be another topic with its rightful entirety. However, would this hinder me as an individual PT to utilize manual therapy? Absolutely not, there are numerous benefits it entails. I put into practice manual therapy + active exercises. I think that with the impairment based concept of Manual Therapy (MT) and Treatment based Concept (TBC), appropriate intervention can be provided to different subgroups identified, which could secondarily lower healthcare and economic costs! I like utilizing thoracic manipulation: techniques with upper thoracic, midthoracic and/or CT junction > cervical manipulation with my mechanical neck pain and headache patient population. Evidence states that thoracic manipulation can be used for reducing pain and disability with patients. (Cleland et al 2010, Jull et al 2002, Masaracchio et al 2013). The primary effect of MT is proposed to be neurophysiologic than mechanical.(Bialosky et al 2008). Choosing a few techniques to compliment active exercise is always in the list for probable solution. There are available studies that state specific techniques are no better than general techniques in patients with neck pain and low back pain. (Chiradejnant et al 2003, Perez et al 2014).
I am inclined to using the body chart and SINSS (Severity, Irritability, Nature, Stage, Stability) concept with my subjective examination, finding the asterisk and pattern recognition. It helps literally to visualize with a body chart. I find active ROM , passive ROM; and with OP (overpressure) very helpful, particularly in conditions with below the arm or elbow symptoms. Otherwise, combined neck motions or prolonged positioning in all planes would do in terms of reproduction of symptoms to rule in/out a pathology. In the case of cervical radiculopathy, I believe that the cluster of tests by Dr. Wainner would be useful for any radicular symptoms manifested below the arm/elbow e.g.tingling/burning/numbness along with the neck pain. ULTT alone is useful in ruling out the condition, having the sensitivity of 97%. (Wainner et al). Cook et al recommended “..stand alone clinical tests provide only marginal value in diagnosis and clusters of clinical tests appear to provide more promising findings; a mechanism that more closely reflects clinical decision making.” Neural tissue management is effective e.g. ULTT (median, ulnar, radial) to determine neck with arm pain distribution. However, clinicians have to be really careful because of its sensitivity with the amount of tension provided. If the irritability level is mild, yes I would consider it, but if it is moderate, I would be cautious, and if it is high, I would most likely defer it. For treatment, gliding/sliding technique performed with caution would be appropriate. As per Nee et al, “neural tissue management techniques would move the nerves that had become overly sensitive to movement, in a gentle and pain-free manner, aiming to reduce the sensitivity.” Unfortunately, in my practice setting, we do not have any MSK (musculoskeletal) clinical pathway. Thus, cervical radiculopathy is one of the neck conditions that we do not address in a way that it should be based on the literature. As concluded on Fritz et al: standard exercise program that included scapular and cervical strengthening e.g. isometrics, deep neck flexor strengthening, plus cervical traction resulted in lower disability and pain intensity too. Upper/midthoracic, cervical (segmental) manipulation (Browder et al); manipulation, mobilization, muscle energy technique or stretching would bring significant outcome (Walker et al). Patient education and compliance with home exercise programs e.g. ROM and self – stretching / mobilization would be good for maintenance. If outcome measures and subjective feedback from the patient progresses, it would be beneficial to advance them into more functional activities, as is deemed to be more important. It may take awhile, with difficulty justifying my intent to the plan of care. Thus, outcome measures would be of paramount necessity.
Headache condition is another that we do not directly address, other than pain medication prescribed unless the patient has issues of dizziness, lightheadedness and balance deficits i.e.more within the vertigo spectrum for neuromuscular education. Migraine and tension type headache are somewhat over utilized diagnoses regardless if findings are validated or not. Cervicogenic headache would never be seen on medical practitioner’s referral as diagnosis, along with CAD (cervical artery dysfunction). Anyway, Jull et al 2008, is a literature that enlightens me to pay more attention to a patient that complains of headache. Instead of setting the bar to rely on pain medications or massage with this complaint, I am convinced with MT and active exercise to be the best evidence based intervention.
CSM (cervical spinal myelopathy) is the condition that I have rarely seen on any H&P of a doctor from any referring setting. Cervical stenosis, DJD and spondylosis are the typical diagnoses. I used to not screen CSM until I had my MSK management course. To be honest, it was then that I first heard of it. I currently utilize neurological screening particularly if patient has neck pain with bilateral LE weakness: including myotomes/dermatomes/MSRs, cluster of clinical tests to determine 3 /5 positive clinical findings: gait deviation (ataxia, wide based gait or spastic gait); pathological signs i.e. Hoffman’s, Babinski’s test or inverted supinator sign and age of >45 years. (Cook et al). As a protocol, any important clinical findings needed to be reported to MD, and then PT to recommend, which I would probably recommend imaging confirmation e.g. MRI or consultation with a specialist. Surgical procedure, which has mostly been recommended during the mild stages in order to prevent further cord damage, whom surgeons are now slowly diverting to less invasive approaches or perhaps to a more conservative approach. According to a study Kadanka et al, this is an era of more careful selection of patients to more specific approaches.
Treatment selection at a therapist’s discretion: ICT, segmental (cervical and thoracic) manipulation/mobilization, strengthening, stretching, coordination, endurance, postural education. Sometimes, particularly those who opted for surgery: reduce the effects of immobility, isometrics, ROM, bed rest, activity modification. Goal: to achieve increased function and decreased pain in order to restore quality of life.
Patient empowerment to self care is critical to maintain progress, which I think is the most important. Thus, a home exercise program is a big factor to follow!
Quite a lot… random thoughts? Nah…PTs do think and act a lot, not just exercise! This mode is turned on every single day to just a single patient.
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Browder D, Erhard R, Piva R, et al. Intermittent Cervical Traction and Thoracic Manipulation for management of mild cervical compression myelopathy attributed to cervical herniated disc: A case series. J Orthop Sports Physical Ther. 2004; 34;11 701-712
Walker M, Boyles R, Young B, Strange J, Garber M, Whitman J, Doyle G, Winner R, et al. The Effectiveness of manual physical therapy and exercise for mechanical neck disorders: A Randomized Clinical Trial. Spine 2008; 33;22 2371-8
Fritz J,Thacker A, Brennan G, Child’s J. Exercise only, exercise with mechanical traction, or exercise with overdoor traction for patients with cervical radiculopathy, with or without consideration of status on a previously described subgrouping rule:a randomized clinical trial. J Orthopedic Sports Physical Ther. 2014;44: 45-57.
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Chiradejnant A, Maher CG, Latimer J, Stepkovitch N. Efficacy of “therapist-selected” versus “randomly selected” mobilisation techniques for the treatment of low back pain: a randomised controlled trial. Aust. J. Physiother. 2003;49(1993):233-241. doi:10.1016/S0004-9514(14)60139
Izquierdo Pérez H, Alonso Perez JL, Gil Martinez A, et al. Is one better than another?: A randomized clinical trial of manual therapy for patients with chronic neck pain. Man. Ther. 2014;19(3):215-21. doi:10.1016/j.math.2013.12.002.
Cook C, Brown C, Isaacs R, et al. Clustered clinical findings for diagnosis of cervical spine myelopathy. J Manual and Manip Ther.2010;18(4):175-180 Kadanka Z, Mare M, Bednarik J, et al. Approaches to spondylotic cervical myelopathy:conservative versus surgical results in a 3 – year follow –up study. Spine 2002: 27 (20): 2205-221.