Monthly Archives: March 2016

High-Velocity Thrust Manipulation: Don’t Get Addicted to the Crack

Your patient walks into the clinic complaining of low back pain, and they fit the clinical prediction rule for a lumbar manipulation. You deliver a high-velocity, low amplitude thrust manipulation…but there was no cavitation (pop). Everything about the set up felt right, but in the patient’s mind “nothing happened” because their back didn’t crack. Thankfully there is some research indicating that a cavitation is not required for success with an HVLA manipulation.

In 2006, Flynn et al examined the relationship between hearing an audible “pop” during an HVLA manipulation and symptom improvement. Over 80% of the participants cavitated during the manipulation technique, but there were no significant differences in improvement between those who popped and those who did not.

So what does this mean? Educate your patients prior to performing any manual technique, especially a thrust manipulation. I tell patients right from the beginning that you may or may not hear a “pop” during the technique, but our goal is to get a quick stretch to the joints and that the sound does not matter. Long story short, don’t get addicted to the crack.


Flynn TW, Childs JD, Fritz JM. The audible pop from high-velocity thrust
manipulation and outcome in individuals with low back pain. J Manipulative
Physiol Ther. 2006 Jan;29(1):40-5.

Clinical Prediction Rule: Thoracic Spine Manipulation

A patient comes into your clinic complaining of neck pain…what do you do? For some patients, treating the thoracic spine may help improve their symptoms. Cleland et al published a study in 2007 in which they published a clinical prediction rule to find a subgroup of patients whom may benefit from thoracic manipulations:

  • Symptoms <30 days
  • No symptoms distal to the shoulder
  • Looking up does not aggravate symptoms
  • FABQ <12
  • Decreased thoracic kyphosis in the upper thoracic spine
  • Cervical extension range of motion <30 degrees

Cleland found that if 3 out of 6 factors were present the probability of success was nearly 86%. While this study proved to be helpful for this subgroup of patients, it was not validated. That being said, the validation study did show that patients with mechanical neck pain who received thoracic spine manipulation and exercise exhibited significantly greater improvements in disability at both the short- and long-term follow-up periods and in pain at the 1-week follow-up compared with patients who received exercise only.

So what does this mean? Take a look a the thoracic spine; if it is justified to perform a thoracic manipulation you may get your patient better faster!

Clinical Prediction Rule: Stabilization Classification

A patient walks into your clinic complaining of low back pain. You aren’t sure exercises to give them, but you think that they would benefit from “core stabilization.” Instead of using a “cookie cutter” approach to treating patients, in which everyone receives the same treatment approach, you may be able to identify those patients who would respond better to stabilization exercises by using this study by Hicks et al. In the study, the researchers identified four factors that may identify patients who would benefit from lumbopelvic stabilization exercises:

  • Positive Prone Instability Test
  • Aberrant movements present
  • Average straight leg raise >91 degrees
  • Age <40

NOTE: Instead of performing the traditional prone instability test as described in the Hicks article, I use a modified version of the test. I begin by having the patient lay prone on the examination table. Apply a posterior to anterior pressure to the lumbar spine, and make note of any pain. At this point, have the patient raise their arms off the table while applying the pressure. If pain is present in the resting position but decreases when the arms are raised, the test would be positive.

So why is it important to provide these patients with stabilization exercises? Well Hides et al conducted a study on the effects of providing patients with stabilization exercises after an onset of low back pain. The study found that in the first year, those who performed specific stabilization exercises had a recurrence rate of 30% versus over 80% for those who did not perform core stabilization exercises.

Use these articles to help educate your patients on the importance of physical therapy in their recovery process, and that completing their rehabilitation may reduce their risk of setbacks in the future.


Low Back Pain: Are Stabilization Exercises Necessary?

How many times have you heard a medical professional say, “You have back pain because your core is weak.” While for some patients this may be true, this treatment approach may not be appropriate for the majority of the population. If your current philosophy for treating patients with low back pain is providing them with core stabilization exercises highly recommend you watch this quick video from Peter O’Sullivan. This video changed my mindset on treating patients with back pain, and hopefully will help a few of your patients down the road.

Peter O’Sullivan is also a huge advocate of patient education and the use of pain sciences. Check out this recent posting about how you can utilize pain science education in your next treatment session!

Evidence Based Approach for Cervical Radiculopathy

Your patient walks into your clinic with neck pain that radiates into their arm…now what? How do you know what it is, what you should do, and if they are going to respond well to conservative therapy? With the help of several research studies we thankfully have the answer to some of these questions.

Wainner et al published a study investigating the reliability and accuracy of different examination procedures for cervical radiculopathy. In the study he found four key features to help rule in the diagnosis of a cervical radiculopathy, with a positive likelihood ratio of over 30 if patients were positive on the rule. These four findings were the following:

  • Positive Upper Limb Tension Test A
  • Positive Spurling A Test
  • Positive Cervical Distraction Test
  • Cervical Rotation <60 degrees (to the involved side)

By using the above clinical prediction rule, you can provide a more accurate diagnosis for your patient, as well as better direct your interventions at addressing the underlying cause of the patient’s symptoms.

Now that we know what it is, how do we fix it? Today we are going to focus on one specific intervention technique; cervical traction. In 2009, Raney et al developed a clinical prediction rule to determine whether or not a patient was more likely to benefit from traction as an intervention:

  • >55 years of age
  • Peripheralization of symptoms with C4-C7 mobility testing
  • Positive Cervical Distraction Test
  • Positive Upper Limb Tension Test A
  • Positive Shoulder Abduction Test

If your patient has 4 out of 5 of the above predictors there is nearly a 95% likelihood that they would benefit from cervical traction as an intervention technique.

Finally, is there any way to know whether or not your patient will short-term success with therapy? Cleland et al found that there were four factors that indicated that the patient will have a positive outcome within 28 days:

  • <54 years old
  • Dominant arm not affected
  • Looking down does not increase symptoms
  • Multimodal treatment approach including manual therapy, cervical traction, and deep neck flexor muscle strengthening for at least 50% of visits

When all four variables were present, Cleland found the probability of success was nearly 90%. Not a bad statistic to provide your patient to motivate them to come to physical therapy.

By using the articles and research above, you can provide better quality care for your patients that complain of neck and arm pain. Stay tuned for more posts about how we can get these patients better faster!

Clinical Prediction Rules: Lumbar Manipulation

Do you ever wonder treatments will give your patient the best results? With the help of clinical prediction rules, we have the opportunity to utilize validated research studies to help with the diagnosis and treatment of individuals with a variety of different “tissue issues.” The next several posts will include various clinical prediction rules and the articles/abstracts associated with the research.

In 2004, Childs et al published the study, “A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study.” This study aimed to confirm what Flynn et al found in 2002 , which was a clinical prediction rule involving a high-velocity, low amplitude thrust technique directed at the lumbar spine. The five clinical predictors are the following:

  • Onset of symptoms less than 16 days.
  • No symptoms distal to the knee.
  • FABQ score less than 19.
  • Passive hip internal rotation greater than 35 degrees.
  • Hypomobility with PA spring testing in the lumbar spine.

The study found a 92% success rate for those who were positive on at least 4 out of the 5 clinical predictors.

An additional study by Fritz et al found that of the five clinical predictors, the most important predictors were the following:

  • No symptoms distal to the knee
  • Symptoms less than 16 days

If your patient is positive on this modified rule, the post-test chance of success is nearly 88%.

So what does this mean? If you are thorough with your clinical examination, you may be able to better treat your patients by applying these clinical predictors into your physical therapy plan of care.

OCS Exam Recommended Study Tools

After spending the past year completing Cayuga Medical Center’s Orthopedic Physical Therapy Residency Program, the day finally came to sit for the Orthopedic Certified Specialty examination. While completing a residency program provided me with an invaluable experience and truly prepared me for the exam, there was some additional material that assisted in my preparation for the test. The following material proved to be extremely helpful, and may help you pass the OCS Exam (note: the information regarding the resources has been taken directly from the sources website):

21.2 Current Concepts of Orthopaedic Physical Therapy, 3rd Edition

This course provides review of anatomy and biomechanics of each body region, application of specific tests and measurements, musculoskeletal pathology, and effective treatment strategies. Recognized experts share evidence-based techniques in orthopaedic physical therapy evaluation, assessment, and intervention. The first monograph describes the multifaceted process of clinical reasoning and utilization of evidence-based practice physical therapy management. The remaining monographs each cover a major joint region of the body, from the cervical spine and temporomandibular joint to the foot and ankle. Each monograph concludes with case scenarios that require clinical problem solving and allows readers to compare their answers with the experts’ rationale. Take advantage of this opportunity to enhance your clinical knowledge and challenge your reasoning skills.

Orthopaedic Physical Therapy Secrets, Second Edition 

Part of the popular Secrets series, this helpful reference presents basic physical therapy concepts and then introduces different healing modalities, specialties and orthopedic procedures typically prescribed for common injuries such as shoulders and extremities. Common diseases are included as well as more innovative diagnostic tools for physical therapists such as radiology. Each chapter features concise information that includes the author’s tips, memory aids and “secrets.” Bulleted lists, algorithms and illustrations provide a quick review of the specific topic discussed. The information is entirely evidence-based, outcome based and up-to-date.

  • All chapters provide an emphasis on outcome studies and evidence-based practice and include the latest research for the concepts presented.
  • Numerous charts, table and algorithms summarize and visually portray concepts covered in the chapters to provide additional information for clinical decision making.
  • Chapters are written by well-known contributors, including some of the best-known physical therapists practicing in the field today.
  • Provides important information on topics covered in the orthopedic specialty exam.
  • Includes detailed information relevant to making an accurate shoulder assessment as well as the most common shoulder disorders.
  • A comprehensive, heavily illustrated new chapter on orthopedic radiology provides a quick review on reading and interpreting radiographs of common orthopedic conditions.
  • A new differential diagnosis chapter describes the process and the purpose of differential diagnosis for physical therapists who are practicing without referral and who need to expand their knowledge of medical problems that mimic musculoskeletal disease.

Motivations, Inc: OCS Exam Prep Course

Motivations, Inc: Orthopedic Certification Specialist Exam Preparatory Course.

Dr. Eric Wilson has taught this Preparatory Course for the Orthopedic Certification Specialist exam with an 88% success rate since 2003. This two-day course includes a complete review of the body by region, with sections on disease processes, modalities and research. This preparation includes more than 150 OCS exam style questions and test-taking strategies. As a former item writer, the instructor brings to light the mechanics for testing and logic for study. While the questions are not actual questions from the OCS exam, they do reflect both the content and style of the questions on the OCS exam. The course packet includes: Exam questions and answer sheet that has a key to allow the participant to go back and see what content area they are weak in; exam and answer section that provides a rationale for why the correct answer is right and why the incorrect answers are wrong; and a detailed study guide by body region. Copies of the instructional PowerPoint slides will also be provided.