A clinical prediction rule to identify patients with neck pain likely to benefit from home-based mechanical cervical traction.

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Eur Spine J Jun;20(6);912 2011

 

The objective of the study was to identify those with neck pain who may be benefited by the use of a home-traction device (over-door, Comfort-trac etc). The treatment was administered for (2) weeks. The prediction rules were a low FABQ, pre-treatment pain of 7/10, positive distraction test and pain in the shoulder or below. NPS score and NDI global rating, of the 103 patients 47 had a positive response to HMCT. With satisfaction of at least 3 of the 4 variables (CPR’s) the interventions’ success rate increased from 46% to over 80%.

Conclusion: it appears that patients’ whose neck pain may benefit from HMCT can be identified.

 

Comment: we have discussed the importance of the FABQ at length for over a decade in regards to physical treatment methods. This study continues that trend. In addition the importance of distraction-testing (and Spurling-compression) cannot be overemphasized. Both home-based and in-office traction benefits those who show tolerance and improvement to manual distraction.

ACA: Removing subluxation language from Medicare is only way to accomplish objectives.

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Thursday Feb 11, 2016

                                     The Chronicles of Chiropractic

The ACA president Anthony Hamm states:

“ACA is of the opinion that nothing less than removal of the “subluxation” language in the definition of physicians will accomplish our objectives. Historically, the facts are that this language has proven to be the major barrier within HHS and CMS when we advocated for regulatory remedies expanding our reimbursement and coverage…”

According to Hamm the language in the preamble only states that DC’s must continue to have the ability to detect and correct subluxations of the spine for Medicare beneficiaries. This language is not in the actual proposed legislation.

The value of intermittent cervical traction in recent cervical radiculopathy

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Jellad A et al. Ann Phys Rehab Med. Nov;52(9) 2009

 

The objective of this study was to assess the effect of intermittent cervical traction (both manual and mechanical) on pain, disability and use of analgesics. There were (3) test groups consisting of (A) conventional rehab with manual traction; (B) conventional rehab with mechanical traction and (C) rehab alone. At the end of the test phase both groups (A) & (B) were significantly better vs. group (C). However analgesic use was comparable in all three groups. Disability and improved cervical & radicular pain were still significant at (6) months in both groups getting traction along with rehab. This “long-term” follow-up finding is echoed in the Fritz et al 2014 study on traction treatment for CR.

Conclusion: Manual or mechanical cervical traction appears to be a major contributor in the rehab of CR especially when added to a multi-modal approach.

 

Comment: We have discussed many CPR and CR studies showing similar conclusions. It’s important to note mechanical ‘traction’ is chosen due to its relative reproducibility, clinical ease-of-application and patient flow perspectives. Though insurance code 97140 (manual traction) pays appreciably more than 97012 (mechanical) it’s more difficult to create an up-sell based on “technology” and to delegate treatment to improve patient volume & flow without a mechanical device.

Intradiscal pressure recordings in the cervical spine.

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Pospiech J et al. Neuroserg Feb;44(2). 1999

 

I reported on a similar, interesting study previously; Prevalence of Adjacent Segment Degeneration After Spine Surgery: A Systematic Review (Xia, Xiao-Peng et al. Spine: 01 April;38 2013) and how the authors suggested the adjacent segments demonstrate consistent increases in degenerative changes post-surgery…and as we teach at our Kdt seminars, these segments often are “hyper-mobile” regions and classify as motion disorders i.e. they seem to improve pain/motion with Form/Force closure testing procedures and thus are ATM2 responsive conditions. They show greater degrees of degeneration than would be expected. Additionally if increases of IDP are occurring decompression is warranted as a co-treatment to address it.

In the above study; Pospiech et al looked at the cervical spine in vitro to establish normal values in the neck under physiological conditions post-fusion and under muscle-force (movement) simulation.

 

Results:  After fusion of C4-C5 there was marked IDP (intradiscal pressure) increases in both adjacent segments. With muscle-force simulation those figures were further increased.

Conclusion: Presuming an increase in IDP has a negative effect on metabolism of the IVD these results may help explain why progressive degeneration occurs in these segments.

 

Comment: Perhaps a further implication can be made for regular Chiropractic ‘mobilization’ exercises & procedures i.e decompression to help keep the disc metabolism more ‘normalized’ and thus help curtail excessive degeneration(?)

 

Increasing evidence against the diagnosis value of ‘orthopedic’ tests

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Facet joints are a common “assumed source” of back pain however NO evidence exists that any test for facet joints is ultimately confirmatory. Kemps-type testing has been proposed to have good sensitivity but that knowledge per se affords no diagnostic prevalence. The effectiveness of common tests is at best “moderate” (Bogduk, Twomey) and only so when multiple tests are used and properly adjudicated (which is still dubious). No one-test can be relied upon. The Slump and SLR do offer insight though both offer confusion thru false-positive & negative results. And confirmation against a “gold-standard” is lacking.  Hancock et al (Eur Spine 07) adds: “conventional investigations do not reveal the cause of LBP”. Even provocative discography has been given a thumbs-down by the American Pain Society official guidelines. Pain researcher Lorimer Moseley on a TED lecture: “You walk into any clinic and see disc models with discs so far out they are sitting on their own…what is your brain to make of that? If you’ve ever seen a cadaver, you CAN’T slip the suckers…they are immobile, they don’t slip…but that’s our language, and it messes with your brain. It cannot NOT mess with your brain”.

An ominous and prophetic conclusory statement has been proffered by numerous researchers: “You (the patient in pain) cannot generally trust professionals to identify a structural origin for your pain…even if you have one, which you probably don’t”.     

Segmental lumbar spine instability at flexion-extension radiography can be predicted by conventional radiography.

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Pitkanen MT et al. Clin Radiol Jul;57(7). 2002

An interesting study to identify plain radiographic findings that predict segmental lumbar ‘instability’ as proven via flexion-extension radiography. The ‘instability’ was classified into either anterior or posterior “sliding”.The authors noted: “sliding instability is strongly associated with various plain radiographic findings. In mechanical back pain, functional F/E radiographs should be limited. These findings were strongest for degenerative spondylolisthesis and spondolytic spondylolisthesis. Retrolisthesis, traction “spur” and spondyloarthrosis were all statistically significant with slightly lower odds ratios.

Of course a relatively in depth examination with ‘Form/Force’ closure tests and shear instability checks will give us heightened awareness as to the instability issues in many cases even if radiographs are unavailable. Clearly extensive degeneration, though not linearly related to severity or even frequency of cLBP does clearly play a moderately large role in pain.

Centralization and directional preference…again

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Manual therapy 17, 2012 

When we take the time to examine patients’ preferential motions (very often extension and lateral bending) and prescribe them for daily repetition we can typically improve response and reduce therapy dependence or iatrogenic chronicity.

 Centralization is a symptom response to repeated or sustained movements that can be used to classify patients into sub-groups, prognosis and treatment strategies. These facilitated-exercises appear to have an effect in up to 70% of LBP patients with a higher prevalence in acute pain (70%) vs. (44%) in cLBP in studies to date. Studies suggest reliability is good.

The associated but separate phenomenon is that of directional preference which is defined as the “repeated or sustained movements” that induces centralization or abolition of symptoms. Movements in the improvement direction are considered “key” movements, those in the opposite direction considered “locks”. A finding of a directional preference at baseline has been shown to predict a significantly better response to DP exercise than non-specific/generalized exercise movements. Non-centralization was generally a negative predictor of outcome and more likely associated with psychosocial issues.

 

Lesegue sign a.k.a. straight leg raise

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Wikipedia is always an interesting place to learn pointless facts: e.g. Dr. Leseque actually suggested extending the lower leg after the thigh was flexed…NOT the traditional SLR ….Dr. Laza Lazarevic actually described the traditional SLR we typically use today. Both are assumed relevant to determining an L5 (but less L4) disc herniation and/or nerve root irritation. Tests on sensitivity mark it at ~60% and specificity at ~25%.

However several researchers have cross-compared the Slump test with the SLR, and (as discussed in a previous blog as well) the Slump edges out the SLR in terms of eliminating false-positives & negatives, making its specificity nearly 85% and sensitivity at least 90%. Of course so-called odds ratios are compilations of several studies and don’t, in my estimation really give you a lot to actually go on. However doing both the SLR and Slump (a 2 minute time expenditure) will allow a better discussion at our ROF in regard predicting the likelihood the patient requires more extensive interventions or possibly to be put on the “watch-list” for MRI (or surgical consult) if treatment fails to resolve the problem.