The Audible Pop from Thoracic Spine Thrust Manipulation and Its Relation to Short-Term Outcomes in Patients with Neck Pain

Clinicians routinely consider the success of a thrust manipulation technique based on the presence or absence of an audible pop despite the lack of evidence suggesting that this pop is associated with improved outcomes. The purpose of this study was to determine the relationship between the number of audible pops with thoracic spinal manipulation and improvement in pain and function in patients with mechanical neck pain. In this prospective cohort study, 78 patients referred to physical therapy with mechanical neck pain underwent a standardized examination and thoracic spine manipulation treatment protocol. All patients were treated with a total of 6 thrust manipulation techniques directed to the thoracic spine followed by a basic cervical range of motion exercise. The treating clinician recorded the presence or absence of a pop during each manipulation. Outcomes were assessed at a 2–4 day follow-up with an 11-point numeric pain rating (NPRS), the Neck Disability Index, the patient Global Rating of Change (GROC), and measurements of cervical range of motion (CROM). The relationship between the number of pops and change scores for pain, disability, and CROM was first examined using Pearson correlation coefficients. Individuals were then categorized as having received ≤3 or >3 pops. Repeated measures analyses of variance were used to examine whether achievement of >3 pops resulted in improved outcome. Seventy-eight patients with a mean age of 42 (SD 11.3) years participated in the study. Pearson correlation coefficients revealed no significant correlation existed between the number of pops and outcomes with the exception of 3 of the 6 CROM measurements, which were inversely related. There was no significant interaction for group X time for any of the dependent measures (P>0.05). The odds ratio for patients experiencing dramatic improvement was in favor of the group experiencing ≤3 pops but this was not clinically meaningful (1.3: 95% CI 0.46, 3.7). The results of this analysis provide preliminary evidence for the hypothesis that there is no relationship between the number of audible pops during thoracic spine thrust manipulation and clinically meaningful improvements in pain, disability, or CROM in patients with mechanical neck pain. Additionally, a greater number of audible pops experienced was not associated with a dramatic improvement with manipulation treatment.Key Words: Cavitation, Manipulation, Neck Pain, Audible Pop, Thoracic SpineThe prevalence of neck pain is high, with nearly 70% of individuals experiencing neck pain at some point in their life and with 15–22% of individuals continuing to experience symptoms 5 years after onset^1,2. This results in a substantial economic burden as nearly 1/3 of patients who experience a first-time onset of neck pain will report continued healthcare utilization for their neck pain at a 10-year follow-up³. Additionally, nearly 25% of all visits in outpatient physical therapy practice consists of patients with a primary report of neck pain⁴.Physical therapists utilize a number of interventions in the management of neck pain including joint manipulation (non-thrust and thrust), therapeutic exercise, traction, and a variety of modalities⁵. Recently, evidence has begun to emerge for the use of manual therapy, specifically thrust procedures, directed to the thoracic spine in patients with mechanical neck pain^6–9. Clinicians often believe that an audible pop associated with a thrust manipulation is a criterion for determining the success of the technique¹⁰. However, ultimately the success of an intervention should be based on whether it is associated with improvements in patient-centered outcomes¹¹.Recently Flynn, Fritz, et al¹² reported on a series of 71 patients with non-radicular low back pain (LBP) who received lumbopelvic thrust manipulation. Participants underwent a standardized examination and standardized spinal manipulation treatment program. All patients were treated with a sacroiliac region manipulative technique, and the presence or absence of an audible pop was noted. Similar to the operational definition of an audible pop used in this study, the number of actual pops that may have occurred during one thrust manipulation was not recorded but only whether an audible sound was perceived during one particular manipulation. The subjects were reassessed 48 hours after the manipulation for changes in range of motion (ROM), in pain as measured by the Numeric Pain Rating Scale (NPRS), and in Oswestry (OSW) scores. There were no between-group differences for flexion ROM, NPRS, and OSW scores (P>0.05). The odds ratio (1.2; 95% CI: 0.38–4.04) suggested that the occurrence of a manipulative pop would not improve the odds of achieving a dramatic reduction in symptoms following the manipulation¹². Based on the data, the authors concluded that there was no relationship between an audible pop during sacroiliac region manipulation and improvement in ROM, pain, or disability in individuals with non-radicular low back pain¹².In a follow-up study, Flynn, Childs, et al¹³ examined whether the occurrence of a manipulative pop during lumbopelvic region manipulation was related to the outcome of the intervention over a 4-week period of time rather than the 48-hour follow-up in the earlier study. Seventy patients were randomly assigned to receive thrust manipulation during the first two sessions. Therapists recorded whether the patient or therapist heard either a single or multiple audible pops. Again similar to the operational definition of an audible pop used in this study, the number of actual pops that may have occurred during one thrust manipulation was not recorded. Outcome was assessed with an 11-point NPRS, the OSW, and measurement of lumbopelvic flexion ROM. No differences were detected at baseline or at any follow-up period in the level of pain, the OSW score, or lumbopelvic ROM based on whether a pop was achieved (P>0.05). The odds ratios and 95% confidence intervals for achieving a successful outcome at each of the follow-up periods all approximated a value of 1, suggesting no improvement in the odds of successful outcome among patients in whom an audible pop occurred. The results supported the previous findings that the audible pop was unrelated to changes in patient-centered outcomes for patients with LBP¹³.While previous studies provide evidence that an audible pop accompanying lumbopelvic thrust manipulation is not associated with improved patient-centered outcomes, this has yet to be examined in other spinal regions. Therefore, the purpose of this study was to examine the relationship between the audible pop and patient-centered outcomes in a cohort of patients with neck pain treated with thoracic spine thrust manipulation.     

Sex differences in predictors of outcome in selected physical therapy interventions for acute low back pain

STUDY DESIGN: Secondary analysis of pooled data from 3 randomized trials. OBJECTIVE: This study investigated sex differences in response to physical therapy intervention for acute low back pain. BACKGROUND: Sex differences in experimental pain sensitivity have been consistently described in the literature. However, clinical consequences of these sex differences have not been widely reported. METHODS AND MEASURES: Subjects (n=165) were participants in 3 randomized trials of physical therapy interventions from outpatient physical therapy clinics in the general and military communities. Subjects were randomly assigned spinal manipulation with range-of-motion exercise, lumbar stabilization exercise, or directional-preference exercise. Outcomes were measured at 4 weeks through self-report of pain intensity and pain-related disability. Sex differences were investigated with independent t tests (baseline data), 2 x 3 analysis of variance (4-week reductions in pain and pain-related disability), and regression models (predictors of outcome). RESULTS: Men and women had similar reductions of pain intensity (raw mean difference, 0.5; 95% Cl, -1.4 to 0.4) and pain-related disability (raw mean difference, 5.3; 95% CI, -0.1 to 10.7) over 4 weeks. Baseline pain intensity, duration of symptoms, and baseline pain-related disability significantly predicted change in pain intensity for women (r2 = 26%, P < .01). Baseline pain intensity and stabilization exercise predicted change in pain intensity for men (r2 = 33%, P<.01). Baseline pain-related disability, duration of pain, and pain intensity predicted change in disability for women (r2 = 24%, P < .01). Baseline pain-related disability, fear-avoidance beliefs, stabilization exercise, and leg pain predicted change in disability for men (r2 = 32%, P < .01). CONCLUSION: For patients with acute low back pain, men and women had similar physical therapy outcomes for reductions in pain intensity and pain-related disability. However, men and women had different factors that predicted treatment outcome.     

High-dose chemotherapy with stem cell rescue as initial therapy for anaplastic oligodendroglioma: long-term follow-up

We previously reported a phase 2 trial of 69 patients with newly diagnosed anaplastic or aggressive oligodendroglioma who were treated with intensive procarbazine, CCNU (lomustine), and vincristine (PCV) followed by high-dose thiotepa with autologous stem cell rescue. This report summarizes the long-term follow-up of the cohort of 39 patients who received high-dose thiotepa with autologous stem cell support. Thirty-nine patients with a median age of 43 (range, 18-67) and a median KPS of 100 (range, 70-100) were treated. Surviving patients now have a median follow-up of 80.5 months (range, 44-142). The median progression-free survival is 78 months, and median overall survival has not been reached. Eighteen patients (46%) have relapsed. Neither histology nor prior low-grade oligodendroglioma correlated with risk of relapse. Persistent nonenhancing tumor at transplant was identified in our initial report as a significant risk factor for relapse; however, long-term follow-up has not confirmed this finding. Long-term neurotoxicity has developed only in those patients whose disease relapsed and required additional therapy; no patient in continuous remission has developed a delayed neurologic injury. This treatment strategy affords long-term disease control to a subset of patients with newly diagnosed anaplastic oligodendroglioma without evidence of delayed neurotoxicity or myelodysplasia.     

Pilot study of mucosal genetic differences in early smokers and nonsmokers

BACKGROUND: Global gene expression analysis is proving to be an important means of assessing human tumors and may identify key components of carcinogenesis or clinical prognosis. This technique has been successfully applied to head and neck squamous cell carcinoma (HNSCC) and thyroid carcinomas; however, little has been done to evaluate premalignant states. METHODS: Human buccal mucosal cells were sampled from smokers and nonsmokers using a noninvasive brush technique. The method was validated by assessing the quantity and quality of RNA obtained. The purified RNA was then assayed using cDNA microarrays containing 27,323 cDNA clones to examine the buccal mucosa in these patients for differences in gene expression patterns. Using unsupervised and supervised hierarchical clustering methods, we developed a gene profile signature for an initial training set of smokers and nonsmokers and then used this to predict smoking status in a subsequent test set of subjects. Selected genes were then cross-referenced with previously published gene sets found in HNSCC identified by our group. RESULTS: Nineteen subjects were used in this pilot analysis, 9 smokers and 10 nonsmokers. Smoking among the study group ranged from 1 to 60 pack years. RNA purified from buccal mucosal brushing demonstrated a high degree of similarity in gene expression profiles among independent samples. Through the application of supervised clustering techniques, we were able to identify 113 genes whose expression differed significantly between samples from smokers and nonsmokers (t test, P < .001). This expression signature was able to accurately predict who within the second set of subjects were smokers, with the exception of one person who had a minimal tobacco history and clustered with the nonsmokers. Cross-referencing data with that found in HNSCC, we were able to identify a tumor suppressor gene involved in the c-myc pathway (Mxi1) that was similarly under-expressed in smokers and cancer patients with progressive disease. CONCLUSIONS: Although the sample size was small in this preliminary dataset, our analysis revealed several groups of genes that were either over- or under-expressed in the smokers and which could be used to predict smoking exposure. Many of these represent genes of possible interest as early molecular markers for head and neck carcinogenesis.     

Distinctive gene expression profiles by cDNA microarrays in endometrioid and serous carcinomas of the endometrium.

Endometrial carcinomas are classified by their morphology into two major subtypes. Endometrioid carcinomas (type I) are generally estrogen dependent, well-differentiated, superficially invasive, and have a good outcome. Serous carcinomas (type II) are hormone independent, frequently deeply invasive and widely metastatic, and have a poor prognosis. Microarray technology and analysis allows us to determine if the global gene expression profiles of these two subtypes correlate with their morphologic phenotype. Fresh tissue from 18 endometrial carcinomas was studied: 7 well-, 2 moderately, and one poorly differentiated endometrioid, 4 serous carcinomas, and 4 high-grade mixed endometrioid-serous carcinomas. Labeled cDNA probes were synthesized (Cy5 for tumor, Cy3 for reference) and applied to microarrays containing 18,098 cDNA clones or ESTs. A pool of equal amounts of total RNA from each tumor served as the reference RNA. By unsupervised cluster analysis, the endometrioid carcinomas clustered together and were separate from the serous carcinomas. The high-grade mixed carcinomas clustered with the serous carcinomas. Using a statistical algorithm based on gene expression pattern and conducting a supervised analysis of the two defined groups, we have identified 315 genes that statistically differentiate type I from type II endometrial carcinomas. In addition to corroborating the predicted overexpression of known markers (e.g., ras and catenin in endometrioid carcinomas), the cDNA microarray technique has revealed novel alterations in gene expression relevant to cell cycle, cell adhesion, signal transduction, apoptosis, and tumor progression not previously implicated in endometrial carcinomas. For serous carcinomas, these include aldolase, desmoplakin, integrin-linked kinase, PKC, and metallopeptidase. In conclusion, the gene expression profiles of type I and type II endometrial carcinomas are different. Refinement of these profiles will permit more accurate diagnostic tumor classification and the development of prognosis assays.     

Intermittent subclavian artery occlusion following clavicular fracture

Although fractures of the clavicle are common, complications are rare. A 41 year old painter developed two uncommon complications of clavicular fracture, mechanical intermittent subclavian artery occlusion and subclavian vein thrombosis. Both conditions were clearly identified on the clinical symptoms and signs and confirmed with dynamic angiography and computerised tomography. Operative intervention led to complete resolution of symptoms.     

As if the cancer wasn't enough! Understanding and treating the pain that comes with cancer

In people with cancer, pain often occurs from the malignancy, from procedures done to diagnose, stage, and treat the malignancy, and from the toxicities of therapy used in treating the cancer. Of people with cancer, 75% complain of some sort of pain. Determining whether the pain is from tissue damage or nerve structures will guide therapy. Assessment of the severity of the pain by location, oncological type, as well as psychosocial and environmental factors are necessary to understand and treat the pain that accompanies cancer. Medical interventions include non-opioid analgesics opioids, and multiple different combinations of medications. Adjuvant medication like anticonvulsants and steroids are being used frequently to help people feel more comfortable. The authors have stated that they do not have a significant financial interest or other relationship with any product manufacturer or provider of services discussed in this article. The authors do not discuss the use of off-label products, which includes unlabeled, unapproved, or investigative products or devices.