What do we want? Cervicothoracic Workgroup. ICF Scheme. start with end in mind. What do consumers want?

Transcription

1 Cervicothoracic Workgroup Use of the International Classification of Functioning to Develop Evidence-Based Treatment Guidelines for the Management of Cervicothoracic Conditions John D. Childs, PT, PhD, MBA, OCS, CSCS Assistant Professor US Army-Baylor University Doctoral Program in Physical Therapy John D. Childs, PT, PhD, MBA, OCS, FAAOMPT Joshua A. Cleland, PT, PhD, OCS, FAAOMPT Mike Dohme, MD Tim Flynn, PT, PhD, OCS, FAAOMPT Deydre S. Teyhen, PT, PhD, OCS Rob Wainner, PT, PhD, OCS, ECS, FAAOMPT February 15, 2007 Combined Sections Meeting of the APTA Boston, MA ICF Scheme Provides unified & standard language & framework for the description of health & health-related states start with end in mind What do consumers want? What do we want? 1

2 Evidence-based Clinically effective Cost effective Safe Ethical Legal 2

3 Good Communicators Professional Educators where are we now??? 3

4 many facets to the problem ceo McGuire 4

5 $35 per visit we share the blame reputable organizations like 5

6 the problem quality of care not managed care high cost drivers 6

7 $billions variability surgical non-surgical Interventions Choices by Physical Therapists Guide to Physical Therapist Practice Mobilization/manipulation Therapeutic exercises Flexibility Range of motion Muscle strength Endurance and power Neuromuscular control Functional activities Modalities (thermal, electrical) 7

8 solutions??? sub-grouping & classification sub-grouping in patients with low back pain What Should We Be Doing? Classification-based Management of Patients with Neck Pain 8

9 Target Behaviors: Clinician practice patterns Appropriate use of treatments within classification Subgroup Headache Acute Neck Pain Neck and Arm Pain Acute Whiplash Chronic Neck Pain Criteria Matched Intervention manual therapy/ exercise traction, exercise AROM, remain active, manual therapy exercise/ conditioning evidence tour Mobility Classification: Acute Neck Pain/Headache Sub-group Acute Neck Pain Group: Presentation Clinical Findings: Recent symptoms (< 4 weeks) Younger age (<60) No symptoms distal to shoulder Restricted neck ROM No signs of root compression Acute Neck Pain Group: Treatment Cervical and/or thoracic mob/manip Cervical AROM and strengthening exercises 9

10 Manipulation/Mobilisation Systematic Review (Gross, Cochrane Collaboration, 2004) Subacute/chronic mechanical neck pain with or without headache 33 trials, 42% high quality Nonsignificant pain reduction benefit with manual therapy alone Strong evidence supporting mobilisation and/or manipulation plus exercise to improve short- and long-term outcomes of care (Hoving et al, Ann Intern Med, 2002) Results: Primary Outcome Measures Perceived Recovery: clinical success Manual PT = 68.3% Standard PT = 50.8% General Practitioner = 35.9% Pain: Manual PT > Standard PT or GP Neck Pain: Manual PT, Standard PT, GP (Ingeborg et al, BMJ, 2003) Results: Manual Physical Therapy $ Standard Physical Therapy $ General Practitioner $ Conclusion: Manual physical therapy was more effective and less costly than standard physical therapy or general practitioner care. Cervicogenic Headache (Jull et al, Spine, 2002) 2005 Mean Change in Headache days per week Control Man Ther Exercise MT + Ex 19 received thoracic manip 68 pts referred to PT with neck pain 52 eligible 36 randomized 17 received placebo 10

11 54% The Rule 4 or more present: Recent onset (<30 days) Low FABQP (<11) No symptoms distal to the shoulder Looking up does NOT aggravate symptoms Cervical ext < 30 Flat T3-T5 86% Pre-test Probability of Dramatic Success with Manipulation +LR = 5.5 Post-test Probability of Dramatic Success with Manipulation Centralization: Neck and Arm Pain Sub-group Neck and Arm Pain: Presentation Peripheralization/Centralization with AROM Symptoms distal to shoulder Signs of nerve root compression Positive distraction, Spurling s and/or ULTT Neck and Arm Pain: Treatment Traction Repeated exercise to centralize symptoms Perhaps manual therapy 11

12 Cervical Radiculopathy CPR ULTT A Cervical Rot Involved < 60 0 Spurling s A Distraction CR Diagnosis: Single Item vs CPR ULTT A (LR- = 0.12) Biceps MSR (LR+ = 4.9) CR TIC (4) (LR+ = 30.3) Play movie. Carpal Tunnel Syndrome CPR Hand shaking improves symptoms Wrist-ratio index >.67 Symptom Severity Score >1.9 Diminished sensation in Median sensory field 1 (thumb) Age >45 Changes in Diagnostic Probability Wrist Ratio <.67 CTS CPR (4) CTS CPR (5) Pretest (34%) to Posttest (90%) probability change using the clinical prediction rule with all 5 tests positive. 12

13 Philadelphia Panel Clinical Practice Guidelines Acute Neck Pain Philadelphia Panel Clinical Practice Guidelines Chronic Neck Pain There is insufficient evidence to include or exclude mechanical traction alone as an intervention for acute nonspecific neck pain. There are insufficient data to make a recommendation regarding mechanical traction alone in chronic neck pain.. Treatment: Cervical Traction To date no conclusions can be drawn about whether as specific traction modality neck pain is effective, or more efficacious than other treatments. There are no clear indications, however, that traction is an ineffective therapy for neck pain. van der Heijden GJ, Beurskens AJ, Koes BW, Assendelft WJ, de Vet HC, Bouter LM. The efficacy of traction for back and neck pain: a systematic, blinded review of randomized clinical trial methods. Phys Ther Feb;75(2):