Eagle's syndrome, elongated styloid process and new evidence for pre-manipulative precautions for potential cervical arterial dysfunction.

INTRODUCTION: Safety with upper cervical interventions is a frequently discussed and updated concern for physical therapists, chiropractors and osteopaths. IFOMPT developed the framework for safety assessment of the cervical spine, and this topic has been discussed in-depth with past masterclasses characterizing carotid artery dissection and cervical arterial dysfunction. Our masterclass will expand on this information with knowledge of specific anatomical anomalies found to produce Eagle's syndrome, and cause carotid artery dissection, stroke and even death. Eagle's syndrome is an underdiagnosed, multi-mechanism symptom assortment produced by provocation of the sensitive carotid space structures by styloid process anomalies. As the styloid traverses between the internal and external carotid arteries, provocation of the vessels and periarterial sympathetic nerve fibers can lead to various neural, vascular and autonomic symptoms. Eagle's syndrome commonly presents as neck, facial and jaw pain, headache and arm paresthesias; problems physical therapists frequently evaluate and treat. PURPOSE: This masterclass aims to outline the safety concerns, assessment and management of patients with Eagle's syndrome and styloid anomalies. By providing evidence of this common anomaly found in almost one-third of the population, hypothesis generation and clinical reasoning with patients presenting with head and neck symptoms can improve. IMPLICATIONS: Including styloid anomalies as potential hypotheses for patients with head and neck complaints can assist therapists in safe practice and expedite referral. The authors recommend updating the IFOMPT framework to incorporate Eagle's syndrome, a comprehensive autonomic assessment, and palpation of the stylohyoid complex to avoid potentially serious complications from conceivably hazardous interventions.

Early use of thrust manipulation versus non-thrust manipulation: a randomized clinical trial.

The purpose of this study was to investigate the comparative effectiveness of early use of thrust (TM) and non-thrust manipulation (NTM) in sample of patients with mechanical low back pain (LBP). The randomized controlled trial included patients with mechanically reproducible LBP, ≥ age 18-years who were randomized into two treatment groups. The main outcome measures were the Oswestry Disability Index (ODI) and a Numeric Pain Rating Scale (NPRS), with secondary measures of Rate of Recovery, total visits and days in care, and the work subscale of the Fears Avoidance Beliefs Questionnaire work subscale (FABQ-w). A two-way mixed model MANCOVA was used to compare ODI and pain, at baseline, after visit 2, and at discharge and total visits, days in care, and rate of recovery (while controlling for patient expectations and clinical equipoise). A total of 149 subjects completed the trial and received care over an average of 35 days. There were no significant differences between TM and NTM at the second visit follow-up or at discharge with any of the outcomes categories. Personal equipoise was significantly associated with ODI and pain. The findings suggest that there is no difference between early use of TM or NTM, and secondarily, that personal equipoise affects study outcome. Within-groups changes were significant for both groups.

Which prognostic factors for low back pain are generic predictors of outcome across a range of recovery domains?

BACKGROUND: Recovery from low back pain (LBP) is multidimensional and requires the use of multiple-response (outcome) measures to fully reflect these many dimensions. Predictive prognostic variables that are present or stable in all or most predictive models that use different outcome measures could be considered "universal" prognostic variables. OBJECTIVE: The aim of this study was to explore the potential of universal prognostic variables in predictive models for 4 different outcome measures in patients with mechanical LBP. DESIGN: Predictive modeling was performed using data extracted from a randomized controlled trial. Four prognostic models were created using backward stepwise deletion logistic, Poisson, and linear regression. METHODS: Data were collected from 16 outpatient physical therapy facilities in 10 states. All 149 patients with LBP were treated with manual therapy and spine strengthening exercises until discharge. Four different measures of response were used: Oswestry Disability Index and Numeric Pain Rating Scale change scores, total visits, and report of rate of recovery. RESULTS: The set of statistically significant predictors was dependent on the definition of response. All regression models were significant. Within both forms of the 4 models, meeting the clinical prediction rule for manipulation at baseline was present in all 4 models, whereas no irritability at baseline and diagnosis of sprains and strains were present in 2 of 4 of the predictive models. LIMITATIONS: The primary limitation is that this study evaluated only 4 of the multiple outcome measures that are pertinent for patients with LBP. CONCLUSIONS: Meeting the clinical prediction rule was prognostic for all outcome measures and should be considered a universal prognostic predictor. Other predictive variables were dependent on the outcomes measure used in the predictive model.

Can a within/between-session change in pain during reassessment predict outcome using a manual therapy intervention in patients with mechanical low back pain?

The purposes of the study were to determine whether the combined occurrence of within/between-session changes were significantly associated with functional outcomes, pain, and self-report of recovery in patients at discharge who were treated with manual therapy for low back pain. A secondary purpose was to determine the extent of change needed for the within/between-session change with association to function. The study involved 100 subjects who were part of a randomized controlled trial that examined manual therapy techniques who demonstrated a positive response to manual therapy during the initial assessment. Within- and between-session findings (within/between session) were defined as a change in pain report from baseline to after the second physiotherapy visit. Within/between-session changes were analyzed for associations between pain change scores at discharge, rate of recovery, and a 50% reduction of the Oswestry disability index (ODI) by discharge. The results suggest there is a significant association between a within/between-session change after the second physiotherapy visit and discharge outcomes for pain and ODI in this sample of patients who received a manual therapy intervention. A 2-point change or greater on an 11-point scale is associated with functional recovery at discharge and accurately described the outcome in 67% of the cases. This is the first study that has shown an association of within/between-session changes with disability scores at discharge and is the first to define the extent of change necessary for prognosis of an outcome. A within/between-session change should be considered as a complimentary artifact along with other examination findings during clinical decision making.