Evaluation of outcomes in patients with neck pain treated with thoracic spine manipulation and exercise: a case series.

BACKGROUND

It has been reported that more than one in five people are currently experiencing neck pain, over 50% of the population has had neck pain in the last 6 months and the lifetime prevalence has been reported to range from 22%-70% (Cote et al 1998, 2000, Palmer et al 2001). Once a person develops neck pain, there is a 1 in 3 chance that they will develop chronic symptoms lasting greater than 6 months, resulting in a tremendous burden on the health care system (Cote et al 2004, Picavet and Schouten 2003). It has also been reported that the incidence of neck pain is increasing (Nygren et al 1995). In the United States, The Guide to Physical Therapist Practice (2001) indicates that manual therapy techniques including mobilisation/ manipulation are appropriate treatment strategies for the management of neck pain, as are modalities and therapeutic exercise. While the Guide uses the terms mobilisation and manipulation synonymously, for the remainder of this paper we will refer to manual therapy techniques as either thrust or non thrust manipulation. A recent systematic review reports that mobilisation/manipulation, strengthening exercises and stretching have strong evidence to support their use in the conservative management of patients with neck pain (Gross et al 2007). Despite evidence supporting the use of these interventions, little evidence exists to guide the practitioner in selecting the most appropriate intervention for patients with varied clinical presentations (2001b).

Recently, a clinical prediction rule (CPR) for guiding treatment of a subgroup of patients with neck pain was published (Cleland et al 2007). Clinical prediction rules and clinical decision rules quantify the individual contributions that components of the history, physical examination and self-report measures make toward establishing a diagnosis, prognosis, or likely response to treatment in an individual patient (McGinn et al 2000). Clinical prediction rules can assist practitioners in selecting the most appropriate intervention for a particular patient by predicting likelihood of a successful outcome following a specific intervention, according to history, physical examination and self-report measures findings. Developing and testing a CPR involves 3 steps: (1) creating or deriving the rule, (2) testing or validating the rule, and (3) assessing the impact of the rule on clinical behavior (impact analysis) (McGinn et al 2000).

The CPR derived by Cleland et al identifies 6 potential predictor variables for likelihood of favorable outcomes in patients with neck pain treated with thoracic spine thrust manipulation (Cleland et al 2007). These 6 variables include: symptom duration <30 days, no symptoms distal to the shoulder, patient reports that looking up does not aggravate symptoms, FABQPA score <12, diminished upper thoracic spine kyphosis (T3-T5), and cervical extension range of motion (ROM) of <30 degrees (Table 1) (Cleland et al 2007). The authors reported that patients presenting with 3 of the 6 variables at initial examination were likely to exhibit a rapid and dramatic response to thoracic spine thrust manipulation, as evidenced by a global rating of change in which the patient rated themselves "quite a bit better," "a great deal better" or "a very great deal better" in 7 days or less (Jaeschke et al 1989). When 3 of the 6 variables were present, the positive likelihood ratio was 5.5, indicating that a patient positive on 3 of the 6 variables would be 5.5 times more likely to respond positively than would an average, unselected patient. This resulted in the probability that a patient would respond favorably to thoracic spine thrust manipulation for treatment of neck pain increased from 54% (pre-test probability) to 86% (post-test probability). In cases where only 1 or 2 predictor variables were present on initial examination, the probability of a successful outcome was 58% and 71%, respectively (Table 1) (Cleland et al 2007). These values suggest that the post-test probability of these patients achieving a successful outcome with thoracic spine thrust manipulation is only marginally better than chance. Positive likelihood ratios for the presence of 1 or 2 predictor variables are 1.2 and 2.09, respectively (Cleland et al 2007). Positive likelihood ratios greater than 5 generate moderate shifts in probability, and should be considered in clinical practice (Fritz and Wainner 2001).

The purpose of this case series is to compare the clinical outcomes of 3 patients referred to physiotherapy with neck pain with reference to their status on the CPR for thoracic spine thrust manipulation. This case series design is not able to provide evidence supporting the utilisation of the preliminary CPR for selecting patients with neck pain that are favorable candidates for thoracic spine thrust manipulation, however other ongoing research is in the process of investigating the validity of the CPR among a large population of patients with mechanical neck pain.

Patient Characteristics

Patients referred for physiotherapy with a primary report of neck pain were examined for eligibility to participate in this case series. The patients in this case series were concurrently participating in a randomised clinical trial (RCT) designed as a validation study following the preliminary CPR of Cleland et al (2007). The inclusion criteria required patients to be between the ages of 18-65 years, with a primary report of neck pain with or without unilateral upper extremity symptoms, and a baseline Neck Disability Index (NDI) score of at least 10%.

Patient demographics, baseline self-report variables and baseline characteristics are described in Table 2. The Institutional Review Board at Concord Hospital, Concord, New Hampshire, USA approved this study and all patients provided informed consent.

Examination

Self Report Measures

Patients completed a variety of self-report questionnaires before undergoing a standardised history and physical examination conducted by a physiotherapist. Self-report measures included a pain diagram and Numeric Pain Rating Scale (NPRS) to determine the distribution of symptoms and intensity of current, best and worst levels of pain, the Neck Disability Index (NDI), and the Fear-Avoidance Beliefs Questionnaire (FABQ) (Cleland et al 2008), (Lee et al 2006). The NDI is widely accepted as a condition-specific disability scale for patients with neck pain and has proven to be a reliable and valid outcome measure (Cleland et al 2008, Vernon and Mior 1991). The NDI consists of ten questions relating to different areas of function that are scored from 0-5, with a maximum score of 50 points. To achieve a percentage of patient-perceived disability, the total score is doubled, with higher scores representing increasing levels of disability up to 100%. Fear-avoidance beliefs were assessed using the fear avoidance beliefs questionnaire (FABQ), which is a 16-item questionnaire that was designed to quantify fear and avoidance beliefs in patients with low back pain (Waddell et al 1993). The FABQ has two sub-scales, a 4-item scale to measure fear-avoidance beliefs about physical activity (FABQPA) and a 7-item scale to measure fear-avoidance beliefs about work (FABQ-W). Each item is scored from 0-6 with possible scores ranging between 0-24 for the physical activity sub-scale and 0-42 for the work sub-scale. The FABQ has been shown to be a valid and reliable tool in patients with neck pain, and has been shown to be an important variable in predicting future disability level and return to work capacity in these patients (Lee et al 2007, Lee et al 2006) The FABQ-PA is also a clinical predictor for patients with neck pain that are likely to respond to thoracic spine thrust manipulation and exercise (Cleland et al 2007).

History and Physical Examination

The history included demographic information, past medical history, mechanism of injury, location and nature of the patient's symptoms, number of days since onset, number of previous episodes of neck pain and treatment for previous episodes. The physical examination began with a neurologic screening examination to rule out nerve root compression, sensory deficits, and upper motor neuron lesions. The screening included assessment of the Hoffmann's and Babinski pathological reflexes, myotomal testing from C5-T1, dermatomal pinprick sensation from C5-T1, and upper extremity deep tendon reflexes (Viikari-Juntura 1987, Viikari-Juntura et al 1989). The patient's posture was then assessed in standing and sitting according to the procedures described by Kendall (Kendall FP et al 1993). Postural observation was included because it is commonly used among therapists for patients with neck pain and is one of the predictors in the CPR (Cleland et al 2007). Cervical/thoracic spine active range of motion (AROM) and its effect on symptoms was assessed. Cervical flexion, extension and unilateral side bending were measured using a single bubble inclinometer (Hole et al 1995). Unilateral rotation was assessed using a long arm goniometer (Youdas et al 1991). Intraclass correlation coefficients (ICC) for measuring cervical spine ROM with a single bubble inclinometer and long arm goniometer range from .81-.94 and 0.540.90 respectively (Hole et al 1995). Thoracic AROM was assessed qualitatively, having the patient rotate with arms crossed over the chest in a seated position; applying overpressure into the direction of rotation and determining the effect on the patient's symptoms.

Special tests, including Spurling's test, the distraction test and the upper limb neurodynamic test were performed to evaluate the presence of cervical radiculopathy (Wainner et al 2003). Vertebral artery and cervical ligament screening tests were performed to determine whether the patient's symptoms resulted from vertebral artery compromise or cervical ligament instability (2001a, Uitvlugt and Indenbaum 1988). Spring testing of the cervical and thoracic spine was tested with the patient prone and the neck in neutral rotation (Maitland G et al 2001, Smedmark et al 2000). The mobility at each segment was judged as normal, hypomobile, or hypermobile. The reliability of spring testing has been shown to be poor in the cervical spine and fair to moderate in the thoracic spine (Cleland JA 2005, Smedmark et al 2000). Strength testing of the serratus anterior, middle and lower trapezius were assessed according to Kendall, as these muscles have been reported to be frequently impaired in patients with neck pain (Kendall FP et al 1993), (Falla et al 2004a, Jull et al 2004b). Finally, the endurance of the deep neck flexors was assessed as described by Harris et al (Harris et al 2005). We chose to use this method rather than the craniocervical flexion test (CCFT) described by Jull et al (Jull et al 1999, Jull et al 2004a) because the CCFT is time consuming, requires the use of additional equipment and is difficult to use as described in a clinical setting. Although the reliability of the CCFT has been reported as excellent, ranging from 0.994 to 0.998, Harris et al (Harris et al 2005) and Cleland et al (Cleland JA 2005) have reported adequate intertester reliability (ICC = 0.67 and 0.57 respectively) using the deep neck flexor endurance test in patients with neck pain.

Clinical Impression

Patients in this case series presented with signs and symptoms consistent with mechanical neck pain. Impairments present in these patients that indicated mechanical neck pain included: postural abnormalities, hypomobility of the cervical and/or thoracic spine, weakness of periscapular musculature and tightness of cervicothoracic musculature (Falla et al 2007, Griegel-Morris et al 1992, Jull et al 2004a, Norlander et al 1996, Norlander et al 1997, O'Leary et al 2007, Zito et al 2006). Interventions targeting the impairments listed above may result in favorable outcomes in patients presenting with mechanical neck pain.

Intervention

All patients in this case series attended physiotherapy twice weekly during the first week and then once weekly for the following 3 weeks for a total of 5 sessions of physiotherapy. Each treatment session lasted for a total of 30 minutes. During the first two sessions, patients received thoracic spine thrust manipulation and a general range of motion (ROM) exercise only. Beginning at the third session, patients began participating in a stretching and strengthening program and continued participation in this program once a week for 3 sessions until the 4-week follow-up visit.

Manual Therapy Interventions

For the first 2 sessions, all patients received 3 different thrust manipulations. We will use the model for describing thrust manipulations as recently proposed by Mintken et al (Mintken P et al 2008a, 2008b):

1. A high-velocity, mid-range, distraction force 1. to the midthoracic spine on the lower thoracic spine in a sitting position (Figure 1)

2. A high-velocity, end-range, anterior-posterior 2. force through the elbows to the upper thoracic spine on the midthoracic spine in a supine position, in cervicothoracic flexion (Figure 2)

3. A high-velocity, end-range, anterior-posterior 3. force through the elbows to the middle thoracic spine on the lower thoracic spine in a supine position, in cervicothoracic flexion (Figure 3)

[FIGURE 1 OMITTED]

Each thrust manipulation was performed twice.

Following the manipulative interventions, all patients were instructed in the "three-finger ROM exercise" which is a general cervical mobility exercise developed by Erhard (Erhard 1998). The exercise is described in Figure 4. This exercise was performed alternately to both sides within the limits of pain tolerance. Patients performed this exercise for 10 repetitions to each side, 3-4 times per day each day during participation in the study. Patients also received instruction to maintain usual activity level within the limits of pain. Advice to maintain usual activity has been found to assist in recovery from neck pain (Bergstrom et al 2007, Chiu et al 2005a). Patients were instructed to participate in all activities that do not increase symptoms, and avoid all activities that aggravate symptoms.

[FIGURE 2 OMITTED]

[FIGURE 3 OMITTED]

Beginning on the third session, patients were instructed in a stretching and strengthening program. Recent guidelines and reviews have supported the use of exercise to decrease pain, improve function and reduce disability in a patient population with neck pain (Brosseau et al 2001, Sarig-Bahat 2003). The strengthening and flexibility program used in this study can be found in Appendices 1 and 2.

[FIGURE 4 OMITTED]

Follow-up Measurements

All patients completed the NDI, Pain Diagram and NPRS and the Patient Global Rating of Change (GROC) at 1-week (3rd visit) and 4 weeks (5th visit) after the initial examination. We defined a successful outcome as a score of +5 (quite a bit better), +6 (a great deal better) or +7 (a very great deal better) on the GROC.

Patients reporting GROC scores of +4 or lower were considered unsuccessful outcomes.

Outcomes

This case series compares the clinical outcomes of three patients with mechanical neck pain who were treated with thoracic spine thrust manipulation and exercise. All patients received identical treatments, but we observed considerable variations in outcomes (Figures 5-7). Of the three patients in this case series, two (patients 1 and 2) met the CPR for thoracic manipulation (Table 3). At short-term follow up (1-week), both of these patients had achieved a successful outcome with GROC scores of +6. Patient 3, who did not meet the CPR, reported no change in her symptoms at 1-week (Figure 7). Similarly, patients 1 and 2 had significant short-term improvements in the NDI and NPRS, while patient 3 actually worsened in regard to NDI and NPRS scores (Figures 5 and 6). At the 4-week follow up, patients 1 and 2 maintained the benefits of treatment reflected at 1-week. Unlike the 1-week follow up, patient 3 displayed significant improvements in NDI and NPRS scores and attained a successful outcome based on her GROC score of +7 following the exercise intervention. Patients 1 and 2 achieved successful outcomes following treatment with thoracic spine thrust manipulation and a general cervical mobility exercise alone, whereas patient 3 did not display significant improvement until after the initiation of the specific exercise program.

[FIGURE 5 OMITTED]

[FIGURE 6 OMITTED]

[FIGURE 7 OMITTED]

DISCUSSION

Previous research has derived a CPR that is purported to identify patients with neck pain that are likely to respond favorably to thoracic spine thrust manipulation (Cleland et al 2007). Prior to the publication of that preliminary CPR, the literature contained no research evidence specifically to guide selection of treatment technique for individual patients with neck pain. All of the patients in this case series received the same treatment, regardless of clinical presentation or status on the CPR. We found that patients 1 and 2 were positive on the rule, and had favorable short-term (1-week) responses to thoracic spine thrust manipulation which were maintained at the 4-week follow up. Patient number 3 was not positive on the rule, did not improve with thoracic spine thrust manipulation, and actually worsened in the short-term (1-week). In fact, patient number 3 only began to improve after the exercise program was initiated. This is consistent with the suggestion that the CPR may correctly identify patients who are likely to exhibit a favorable response to the thoracic spine thrust manipulations.

Although the underlying effects and mechanism of spinal manipulation are not widely understood, recent research suggests that that spinal manipulation is associated with a neurophysiological response that may result in measureable therapeutic effects (Pickar 2002). Spinal manipulation has been shown to change intradiscal pressure, relax paraspinal musculature, induce hypoalgesia, increase the production of B-endorphins, and downregulate the production of inflammatory proteins (George et al 2006, Maigne and Vautravers 2003, Teodorczyk-Injeyan et al 2006). Determining the physiological mechanisms that may have been responsible for the improvements in our patients is beyond the scope of this case series.

Impairments in muscle performance and motor control are common in patients with neck pain (Chiu et al 2005b, Falla et al 2004a, Falla et al 2004b, Falla et al 2004c, Falla et al 2004d, Falla et al 2004e, O'Leary et al), Jull 2004). Neck pain patients frequently have underlying neuromuscular problems including altered coordination between superficial and deep neck flexors, greater fatigue of cervical musculature under low load, and deficits in kinesthetic sense (O'Leary et al 2003). Although changes have been found in patterns of cervical muscle activation in cognitive, functional and automatic tasks, patients with neck pain also frequently present with impairments in the postural control system which may implicate the musculature and joints of the cervicothoracic and periscapular regions (Jull 2004). In a recent systematic review Kay et al (2005) recommended that exercise programs for acute or chronic mechanical neck pain consist of stretching and strengthening exercises targeting the musculature of the cervical region, shoulder-thoracic region or both. This review revealed that exercise programs consisting of stretching and strengthening exercises for the cervical or cervical and shoulder-thoracic region resulted in benefits in pain and function in patients with mechanical neck disorders (Kay et al 2005).

As pathoanatomic models for examining and managing patients with spinal pain have been largely unsuccessful, there has been a recent trend towards utilising treatment-based classifications in an attempt to improve clinical outcomes (Waddell 1987, Waddell 1999, Waddell et al 1993)(Childs et al 2004, Delitto et al 1995). The treatment-based classification system proposed by Delitto et al (1995) has been shown to be reliable, valid and result in improved clinical outcomes in patients with mechanical low back pain (Brennan et al 2006, Fritz and George 2000, George and Delitto 2005). A treatment based classification system for patients with neck pain has been proposed by Childs et al (Childs et al 2004). Subsequent research by Fritz and Brennan demonstrated that patients receiving interventions matched to the classification system had better outcomes than patients receiving unmatched interventions (Fritz and Brennan 2007). The recent CPR may help further guide clinicians by identifying a subgroup that responds dramatically to a specific intervention (Cleland et al 2007). It is important to note that classification is not the same as a pathoanatomic diagnosis: indeed, in our experience, patients with apparently very similar 'pathoanatomy' may respond differently to the same intervention. Therefore, it is useful to have clinical predictors that may be useful in identifying which patients need which treatment based on clinical presentation.

If the CPR is validated by subsequent research, it will be extremely useful for clinicians to know, a priori, which patients have a significantly greater likelihood of responding to thoracic spine thrust manipulation (Cleland et al 2007). If a patient is not positive on the CPR, as occurred with patient number 3, the CPR and the results of this case series would suggest that thoracic manipulation may be of limited value, and the therapist and patient's time would be better spent utilising other evidence-based interventions, however this must be confirmed in a validation study of the preliminary CPR.

CONCLUSION

This case series illustrates the potential utility of the CPR rule in identifying patients with mechanical neck pain who may experience dramatic short-term improvements with thoracic spine thrust manipulation. Three patients were evaluated in this case series, two of whom were positive on the rule, and one who did not satisfy the criteria outlined by the CPR. Although a case series design is not capable of providing evidence able to support or refute the preliminary CPR of Cleland et al (2007), the results presented here are consistent with the CPR findings. The CPR correctly predicted which patients may benefit from a particular intervention, thus increasing a practitioner's probability of appropriately and efficiently treating patients with neck pain. Future research is necessary to validate the use of the CPR on a large sample of patients to determine whether the trends observed in this case series persist.

Key Points

* It appears that some patients with neck pain do well with thoracic manipulation while others may require different interventions. Previous research has derived a preliminary clinical prediction rule (CPR) that is purported to identify patients with neck pain that would benefit from thoracic manipulation.

* Two of the patients in this case series were positive on the CPR and had excellent short-term outcomes following manipulation while the third patient did not meet the CPR, failed to improve following manipulation, and did well only when therapeutic exercises were introduced.

* Further research is needed to validate the preliminary CPR in a randomised clinical trial design.

Appendix 1: Stretching Exercises

Name of Stretching
Exercise                  Instructions to Patient

Upper Trapezius           In order to stretch the right upper
Stretch                   trapezius, the patient was instructed to
                          grasp the chair with the right hand and
                          slowly lean the body slightly forward and to
                          the left. The patient was instructed to bend
                          the head forward and to the left, then
                          rotate the head to look right. The patient
                          was permitted to support the head with the
                          left hand without pulling on the head. The
                          patient was instructed to hold this position
                          for 30 seconds x 2 repetitions and to repeat
                          on the opposite side.

(1) Right Scalene/        In order to stretch the right scalenes and
(2) Sternocleidomastoid   sternocleidomastoid, the patient was
Stretch                   instructed to sit upright in a chair and to
                          use a sheet (1) or the left hand (2) to hold
                          the right shoulder down. The patient was
                          then instructed to bend the head to the
                          left, followed by rotating to look to the
                          right. Finally, the patient was instructed
                          to tuck the chin (make a "double chin")
                          until a stretch was felt along the right
                          side of the neck. The patient was instructed
                          to hold this position for 30 seconds x 2
                          repetitions and to repeat twice on the
                          opposite side.

Levator Scapulae          In order to stretch the right levator
Stretch                   scapulae, the patient was instructed to
                          grasp the chair with the right hand and
                          slowly lean the body slightly forward and to
                          the left. The patient was instructed to bend
                          the head forward and to the left, then
                          rotate the head to the left until a stretch
                          was felt along the right side of the neck.
                          The patient was permitted to support the
                          head with the left hand without pulling on
                          the head. The patient was instructed to hold
                          this position for 30 seconds x 2 repetitions
                          and to repeat twice on the opposite side.

Pectoralis Major and      In order to stretch the right pectoralis
Minor Stretch             major and minor, the patient was instructed
                          to stand and face a wall with the arm
                          outstretched against the wall. The patient
                          was instructed to bend the right elbow
                          slightly and to hold the shoulder blade down
                          and in towards the spine as the body was
                          slowly rotated to the left until a stretch
                          was felt along the chest. The patient was
                          instructed to hold this position for 30
                          seconds x 2 repetitions and to repeat twice
                          on the opposite side.

Appendix 2: Strengthening Exercises

Name of Exercise          Instructions to Patient

Deep Neck Flexor          The patient was instructed to lie on his
Training                  back with the knees bent without a pillow
                          under the head/neck. The patient was then
                          instructed to locate a spot on the wall just
                          above the knees and to nod the head as if
                          indicating "yes" and to hold this position
                          for 10 seconds. The patient was instructed
                          to perform 10 repetitions of this exercise.
                          While performing this exercise, the patient
                          was instructed to place his hand gently on
                          the front of the neck to feel the
                          superficial muscles to ensure that these
                          muscles stayed soft and relaxed while
                          performing this exercise. The patient was
                          instructed to stop the exercise at the point
                          that he sensed hardening of the superficial
                          muscles.

Neck Isometric            In a seated position, the patient was
Strengthening             instructed to place the fingers against the
                          forehead while maintaining a neutral
                          position of the neck. The patient was
                          instructed to perform an isometric
                          contraction by pushing the head forward
                          against the fingers. The patient was
                          instructed to repeat this exercise while
                          pushing the head backwards and to both sides
                          against the resistance of the fingers. The
                          patient was instructed to hold each position
                          for 10 seconds, relax, and to repeat the
                          exercise 10 times in each direction.

Middle Trapezius          In the prone position, the patient was
Strengthening             instructed to raise both arms towards the
                          ceiling with the arms in line with the
                          shoulders and the thumbs pointing up. The
                          patient was instructed to hold this position
                          for 10 seconds, relax, and to repeat the
                          exercise 10 times.

Lower Trapezius           In the prone position with the arms
Strengthening             overhead, the patient was instructed to
                          raise the arms towards the ceiling with the
                          thumbs pointing up. The patient was
                          instructed to hold this position for 10
                          seconds, relax, and to repeat the exercise
                          10 times.

Serratus Wall Push-Ups    While standing at the wall with the arms
                          approximately shoulder width apart and
                          shoulder height, the patient was instructed
                          to perform a "push-up with a plus" exercise
                          by pushing away from the wall until the
                          elbows were fully extended and the shoulder
                          blades were pulled away from the spine. The
                          patient was instructed to hold this position
                          for 10 seconds, relax, and to repeat the
                          exercise 10 times.

ACKNOWLEDGEMENTS

The patients in this case series were treated at Concord Hospital, Concord, New Hampshire, USA. All patients signed a consent form as part of a research project investigating the effects of thoracic manipulation in people with neck pain. This study had ethical approval by the Human Investigations committee at Concord Hospital, Concord, New Hampshire, USA. No external funding was used in this case series. The authors affirm that they have no financial affiliation (including research funding) or involvement with any commercial organisation that has a direct financial interest in any matter included in this manuscript.

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Kristin J Carpenter, PT, DPT

Doctor of Physical Therapy, University of Colorado Denver, School of Medicine, Department of Physical Therapy, Denver, CO.

Paul E Mintken PT, DPT

Assistant Professor, University of Colorado Denver, School of Medicine, Department of Physical Therapy, Denver, CO; Fellow in the Regis University Manual Physical Therapy Fellowship, Regis University, Denver, CO.

Joshua A Cleland PT, PhD

Associate Professor, Department of Physical Therapy, Franklin Pierce University, Concord; Physiotherapist, Rehabilitation Services, Concord Hospital, Concord, NH; and Faculty, Manual Physical Therapy Fellowship Program, Regis University, Denver, CO.

ADDRESS FOR CORRESPONDENCE

Dr Paul Mintken, University of Colorado Denver, School of Medicine, Physical Therapy Program, Mail Stop C244, 13121 E 17th Avenue Aurora, Colorado, USA zip code 80045. Telephone + [phone], fax + [phone]. Email: Paul.mintken@ ucdenver.edu

Table 1: Combination of Predictor Variables and Likelihood
of Success from the Clinical Prediction Rule of Cleland et al
(2007).

Number of                                          Probability
variables   Sensitivity   Specificity     +LR      of Success

6               .05           1.0       Infinite      100%
5+              .12           1.0       Infinite      100%
4+              .33           .97          12          93%
3+              .76           .86         5.5          86%
2+              .93           .56         2.1          71%
1+              1.0           .17         1.2          58%

Table 2: Patient Demographics, Self-report Variables,
and Baseline Characteristics

                          Patient 1       Patient 2      Patient 3

Age                          42              61             27
Gender                      Male           Female         Female
Duration of symptoms     7 mos, 26 d     7 mos, 25 d       15 d
FABQ-PA                       5               0             14
FABQ-W                       23               0             14
Status on the CPR            4/6             3/6            1/6
Baseline NDI               50/100          24/100         24/100
3rd Visit NDI              18/100           6/100         26/100
Discharge NDI               8/100           0/100          6/100
Baseline NPRS                 5               5              5
3rd visit NPRS                1               1              7
Discharge NPRS                0               1              1

FABQ-PA = Fear Avoidance Beliefs Questionnaire Physical Activity
Subscale

FABQ-W = Fear Avoidance Beliefs Questionnaire Work Subscale

CPR = Clinical prediction rule

NDI = Neck Disability Index

NPRS = Numerical Pain Rating Scale

Table 3: Patient Status on Predictor Variables

Variable                      Patient 1     Patient 2     Patient 3

Symptoms <30d                    No            No            Yes

No symptoms distal to the        Yes           Yes           No
shoulder

Looking up does not              Yes           No            No
aggravate symptoms

FABQ-PA score <12              Yes (5)       Yes (0)       No (14)

Diminished upper thoracic        Yes           Yes           No
spine kyphosis

Cervical extension               No            No            No
ROM <30[degrees]

Total number predictor           4/6           3/6           1/6
variables met

FABQ-PA = Fear Avoidance Beliefs Questionnaire Physical Activity

Subscale

ROM = Range of motion