Author: Dr. Gary Welch, PT

 

This article is to help educate practitioners and patients on the most recent evidence regarding the use of physical therapy for treatment of the cervical spine and the lumbar spine.  One key point to make, is that the physical therapist you are using is trained as an orthopedic manual therapist.  Not all physical therapists are trained with these advanced skills. Seek out a physical therapist who is skilled in orthopedic manual therapy.

Optimal patient outcomes are supported by three pillars of evidence that include clinical expertise, patient’s values and circumstances and the best available scientific research. 

Research designs and the hierarchies used to rank them are consistent with an investigative paradigm that emphasizes objectivity, faithfulness to rules of engagement with subjects, and use of quantitative data to describe clinical phenomena. 

Clinical Practice Guidelines – is a selection of studies through the use of hierarchies will improve the efficiency of the search process for busy clinicians.  These schemas also are used regularly to grade evidence to facilitate the clinical practice guidelines.  These guidelines are produced by national and international government agencies as well as professional associations in an effort to promote effective and efficient healthcare.  The American Physical Therapy Association create guidelines for physical therapy, targeted at physical therapists, policy makers, and insurance companies in the United States.  Clinical practice guidelines are systematically developed statements designed to facilitate evidence-based decision making for the management of specific health conditions, such as knee osteoarthritis.  Clinical practice guidelines incorporate evidence from research, clinical expertise, and, ideally, patient perspectives.

Systematic Reviews – are utilized to produce conclusions based on a critical appraisal of a number of individual studies that have been selected according to preestablished criteria.  The studies reviewed typically have research designs that minimize the chance of bias, are pertinent to the therapist’s question, and provide a more definitive answer to the question.  Systematic reviews are developed using a documented, systematic approach that minimizes bias.  Authors of a systematic review define a specific purpose for the study and the methods that minimize bias are determined prior to the beginning of the study.   Systematic reviews of treatment interventions are most common; however, reviews can also appraise diagnostic tests, outcome measures, and prognostic factors.

Randomized Control Trials – the intention of the researcher in these studies is reduce unwanted influences in the study through random assignment of study participants to two or more groups and through controlled manipulation of the experimental intervention.  A randomized control trial is best suited to answer questions about whether an experimental intervention has an effect and whether that effect is beneficial or harmful to the subjects.  

Jewell, D. V. (2018). Guide to evidence-based physical therapist practice. Burlington, MA: Jones & Bartlett Learning.     Fetters, L., & Tilson, J. (2019). Evidence based physical therapy. Philadelphia, PA: F.A. Davis Company.

STUDIES – there are 5 levels of evidence. Level 1 is the highest quality of evidence-based practice, and level 5 is considered the lowest.

1. LEVEL I – evidence obtained from high-quality diagnostic studies, prospective studies, or randomized controlled trials.  
2. LEVEL II – evidence obtained from lesser-quality diagnostic studies, prospective studies, or randomized controlled trials.
3. LEVEL III – case-controlled studies or retrospective studies
4. LEVEL IV – case series
5. LEVEL V – expert opinion

GRADES OF RECOMMENDATION BASED ON THE STRENGTH OF THE EVIDENCE

• GRADE A is strong evidence which means that a preponderance of level I and/or level II studies support the recommendation.  This must include at least 1 level I study.  
• GRADE B is moderate evidence which means that a single high quality randomized controlled trial or a preponderance of level II studies support the recommendation.
• GRADE C is weak evidence which means a single level II study or a preponderance of level III and IV studies, including statements of consensus by content experts, support the recommendation
• GRADE D is conflicting evidence which means that higher-quality studies conducted on this topic disagree with respect to their conclusions.  The recommendation is based on these conflicting studies.
• GRADE E is theoretical/foundational evidence which means a preponderance of evidence from animal or cadaver studies, from conceptual models/principles, or from basic science/bench research supports the conclusion.
• GRADE F is expert opinion which means the best practice is based on the clinical experience of the guideline’s development team.  

Jewell, D. V. (2018). Guide to evidence-based physical therapist practice. Burlington, MA: Jones & Bartlett Learning.      Kelley, M. J., Shaffer, M. A., Kuhn, J. E., Michener, L. A., Seitz, A. L., Uhl, T. L., . . . Mcclure, P. (2013). Shoulder Pain and Mobility Deficits: Adhesive Capsulitis. Journal of Orthopaedic & Sports Physical Therapy, 43(5). doi:10.2519/jospt.2013.0302

LUMBAR SPINE

2012 Journal of Orthopaedic & Sports Physical Therapy clinical practice guidelines for patients with low back pain states there is strong grade A evidence for manual therapy for thrust manipulations and nonthrust manipulations of the lumbar spine.  The guidelines state explicitly that clinicians should consider utilizing thrust manipulative procedures to reduce pain and disability in patients with mobility deficits and acute low back and back-related buttock or thigh pain.  Thrust manipulative and nonthrust mobilization procedures can also be used to improve spine and hip mobility and reduce pain and disability in patients with subacute and chronic low back and back-related lower extremity pain.

Delitto, A., George, S. Z., Dillen, L. V., Whitman, J. M., Sowa, G., Shekelle, P., . . . Godges, J. J. (2012). Low Back Pain. Journal of Orthopaedic & Sports Physical Therapy, 42(4). doi:10.2519/jospt.2012.42.4.a1

2015 Journal of the American Osteopathic Association clinical practice guidelines for osteopathic manipulative treatment for patients with low back pain included 15 intervention studies in their guidelines.  The American Osteopathic Association concluded in these guidelines that osteopathic manipulative treatment significantly reduces pain and improves functional status in patients, including pregnant and postpartum women, with nonspecific acute and chronic low back pain.  The strength of the evidence in these guidelines that OMT had a significant effect on pain relief and functional status is moderate in patients with nonspecific acute and chronic low back pain. 

American Osteopathic Association Guidelines for Osteopathic Manipulative Treatment (OMT) for Patients with Low Back Pain. (2016). The Journal of the American Osteopathic Association, 116(8), 536. doi:10.7556/jaoa.2016.107

CERVICAL SPINE

2017 Journal of Orthopedic & Sports Physical Therapy clinical practice guidelines for patients with acute neck pain states there is moderate grade B evidence stating that clinicians should provide a multimodal intervention approach including manual mobilization techniques plus exercise for those patients expected to experience a moderate to slow recovery with persistent impairments.  The same guidelines states that there is moderate grade B evidence for patients with chronic neck pain that is radiating stating that clinicians should provide mechanical intermittent cervical traction, combined with other interventions such as stretching and strengthening exercise plus cervical and thoracic mobilization/manipulation.

Neck Pain Guidelines: Revision 2017: Using the Evidence to Guide Physical Therapist Practice. (2017). Journal of Orthopaedic & Sports Physical Therapy, 47(7), 511-512. doi:10.2519/jospt.2017.0507