Direct Physical Therapy Access Could Reduce Healthcare Costs

A policy brief from the Health Care Cost Institute reports that Individuals with lower back pain who received physical therapy had reduced healthcare costs.

When it comes to healthcare costs, the federal government, medical providers, and payers are attempting to reduce rising spending and adopt value-based care reimbursement.  A number of different strategies have been implemented including bundled payment models and accountable care organizations. In the realm of physical therapy, patients with lower back pain could benefit from reduced healthcare costs.

A policy brief from the Health Care Cost Institute reports that Individuals with lower back pain who received physical therapy had reduced healthcare costs when compared to patients who visited with another provider first. Patients who visited a physical therapist at the beginning of their treatment were less likely to end up in an emergency room. A lower likelihood of emergency department visits also produces hospitalization costs.

Since low back pain is a very common occurrence in the healthcare setting and a likely contribution to disability, these findings are key to reducing medical spending across the industry. In fact, $90.6 billion in direct healthcare costs are spent on treating back pain throughout the United States.

The study authors focused on analyzing beneficiary claims data from six states including Oregon, Washington, Wyoming, Alaska, Idaho, and Montana. The researchers  looked at claims data  showing three different groups of people including those who never saw a physical therapist, those who saw a physical therapist later in their treatment, and those who immediately received physical therapy.

The study found that patients who saw a physical therapist first were also less likely to be prescribed a painkiller when compared to others who saw a different type of clinician. The policy brief emphasizes that visiting with a physical therapist first will reduce the use of costly healthcare services and thereby cut spending across the board.

Researchers from the University of Washington and the George Washington University also found that taking away state restrictions on physical therapy could improve health outcomes among those on opioid prescriptions as well as enhance imaging. Individual states should consider addressing restrictions on direct physical therapy access, according to the policy brief.

State restrictions on physical therapy access could affect overall healthcare costs by impacting the use of differing medical services. Essentially, in order to reduce healthcare costs, state policymakers should allow patients direct access to physical therapy without physician referral, according to the study.

“The findings from this study suggest that seeing a physical therapist as the first point of care compared to seeing a physical therapist at a later point in time (or not seeing a PT) reduces utilization of potentially costly services,” the study from the Health Care Cost Institute stated.

“Of particular interest was the significant decrease in opioid prescription, ED visits, and imaging for those patients receiving PT first. The potential reduction in opioid prescriptions is notable given the increasing awareness on the overprescription of opioids and the high risk of substance abuse. These findings suggest that having access to PT could have an impact on healthcare costs including out-of-pocket costs across all settings.”

While reducing healthcare costs is an imperative within the medical industry, quality care and patient needs come first. However, a study from the American Physical Therapy Association shows that patient needs may not come first in a referral-for-profit environment.

The study illustrates that patients who obtained physical therapy services from a clinic owned by their original physician received twice as many PT visits as compared to patients who were referred to physical therapy not affiliated with the referring surgeon. The therapy was also less customized and less intensive, the researchers found.

“When there is referral-for-profit, and from this data as related to group therapy and an extended number of visits, it stands to reason there is increased risk that the patient’s individual needs are of secondary importance to revenue. This has long been the concern here at the American Physical Therapy Association (APTA) and it is why we have fought so hard, alongside our partners in the AIM Coalition, against physician-owned physical therapy services (POPTS),” American Physical Therapy Association President Sharon Dunn, PT, PhD, OCS, stated in a press release.

“This study provides further evidence that when the bottom line takes precedence in healthcare, the patient loses. A patient’s welfare and recovery should always be the primary focus of treatment.”

The researchers looked at more than 3,000 patients who underwent total knee replacement surgery. Out of all of these, nearly 19 percent were found to be completed through a physician self-referral process while 72.3 percent of cases did not have a doctor who had “ownership interest in physical therapy services.”

The findings show that treatment in a physician-owned physical therapy setting lasted a week longer than services not affiliated with the referring physician. About twice as many visits were seen in physical therapy offices in which the referring doctor had a financial stake.

The issue seems to be that, in physician self-referral cases, patients were more likely to receive group therapy instead of individual, one-on-one care, which tends to extend the amount of visits needed to complete treatment.

This type of physician self-referral practice may improve revenue for an individual physical therapy clinic, but it only increases overall healthcare spending and negatively impacts patient care, the researchers wrote. In order to meet the Triple Aim of Healthcare, providers will need to look beyond their own revenue cycle and consider patient needs first.

Physical Therapy vs Opioids: When to Choose Physical Therapy for Pain Management

According to the Centers for Disease Control and Prevention (CDC), sales of prescription opioids have quadrupled in the United States, even though "there has not been an overall change in the amount of pain that Americans report."

In response to a growing opioid epidemic, the CDC released opioid prescription guidelines in March 2016. The guidelines recognize that prescription opioids are appropriate in certain cases, including cancer treatment, palliative care, and end-of-life care, and also in certain acute care situations, if properly dosed.

But for other pain management, the CDC recommends nonopioid approaches including physical therapy.

Patients should choose physical therapy when ...

... Patients are concerned about the risks of opioid use.

"Given the substantial evidence gaps on opioids, uncertain benefits of long-term use, and potential for serious harms, patient education and discussion before starting opioid therapy are critical so that patient preferences and values can be understood and used to inform clinical decisions," the CDC states. Physical therapists can play a valuable role in the patient education process, including setting realistic expectations for recovery with or without opioids. As the CDC guidelines note, even in cases when evidence on the long-term benefits of nonopioid therapies is limited, "risks are much lower" with nonopioid treatment plans.

... Pain or function problems are related to low back pain, hip or knee osteoarthritis, or fibromyalgia.

The CDC cited "high-quality evidence" supporting exercise as part of a physical therapy treatment plan for those familiar conditions.

... Opioids are prescribed for pain.

Even in situations when opioids are prescribed, the CDC recommends that patients should receive "the lowest effective dosage," and opioids "should be combined" with nonopioid therapies, such as physical therapy.

... Pain lasts 90 days.

At this point, the pain is considered "chronic," and the risks for continued opioid use increase. An estimated 116 million Americans have chronic pain each year. The CDC guidelines note that nonopioid therapies are "preferred" for chronic pain and that "clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient."

Before you agree to a prescription for opioids, consult with a physical therapist to discuss options for nonopioid treatment.

Evidence of Nervous System Sensitization in Commonly Presenting and Persistent Painful Tendinopathies: A Systematic Review.

Plinsinga ML, et al. J Orthop Sports Phys Ther. 2015.

Show full citation

Abstract

Study Design Systematic review. Objectives Elucidate if there is sensitization of the nervous system in those with persistent rotator cuff (shoulder), lateral elbow, patellar, and Achilles tendinopathies. Background Tendinopathy can be difficult to treat and persistent intractable pain and dysfunction frequent. It is hypothesized that induction or maintenance of persistent pain in tendinopathy is at least in part based on changes in the nervous system. Methods Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines were followed. Relevant articles were identified through a computerized search in Embase, PubMed, and Web of Science followed by a manual search of reference lists of retained articles. To be eligible, studies had to include quantitative sensory testing (QST) and evaluate individuals diagnosed with a persistent tendinopathy of the rotator cuff (shoulder), lateral elbow, patellar, or Achilles tendon. Methodological quality assessment was evaluated with the Newcastle-Ottawa Scale. Results In total, 16 full-text articles met the criteria for inclusion, of which the majority were case-control studies with heterogeneous methodological quality. No studies on Achilles tendinopathy were found. Mechanical algometry was the predominant QST used. Lowered pressure pain threshold was observed across different tendinopathies at the site of tendinopathy as well as at other sites, with the latter being suggestive of central sensitization. Conclusion Although more research on sensory abnormalities is warranted, it appears likely that there is an association between persistent tendon pain and sensitization of the nervous system. This evidence is primarily from studies of upper limb tendinopathy and caution should be exercised with inference to lower limb tendinopathy. J Orthop Sports Phys Ther, Epub 21 Sep 2015. doi:10.2519/jospt.2015.5895.

As I sit recovering from abdominal surgery, I can't help but understand the relationsip between the myofascial abdominal wall referral and underlying organ dysfunction. For years I had been plagued with stomach pain, and some still. Likely a myofascial perpetuator?

Myofascial Dysfunction and Its Relationship to Laparoscopy John Jarrell University of Calgary, Calgary, AB, Canada

Check the link out to see relationship between muscle and visceral pain in regards to laprosocpy. 

http://cdn.intechopen.com/pdfs-wm/18365.pdf

When pain is predictably provoked by mechanical stress, and eased by its alleviation, we quickly implicate a mechanical, or at least peripheral, nociceptive mechanism, and apply diagnoses like mechanical low-back pain that justify our favoured peripherally directed interventions. While the logic is attractive, what if central processes could mediate this presentation? Centrally mediated pain masquerading as peripheral.

We recently investigated the idea of centrally-mediated mechanical symptoms (Harvie et. al 2015 PDF). The study involved twenty-four people with the type of persistent neck pain problems seen in everyday practice, and all with pain on rotation. They performed head rotation to their first onset of pain (P1), in three virtual-reality conditions where the amount of rotation that they saw did not match reality. Instead, the viewed rotation was more or less than was actually occurring, creating an illusion of movement that was different to actual movement. Remarkably, pain with movement depended not only on how far people actually moved, but how far it appeared they had moved (see figure and explanation in caption below).

Mean (circle) and 95% confidence interval (error bars) for the range of motion to first onset of pain presented as a proportion of the mean range of rotation for the neutral condition. When the visual feedback suggested less movement, the first onset of pain (P1) was delayed by 6%, when the visual feedback suggested more movement, P1 7% sooner.

That pain with movement can be reliably modulated by the (visual) suggestion of more or less movement (i.e. by a non-mechanical input) is significant, and prompts us to reconsider the mechanical presentation.

In the past, perceptions such as pain were simply considered a read-out of incoming information. However, it has become clear that we could not make sense of the world if sensory information was not first filtered and arranged by our subconscious. In the case of visual perception, for example, the infinite array of colours, edges and shapes are arranged by our subconscious into the meaningful objects that we see and understand. Certain rules seem to govern this process — such as the way objects are arranged according to continuity of lines, colour and motion. The rules that govern the construction of pain, while only recently receiving attention, appear to involve the brains analysis of information relating to bodily danger. Nociception is the most obvious signal of danger to the body — but not the only one. Specific movements for example, might also become signals of bodily danger because of their meaning derived from association with injury. This would explain how (visual) signals of movement may have come to be a contributor to pain in these people with neck pain.

While ample research supports the idea that signals of threat influence pain, this study suggests specifically that information about the body in space (whether visual, proprioceptive or vestibular) that has been associated with an injury, might be relevant signals of threat. Indeed their influence may even result in a clinical pattern that appears mechanical, but is in fact centrally driven.

The treatment of threatening pain-associations is an ongoing field of study. In the meantime I think that there are a few things we can do to better align clinical practice with the threat-based understanding of pain that this finding aligns with. Firstly, we can expand our minds and clinical assessments to identify both nociceptive and non-nociceptive sources of threat (guaranteed we wont treat something we don’t assess!). Secondly, we can leverage our skills in education and behaviour therapy to encourage thoughts and actions that counter threat.

Your back hurts (join the club) and you go to see your primary care physician. Most of the time, your doctor will tell you to rest, maybe take some ibuprofen or ice the affected area.

But when researchers looked at 841 people who needed additional care, they found that the ones sent first for MRIs were more likely to have surgery or injections, see a specialist or visit an emergency room than those who were first sent to physical therapists. And they (or their insurance companies) paid an average of $4,793 more.

The reasons, said the study's lead author, are more likely found in the heads of patients and doctors than in anyone's back. MRIs tend to turn up all kinds of benign changes in spines and backs that occur as we move through life. But those prompt patients to look for fixes and to pressure doctors to refer them for those.

"The patient may feel and exert some pressure to wanting to work it up more," said Julie Fritz, a professor of physical therapy at the University of Utah. "It just changes the mind set of everyone involved. It tends to accelerate the course of intervention."

Take degenerative disc disease, for example. Most people older than 40 or 50 have it to some degree, Fritz said, but often not to the extent that it causes pain or other symptoms. But when an MRI turns up that ominous-sounding bit of news, patients often ask for therapy and primary care doctors can succumb, she said.

"It motivates patients to want to do more to look for fixes for that problem, when it probably should be [considered] more like wrinkles and gray hair," she said.

Another possibility is that some physicians have financial interests in imaging services, the study notes.

Low back pain is incredibly common and debilitating. According to one study, it causes more time disabled around the world than HIV, road injuries, tuberculosis, lung cancer, chronic obstructive pulmonary disease and pre-term birth complications. In the United States, Fritz's team noted in its paper, the direct cost of treating low back pain was $86 billion in 2005.

An MRI exam can cost $1,000 or $1,500 and while many are covered by insurance, patients often have to put up co-payments and meet deductibles. Several studies have shown no evidence of benefits to low back patients unless there are specific symptoms, according to Fritz's paper, which was published March 16 in the journal Health Services Research. [Fritz is a professor of physical therapy herself, but the paper is a peer-reviewed study, not her opinion.]

Fritz and her colleagues set out to compare what happens to patients sent first for MRIs versus those sent directly to physical therapists. "Patients have expectations around receiving something perceived as beneficial," they wrote. "Breaking an expectation by denying imaging may be unacceptable to patients or providers. Consumer research suggests offering an alternative to replace the broken expectation is important to patients."

In addition to seeking less invasive follow-up care, the people who went directly to physical therapists spent an average of $1,871, while those whose first move was an MRI spent an average of $6,664 in the year following their initial complaint to their doctors. With only a few hundred people in each sample, Fritz acknowledged, the cost figure was somewhat skewed by a small number of very expensive surgeries among those who had MRIs first. But overall, the cost difference is very clear.

Physical therapy focuses on educating patients about what might be causing their back pain, assuring them that most problems subside in time, and engaging them in their therapy, even if the therapist is providing hands-on aid, Fritz said. Perhaps people who choose that option are more motivated to be part of clearing up their problem, or they may just profit from the approach; the research doesn't make that clear.

Either way, "we think this is an area where our profession has something to offer, especially when it's timed correctly," Fritz said. "There's a place for advanced imaging. It's just not early in the course of care for most patients."

Take home message: CALL BDPT and get PT FIRST!

Why Cash Practice Physical Therapy May Be Better for You: And why it may even be LESS expensive than your in-network PT Mill!

There is a new trend in physical therapy designed to shift the balance of power back toward caregivers and patients. It's called the "Cash Practice Movement". Here we'll discuss how this not only empowers you, the client, to make the best decision for your physical health but also liberates skilled physical therapists EVERYWHERE from the handcuffs of the PT Mill and the constraints of a third party payment system.

PT Mill (noun): a rehab clinic setting where patients are numbers and simply shuffled along from one area of the clinic to another, most of the time by unskilled technicians and/or without any supervision.

The physical therapist in this setting becomes adept at managing traffic and less so at treating their clients effectively.

This business model for medical care is not a new one. Professionals in the fields of dentistry, specialty medicine and even surgery have begun to operate this way. All in the name of PATIENT SATISFACTION and doing what is NEEDED not just what is easy to document so the doc doesn't get left eating the cost! After all, when did the objective of medical care shift from getting completely better to 'how cheaply you could be cared for'?

In a cash practice maximum accessibility and value are stressed. Have a question for the doctor? They will answer it thoroughly. Need some extra hands on care? They will be excited to give it to you. Valuable patient education and teamwork are hallmarks of cash practices. And another great bonus: ALL of this great treatment and you are still 100% entitled to reimbursement by your health insurance provider.

Almost all of us who have health insurance have out-of-network benefits. Knowing your out-of-network coverage, your total out of pocket maximums and deductibles should be the main points of your health coverage that you keep at top of mind. If you know this info you're doing what is needed to stay in the driver's seat of your care.

In a blog post that came across my desk recently, an MD colleague of ours eloquently wrote about 'what would happen if a restaurant were operated in the same manner as a medical practice'. This piece is ESSENTIAL reading for anyone who is looking to be their own best health care advocate.

"Alas, I wish this were a fictional tale, but it is not.

The only fictional portion is that this is

not your favorite restaurant,

but your favorite doctor’s office, which is responsible not for meeting your dining needs, but those of your health."

With greater volumes of clients comes less attention to any one client. This isn't a value statement; this is math.

Clinicians working in a cash practice STUFF AS MUCH TREATMENT AS POSSIBLE into each visit. The 'PT Mill' employs a different strategy: to be judicious about the amount of time that is spent with any one patient so that the clinic can bill your insurance company for many different units/CODES (the special language of health insurance billing).

In a conversation that our office administrator recently had with an insurance company, she was actually advised to, "make sure that she and the our therapists were aware about each clients' treatment allowances". That, "each client is only WORTH what that insurance company dictates they are WORTH", and that, "if that client needs 30 minutes of intensive hands on care, but we had been told they would only be allowed to bill for 20 minutes, just don't treat them for that extra time" (read: unnecessary time according to a pencil pusher behind a desk with NO medical background). This is the best example I've ever heard of an attempt at third-party-dictated-care.

No offense to pencil pushers the world over, but this group of people are different; they are SUPPOSED to be on your side!! They are most certainly not. I, like our office administrator and I'm sure YOU, am APPALLED at this. This is not the reason that any of us went into the physical therapy field and until the premium-paying-public truly understands that this is going on behind the scenes, less valuable and less effective care will continue to be the norm.WE, the physical therapists, the physicians, the surgeons; WE are in your corner. We want what's best for each of our clients and those of us who operate as fee-for-service professionals are the ones who will always be able to provide our clients with THE CARE YOU NEED.

As it turns out, our clients are great advocates for themselves AND for rehab practices like ours! Little excites us more than to keep the friends and family of our clients pain free and moving well. In an email to a friend, one of our clients laid this info out:

In-Network provider:

$30.00 / 60 min visit, with approximately 15 min contact time with PT provider.

I would go 3x/week totaling approximately 180 min of my time, and 45 min of contact time with PT provider.

Total out of pocket expense: $90.00

Treatment: several months

Results: no improvement.

Bluegrass Doctors of PT (out-of-network provider):

$125.00 / 60 min visit, with approximately 60 min contact time with PT provider.

I would go 1x/week totaling approximately 60 min of my time, and 60 min of contact time with PT provider.

Total out of pocket expense: $125.00, less 50% of the maximum allowable reimbursement from my insurance, totaling about $95.00 out of pocket.

Treatment: 2 months

Results: significant improvement and return to normal activities.

Ours are the clients who expect more than just good enough. They seek high quality care but with the reassurance that they will receive the reimbursement they are entitled to because we go through the trouble of billing that person’s insurance on their behalf.

All physical therapists and clinics are not created equal. I am teaming up with colleagues across the country who are emphatic about this. People who go to physical therapy clinics that bill every insurance company under then sun don’t realize that they’re getting higher volume/lower quality care. PTs working in PT Mills always have good intentions, but there is no way to learn your patients' complete story when you have only 15 minutes with them and maybe 2, 3, or even 4 patients waiting to be seen at the same time.

Regardless of the skill level of the therapist, it is impossible to deliver the quality that we deliver because of the amount of time and effort we expend on each individual. The extra effort spent with hands on, with eyes on and providing detailed education translates into clients who get better faster and with a more valued experience. If more people knew that there is another option, they would likely think twice before accepting care in a 'mill'. I'm excited to say that we are helping lead the initiative to reestablish the concept of VALUE in physical therapy.

In a recent article in Forbes magazine, this trend is analyzed and appears to be in line

with the way more consumers would like to be treated.

The term cash practice may scare off some people because they believe it must be more expensive. Simply put, at a cash practice you will pay for high-level care and get the best result possible. In many of these clinics they will assist you in billing your insurance company for reimbursement. Out of pocket expense is comparable, but the quality of care is much greater.

IOM committee calls for new criteria, name for chronic fatigue syndrome

Chronic fatigue syndrome is a serious, real disease, one that deserves a more accurate name — systemic exertion intolerance disease — and a new code in the International Classification of Diseases, 10th Edition, according to the Institute of Medicine.

“Many ME/CFS patients believe that the term ‘chronic fatigue syndrome’ perpetuates misunderstanding of the illness and dismissive attitudes from healthcare providers and the public,” the committee wrote in the report brief.

ME/CFS, which causes profound fatigue, sleep abnormalities, cognitive dysfunction, pain, autonomic manifestations and other symptoms that worsen with exertion, can severely impair patients’ ability to lead normal lives. Between 836,000 and 2.5 million Americans suffer from this disease, according to the report. However, the authors wrote, many wait years for a diagnosis, partly because many clinicians misunderstand the disease or lack information to diagnose or treat it.

“Many healthcare providers are skeptical about the seriousness of ME/CFS, mistake it for a mental health condition, or consider it a figment of the patient’s imagination,” the authors wrote in the report. “Misconceptions or dismissive attitudes on the part of healthcare providers make the path to diagnosis long and frustrating for many patients. The committee stresses that healthcare providers should acknowledge ME/CFS as a serious illness that requires timely diagnosis and appropriate care.”

To develop the new diagnostic criteria, the committee completed a comprehensive review of available evidence and also considered input from patients, advocates and researchers.

For a patient to be diagnosed with ME/CFS, all three of the following symptoms must be present:

A substantial reduction or impairment in the ability to engage in pre-illness levels of occupational, educational, social or personal activities accompanied by fatigue

Worsening of symptoms after physical, cognitive or emotional activity

Unrefreshing sleep

At least one of the following two symptoms also must be present:

Cognitive impairment

Orthostatic intolerance

To distinguish ME/CFS from other diseases, these symptoms must have persisted for at least six months, and the patient must be moderately, substantially or severely affected by them at least half of the time.

The committee wrote that clinicians should diagnose ME/CFS if the new criteria are met after a patient history, physical exam and medical work-up.

Recommendations in the report also call on the U.S. Department of Health and Human Services to develop a toolkit for evaluating and diagnosing patients in clinical settings including primary care offices, PT and OT clinics, EDs, behavioral and mental health clinics, and some specialty settings.

Included in the report is a table listing examples of patient descriptions, potential questions for taking medical histories or in-office questionnaires.

The authors call for more research, especially focusing on patients diagnosed using the new criteria. They also propose another review of the evidence after no more than five years.

“The primary message of this report is that ME/CFS is a serious, chronic, complex, multisystem disease that frequently and dramatically limits the activities of affected patients,” the authors wrote. “It is ‘real.’ It is not appropriate to dismiss these patients by saying, ‘I am chronically fatigued, too.’”

The study was sponsored by HHS, the CDC, the National Institutes of Health, the Agency for Healthcare Research and Quality, the Food and Drug Administration and the Social Security Administration.

To read the full 282-page report, visit http://books.nap.edu/openbook.php?record_id=19012&page=1.

Report brief: www.iom.edu/~/media/Files/Report%20Files/2015/MECFS/MECFS_ReportBrief.pdf

Pre-Manipulative Testing Prior to Cervical Manipulation: Time to Abandon the VBI Test?

Considerable attention has been given to the potential risks associated with high-velocity, low-amplitude (HVLA) thrust manipulation procedures in the cervical region.1-5 The most recent and robust evidence for the risk of vertebrobasilar (VBA) stroke and cervical HVLA thrust manipulation comes from the case control study (n=818) by Cassidy et al.3 Contrary to traditionally held views,6,7 Cassidy et al3 found no evidence of excess risk of VBA stroke associated with cervical HVLA thrust manipulation compared to primary medical physician care. Moreover, after quantifying the strains and forces sustained by the vertebral artery in situ during manipulation, Symons et al8 concluded cervical HVLA thrust manipulation is “very unlikely to mechanically disrupt the vertebral artery.” Similarly, Austin et al9 found 1,000 repeat strain cycles mimicking cervical HVLA thrust manipulation did not cause histologically identifiable microdamage in arterial tissue. Additionally, using piezoelectric ultrasound crystals to measure strains and instantaneous lengths of vertebral artery segments within the transverse foramina, Wuest et al10 found the vertebral artery strains experienced during cervical HVLA thrust manipulation were substantially less than the strain in the C1-6 vertebral artery segments experienced during normal neck rotation or pre-manipulative vertebrobasilar insufficiency testing (i.e. sustained cervical extension plus rotation). Moreover, after a review of the literature,8-11 Herzog et al12 concluded, “cervical spinal manipulative therapy performed by trained clinicians does not appear to place undue strain on the vertebral artery, and thus does not seem to be a factor in vertebrobasilar injuries.”

Using magnetic resonance angiography to examine the effects of selected manual therapy interventions on blood flow in the craniocervical arteries and blood supply to the brain, Thomas et al13 concluded total blood supply to the brain was not compromised by C1-2 rotation, end-range rotation, or rotation and distraction positions commonly used in manual therapy. Likewise, using phase-contrast magnetic resonance imaging, Quesnele et al14 found no significant changes in blood flow or velocity in the vertebral arteries after various head positions and upper cervical HVLA thrust manipulations.

Physical therapists that still insist on using variations of the “VBI” test before manual therapy to the cervical spine—often due to claiming “it is standard practice” or “it provides legal protection”—should remember that the most recent literature suggests pre-manipulative cervical artery testing is unable to identify those individuals at risk of vascular complications from cervical HVLA thrust manipulation,2,15,16 and any symptoms detected during pre-manipulative testing are likely unrelated to changes in blood flow in the vertebral artery,13,14 so that a negative test neither predicts the absence of arterial pathology nor the propensity of the artery to be injured during cervical HVLA thrust manipulation, with testing neither sensitive or specific.2,5,15-18 Moreover, in a recent systematic review to evaluate the diagnostic accuracy of premanipulative tests, Hutting et al16 reported the sensitivity of the VBI tests was low (0% to 57%) and is considered not sufficient for clinical use in premanipulative screening procedures. In short, a large body of literature does not support continued use of the “VBI” test or what is now commonly referred to as pre-manipulative functional screening for Cervical Artery Dysfunction (CAD).

In another recent literature review, Murphy19 concluded “the current evidence indicates vertebral artery dissection syndrome is not a complication to cervical manipulation.” Similarly, in a 2014 systematic review, Chung et al20 found no epidemiologic studies to support the hypothesis that cervical spine manipulation is associated with an increased risk of internal carotid artery dissection in patients with neck pain or headaches. Moreover, another recent systematic review4 concluded there is no strong evidence linking the occurrence of serious adverse events with the use of cervical manipulation or mobilization in adults with neck pain.

The two largest randomized controlled trials21,22 within the past 10 years that have directly compared the effectiveness of cervical HVLA thrust manipulation with cervical non-thrust mobilization, did not report the specific vertebral motion segment targeted with the cervical HVLA thrust manipulation procedure. That is, it is not known whether patients with acute or chronic neck pain received upper, middle or lower cervical HVLA thrust manipulation in these two trials.21,22 Nevertheless, there were no serious neurovascular adverse events reported by any participants in either of the trials,21,22 and both trials reported no statistically significant difference in the incidence of minor adverse events between the cervical HVLA thrust manipulation and cervical non-thrust mobilization groups. Therefore to date, and in contrast to what many of us were taught in physical therapy school, there is no strong empirical evidence to support the notion that upper cervical HVLA thrust manipulation carries any greater risk of injury than middle or lower cervical HVLA thrust manipulation, or that non-thrust mobilization to any region of the cervical spine carries any less risk than HVLA thrust manipulation to the same region.1-4

AUTHORS:

James Dunning, DPT, MSc (Manip Ther), MMACP (UK), FAAOMPT

Director, AAMT Fellowship in Orthopaedic Manual Physical Therapy

President, Alabama Physical Therapy & Acupuncture

Montgomery, AL

Raymond Butts, PhD, DPT, MSc (NeuroSci), Cert. DN, Cert. SMT

Senior Instructor, Spinal Manipulation Institute & Dry Needling Institute

Senior Faculty, AAMT Fellowship in Orthopaedic Manual Physical Therapy

Atlanta, GA

Ulysses Juntilla, DPT, OCS, Cert. DN, Cert. SMT, Dip. Osteopractic

Senior Physical Therapist, WJB DORN VA Medical Center, Columbia, SC

Fellow-in-Training, AAMT Fellowship in Orthopaedic Manual Physical Therapy

Columbia, SC

REFERENCES

Haldeman S, Kohlbeck FJ, McGregor M. Unpredictability of cerebrovascular ischemia associated with cervical spine manipulation therapy: a review of sixty-four cases after cervical spine manipulation. Spine (Phila Pa 1976). Jan 1 2002;27(1):49-55.

Kerry R, Taylor AJ, Mitchell J, McCarthy C, Brew J. Manual therapy and cervical arterial dysfunction, directions for the future: a clinical perspective. J Man Manip Ther. 2008;16(1):39-48.

Cassidy JD, Boyle E, Cote P, et al. Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. Spine (Phila Pa 1976). Feb 15 2008;33(4 Suppl):S176-183.

Carlesso LC, Gross AR, Santaguida PL, Burnie S, Voth S, Sadi J. Adverse events associated with the use of cervical manipulation and mobilization for the treatment of neck pain in adults: a systematic review. Manual therapy. Oct 2010;15(5):434-444.

Kerry R, Taylor AJ. Cervical arterial dysfunction assessment and manual therapy. Manual therapy. Nov 2006;11(4):243-253.

Rothwell DM, Bondy SJ, Williams JI. Chiropractic manipulation and stroke: a population-based case-control study. Stroke. May 2001;32(5):1054-1060.

Smith WS, Johnston SC, Skalabrin EJ, et al. Spinal manipulative therapy is an independent risk factor for vertebral artery dissection. Neurology. May 13 2003;60(9):1424-1428.

Symons BP, Leonard T, Herzog W. Internal forces sustained by the vertebral artery during spinal manipulative therapy. J Manipulative Physiol Ther. Oct 2002;25(8):504-510.

Austin N, DiFrancesco LM, Herzog W. Microstructural damage in arterial tissue exposed to repeated tensile strains. J Manipulative Physiol Ther. Jan 2010;33(1):14-19.

Wuest S, Symons B, Leonard T, Herzog W. Preliminary report: biomechanics of vertebral artery segments C1-C6 during cervical spinal manipulation. J Manipulative Physiol Ther. May 2010;33(4):273-278.

Symons B, Wuest S, Leonard T, Herzog W. Biomechanical characterization of cervical spinal manipulation in living subjects and cadavers. J Electromyogr Kinesiol. Oct 2012;22(5):747-751.

Herzog W, Leonard TR, Symons B, Tang C, Wuest S. Vertebral artery strains during high-speed, low amplitude cervical spinal manipulation. J Electromyogr Kinesiol. Oct 2012;22(5):740-746.

Thomas LC, Rivett DA, Bateman G, Stanwell P, Levi CR. Effect of selected manual therapy interventions for mechanical neck pain on vertebral and internal carotid arterial blood flow and cerebral inflow. Phys Ther. Nov 2013;93(11):1563-1574.

Quesnele JJ, Triano JJ, Noseworthy MD, Wells GD. Changes in vertebral artery blood flow following various head positions and cervical spine manipulation. J Manipulative Physiol Ther. Jan 2014;37(1):22-31.

Taylor AJ, Kerry R. The ‘vertebral artery test’. Manual therapy. Nov 2005;10(4):297; author reply 298.

Hutting N, Verhagen AP, Vijverman V, Keesenberg MD, Dixon G, Scholten-Peeters GG. Diagnostic accuracy of premanipulative vertebrobasilar insufficiency tests: a systematic review. Man Ther. Jun 2013;18(3):177-182.

Licht PB, Christensen HW, Hoilund-Carlsen PF. Is there a role for premanipulative testing before cervical manipulation? J Manipulative Physiol Ther. Mar-Apr 2000;23(3):175-179.

Magarey ME, Rebbeck T, Coughlan B, Grimmer K, Rivett DA, Refshauge K. Pre-manipulative testing of the cervical spine review, revision and new clinical guidelines. Manual therapy. May 2004;9(2):95-108.

Murphy DR. Current understanding of the relationship between cervical manipulation and stroke: what does it mean for the chiropractic profession? Chiropr Osteopat. 2010;18:22.

Chung CL, Cote P, Stern P, L’Esperance G. The Association Between Cervical Spine Manipulation and Carotid Artery Dissection: A Systematic Review of the Literature. J Manipulative Physiol Ther. Jan 3 2014.

Hurwitz EL, Morgenstern H, Harber P, Kominski GF, Yu F, Adams AH. A randomized trial of chiropractic manipulation and mobilization for patients with neck pain: clinical outcomes from the UCLA neck-pain study. Am J Public Health. Oct 2002;92(10):1634-1641.

Leaver AM, Maher CG, Herbert RD, et al. A randomized controlled trial comparing manipulation with mobilization for recent onset neck pain. Arch Phys Med Rehabil. Sep 2010;91(9):1313-1318.