Development of a Clinical Prediction Rule to Identify Patients with Neck Pain likely to benefit from Cervical Spine Manipulation and a Range of Motion Exercise

Background: Patients with primary reports of neck pain often present with impairments of mobility, proprioception and motor control within the cervical spine, and these impairments can negatively impact patient outcomes. Cervical spine manipulation (CSM), which involves the use of thrust techniques, has been shown to be effective for some patients presenting with a primary report of neck pain. It would be useful for clinicians to have a decision making tool, such as a clinical prediction rule (CPR), that could accurately identify that subgroup of patients that would respond dramatically to CSM. The purpose of this project was to develop that CPR. Research Design and Methods: A prospective, cohort study of consecutive patients referred to physical therapy with a primary complaint of neck pain. Eligible patients who consented to participate completed a series of self-report measures, and then received a detailed standardized history and physical examination consisting of a variety of factors commonly used to assess patients with neck pain. Regardless of the results of the clinical examination, all patients received a standardized treatment regimen consisting of CSM and exercise. Depending on response to treatment, patients were treated for one to two treatment sessions over approximately 1 week. At the end of their participation in the study, patients were classified as having experienced a successful outcome or not based on a well-accepted patient-reported reference standard of success, the Global Rating of Change Scale. Analysis: Sensitivity, specificity, and positive and negative likelihood ratios were calculated for all potential predictor variables. Univariate techniques and step-wise logistic regression were used to determine the most parsimonious set of variables for prediction of treatment success. Variables retained in the regression model were used to develop a multivariate CPR to identify patients with neck pain likely to benefit from CSM. Results: Eighty-two patients were included in data analysis of which 32 (39%) had achieved a successful outcome. A CPR with 4 variables (symptom duration \u3c 38 days, positive expectation that manipulation will help, difference in cervical rotation range of motion to either side ¡Ý 10 degrees, and pain with spring (PA) testing of the middle cervical spine) was identified. If 3 of the 4 variables (+LR 13.5) were present the chance of experiencing a successful outcome improved from 39% to 90%. Discussion: The CPR should improve decision-making for patients with neck pain by providing the ability to a priori identify patients with neck pain who are likely to benefit from CSM and exercise. However, this is only the first step in the process of developing and testing a CPR as future studies will be necessary to validate the results and should also include long-term follow-up and a comparison group to further examine the predictive value of the variables identified in the CPR