Manual Therapy

Editorial Board

2012-06-01

Hands on, hands off? The swings in musculoskeletal physiotherapy practice

Gwendolen Jull, Ann Moore — 2012-06-01

There are swings and roundabouts in every sphere of life which are often driven by prevailing socioeconomic factors, societal needs and desires as well as an increase in knowledge or evidence base. This includes healthcare. Of interest in this instance is the conservative management of neck and back pain where in simple terms, the extremes are solely passive or solely active treatment approaches. In this context, we question whether it is time to steady the swing in musculoskeletal physiotherapy practice and offer ‘coffee time’ observations and comments.

The effectiveness of sub-group specific manual therapy for low back pain: A systematic review

2012-03-05

Abstract: Background: Manual therapy is frequently used to treat low back pain (LBP), but evidence of its effectiveness is limited. One explanation may be sample heterogeneity and inadequate sub-grouping of participants in randomized controlled trials (RCTs) where manual therapy has not been targeted toward those likely to respond.Objectives: To determine the effectiveness of specific manual therapy provided to sub-groups of participants identified as likely to respond to manual therapy.Data sources: A systematic search of electronic databases of MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled trials (CENTRAL).Trial eligibility criteria: RCTs on manual therapy for participants identified as belonging to a sub-group of LBP likely to respond to manual therapy were included.Trial appraisal and synthesis methods: Identified trials were assessed for eligibility. Data from included trials were extracted by two authors independently. Risk of bias in each trial was assessed using the PEDro scale and the overall quality of evidence rated according to the GRADE domains. Treatment effect sizes and 95% confidence intervals were calculated for pain and activity.Results: Seven RCTs were included in the review. Clinical and statistical heterogeneity precluded meta-analysis. Significant treatment effects were found favouring sub-group specific manual therapy over a number of comparison treatments for pain and activity at short and intermediate follow-up. However, the overall GRADE quality of evidence was very low.Conclusions: This review found preliminary evidence supporting the effectiveness of sub-group specific manual therapy. Further high quality research on LBP sub-groups is required.

Psychometric properties of the Pain Attitudes and Beliefs Scale for Physiotherapists: A systematic review

J.-H.A.M. Mutsaers, R. Peters, A.L. Pool-Goudzwaard, B.W. Koes, A.P. Verhagen — 2012-01-25

Abstract: Objective: Evidence suggests that care providers' attitudes influence their perception of patient characteristics and the way they manage their cases. Attitudes and beliefs of care providers can be measured with the Pain Attitude and Beliefs Scale for Physiotherapists (PABS-PT). This study evaluates the measurement properties of the PABS-PT.Methods: Databases (PubMed-Medline, Embase, Cinahl and Pedro) were searched for studies on the development or evaluation of measurement properties of the PABS-PT. Methodological quality was assessed and rated using the COSMIN checklist and scoring system.Results: Of the 139 identified publications, 10 met the selection criteria. Most of the included studies had fair to excellent methodological quality scores. Positive results were found for internal consistency, construct validity, reliability and responsiveness. No psychometric data were found for the content validity and interpretability of the PABS-PT.Conclusion: The PABS-PT is still in a developmental stage. Results for the psychometric properties are promising, but content validity and interpretability need more study. The relationship between implicit and explicit attitudes, and their influence on test scores, remains unclear.

Can a functional postural exercise improve performance in the cranio-cervical flexion test? – A preliminary study

Alexi Beer, Julia Treleaven, Gwendolen Jull — 2012-02-10

Abstract: Deep cervical flexor (DCF) muscle impairment is common in patients with neck pain. Retraining function is often commenced with a motor relearning approach, requiring the patient to practice and hold a cranio-cervical flexion position in supine lying. Motor relearning requires multiple repetitions which is difficult to achieve if only exercising in supine. This preliminary study investigated the effects of training the DCF with a functional exercise: assumption of an upright lumbo-pelvic and spinal postural position, adding a neck lengthening manoeuvre. The exercise effect was evaluated by changes in sternocleidomastoid (SCM) muscle activity in the cranio-cervical flexion test (CCFT). Twenty subjects with neck pain were randomly assigned to an exercise or control group. The exercise group trained for two weeks. Pre and post-intervention, electromyographic (EMG) signals were recorded from the SCM muscles during the five stages of the CCFT. Results indicated that the exercise improved performance. SCM EMG signal amplitudes decreased across all CCFT stages, albeit significant only at the first and third stages of the test; 22 mmHg (p = 0.043) and 26 mmHg (p = 0.003). No differences were evident in the control group (all p > 0.05). There was no difference between groups for pain and disability measures. This initial study indicates that a postural exercise, convenient to perform during the working day, improves the pattern of SCM muscle activity in the CCFT. Whilst further research is necessary, these observations suggest the worth of such an exercise to augment other training in the rehabilitation of patients with neck pain.

Association between the serum levels of relaxin and responses to the active straight leg raise test in pregnancy

Nina K. Vøllestad, Peter A. Torjesen, Hilde Stendal Robinson — 2012-01-30

Abstract: There is a common belief that the laxity of pelvic joints increases in pregnancy. The hormone relaxin is suggested to be one of the most influential factors implementing this effect. Furthermore, increased laxity is assumed to induce pelvic girdle pain (PGP). The objectives were to examine the serum relaxin levels in pregnancy and to investigate whether relaxin levels relate to symptoms and clinical tests for PGP. Data from questionnaires, clinical tests and blood samples were collected once in pregnancy (gestation week 5–24) from 212 women. Serum from blood samples were analyzed by ELIZA to determine the concentration of relaxin. Self reported symptoms were assessed by Disability Rating Index (DRI) and pain intensity (VAS). Clinical examinations included Active Straight Leg Raise (ASLR) test and pain provocation tests. ANOVA was used to assess the effect of gestation age and multivariable statistics to examine the association between relaxin levels and the symptoms or responses to clinical tests.The serum levels of relaxin varied widely between individuals and were only marginally influenced by the gestation age. There was no association between gestation age and responses to clinical tests or pain intensity, but DRI increased with gestation age. Serum concentration of relaxin showed a significant association to positive score on the ASLR test, but no significant associations to responses to pain provocation tests, pain intensity or DRI.The results indicate that relaxin contributes to laxity of pelvic joints in pregnancy. Yet, no evidence of relaxin having an impact on symptoms or perceived disability was found.

Comparison of hip rotation range of motion in judo athletes with and without history of low back pain

2012-01-27

Abstract: This study compared hip rotation range of motion in judo athletes with and without a history of low back pain. Forty-two athletes (22 males) were divided into two groups: 21 with history of low back pain (HLBP) and 21 without history of low back pain (Control). Internal and external hip rotation range of motion in active and passive movement were measured using computed photogrammetry. The HLBP group exhibited a significant reduction in active internal rotation (27.5 ± 6.5° vs 38.2 ± 6.5°), active total rotation (80.1 ± 9.5° vs 87.4 ± 7.9°) of the non-dominant limb (P < 0.01) and active total rotation (82.6 ± 7.6° vs 87.6 ± 9.8°; P = 0.04) in comparison with the control group. In passive rotation, the HLBP group showed a significant reduction in internal rotation of the dominant (41.9 ± 6.1° vs 46.1 ± 8.4°; P = 0.04) and non-dominant limb (37.1 ± 8.4° vs 47.3 ± 7.6°; P < 0.001), total rotation of the non-dominant limb (96.7 ± 10.2° vs 105.1 ± 11°; P = 0.005) and total rotation (98.5 ± 9.2° vs 105 ± 11.2°; P = 0.02). Within the HLBP group, a significant reduction in both active and passive internal rotation (P < 0.001) and active and passive total rotation (P < 0.01) of the non-dominant limb was detected. The same was not found in the control group. The results demonstrate that judo athletes with a history of low back pain exhibit deficits in hip rotation and greater asymmetry between limbs.

Experimentally induced pain alters the EMG activity of the lumbar multifidus in asymptomatic subjects

2012-02-17

Abstract: Lumbar musculature plays an important role in stabilization during functional movements such as walking, bending and overhead activities. Current research has focused on the lumbar multifidus (LM) muscle to determine if altered activity of the LM may contribute to low back pain (LBP). Therefore, the purpose of this study was to determine whether experimentally induced LBP affects deep LM muscle activity during functionally oriented tasks, weight shifting and upper extremity lifting. Intramuscular electromyography (EMG) activity of the LM at L4 was measured in 17 healthy adults during a dominant side shoulder flexion and extension task and during a staggered-stance weight shift task. Data were collected at baseline, after pain was induced with hypertonic saline and after the pain had subsided. Comparisons of within-subjects effects were performed with the use of a two-way repeated-measure ANOVA. A significantly higher magnitude of activity was found in the induced pain condition as compared to the baseline condition for the shoulder extension phase of the upper extremity task (p = 0.04). During forward weight shifting, lower values in both the induced pain (p = 0.02) and the recovery conditions (p = 0.01) were measured. During backward weight shifting, lower values were measured during the recovery condition as compared to baseline (p = 0.03). Across trials and subjects the EMG amplitudes were increased during the extension phase of the upper extremity task and decreased during the weight shifting task. These results suggest that the LM does not respond to induced pain in the same manner during different phases of functionally oriented tasks.

Comparison of force development strategies of spinal manipulation used for thoracic pain

Edward D.J. Cambridge, John J. Triano, J. Kim Ross, Melanie S. Abbott — 2012-03-05

Abstract: Introduction: To date, there is a paucity of comparative analysis of manual therapeutic procedures for the treatment of pain in the same spinal region. This paper examines the cross correlation of force-time histories across three distinct strategies of force production for the same thoracic spine procedure. Secondary analysis includes examination of the characteristics that account for potential differences.Methods: A homogeneous sample of 21 male volunteers and three clinicians were selected as a convenience sample. The force-time histories were recorded using a table mounted force plate (AMTI model number OR6-7-2000, London, ON), and cross-correlation analysis was applied by strategy type, for analysis between group data. Secondary parameters included: peak force, preload force, slope of the thrust, instantaneous loading rate and thrust duration, of the total force magnitude.Results: Primary results indicate strong correlations among all strategies but with notably different cross-correlation coefficients (0.894 ≤ r ≤ 0.946) based on individual comparisons. Classical descriptive components of the force-time curves (e.g. preload, peak force, slope) for each strategy group were examined. Significant differences in the raw data were noted on slope and loading rate (adjusted p < 0.01). One strategy of force development was significantly different from the others in four of the five characteristics. The effects of clinician stature were evaluated by normalizing force to body mass.Conclusion: Quantitative biomechanical differences in procedures may be responsible for differences in outcomes based on the method of treatment selected. This data set begins a basis for translational research to assist in identifying populations of thoracic spine pain patients for whom one procedure or other may be more effective.

Clinical reasoning and patient-centred care in musculoskeletal physiotherapy in Portugal – A qualitative study

Eduardo B. Cruz, Ann Moore, Vinette Cross — 2012-03-05

Abstract: Clinical reasoning has been described as a common process that underpins the myriad of tasks in the clinicians' practice. To date clinical reasoning models have emerged from research developed in specific and well-developed health care and professional cultures, such as those in Australia and the United States, but there has been little discussion of their relevance and applicability to other cultural settings. The aim of this investigation was to explore clinical reasoning processes in a sample of experienced Portuguese musculoskeletal physiotherapists. The study focused on clinicians' interaction with their patients in order to define and manage clinical problems. Data were collected through non-participant observation, semi-structured interviews, memos and field notes, and analysed thematically to explore and interpret clinical practice and reasoning. Findings highlighted that the clinicians were more likely to carry out their reasoning approach as a purely cognitive and clinician centred process. Perspectives of clinical reasoning therefore differ between cultures and contexts of practice and this has potential implications in the way physiotherapists interpret health and illness, their role as clinicians, as well as the patient–physiotherapist relationship.

Bilateral leg symptoms – The T10 syndrome?

Wouter Kristiaan Geerse — 2011-09-23

Abstract: Prior studies have investigated the role of the sympathetic nervous system and the thoracic spine related to the upper extremities (known as the T4 syndrome). However, there is only little known about the role of the thoracic spine related to the lower extremities. In this case report, a patient with a heavy, tired feeling in both legs and hypomobile thoracic segments was treated with passive mobilisations of the thoracic spine.

Neck-shoulder pain and weakness: An uncommon presentation

Hilla Sarig Bahat, Hilla Eshkol Izrael — 2011-10-10

Abstract: Neck and shoulder pain is a very common complaint in Western society that most often does not include motor compromise. Although peripheral nerve injuries are not as common, they should not be misdiagnosed. This case report describes the subjective assessment and physical examination of a patient with neck-shoulder pain and disabilities following a cervicofacial lift surgery. The patient was referred to physiotherapy treatment for what was diagnosed as a multi-level cervical disorder. Physical examination by the physiotherapist revealed diagnostic signs of accessory and suprascapular nerve injury as the cause of the shoulder impairment. Physiotherapy treatment included electrical motor stimulation and a comprehensive strengthening program, which resulted in full recovery.The purpose of this case study is to differentiate this presentation from commonly seen neck and shoulder pain by exploring the diagnostic factors for accessory and suprascapular nerve injury, based on the available evidence. The presented case report aims to raise the awareness of clinicians about the potential risk of peripheral nerve injury following cervicofacial lift, a common and elective surgical procedure.

Manual palpation of lumbo-pelvic landmarks: A validity study

Julia Kilby, Nicola R. Heneghan, Mark Maybury — 2011-09-26

Abstract: Manual palpation (MP) is commonly used for the assessment of patients with neuromusculoskeletal dysfunction. During assessment of lumbo-pelvic disorders in particular, it may be used not only to explore pain and resistance in the region, but also to evaluate the symmetry and movement quality of the area. Whilst reliability of MP has been extensively investigated, its validity remains relatively under researched. The aim of this study was to explore the accuracy of MP of lumbo-pelvic bony points. Ultrasound images of three bony landmarks [4th lumbar spinous process (L4), left and right posterior superior iliac spines (PSIS)] were acquired from models (n = 3) in the prone position and the points marked with an ultra-violet (UV) pen. Nine musculoskeletal physiotherapists were asked to identify the bony landmarks using MP. Measurements (mms) were taken between the UV marks and the palpators’ marks. The mean error (standard deviation) (mm) for MP of L4, LPSIS, RPSIS were 15.63 (3.89), 20.07 (4.60), 20.59 (2.79) respectively. Bland and Altman analysis gave a mean value of 0.173, with 95% limits of agreement ranging from −27.8 to 26.3. This study suggests that MP of specific lumbo-pelvic bony points has limited validity.

Reliability and accuracy of visual assessment: Can osteopaths reliably assess lateral anatomical landmarks of standing subjects?

Elise Pattyn, Dévan Rajendran — 2012-03-19

Visual assessment of posture and landmark position informs differential diagnosis. No study has assessed reliability and validity of this procedure. To a) assess reliability of visually rating anatomical landmarks (lateral malleolus, lateral femoral epicondyle, greater trochanter, mastoid process and acromion) on side-view photographs of anonymised subjects; b) assess inter-rater reliability when these landmarks are highlighted; c) investigate differences in reliability score between individual landmarks; d) measure the validity of this procedure.

Biomedical acupuncture for sports and trauma rehabilitation

Jason Porr — 2012-01-30

For many western healthcare professionals, Traditional Chinese Acupuncture can be both confusing and frustrating, which has lead to the anatomically and physiologically based Western Medical Acupuncture. The text Biomedical Acupuncture for Sports and Trauma Rehabilitation presents an approach to dry needling techniques that amalgamates these two distinct views on acupuncture. This book has been written for any medical professional trained in acupuncture, with the intent that once the proper understanding of the physiological mechanisms underlying dry needling have been understood, the technique can be adapted for a variety of practice styles and techniques.

Which types of stretching modifies biomechanical dimensions of a muscle-tendon unit?

Vikram Mohan, Srijit Das — 2012-02-01

We enjoyed reading the published article entitled ‘The effects of dynamic stretching on plantar flexor muscle-tendon tissue properties’ by . The authors presented an interesting article on the biomechanical properties of the muscle following a dynamic stretching on the plantar flexors group of muscle. Stretching is considered as one of the integral part of any exercise program. In the present study, stretching was incorporated as a dynamic form to know the displacement of the Myotendinous junction (MTJ) as well as on other dimensions of the muscle-tendon unit.

Which types of stretching modifies biomechanical dimensions of a muscle-tendon unit? Authors reply

Mina Samukawa — 2012-03-01

I really appreciate the authors of this letter for their constructive comments on our paper. Although the authors express their concerns about the resemblance of the results of our study (), which described the effects of dynamic stretching, to those of the study by , which tested static stretching effects, there are in fact several major differences between them. Although both studies examined the effects of stretching on plantar flexor muscle-tendon tissue properties by use of ultrasound, the displacement of the muscle tendinous junction (MTJ) occurred in opposite directions after stretching. In our research, the MTJ displacement occurred in the proximal direction, which indicated that the tendon length might have changed. Supporting this result, the pennation angle, muscle thickness, and fascicle length - all indicators of modified muscle length - were also unchanged. Therefore, the dynamic stretching used in our study was thought to affect tendon length, not muscle length. Conversely, distal MTJ displacement was found in the study of Nakamura et al., even though there was no significant change in fascicle length. They concluded that static stretch training might be related to MTU components other than muscle fiber length. Interestingly, although these 2 studies seem to have different results, both stretching programs may affect the biomechanical properties of muscle-tendon tissues. Another difference between the two studies that should be mentioned was that we reported the immediate effects whereas Nakamura et al. assessed after a 4-week period of static stretching training, so care should be taken when comparing the results. Other studies () have shown significant changes in MTJ displacement as well as in fascicle length immediately after static stretching, so the effects on the muscle-tendon unit might not endure.

Comments on the article by Jing-lan Yang et al. “Effectiveness of the end-range mobilization and scapular mobilization approach in a subgroup of subjects with frozen shoulder syndrome: A randomized control trial”, Manual Therapy 2012; 17 (1): 47–52

Amrita S. Raghoenath, Jantine Scheele, Arianne P. Verhagen — 2012-01-27

With interest we read the article of Yang et al. about the end-range mobilization and scapular mobilization approach (). It is interesting to evaluate whether a subgroup of subjects with frozen shoulder syndrome will benefit from the end-range mobilization/scapular mobilization treatment approach (EMSMTA). However, a few questions about the control-group, the number of patients and their characteristics and the measurements remain unanswered.

Response letter to "Effectiveness of the End-Range Mobilization and Scapular Mobilization Approach in a Subgroup of Subjects with Frozen Shoulder Syndrome: A Randomized Control Trial"

Jiu-jenq Lin, Jing-lan Yang, Mei-Hwa Jan, Chein-wei Chang — 2012-03-09

Thank you for the interest and questions about our article. Our study evaluated the end-range mobilization and scapular mobilization in subjects with frozen shoulder. The rationale for our study was to validate our prediction rule (). In this study, we identified patients who were most likely to benefit and those who respond poorly to general physical therapy treatments. The subjects with severe loss of motion were those who respond poorly to general physical therapy treatments. Thus, specific end-range mobilization and scapular mobilization were evaluated in a randomized control trial. Additionally, the subjects with less loss of motion who were likely to benefit from general physical therapy treatments were also evaluated in our investigation.