Manual Therapy

Editorial Board

2012-02-01

Editorial

Ann Moore, Gwen Jull — 2012-02-01

Happy New Year for all our readers. As we move into 2012 we can look forward to an interesting and stimulating year. For example, we have been witnessing the work and indeed debate on important future clinical directions for the management of spinal disorders in particular. 2012 will undoubtedly see more work published on areas such as sub-grouping, classification schemes and clinical prediction rules. Some promising work has been done and future work must identify clearly the populations to whom these clinical methodologies best apply and indeed do not apply. As well, the evidence must be strengthened to present their true worth to improve patient outcomes against more traditional assessment and management approaches. Equally, patient centeredness and the needs of the individual and relevant others require deeper research in the musculoskeletal field. The role and outcomes of quality qualitative research will, we predict, further increase in 2012, which stands to increase the value and relevance of care.

Strain counterstrain: Current concepts and clinical evidence

Christopher Kevin Wong — 2011-10-26

Abstract: Strain counterstrain is an osteopathic manipulative technique about which research is only recently emerging. This master class reviews the evidence investigating proposed physiologic mechanisms and clinical effects of strain counterstrain. Clinical application guidelines are presented with specific treatments for key clinical scenarios.

Clinical prediction rules in the physiotherapy management of low back pain: A systematic review

Robin Haskins, Darren A. Rivett, Peter G. Osmotherly — 2011-06-06

Abstract: Objective: To identify, appraise and determine the clinical readiness of diagnostic, prescriptive and prognostic Clinical Prediction Rules (CPRs) in the physiotherapy management of Low Back Pain (LBP).Data sources: MEDLINE, EMBASE, CINAHL, AMED and the Cochrane Database of Systematic Reviews were searched from 1990 to January 2010 using sensitive search strategies for identifying CPR and LBP studies. Citation tracking and hand-searching of relevant journals were used as supplemental strategies.Study selection: Two independent reviewers used a two-phase selection procedure to identify studies that explicitly aimed to develop one or more CPRs involving the physiotherapy management of LBP. Diagnostic, prescriptive and prognostic studies investigating CPRs at any stage of their development, derivation, validation, or impact-analysis, were considered for inclusion using a priori criteria. 7453 unique records were screened with 23 studies composing the final included sample.Data extraction: Two reviewers independently extracted relevant data into evidence tables using a standardised instrument.Data synthesis: Identified studies were qualitatively synthesized. No attempt was made to statistically pool the results of individual studies. The 23 scientifically admissible studies described the development of 25 unique CPRs, including 15 diagnostic, 7 prescriptive and 3 prognostic rules. The majority (65%) of studies described the initial derivation of one or more CPRs. No studies investigating the impact phase of rule development were identified.Conclusions: The current body of evidence does not enable confident direct clinical application of any of the identified CPRs. Further validation studies utilizing appropriate research designs and rigorous methodology are required to determine the performance and generalizability of the derived CPRs to other patient populations, clinicians and clinical settings.

Intra-individual variations in the bifurcation of the radial nerve and the length of the posterior interosseous nerve

2011-09-07

Abstract: Anatomical literature on the radial nerve predominantly features inter-individual variations, with comparatively few studies investigating intra-individual variations. The radial nerve has a complex and variable course, particularly in relation to the location at which the nerve bifurcates to form the superficial branch of the radial nerve and the posterior interosseous nerve. Variations of the radial nerve may change the way the nerve and its branches, their blood supply and nerve transmission respond to forces. This study investigated the presence of intra-individual differences in the bifurcation point of the radial nerve and the length of the posterior interosseous nerve from the bifurcation to the radial tunnel. Eighteen embalmed human cadavers were dissected to reveal the radial nerve. Measurements were taken from the level of the lateral humeral epicondyle to the bifurcation of the radial nerve, and from the bifurcation to the radial tunnel. All cadavers presented with intra-individual variations between the left and right limbs. Significant differences were found between the left and right limbs for the measurement from the lateral humeral epicondyle to the bifurcation (median difference = 18.0 mm; p = 0.016) but not for the measurement from the bifurcation to the radial tunnel (median difference = 7.0 mm; p = 0.396). In conclusion, the location of the radial nerve bifurcation is subject to both intra- and inter-individual variations. Its specific relationship to the lateral humeral epicondyle also varies, occurring both distal and proximal to the level of the epicondyle. Clinical implications of these findings warrant further investigation.

The relationships between measures of stature recovery, muscle activity and psychological factors in patients with chronic low back pain

Sandra Lewis, Paul Holmes, Steve Woby, Jackie Hindle, Neil Fowler — 2011-09-07

Abstract: Individuals with low back pain (LBP) often exhibit elevated paraspinal muscle activity compared to asymptomatic controls during static postures such as standing. This hyperactivity has been associated with a delayed rate of stature recovery in individuals with mild LBP. This study aimed to explore this association further in a more clinically relevant population of NHS patients with LBP and to investigate if relationships exist with a number of psychological factors. Forty seven patients were recruited from waiting lists for physiotherapist-led rehabilitation programmes. Paraspinal muscle activity while standing was assessed via surface electromyogram (EMG) and stature recovery over a 40-min unloading period was measured on a precision stadiometer. Self-report of pain, disability, anxiety, depression, pain-related anxiety, fear of movement, self-efficacy and catastrophising were recorded.Correlations were found between muscle activity and both pain (r=0.48) and disability (r=0.43). Muscle activity was also correlated with self-efficacy (r=−0.45), depression (r=0.33), anxiety (r=0.31), pain-related anxiety (r=0.29) and catastrophising (r=0.29) and was a mediator between self-efficacy and pain. Pain was a mediator in the relationship between muscle activity and disability. Stature recovery was not found to be related to pain, disability, muscle activity or any of the psychological factors. The findings confirm the importance of muscle activity within LBP, in particular as a pathway by which psychological factors may impact on clinical outcome. The mediating role of muscle activity between psychological factors and pain suggests that interventions that are able to reduce muscle tension may be of particular benefit to patients demonstrating such characteristics, which may help in the targeting of treatment for LBP.

Reliability and smallest real difference of the ankle lunge test post ankle fracture

David Simondson, Kim Brock, Susan Cotton — 2011-09-28

Abstract: This study aimed to determine the reliability and the smallest real difference of the Ankle Lunge test in an ankle fracture patient population.In the post immobilisation stage of ankle fracture, ankle dorsiflexion is an important measure of progress and outcome. The Ankle Lunge test measures weight bearing dorsiflexion, resulting in negative scores (knee to wall distance) and positive scores (toe to wall distance), for which the latter has proven reliability in normal subjects only.A consecutive sample of ankle fracture patients with permission to commence weight bearing, were recruited to the study. Three measurements of the Ankle Lunge Test were performed each by two raters, one senior and one junior physiotherapist. These occurred prior to therapy sessions in the second week after plaster removal. A standardised testing station was utilised and allowed for both knee to wall distance and toe to wall distance measurement.Data was collected from 10 individuals with ankle fracture, with an average age of 36 years (SD 14.8). Seventy seven percent of observations were negative. Intra and inter-rater reliability yielded intra class correlations at or above 0.97, p < .001. There was a significant systematic bias towards improved scores during repeated measurement for one rater (p = .01). The smallest real difference was calculated as 13.8mm.The Ankle Lunge test is a practical and reliable tool for measuring weightbearing dorsiflexion post ankle fracture.

Use of ultrasound imaging by physiotherapists: A pilot study to survey use, skills and training

Catherine L. Potter, Mindy C. Cairns, Maria Stokes — 2011-09-28

Abstract: Objective: This study aimed to design and pilot a questionnaire to survey the use of ultrasound imaging (USI) by physiotherapists in the United Kingdom (UK), the type and content of ultrasound training physiotherapists using USI had undertaken and their perceived future training needs.Background: The use of USI by physiotherapists is becoming increasingly common but is highly operator dependent and there are safety and professional issues regarding use in physiotherapy practice. Currently there are no specific training guidelines relating to physiotherapists using USI.Methods: A questionnaire was developed, based on research literature and guidelines. Twelve experts in USI commented on the content and design. The electronic on-line questionnaire was piloted on groups that were likely to be users of USI.Results: Forty-six respondents completed the questionnaire. Results indicated that USI is used predominantly for biofeedback and there are many unmet training needs. Respondents reported a mismatch between techniques for which they had received training and those that they used in practice and indicated a more structured training framework is required.Conclusions: The development and piloting of the questionnaire provides a starting point for a more extensive evaluation of how USI is being used, the training needs of physiotherapists and benefits as a biofeedback tool. Refinement is needed and replication in a larger sample. Results could assist the development of a structured formal training framework encompassing key skills.

Effectiveness of the end-range mobilization and scapular mobilization approach in a subgroup of subjects with frozen shoulder syndrome: A randomized control trial

Jing-lan Yang, Mei-Hwa Jan, Chein-wei Chang, Jiu-jenq Lin — 2011-09-26

Abstract: Treatment strategies targeting abnormal shoulder kinematics may prevent pathology or if the pathology develops, shorten its duration. We examined the effectiveness of the end-range mobilization/scapular mobilization treatment approach (EMSMTA) in a subgroup of subjects with frozen shoulder syndrome (FSS). Based on the kinematics criteria from a prediction method, 34 subjects with FSS were recruited. Eleven subjects were assigned to the control group, and 23 subjects who met the criteria were randomly assigned to the criteria-control group with a standardized physical therapy program or to the EMSMTA group. Subjects attended treatment sessions twice a week for 8 weeks. Range of motion (ROM), disability score, and shoulder complex kinematics were obtained at the beginning, 4 weeks, and 8 weeks. Subjects in the EMSMTA group experienced greater improvement in outcomes compared with the criteria-control group at 4 weeks (mean difference=0.2 of normalized hand-behind-back reach) and 8 weeks (mean difference=22.4 degrees humeral external rotation, 0.31 of normalized hand-behind-back reach, 7.5 disability, 5 degrees tipping and 0.32 rhythm ratio). Similar improvements were found between the EMSMTA group and control group. The EMSMTA was more effective than a standardized physical therapy program in a subgroup of subjects who fit the criteria from a prediction method.

Range of motion in the upper and lower cervical spine in people with chronic neck pain

Thomas Rudolfsson, Martin Björklund, Mats Djupsjöbacka — 2011-09-27

Abstract: Reduced cervical range of motion (ROM) is a common finding in people with neck pain. With few exceptions, only the angle between head and thorax has been measured. Our aim was to use an extended model to compare active cervical flexion and extension, separate for upper and lower cervical levels, between people with chronic non-traumatic neck pain and controls. We also investigated associations between ROM measures, symptoms and self-rated functioning.In this cross-sectional study, 102 subjects with neck pain and 33 healthy controls participated. An electromagnetic tracker system was used to measure the kinematics to construct a three-segment model including the thorax, cervical spine and head. Neutral flexion/extension were defined at subjects’ self-selected seated posture.We found that in the neck pain group, extension in the upper cervical levels and predominately flexion for the lower levels were reduced. The ratio between ROM for the upper and lower levels was altered in the neck pain group so that the lower levels contributed to a lesser extent to the total sagittal ROM compared to controls. These findings could not be explained by a greater forward head posture but must have other origins. For the neck pain group, ROM measures were weakly associated to pain and self-rated functioning. Altogether, this implies that using a three-segment model for assessment of ROM can be a valuable improvement for characterisation of patients and treatment evaluation.

Two different courses of impaired cervical kinaesthesia following a whiplash injury. A one-year prospective study

Gudny Lilja Oddsdottir, Eythor Kristjansson — 2011-09-28

Abstract: A longitudinal study was conducted to observe persons with neck pain after motor vehicle collisions. The aims were to reveal the prospective development of cervical kinaesthesia and to investigate the association between the test results and self-reported pain and disabilities. Two different cervical kinaesthetic tests, the Fly test and the Head-Neck Relocation test, measured movement control and the relocation accuracy of the cervical spine, respectively. Self-assessment measures included pain intensity (VAS), neck pain and disability (NDI), fear of re-injury (TAMPA) and psychological distress (GHQ-28). Seventy-four subjects entered the study, but 47 were eligible, as they participated in all 4 measurements at 1, 3, 6 and 12 months post-collision. According to the performances on the two kinaesthetic tests, the subjects could be classified into improvement and non-improvement groups, respectively. The result revealed, for the first time, two different courses of deficient cervical kinaesthesia. About half of the participants showed significant deteriorating performances in both kinaesthetic tests throughout the year (p < 0.002), while the other half improved their performances (p < 0.02). Generally, the relationships between the kinaesthetic tests and the self-assessment scores were not significant, irrespective of the performances on the two kinaesthetic tests. Accordingly, the results of the questionnaires correlated poorly or weakly with the kinaesthetic test results at all assessment points. The need for developing a new questionnaire, capturing the symptoms prevalent in patients with neck pain and cervical sensorimotor impairments is urgent. What determines the two different kinaesthetic courses need to be scrutinised in future research.

Deformation of the innominate bone and mobility of the pubic symphysis during asymmetric moment application to the pelvis

Annelies Pool-Goudzwaard, Rafael Gnat, Kees Spoor — 2011-10-24

Abstract: Background: Angular motions of human joints are frequently accompanied by bony deformations. In the case of the pelvis it is unknown how much deformation within the innominate and movement within pelvic joints will occur during an asymmetrical loading. Deeper insight into this topic could help to increase the understanding of the biomechanics of the pelvis during e.g. locomotion and improve interpretation of clinical tests in which manual force is asymmetrically applied to the pelvic bones.Objective: To test the occurrence of deformation within the innominate and movement within the pubic symphysis during asymmetric moment application to the pelvis.Methods: In 15 embalmed specimens an incremental moment was applied to one innominate bone in the sagittal plane with respect to the fixated contralateral innominate. The three-dimensional (3D) deformation within the fixated innominate, as well as displacement of the pubic symphysis, were described during each increment of the moment. Maximal amount of deformation within the fixated innominate was compared with displacement in the pubic symphysis and tested for significant difference for all subjects and separately by gender.Results: Mean range of 3D deformation of the innominate bone (3.39 ± 2.92 mm) is comparable to the range of symphysis motion (3.20 ± 2.58 mm; p > 0.05). Largest deformation within the innominate was present in the transverse plane (1.41 ± 3.1 mm). Significant differences (p < 0.01) occured in the mobility of the pubic symphysis between male and female specimens. No significant gender differences were present in the deformation of the innominate bone.Conclusions: During asymmetrical loading both movement within the pubic symphysis as well as deformation within the innominate occur simultaneously. Deformation of the innominate is the largest in the transverse plane.

Inter-tester reliability of non-invasive technique for measurement of innominate motion

2011-11-28

Abstract: Although the complex anatomical orientation and position of the sacroiliac joints (SIJ) has rendered their 3D kinematic evaluation difficult, recent techniques of palpation–digitization of pelvic landmarks using electromagnetic tracking device have been able to accurately and non-invasively quantify the subtle SIJ kinematics. While this technique demonstrates radiographic validity and high test-retest reliability, it is yet to be assessed with regards to inter-tester and trial-to-trial reliability. A single-group repeated measure design using 4 testers was conducted to evaluate the inter-tester and trial-to-trial reliability of palpation–digitization technique for innominate vector length measurements using the Polhemus electromagnetic tracking device. Fourteen young, healthy adults between the ages of 18–40 years participated in the study. The innominate vector length was calculated from 3D co-ordinates of palpated and digitized pelvic landmarks in two test positions of hip. A sensitivity analysis was conducted to determine how palpation–digitization errors for pelvic landmarks impacts on innominate angle calculation. Reliability indexes of Intraclass correlation coefficient (ICC) (≥0.97) and Standard error of measurement (SEM) (≤2.02 mm) demonstrated very high inter-tester and trial-to-trial reliability and accuracy of palpation–digitization technique for innominate vector length measurements, irrespective of the two test positions. A higher consistency of measurements was obtained within-testers as compared to between testers, and sensitivity analysis demonstrated a negligible influence of palpation–digitization errors on the innominate angle measurements. The results support clinical and research utility of this technique for non-invasive kinematic evaluation of SIJ motion for this population. Further research on the use of this palpation–digitization technique in symptomatic population is warranted.

Towards monitoring lumbo-pelvic posture in real-life situations: Concurrent validity of a novel posture monitor and a traditional laboratory-based motion analysis system

2011-10-20

Abstract: Many factors are associated with low back pain (LBP), including provocative spinal postures. Consequently, lumbo-pelvic posture is commonly assessed in LBP patients. A novel wireless monitor (BodyGuard™) can monitor lumbo-pelvic sagittal plane movements reliably, and has demonstrated concurrent validity during non-functional tasks.This study evaluated the concurrent validity of this monitor during functional tasks, as a precursor to LBP field studies. Twelve painfree participants performed a series of postural tasks (in sitting and standing) three times. Simultaneous postural measurements were obtained by the wireless monitor and a laboratory-based system (CODA™).Postural measurements were strongly correlated (rs = 0.88, r2 = 0.78). The mean difference observed was small (<10% lumbo-pelvic ROM), however some tasks displayed greater error.The results support the concurrent validity of the wireless monitor for analysing lumbo-pelvic posture during functional tasks. Specific limitations of the monitor for certain postural tasks were identified, and should be considered before implementation in future field studies.

Novel use of a manual therapy technique and management of a patient with peroneal tendinopathy: A case report

Craig P. Hensley, Alicia J. Emerson Kavchak — 2011-05-16

Abstract: Peroneal tendinopathy is an uncommon but underappreciated source of lateral hindfoot pain and dysfunction. There is a paucity of literature describing optimal intervention for those suffering with pain secondary to peroneal tendinopathy. The purpose of this case report is to describe the evaluation and treatment incorporating manual therapy and therapeutic exercise for a patient diagnosed with peroneal tendinopathy. The patient was a 50 year-old female with a history of chronic lateral ankle pain and whose presentation was consistent with peroneal tendinopathy. Despite attempts to improve pain and function with over-the-counter orthotics, manual therapy to a hypomobile talocrural joint, and strengthening of the peroneal tendons, successful response was not reported until a lateral calcaneal glide was added. Improvement in impairments (pain, talocrural dorsiflexion, unilateral heel raises, and Star Excursion Balance Test) and function (Lower Extremity Functional Scale and Global Rating of Change), were observed over a course of eight visits. The patient was able to return to work and her recreational work out routine without limitations. In conclusion a successful physical therapy intervention for a patient with peroneal tendinopathy included a unique manual therapy technique, the lateral calcaneal glide, in conjunction with other manual therapy techniques and a structured home exercise program.

Continuing professional development: The missing link

Lucy S. Chipchase, Venerina Johnston, Phillip D. Long — 2011-10-24

Abstract: Attending formal course-based learning forms a major part of continuing professional development for physiotherapists. There is a vast array of formal courses available to physiotherapists each holding the tantalising prospect of improving knowledrge, skills and patient outcomes. However, educational evidence suggests that, while participation in traditionally organised workshops and conferences improves knowledge and practice behaviours of the individual attendee, there is no corollary improvement in patient outcomes. This paper discusses reasons why formal course-based learning has yet to be successful at improving the patient outcomes of those who participate. Suggestions and strategies for reconceptualising this aspect of continuing professional development are provided.

Do inertial sensors represent a viable method to reliably measure cervical spine range of motion?

Peter S. Theobald, Michael D. Jones, Jonathan M. Williams — 2011-07-25

Abstract: A rise in neck pain cases has initiated an exponential interest in the assessment and treatment of cervical spine range of motion (CROM). Experimental limitations, however, have been reported as therapists strive to collect continuous, dynamic data to aid prognosis. This technical report seeks to explore the viability of using inertial sensors to reliably assess CROM. In recognition of the need for secure skin-sensor attachment, four combinations of sensor pairings were established and investigated based upon four clinically identifiable surface landmarks. Twelve participants were recruited and asked to perform three specific movement cycles in each plane (i.e. flexion–extension; rotation; lateral bending). The reliability of the peak CROM, and the movement pattern, recorded in each of the three movement cycles was statistically analysed using the intra-class correlation coefficient (ICC) and coefficient of multiple correlations (CMC). It was determined that the most reliable positions of the orientation sensors, with one adhered to the forehead and the other representing T4, enables data to be recorded with a reliability that is comparable to other CROM measuring techniques. Subsequently, it is concluded that inertial sensors represent a viable method to assess CROM.

Re: The use of RCT’s in manual therapy – Are we trying to fit a round peg into a square hole?

Chris Littlewood — 2011-06-27

I read the article ‘The use of RCT’s in manual therapy – are we trying to fit a round peg into a square hole?’ by with interest. As a profession we should welcome methodological debate as a means of developing physiotherapy practice. To this end, I am keen to seek further opinion from the author with regard to some of the comments made in the article.

Response to letter to the editor

Steve Milanese — 2011-08-02

I thank the writer for their comments on the article ‘The use of RCT’s in manual therapy – are we trying to fit a round peg into a square hole?’ and welcome their considered thoughts. The issues the writer raises encompasses the type of debate that needs to be undertaken within the manual therapy profession.