Manual Therapy

Editorial Board

2010-08-01

Systematic reviews assessing multimodal treatments

Gwendolen Jull, Ann Moore — 2010-06-01

Systematic reviews can consider either single modality or multimodal treatments in evaluating treatment effects for musculoskeletal disorders, in this case, neck pain. The Cochrane Collaboration Back Group is currently expressing a preference for focussing systematic reviews to single treatment approaches rather than combined therapies, as in the latter, it is impossible to isolate the individual effects of, for example, mobilisation or manipulation from the effects of the total treatment. While this is true and has scientific merit, the risk is loosing comparisons of combined care (i.e., mobilisation, manipulation and soft tissue techniques; manipulation or mobilisation plus other physical medicine agents; mobilisation and manipulation plus exercise) from the Cochrane Review. The concern for clinicians is that in real life practice, patients with neck pain often present with several problems within the biopsychosocial spectrum. Furthermore and not surprisingly, there is evidence from physiological studies and clinical trials that each of the multiple dimensions of a patient’s presentation does not automatically respond to a single treatment approach and hence multimodal approaches are the real life clinical practice and are increasingly, the type of intervention tested in contemporary clinical trials.

Thoracic outlet syndrome Part 2: Conservative management of thoracic outlet

L.A. Watson, T. Pizzari, S. Balster — 2010-04-12

Abstract: Thoracic outlet syndrome (TOS) is a symptom complex attributed to compression of the nerves and vessels as they exit the thoracic outlet. Classified into several sub-types, conservative management is generally recommended as the first stage treatment in favor of surgical intervention. In cases where postural deviations contribute substantially to compression of the thoracic outlet, the rehabilitation approach outlined in this masterclass will provide the clinician with appropriate management strategies to help decompress the outlet. The main component of the rehabilitation program is the graded restoration of scapula control, movement, and positioning at rest and through movement. Adjunctive strategies include restoration of humeral head control, isolated strengthening of weak shoulder muscles, taping, and other manual therapy techniques. The rehabilitation outlined in this paper also serves as a model for the management of any shoulder condition where scapula dysfunction is a major contributing factor.

Manipulation or mobilisation for neck pain: A Cochrane Review

2010-06-01

Abstract: Manipulation and mobilisation are often used, either alone or combined with other treatment approaches, to treat neck pain. This review assesses if manipulation or mobilisation improves pain, function/disability, patient satisfaction, quality of life (QoL), and global perceived effect (GPE) in adults experiencing neck pain with or without cervicogenic headache or radicular findings. A computerised search was performed in July 2009. Randomised trials investigating manipulation or mobilisation for neck pain were included. Two or more authors independently selected studies, abstracted data, and assessed methodological quality. Pooled relative risk (pRR) and standardised mean differences (pSMD) were calculated. 33% of 27 trials had a low risk of bias. Moderate quality evidence showed cervical manipulation and mobilisation produced similar effects on pain, function and patient satisfaction at intermediate-term follow-up. Low quality evidence suggested cervical manipulation may provide greater short-term pain relief than a control (pSMD −0.90 (95%CI: −1.78 to −0.02)). Low quality evidence also supported thoracic manipulation for pain reduction (NNT 7; 46.6% treatment advantage) and increased function (NNT 5; 40.6% treatment advantage) in acute pain and immediate pain reduction in chronic neck pain (NNT 5; 29% treatment advantage). Optimal technique and dose need to be determined.

Manual therapy and exercise for neck pain: A systematic review

2010-06-04

Abstract: Manual therapy is often used with exercise to treat neck pain. This cervical overview group systematic review update assesses if manual therapy, including manipulation or mobilisation, combined with exercise improves pain, function/disability, quality of life, global perceived effect, and patient satisfaction for adults with neck pain with or without cervicogenic headache or radiculopathy. Computerized searches were performed to July 2009. Two or more authors independently selected studies, abstracted data, and assessed methodological quality. Pooled relative risk (pRR) and standardized mean differences (pSMD) were calculated. Of 17 randomized controlled trials included, 29% had a low risk of bias. Low quality evidence suggests clinically important long-term improvements in pain (pSMD-0.87(95% CI:−1.69,−0.06)), function/disability, and global perceived effect when manual therapy and exercise are compared to no treatment. High quality evidence suggests greater short-term pain relief [pSMD-0.50(95% CI:−0.76,−0.24)] than exercise alone, but no long-term differences across multiple outcomes for (sub)acute/chronic neck pain with or without cervicogenic headache. Moderate quality evidence supports this treatment combination for pain reduction and improved quality of life over manual therapy alone for chronic neck pain; and suggests greater short-term pain reduction when compared to traditional care for acute whiplash. Evidence regarding radiculopathy was sparse. Specific research recommendations are made.

Adverse events and manual therapy: A systematic review

Dawn Carnes, Thomas S. Mars, Brenda Mullinger, Robert Froud, Martin Underwood — 2010-01-25

Abstract: Objective: To explore the incidence and risk of adverse events with manual therapies.Method: The main health electronic databases, plus those specific to allied medicine and manual therapy, were searched. Our inclusion criteria were: manual therapies only; administered by regulated therapists; a clearly described intervention; adverse events reported. We performed a meta-analysis using incident estimates of proportions and random effects models.Results: Eight prospective cohort studies and 31 manual therapy RCTs were accepted. The incidence estimate of proportions for minor or moderate transient adverse events after manual therapy was ∼41% (CI 95% 17–68%) in the cohort studies and 22% (CI 95% 11.1–36.2%) in the RCTs; for major adverse events ∼0.13%. The pooled relative risk (RR) for experiencing adverse events with exercise, or with sham/passive/control interventions compared to manual therapy was similar, but for drug therapies greater (RR 0.05, CI 95% 0.01–0.20) and less with usual care (RR 1.91, CI 95% 1.39–2.64).Conclusions: The risk of major adverse events with manual therapy is low, but around half manual therapy patients may experience minor to moderate adverse events after treatment. The relative risk of adverse events appears greater with drug therapy but less with usual care.

The effect of unilateral muscle pain on recruitment of the lumbar multifidus during automatic contraction. An experimental pain study

N. Dickx, B. Cagnie, T. Parlevliet, A. Lavens, L. Danneels — 2010-03-08

Abstract: Changes in control of the multifidus muscle are a likely contributor to low back pain (LBP), however, the underlying mechanisms of these changes are not well understood. To date it remains uncertain if pain has a selective effect on the multifidus muscles, in line with the observations of the selective changes in structure in acute LBP, or a more generalized effect.The objective of this study is to help to elucidate whether acute unilateral muscle pain alters the activation of the multifidus specific at the level and side of the pain or has a more widespread effect.An experimental pain protocol using hypertonic saline was applied to induce unilateral low back muscle pain. Automatic activity of the multifidus muscle during arm lifts was evaluated with dynamic ultrasound measurement, by assessing muscle thickness change during contraction. Multifidus activity of 15 healthy subjects was compared in a non-pain and in a pain condition, at different spinal levels (L3–L4–L5) and at both body sides.Unilateral induced pain at one segmental level reduced muscle thickness increase during contraction, at both body sides and at different lumbar levels.These results do suggest that unilateral pain may have a more widespread effect on multifidus muscle recruitment, affecting the left and right muscles, at different lumbar levels.

Pain catastrophizing predicts pain intensity during a neurodynamic test for the median nerve in healthy participants

Jason M. Beneciuk, Mark D. Bishop, Steven Z. George — 2010-04-01

Abstract: Psychological factors within the Fear-Avoidance Model of Musculoskeletal Pain (FAM) predict clinical and experimental pain in both symptomatic and asymptomatic individuals. Clinicians routinely examine individuals with provocative testing procedures that evoke symptoms. The purpose of this study was to investigate which FAM factors were associated with evoked pain intensity, non-painful symptom intensity, and range of motion during an upper-limb neurodynamic test. Healthy participants (n = 62) completed psychological questionnaires for pain catastrophizing, fear of pain, kinesiophobia, and anxiety prior to neurodynamic testing. Pain intensity, non-painful sensation intensity, and elbow range of motion (ROM) were collected during testing and served as dependent variables in separate simultaneous regression models. All the psychological predictors in the model accounted for 18% of the variance in evoked pain intensity (p = .02), with only pain catastrophizing (β = .442, p < .01) contributing uniquely to the model. Psychological predictors did not explain significant amounts of variance for the non-painful sensation intensity and ROM models. These findings suggest that pain catastrophizing contributed specifically to evoked pain intensity ratings during neurodynamic testing for healthy subjects. Although these findings cannot be directly translated to clinical practice, the influence of pain catastrophizing on evoked pain responses should be considered during neurodynamic testing.

Impact of order of movement on nerve strain and longitudinal excursion:A biomechanical study with implications for neurodynamic test sequencing

2010-04-02

Abstract: It is assumed that strain in a nerve segment at the end of a neurodynamic test will be greatest if the joint nearest that nerve segment is moved first in the neurodynamic test sequence. To test this assumption, the main movements of the median nerve biased neurodynamic test were applied in three different sequences to seven fresh-frozen human cadavers. Strain and longitudinal excursion were measured in the median nerve at the distal forearm. Strain and relative position of the nerve at the end of a test did not differ between sequences. The nerve was subjected to higher levels of strain for a longer duration during the sequence where wrist extension occurred first. The pattern of excursion was different for each sequence. The results highlight that order of movement does not affect strain or relative position of the nerve at the end of a test when joints are moved through comparable ranges of motion. When used clinically, different neurodynamic sequences may still change the mechanical load applied to a nerve segment. Changes in load may occur because certain sequences apply increased levels of strain to the nerve for a longer time period, or because sequences differ in ranges of joint motions.

Pain biology education and exercise classes compared to pain biology education alone for individuals with chronic low back pain: A pilot randomised controlled trial

Cormac G. Ryan, Heather G. Gray, Mary Newton, Malcolm H. Granat — 2010-04-01

Abstract: The aim of this single-blind pilot RCT was to investigate the effect of pain biology education and group exercise classes compared to pain biology education alone for individuals with chronic low back pain (CLBP). Participants with CLBP were randomised to a pain biology education and group exercise classes group (EDEX) [n = 20] or a pain biology education only group (ED) [n = 18]. The primary outcome was pain (0–100 numerical rating scale), and self-reported function assessed using the Roland Morris Disability Questionnaire, measured at pre-intervention, post-intervention and three month follow up. Secondary outcome measures were pain self-efficacy, pain related fear, physical performance testing and free-living activity monitoring. Using a linear mixed model analysis, there was a statistically significant interaction effect between time and intervention for both pain (F[2,49] = 3.975, p < 0.05) and pain self-efficacy (F[2,51] = 4.011, p < 0.05) with more favourable results for the ED group. The effects levelled off at the three month follow up point. In the short term, pain biology education alone was more effective for pain and pain self-efficacy than a combination of pain biology education and group exercise classes. This pilot study highlights the need to investigate the combined effects of different interventions.

Challenging presumptions: Is reciprocal inhibition truly reciprocal? A study of reciprocal inhibition between knee extensors and flexors in humans

Karen Hamm, Caroline M. Alexander — 2010-04-30

Abstract: Reciprocal inhibition (RI) between different muscles has been used as an explanation for the effect of some treatments. Consequently, there may be a presumption that RI is bi-directional and equal between every agonist antagonist muscle pair. That is, the strength of RI from agonist to antagonist is equal to that from antagonist to agonist. With this in mind we investigated RI between quadriceps and hamstrings using 2 techniques to explore if a) it is evoked between this agonist antagonist pair and b) if it is equal and opposite in strength. Firstly, electromygraphic (EMG) activity of one muscle was recorded whilst stimulating group Ia afferents from the other. The second approach involved conditioning a reflex evoked in one muscle by stimulating Ia afferents from the other. Using the first approach, short-latency inhibition thought to be RI, was observed more frequently (p<0.000) and was larger (p<0.05) from femoral nerve stimulation to hamstrings than the inhibition evoked in quadriceps by sciatic nerve stimulation. The second approach revealed a similar pattern. RI between quadriceps and hamstrings is not actually reciprocal i.e. not equal in both directions. Our presumptions about the frequency and strength of other pathways between different agonist antagonist pairs need to be assessed.

The clinical reasoning of musculoskeletal physiotherapists in relation to the assessment of vertebrobasilar insufficiency: A qualitative study

Aoife Sweeney, Catherine Doody — 2010-04-09

Abstract: The aim of this study was to investigate the clinical reasoning processes of physiotherapists in relation to the assessment of vertebrobasilar insufficiency (VBI).Using a qualitative multiple case studies design 12 physiotherapists (mean=12.89 years clinical experience, SD=3.44) with an MSc in Manipulative Physiotherapy were shown 2 patient vignettes of a cervical spine disorder and associated symptoms of VBI sequentially in 4 sections and questioned as to their clinical reasoning processes via audio taped semi-structured interviews. Transcripts of the interviews were analysed for common themes.The therapists’ hypothesis generation in relation to VBI was mainly based on the subjective examination (SE) with no new patho-anatomic hypotheses being generated in the physical examination. The major indicators of VBI involvement were dizziness particularly if associated with other symptoms (visual disturbances, history of trauma and headache) and if exacerbated by cervical spine movements. Therapists demonstrated a lack of confidence in functional positional testing (FPT) and based decisions on the use of high velocity thrust techniques on subjective findings.The results of this study emphasise the importance of physiotherapists’ clinical reasoning process during the SE particularly in view of the questionable diagnostic utility of FPT.

Preliminary study of neck muscle size and strength measurements in females with chronic non-specific neck pain and healthy control subjects

Asghar Rezasoltani, Ahmadipor Ali-Reza, Khademi-Kalantari Khosro, Rahimi Abbass — 2010-04-30

Abstract: Neck muscle weakness and atrophy are two common causes of pain and disability among office workers. The aim of this study was to compare the strength of the neck extensor and flexor muscles and the size of the semispinalis capitis muscle (SECM) in patients with chronic non-specific neck pain (CNNP) and healthy subjects. Twenty female office workers (10 patients with CNNP and 10 healthy subjects) participated in this study. The strength of the neck extensor and flexor muscles was measured by an isometric device and the SECM size was measured by ultrasonography. Neck muscle strength, size of the SECM and the ratios of neck strength to body weight, neck extensor strength to SECM size, SECM size to body weight and neck flexor to extensor strength were all significantly lower in patients compared to controls (P < 0.05). In conclusion, neck strength, the size of the SECM and the ratio of neck muscle strength to SECM size appear to be useful parameters in appraising patients with CNNP.

Responsiveness, minimal importance difference and minimal detectable change scores of the shortened disability arm shoulder hand (QuickDASH) questionnaire

Kate Polson, Duncan Reid, Peter J. McNair, Peter Larmer — 2010-05-03

Abstract: The aim of this study was to determine the responsiveness, Minimal Important Difference (MID) and Minimal Detectable Change (MDC) scores of the shortened Disability Arm Shoulder Hand (QuickDASH) questionnaire. Participants (n = 35) were recruited from private physiotherapy practices. Participants completed the QuickDASH questionnaire on two occasions; the first prior to treatment and the second at discharge or at six weeks post baseline, whichever event occurred first. The participants also completed a Global Change in Status Questionnaire (GSCQ). Responsiveness across treatment to discharge or at six weeks post initial visit was analysed by calculating the Effect Size (ES) and Standardised Response Mean (SRM). The MID was calculated using an anchor based approach and the MDC score was based upon calculations of the standard error of measurement (SEM). The results indicated that responsiveness was high (ES = 1.02, SRM = 1.1). The MID was 19 points while the MDC was 11 points.These results provide evidence that the QuickDASH is a responsive instrument when utilised in patients seen in private practice over a typical treatment interval.

Cauda Equina Syndrome (CES) and the communication of risk

J.F. Dummett, J. Langworthy — 2010-04-02

Rationale: Risk disclosure is the most contentious and uncertain element of the consent process, particularly where data are unavailable, unquantifiable or unknown. To date, complications of lumbar spine manipulation (LSM) have been largely overlooked. Whilst a rare consequence of LSM, CES is the most severe sequela of lumbar disc herniation and merits further consideration.