Manual Therapy

Editorial Board

2010-04-01

Capitalising on effective treatment strategies for low back pain – How do we bridge the self-management gap?

Ann Moore, Gwen Jull — 2010-04-01

Epidemiological evidence confirms that low back pain has a tendency to recur. Over the last decade, insights have increased significantly into diagnostic approaches and the development of effective treatment packages which are often multi-modal in nature. There has been a move into a bio-psychosocial philosophical approach to care, although, contrary to this integrated philosophy there are Instances where some clinicians take a completely hands-off approach to care, whilst others simply ignore the psychosocial dimension. Patients of course are not really in a position of awareness or knowledge to be able to comment or express their views and needs in relation to treatment and therefore, to a large extent, this polarity may go un-noticed.

Recognition of central sensitization in patients with musculoskeletal pain: Application of pain neurophysiology in manual therapy practice

Jo Nijs, Boudewijn Van Houdenhove, Rob A.B. Oostendorp — 2009-12-25

Abstract: Central sensitization plays an important role in the pathophysiology of numerous musculoskeletal pain disorders, yet it remains unclear how manual therapists can recognize this condition. Therefore, mechanism based clinical guidelines for the recognition of central sensitization in patients with musculoskeletal pain are provided. By using our current understanding of central sensitization during the clinical assessment of patients with musculoskeletal pain, manual therapists can apply the science of nociceptive and pain processing neurophysiology to the practice of manual therapy. The diagnosis/assessment of central sensitization in individual patients with musculoskeletal pain is not straightforward, however manual therapists can use information obtained from the medical diagnosis, combined with the medical history of the patient, as well as the clinical examination and the analysis of the treatment response in order to recognize central sensitization. The clinical examination used to recognize central sensitization entails the distinction between primary and secondary hyperalgesia.

International identification of research priorities for postgraduate theses in musculoskeletal physiotherapy using a modified Delphi technique

Alison Rushton, Ann Moore — 2009-11-04

Abstract: Research priorities are established to identify gaps and maximise opportunities in developing an evidence base. Numerous postgraduate research theses are undertaken each year within the specialist area of musculoskeletal physiotherapy, and although some are published, greater potential for influence exists. This paper identifies international research priorities for postgraduate theses developed using a consensual Delphi process. A purposive sample included course tutors and expert clinicians nominated by Member Organisations of the International Federation of Orthopaedic Manipulative Physical Therapists (N=91). Round 1 requested >10 priorities for theses, and content analysis identified research themes. Round 2 requested participants rank the importance of each theme on a 1–5 scale, and round 3 requested ranking the importance and feasibility of the research question areas within each agreed theme. Descriptive analysis and use of Kendall's coefficient of concordance enabled interpretation of consensus. The response rate of 68% was good, identifying 23 research themes in round 1. Round 2 identified 14 research themes as important. Participant rating of the importance and feasibility of research question areas in round 3 supported 43 agreed priorities demonstrating good measurement validity. Establishing priorities provides a vision of how postgraduate theses can contribute to the developing evidence base and offer a focus for international collaboration.

Cervical lateral glide increases nociceptive flexion reflex threshold but not pressure or thermal pain thresholds in chronic whiplash associated disorders: A pilot randomised controlled trial

2009-11-02

Abstract: Sensory hypersensitivity indicative of augmented central pain processing is a feature of chronic whiplash associated disorders (WAD). This study investigated the immediate effects of a cervical spine manual therapy (SMT) technique on measures of central hyperexcitability. In a randomised, single blind, clinical trial, 39 participants with chronic WAD were randomly assigned to a cervical SMT (lateral glide) or manual contact intervention. The Neck Disability Index (NDI) and GHQ-28 were administered at baseline. Pressure pain thresholds (PPTs), thermal pain thresholds (TPTs) and Nociceptive Flexion Reflex (NFR) responses (threshold and VAS of pain) were measured pre and post intervention. There was a significantly greater increase in NFR threshold following SMT compared to the manual contact intervention (p = 0.04). PPTs at the cervical spine increased following both SMT (mean ± SE: 24.1 ± 7.3%) and manual contact (21 ± 8.4%) with no difference between interventions. There was no difference between interventions for pain ratings with the NFR test, PPTs at the Median Nerve or Tibialis Anterior, heat or cold TPT. SMT may be effective in reducing spinal hyperexcitability in chronic WAD.

Relationships between pain thresholds, catastrophizing and gender in acute whiplash injury

2009-11-06

Abstract: The mechanisms underlying sensory hypersensitivity (SH) in acute whiplash associated disorders (WAD) are not well understood. We examined the extent of the relationships between the sensory measures of pressure pain threshold (PPT) and cold pain threshold (CPT), catastrophizing, pain and disability levels and gender in acute WAD. Thirty-seven subjects reporting neck pain following a motor vehicle accident were examined within five weeks post-injury. Measures of neck pain and disability (Neck Disability Index, NDI) and catastrophizing (Pain Catastrophizing Scale, PCS) were taken. CPT was assessed in the cervical spine and PPTs were assessed in the cervical spine (PPTcx) and at a remote site (PPTdistal). CPT and PCS were moderately correlated (r=0.46; p < 0.01); however there were no significant relationships between PPT (cervical and distal) and PCS. Both CPT (r=0.55, p < 0.01) and PPTcx (r=−0.42, p < 0.01) were significantly correlated with NDI but PPTdistal was not (r=−0.08, p=0.65). Finally, gender modulated the relationships between sensory measures, catastrophizing, and pain and disability levels. In conclusion, subjects with higher levels of catastrophizing presented with sensory hypersensitivity to cold stimuli in the acute phase of whiplash. Differences between genders are in accordance with the growing body of evidence suggesting that the relationships between some psychological factors and injury-related symptoms are modulated by gender.

The Spineangel®: Examining the validity and reliability of a novel clinical device for monitoring trunk motion

2009-11-30

Abstract: Spinal loading in excessive and repeated trunk flexion may hinder recovery from acute low back pain. The Spineangel® device provides real-time patient biofeedback on trunk flexion and may facilitate recovery from lower back injury. This cross-sectional study evaluates validity and reliability of this device in the laboratory setting.Participants included 18 healthy males. Angular displacements were simultaneously obtained from a Spineangel® device placed on the hip and criterion measures of hip, lumbar and total sagittal rotation, and pelvic tilt obtained via 3D Motion Analysis®. Each participant repeated four movements five times in a random order (forward bending fingertips-to-knees and to mid-lower leg, full flexion, and full extension).Intraclass correlation coefficients (ICC) for Spineangel® measurement of trunk motion were excellent (ICC>0.9). The coefficient of repeatability was less than 5.2° in both flexion and extension. Spineangel® showed the highest correlation with Motion Analysis® measurement of pelvic tilt with no statistical difference between measures when bending forward to fingertips-to-knees.Given its high reliability, the Spineangel® device has potential as a trunk flexion biofeedback device. Further investigation is required to see if these laboratory results can be reproduced in the clinical setting and to determine the clinical benefits of such a device.

Examination of musculoskeletal chest pain – An inter-observer reliability study

2009-12-04

Abstract: Chest pain may be caused by joint and muscle dysfunction of the neck and thorax (termed musculoskeletal chest pain). The objectives of this study were (1) to determine inter-observer reliability of the diagnosis ‘musculoskeletal chest pain’ in patients with acute chest pain of non-cardiac origin using a standardized examination protocol, (2) to determine inter-observer reliability of single components of the protocol, and (3) to determine the effect of observer experience. Eighty patients were recruited from an emergency cardiology department. Patients were eligible if an obvious cardiac or non-cardiac diagnosis could not be established at the cardiology department. Four observers (two chiropractors and two chiropractic students) performed general health and manual examination of the spine and chest wall. Percentage agreement, Cohen's Kappa and ICC were calculated for observer pairs (chiropractors and students) and all. Musculoskeletal chest pain was diagnosed in 45 percent of patients. Inter-observer kappa values were substantial for the chiropractors and overall (0.73 and 0.62, respectively), and moderate for the students (0.47). For single items of the protocol, the overall kappa ranged from 0.01 to 0.59. Provided adequate training of observers, the examination protocol can be used in carefully selected patients in clinical settings and should be included in pre- and post-graduate clinical training.

The initial effects of different rates of lumbar mobilisations on pressure pain thresholds in asymptomatic subjects

Elaine Willett, Clair Hebron, Oliver Krouwel — 2009-11-30

Abstract: Lumbar mobilisations are commonly used in clinical practice to reduce pain and increase function. Mobilisations to the cervical spine have been shown to reduce pain using pressure pain thresholds (PPTs). Yet there is no evidence to confirm that this happens in the lumbar spine. Furthermore little is known about the effects of different treatment doses on the amount of hypoalgesia produced. It is unknown if changing the rate of application of mobilisations has an effect on hypoalgesia. The aim of this study was to investigate the immediate effects of lumbar posteroanterior mobilisations performed at different rates on PPT and the extent of the hypoalgesia.A repeated measures, single blind, randomised-trial was conducted on 30 asymptomatic subjects. PPTs were measured at 4 sites in the upper and lower quadrants, before and after the application of lumbar posteroanterior mobilisations performed at 2 Hz, 1 Hz and quasi-static. The results demonstrated an immediate and significant improvement in PPT measures (P = 0.000) irrespective of the rate or site tested. The effects were both local and widespread. There was no significant difference in PPT between the rates of mobilisations.This study provides new experimental evidence that lumbar posteroanterior mobilisations produce an immediate and significant widespread hypoalgesic effect, regardless of the rates of mobilisation in asymptomatic subjects.

Experiences of individuals with chronic low back pain during and after their participation in a spinal stabilisation exercise programme – A pilot qualitative study

Oluwaleke Sokunbi, Vinette Cross, Peter Watt, Ann Moore — 2009-11-26

Abstract: Spinal stabilisation exercises are commonly used in the management of low back pain (LBP). There is limited evidence relating to patients' experiences of their involvement in such programmes. The aim of this study was to explore the experiences of a sample of individuals with chronic LBP who participated in a randomised controlled trial (RCT) investigating the most efficacious dosage and frequency of spinal stabilisation exercises. The qualitative study involved nine participants who took part in focus group discussions. The data were analysed using thematic content analysis and provided insights into the experiences of the participants. Four themes emerged: Physical dimensions of the LBP experience, emotional and psychological dimensions of the LBP experience and perceived effects of the programme and lastly, the impact of the treatment programme on participants' knowledge, understanding and adherence. In conclusion participants' experiences were not limited to the positive effects of stabilisation exercises on pain, functional disability and quality of life, but also reflected increases in confidence, the formulation of self help strategies and the ability to exert better control over their LBP. The findings highlight the importance of well planned associated educational support packages in the treatment of LBP paving the way for future qualitative research.

The relationship between psychological distress and free-living physical activity in individuals with chronic low back pain

Cormac G. Ryan, Heather G. Gray, Mary Newton, Malcolm H. Granat — 2009-11-30

Abstract: The aim of this cross-sectional pilot-study was to investigate the relationship between psychological distress and free-living physical activity (PA) in individuals with chronic low back pain (CLBP). Thirty-eight participants with non-specific CLBP (29=distressed; 9=non-distressed) were recruited. PA levels were measured using an accelerometer (activPAL™ activity monitor) over a one week period. The following parameters of physical activity were recorded: time upright (standing or walking), time standing, time walking, and step count. Psychological distress was assessed using a modified version of the distress risk assessment method (DRAM) which is a combination of somatic anxiety and depressive symptoms. The Distressed group spent significantly less time upright over a mean 24h day (−1.47h, 95% CI −2.70 to −0.23h, p<0.05), attributable to 1.01h less standing and 0.46h less walking. Depressive symptoms were a statistically significant independent predictor of time upright (β=−0.49, p<0.05). This pilot-study found that individuals with CLBP and elevated levels of distress spend less time upright than their non-distressed counterparts. Clinically, when treating individuals with CLBP and elevated distress levels, free-living PA may be low and interventions aimed at increasing upright activity may be appropriate.

The effects of manual pelvic compression on trunk motor control during an active straight leg raise in chronic pelvic girdle pain subjects

Darren John Beales, Peter Bruce O'Sullivan, N. Kathryn Briffa — 2009-11-30

Abstract: A sub-group of pelvic girdle pain (PGP) patients with a positive active straight leg raise (ASLR) responds positively to the application of external pelvic compression during the test. This study investigated the effect of this phenomenon on electromyographic (EMG) activity of the trunk muscles and intra-abdominal and intra-thoracic pressures in subjects with a unilateral sacroiliac joint (SIJ) pain disorder (n=12). All subjects reported reduced difficulty ratings during an ASLR with pelvic compression (paired t-test: p<0.001), yet no statistically significant changes in the muscle activation or pressure variables were found. However, visual inspection of the data revealed two divergent motor control strategies with the addition of compression. Seven subjects displayed characteristics of a decreased EMG profile, while in the other five subjects the EMG profile appeared to increase. As such this study provides preliminary evidence of two disparate patterns of motor control in response to the addition of pelvic compression to an ASLR. The findings may reflect different mechanisms, not only in the response to pelvic compression, but also of the underlying PGP disorder.

Resting thickness of transversus abdominis is decreased in athletes with longstanding adduction-related groin pain

Jaap Jansen, Adam Weir, Renee Dénis, Jan Mens, Frank Backx, Henk Stam — 2010-01-14

Abstract: The purpose of the study was to compare thickness of the transversus abdominis (TA) and obliquus internus (OI) muscles between athletes with and without longstanding adduction-related groin pain (LAGP).Forty two athletes with LAGP and 23 controls were included. Thickness of TA and OI were measured with ultrasound imaging on the right side of the body during rest. Relative muscle thickness (compared to rest) was measured during the active straight leg raise (ASLR) left and right, and during isometric hip adduction.TA resting thickness was significantly smaller in injured subjects with left-sided (4.0±0.82mm; P<0.001) or right-sided (4.3±0.64mm; P=0.015) groin complaints compared with controls (4.9±0.90mm). No significant differences between patients and controls in TA or OI relative thickness during the ASLR and isometric hip adduction were found (all cases P≥0.15).In conclusion, TA resting thickness is smaller in athletes with LAGP and may thus be a risk factor for (recurrent) groin injury. This may have implications for therapy and prevention of LAGP.

A tailored sensorimotor approach for management of whiplash associated disorders. A single case study

Julia Treleaven — 2009-06-15

Deficits in cervical joint position (JPE) (), eye movement control () and postural stability () and reports of dizziness and unsteadiness by patients with neck disorders are often noted especially in those who have sustained whiplash injury and report dizziness (). Such disturbances are thought to be due primarily to abnormal cervical afferent input to the sensorimotor control system. Secondary changes to the vestibular and visual systems are also thought to contribute to such deficits and complaints ().