Manual Therapy - Articles in Press

Comparison of changes in the contraction of the lateral abdominal muscles between the abdominal drawing-in maneuver and breathe held at the maximum expiratory level - Corrected Proof

Hiroshi Ishida, Ryohei Hirose, Susumu Watanabe — 2012-05-18

Abstract: The abdominal drawing-in maneuver (ADIM) is commonly used as a fundamental component of lumbar stabilization training programs. One potential limitation of lumbar stabilization programs is that it can be difficult and time consuming to train people to perform the ADIM.The transverse abdominis (TrA), internal oblique (IO), and external oblique (EO) muscles are the most powerful muscles involved in expiration. However, little is known about the differences in the recruitment of the abdominal muscles between the ADIM and breathe held at maximum expiratory level (maximum expiration).The thickness of the TrA and IO muscles was measured by ultrasound imaging, and the activity of the EO muscle was measured by electromyography (EMG) in 33 healthy male performing the ADIM and maximum expiration.Maximum expiration produced a significant increase in the thickness of the TrA and IO muscles compared to the ADIM (p < 0.001). The EMG activity of the EO muscle was significantly higher during maximum expiration than during the ADIM (p < 0.001). The intensity of the EMG activity of the EO muscle was approximately 30% of the maximal voluntary contraction during maximum expiration.Thus, maximum expiration may be an effective method for training of co-activation of the lateral abdominal muscles.

What do physiotherapists consider to be the best sitting spinal posture? - Corrected Proof

Kieran O'Sullivan, Peter O'Sullivan, Leonard O'Sullivan, Wim Dankaerts — 2012-05-18

Abstract: While sitting is a common aggravating factor in low back pain (LBP), the best sitting posture remains unclear. This study investigated the perceptions of 295 physiotherapists in four different European countries on sitting posture. Physiotherapists selected their perceived best sitting posture from a sample of nine options that ranged from slumped to upright sitting, as well as completing the back beliefs questionnaire (BBQ). 85% of physiotherapists selected one of two postures as best, with one posture being selected significantly more frequently than the remainder (p < 0.05). Interestingly, these two most frequently selected postures were very different from each other. Those who selected the more upright sitting posture had more negative LBP beliefs on the BBQ (p < 0.05). The choice of best sitting posture also varied between countries (p < 0.05). Overall, disagreement remains on what constitutes a neutral spine posture, and what is the best sitting posture. Qualitative comments indicated that sitting postures which matched the natural shape of the spine, and appeared comfortable and/or relaxed without excessive muscle tone were often deemed advantageous. Further research on the perceptions of people with LBP on sitting posture are indicated.

Utilization of mobilization with movement for an apparent sprain of the posterior talofibular ligament: A case report - Corrected Proof

Russell Woodman, Kevin Berghorn, Traci Underhill, Meredith Wolanin — 2012-05-14

Abstract: Ankle sprains are a common injury. According to the National Electronic Injury Surveillance System (NEISS), an estimated 630,891 ankle sprains occurred in 2009 (). The anterior talofibular ligament (AFTL) is frequently sprained as a result of a plantarflexion-inversion injury. Sometimes the calcaneofibular ligament or posterior talofibular ligament (PTFL) is also sprained (). The patient in this study presented with lateral ankle pain reproducible by passive plantarflexion and eversion, complaining of pain during exercise and playing sports. These findings are consistent with a sprain of the PTFL. Positional faults have also been shown to occur at tibiofibular joint, mimicking the symptoms of an ankle sprain. Brian Mulligan first hypothesized the occurrence of positional faults at the ankle. He developed a Mobilization with Movement (MWM) technique to treat these positional faults. Mulligan also hypothesized that a similar positional fault could occur in a posterior direction mimicking a sprain of the PTFL (, p. 71, 96–97). The purpose of this case study is to present a patient with an apparent posterior talofibular ligament sprain who responded to an anterior glide MWM of the fibula. The two measurements used to assess function and pain were the Foot and Ankle Ability Measure (FAAM) and a 10-point numeric pain scale. Each measure was conducted prior to treatment, after treatment was discontinued, 6 months post treatment and 12 months post treatment. A positive response was achieved, as her symptoms were reduced and she was able return to her prior level of function.

A blended learning approach to palpation and ultrasound imaging skills through supplementation of traditional classroom teaching with an e-learning package - Corrected Proof

2012-05-14

Abstract: The objective of this study was to evaluate the effectiveness of e-learning as a supplement to on-campus education for the acquisition of skills in palpation and ultrasound examination of the knee in a physiotherapy degree course. Forty-six students (28 females) from the University of Granada, with a mean age of 21.5 yrs, received 4 h of theoretical and practical on-campus training on palpation and ultrasound examination of the knee joint. They were then randomly distributed into two groups: experimental, with free access to the ECOFISIO website on musculoskeletal palpation and ultrasound assessment; and control, with access to documents and books on the topic. Structured objective clinical evaluation (SOCE) and multiple-choice questionnaire (MCQ) were used to assess the educational intervention. We also measured the time taken by the students to generate a reliable ultrasound image and to localize a specific knee structure by palpation. There was no significant intergroup difference in the acquisition of theoretical knowledge as assessed by the MCQ (p = 0.39). Scores were significantly higher in the experimental group than in the control group for skills in palpation ability (p = 0.041) and ultrasound assessment (p < 0.001) of the knee. Students in the e-learning group needed less time to palpate the musculoskeletal structure (p = 0.041) but more time (p = 0.012) to obtain their superior ultrasound images. In conclusion, these results contribute evidence that e-learning is an effective educational strategy for physiotherapy students to acquire skills in palpation and ultrasound imaging of the knee as a supplement to on-campus education.

Response to letter to the Editor: “Innominate 3D motion modeling: Biomechanically interesting, but clinically irrelevant” - Corrected Proof

Melanie D. Bussey, Stephan Milosavljevic, Divya Adhia — 2012-05-14

We thank the writers for their comments on the article ‘Inter-tester reliability of non-invasive technique for measurement of innominate motion’ and welcome their considered thoughts.

Measurement of lumbar spine range of movement and coupled motion using inertial sensors – A protocol validity study - Corrected Proof

Tshui-Hung Ha, Kambiz Saber-Sheikh, Ann P. Moore, Mark P. Jones — 2012-05-11

Abstract: Measurement of spinal lumbar range of movement is useful in clinical examination of the spine and for monitoring changes in spinal movement characteristics of individuals over time, particularly in the research context. As the spine exhibits six degrees of movement, three dimensional measurements provide additional information that could benefit the study of spinal conditions. Inertial measurement systems present an innovative method of spinal motion measurement. These systems are small and portable, and of low cost compared to laboratory based three dimensional measurement systems such as electromagnetic and opto-electronic systems. The present study aimed to validate the use of inertial measurement systems in three dimensional spinal range of movement measurement using an electromagnetic tracking system as a reference. Twenty-six healthy participants had their lumbar spine range of movement measured using both an inertial measurement system and an electromagnetic tracking system. Measurements taken by the inertial measurement system were found to be highly correlated with the electromagnetic tracking system (overall regression R2 0.999, p 0.05). The ranges of movement measured were also highly comparable to those reported in the literature. Inertial measurement systems that consist of triaxial gyroscopes, accelerometers and magnetometers are concluded to be valid tools for three dimensional spinal range of movement measurement within or outside of the laboratory settings due to their cost, size and portability.

The anterior shear and distraction tests for craniocervical instability. An evaluation using magnetic resonance imaging - Corrected Proof

Peter G. Osmotherly, Darren A. Rivett, Lindsay J. Rowe — 2012-05-07

Abstract: Screening for integrity of the ligaments of the craniocervical complex has been suggested prior to the application of manual techniques to the upper cervical spine. However, most tests proposed lack validation limiting their usefulness clinically. This study examined the effect of the anterior shear test for the transverse ligament and the distraction test for the tectorial membrane in normal volunteers. MRI was performed in supine in neutral and end-range stress test positions in 16 individuals using proton density-weighted sequences and a standard head coil in a 3-T system. Measurements were made with respect to a strictly standardised protocol. The anterior shear test was assessed using changes in atlantodental interval and distance from the anterior arch of the atlas to the posterior aspect of the odontoid process. Distraction testing for the tectorial membrane was assessed by changes in basion-dental interval and by direct measurement of the tectorial membrane. Differences were compared using Wilcoxon Sign Rank tests or paired t-test depending upon each variables assessment of normality. Anterior shear testing resulted in a 0.41 mm mean increase in atlantodental interval (p = 0.03) and 0.35 mm mean increase in axial plane distance (p = 0.05). Distraction testing for the tectorial membrane resulted in a 0.64 mm increase in basion-dental interval (p < 0.01) and a 1.11 mm increase in direct ligament length measurement (p = 0.02). Reliability of measurements ranged from moderate to substantial. These results indicate that these tests produce a consistent direct effect on the transverse ligament and the tectorial membrane which is consistent with their theorised mechanism for clinical use.

Tension – Type – Headache treated by Positional Release Therapy: A case report - Corrected Proof

Marzieh Mohamadi, Ali Ghanbari, Abbas Rahimi jaberi — 2012-05-07

Abstract: Tension Type Headache (T.T.H) is the most prevalent headache. Myofascial abnormalities & trigger points are important in this type of headache which can be managed by Positional Release Therapy (PRT). This is a report of a 47 years old female patient with Tension Type Headache treated by Positional Release Therapy for her trigger points. She had a constant dull headache, which continued all the day for 9 months. A physiotherapist evaluated the patient and found active trigger points in her cervical muscles. Then, she received Positional Release Therapy for her trigger points. After 3 treatment sessions, the patient's headache stopped completely. During the 8 months following the treatment she was without pain, and did not use any medication. Positional Release Therapy was effective in treating Tension Type Headache. This suggests that PRT could be an alternative treatment to medication in patients with T.T.H if the effectiveness of that can be confirmed by further studies.

Assessment of spinal mobility in ankylosing spondylitis using a video-based motion capture system - Corrected Proof

2012-05-04

Abstract: This paper describes the use of a video-based motion capture system to assess spinal mobility in patients with ankylosing spondylitis (AS). The aim of the study is to assess reliability of the system comparing it with conventional metrology in order to define and analyze new measurements that reflect better spinal mobility. A motion capture system (UCOTrack) was used to measure spinal mobility in forty AS patients and twenty healthy subjects with a marker set defining 33 3D measurements, some already being used in conventional metrology. Radiographic studies were scored using the modified Stoke Ankylosing Spondylitis Spine Score index (mSASSS). Test–retest reliability studies were performed on the same day and over a two-week period. Motion capture shows very high reliability with Intraclass Correlation Coefficient values ranging from 0.89 to 0.99, low Standard Error of the Measurement (0.37–1.33 cm and 1.58°–6.54°), correlating very well with the Bath Ankylosing Spondylitis Metrology Index (BASMI) (p < 0.001) and, in some individual measures (cervical flexion, cervical lateral flexion, back inclination, shoulder–hip angle and spinal rotation), with mSASSS (p < 0.01). mSASSS also added significantly to the variance in multivariate linear regression analysis to certain measures (back inclination, cervical flexion and cervical lateral flexion). Quantitative results obtained with motion capture system using the protocol defined show to be highly reliable in patients with AS. This technique could be a useful tool for assessing the outcome of the disease and for monitoring the evolution of spinal mobility in AS patients.

Corrected Proof

Cameron M. Marshall — 2012-04-30

Managing injuries in a sports setting can be a very challenging task. Differential diagnoses must be weighed and serious pathology ruled out in a timely manner followed by the difficult decisions regarding management and return to play. Managing the Injured Athlete is an 8” pocketbook, organized into 5 sections and directed towards clinicians who are working with athletes and in musculoskeletal medicine.

Is there a future for electrophysical agents in musculoskeletal physiotherapy? - Corrected Proof

Lucy Chipchase — 2012-04-30

Electrophysical agents (EPAs) are part of the arsenal of techniques that manual therapists have at their disposal for the management of neuromusculoskeletal disorders. An argument can be made that when used judiciously and appropriately as one part of a multimodal approach to treatment, EPAs have the potential to enhance patient care. For the discerning manual therapist, there are several issues to reflect on when considering the use of EPAs as an adjunct to other techniques.

Mechanisms-based classifications of musculoskeletal pain: Part 1 of 3: Symptoms and signs of central sensitisation in patients with low back (±leg) pain - Corrected Proof

Keith M. Smart, Catherine Blake, Anthony Staines, Mick Thacker, Catherine Doody — 2012-04-25

Abstract: As a mechanisms-based classification of pain ‘central sensitisation pain’ (CSP) refers to pain arising from a dominance of neurophysiological dysfunction within the central nervous system. Symptoms and signs associated with an assumed dominance of CSP in patients attending for physiotherapy have not been extensively studied. The purpose of this study was to identify symptoms and signs associated with a clinical classification of CSP in patients with low back (±leg) pain.Using a cross-sectional, between-subjects design; four hundred and sixty-four patients with low back (±leg) pain were assessed using a standardised assessment protocol. Patients’ pain was assigned a mechanisms-based classification based on experienced clinical judgement. Clinicians then completed a clinical criteria checklist specifying the presence or absence of various clinical criteria.A binary logistic regression analysis with Bayesian model averaging identified a cluster of three symptoms and one sign predictive of CSP, including: ‘Disproportionate, non-mechanical, unpredictable pattern of pain provocation in response to multiple/non-specific aggravating/easing factors’, ‘Pain disproportionate to the nature and extent of injury or pathology’, ‘Strong association with maladaptive psychosocial factors (e.g. negative emotions, poor self-efficacy, maladaptive beliefs and pain behaviours)’ and ‘Diffuse/non-anatomic areas of pain/tenderness on palpation’.This cluster was found to have high levels of classification accuracy (sensitivity 91.8%, 95% confidence interval (CI): 84.5–96.4; specificity 97.7%, 95% CI: 95.6–99.0).Pattern recognition of this empirically-derived cluster of symptoms and signs may help clinicians identify an assumed dominance of CSP in patients with low back pain disorders in a way that might usefully inform their management.

The role of experimentally-induced subacromial pain on shoulder strength and throwing accuracy - Corrected Proof

Craig A. Wassinger, Gisela Sole, Hamish Osborne — 2012-04-16

Abstract: Shoulder injuries often comprise two separate yet related components, structural tissue damage and pain. The role of each of these components on shoulder function is difficult to ascertain. Experimental pain models allow the assessment of consequences of localized pain when applied to healthy individuals. By understanding the role of pain on shoulder function, clinicians will be able to more efficiently assess and treat shoulder injuries. The objective of the study was to evaluate the role of experimentally-induced sub-acromial pain on shoulder isokinetic rotational strength and throwing accuracy. This was a block counterbalanced, crossover, repeated measures study design utilizing 20 individuals without self-reported shoulder or cervical pathology. Shoulder function was measured with and without experimental pain injection (2 mL of 5% hypertonic saline) in the sub-acromial space. Functional tasks consisted of shoulder rotational strength utilizing isokinetic testing and throwing accuracy via the functional throwing performance index. The hypertonic saline induced moderate pain levels in all participants (4.3–5.1/10). Normalized shoulder internal (t = 3.76, p = 0.001) and external (t = 3.12, p = 0.006) rotation strength were both diminished in the painful condition compared to the pain free condition. Throwing accuracy was also reduced while the participants experienced pain (t = 3.99, p = 0.001). Moderate levels of experimental shoulder pain were sufficient to negatively influence shoulder strength and throwing accuracy in participants without shoulder pathology.

Manual testing for ankle instability - Corrected Proof

2012-04-09

Abstract: Aim: To assess inter-rater reliability of ankle manual tests. We also correlated the manual tests with the Cumberland Ankle Instability Tool (CAIT).Method: One ankle from each of 60 participants was assessed using four different manual tests (anterior drawer in supine and crook lying, talar tilt, inversion tilt). Three different raters, varying in experience, tested each participant. The CAIT questionnaire was also administered. The study received ethics approval from the University of Sydney Human Research Ethics Committee. Intraclass correlation coefficients (ICC), standard error of the mean (SEM) and percent close agreement (PCA) were used to determine reliability of the four tests. Pearson's correlation coefficients were used to determine relationships between the manual tests and CAIT scores.Results: Inter-rater reliability for the four manual tests was poor regardless of therapist's experience (ICC[1,1] −0.12 to 0.33; SEM 0.93–1.69). Correlations between the CAIT and manual tests were also low varying between r = −0.12 and −0.42.Conclusions: Inter-rater reliability was poor for manual tests of ankle stability. Reliability may be improved by using a grading scale with fewer intervals. The CAIT scores and manual tests correlated poorly, potentially reflecting the variety of conditions leading to ankle instability.

Cross-cultural adaptation and measurement properties of the Brief Illness Perception Questionnaire-Dutch Language Version - Corrected Proof

2012-04-06

Abstract: Objective: Ever since Engel’s Biopsychosocial Model (1977) emotions, thoughts, beliefs and behaviors are accepted as important factors of health. The Brief Illness Perception Questionnaire (Brief IPQ) assesses these beliefs. Aim of this study was to cross-culturally adapt the Brief IPQ into the Brief IPQ Dutch Language Version (Brief IPQ-DLV), and to assess its face validity, content validity, reproducibility, and concurrent validity.Methods: Beaton’s guideline was used for cross-culturally adaptation. Face and content validity were assessed in 25 patients, 15 physiotherapists and 24 first-grade students. Reproducibility was established in 27 individuals with chronic obstructive pulmonary disease using Cohen’s kappa coefficient (Kw) and the Smallest Detectable Change (SDC). Concurrent validity was assessed in 163 patients visiting 11 different physical therapists.Results: The Brief IPQ-DLV is well understood by patients, health care professionals and first-grade students. Reliability at 1 week for the dimensions Consequences, Concern and Emotional response Kw>0.70, for the dimensions Personal control, Treatment control, Identity, Kw<0.70. A time interval of 3 weeks, reliability coefficients were lower for almost all dimensions. SDC was between 2.45 and 3.37 points for individual measurement purposes and between 0.47 and 0.57 points for group evaluative measurement purposes. Concurrent validity showed significant correlations (P<.05) for four out of eight illness perceptions (IPs) dimensions.Conclusion: The face and content properties were found to be acceptable. The reproducibility and concurrent validity needs further investigated.

Cold hyperalgesia as a prognostic factor in whiplash associated disorders: A systematic review - Corrected Proof

Robert Goldsmith, Chris Wright, Sarah F. Bell, Alison Rushton — 2012-04-05

Abstract: Objective: To review and critically evaluate the existing literature for the prognostic value of cold hyperalgesia in Whiplash Associated Disorders (WAD).Methods: Embase, PsycINFO, and Medline databases were systematically searched (from inception to 20th September 2011) for prospective studies investigating a prognostic ability for cold hyperalgesia in WAD. Reference lists and lead authors were cross-referenced. Two independent reviewers selected studies, and consensus was achieved via a third reviewer. The risk of bias in identified studies was systematically evaluated by two reviewers using previously published guidance. The influences of seven potential covariates of cold hyperalgesia were considered. Quantitative synthesis was planned and homogeneity assessed. A modified Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) approach was used to qualitatively assess trials.Results: The review screened 445 abstracts, from these 20 full text studies were retrieved and assessed for eligibility. Six prospective studies on four cohorts were identified and reviewed. Findings from all four cohorts supported cold hyperalgesia as a prognostic factor in WAD.Conclusions: There is moderate evidence supporting cold hyperalgesia as a prognostic factor for long-term pain and disability outcome in WAD. Further validation of the strength of this relationship and the influence of covariates are required. The mechanism for this relationship is unknown.

Acute low back pain information online: An evaluation of quality, content accuracy and readability of related websites - Corrected Proof

2012-04-05

Abstract: The internet is increasingly being used as a source of health information by the general public. Numerous websites exist that provide advice and information on the diagnosis and management of acute low back pain (ALBP), however, the accuracy and utility of this information has yet to be established. The aim of this study was to establish the quality, content and readability of online information relating to the treatment and management of ALBP. The internet was systematically searched using Google search engines from six major English-speaking countries. In addition, relevant national and international low back pain-related professional organisations were also searched. A total of 22 relevant websites was identified. The accuracy of the content of the ALBP information was established using a 13 point guide developed from international guidelines. Website quality was evaluated using the HONcode, and the Flesch-Kincaid Grade level (FKGL) was used to establish readability. The majority of websites lacked accurate information, resulting in an overall mean content accuracy score of 6.3/17. Only 3 websites had a high content accuracy score (>14/17) along with an acceptable readability score (FKGL 6–8) with the majority of websites providing information which exceeded the recommended level for the average person to comprehend. The most accurately reported category was, “Education and reassurance” (98%) while information regarding “manipulation” (50%), “massage” (9%) and “exercise” (0%) were amongst the lowest scoring categories. These results demonstrate the need for more accurate and readable internet-based ALBP information specifically centred on evidence-based guidelines.

Mechanisms-based classifications of musculoskeletal pain: Part 3 of 3: Symptoms and signs of nociceptive pain in patients with low back (±leg) pain - Corrected Proof

Keith M. Smart, Catherine Blake, Anthony Staines, Mick Thacker, Catherine Doody — 2012-04-05

Abstract: As a mechanisms-based classification of pain ‘nociceptive pain’ (NP) refers to pain attributable to the activation of the peripheral receptive terminals of primary afferent neurones in response to noxious chemical, mechanical or thermal stimuli. The symptoms and signs associated with clinical classifications of NP have not been extensively studied. The purpose of this study was to identify symptoms and signs associated with a clinical classification of NP in patients with low back (±leg) pain.Using a cross-sectional, between-subjects design; four hundred and sixty-four patients with low back (±leg) pain were assessed using a standardised assessment protocol after which their pain was assigned a mechanisms-based classification based on experienced clinical judgement. Clinicians then completed a clinical criteria checklist indicating the presence/absence of various symptoms and signs.A regression analysis identified a cluster of seven clinical criteria predictive of NP, including: ‘Pain localised to the area of injury/dysfunction’, ‘Clear, proportionate mechanical/anatomical nature to aggravating and easing factors’, ‘Usually intermittent and sharp with movement/mechanical provocation; may be a more constant dull ache or throb at rest’, and the absence of ‘Pain in association with other dysesthesias’, ‘Night pain/disturbed sleep’, ‘Antalgic postures/movement patterns’ and ‘Pain variously described as burning, shooting, sharp or electric-shock-like’. This cluster was found to have high levels of classification accuracy (sensitivity 90.9%, 95% CI: 86.6–94.1; specificity 91.0%, 95% CI: 86.1–94.6).Pattern recognition of this empirically-derived cluster of symptoms and signs may help clinicians identify an assumed dominance of NP mechanisms in patients with low back pain disorders.

Mechanisms-based classifications of musculoskeletal pain: Part 2 of 3: Symptoms and signs of peripheral neuropathic pain in patients with low back (±leg) pain - Corrected Proof

Keith M. Smart, Catherine Blake, Anthony Staines, Mick Thacker, Catherine Doody — 2012-04-05

Abstract: As a mechanisms-based classification of pain ‘peripheral neuropathic pain’ (PNP) refers to pain arising from a primary lesion or dysfunction in the peripheral nervous system. Symptoms and signs associated with an assumed dominance of PNP in patients attending for physiotherapy have not been extensively studied. The purpose of this study was to identify symptoms and signs associated with a clinical classification of PNP in patients with low back (±leg) pain.Using a cross-sectional, between-subjects design; four hundred and sixty-four patients with low back (±leg) pain were assessed using a standardised assessment protocol. Patients' pain was assigned a mechanisms-based classification based on experienced clinical judgement. Clinicians then completed a clinical criteria checklist specifying the presence or absence of various clinical criteria.A binary logistic regression analysis with Bayesian model averaging identified a cluster of two symptoms and one sign predictive of PNP, including: ‘Pain referred in a dermatomal or cutaneous distribution’, ‘History of nerve injury, pathology or mechanical compromise’ and ‘Pain/symptom provocation with mechanical/movement tests (e.g. Active/Passive, Neurodynamic) that move/load/compress neural tissue’.This cluster was found to have high levels of classification accuracy (sensitivity 86.3%, 95% CI: 78.0–92.3; specificity 96.0%, 95% CI: 93.4–97.8; diagnostic odds ratio 150.9, 95% CI: 69.4–328.1).Pattern recognition of this empirically-derived cluster of symptoms and signs may help clinicians identify an assumed dominance of PNP mechanisms in patients with low back pain disorders in a way that might usefully inform subsequent patient management.

Ready for a paradigm shift? Part 2: Introducing qualitative research methodologies and methods - Corrected Proof

Nicola J. Petty, Oliver P. Thomson, Graham Stew — 2012-04-05

Abstract: This paper explores a number of commonly used methodologies and methods in qualitative research, namely grounded theory, case study, phenomenology, ethnography and narrative research. For each methodology a brief history of its development and variants is given, followed by typical methods of data collection and analysis. Examples of manual therapy qualitative research studies are highlighted for each methodology. Data collection methods are then discussed and include individual interviews, focus groups, observation and documentary analysis. A frequently used method of data analysis, thematic analysis, is briefly explained. Finally, the strategies to enhance the quality of qualitative research is explored and compared to those of quantitative research.

Ready for a paradigm shift? Part 1: Introducing the philosophy of qualitative research - Corrected Proof

Nicola J. Petty, Oliver P. Thomson, Graham Stew — 2012-04-05

Abstract: The manual therapy professions have almost exclusively focused on the use of quantitative research to help inform their practices. This paper argues that a greater use of qualitative research will help develop a more robust and comprehensive knowledge base in manual therapy. The types of knowledge used in practice and generated from the two research paradigms are explored. It is hoped that an understanding of the philosophical and theoretical underpinnings of qualitative research may encourage more manual therapists to value and use this approach to help further inform their practice; for some, this may involve a paradigm shift in thinking.

Description, reliability and validity of a novel method to measure carpal tunnel pressure in patients with carpal tunnel syndrome - Corrected Proof

Michel W. Coppieters, Annina B. Schmid, Paul A. Kubler, Paul W. Hodges — 2012-03-30

Abstract: Elevated carpal tunnel pressure is an important pathomechanism in carpal tunnel syndrome (CTS). Several invasive methods have been described for direct measurement of carpal tunnel pressure, but all have two important limitations. The pressure gauge requires sterilisation between uses, which makes time-efficient data collection logistically cumbersome, and more importantly, the reliability of carpal tunnel pressure measurements has not been evaluated for any of the methods in use. This technical note describes a new method to measure carpal tunnel pressure using inexpensive, disposable pressure sensors and reports the within and between session reliability of the pressure recordings in five different wrist positions and during typing and computer mouse operation. Intraclass correlation coefficients (ICC[3,1]) were calculated for recordings within one session for healthy participants (n = 7) and patients with CTS (n = 5), and for recordings between two sessions for patients with CTS (n = 5). Overall, the reliability was high. With the exception of two coefficients, the reliability of the recordings at different wrist angles varied from 0.63 to 0.99. Reliability for typing and mouse operation ranged from 0.86 to 0.99. The new method described in this report is inexpensive and reliable, and data collection can be applied more efficiently as off-site sterilisation of equipment is not required. These advances are likely to promote future research into carpal tunnel pressure, such as investigation of the therapeutic mechanisms of various conservative treatment modalities that are believed to reduce elevated carpal tunnel pressure.

Effectiveness of proprioceptive exercises for ankle ligament injury in adults: A systematic literature and meta-analysis - Corrected Proof

K. Postle, D. Pak, T.O. Smith — 2012-03-29

Abstract: The purpose of this study was to assess the effectiveness of such proprioceptive exercise following ankle ligament injury. A systematic review of the databases MEDLINE, EMBASE, CINHAL, AMED, the Cochrane library database and the PEDro database, in addition to unpublished literature databases was conducted to July 2011. When appropriate, meta-analysis was conducted to pool results from homogeneous studies. The methodological quality of the literature was reviewed using the Critical Appraisal Skills Programme tool. The results indicated that there is no statistically significant difference in recurrent injury between the addition of proprioceptive exercises during the rehabilitation of patients following ankle ligament injury (p = 0.68). The addition of proprioceptive training demonstrated a significant reduction in subjective instability and functional outcomes (p < 0.05). There was no consensus on the advantages of including proprioceptive training in the rehabilitation of this population for swelling, postural sway, joint position sense, ankle range of motion or return to sport outcomes. Further study is warranted to develop the rigour of the evidence-base and to determine the optimal proprioceptive training programme following ankle ligament injury with different populations.

Innominate 3D motion modeling: Biomechanically interesting, but clinically irrelevant - Corrected Proof

Kyle Ridgeway, Jason Silvernail — 2012-03-29

We thank Adhia and colleagues for their contribution regarding Sacro-Iliac joint (SIJ) motion (). They conclude, “The results support clinical and research utility of this technique for non-invasive kinematic evaluation of SIJ motion…Further research… is warranted.” In our opinion, their findings are not relevant to manual therapy practice, and we don't see the need for further clinical research using this method.

Can a within/between-session change in pain during reassessment predict outcome using a manual therapy intervention in patients with mechanical low back pain? - Corrected Proof

Chad E. Cook, Chris Showalter, Vincent Kabbaz, Bryan O’Halloran — 2012-03-23

Abstract: The purposes of the study were to determine whether the combined occurrence of within/between-session changes were significantly associated with functional outcomes, pain, and self-report of recovery in patients at discharge who were treated with manual therapy for low back pain. A secondary purpose was to determine the extent of change needed for the within/between-session change with association to function. The study involved 100 subjects who were part of a randomized controlled trial that examined manual therapy techniques who demonstrated a positive response to manual therapy during the initial assessment. Within- and between-session findings (within/between session) were defined as a change in pain report from baseline to after the second physiotherapy visit. Within/between-session changes were analyzed for associations between pain change scores at discharge, rate of recovery, and a 50% reduction of the Oswestry disability index (ODI) by discharge. The results suggest there is a significant association between a within/between-session change after the second physiotherapy visit and discharge outcomes for pain and ODI in this sample of patients who received a manual therapy intervention. A 2-point change or greater on an 11-point scale is associated with functional recovery at discharge and accurately described the outcome in 67% of the cases. This is the first study that has shown an association of within/between-session changes with disability scores at discharge and is the first to define the extent of change necessary for prognosis of an outcome. A within/between-session change should be considered as a complimentary artifact along with other examination findings during clinical decision making.

Comparing lower lumbar kinematics in cyclists with low back pain (flexion pattern) versus asymptomatic controls – field study using a wireless posture monitoring system - Corrected Proof

2012-03-22

Abstract: The aim of this study was to examine lower lumbar kinematics in cyclists with and without non-specific chronic low back pain (NS-CLBP) during a cross-sectional cycling field study. Although LBP is a common problem among cyclists, studies investigating the causes of LBP during cycling are scarce and are mainly focussed on geometric bike-related variables. Until now no cycling field studies have investigated the relationship between maladaptive lumbar kinematics and LBP during cycling. Eight cyclists with NS-CLBP classified as having a ‘Flexion Pattern’ (FP) disorder and nine age- and gender-matched asymptomatic cyclists were tested. Subjects performed a 2 h outdoor cycling task on their personal race bike. Lower lumbar kinematics was measured with the BodyGuard™ monitoring system. Pain intensity during and after cycling was measured using a numerical pain rating scale. The NS-CLBP (FP) subjects were significantly more flexed at the lower lumbar spine during cycling compared to healthy controls (p = 0.018), and reported a significant increase in pain over the 2 h of cycling (p < 0.001). One-way repeated measures ANOVA revealed a significant main effect for group (p = 0.035, F = 5.546) which remained just significant when adding saddle angle as a covariate (p = 0.05, F = 4.747). The difference in posture between groups did not change over time. These findings suggest that a subgroup of cyclists with NS-CLBP (FP) demonstrate an underlying maladaptive motor control pattern resulting in greater lower lumbar flexion during cycling which is related to a significant increase in pain.

What puts the adverse in ‘adverse events’? Patients’ perceptions of post-treatment experiences in osteopathy – A qualitative study using focus groups - Corrected Proof

Dévan Rajendran, Philip Bright, Steven Bettles, Dawn Carnes, Brenda Mullinger — 2012-03-19

Abstract: Patients commonly report mild to moderate effects following all forms of manual therapy. These are often regarded as adverse events by practitioners but there is limited evidence on how patients view their post-treatment experiences, and what meaning they ascribe to them. This qualitative study used three focus group discussions (19 participants) to explore osteopathic patients’ perspectives; a framework approach was used to analyse the data. There were four emergent themes (and 23 sub-themes). Interpretative (level two) analysis of the data led to a conceptual model of meaning with four inter-related components: Expectations; Personal investment; Osteopathic encounter; Clinical change, under an overarching construct, the ‘global osteopathic experience’. These four components, designated EPOC, can have a profound impact on a patient’s post-treatment experiences and their perception of what is adverse. This model suggests there is disparity between patient perceptions and clinical definitions of adverse events; awareness by practitioners of this disparity is essential for effective clinical management.

Minimum repetitions for stable measures of visual dependency using the dot version of the computer-based Rod-Frame test - Corrected Proof

Hiroshi Takasaki, Julia Treleaven, Venerina Johnston, Gwendolen Jull — 2012-03-19

Abstract: Visual dependency is a condition where spatial orientation is mainly dependent on visual information. It can be affected in conditions such as vestibular disorders, brain injuries and neck pain including whiplash. Visual dependency can be assessed with a computer-based, dot version, Rod-Frame test (C-RFTdot) by measuring the deviation of a rod (comprised of two dots) from the true vertical within tilted frames at 18° in both clockwise and anticlockwise directions. However, the number of test repetitions differs between studies. The purpose of this study was to investigate the minimum number of repetitions to obtain stable C-RFTdot outcomes. Thirty-one asymptomatic subjects were recruited. With a frame tilt of 18° (clockwise and anticlockwise), the rod was pre-set at 20° in both clockwise and anticlockwise directions. The rod could be rotated, using a mouse, to a minimum of 0.01°. The clockwise and anticlockwise deviations from the true vertical were positive values and negative values, respectively. A session consisted of two measures of deviations of pre-set rod conditions in each frame. Their signed values were averaged for analysis. Eight sessions were conducted. The differences between the mean values of N−1 and N repetitions (2 ≦ N ≦ 8) were measured. Differences were similar across repetitions and the standard deviations tended to decline over repetitions. Intraclass correlation coefficients (ICC) for five and more repetitions became >0.8 in each frame condition. Hence, five was considered the minimum number of testing so that the C-RFTdot can give consistent measures of deviation from the vertical in asymptomatic healthy individuals.

Clinical measurement of mechanical ankle instability - Corrected Proof

2012-03-19

Abstract: Clinicians commonly use the anterior draw test (ligament laxity) and distal fibular position (lateral malleolus displacement), to measure ankle instability. The purpose of this study was to establish intra-rater and inter-rater reliability for the anterior draw test and distal fibular position in a clinical setting.The anterior draw test (AD) was measured with a plastic Goniometer, and was defined as the linear displacement of the foot as it is drawn anteriorly with the ankle held in 20 degrees of plantar-flexion. Distal fibular position (DFP) was measured in standing using a digital vernier caliper and was the relative linear distance between the lateral and the medial malleoli.20 participants aged 21–28 volunteered for the study and were measured on both ankles. It was found that Intra-tester reliability (ICC) ranged from 0.88 to 0.97 for AD and DFP; while inter-tester reliability (ICC) was 0.6 for AD and 0.77 for DFP. In addition for measures across trials, the standard error of the measurement (SEM) was, on average 0.66 mm for AD and 1.7 mm for DFP. While the limits of agreement (LOA) was ±0.17 mm for AD and ±4.03 mm for DFP. However, the SEM and LOA between testers was 2.27 mm and ±2.27 mm respectively for AD; and for 3.1 mm and ±10.4 mm for DFP. Overall the results suggest that both measures, as defined in this study exhibit moderate to good reliability and low standard error of measurement, suggesting a high degree of repeatability across trials.

The efficacy of targeted interventions for modifiable psychosocial risk factors of persistent nonspecific low back pain – A systematic review - Corrected Proof

Peter Kent, Per Kjaer — 2012-03-16

Abstract: Background: There is considerable interest in whether best practice management of nonspecific low back pain (NSLBP) should include the targeting of treatment to subgroups of people with identifiable clinical characteristics. However, there are no published systematic reviews of the efficacy of targeted psychosocial interventions.Aim: This review aimed to determine if the efficacy of interventions for psychosocial risk factors of persistent NSLBP is improved when targeted to people with particular psychosocial characteristics.Method: Bibliographic databases were searched. Inclusion criteria were randomised controlled trials of targeted psychosocial interventions that used trial designs capable of providing robust information on the efficacy of targeted treatment (treatment effect modification) for the outcomes of pain, activity limitation and psychosocial factors (fear avoidance, catastrophisation, anxiety and depression).Results and conclusion: Four studies met the inclusion criteria and collectively investigated nine hypotheses about targeted treatment on 28 subgroup/treatment outcomes. There were only two statistically significant results. Graded activity plus Treatment Based Classification targeted to people with high movement-related fear was more effective than Treatment Based Classification at reducing movement-related fear at 4 weeks. Active rehabilitation (physical exercise classes with cognitive-behavioural principles) was more effective than usual GP care at reducing activity limitation at 12 months, when targeted to people with higher movement-related pain.Few studies have investigated targeted psychosocial interventions in NSLBP, using trial designs suitable for measuring treatment effect modification, and they do not provide consistent evidence supporting such targeting. There is a need for appropriately designed and adequately powered trials to investigate targeted psychosocial interventions.

Spinal manual therapy produces rapid onset analgesia in a rodent model - Corrected Proof

Jane E. Grayson, Tom Barton, Peter J. Cabot, Tina Souvlis — 2012-03-15

Abstract: A rapid hypoalgesic effect following spinal manual therapy (SMT) has been demonstrated in humans. Although the characteristics of the pain relief are well described, the mechanisms have remained speculative. The purpose of this suite of studies was to investigate the effects of SMT on pain measures using animal models. This study employed a randomized, controlled design. Study 1: Rats without inflammation were allocated to either a treatment group (n = 6) that received three applications of joint mobilization centrally over L5 or a sham-treated group (n = 6) who received non-specific handling. Pressure pain threshold (PPT) and thermal pain threshold (TPT) were measured before and immediately after each intervention. Results demonstrated significantly increased mechanical nociceptive thresholds in the SMT group (p = 0.01) compared to that of the sham-treated group but no difference for thermal nociceptive thresholds. Study 2: The time course effect of an inflammatory and mechanical response following i.pl injection of inflammatory mediators was investigated to determine the appropriate time period for a treatment intervention. Study 3: The effects of SMT on mechanical nociception were investigated following interplanar injection of inflammatory mediators into the right hind paw of rats as a pain model (n = 6 for both SMT and sham-treated groups). Injection of endogenous metabolites produced significant swelling and flaring as well as increased PPT values following SMT (p < 0.02) compared with controls. These results demonstrate a rapid analgesic response following application of SMT, which has similar characteristics as that seen in both symptomatic and asymptomatic human populations.

Within-day reliability of shoulder range of motion measurement with a smartphone - Corrected Proof

Seung Han Shin, Du Hyun Ro, O-Sung Lee, Joo Han Oh, Sae Hoon Kim — 2012-03-15

Abstract: Measuring range of motion (ROM) is the first step of a physical examination and functional evaluation of the shoulder joint. Digital inclinometers are available on the market; however, they are expensive, and hence will not come into wide use. In this study, we present a new method for the shoulder ROM measurement using the inclinometer application on a smartphone. We hypothesized that the method would demonstrate acceptable reliability and reproducibility. Three observers performed goniometric and smartphone inclinometric measurements of various shoulder movements, including both active and passive ROM for forward flexion, abduction, external rotation while the arms are at the sides, external rotation at 90° abduction, and internal rotation at 90° abduction. Measurements were performed in the affected shoulders of 41 patients. All measurements were taken twice to assess the intra-observer reliability. Inter- and intra-observer reliabilities were evaluated using the intraclass correlation coefficient (ICC). Reliability between two measurements was also assessed in terms of the ICC. Both the goniometric and inclinometric measurements showed satisfactory inter-observer reliability except for internal rotation at 90° abduction for which the ICC value was <0.7 (range, 0.63–0.68). Intra-observer reliability was excellent with an ICC value>0.9, except for some movements. Within-day inclinometric measurements with a smartphone showed acceptable reliability compared to the classical goniometric measurements of movements and the correlation between the two measurements was fairly high. Considering convenience and cost-effectiveness, this new method could be widely used for measuring the shoulder ROM, although the between-day reliability needs to be established first.

Mixed methods research – So far easier said than done? - Corrected Proof

Anne Marit Mengshoel — 2012-03-14

Abstract: Mixed methods research (MMR) involves the application of both quantitative and qualitative approaches in a single study, and has been advocated for physiotherapy research. MMR studies are considered to be useful in cases where several different but related research questions are examined or when the purpose is to triangulate quantitative and qualitative data addressing one research question. Few MMR studies have been published in physiotherapy journals, and no papers are found to discuss the actual experience of conducting an MMR study. In this paper an MMR study is used to exemplify how a study applying a concurrent triangulation design was performed, and some aspects related to performing MMR are discussed. Some challenges are identified, and questions are raised about how to incorporate the findings of the two data sets and which skills are needed for doing MMR.

Vibration testing: A pilot study investigating the intra-tester reliability of the Vibrameter for the Median and Ulnar nerves - Corrected Proof

Gill James, Claire Scott — 2012-03-14

Abstract: The measurement of vibration thresholds (VTs) is a sensitive test for identifying and monitoring neuropathies. Such a test needs established reliability. The purpose of this research was to evaluate the intra-tester reliability of VT measurements of the Median and Ulnar nerves in asymptomatic participants.A double blinded repeated measures study was carried out. The VTs of the Median and Ulnar nerves were measured on two occasions with seven days between measurements. Participants were trained in identifying the sensation before commencing measurement. 22 participants who fulfilled the inclusion criteria were recruited.Intra-rater reliability was analysed used the intra-class correlation. The median nerve showed excellent reliability (ICC = .922; standard error of the mean = .0225 μm; ‘true’ SEM = .045 μm; smallest real difference = .062 μm). Ulnar nerve reliability was ‘substantial’ (ICC = .632; standard error of the mean = .0225 μm; ‘true’ SEM = .055 μm; smallest real difference = .085 μm).The VT measurements showed excellent to substantial reliability. The Vibrameter has the potential for excellent reliability providing manual therapists practice the technique of using it. It could usefully be considered by manual therapists to support their practice.

Effects of external pelvic compression on form closure, force closure, and neuromotor control of the lumbopelvic spine – A systematic review - Corrected Proof

Ashokan Arumugam, Stephan Milosavljevic, Stephanie Woodley, Gisela Sole — 2012-03-05

Abstract: Optimal lumbopelvic stability is a function of form closure (joint anatomy), force closure (additional compressive forces acting across the joints) and neuromotor control. Impairment of any of these mechanisms can result in pain, instability, altered lumbopelvic kinematics, and changes in muscle strength and motor control. External pelvic compression (EPC) has been hypothesised to have an effect on force closure and neuromotor control. However, the specific application parameters (type, location and force) and hypothesized effects of EPC are unclear. Thus, a systematic review was conducted to summarize the in vivo and in vitro effects of EPC. Eighteen articles met the eligibility criteria, with quality ranging from 33% to 72% based on a modified Downs and Black index. A modified van Tulder’s rating system was used to ascertain the level of evidence synthesised from this review. There is moderate evidence to support the role of EPC in decreasing laxity of the sacroiliac joint, changing lumbopelvic kinematics, altering selective recruitment of stabilizing musculature, and reducing pain. There is limited evidence for effects of EPC on decreasing sacral mobility, and affecting strength of muscles surrounding the SIJ, factors which require further investigation.

Low back pain post partum – A case report - Corrected Proof

Neasa De Búrca — 2012-02-27

Abstract: Sacral stress fracture is an unusual source of low back pain and can be easily confused with a number of other clinical conditions seen in physiotherapy clinics. The purpose of this case report is to describe the case of a patient presenting with low back pain post partum illustrating pertinent aspects of differential diagnosis and issues of management. A 31 year old female presented complaining of low back pain since the birth of her second child 11 months earlier. Subjective and objective examination led the Therapist to consider a diagnosis of sacral stress fracture. This diagnosis was confirmed by MRI. Three months after presenting to physiotherapy the patient was pain free and had returned to all aspects of her daily life without any difficulties. Clinicians must be aware of the less common pathologies in any hypotheses development. A careful history and physical examination and broad hypotheses generation will ensure that patients are accurately diagnosed and receive appropriate and effective treatments.

The Active Straight Leg Raise test in lumbopelvic pain during pregnancy - Corrected Proof

Jan M.A. Mens, Yvonne H. Huis in ’t Veld, Annelies Pool-Goudzwaard — 2012-02-24

Abstract: Although many properties of the Active Straight Leg Raise (ASLR) test as a diagnostic test in lumbopelvic pain (LPP) are well documented, various elements are lacking. A cross-sectional study was performed to compute sensitivity and specificity, to assess the advantages and disadvantages of various cutoff points, to analyze the relation between the ASLR test and the Posterior Pelvic Pain Provocation (PPPP) test, and to investigate the relation with confounders.Data of 110 women with LPP and 72 without LPP were available. The advantages and disadvantages of four cutoff points of ASLR, and combinations of the ASLR and PPPP, were investigated by comparing sensitivity, specificity and area under the curves (AUC) of receiver operating characteristic curves (ROC). The influence of the site of pain was analyzed by means of AUC. The relation with confounders was measured using Pearson correlation coefficients.Results show that for diagnostic use the best cutoff for the ASLR test in pregnancy is between score 0 and 1. Specificity of the ASLR test is good (88%). Sensitivity for all types of LPP during pregnancy is moderate (54%), and is larger in case of more pain and disability. When combined with the PPPP test, sensitivity of the ASLR test is larger (68%). Isolated symphyseal pain, isolated low back pain and isolated coccyx pain are not diagnosed by these two tests. The ASLR test is not influenced by age, number of previous deliveries, BMI, cause of LPP (pregnancy-related or not), the existence of urinary incontinence and/or level of fatigue.

Sacroiliac joint and weight distribution to feet: An opinion towards clinical and research practice – Authors reply - Corrected Proof

2012-01-16

We appreciate the queries brought forth and would like to share our point of view regarding our article. The study by is part of an ongoing larger research study related to functional alterations in gait, balance, and weight distribution behavior in response to manual therapy interventions. We agree that walking resembles more closely the functional mobility of the sacroiliac joint (SIJ). However, force transmission during standing is also a fundamental role of the joint due to its anatomical and functional nature (), and we opted to utilize only baropodometric values during standing.

Derangement of the temporomandibular joint; a case study using Mechanical Diagnosis and Therapy - Corrected Proof

C. Krog, S. May — 2011-12-19

Abstract: Mechanical Diagnosis and Therapy (MDT) is widely used for spinal problems, and more recently the principles and mechanical syndromes have been applied to extremity musculoskeletal problems. One of the most common classifications is derangement syndrome, which describes a presentation in which repeated movements causes a decrease in symptoms and a restoration of restricted range of movement. The case study describes the application of repeated movements to a patient with a 7-year history of non-specific temporomandibular pain and reduced function, who had had lots of previous failed treatment. Examination using repeated movements resulted in a classification of derangement, and the patient rapidly responded in 4 treatment sessions, with an abolition of pain and full restoration of function, and remained improved after many years. The case study demonstrates the application of Mechanical Diagnosis and Therapy principles to a patient with a temporomandibular problem.

Cross-frictional therapy and stretching for the treatment of palmar adhesions due to Dupuytren’s contracture: A prospective case study - Corrected Proof

W. Scott Christie, Aaron A. Puhl, Octavian Calin Lucaciu — 2011-11-28

Abstract: Objective: To examine the potential for treatment of palmar adhesions associated with Dupuytren’s contracture using instrument-assisted cross-frictional massage (CFM) and stretching.Methods: This was a prospective case study. The primary intervention consisted of a 2-min multi-planar CFM over the affected area of the palm, followed by a 2-min maximal finger-extension stretch.Results: Following eight weeks of treatment there were increases in both passive and active extension range of motion of the digits, reduction in the visibility of palmar adhesions, and subjective improvements in hand function.Conclusions: This treatment protocol may offer a substitute for the current invasive surgical and injection procedures that are available.

Augmented home exercise program for a 37-year-old female with a clinical presentation of femoroacetabular impingement - Corrected Proof

Alexis A. Wright, Eric J. Hegedus — 2011-11-14

Abstract: Previous researchers have reported on the use of augmented home exercise programs with potential carry-over effects from manual therapy treatment. While there is no direct evidence to support augmented manual therapy, tangential evidence demonstrates that specific, supervised, and adherent exercises result in improved outcomes. The purpose of this case report is to describe an augmented home program simulating the manual techniques provided by the therapist. A 37-year-old female presented with symptoms and signs consistent with femoroacetabular impingement (FAI). Grade III lateral and inferior femoral glides decreased reported pain from 5/10 to 0/10. Given the immediate response to hip mobilizations, the patient was prescribed standing lateral glides and supine inferior glides of the hip with the use of a belt. During this time, the patient’s Lower Extremity Functional Scale score improved from 74 to 78 and she reported increased ability to self-manage her symptoms. The immediate report of decreased pain helped determine the specific home program selected for this individual patient. This case highlights the importance of a specific augmented home exercise program unique to the individual patient resulting in self-management of pain associated with FAI.

Sacroiliac joint and weight distribution to feet: An opinion towards clinical and research practice - Corrected Proof

Leonard Joseph, Aatit Puangmali, Ubon Pirunsan, Srijit Das — 2011-10-20

We enjoyed reading the published manuscript entitled ‘Immediate and lasting improvements in weight distribution seen in baropodometry following a high-velocity, low-amplitude thrust manipulation of the sacroiliac joint.’ by . We thought of sharing our views on the published article. The authors took a common clinical concept and related it eloquently to sacroiliac joint dysfunction and after effects of sacroiliac manipulation.