Manual Therapy - Articles in Press

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

N. Dickx, B. Cagnie, T. Parlevliet, 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.

Geoffrey Douglas Maitland MBE - A tribute from Musculoskeletal Physiotherapy Australia - Corrected Proof

Patricia Trott, Ruth Grant — 2010-03-08

Internationally renowned physiotherapist Born: 27 August 1924, Adelaide

A tribute to the life and work of G.D. Maitland 1924–2010 by the International Maitland Teachers Association - Corrected Proof

2010-03-08

Geoff Maitland passed away peacefully on Friday 22 January 2010 almost one year after the death of his dear wife Anne. It is, therefore, a poignant time for the whole of the Physiotherapy World to stop and reflect upon the achievements and legacy of a man who has done as much as anyone to shape and define the Physiotherapy profession as it is today.

Tribute to Geoffrey Maitland (1924–2010) by the manipulation association of chartered physiotherapists (UK) - Corrected Proof

2010-03-08

“If I have seen further, it is by standing on the shoulders of giants” – Sir Isaac Newton's quote could aptly be applied to the progression of the physiotherapy profession, and its debt of gratitude to one of its own giants and pioneers, Geoffrey Maitland MBE.

An alternative intervention for urinary incontinence: Retraining diaphragmatic, deep abdominal and pelvic floor muscle coordinated function - Corrected Proof

Hsiu-Chuan Hung, Sheng-Mou Hsiao, Shu-Yun Chih, Ho-Hsiung Lin, Jau-Yih Tsauo — 2010-02-25

Abstract: This study was a randomized controlled trial to investigate the effect of treating women with stress or mixed urinary incontinence (SUI or MUI) by diaphragmatic, deep abdominal and pelvic floor muscle (PFM) retraining. Seventy women were randomly allocated to the training (n = 35) or control group (n = 35). Women in the training group received 8 individual clinical visits and followed a specific exercise program. Women in the control group performed self-monitored PFM exercises at home. The primary outcome measure was self-reported improvement. Secondary outcome measures were 20-min pad test, 3-day voiding diary, maximal vaginal squeeze pressure, holding time and quality of life. After a 4-month intervention period, more participants in the training group reported that they were cured or improved (p < 0.01). The cure/improved rate was above 90%. Both amount of leakage and number of leaks were significantly lower in the training group (p < 0.05) but not in the control group. More aspects of quality of life improved significantly in the training group than in the control group. Maximal vaginal squeeze pressure, however, decreased slightly in both groups. Coordinated retraining diaphragmatic, deep abdominal and PFM function could improve symptoms and quality of life. It may be an alternative management for women with SUI or MUI.

Standardized simulated palpation training – Development of a Palpation Trainer and assessment of palpatory skills in experienced and inexperienced clinicians - Corrected Proof

2010-02-19

Abstract: Specific palpation skills are required to identify and treat myofascial pain. The aim of this study was to develop a device that reflects absolute pressure values during simulated palpation, and to test the hypothesis that training through standardized manual palpation results in improved skills for experienced and inexperienced examiners. Experienced (n = 30) and inexperienced (n = 30) examiners were randomly divided into either training or control. A device (Palpation Trainer) was constructed to measure pressure intensity (Ppeak) and rate of pressure development (RPD). Training consisted of 8–10 min standardized simulated palpation, during which examiners followed a standardized pressure–time curve (visualized in real-time on a pc-monitor). Controls received no training. Tests were performed at baseline, immediately post training and again after 48 h and analyzed for Ppeak and RPD. After simulated palpation training, experienced examiners improved palpatory skills related to Ppeak and RPD (i.e. performed closer to predetermined guidelines and with reduced inter-examiner variation), while inexperienced examiners only improved RPD (p < 0.05). Thus, standardized training resulted in acute and temporary (48 h) changes in selected analysis variables during simulated palpation in experienced and to some extent also in inexperienced clinicians. Whether this can be transferred to clinical in vivo setting requires further study.

Barriers to treatment adherence in physiotherapy outpatient clinics: A systematic review - Corrected Proof

Kirsten Jack, Sionnadh Mairi McLean, Jennifer Klaber Moffett, Eric Gardiner — 2010-02-17

Abstract: Poor adherence to treatment can have negative effects on outcomes and healthcare cost. However, little is known about the barriers to treatment adherence within physiotherapy. The aim of this systematic review was to identify barriers to treatment adherence in patients typically managed in musculoskeletal physiotherapy outpatient settings and suggest strategies for reducing their impact. The review included twenty high quality studies investigating barriers to treatment adherence in musculoskeletal populations. There was strong evidence that poor treatment adherence was associated with low levels of physical activity at baseline or in previous weeks, low in-treatment adherence with exercise, low self-efficacy, depression, anxiety, helplessness, poor social support/activity, greater perceived number of barriers to exercise and increased pain levels during exercise. Strategies to overcome these barriers and improve adherence are considered. We found limited evidence for many factors and further high quality research is required to investigate the predictive validity of these potential barriers. Much of the available research has focussed on patient factors and additional research is required to investigate the barriers introduced by health professionals or health organisations, since these factors are also likely to influence patient adherence with treatment.

Pain severity and catastrophising modify treatment success in neck pain patients in primary care - Corrected Proof

2010-02-08

Abstract: The objective of this study was to evaluate whether clinical factors at baseline in patients with non-specific neck pain are related to recovery after treatment with manual therapy versus physiotherapy. Participating physiotherapists recruited new consulters with complaints of the neck and/or upper extremity. For this study we selected patients from this cohort with non-specific neck complaints. Participants filled in questionnaires at baseline, 3 and 6 months. The main outcome measure was recovery at 6 months follow-up. Possible predictors like complaint-specific factors, physical factors, social and psychological factors were evaluated for interaction with treatment. Of the 396 participants in this study, 97 (24.5%) received manual therapy, all others received physiotherapy, consisting of exercises, massage or physical applications. In the multivariable model four variables were significantly related to recovery: duration of complaint, catastrophising, distress and somatisation. Severity of main complaint and catastrophising appeared to show interaction with treatment. It appeared that every point increase in severity or catastrophising resulted in a lower chance to recover from physiotherapy compared to manual therapy.In conclusion, severity of main complaint and catastrophising seem to modify treatment success. Increased pain severity or catastrophising at baseline increased the chance of treatment success after manual therapy compared to physiotherapy.

Comparing postural strategy changes following adapted versus non-adapted responses in subjects with and without spinal stenosis - Corrected Proof

Paul S. Sung, Yong Woon Ham — 2010-02-01

Abstract: Musculoskeletal evaluation skills are needed to examine postural compensation techniques, but little is known about ground reaction forces (GRF) in standing posture. Even though a number of studies have evaluated GRF in patients with low back pain (LBP) during vertical perturbations, it would be important to consider compensation characteristics which might be associated with abnormal patterns of postural responses. The vertical excursions of the body center of mass (BCOM) were measured with delay time and normalized amplitude of GRF. Overall, there was no difference based on the vertical excursion of the BCOM (F=0.12, p=0.90), amplitude of the normalized GRF (F=0.16, p=0.74), or response time (F=1.98, p=0.17) between subjects with and without spinal stenosis.There was a gender difference based on the vertical excursion of the normalized BCOM (F=5.92, p=0.02) as well as the normalized amplitude of GRF (F=4.17, p=0.04). It was shown that male subjects implemented better adjustment strategies during adapted and non-adapted responses in order to improve body stability. In this way, manual therapists should be aware that gender differences exist in patients with spinal stenosis since the condition may change the individual's postural adjustment ability.

Pelvic girdle pain, clinical tests and disability in late pregnancy - Corrected Proof

2010-02-01

Abstract: The objective of this cross-sectional study was to explore the associations between pain locations, responses to the posterior pelvic pain provocation (P4) test, responses to the active straight leg raise (ASLR) test and disability in late pregnancy.283 women in gestation week 30 (mean age 31.3 years; 59% nullipara) completed a questionnaire (including pain drawing and Disability Rating Index, DRI). A physiotherapist blinded for the questionnaire data assessed responses to the P4 and ASLR tests. The pain drawing was used to: 1) distinguish between Pelvic girdle pain (PGP) and low back pain (LBP); 2) discriminate between pain locations within the pelvic area.A large variation was found in DRI within each pain location group. Women with PGP were more afflicted than the women with LBP and those without PGP. Highest DRI score was reported by women having combined symphysis pain and bilateral posterior pain. The multivariate analyses showed that results from P4 and ASLR contributed independently to DRI. Taken together, pain location combined with responses to P4 and ASLR tests are relevant when evaluating affliction in pregnant women with possible PGP.

A detailed characterisation of pain, disability, physical and psychological features of a small group of adolescents with non-specific chronic low back pain - Corrected Proof

Roslyn G. Astfalck, Peter B. O'Sullivan, Leon M. Straker, Anne J. Smith — 2010-01-29

Abstract: The objective of the study was to provide a detailed biopsychosocial evaluation of adolescent NSCLBP compared to those without LBP. NSCLBP was described by pain level, duration, levels of disability and kinesiophobia, aggravating factors and functional movements. Each pain subject was sub-classified using the O'Sullivan system. Groups were compared on physical activity levels, sitting posture, trunk extensor and thigh muscle endurance, psychosocial behaviour, depression, family functioning and exposure to stressful life events. Adolescents with NSCLBP reported moderate levels of pain (4.4/10 ± 1.9), disability (17.9 ± 10.1%) and fear avoidance beliefs (36.1/68 ± 7.1). Differences between control and pain groups were only found for back muscle (p = 0.033) and squat endurance times (p = 0.032) and stressful life events (p = 0.030). Differences in sitting posture between pain and no pain groups were only found when pain subjects were sub-classified (lumbar angle p = 0.001). In conclusion, adolescents with NSCLBP reported moderate pain and disability with deficits in trunk and squat endurance. That they remained physically active is at odds with the activity avoidance and subsequent deconditioning model proposed for adults with NSCLBP. Differences between control and pain groups on history of stressful life events suggest this may contribute to adolescent NSCLBP. Differences with sitting posture are only seen when patients were sub-classified.

Depression may contribute to the sensory changes in whiplash patients? Re: Chien, A, Sterling, M. Sensory hypoaesthesia is a feature of chronic whiplash but not chronic idiopathic neck pain – Authors reply - Corrected Proof

Michele Sterling — 2010-01-27

I would like to thank Wand and colleagues for their comments on our paper. I agree that psychological factors (including depression but not only depression) may influence the results of sensory testing in whiplash and other musculoskeletal conditions. Indeed we have already shown some association between psychological distress, posttraumatic stress symptoms and sensory hypersensitivity (). Elevated sensory detection thresholds are also a feature of other psychological conditions such as posttraumatic stress disorder () and posttraumatic stress symptoms show some association with hypoaesthesia in whiplash (). Thus the point here is that various psychological factors may be associated with altered sensory perception.

Adverse events and manual therapy: A systematic review - Corrected Proof

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.

Depression may contribute to the sensory changes in whiplash patients? Re: Chien, A, Sterling, M. Sensory hypoaesthesia is a feature of chronic whiplash but not chronic idiopathic neck pain. Manual therapy 2010;15:48–53. - Corrected Proof

Benedict Martin Wand, Neil O'Connell, Luke Parkitny — 2010-01-25

We read with great interest the recent paper by Chien and Sterling contrasting the sensory impairments of patients with chronic whiplash and chronic idiopathic neck pain (). Work from this group has previously provided invaluable insight into the problem of whiplash and this paper is no exception. In this study, chronic whiplash patients demonstrated sensory hypoaesthesia whereas idiopathic neck pain patients did not, and while both patient groups had lowered pressure pain thresholds, only the whiplash group demonstrated lowered cold pain thresholds.

Assessment of pelvic floor muscle function in women with and without low back pain using transabdominal ultrasound - Corrected Proof

Amir Massoud Arab, Roxana Bazaz Behbahani, Leila Lorestani, Afsaneh Azari — 2010-01-21

Abstract: Pelvic floor muscle (PFM) dysfunction has been recently associated with the development of low back pain (LBP). Transabdominal ultrasound imaging has been established as an appropriate method for visualizing and measuring PFM function. No study has directly evaluated PFM function in individuals with and without LBP. The purpose of this study was to investigate the PFM function in women with and without LBP using transabdominal ultrasound. Convenience sample of 40 non-pregnant female participated in the study. Subjects were categorized into two groups: with LBP (n = 20) and without LBP (n = 20). The amount of bladder base movement on ultrasound (normalized to body mass index) was measured in all subjects and considered as an indicator of PFM function. Statistical analysis (Independent t-test) revealed significant difference in transabdominal ultrasound measurements for PFM function between the two groups (P = 0.04, 95% CI of difference: 0.002–0.27).The results of this study indicate PFM dysfunction in individuals with LBP compared to those without LBP. The results could be beneficial to clinicians when assessing and prescribing therapeutic exercises for patients with LBP.

Sympathetic nervous system effects in the hands following a grade III postero-anterior rotatory mobilisation technique applied to T4: A randomised, placebo-controlled trial - Corrected Proof

Pete Jowsey, Jo Perry — 2010-01-21

Abstract: Joint mobilisation to the T4 vertebra has been advocated as a treatment for T4 syndrome. To date no controlled studies have investigated the effects of thoracic spinal manual therapy (SMT) applied to T4 on sympathetic activity in the hands. This study investigated whether a grade III postero-anterior rotatory joint mobilisation technique applied to the T4 vertebra at a frequency of 0.5 Hz had demonstrably greater effects than a validated placebo intervention on skin conductance (SC) in the hands of healthy subjects.A power analysis calculation was performed and using a double blind, placebo-controlled, independent groups design, 36 healthy subjects (18–35 years) were randomly assigned to two groups (placebo intervention or treatment intervention). A BioPac unit recorded continuous SC measures before, during and after each experimental intervention. An exit questionnaire was used to validate the expectancy effects of the placebo intervention. Results demonstrated a significant difference between groups in SC in the right hand during the post-treatment rest period (F = 4.888, p = 0.034); with the treatment intervention being sympathoexcitatory in nature. A trend towards a significant difference between groups was also demonstrated in the left hand during the rest period (F = 4.072, p = 0.052).This study provides preliminary evidence that joint mobilisation applied to the T4 vertebra at a frequency of 0.5 Hz can produce sympathoexcitatory effects in the hand. Further research is recommended in a patient population.

Influence of prolonged unilateral cervical muscle contraction on head repositioning – Decreased overshoot after a 5-min static muscle contraction task - Corrected Proof

2010-01-18

Abstract: The ability to reproduce a specified head-on-trunk position can be an indirect test of cervical proprioception. This ability is affected in subjects with neck pain, but it is unclear whether and how much pain or continuous muscle contraction factors contribute to this effect. We studied the influence of a static unilateral neck muscle contraction task (5 min of lateral flexion at 30% of maximal voluntary contraction) on head repositioning ability in 20 subjects (10 women, 10 men; mean age 37 years) with healthy necks. Head repositioning ability was tested in the horizontal plane with 30° target and neutral head position tests; head position was recorded by Zebris®, an ultrasound-based motion analyser. Head repositioning ability was analysed for accuracy (mean of signed differences between introduced and reproduced positions) and precision (standard deviation of the differences). Accuracy of head repositioning ability increased significantly after the muscle contraction task, as the normal overshoot was reduced. An average overshoot of 7.1° decreased to 4.6° after the muscle contraction task for the 30° target and from 2.2° to 1.4° for neutral head position. The increased accuracy was most pronounced for movements directed towards the activated side. Hence, prolonged unilateral neck muscle contraction may increase the sensitivity of cervical proprioceptors.

What is ‘manipulation’? A reappraisal - Corrected Proof

David W. Evans, Nicholas Lucas — 2010-01-18

Abstract: Due primarily to its colloquial function, ‘manipulation’ is a poor term for distinguishing one healthcare intervention from another. With reports continuing to associate serious adverse events with manipulation, particularly relating to its use in the cervical spine, it is essential that the term be used appropriately and in accordance with a valid definition. The purpose of this paper is to identify empirically-derived features that we propose to be necessary and collectively sufficient for the formation of a valid definition for manipulation. A final definition is not offered. However, arguments for and against the inclusion of features are presented. Importantly, these features are explicitly divided into two categories: the ‘action’ (that which the practitioner does to the recipient) and the ‘mechanical response’ (that which occurs within the recipient). The proposed features are: 1) A force is applied to the recipient; 2) The line of action of this force is perpendicular to the articular surface of the affected joint; 3) The applied force creates motion at a joint; 4) This joint motion includes articular surface separation; 5) Cavitation occurs within the affected joint.

Treatment of myofascial pain in the shoulder with Kinesio Taping. A case report - Corrected Proof

Francisco García-Muro, Ángel L. Rodríguez-Fernández, Ángel Herrero-de-Lucas — 2009-10-16

Kinesio Taping was a technique developed by Dr. Kenzo Kase in the 70s. The adhesive pliable material, directly applied to the skin, differs from classical tape in its physical characteristics. Furthermore, its clinical application departs from the usual restriction of mobility. This technique claims four effects: to normalize muscular function, to increase lymphatic and vascular flow, to diminish pain and aid in the correction of possible articular malalignments (). This taping technique is frequently applied for pathologies in the musculoskeletal system, especially in the field of sports injuries ().

Why do spinal manipulation techniques take the form they do? Towards a general model of spinal manipulation - Corrected Proof

David W. Evans — 2009-05-12

Abstract: For centuries, techniques used to manipulate joints in the spine have been passed down from one generation of manipulators to the next. Today, spinal manipulation is in the curious position that positive clinical effects have now been demonstrated, yet the theoretical base underpinning every aspect of its use is still underdeveloped. An important question is posed in this masterclass: why do spinal manipulation techniques take the form they do? From the available literature, two factors appear to provide an answer: 1. Action of a force upon vertebrae. Any ‘direct’ spinal manipulation technique requires that the patient be orientated in such a way that force is applied perpendicular to the overlying skin surface so as to act upon the vertebrae beneath. If the vertebral motion produced by ‘directly’ applied force is insufficient to produce the desired effect (e.g. cavitation), then force must be applied ‘indirectly’, often through remote body segments such as the head, thorax, abdomen, pelvis, and extremities. 2. Spinal segment morphology. A new hypothesis is presented. Spinal manipulation techniques exploit the morphology of vertebrae by inducing rotation at a spinal segment, about an axis that is always parallel to the articular surfaces of the constituent zygapophysial joints. In doing so, the articular surfaces of one zygapophysial joint appose to the point of contact, resulting in migration of the axis of rotation towards these contacting surfaces, and in turn this facilitates gapping of the other (target) zygapophysial joint. Other variations in the form of spinal manipulation techniques are likely to depend upon the personal style and individual choices of the practitioner.