Manual Therapy - Articles in Press

Cortical changes in chronic low back pain: Current state of the art and implications for clinical practice - Corrected Proof

2010-07-26

Abstract: There is increasing evidence that chronic pain problems are characterised by alterations in brain structure and function. Chronic back pain is no exception. There is a growing sentiment, with accompanying theory, that these brain changes contribute to chronic back pain, although empirical support is lacking. This paper reviews the structural and functional changes of the brain that have been observed in people with chronic back pain. We cast light on the clinical implications of these changes and the possibilities for new treatments but we also advise caution against concluding their efficacy in the absence of solid evidence to this effect.

A tissue velocity ultrasound imaging investigation of the dorsal neck muscles during resisted isometric extension - Corrected Proof

Anneli Peolsson, Lars-Åke Brodin, Michael Peolsson — 2010-07-23

Abstract: Persons with neck pain exhibit altered patterns of muscle patterning, but limited investigations have been carried out on these alterations or muscle patterning in healthy volunteers. This study investigated the tissue motion of the dorsal neck muscles at the C4 segmental level in 15 healthy subjects during manually resisted head extension. Doppler-based tissue velocity ultrasound imaging (TVI) was used to detect regional tissue deformation, providing indirect evidence of inter-muscular movement patterning. The deep muscles, multifidus and semispinalis, had different muscular movement patterning than the superficial muscles, especially the trapezius muscle. The semispinalis cervicis (SSCerv) was the first deformed upon exercise initiation, followed by multifidus and semispinalis capitis (SSCap). The semispinalis muscles, notably capitis, exhibited a high rate of deformation during the exercise. The trapezius muscle exhibited the least and lowest deformation rate. In conclusion, TVI provided detailed information on regional tissue activity and muscle movement patterning among the dorsal neck muscles. In future studies, data from patients with neck disorders will have to be matched to data from healthy volunteers in a variety of situations and activities.

The effect of a scapular postural correction strategy on trapezius activity in patients with neck pain - Corrected Proof

Sally Wegner, Gwendolen Jull, Shaun O’Leary, Venerina Johnston — 2010-07-22

Abstract: Extensive computer use amongst office workers has lead to an increase in work-related neck pain. Aberrant activity within the three portions of the trapezius muscle and associated changes in scapular posture have been identified as potential contributing factors. This study compared the activity (surface electromyography) of the three portions of the trapezius in healthy controls (n=20) to a neck pain group with poor scapular posture (n=18) during the performance of a functional typing task. A scapular postural correction strategy was used to correct scapular orientation in the neck pain group and electromyographic recordings were repeated. During the typing task, the neck pain group generated greater activity in the middle trapezius (MT) (p=0.02) and less activity in the lower trapezius (LT) (p=0.03) than the control group. Following correction of the scapula, activity recorded by the neck pain group was similar to the control group for the middle and lower portions (p=0.09; p=0.91). These findings indicate that a scapular postural correction exercise may be effective in altering the distribution of activity in the trapezius to better reflect that displayed by healthy individuals.

Multimodal group rehabilitation compared to usual care for patients with chronic neck pain: A pilot study - Corrected Proof

Julie Sarah Hudson, Cormac Gerard Ryan — 2010-07-20

Abstract: The aim of this pilot randomised controlled trial (RCT) was to compare multimodal group rehabilitation to usual care physiotherapy for patients with chronic neck pain (CNP). Participants (n=14) were randomly assigned to one of two interventions, multimodal group rehabilitation or usual care physiotherapy. Multimodal group rehabilitation involved stability, strengthening and proprioceptive exercises along with an educational programme. Patients attended for 1h, once a week for six weeks. The usual care group was treated as deemed appropriate by their physiotherapist. A blinded assessor recorded baseline and post-intervention scores of disability and pain using the neck disability index (NDI) and the 0–10 pain numerical rating scale (NRS), respectively. One participant from each group dropped out before receiving any intervention. Post-intervention both groups significantly improved in both function and pain scores (p≤0.01). The mean change in the NDI scores for the multimodal group versus the usual care group were 12.3±5.3% and 7.4±4.8%, and pain NRS score changes were 4.6±2.3 and 4.5±2.2, respectively. There was no significant difference in improvements in disability (p=0.84) or pain (p=0.67) between groups. These results warrant further investigation of multimodal group rehabilitation for CNP, and provide data to inform an appropriately powered full-scale RCT with long-term follow-up.

Neutral lumbar spine sitting posture in pain-free subjects - Corrected Proof

2010-07-20

Abstract: Sitting is a common aggravating factor in low back pain (LBP), and re-education of sitting posture is a common aspect of LBP management. However, there is debate regarding what is an optimal sitting posture. This pilot study had 2 aims; to investigate whether pain-free subjects can be reliably positioned in a neutral sitting posture (slight lumbar lordosis and relaxed thorax); and to compare perceptions of neutral sitting posture to habitual sitting posture (HSP). The lower lumbar spine HSP of seventeen pain-free subjects was initially recorded. Subjects then assumed their own subjectively perceived ideal posture (SPIP). Finally, 2 testers independently positioned the subjects into a tester perceived neutral posture (TPNP). The inter-tester reliability of positioning in TPNP was very good (intraclass correlation coefficient (ICC)=0.91, mean difference=3% of range of motion). A repeated measures ANOVA revealed that HSP was significantly more flexed than both SPIP and TPNP (p <0.05). There was no significant difference between SPIP and TPNP (p >0.05). HSP was more kyphotic than all other postures. This study suggests that pain-free subjects can be reliably positioned in a neutral lumbar sitting posture. Further investigation into the role of neutral sitting posture in LBP subjects is warranted.

Interventions for enhancing adherence with physiotherapy: A systematic review - Corrected Proof

Sionnadh Mairi McLean, Maria Burton, Lesley Bradley, Chris Littlewood — 2010-07-15

Abstract: Poor adherence to treatment is commonplace and may adversely affect outcomes, efficiency and healthcare cost. The aim of this systematic review was to identify strategies to improve adherence with musculoskeletal outpatient treatment. Five suitable studies were identified which provided moderate evidence that a motivational cognitive–behavioural (CB) programme can improve attendance at exercise-based clinic sessions. There was conflicting evidence that adherence interventions increase short-term adherence with exercise. There was strong evidence that adherence strategies are not effective at improving long-term adherence with home exercise. Due to the multi-dimensional nature of non-adherence, the strategies to improve adherence with physiotherapy treatment are likely to be broad in spectrum. Combined interventions may be effective at promoting adherence with clinic appointments and exercise, though further research would be required to confirm this. Further research to increase basic understanding of the factors, which act as a barrier to adherence, could facilitate development of strategies to overcome non-adherence.

Abdominal muscle contraction thickness and function after specific and general exercises: A randomized controlled trial in chronic low back pain patients - Corrected Proof

Ottar Vasseljen, Anne Margrethe Fladmark — 2010-07-12

Abstract: The aim of this study was to assess changes in deep abdominal muscle function after 8 weeks of exercise in chronic low back pain patients. Patients (n = 109) were randomized to specific ultrasound guided, sling or general exercises. Contraction thickness ratio in transversus abdominis (TrA), obliquus internus (OI) and externus (OE), and TrA lateral slide were assessed during the abdominal drawing-in maneuver by b-mode ultrasound. Changes in abdominal muscle function were also regressed on changes in pain. Only modest effects in deep abdominal muscle function were observed, mainly due to reduced activation of OI (contraction thickness ratio: 1.42–1.22, p = 0.01) and reduced TrA lateral slide (1.26–1.01 cm, p = 0.02) in the ultrasound group on the left side. Reduced pain was associated with increased TrA and reduced OI contraction ratio (R2 = 0.18). It is concluded that 6–8 treatments with specific or general exercises for chronic low back patients attained only marginal changes in contraction thickness and slide in deep abdominal muscles, and could only to a limited extent account for reductions in pain.

Soft tissue artefact in the thoracic spine during axial rotation and arm elevation using ultrasound imaging: A descriptive study - Corrected Proof

Nicola R Heneghan, George M. Balanos — 2010-07-12

Abstract: Much of the current understanding of thoracic motion analysis is based on the use of skin sensors or markers. Skin tissue artefact, movement occurring between the skin and underlying bone, is readily acknowledged by researchers as a source or measurement error, yet to date has not been quantified. The aim of this study was therefore to evaluate skin tissue artefact, during thoracic axial rotation and single arm elevation. Using an ultrasound imaging technique this study describes soft tissue artefact in the thoracic spine during axial rotation and single arm elevation in sitting using 30 asymptomatic individuals. The findings from this study indicate that soft tissue artefact (STA) in the mid thoracic region ranges between 14 and 16 mm for 35-degrees of rotation. During single arm elevation 0.8–1.5 mm STA was measured at the levels of T1–T6–T12. The results of this study suggests that STA is a considerable and variable source of error in all regions of the thoracic spine, but most notably for the mid thoracic region during axial rotation.

Reliability of a new hand-held dynamometer in measuring shoulder range of motion and strength - Corrected Proof

Angela Cadogan, Mark Laslett, Wayne Hing, Peter McNair, Maynard Williams — 2010-07-12

Abstract: Acceptable reliability is a prerequisite for inclusion of physical examination tests in clinical examinations of the painful shoulder. The aim of this study was to establish the intraexaminer and interexaminer reliability of measures of shoulder range of motion (ROM) and muscle force using a new hand-held dynamometer with the ability to standardize overpressure force during passive ROM tests. Forty consecutive subjects with shoulder pain were recruited, and tests were performed by two physiotherapists. Tests included active ROM elevation, passive ROM glenohumeral abduction and external rotation and resisted abduction and external rotation. All tests demonstrated high levels of intraexaminer reliability (ICC 0.85–0.99; LOA 6–24° and 1.1–7.0 kg). Highest levels of interexaminer reliability reliability were observed for measures of active ROM flexion (ICC 0.88–0.95; LOA 14–22°). Passive ROM tests demonstrated ’moderate – substantial’ interexaminer reliability (ICC 0.45–0.62; LOA 25–34°). The ICCs for resisted tests ranged from 0.68 to 0.84, and LOA ranged from 3.2 to 8.5 kg. Active ROM flexion demonstrated high levels of both intra- and interexaminer reliability. Measures of passive ROM and peak isometric force demonstrated acceptable levels of intraexaminer reliability.

Pelvic girdle pain: Potential risk factors in pregnancy in relation to disability and pain intensity three months postpartum - Corrected Proof

Hilde Stendal Robinson, Anne Marit Mengshoel, Marit B. Veierød, Nina Vøllestad — 2010-07-12

Abstract: The objective of this prospective cohort study was to examine how results of clinical tests on women with pelvic girdle pain (PGP) in late pregnancy were associated with disability and pain intensity 12 weeks postpartum controlling for socio-demographical and psychological factors.Out of the 283 women clinically examined in gestation week 30, 179 were considered afflicted from PGP and constituted the study sample.Potential risk factors were assessed by questionnaires (at inclusion and in gestation week 30) and clinical examination in gestation week 30. The clinical examination included pain provocation tests for the pelvis as well as the active straight leg raise test. We used pain intensity and disability (disability rating index, DRI) as response variables, derived from questionnaires 12 weeks postpartum.Using multivariable linear regression analyses, sum of pain provocation tests and pre-pregnancy low back pain (LBP) were significantly associated with DRI 12 weeks postpartum. Furthermore, sum of pain provocation tests and number of pain sites were significantly associated with pain intensity.In conclusion, we found that when including results of clinical tests as risk factors together with socio-demographical and psychological factors in multivariable regression models, the clinical risk factors are the ones that remain significant. These results are of clinical importance because they seem to have the potential to identify women with a poor prognosis.

The role of motor learning and neuroplasticity in designing rehabilitation approaches for musculoskeletal pain disorders - Corrected Proof

Shellie A. Boudreau, Dario Farina, Deborah Falla — 2010-07-08

Abstract: The extent of cortical neuroplastic changes has been shown to be a key neurophysiological feature that correlates with the level of functional recovery. Therefore, rehabilitation efforts that attempt to maximize cortical reorganization provide the greatest potential for rehabilitation success. This paper reviews the evidence of cortical neuroplastic changes that have been shown to occur in association with experimental or chronic pain disorders. Further, the promising role of novel motor-skill training is discussed in order to best direct the clinician to optimize rehabilitation strategies for patients with musculoskeletal pain disorders.

Scapular kinematics and impairment features for classifying patients with subacromial impingement syndrome - Corrected Proof

Cheng-Ju Hung, Mei-Hwa Jan, Yeong-Fwu Lin, Tyng-Quey Wang, Jiu-Jenq Lin — 2010-07-08

Abstract: Subacromial impingement syndrome (SAIS), which is associated with pain and a loss of function, has a high occurrence in the physically active population. Not all patients respond positively to treatment. Classifying patients can improve decision-making. The scapular kinematic and clinical impairments can aid in classifying the patients who are more likely to respond to physical therapy treatment. Thirty-three subjects (males, 20–33 years) presenting SAIS were studied to determine altered scapular kinematics and clinical impairments. Three measurements were collected: (1) three-dimensional scapular kinematics during performing functional tasks; (2) impairment outcomes of range of motion and muscle force; and (3) self-reported measurements of pain, satisfaction, and function. All patients received 6-week (2 times per week) physical therapy treatment. Improvement with treatment was determined using the Global Rating of Change Scale. Scapular kinematics and clinical impairments were first identified by t-test in predicting improvement and then combined into a multivariate prediction method. A prediction method with three variables (Flexilevel Scale of Shoulder Function score<41, muscle power of serratus anterior<27.4% body weight, degree of scapular internal rotation at 30° shoulder elevation during descending arm phase in unloaded condition<0.7°) were identified. It appears that scapular kinematics and impairment features can be used to classify subjects with SAIS in addition to self-report. Prospective validation of the proposed prediction method requires further investigation.

Reliability of manual examination and frequency of symptomatic cervical motion segment dysfunction in cervicogenic headache - Corrected Proof

Toby Hall, Kathy Briffa, Diana Hopper, Kim Robinson — 2010-07-07

Abstract: This study investigated the reliability of manual examination procedures and the frequency that each or multiple segments in the upper cervical spine above the C4 vertebra were the dominant source of pain in subjects with cervicogenic headache (CGH). Eighty subjects were evaluated, 60 with CGH (39 females, mean age 33 years) and arbitrarily a further 20 asymptomatic subjects (13 females, mean age 34 years) included to reduce examiner bias, but subsequently omitted from data analysis. Two experienced physiotherapists examined on the same day each subject with standard manual examination procedures, independently rating each segment in the upper cervical spine above the C4 vertebra for involvement. Examiners were blind to each other’s findings and the subject’s clinical status. Standard and adjusted Kappa coefficients were calculated for each segment in symptomatic subjects only. Chi-squared analysis for goodness of fit was used to identify the segment that was most frequently determined the predominant symptomatic segment. Manual examination above the C4 vertebra showed good reliability. The C1/2 segment was most commonly symptomatic, with a positive finding at this segment in 63% of cases. The high frequency of C1/2 involvement in CGH highlights the importance of examination and treatment procedures for this motion segment.

Shoulder girdle control; some mechanisms of function to dysfunction - Corrected Proof

Caroline M Alexander — 2010-06-29

Fast conducting, group I afferents that originate in forearm and hand muscles evoke long latency, facilitatory reflexes in the scapulothoracic muscles, trapezius and serratus anterior in healthy subjects (). These reflexes are thought to follow a transcortical pathway. That is, they originate from spindle afferents within forearm and hand muscles, use ascending pathways within the spinal cord and synapse with the sensory-motor cortex. Then, using descending pathways they modulate the motoneurone pool of the scapulothoracic muscles. The amplitudes of these reflexes are increased during tasks that require precise use of the hand (). Presumably this feedback mechanism helps to assist the stabilisation and appropriate positioning of the scapula upon the chest wall whilst doing a precise hand task. Furthermore, these reflexes are similarly modulated by observation of this hand task alone (). That is, the reflex is facilitated when the subject imagines them-selves doing the task, along side observing them-selves doing the hand task on a video, without actually doing the task at all. Interestingly, this modulation does not occur if the subject closely observes a non-kinetic task such as the ‘stroop’ test.

Head movement kinematics during rapid aiming task performance in healthy and neck-pain participants: The importance of optimal task difficulty - Corrected Proof

Martin Descarreaux, Steven R. Passmore, Vincent Cantin — 2010-06-28

Abstract: Background: Head repositioning tasks have been used in different experimental and clinical contexts but have yet to offer insight as to the task performance strategy. The purpose of this study was to explore the kinematics from a head aiming task that encompasses a Fitts' task in neck pain patients and healthy control subjects.Methods: Chronic neck pain patients and healthy individuals were compared in a head aiming task. Participants were asked to move their head as quickly, and precisely as possible to a target under 4 different experimental conditions. Dependent variables included movement time, movement time variability, acceleration phase duration, deceleration phase duration and absolute positioning error.Results: The chronic neck pain patients, when compared to healthy participants showed a significant increase in movement time and deceleration phase duration for the small target/large movement amplitude condition. No group difference was observed for movement time variability, acceleration phase duration and absolute positioning errors.Conclusions: Decreased motor performance was observed in chronic neck pain patients during the most challenging cervical pointing task condition. These results may imply that in order for a performance based outcome measure to yield observable differences conditions that meet or exceed the optimum challenge point of the population tested should be employed.

Myofascial trigger point needling for whiplash associated pain – A feasibility study - Corrected Proof

Elizabeth A. Tough, Adrian R. White, Suzanne H. Richards, John L. Campbell — 2010-06-28

Abstract: Clinicians claim that myofascial trigger points (MTrPs) are a primary cause of pain in whiplash injured patients. Pain from MTrPs is often treated by needling, with or without injection. We conducted a placebo controlled study to test the feasibility of a phase III randomised controlled trial investigating the efficacy of MTrP needling in patients with whiplash associated pain.Forty-one patients referred for physiotherapy with a recent whiplash injury, were recruited. Patients were randomised to receive standardised physiotherapy plus either acupuncture or a sham needle control. A trial was judged feasible if: i) the majority of eligible patients were willing to participate; ii) the majority of patients had MTrPs; iii) at least 75% of patients provided completed self-assessment data; iv) no serious adverse events were reported and v) the end of treatment attrition rate was less than 20%.70% of those patients eligible to participate volunteered to do so; all participants had clinically identified MTrPs; a 100% completion rate was achieved for recorded self-assessment data; no serious adverse events were reported as a result of either intervention; and the end of treatment attrition rate was 17%.A phase III study is both feasible and clinically relevant. This study is currently being planned.

Subgrouping patients with low back pain in primary care: Are we getting any better at it? - Corrected Proof

Nadine E. Foster, Jonathan C. Hill, Elaine M. Hay — 2010-06-28

Abstract: Low back pain is a common, disabling condition with high personal and economic costs. Despite clinical guidelines, there have not been tangible reductions in the population prevalence of back pain or its serious long-term consequences. One reason for this might be that the ‘one-size fits all approach’ advocated by many guidelines fails to target treatments at patients who might benefit the most, thus diluting their potential benefits. Identifying subgroups of patients for whom different treatments are superior has been referred to as the ‘Holy Grail’ of low back pain research.Maximising the potential for targeted interventions is predicated on better understanding of the prognostic factors that are causally related to clinical outcome and identifying which are a) most predictive of outcome and b) most likely to be modifiable. Systematic identification of key obstacles to recovery in primary care back pain patients from high quality epidemiological studies can inform the development of early, targeted interventions. Only then can closer matching of treatments to patient characteristics be a clinical reality.This paper critically reviews progress in subgrouping for targeted treatment for patients with low back pain, identifies the key arguments for and against subgrouping and highlights the attributes of robust approaches in this field.

Corrected Proof

Peter Kissel — 2010-06-25

A disconnection between radiologists and clinicians is often cited as a hindrance in the contemporary medical model. Magnetic Resonance Imaging in Orthopedic Sports Medicine endeavours to amalgamate these disciplines in a cooperative effort by leading experts in these respective fields. This point is made paramount in the preface where the editors state the impetus for their text as a practical reference that would integrate the basic needs of radiologists and clinicians alike. Numerous contributing authors (37) facilitate a text whose final product does a fair job of bridging the gap. Though lacking in chapter consistency, the final product is a commendable effort that is truly the first of its kind.

A randomised controlled study examining the short-term effects of Strain–Counterstrain treatment on quantitative sensory measures at digitally tender points in the low back - Corrected Proof

Cynan Lewis, Asad Khan, Tina Souvlis, Michele Sterling — 2010-06-25

Abstract: Strain–Counterstrain (SCS) intervention has been claimed to elicit immediate and sustained reductions in tenderness at digitally tender points (DTPs), however, there is little experimental evidence to support this. Twenty-eight volunteer participants with low back pain – LBP (17 females and 11 males with mean [SD] age of 39.2 [11.1] and Oswestry disability index of 15.7 [8.6]) participated in this controlled, within-participants study of the immediate and short-term effects of SCS intervention, on pressure pain threshold (PPT) electrical detection threshold (EDT) and electrical pain threshold (EPT) at DTPs in the low back region. Immediate increases in PPT at DTPs were found following all interventions; control intervention: 30.7kPa [CI 95% – 3.3–64.8] (p=0.041), sham-SCS intervention: 48.2kPa [CI 95% 14.8–81.7] (p=0.008) and SCS intervention: 93.4kPa [CI 95% 60.0–126.9] (p<0.0001). Results suggest that SCS intervention does elicit an immediate quantifiable reduction in tenderness at DTPs but that some of this reduction is attributable to the manual-contact component of the treatment. Increases in PPT at DTPs following SCS intervention did not appear to be maintained between 24 and 96h after treatment. A further finding was that the control intervention elicited significant increases in both EDT (p=0.044) and EPT (p=0.026). The explanation for these findings is unclear.

A study to explore the reliability and precision of intra and inter-rater measures of ULNT1 on an asymptomatic population - Corrected Proof

George S. Oliver, Alison Rushton — 2010-06-24

Abstract: Upper Limb Neurodynamic Test 1 (ULNT1) is commonly used within clinical practice. However, the existing evidence regarding its reliability is conflicting and raises methodological questions. Therefore, the aim of this study was to investigate how reliable and precise physiotherapists are at recording both intra and inter-rater measurements of ULNT1 on an asymptomatic population. Forty asymptomatic subjects, 29 females and 11 males (18–42 years, mean 23.35), were recruited into this intra (stability) and inter-rater (equivalence) reliability and precision study. ULNT1 was recorded twice using an electrogoniometer by two experienced physiotherapists using a standardised operational description in conditions replicating clinical practice. Reliability was analysed using the Intraclass Correlation Coefficient (ICC2,1), and precision using Standard Error of Measurement (SEM) and Smallest Detectable Difference (SDD). The findings demonstrated excellent intra-rater (ICC2,1 0.98 Rater 1; ICC2,1 0.96 Rater 2) and good inter-rater (ICC2,1 0.80) reliability. Precision was acceptable for both intra-rater (SEM 2.59° Rater 1; SEM 0.97° Rater 2; SDD 7.16° Rater 1; SDD 2.68° Rater 2), and inter-rater (SEM 3.83°; SDD 10.58°) measurements. These findings demonstrate that physiotherapists can use ULNT1 reliably and with precision for intra and inter-rater measurements of asymptomatic subjects in conditions that replicate clinical practice. The reproduction of this study on a population of symptomatic subjects is now warranted.

Manual therapy with or without physical medicine modalities for neck pain: a systematic review - Corrected Proof

2010-06-10

Abstract: Manual therapy interventions are often used with or without physical medicine modalities to treat neck pain. This review assessed the effect of 1) manipulation and mobilisation, 2) manipulation, mobilisation and soft tissue work, and 3) manual therapy with physical medicine modalities on pain, function, patient satisfaction, quality of life (QoL), and global perceived effect (GPE) in adults with neck pain. A computerised search for randomised trials was performed up to July 2009. Two or more authors independently selected studies, abstracted data, and assessed methodological quality. Pooled relative risk (RR) and standardised mean differences (SMD) were calculated when possible. We included 19 trials, 37% of which had a low risk of bias. Moderate quality evidence (1 trial, 221 participants) suggested mobilisation, manipulation and soft tissue techniques decrease pain and improved satisfaction when compared to short wave diathermy, and that this treatment combination paired with advice and exercise produces greater improvements in GPE and satisfaction than advice and exercise alone for acute neck pain. Low quality evidence suggests a clinically important benefit favouring mobilisation and manipulation in pain relief [1 meta-analysis, 112 participants: SMD −0.34(95% CI: −0.71, 0.03), improved function and GPE (1 trial, 94 participants) for participants with chronic cervicogenic headache when compared to a control at intermediate and long term follow-up; but no difference when used with various physical medicine modalities.

Sensory characteristics of tender points in the lower back - Corrected Proof

Cynan Lewis, Tina Souvlis, Michele Sterling — 2010-06-07

Abstract: Palpation of tender points in superficial tissue is commonly undertaken in the management of musculoskeletal pain. The sensory characteristics of digitally tender points (DTPs) have not been defined. This study had two major aims: 1) to characterise ‘Strain–Counterstrain’ DTPs, using quantitative sensory testing (QST) in participants with low back pain (LBP); 2) to compare corresponding points at lumbar sites in participants with LBP to those without LBP. Fifteen participants with LBP (9 females), mean (SD) Oswestry scores 20.8 (10.1)) and 15 participants without LBP (6 females) were included. QST was undertaken by a single examiner blind to the location of DTPs and included measurement of electrical detection and electrical pain threshold, thermal (hot/cold) detection and thermal pain threshold, vibration detection threshold and pressure-pain threshold. In participants with LBP, DTPs demonstrated significantly lower electrical detection and electrical pain thresholds compared to contralateral non-tender points (p<0.0001). These findings may be indicative of altered central processing of Aβ afferents with terminal receptors at DTPs. Participants with LBP demonstrated elevated cold pain thresholds at lower back sites and at the peripheral shoulder site compared to participants without LBP (p<0.001). This may also indicate augmented central pain processing in participants with LBP.

Deep and superficial abdominal muscle activation during trunk stabilization exercises with and without instruction to hollow - Corrected Proof

Anna Bjerkefors, Maria M. Ekblom, Karin Josefsson, Alf Thorstensson — 2010-06-07

Abstract: The deepest muscle of the human ventro-lateral abdominal wall, the Transversus Abdominis (TrA), has been ascribed a specific role in spine stabilization, which has motivated special core stability exercises and hollowing instruction to specifically involve this muscle. The purpose here was to evaluate the levels of activation of the TrA and the superficial Rectus Abdominis (RA) muscles during five common stabilization exercises performed in supine, bridging and four-point kneeling positions, with and without instruction to hollow, i.e. to continuously pull the lower part of the abdomen towards the spine. Nine habitually active women participated and muscle activity was recorded bilaterally from TrA and RA with intramuscular fine-wire electrodes introduced under the guidance of ultrasound. Results showed that subjects were able to selectively increase the activation of the TrA, isolated from the RA, with the specific instruction to hollow and that side differences in the amplitude of TrA activity, related to the asymmetry of the exercises, remained even after the instruction to hollow. The exercises investigated caused levels of TrA activation from 4 to 43% of that during maximal effort and can thus be used clinically to grade the load on the TrA when designing programs aiming at training that muscle.

Reliability and validity of head posture assessment by observation and a four-category scale - Corrected Proof

Anabela G. Silva, T. David Punt, Mark I. Johnson — 2010-06-04

Abstract: Head posture (HP) is assessed as part of the clinical examination of patients with neck pain using observation and qualitative descriptors. In research, HP is characterised through the measurement of angles and distances between anatomical landmarks. This study investigated whether the assessment of HP as performed in clinical practice is reliable and valid. Ten physiotherapists assessed forward HP, head extension and side-flexion from images of 40 individuals with and without previous experience of neck pain using a four-category scale. The assessment was repeated twice with a 1-week gap. Physiotherapists’ ratings were then compared with angular measurements of the same components of HP. K values for intra-rater reliability varied between 0.22 and 0.81 for forward HP, between 0.19 and 0.69 for head extension and between 0.38 and 0.67 for side-flexion. K values for inter-rater reliability were 0.02 for forward HP, 0.07 for head extension and 0.19 for side-flexion. Correlation coefficients between the ratings and the angular measurements varied between −0.16 and −0.49 for forward HP, between −0.17 and 0.68 for head extension and between −0.04 and 0.37 for side-flexion. The assessment of HP by observation and a four-category scale showed poor reliability and validity.

The effect of within-session instruction on lumbopelvic motion during a lower limb movement in people with and people without low back pain - Corrected Proof

Sara A. Scholtes, Barbara J. Norton, Catherine E. Lang, Linda R. Van Dillen — 2010-06-03

Abstract: The purpose of the current study was to examine how effectively people with and people without low back pain (LBP) modify lumbopelvic motion during a limb movement test. Nineteen subjects with LBP and 20 subjects without LBP participated. Kinematic data were collected while subjects performed active hip lateral rotation (HLR) in prone. Subjects completed trials (1) using their natural method (Natural condition) of performing HLR, and (2) following standardized instructions to modify lumbopelvic motion while performing HLR (Modified condition). Variables of interest included (1) the amount of HLR completed prior to the start of lumbopelvic motion, and (2) the maximum amount of lumbopelvic motion demonstrated during HLR. Compared to the Natural Condition, all subjects improved their performance during the Modified condition by (1) completing a greater amount of HLR prior to the start of lumbopelvic motion, and (2) demonstrating less lumbopelvic motion (P<0.01 for all comparisons). There was a tendency for people without LBP to demonstrate a greater difference in maximal lumbopelvic rotation between the Natural and Modified conditions (P=0.07). In conclusion, people are able to modify lumbopelvic motion following instruction. Further study is needed to determine if people without LBP improve lumbopelvic motion following instruction to a greater extent than people with LBP.

Sickness absence in patients with arm, neck and shoulder complaints presenting in physical therapy practice: 6 months follow-up - Corrected Proof

2010-05-31

Abstract: Objective: To describe sickness absence in patients with arm, neck and/or shoulder complaints and to evaluate determinants of sickness absence during 6 months follow-up.Methods: A prospective cohort study in physical therapy practice with follow-up measurements at 3 and 6 months. The main outcome measure was the occurrence of sickness absence due to arm, neck and shoulder complaints during 6 months follow-up. Determinants were tested in univariate and multivariate GEE (Generalized Estimating Equations) analysis.Results: At baseline 161 patients (33%) reported absence from work. The multivariate analysis showed that self-reported work-relatedness of complaints, previous musculoskeletal trauma, higher severity of complaints at baseline, more somatization and low decision authority at work were associated with sickness absence during the follow-up period.Conclusion: In physical therapy practice, social and psychological factors (at work) influence the occurrence of sickness absence in patients with arm, neck and/or shoulder complaints. These factors can be taken into account when developing and evaluating interventions to reduce sickness absence among these patients.

Immediate effects of a high-velocity spine manipulation in paraspinal muscles activity of nonspecific chronic low-back pain subjects - Corrected Proof

2010-05-06

Abstract: High-velocity spinal manipulation is commonly adopted for treating chronic low-back pain (CLBP) and has been associated with changes in muscle activity, but the evidence is controversial. The aim of this study was to analyse the immediate effects of high-velocity spine manipulation on paraspinal activity during flexion–extension trunk movements. Forty nonspecific CLBP patients were randomised into two groups, manipulation (n=20) and control (n=20). While the manipulation group received high-velocity spine manipulation at the L4-L5 level, the control group remained lying in the same position. EMG-related variables, perceived pain intensity (100 mm VAS) and finger-floor distance were collected before and after spinal manipulation at the L4-L5 level. EMG surface signals from the right and left paraspinal muscles (L5-S1 level) were acquired during trunk flexion–extension cycles. EMG activity during the static relaxation phase was significantly reduced following intervention for the manipulation group but not for the control group. The extension-phase EMG activity was also reduced after manipulation, but the flexion-phase EMG levels remained unchanged. Accordingly, the percent changes in FRR and ERR were significantly larger for the manipulation group compared to the control. The results suggest that a high-velocity spinal manipulation is able to acutely reduce abnormal EMG activity during the full-flexion static phase and activation during the extension phase.

Relationships between sagittal postures of thoracic and cervical spine, presence of neck pain, neck pain severity and disability - Corrected Proof

2010-04-30

Abstract: This was a cross-sectional correlation study to explore the relationships between sagittal postures of thoracic and cervical spine, presence of neck pain, neck pain severity and disability. Moreover, the reliability of the photographic measurement of the sagittal posture of thoracic and cervical spine was investigated. Forty-five subjects without neck pain and forty-seven subjects with neck pain were recruited. Using a photographic method, the sagittal thoracic and cervical postures were measured by the upper thoracic and the craniovertebral (CV) angles respectively. The Numeric Pain Rating Scale (NPRS) and Chinese version Northwick Park Neck Pain Questionnaire (NPQ) were used to assess neck pain severity and disability. The upper thoracic angle was positively correlated (rs = 0.63, p < 0.01) while the CV angle was negatively correlated (rs = −0.56, p < 0.01) with the presence of neck pain. The upper thoracic angle was negatively correlated with the CV angles (rs = −0.62, p < 0.01) in subjects with neck pain. Similar to the CV angle, the upper thoracic angle was moderately correlated with the neck pain severity (rs = 0.43, p = 0.01) and disability (rs = 0.44, p = 0.02). The upper thoracic angle (OR = 1.37, p < 0.01) was a good predictor for presence of neck pain even better than that of the CV angle (OR = 0.86, p = 0.04).

Comparison between the reliability levels of manual palpation and pressure pain threshold in children who reported orofacial pain - Corrected Proof

2010-04-30

Abstract: The aim of this study was to compare the intra- and inter-rater reliability of pressure pain threshold (PPT) and manual palpation (MP) of orofacial structures in symptomatic and symptom-free children for temporomandibular disorders (TMD). Fourteen children reporting pain in masticatory muscles or the temporomandibular joint and 16 symptom-free children were randomly assessed on three different occasions: by rater-1 in the first and third session and by rater-2 in the second session. The trained raters applied algometry and MP as recommended by the Research Diagnostic Criteria for TMD. Intraclass correlation coefficients and the Kappa statistic were used to assess the levels of reliability of PPT and MP, respectively. Excellent intra- and inter-rater reliability levels were observed for PPT values at most of the examined sites for symptom-free children and excellent and moderate reliability levels for children reporting pain. For MP, moderate and poor intra-rater and inter-rater reliability levels were observed for most sites in both groups. Algometry showed higher reliability levels for both groups of children and is recommended for pain assessment in children in association with MP.

Site of maximum neovascularisation correlates with the site of pain in recalcitrant mid-tendon Achilles tendinopathy - Corrected Proof

2010-04-30

Abstract: Background: Neovascularisation is associated with pain in Achilles tendinopathy (AT). The anatomical relationship between ultrasound (US)-defined indicators of tendinopathy and clinically determined pain sites has not been investigated.Purpose: To measure the spatial correlation between the sites of maximum palpated tenderness, site of patient-indicated pain, maximum US-determined neovascularisation and maximum antero-posterior tendon thickness in patients with chronic recalcitrant AT (CRAT).Methods: A custom-designed measuring apparatus and clinical examination were used to measure the sites of maximum tenderness and subjectively defined pain on 29 tendons from patients diagnosed with mid-tendon CRAT. All tendons had been previously non-responsive to eccentric loading. Maximal neovascularisation and tendon thickness were measured by US scanning in conjunction with the measuring device.Results: A significant association exists between clinically determined pain and neovascularisation (r=0.85, p<0.001), patient reported pain (r=0.91, p<0.001), maximal tendon thickness (r=0.91, p<0.001), maximal thickness and maximal neovascularisation (r=0.86, p<0.001).Conclusion: Sites of subjectively defined pain, clinically palpated tenderness, tendon thickness and neovascularisation are anatomically associated. Palpation can be reliably used as a clinical guide when planning interventions in patients with CRAT.

Adverse events associated with the use of cervical manipulation and mobilization for the treatment of neck pain in adults: A systematic review - Corrected Proof

2010-03-15

Abstract: Adverse events (AE) are a concern for practitioners utilizing cervical manipulation or mobilization. While efficacious, these techniques are associated with rare but serious adverse events. Five bibliographic databases (PubMed, CINAHL, PEDro, AMED, EMBASE) and the gray literature were searched from 1998 to 2009 for any AE associated with cervical manipulation or mobilization for neck pain. Randomized controlled trials (RCTs), prospective or cross-sectional observational studies were included. Two independent reviewers conducted study selection, method quality assessment and data abstraction. Pooled relative risks (RR) were calculated. Study quality was assessed using the Cochrane system, a modified Critical Appraisal Skills Program form and the McHarm scale to assess the reporting of harms. Seventeen of 76 identified citations resulted in no major AE. Two pooled estimates for minor AE found transient neurological symptoms [RR 1.96 (95% CI: 1.09–3.54) p<0.05]; and increased neck pain [RR 1.23 (95% CI: 0.85–1.77) p>.05]. Forty-four studies (58%) were excluded for not reporting AE. No definitive conclusions can be made due to a small number of studies, weak association, moderate study quality, and notable ascertainment bias. Improved reporting of AE in manual therapy trials as recommended by the CONSORT statement extension on harms reporting is warranted.