Manipulative and multimodal therapy for upper extremity and temporomandibular disorders: a systematic review

Orthopaedic Manual Physical Therapy: A Modern Definition and Description

Currently, orthopaedic manual physical therapy (OMPT) lacks a description of practice that reflects contemporary thinking and embraces advances across the scientific, clinical, and educational arms of the profession. The absence of a clear definition of OMPT reduces understanding of the approach across health care professions and potentially limits OMPT from inclusion in scientific reviews and clinical practice guidelines. For example, it is often incorrectly classified as passive care or incorrectly contrasted with exercise-therapy approaches. This perspective aims to provide clinicians, researchers, and stakeholders a modern definition of OMPT that improves the understanding of this approach both inside and outside the physical therapist profession. The authors also aim to outline the unique and essential aspects of advanced OMPT training with the corresponding examination and treatment competencies. This definition of practice and illustration of its defining characteristics is necessary to improve the understanding of this approach and to help classify it correctly for study in the scientific literature. This perspective provides a current definition and conceptual model of OMPT, defining the distinguishing characteristics and key elements of this systematic and active patient-centered approach to improve understanding and help classify it correctly for study in the scientific literature.

Craniofacial disorders and headaches. A narrative review

OBJECTIVES

Craniofacial- and headache disorders are common co-morbid disorders. The aim of this review is to provide an overview of the research discussing craniofacial pain, especially temporomandibular disorders, and its relationship and impact on headaches, as well as suggestions for diagnostic assessment tools and physical therapeutic management strategies.

METHOD

A narrative structured review was performed. A search was conducted in MEDLINE using terms related to craniofacial pain and headaches. Additionally, papers regarding this topic were also extracted from the authors' personal libraries. Any study design (i.e., RCT, observational studies, systematic review, narrative review) that reported the concepts of interest was included, using Covidence. Results were narratively synthesized and described.

RESULTS

From an epidemiological perspective, craniofacial pain and headaches are strongly related and often co-existing. This may be due to the neuroanatomical connection with the trigeminal cervical complex, or due to shared predisposing factors such as age, gender, and psychosocial factors. Pain drawings, questionnaires, and physical tests can be used to determine the cause of pain, as well as other perpetuating factors in patients with headaches and craniofacial pain. The evidence supports different forms of exercise and a combination of hands-on and hands-off strategies aimed at both the craniofacial pain as well as the headache.

CONCLUSION

Headaches may be caused or aggravated by different disorders in the craniofacial region. Proper use of terminology and classification may help in understanding these complaints. Future research should look into the specific craniofacial areas and how headaches may arise from problems from those regions. (249 words).

It Is Time for a Multidisciplinary Rehabilitation Approach: A Scoping Review on Stomatognathic Diseases in Neurological Disorders

Patients affected by neurological disorders can develop stomatognathic diseases (SD) related to decreased bite force and quality of mastication, bruxism, severe clicking and other temporomandibular disorders (TMD), which deeply affect patients' swallowing, masticatory and phonation functions and, therefore, their quality of life. The diagnosis is commonly based on medical history and physical examination, paying attention to the temporomandibular joint (TMJ) range of movements, jaw sounds and mandibular lateral deviation. Diagnostic tools such as computed tomography and magnetic resonance imaging are used instead in case of equivocal findings in the anamnesis and physical evaluation. However, stomatognathic and temporomandibular functional training has not been commonly adopted in hospital settings as part of formal neurorehabilitation. This review is aimed at describing the most frequent pathophysiological patterns of SD and TMD in patients affected by neurological disorders and their rehabilitative approach, giving some clinical suggestions about their conservative treatment. We have searched and reviewed evidence published in PubMed, Google Scholar, Scopus and Cochrane Library between 2010 and 2023. After a thorough screening, we have selected ten studies referring to pathophysiological patterns of SD/TMD and the conservative rehabilitative approach in neurological disorders. Given this, the current literature is still poor and unclear about the administration of these kinds of complementary and rehabilitative approaches in neurological patients suffering from SD and/or TMD.

Education-Enhanced Conventional Care versus Conventional Care Alone for Temporomandibular Disorders: A Randomized Controlled Trial

The objective of this study was to determine the effect of enhancing conventional care for people with chronic painful temporomandibular disorders (TMD) with an individualised contemporary pain science education (PSE) intervention. In this randomized controlled trial, a consecutive sample of 148 participants (18-55 years of age) was randomized into 2 groups: PSE-enhanced conventional care or Conventional care alone. Conventional care involved a 6-week, 12-session manual therapy and exercise program. The PSE enhancement involved 2 sessions of modern PSE, undertaken in the first 2 treatment sessions. Primary outcomes were pain intensity, assessed with a numeric pain rating scale, and disability, assessed with the craniofacial pain and disability inventory, post-treatment. Linear mixed model analyses were used to investigate between-group differences over time. There was a statistically and clinically meaningful effect of PSE enhancement on disability (Mean Difference = 6.1, 95% CI: 3.3-8.8), but not on pain intensity, post-treatment. Secondary analyses suggested clinically meaningful benefit of PSE enhancement on pain and disability ratings at 10-week and 18-week follow-ups, raising the possibility that preceding conventional care with a PSE intervention may result in long-term benefits. PERSPECTIVE: The addition of modern Pain Science Education (PSE) intervention improved disability for people with chronic TMD receiving manual therapy and exercise, but not pain. A mean difference in pain and disability favoring the PSE group at the 10- and 18-week follow-ups, respectively, suggests that PSE addition resulted in longer-lasting effects. Trial registration: NCT03926767. Registered on April 29, 2019. https://clinicaltrials.gov/ct2/show/NCT03926767.

Effectiveness of Manual Trigger Point Therapy in Patients with Myofascial Trigger Points in the Orofacial Region-A Systematic Review

The objective was to compile, synthetize, and evaluate the quality of the evidence from randomized controlled trials (RCTs) regarding the effectiveness of manual trigger point therapy in the orofacial area in patients with or without orofacial pain. This project was registered in PROSPERO and follows the PRISMA guidelines. Searches (20 April 2021) were conducted in six databases for RCTs involving adults with active or latent myofascial trigger points (mTrPs) in the orofacial area. The data were extracted by two independent assessors. Four studies were included. According to the GRADE approach, the overall quality/certainty of the evidence was very low due to the high risk of bias of the studies included. Manual trigger point therapy showed no clear advantage over other conservative treatments. However, it was found to be an equally effective and safe therapy for individuals with myofascial trigger points in the orofacial region and better than control groups. This systematic review revealed a limited number of RCTs conducted with patients with mTrPs in the orofacial area and the methodological limitations of those RCTs. Rigorous, well-designed RCTs are still needed in this field.

Physiotherapists and Osteopaths’ Attitudes: Training in Management of Temporomandibular Disorders

Temporomandibular disorders (TMDs) are a condition which has multifactorial etiology. The most acknowledged method to classify TMDs is the diagnostic criteria (DC) introduced firstly by Dworkin. This protocol considers different aspects that are not only biological, but even psychosocial. Diagnosis is often based on anamnesis, physical examination and instrumental diagnosis. TMDs are classified as intra-articular and/or extra-articular disorders. Common signs and symptoms include jaw pain and dysfunction, earache, headache, facial pain, limitation to opening the mouth, ear pain and temporomandibular joint (TMJ) noises. This study regards two kind of clinicians that started in the last years to be more involved in the treatment of TMDs: osteopaths (OOs) and physiotherapists (PTs). The purpose is to analyze their attitude and clinical approach on patients affected by TMDs. Four hundred therapists answered an anonymous questionnaire regarding TMJ and TMDs. OOs showed greater knowledges on TMDs and TMJ and, the therapists with both qualifications seemed to be most confident in treating patients with TMDs. In conclusion this study highlights OOs and all the clinicians with this qualification, have a higher confidence in treating patients with TMD than the others. Dentists and orthodontists, according to this study, should co-work with OOs and PTs, because they are the specialists more requested by them than other kinds of specialists.

Throwing performance after high-velocity low-amplitude thrust manipulation at the cervicothoracic and thoracolumbar junction in elite female water polo players: a randomized blind cross-over study

BACKGROUND

The effect of high-velocity low-amplitude (HVLA) thrust manipulation at the cervicothoracic and thoracolumbar junction in healthy elite female water polo players on throwing performance is unknown.

METHODS

Ten healthy members of the Dutch National female water polo team participated in this randomized blind cross-over study. All received a HVLA manipulation and a sham manipulation at the cervicothoracic and thoracolumbar junction. Hereafter maximum throwing speed, range of motion and isometric strength were measured at 1 hour, 48 hours and 4 weeks follow-up.

RESULTS

No significant differences in maximum throwing speed was found between HVLA and sham manipulation. In the non-dominant shoulder external rotation increased significantly (5.3±6.7°) 48 hours after sham manipulation, this effect was not considered clinically significant and diminished after four weeks.

CONCLUSIONS

Our results suggest that HVLA and sham manipulation had no effect on shot velocity or shoulder mobility and the same effect on shoulder strength in healthy elite female water polo players. The common use of cervicothoracic and thoracolumbar HVLA manipulation for improving performance in this specific group of athletes is therefore questionable.

The Effect of Scapular Muscle Strengthening on Functional Recovery in Patients With Lateral Elbow Tendinopathy: A Pilot Randomized Controlled Trial

CONTEXT

There is a lack of consensus on the best management approach for lateral elbow tendinopathy (LET). Recently, scapular stabilizer strength impairments have been found in individuals with LET.

OBJECTIVE

The purpose of this study was to compare the effectiveness of local therapy (LT) treatment to LT treatment plus a scapular muscle-strengthening (LT + SMS) program in patients diagnosed with LET.

DESIGN

Prospective randomized clinical trial.

SETTING

Multisite outpatient physical therapy.

PATIENTS

Thirty-two individuals with LET who met the criteria were randomized to LT or LT + SMS.

INTERVENTIONS

Both groups received education, a nonarticulating forearm orthosis, therapeutic exercise, manual therapy, and thermal modalities as needed. Additionally, the LT + SMS group received SMS exercises.

MAIN OUTCOME MEASURE

The primary outcome measure was the patient-rated tennis elbow evaluation; secondary outcomes included global rating of change (GROC), grip strength, and periscapular muscle strength. Outcomes were reassessed at discharge, 6, and 12 months from discharge. Linear mixed-effect models were used to analyze the differences between groups over time for each outcome measure.

RESULTS

The average duration of symptoms was 10.2 (16.1) months, and the average total number of visits was 8.0 (2.2) for both groups. There were no significant differences in gender, age, average visits, weight, or height between groups at baseline (P > .05). No statistical between-group differences were found for any of the outcome measures. There were significant within-group improvements in all outcome measures from baseline to all follow-up points (P < .05).

CONCLUSION

The results of this pilot study suggest that both treatment approaches were equally effective in reducing pain, improving function, and increasing grip strength at discharge as well as the 6- and 12-month follow-ups. Our multimodal treatment programs were effective at reducing pain and improving function up to 1 year after treatment in a general population of individuals with LET.

Interaction between Pain, Disability, Mechanosensitivity and Cranio-Cervical Angle in Subjects with Cervicogenic Headache: A Cross-Sectional Study

The relationship between the forward head posture and mechanosensitivity in subjects with a cervicogenic headache (CGH) remains uncertain. The aim of the study was to evaluate if there was a relationship between the tissue mechanosensitivity and cranio-cervical angle (CCA) that was moderated by pain intensity and/or disability in subjects with CGH. A convenience sample of 102 subjects was recruited. The CCA was measured with photographs, using a postural assessment software. The pain intensity was measured with a visual analogue scale (VAS), and the disability was measured with the Northwick Park Questionnaire. The pressure pain threshold (PPT) was measured at the spinous process of C2, the upper trapezius and splenius capitis muscles, and the median nerve. Simple moderation multiple regression analyses were constructed. There was a positive relationship between PPT at C2 and CCA, but a nonsignificant relationship for the PPT measured at the muscles and median nerve. The effect of PPT at C2 over CCA was moderated by pain intensity (R² = 0.17; R² change = 0.06; p < 0.05) but not disability. The Johnson–Neyman analysis revealed a cut-off point for the statistical significance of 4.66 cm in VAS. There seems to be a positive relationship between PPT at C2 and CCA, which is positively moderated by pain intensity in subjects with CGH.

Chiropractic Day: A Historical Review of a Day Worth Celebrating

OBJECTIVE

The purpose of this paper is to review and discuss historical concepts about the celebration of Chiropractic Day.

DISCUSSION

Daniel David Palmer attributed September 18, 1895 to be the day that he delivered the first chiropractic adjustment. As the chiropractic profession grew, the celebration of Chiropractic Day became more widespread throughout the United States and the world. This paper offers suggestions about how to celebrate Chiropractic Day. Activities include educating, learning, honoring, volunteering, and engaging.

CONCLUSION

The chiropractic profession celebrates its birth on September 18. Regardless of the many different names used over the past 125 years, including Chiropractic Founder's Day, Chiropractic Rally Day, Chiropractic Anniversary, and Chiropractic Discovery Day, the celebration of this special day provides an opportunity to reflect on how far the profession has come and how chiropractors continue to help and serve their patients.

Manipulative and manual therapies in the management of patients with prior lumbar surgery: A systematic review

BACKGROUND AND PURPOSE

Pain and disability may persist following lumbar spine surgery and patients may subsequently seek providers trained in manipulative and manual therapy (MMT). This systematic review investigates the effectiveness of MMT after lumbar surgery through identifying, summarizing, assessing quality, and grading the strength of available evidence. Secondarily, we synthesized the impact on medication utilization, and reports on adverse events.

METHODS

Databases and grey literature were searched from inception through August 2020. Article extraction consisted of principal findings, pain and function/disability, medication consumption, and adverse events.

RESULTS

Literature search yielded 2025 articles,117 full-text articles were screened and 51 citations met inclusion criteria.

CONCLUSION

There is moderate evidence to recommend neural mobilization and myofascial release after lumbar fusion, but inconclusive evidence to recommend for or against most manual therapies after most surgical interventions. The literature is primarily limited to low-level studies. More high-quality studies are needed to make recommendations.

Impact of Extremity Manipulation on Postural Sway Characteristics: A Preliminary, Randomized Crossover Study

OBJECTIVE

Evaluate multisegmental postural sway after upper- vs lower-extremity manipulation.

METHODS

Participants were healthy volunteers (aged 21-40 years). Upper- or lower-extremity manipulations were delivered in a randomized crossover design. Postural assessments were made pre-post manipulation, in floor and rocker board conditions. Analysis included traditional balance measures of pathlength and range and sample entropy (SampEn) to examine the temporal structure of sway of the head, trunk, and surface.

RESULTS

No statistical changes in pathlength or sway range on the ground surface condition were observed. No increases in the amount of sway occurred in any condition. Chiropractic manipulation of either upper or lower extremities led to reductions in traditional measures of postural control on the rocker board. In the anteroposterior direction (sagittal plane), lower-extremity manipulation led to increased trunk SampEn while on the ground, and conversely a decreased SampEn while on the rocker board. In the mediolateral rocker board condition (frontal plane), manipulation elicited a change in SampEn that differed according to site of manipulation; upper-extremity manipulation increased SampEn, whereas lower-extremity manipulation reduced SampEn.

CONCLUSION

Both upper- and lower-extremity manipulation influenced several measures of postural sway on both the ground and the rocker board. Lower-extremity manipulation improved the organization of sway at the trunk (anteroposterior direction) and the board (mediolateral direction). Given the reduction and reorganization of sway metrics seen in this study, we propose extending this line of research to the elderly who are at greatest risk of increased sway and falls.

Graded exposure and orthopedic manual physical therapy for kinesiophobia and function in chronic temporomandibular dysfunction: A case report

BACKGROUND

This case report describes the successful use of multi-modal physical therapy (PT), including orthopedic manual physical therapy (OMPT) and graded exposure, in a patient with chronic temporomandibular dysfunction (TMD).

CLINICAL PRESENTATION

A 41-yr old female presented with a five-year history of bilateral chronic myofascial TMD and comorbid neck/right arm pain. The patient was treated for 12 weeks with a focus on OMPT and graded exposure. The patient demonstrated clinically significant improvements on the Tampa Scale of Kinesiophobia-TMD, maximal mouth opening, Global Rating of Change, and Jaw Functional Limitation Scale.

CLINICAL RELEVANCE

Mechanisms underlying chronic TMD are complex. Current evidence supports PT management of physical impairments; however, neglecting central drivers or psychosocial factors may result in suboptimal outcomes. Physical therapists are able to address both peripheral and central mechanisms of pain, and future research should examine the utilization of multi-modal PT to improve kinesiophobia and function in patients with chronic TMD.

A SMART design to determine the optimal treatment of chronic pain among military personnel

Chronic pain is a leading cause of disability among active duty service members in the U.S. armed forces. Standard rehabilitative care and complementary and integrative health therapies are used for chronic pain rehabilitation. However, the optimal sequence and duration of these therapies has yet to be determined. This article describes a sequential multiple assignment randomized trial (SMART) protocol being used to identify the optimal components and sequence of standard rehabilitative care and complementary and integrative health therapies for reducing pain impact and improving other patient outcomes. Active duty service members referred to Madigan Army Medical Center for treatment of chronic pain are being recruited to the Determinants of the Optimal Dose and Sequence of Functional Restoration and Integrative Therapies study. Study participants are randomized to either standard rehabilitative care (physical and occupational therapy and psychoeducation) or complementary and integrative health therapies (chiropractic, acupuncture, yoga and psychoeducation). Those participants who do not respond to the first 3 weeks of treatment are randomized to receive an additional 3 weeks of either (1) the alternative treatment or (2) the first-stage treatment plus the alternative treatment. This study will also determine factors associated with treatment response that can support clinical decision making, such as baseline fitness, pain catastrophizing, kinesiophobia, post-traumatic stress, pain self-efficacy, and biological indicators. The information gained from this research will be applicable to all integrative chronic pain rehabilitation programs throughout the U.S. Department of Defense and the U.S. Department of Veterans Affairs, and the broader rehabilitation community.

Evidence-Based Nonpharmacologic Strategies for Comprehensive Pain Care: The Consortium Pain Task Force White Paper

Medical pain management is in crisis; from the pervasiveness of pain to inadequate pain treatment, from the escalation of prescription opioids to an epidemic in addiction, diversion and overdose deaths. The rising costs of pain care and managing adverse effects of that care have prompted action from state and federal agencies including the DOD, VHA, NIH, FDA and CDC. There is pressure for pain medicine to shift away from reliance on opioids, ineffective procedures and surgeries toward comprehensive pain management that includes evidence-based nonpharmacologic options. This White Paper details the historical context and magnitude of the current pain problem including individual, social and economic impacts as well as the challenges of pain management for patients and a healthcare workforce engaging prevalent strategies not entirely based in current evidence. Detailed here is the evidence-base for nonpharmacologic therapies effective in postsurgical pain with opioid sparing, acute non-surgical pain, cancer pain and chronic pain. Therapies reviewed include acupuncture therapy, massage therapy, osteopathic and chiropractic manipulation, meditative movement therapies Tai chi and yoga, mind body behavioral interventions, dietary components and self-care/self-efficacy strategies. Transforming the system of pain care to a responsive comprehensive model necessitates that options for treatment and collaborative care must be evidence-based and include effective nonpharmacologic strategies that have the advantage of reduced risks of adverse events and addiction liability. The evidence demands a call to action to increase awareness of effective nonpharmacologic treatments for pain, to train healthcare practitioners and administrators in the evidence base of effective nonpharmacologic practice, to advocate for policy initiatives that remedy system and reimbursement barriers to evidence-informed comprehensive pain care, and to promote ongoing research and dissemination of the role of effective nonpharmacologic treatments in pain, focused on the short- and long-term therapeutic and economic impact of comprehensive care practices.

Validation of the Japanese version of the Central Sensitization Inventory in patients with musculoskeletal disorders

Background

Many musculoskeletal pain conditions are characterized by hypersensitivity, which is induced by central sensitization (CS). A questionnaire, the Central Sensitization Inventory (CSI), was recently developed to help clinicians identify patients whose presenting symptoms may be related to central sensitivity syndrome (CSS). The aims of the present study were to examine criterion validity and construct validity of the Japanese version of the CSI (CSI-J), and to investigate prevalence rates of CS severity levels in patients with musculoskeletal disorders.

Methods

Translation of the CSI into Japanese was conducted using a forward-backward method. Two hundred and ninety patients with musculoskeletal pain disorders completed the resultant CSI-J. A subset of the patients (n = 158) completed the CSI-J again one week later. The relationships between CSI and clinical symptoms, EuroQol 5-dimension (EQ-5D) and Brief Pain Inventory (BPI), were examined for criterion validity. EQ-5D assesses Health-related QOL and BPI measures pain intensity and pain interference. The psychometric properties were evaluated with analyses of construct validity, factor structure and internal consistency, and subsequently investigate the prevalence rates of CS severity levels.

Results

The CSI-J demonstrated high internal consistency (Cronbach’s α = 0.89) and test-retest reliability was excellent value (ICC = 0.85). The CSI-J was significantly correlated with EQ-5D (r = −0.44), pain intensity (r = 0.42), and pain interference (r = 0.48) (p < 0.01 for all). Ten percent of the participants were above the cutoff “40”. The exploratory factor analysis resulted in 5-factor model.

Conclusions

This study reported that the CSI-J was a useful and psychometrically sound tool to assess CSS in Japanese patients with musculoskeletal disorders. The finding of the prevalence rates of CS severity levels in patients with musculoskeletal disorders may help clinicians to decide strategy of treatment.

Association Between Severity of Temporomandibular Disorders and the Frequency of Headache Attacks in Women With Migraine: A Cross-Sectional Study

OBJECTIVE

The aim of this study was to investigate the magnitude of association of the severity of temporomandibular disorders (TMDs) in women with episodic and chronic migraine.

METHODS

Thirty-one women with episodic migraine (mean age: 33 years), 21 with chronic migraine (mean age: 35 years) and 32 healthy controls (mean age: 31 years) were included. The Fonseca Anamnestic Index was applied to assess severity of TMDs. TMD severity was considered as follows: no TMD (0-19 points), mild TMD (20-49 points), moderate TMD (50-69 points), and severe TMD (70-100 points). To compare the proportion of TMD severity among groups, a χ² test was performed. Prevalence ratio (PR) was calculated to determine the association of TMD severity and both migraine groups using the control group as the reference.

RESULTS

Women with chronic and episodic migraine were more likely to exhibit TMD signs and symptoms of any severity than healthy controls (χ² = 30.26; P < .001). TMD prevalence was 54% for healthy controls, 78% for episodic migraine, and 100% for chronic migraine. Women with chronic migraine exhibited greater risk of more severe manifestations of TMD than healthy controls (PR: 3.31; P = .008). This association was not identified for episodic migraine (PR: 2.18; P = .101).

CONCLUSION

The presence of TMD signs and symptoms was associated with migraine independently of the frequency; however, the magnitude of the association of more severe TMD was significantly greater in chronic, but not episodic, migraine.

The risk associated with spinal manipulation: an overview of reviews

BACKGROUND

Spinal manipulative therapy (SMT) is a widely used manual treatment, but many reviews exist with conflicting conclusions about the safety of SMT. We performed an overview of reviews to elucidate and quantify the risk of serious adverse events (SAEs) associated with SMT.

METHODS

We searched five electronic databases from inception to December 8, 2015. We included reviews on any type of studies, patients, and SMT technique. Our primary outcome was SAEs. Quality of the included reviews was assessed using a measurement tool to assess systematic reviews (AMSTAR). Since there were insufficient data for calculating incidence rates of SAEs, we used an alternative approach; the conclusions regarding safety of SMT were extracted for each review, and the communicated opinion were judged by two reviewers independently as safe, harmful, or neutral/unclear. Risk ratios (RRs) of a review communicating that SMT is safe and meeting the requirements for each AMSTAR item, were calculated.

RESULTS

We identified 283 eligible reviews, but only 118 provided data for synthesis. The most frequently described adverse events (AEs) were stroke, headache, and vertebral artery dissection. Fifty-four reviews (46%) expressed that SMT is safe, 15 (13%) expressed that SMT is harmful, and 49 reviews (42%) were neutral or unclear. Thirteen reviews reported incidence estimates for SAEs, roughly ranging from 1 in 20,000 to 1 in 250,000,000 manipulations. Low methodological quality was present, with a median of 4 of 11 AMSTAR items met (interquartile range, 3 to 6). Reviews meeting the requirements for each of the AMSTAR items (i.e. good internal validity) had a higher chance of expressing that SMT is safe.

CONCLUSIONS

It is currently not possible to provide an overall conclusion about the safety of SMT; however, the types of SAEs reported can indeed be significant, sustaining that some risk is present. High quality research and consistent reporting of AEs and SAEs are needed.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015030068 .

A systematic review of thrust manipulation for non-surgical shoulder conditions

Purpose

Although many conservative management options are available for patients with non-surgical shoulder conditions, there is little evidence of their effectiveness. This review investigated one manual therapy approach, thrust manipulation, as a treatment option.

Methods

A systematic search was conducted of the electronic databases from inception to March 2016: PubMed, PEDro, ICL, CINAHL, and AMED. Two independent reviewers conducted the screening process to determine article eligibility. Inclusion criteria were manuscripts published in peer-reviewed journals with human participants of any age. The intervention included was thrust, or high-velocity low-amplitude, manipulative therapy directed to the shoulder and/or the regions of the cervical or thoracic spine. Studies investigating secondary shoulder pain or lacking diagnostic confirmation procedures were excluded. Methodological quality was assessed using the PEDro scale and the Cochrane risk-of-bias tool.

Results

The initial search rendered 5041 articles. After screening titles and abstracts, 36 articles remained for full-text review. Six articles studying subacromial impingement syndrome met inclusion criteria. Four studies were randomized controlled trials (RCTs) and 2 were uncontrolled clinical studies. Five studies included 1 application of a thoracic spine thrust manipulation and 1 applied 8 treatments incorporating a shoulder joint thrust manipulation. Statistically significant improvements in pain scores were reported in all studies. Three of 4 RCTs compared a thrust manipulation to a sham, and statistical significance in pain reduction was found within the groups but not between them. Clinically meaningful changes in pain were inconsistent; 3 studies reported that scores met minimum clinically important difference, 1 reported scores did not, and 2 were unclear. Four studies found statistically significant improvements in disability; however, 2 were RCTs and did not find statistical significance between the active and sham groups.

Conclusions

No clinical trials of thrust manipulation for non-surgical shoulder conditions other than subacromial impingement syndrome were found. There is limited evidence to support or refute thrust manipulation as a solitary treatment for this condition. Studies consistently reported pain reduction, but active treatments were comparable to shams. High-quality studies of thrust manipulation with safety data, longer treatment periods and follow-up outcomes are needed.

Electronic supplementary material

The online version of this article (doi:10.1186/s12998-016-0133-8) contains supplementary material, which is available to authorized users.

Effectiveness of manual therapy for cervical radiculopathy, a review

Manual therapy is often used for patients with neck pain with or without radicular symptoms. There is sparse evidence on the effectiveness in cervical radiculopathy. The aim of this study was to assess current levels of evidence on the effectiveness of manual therapy interventions for patients with cervical radiculopathy. Electronic data bases were systematically searched for clinical guidelines, reviews and randomised clinical trials (RCTs) reporting on the effectiveness of manual therapy for patients with cervical radiculopathy. Eight relevant reviews, two guidelines and two recent RCTs, that had not yet been included in either, were retrieved. The overall quality of the evidence of included studies was evaluated using the GRADE method. Most interventions were only studied in one single RCT. There is low level evidence that cervical manipulation and mobilisation as unimodal interventions are effective on pain and range of motion at the immediate follow up, but no evidence on the effectiveness of thoracic manipulation or mobilisation as unimodal interventions. There is low level evidence that a combination of spinal mobilisation and motor control exercises is more effective on pain and activity limitations than separate interventions or a wait-and-see policy. There is low level evidence of the effectiveness of cervical mobilisation with a neurodynamical intent as unimodal intervention, on the effectiveness of a multimodal intervention with neurodynamic intent on pain activity limitations and global perceived effect compared to a wait-and-see policy. There is also low level evidence that a multimodal intervention consisting of spinal and neurodynamic mobilisations and specific exercises is effective on pain in patients with CR. There is low level evidence that traction is no more effective than placebo traction.

Professional Identity at Los Angeles College of Chiropractic

OBJECTIVE

The objective of this article is to describe chiropractic professional identity as espoused by the Los Angeles College of Chiropractic.

DISCUSSION

Professional identity is a construct that begins formation prior to career selection, can be considered the backbone of health care education, and has been linked to career success. Los Angeles College of Chiropractic's professional identity is shaped by a philosophy of health care that is focused on vitalism, holism, naturalism, therapeutic conservatism, critical rationalism, phenomenology, humanism, and interprofessionalism. Other distinguishing aspects include portal-of-entry professionals with broad diagnostic skills; a focus on spine care; promotion of public-health; and delivery of manual treatments.

CONCLUSION

The chiropractic professional identity at the Los Angeles College of Chiropractic focuses on serving the needs of the people who entrust their health to its graduates and will continue to evolve on the basis of many factors, such as politics, social perceptions, and economic conditions.

Chiropractic Identity: A Neurological, Professional, and Political Assessment

OBJECTIVE

The purpose of this article is to propose a focused assessment of the identity of chiropractic and its profession, triangulating multiple viewpoints converging upon various aspects and definitions of neurology, manual medicine, and alternative or mainstream medicine.

DISCUSSION

Over 120 years since its inception, chiropractic has struggled to achieve an identity for which its foundations could provide optimal health care. Despite recognition of the benefits of spinal manipulation in various government guidelines, advances in US military and Veterans Administration, and persistently high levels of patient satisfaction, the chiropractic profession remains underrepresented in most discussions of health care delivery. Distinguishing characteristics of doctors of chiropractic include the following: (1) they embrace a model of holistic, preventive medicine (wellness); (2) they embrace a concept of neurological imbalance in which form follows function, disease follows disturbed biochemistry, and phenomenology follows physiology; (3) they diagnose, and their institutions of training are accredited by a body recognized by the US Department of Education; (4) they manage patients on a first-contact basis, often as primary care providers in geographical areas that are underserved; (5) the spine is their primary-but not exclusive-area of interaction; (6) they deliver high-velocity, low-amplitude adjustments with a superior safety record compared with other professions; and (7) they use a network of institutions worldwide that have shown increasing commitments to research.

CONCLUSION

This article provides an overview of chiropractic identity from 6 points of view: (1) concepts of manual medicine; (2) areas of interest beyond the spine; (3) concepts of the chiropractic subluxation; (4) concepts of neurology; (5) concepts of mainstream or alternative health care; and (6) concepts of primary care, first-contact provider, or specialist.

Effectiveness of Manual Therapy and Therapeutic Exercise for Temporomandibular Disorders: Systematic Review and Meta-Analysis

BACKGROUND

Manual therapy (MT) and exercise have been extensively used to treat people with musculoskeletal conditions such as temporomandibular disorders (TMD). The evidence regarding their effectiveness provided by early systematic reviews is outdated.

PURPOSE

The aim of this study was to summarize evidence from and evaluate the methodological quality of randomized controlled trials that examined the effectiveness of MT and therapeutic exercise interventions compared with other active interventions or standard care for treatment of TMD.

DATA SOURCES

Electronic data searches of 6 databases were performed, in addition to a manual search.

STUDY SELECTION

Randomized controlled trials involving adults with TMD that compared any type of MT intervention (eg, mobilization, manipulation) or exercise therapy with a placebo intervention, controlled comparison intervention, or standard care were included. The main outcomes of this systematic review were pain, range of motion, and oral function. Forty-eight studies met the inclusion criteria and were analyzed.

DATA EXTRACTION

Data were extracted in duplicate on specific study characteristics.

DATA SYNTHESIS

The overall evidence for this systematic review was considered low. The trials included in this review had unclear or high risk of bias. Thus, the evidence was generally downgraded based on assessments of risk of bias. Most of the effect sizes were low to moderate, with no clear indication of superiority of exercises versus other conservative treatments for TMD. However, MT alone or in combination with exercises at the jaw or cervical level showed promising effects.

LIMITATIONS

Quality of the evidence and heterogeneity of the studies were limitations of the study.

CONCLUSIONS

No high-quality evidence was found, indicating that there is great uncertainty about the effectiveness of exercise and MT for treatment of TMD.

Efficacy of musculoskeletal manual approach in the treatment of temporomandibular joint disorder: A systematic review with meta-analysis

BACKGROUND

Temporomandibular joint disorder (TMD) requires a complex diagnostic and therapeutic approach, which usually involves a multidisciplinary management. Among these treatments, musculoskeletal manual techniques are used to improve health and healing.

OBJECTIVES

To assess the effectiveness of musculoskeletal manual approach in temporomandibular joint disorder patients.

DESIGN

A systematic review with meta-analysis.

METHODS

During August 2014 a systematic review of relevant databases (PubMed, The Cochrane Library, PEDro and ISI web of knowledge) was performed to identify controlled clinical trials without date restriction and restricted to the English language. Clinical outcomes were pain and range of motion focalized in temporomandibular joint. The mean difference (MD) or standard mean difference (SMD) with 95% confidence intervals (CIs) and overall effect size were calculated at every post treatment. The PEDro scale was used to demonstrate the quality of the included studies.

RESULTS/FINDINGS

From the 308 articles identified by the search strategy, 8 articles met the inclusion criteria. The meta-analysis showed a significant difference (p < 0.0001) and large effect on active mouth opening (SMD, 0.83; 95% CI, 0.42 to 1.25) and on pain during active mouth opening (MD, 1.69; 95% CI, 1.09 to 2.30) in favor of musculoskeletal manual techniques when compared to other conservative treatments for TMD.

CONCLUSIONS

Musculoskeletal manual approaches are effective for treating TMD. In the short term, there is a larger effect regarding the latter when compared to other conservative treatments for TMD.

Immediate Effects of Combining Local Techniques in the Craniomandibular Area and Hamstring Muscle Stretching in Subjects with Temporomandibular Disorders: A Randomized Controlled Study

OBJECTIVE

To assess the immediate effects on vertical mouth opening, orofacial mechanosensitivity, and lumbar and suboccipital mobility after adding a myofascial induction technique to a multimodal protocol in subjects with temporomandibular disorders (TMD).

DESIGN

A randomized and double-blind controlled trial was carried out.

SETTINGS/LOCATION

University-based physical therapy research clinic.

SUBJECTS

Sixty subjects (35±11.22 years) with TMD, and restricted mobility of the mandibular condyles and the first cervical vertebrae, were recruited and randomized to either a control group (CG) (n=30) or an experimental group (EG) (n=30).

INTERVENTIONS

The CG underwent a neuromuscular technique over the masseter muscles and passive hamstring muscle stretching. A suboccipital muscle inhibition technique was added to this protocol in the EG.

OUTCOME MEASURES

Primary measurements were made of vertical mouth opening and pressure pain threshold of the masseter muscles. Secondary outcome measures included pressure algometry of the trigeminal nerve, suboccipital range of motion, and lumbar spine mobility, assessed with the sit-and-reach (SAR) test and lumbar forward bending. All evaluations were collected at baseline and immediately after intervention.

RESULTS

In the intragroup comparison, the EG observed an increase in suboccipital flexion (p<0.001; F1,29=14.47; R(2)=0.33) and the SAR test (p=0.009; F1,29=7.89; R(2)=0.21). No significant differences were found in the between-group comparison for any variable (p>0.05).

CONCLUSION

The inclusion of a myofascial induction maneuver in a protocol combining local (neuromuscular treatment) and distal techniques (hamstring stretching) in subjects with TMD has no impact on improving mouth opening, suboccipital and lumbar mobility, and orofacial sensitivity to mechanical pressure.

Cranial Treatment and Spinal Manipulation for a Patient With Low Back Pain: A Case Study

OBJECTIVE

The purpose of this case study is to present chiropractic management of a patient with chronic low back pain by focusing on the craniomandibular system.

CLINICAL FEATURES

A 37-year-old man consulted a chiropractor for pain in the lumbosacral area with radiation down the anterolateral side of the upper left leg. The symptoms started after a fall the previous year. Examination showed a post-traumatic chronic L4-L5 facet dysfunction and left sacro-iliac joint dysfunction. Chiropractic spinal manipulation to the lumbar spine and pelvis gave only temporary relief from the pain.

INTERVENTION AND OUTCOME

A year later a bone scintigraphy was conducted, in which a lesion was found over the right sphenoid area. Cranial treatment of this area was added to the chiropractic treatment plan. After this treatment, the patient reported that he was pain free and could return to normal activities of daily living.

CONCLUSION

The clinical progress of this case suggests that for some patients, adding craniosacral therapy may be helpful in patients with low back symptoms.