Spinal manipulation and spinal mobilization influence different axial sensory beds

Effectiveness of Osteopathic Treatment in Adults with Short Hamstring Syndrome: A Systematic Review

Background/Objective: Short hamstring syndrome is common in the general population and can lead to impaired balance, function, and posture, and increased risk of injuries. Local treatments have obtained controversial results, so it is necessary to evaluate the effectiveness of other types of therapy such as osteopathic treatment. To evaluate the efficacy of osteopathic techniques in increasing the elasticity of the hamstring musculature in short hamstring syndrome. Methods: A systematic review of randomised controlled trials was conducted in PubMed, Medline, Cinhal, Scopus, WOS, SPORTDiscuss, and PEDro. The PEDro scale was used to evaluate the methodological quality and the RoB2 for the evaluation of biases. Results: A total of eight articles were selected. Most of the participants were assessed with the Active Knee Extension or Straight Leg Raise tests. The osteopathic techniques used were the muscle energy technique, suboccipital inhibition, and vertebral mobilisations. As for the control interventions, they mainly included passive stretching and placebo. Conclusions: The results suggest that osteopathic techniques are more effective than placebo or other interventions in increasing flexibility in adult patients with short hamstring syndrome. This effect can be explained by neurophysiological (Golgi apparatus, neuromuscular spindle activity, and Hoffmann reflex) and structural factors (dura mater, posture, and myofascial chains). Nevertheless, the evidence suggests that it would be beneficial to incorporate this type of treatment into flexibility improvement programmes.

Dry needling in the management of chronic tension-type headache associated with levator scapulae syndrome: A case report

Key Clinical Message

The use of DN to the muscular trigger points and distal periosteal enthesis of the levator scapulae may be a useful adjunct intervention within a multi-modal plan of care for the management of work-related chronic tension-type headaches associated with LSS.

Abstract

Chronic tension-type headaches (CTTH) have a lifetime prevalence of 42% and account for more lost workdays than migraine headaches. Dry needling (DN) is being increasingly used by physical therapists in the management of CTTH; however, to date, the supporting evidence is limited. The purpose of this case report was to describe how three sessions of DN targeting myofascial trigger points in the levator scapulae (LS) muscle and its distal enthesis was used to treat a 63-year-old male patient who presented with work-related CTTH associated with levator scapulae syndrome (LSS). The patient was treated for five visits over the course of 2 months. At discharge and 6-month follow-up, the patient reported full resolution of symptoms. Self-report outcomes included the numeric pain rating scale and the Neck Disability Index. The use of DN to the LS muscle and its distal enthesis may be a valuable addition to a multi-modal plan of care in the treatment of work-related CTTH associated with LSS.

Comparative effectiveness of cervical vs thoracic spinal-thrust manipulation for care of cervicogenic headache: A randomized controlled trial

BACKGROUND

There is ample evidence supporting the use of different manipulative therapy techniques for Cervicogenic Headache (CgH). However, no technique can be singled as the best available treatment for patients with CgH. Therefore, the objective of the study is to find and compare the clinical effects of cervical spine over thoracic spine manipulation and conventional physiotherapy in patients with CgH.

DESIGN, SETTING, AND PARTICIPANTS

It is a prospective, randomized controlled study conducted between July 2020 and January 2023 at the University hospital. N = 96 eligible patients with CgH were selected based on selection criteria and they were divided into cervical spine manipulation (CSM; n = 32), thoracic spine manipulation (TSM; n = 32) and conventional physiotherapy (CPT; n = 32) groups, and received the respective treatment for four weeks. Primary (CgH frequency) and secondary CgH pain intensity, CgH disability, neck pain frequency, neck pain intensity, neck pain threshold, cervical flexion rotation test (CFRT), neck disability index (NDI) and quality of life (QoL) scores were measured. The effects of treatment at various intervals were analyzed using a 3 × 4 linear mixed model analysis (LMM), with treatment group (cervical spine manipulation, thoracic spine manipulation, and conventional physiotherapy) and time intervals (baseline, 4 weeks, 8 weeks, and 6 months), and the statistical significance level was set at P < 0.05.

RESULTS

The reports of the CSM, TSM and CPT groups were compared between the groups. Four weeks following treatment CSM group showed more significant changes in primary (CgH frequency) and secondary (CgH pain intensity, CgH disability, neck pain frequency, pain intensity, pain threshold, CFRT, NDI and QoL) than the TSM and CPT groups (p = 0.001). The same gradual improvement was seen in the CSM group when compared to TSM and CPT groups (p = 0.001) in the above variables at 8 weeks and 6 months follow-up.

CONCLUSION

The reports of the current randomized clinical study found that CSM resulted in significantly better improvements in pain parameters (intensity, frequency and threshold) functional disability and quality of life in patients with CgH than thoracic spine manipulation and conventional physiotherapy.

TRIAL REGISTRATION

Clinical trial registration: CTRI/2020/06/026092 trial was registered prospectively on 24/06/2020.

Why is the prevailing model of joint manipulation (still) incorrect?

For manipulation, this paper addresses arguably the most fundamental question that can be asked about any therapeutic intervention: what is it? In answering this question, this paper presents the prevailing model of joint manipulation (of Sandoz) and explains why this influential model is fundamentally flawed. The early research on 'joint cracking' that led to the development of this model is described in chronological order, alongside how this research was misinterpreted, which gave rise to the model's flaw. Of concern, the flaw in this model makes worrying predictions that could lead to dangerous clinical decisions. Understandably, these predictions have attracted criticism over the use of manipulation as a therapeutic intervention. A corrected model, first published by Evans and Breen more than 15 years ago, is then presented and explained. Unlike the flawed model, this corrected model makes predictions in line with all available empirical data and additionally provides reassuring answers to critics. Many current definitions of manipulation have inherited the flaw from Sandoz's model. Hence, a better, empirically derived definition, consistent with the corrected model, is now required.

Clinical Effectiveness and Efficacy of Chiropractic Spinal Manipulation for Spine Pain

Spine pain is a highly prevalent condition affecting over 11% of the world's population. It is the single leading cause of activity limitation and ranks fourth in years lost to disability globally, representing a significant personal, social, and economic burden. For the vast majority of patients with back and neck pain, a specific pathology cannot be identified as the cause for their pain, which is then labeled as non-specific. In a growing proportion of these cases, pain persists beyond 3 months and is referred to as chronic primary back or neck pain. To decrease the global burden of spine pain, current data suggest that a conservative approach may be preferable. One of the conservative management options available is spinal manipulative therapy (SMT), the main intervention used by chiropractors and other manual therapists. The aim of this narrative review is to highlight the most relevant and up-to-date evidence on the effectiveness (as it compares to other interventions in more pragmatic settings) and efficacy (as it compares to inactive controls under highly controlled conditions) of SMT for the management of neck pain and low back pain. Additionally, a perspective on the current recommendations on SMT for spine pain and the needs for future research will be provided. In summary, SMT may be as effective as other recommended therapies for the management of non-specific and chronic primary spine pain, including standard medical care or physical therapy. Currently, SMT is recommended in combination with exercise for neck pain as part of a multimodal approach. It may also be recommended as a frontline intervention for low back pain. Despite some remaining discrepancies, current clinical practice guidelines almost universally recommend the use of SMT for spine pain. Due to the low quality of evidence, the efficacy of SMT compared with a placebo or no treatment remains uncertain. Therefore, future research is needed to clarify the specific effects of SMT to further validate this intervention. In addition, factors that predict these effects remain to be determined to target patients who are more likely to obtain positive outcomes from SMT.

Thoracic Spinal Manipulation Effect on Neuroendocrine Response in People With Achilles Tendinopathy: A Randomized Crossover Trial

OBJECTIVE

The purpose of the present study was to determine the neuroendocrine response after a thoracic spinal manipulation in people with Achilles tendinopathy.

METHODS

This was a randomized 2-sequence, 2-period crossover trial. A total of 24 participants, mean (standard deviation) age of 48 (7) years, with a diagnosis of Achilles tendinopathy (>3 mo) were randomly assigned into sequence 1 (sham intervention and then thoracic spinal manipulation) or sequence 2 (thoracic spinal manipulation and then sham intervention). The trial was conducted at a university laboratory with a washout period of 1 week. The primary outcome measure was the testosterone/cortisol (T/C) ratio (salivary samples). The secondary outcome measures included heart rate variability (measured with electrocardiography) and total oxygenation index (nmol/L) of calf muscle and Achilles tendon (measured with near-infrared spectroscopy). A 2-way mixed-model analysis of variance was performed. The statistic of interest was the condition by time interaction.

RESULTS

A statistically significant condition by time interaction was found for the T/C ratio (mean difference: -0.16; confidence interval: -0.33 to 0.006; interaction: P < .05) and the total oxygenation index (mean difference: 1.35; confidence interval: -1.3 to 4.1; interaction: P < .05) of calf muscle but not for Achilles tendon (P = .6); however, no difference was found for heart rate variability (P = .5).

CONCLUSION

In people with Achilles tendinopathy, thoracic spinal manipulation resulted in immediate increase in the total oxygenation index in the calf muscle followed by an increase in the T/C ratio 6 hours post-intervention.

Spine adjusting instrument (Impulse®) attenuates nociception and modulates oxidative stress markers in the spinal cord and sciatic nerve of a rat model of neuropathic pain

OBJECTIVE

Oxidative stress plays an important role in neuropathic pain. Spinal manipulative therapy (SMT) can exert beneficial effects in pain outcomes in humans and animal models. SMT can also modulate oxidative stress markers in both humans and animals. We aimed to determine the effect of Impulse®-assisted SMT (ISMT) on nociception and oxidative stress biomarkers in the spinal cord and sciatic nerve of rats with neuropathic pain (NP).

METHODS

NP was induced by chronic constriction injury (CCI) of the sciatic nerve. Animals were randomly assigned to naive, sham (rats with sciatic nerve exposure but without ligatures) and CCI, with and without ISMT. ISMT was applied onto the skin area corresponding to the spinous process of L4-L5, 3 times/week, for 2 weeks. Mechanical threshold, latency to paw withdrawal to thermal stimulus and oxidative stress biomarkers in spinal cord and sciatic nerve were the main outcomes evaluated.

RESULTS

ISMT significantly increased mechanical threshold and withdrawal latency after CCI. In the spinal cord, ISMT prevented the increase of pro-oxidative superoxide anion generation and hydrogen peroxide levels. Lipid hydroperoxide levels both in the spinal cord and in the sciatic nerve were attenuated by ISMT. Total antioxidant capacity increased in the spinal cord and sciatic nerve of CCI rats with and without ISMT. CCI and ISMT did not significantly change the total thiol content of the spinal cord.

CONCLUSIONS

Our findings suggest reduced oxidative stress in the spinal cord and/or nerve may be an important mechanism underlying a therapeutic effect of SMT to manage NP non-pharmacologically.

Influence of Lumbar Mobilizations During the Nordic Hamstring Exercise on Hamstring Measures of Knee Flexor Strength, Failure Point, and Muscle Activity: A Randomized Crossover Trial

OBJECTIVE

The aims of this study were to quantify the effects of spinal mobilization on force production, failure point, and muscle activity of the hamstrings during the Nordic hamstring exercise (NHE), and to explore individual differences in responses.

METHODS

In a replicated randomized crossover trial, 24 asymptomatic, recreationally active men (age [mean ± standard deviation]: 27 ± 6 years; body mass: 82 ± 17 kg; height: 181 ± 8 cm) completed 2 standardized intervention trials (L4/5 zygapophyseal mobilizations) and 2 control trials. The failure point of the NHE was determined with 3D motion capture. Peak force, knee flexor torque, and electromyography (EMG) of the biceps femoris were measured. Data analyses were undertaken to quantify mean intervention response and explore any individual response heterogeneity.

RESULTS

Mean (95% confidence interval) left-limb force was higher in intervention than in control trials by 18.7 (4.6-32) N. Similarly, right-limb force was higher by 22.0 (3.4-40.6) N, left peak torque by 0.14 (0.06-0.22) N • m, and right peak torque by 0.14 (0.05-0.23) N • m/kg. Downward force angle was decreased in intervention vs control trials by 4.1° (0.5°-7.6°) on the side of application. Both peak EMG activity (P = .002), and EMG at the downward force (right; P = .020) increased in the intervention condition by 16.8 (7.1-26.4) and 8.8 (1.5-16.1) mV, respectively. Mean downward acceleration angle changed by only 0.3° (-8.9° to 9.4°) in intervention vs control trials. A clear response heterogeneity was indicated only for right force (Participant × Intervention interaction: P = .044; response heterogeneity standard deviation = 34.5 [5.7-48.4] N). Individual response heterogeneity was small for all other outcomes.

CONCLUSION

After spinal mobilization, immediate changes in bilateral hamstring force production and peak torque occurred during the NHE. The effect on the NHE failure point was unclear. Electromyographic activity increased on the ipsilateral side. Response heterogeneity was generally similar to the random trial-to-trial variability inherent in the measurement of the outcomes.

The Effect of Shoulder Mobilization on Scapular and Shoulder Muscle Activity During Resisted Shoulder Abduction: A Crossover Study of Asymptomatic Individuals

OBJECTIVE

The primary aim was to investigate the effect of inferior shoulder mobilization on scapular and shoulder muscle activity during resisted shoulder abduction in asymptomatic individuals.

METHODS

This was a lab-based, repeated-measures, crossover, randomized controlled study. Twenty-two participants were recruited. The order of experimental conditions was randomized. Each participant performed 5 repetitions of resisted shoulder abduction before and after the control and mobilization (grade +IV inferior shoulder mobilization, 3 sets, 60 seconds) conditions. Surface electromyography recorded the muscle activity of anterior, middle, and posterior deltoid; supraspinatus; infraspinatus; upper and lower trapezius; serratus anterior; and latissimus dorsi muscles.

RESULTS

Muscle activity levels reduced for infraspinatus (11.3% MVIC, 95% CI: 1.7-20.8), middle (22.4% MVIC, 95% CI: 15.9-28.8) and posterior deltoid (8.7 % MVIC, 95% CI: 4.6-12.9), and serratus anterior (-28.1% MVIC, 95% CI: 15.6-40.8) muscles after the mobilization condition during the eccentric phase of shoulder abduction. No carryover effects were observed, and within-session reliability was excellent (intraclass correlation coefficient scores ranging from 0.94 to 0.99).

CONCLUSION

Our findings suggest that inferior glenohumeral mobilization reduces activity levels of some scapular and shoulder muscles. Given the exploratory nature of our study, changes in muscle activity levels may have been found by chance. Confirmatory studies are required.

The Effectiveness of Spinal Manipulation in Increasing Muscle Strength in Healthy Individuals: A Systematic Review and Meta-Analysis

OBJECTIVE

The purpose of this study was to systematically review the effects of spinal manipulation on muscular strength in healthy individuals and conduct a meta-analysis to appraise the quality of evidence.

METHODS

Articles were searched and retrieved from MEDLINE, EMBASE, CINAHL, Cochrane Library, PubMed, Academic Search Premier, SPORTDiscus, and AMED. Searches were conducted in September 2017 without a limit on the starting period. The Physiotherapy Evidence Database scale was used to appraise the quality of the included studies. Data from eligible articles were pooled, and meta-analyses were conducted. The quality of evidence was appraised by the Grading of Recommendations, Assessment, Development and Evaluations approach. The registration number for the review on PROSPERO is CRD42017075215.

RESULTS

A total of 911 records were screened, and 3 randomized controlled trials were eligible to be included in this review. There was a significant pooled standardized mean difference in isometric strength (0.93, 95% confidence interval [CI], 0.17-1.68; P = .02) between the experimental and control groups, with a moderate level of heterogeneity.

CONCLUSION

This review suggests that spinal manipulative therapy augments the percentage of change in isometric strength gain among healthy participants when compared to no intervention or sham manipulation. However, the heterogeneity of pooled studies in this review suggests that the results should be interpreted with caution.

Acute effects of centrally- and unilaterally-applied posterior-anterior mobilizations of the lumbar spine on lumbar range of motion, hamstring extensibility and muscle activation

BACKGROUND

Lumbar mobilizations are used to clinically treat the lumbar and hamstring region. However, evidence is limited regarding the effectiveness of specific mobilization methods.

OBJECTIVE

To compare central and unilateral posterior-anterior mobilizations (CPA, UPA) of the lumbar spine on lumbar and hamstring range of motion (ROM), and muscle activity (sEMG).

METHODS

Twenty participants received CPA, UPA, or no mobilization (CON) on separate occasions (crossover design). Post-treatment outcome measures were ROM during active lumbar flexion (ALF) and active knee extension (AKE), as well as sEMG of the Erector Spinae (ES) and Biceps Femoris (BF) during these movements.

RESULTS

sEMG was possibly to very likely lower following CPA (mean difference range =-5% to -21%) and UPA (-7% to -36%), while ROM was most likely greater (-12% to 25% and -17% to 24%, respectively). Most sEMG measures were possibly to likely lower following UPA versus CPA (-18% to -11%), while AKE ROM was possibly greater (-5.5%). Differences in ES sEMG (-2.5%) and ROM (-1.4%) during ALF were unclear and most likely trivial, respectively.

CONCLUSIONS

CPA and UPA mobilizations increase lumbar and hamstring ROM whilst reducing local muscle activity. These effects appear to be greater for UPA mobilizations when compared with CPA.

Motor Neuron Excitability Attenuation as a Sequel to Lumbosacral Manipulation in Subacute Low Back Pain Patients and Asymptomatic Adults: A Cross-Sectional H-Reflex Study

OBJECTIVE

The purpose of the study was to compare a time series of tibial nerve H-reflex trials between patients with subacute low back pain (LBP) and asymptomatic adults using pre and post high-velocity, low-amplitude (HVLA) spinal manipulation (SM) and control procedures.

METHODS

Asymptomatic adults (n = 66) and patients with subacute LBP (n = 45) were randomized into 3 lumbosacral procedures: side-posture positioning, joint preloading with no thrust, and HVLA SM. A time series of 40 H_max/M_max ratios at a rate of 0.1 Hz were recorded in blocks of 10 trials at baseline and after the lumbosacral procedures at time points corresponding to immediately after, 5 minutes after, and 10 minutes after the procedure. Descriptive time series analysis techniques included time plots, outlier detection, and autocorrelation functions. A mixed analysis of variance model (group × procedure × time) was used to compare the effects of lumbosacral procedures on H_max/M_max ratios between the patients with subacute LBP and asymptomatic participants.

RESULTS

The time series analysis and the significant lumbosacral × time interaction term (P < .05) indicated that inhibition of the H_max/M_max ratios at the 10-second postlumbosacral procedure time point was greatest after the HVLA SM procedure. The effects of lumbosacral procedures on H_max/M_max ratios were similar between patients with subacute LBP and asymptomatic participants.

CONCLUSIONS

Although nonspecific effects of movement or position artifacts on the H_max/M_max ratio were present, a reliable and valid attenuation of the H_max/M_max ratio occurred as a specific aspect of HVLA SM in both asymptomatic adults and patients with subacute LBP.

Grade-IV inferior glenohumeral mobilization does not immediately alter shoulder and scapular muscle activity: a repeated-measures study in asymptomatic individuals

OBJECTIVES

To assess: (1) the presence of any carry-over effect between interventions; (2) the immediate effects of inferior shoulder mobilization on shoulder and scapular muscle activity; and (3) to compare muscle activity response between the control and mobilization conditions. Repeated measures, cross-over, pre-post intervention study with sample of convenience.

METHODS

Twenty-two asymptomatic individuals performed 10 repetitions of shoulder abduction before and after the control and mobilization, with a dosage of three sets of 30-s duration, with grade-IV. The order of intervention was randomized. Surface electromyography was used for recording activity of upper and lower trapezius; anterior, middle and posterior deltoids; supraspinatus; infraspinatus; and serratus anterior. Repeated measures mixed-model analysis of variance was used to assess immediate changes in muscle activity levels following inferior shoulder mobilization. Statistical parametric mapping (SPM) was used for comparing muscle activity waveforms between control and mobilization conditions throughout the range of motion.

RESULTS

No systematic changes in muscle activity levels were found between: (1) baseline and follow-up for each condition, at the concentric and eccentric phases of shoulder abduction; (2) control and mobilization conditions during the concentric and eccentric phases of shoulder abduction. SPM results suggested no differences in muscle activity pattern between conditions.

CONCLUSIONS

Inferior shoulder mobilization did not produce immediate effects on shoulder and scapular muscle activity. It is possible that the dose used was insufficient to generate an immediate neuromuscular response to the mobilization.

Comparison of 2 Lumbar Manual Therapies on Temporal Summation of Pain in Healthy Volunteers

The purpose of this study was to compare the immediate change in temporal summation of heat pain (TSP) between spinal manipulation (SMT) and spinal mobilization (MOB) in healthy volunteers. Ninety-two volunteers (24 male; 23.8 ± 5.3 years) were randomized to receive SMT, MOB, or no treatment (REST) for 1 session. Primary outcomes were changes in TSP, measured at the hand and foot, immediately after the session. A planned subgroup analysis investigated effects across empirically derived TSP clusters. For the primary outcome there were no differences in the immediate change in TSP measured at the foot between SMT and MOB, however, both treatments were superior to the REST condition. In the subgroup analysis the response to a standard TSP protocol was best characterized by 3 clusters: 52% no change (n = 48, 52%); facilitatory response (n = 24, 26%), and inhibitory response (n = 20, 22%). There was a significant Time × Treatment group × Cluster interaction for TSP measured at the foot. The inhibitory cluster showed the greatest attenuation of TSP after SMT and MOB compared with REST. These data suggest lumbar manual therapies of different velocities produce a similar localized attenuation of TSP, compared with no treatment. Attenuation of localized pain facilitatory processes by manual therapies was greatest in pain-free individuals who show an inhibitory TSP response.

PERSPECTIVE

The attenuation of pain facilitatory measures may serve an important underlying role in the therapeutic response to manual therapies. Identifying patients in pain who still have an inhibitory capacity (ie, an inhibitory response subgroup) may be useful clinically in identifying the elusive "manual therapy" responder.

Joint Mobilization and Manipulation for the Equine Athlete

Joint mobilization and manipulation provide important diagnostic and therapeutic approaches for addressing musculoskeletal issues in veterinary medicine. Soft tissue and joint mobilization are used to assess the quality and quantity of joint range of motion and as a primary means of treating musculoskeletal disorders. Spinal manipulation was shown to be effective for reducing pain, improving flexibility, reducing muscle tone, and improving symmetry of spinal kinematics in horses. Because of potential misuse and safety issues, joint mobilization and manipulative therapies should be provided only by specially trained veterinarians or licensed human manual therapists.

Upper cervical and upper thoracic manipulation versus mobilization and exercise in patients with cervicogenic headache: a multi-center randomized clinical trial

Background

Although commonly utilized interventions, no studies have directly compared the effectiveness of cervical and thoracic manipulation to mobilization and exercise in individuals with cervicogenic headache (CH). The purpose of this study was to compare the effects of manipulation to mobilization and exercise in individuals with CH.

Methods

One hundred and ten participants (n = 110) with CH were randomized to receive both cervical and thoracic manipulation (n = 58) or mobilization and exercise (n = 52). The primary outcome was headache intensity as measured by the Numeric Pain Rating Scale (NPRS). Secondary outcomes included headache frequency, headache duration, disability as measured by the Neck Disability Index (NDI), medication intake, and the Global Rating of Change (GRC). The treatment period was 4 weeks with follow-up assessment at 1 week, 4 weeks, and 3 months after initial treatment session. The primary aim was examined with a 2-way mixed-model analysis of variance (ANOVA), with treatment group (manipulation versus mobilization and exercise) as the between subjects variable and time (baseline, 1 week, 4 weeks and 3 months) as the within subjects variable.

Results

The 2X4 ANOVA demonstrated that individuals with CH who received both cervical and thoracic manipulation experienced significantly greater reductions in headache intensity (p < 0.001) and disability (p < 0.001) than those who received mobilization and exercise at a 3-month follow-up. Individuals in the upper cervical and upper thoracic manipulation group also experienced less frequent headaches and shorter duration of headaches at each follow-up period (p < 0.001 for all). Additionally, patient perceived improvement was significantly greater at 1 and 4-week follow-up periods in favor of the manipulation group (p < 0.001).

Conclusions

Six to eight sessions of upper cervical and upper thoracic manipulation were shown to be more effective than mobilization and exercise in patients with CH, and the effects were maintained at 3 months.

Trial registration

NCT01580280 April 16, 2012.

Immediate effects of thoracic spinal mobilisation on erector spinae muscle activity and pain in patients with thoracic spine pain: a preliminary randomised controlled trial

OBJECTIVES

To investigate the activity of the thoracic erector spinae muscles and perceived pain intensity immediately after central postero-anterior (PA) mobilisation of the thoracic spine.

DESIGN

Randomised, placebo-controlled, experimental design.

PARTICIPANTS AND INTERVENTIONS

Thirty-four participants with non-specific thoracic pain were randomised to the experimental group [grade III central PA mobilisation performed for 3minutes at the level of the seventh thoracic vertebra (T7)] or the placebo group (less than grade I central PA mobilisation performed for 3minutes at T7).

MAIN OUTCOME MEASURES

Before and immediately after PA mobilisation, surface electromyography (EMG) was recorded from the thoracic erector spinae muscles as the participants performed 10° spine extension from a prone position for 10seconds. Each participant rated their pain intensity as an investigator performed grade III central PA over the most symptomatic thoracic segment, and the pressure pain threshold (PPT) was evaluated bilaterally over the erector spinae muscles.

RESULTS

The EMG amplitude of thoracic erector spinae activity was reduced significantly after the intervention in the experimental group (P<0.05), but not in the placebo group. The difference between the groups was significant {pre-post change: placebo -14 [standard deviation (SD) 50]mV, experimental 28 (SD 48)mV; mean difference -42mV; 95% confidence interval of the difference -76 to 7; P<0.05} albeit small (Grissom=0.44). However, both groups showed a significant reduction in pain immediately after the intervention, and both groups showed a similar pre-post change in PPT.

CONCLUSION

These preliminary findings indicate that grade III central mobilisation over the most symptomatic thoracic segment reduces thoracic erector spinae activity during extension of the trunk in people with non-specific thoracic spine pain.

CLINICAL TRIAL REGISTRATION NUMBER

ISRCTN47601528.

Antinociceptive Effects of Spinal Manipulative Therapy on Nociceptive Behavior of Adult Rats during the Formalin Test

Optimizing pain relief resulting from spinal manipulative therapies, including low velocity variable amplitude spinal manipulation (LVVA-SM), requires determining their mechanisms. Pain models that incorporate simulated spinal manipulative therapy treatments are needed for these studies. The antinociceptive effects of a single LVVA-SM treatment on rat nociceptive behavior during the commonly used formalin test were investigated. Dilute formalin was injected subcutaneously into a plantar hindpaw. Licking behavior was video-recorded for 5 minutes. Ten minutes of LVVA-SM at 20° flexion was administered with a custom-made device at the lumbar (L5) vertebra of isoflurane-anesthetized experimental rats (n = 12) beginning 10 minutes after formalin injection. Hindpaw licking was video-recorded for 60 minutes beginning 5 minutes after LVVA-SM. Control rats (n = 12) underwent the same methods except for LVVA-SM. The mean times spent licking the formalin-injected hindpaw of both groups 1–5 minutes after injection were not different. The mean licking time during the first 20 minutes post-LVVA-SM of experimental rats was significantly less than that of control rats (P < 0.001). The mean licking times of both groups during the second and third 20 minutes post-LVVA-SM were not different. Administration of LVVA-SM had a short-term, remote antinociceptive effect similar to clinical findings. Therefore, mechanistic investigations using this experimental approach are warranted.

Neural responses to the mechanical characteristics of high velocity, low amplitude spinal manipulation: Effect of specific contact site

BACKGROUND

Systematic investigations are needed identifying how variability in the biomechanical characteristics of spinal manipulation affects physiological responses. Such knowledge may inform future clinical practice and research study design.

OBJECTIVE

To determine how contact site for high velocity, low amplitude spinal manipulation (HVLA-SM) affects sensory input to the central nervous system.

DESIGN

HVLA-SM was applied to 4 specific anatomic locations using a no-HVLA-SM control at each location randomized in an 8×8 Latin square design in an animal model.

METHODS

Neural activity from muscle spindles in the multifidus and longissimus muscles were recorded from L6 dorsal rootlets in 16 anesthetized cats. A posterior to anterior HVLA-SM was applied through the intact skin overlying the L6 spinous process, lamina, inferior articular process and L7 spinous process. HVLA-SMs were preceded and followed by simulated spinal movement applied to the L6 vertebra. Change in mean instantaneous discharge frequency (ΔMIF) was determined during the thrust and the simulated spinal movement.

RESULTS

All contact sites increased L6 muscle spindle discharge during the thrust. Contact at all L6 sites significantly increased spindle discharge more than at the L7 site when recording at L6. There were no differences between L6 contact sites. For simulated movement, the L6 contact sites but not the L7 contact site significantly decreased L6 spindle responses to a change in vertebral position but not to movement to that position.

CONCLUSIONS

This animal study showed that contact site for an HVLA-SM can have a significant effect on the magnitude of sensory input arising from muscle spindles in the back.

Intended and non-intended kinematic effects of atlanto-axial rotational high-velocity, low-amplitude techniques

INTRODUCTION

The study of neck kinematics during high-velocity, low-amplitude manipulations of the atlanto-axial segment is essential to understanding cervical motion mechanisms and their impact and possible risk for soft-tissue injuries during treatment of spine disorders.

METHODS

Twenty fresh-frozen specimens were tested during manual application of an axial rotation technique.

FINDINGS

The kinematics indicate the thrust induced motion components of approximately 1° at the treated segment around all three axes of the local embedded reference frame. Moreover, an equal amount of axial rotation motion took place at the adjacent atlanto-occipital joint.

INTERPRETATION

Overall atlanto-axial motion remained below the level of slow regional mobilization of the cervical spine. These findings can be correlated to literature data concerning the limited increase in vertebral artery strain during high-velocity, low-amplitude manipulation.

Bilateral sensory effects of unilateral passive accessory mobilization in patients with thumb carpometacarpal osteoarthritis

OBJECTIVE

The purpose of this study was to investigate changes in pressure sensitivity and pinch grip force in the nonsymptomatic side in patients with thumb carpometacarpal (CMC) osteoarthritis (OA) after the application of a unilateral passive accessory mobilization to the symptomatic hand.

METHODS

Secondary analysis of data from a randomized trial with concealed allocation, blinded assessor, and intention-to-treat analysis was performed. Twenty-eight patients (72% females), with unilateral CMC OA and mean age ± SD of 82 ± 6 years, met all the inclusion criteria and agreed to participate. The experimental group received passive accessory mobilization to the CMC OA, and the control group received a nontherapeutic dose of intermittent ultrasound on the affected side for 4 sessions over 2 weeks. Outcome measures including pressure pain thresholds (PPTs) at the lateral epicondyle, thumb CMC joint, tubercle of the scaphoid bone, and the unciform apophysis of the hamate bone and tip and tripod pinch and grip strength of the contralateral/unaffected hand were assessed at baseline as well as 1 and 2 weeks after treatment by an assessor blinded to the group allocation. A repeated measures analysis of variance was used to determine changes in PPT and pinch and grip strength.

RESULTS

No important baseline differences were observed between groups. At the end of the follow-up period, the experimental group exhibited a significant increase in PPT at the CMC joint as compared with the control group 0.6 kg/cm(2) (95% confidence interval, 0.3-1.0; F3.0 = 4.89; P = .009). Although PPT changes in the experimental group were higher than the control group at the remaining sites, differences did not reach statistically significance. Similarly, tip, tripod pinch, and grip strength remained unchanged after the intervention.

CONCLUSION

This secondary analysis found that the application of a unilateral passive accessory mobilization targeted to the symptomatic CMC joint induced an increase of PPT levels 2 weeks after treatment; however, differences were small and likely of limited clinical value. No contralateral motor effects were observed. Future studies including larger sample sizes are needed to examine the effects of joint mobilization on motor and sensory effects.

The effect of thoracic spine manipulation on pain and disability in patients with non-specific neck pain: a systematic review

PURPOSE

The aim of this systematic review was to determine the efficacy of thoracic spine manipulation (TSM) in reducing pain and disability in patients diagnosed with non-specific neck pain.

METHODS

An extensive literature search of PubMed, The Cochrane Library, CINAHL and EMBASE was conducted in February 2012. Randomized controlled trials (RCTs) or controlled clinical trials evaluating the effect of TSM in patients aged 18 to 65 years with non-specific neck pain were eligible. Methodological quality of the studies was assessed according to the Physiotherapy Evidence Database scale (PEDro). Qualitative analyses were conducted by means of the best evidence synthesis of van Peppen et al.

RESULTS

The methodological quality of the 10 included RCTs (677 patients) varied between four and eight points. Eight studies reported significant reduction in pain and/or disability by TSM. Overall, according to the best evidence synthesis, there is insufficient evidence that TSM is more effective than control interventions in reducing pain and disability in patients with non-specific neck pain.

CONCLUSIONS

TSM has a therapeutic benefit to some patients with neck pain, when compared to the effect of interventions such as electrotherapy/thermal programme, infrared radiation therapy, spinal mobilization and exercises. However, in comparison to cervical spine manipulation, no evidence is found that TSM is more effective in reducing pain and disability. Implications for Rehabilitation TSM is often used in the treatment of non-specific neck pain, which is a major health problem in the Western society. There is insufficient evidence that TSM is more effective in reducing pain and disability than control treatments in patients with non-specific neck pain. Despite the insufficient evidence that TSM is more effective than control treatments, TSM has a therapeutic benefit to some patients with neck pain. Therefore, TSM alone or in combination with other interventions is a suitable intervention to use in the treatment of non-specific neck pain.

Understanding inhibitory mechanisms of lumbar spinal manipulation using H-reflex and F-wave responses: a methodological approach

The purpose of this research was to characterize unique neurophysiologic events following a high velocity, low amplitude (HVLA) spinal manipulation (SM) procedure. Descriptive time series analysis techniques of time plots, outlier detection and autocorrelation functions were applied to time series of tibial nerve H-reflexes that were evoked at 10-s intervals from 100 s before the event until 100 s after three distinct events L5-S1 HVLA SM, or a L5-S1 joint pre-loading procedure, or the control condition. Sixty-six subjects were randomly assigned to three procedures, i.e., 22 time series per group. If the detection of outliers and correlograms revealed a pattern of non-randomness that was only time-locked to a single, specific event in the normalized time series, then an experimental effect would be inferred beyond the inherent variability of H-reflex responses. Tibial nerve F-wave responses were included to determine if any new information about central nervous function following a HVLA SM procedure could be ascertained. Time series analyses of H(max)/M(max) ratios, pre-post L5-S1 HVLA SM, substantiated the hypothesis that the specific aspects of the manipulative thrust lead to a greater attenuation of the H(max)/M(max) ratio as compared to the non-specific aspects related to the postural perturbation and joint pre-loading. The attenuation of the H(max)/M(max) ratio following the HVLA SM procedure was reliable and may hold promise as a translational tool to measure the consistency and accuracy of protocol implementation involving SM in clinical trials research. F-wave responses were not sensitive to mechanical perturbations of the lumbar spine.

Upper cervical and upper thoracic thrust manipulation versus nonthrust mobilization in patients with mechanical neck pain: a multicenter randomized clinical trial

STUDY DESIGN

Randomized clinical trial.

OBJECTIVE

To compare the short-term effects of upper cervical and upper thoracic high-velocity low-amplitude (HVLA) thrust manipulation to nonthrust mobilization in patients with neck pain.

BACKGROUND

Although upper cervical and upper thoracic HVLA thrust manipulation and nonthrust mobilization are common interventions for the management of neck pain, no studies have directly compared the effects of both upper cervical and upper thoracic HVLA thrust manipulation to nonthrust mobilization in patients with neck pain.

METHODS

Patients completed the Neck Disability Index, the numeric pain rating scale, the flexion-rotation test for measurement of C1-2 passive rotation range of motion, and the craniocervical flexion test for measurement of deep cervical flexor motor performance. Following the baseline evaluation, patients were randomized to receive either HVLA thrust manipulation or nonthrust mobilization to the upper cervical (C1-2) and upper thoracic (T1-2) spines. Patients were reexamined 48-hours after the initial examination and again completed the outcome measures. The effects of treatment on disability, pain, C1-2 passive rotation range of motion, and motor performance of the deep cervical flexors were examined with a 2-by-2 mixed-model analysis of variance (ANOVA).

RESULTS

One hundred seven patients satisfied the eligibility criteria, agreed to participate, and were randomized into the HVLA thrust manipulation (n = 56) and nonthrust mobilization (n = 51) groups. The 2-by-2 ANOVA demonstrated that patients with mechanical neck pain who received the combination of upper cervical and upper thoracic HVLA thrust manipulation experienced significantly (P<.001) greater reductions in disability (50.5%) and pain (58.5%) than those of the nonthrust mobilization group (12.8% and 12.6%, respectively) following treatment. In addition, the HVLA thrust manipulation group had significantly (P<.001) greater improvement in both passive C1-2 rotation range of motion and motor performance of the deep cervical flexor muscles as compared to the group that received nonthrust mobilization. The number needed to treat to avoid an unsuccessful outcome was 1.8 and 2.3 at 48-hour follow-up, using the global rating of change and Neck Disability Index cut scores, respectively.

CONCLUSION

The combination of upper cervical and upper thoracic HVLA thrust manipulation is appreciably more effective in the short term than nonthrust mobilization in patients with mechanical neck pain.

LEVEL OF EVIDENCE

Therapy, level 1b.

Repeated Applications of Thoracic Spine Thrust Manipulation do not Lead to Tolerance in Patients Presenting with Acute Mechanical Neck Pain: A Secondary Analysis

It has been demonstrated that patients receiving mobilization techniques do not exhibit tolerance to repeated applications. However, this phenomenon has not been investigated for thoracic manipulation. Our aim was to determine if patients receiving thoracic thrust manipulation exhibit tolerance to repeated applications in acute mechanical neck pain. Forty-five patients were randomly assigned to two groups. The control group received electro- and thermotherapy for 5 sessions, and the experimental group received the same program and also received a thoracic thrust manipulation once a week for 3 consecutive weeks. Outcome measures included neck pain and cervical mobility. Within-session change scores for pain and mobility during treatment sessions #1, 3, and 5 were examined with a one-way repeated measured ANOVA. A 2-way ANOVA with session as within-subject variable and group as between-subject variable was used to compare change scores for each visit between groups to ascertain if there were significant between-group differences in within-session changes for the experimental versus the control group. The ANOVA showed that for either group the 3 within-session change scores were not significantly different (P > 0.1). The 2-way ANOVA revealed significant differences between groups for both pain and neck mobility in within-session change scores (all, P < 0.001). Change scores in each session were superior in the experimental group as compared to those in the control group. The results suggest that patients receiving thoracic manipulation do not exhibit tolerance to repeated applications with regard to pain and mobility measures in acute mechanical neck pain. Further studies should investigate the dose-response relationship of thoracic thrust manipulation in this population.

The role of manual therapies in equine pain management

Manual therapy includes a diverse array of techniques, such as touch therapies, massage, physical therapy, osteopathy, and chiropractic, that were originally developed for use in humans and have been gradually applied to horses. All forms of manual therapy have variable reported levels of effectiveness for treating musculoskeletal issues in humans, but mostly only anecdotal evidence exists in horses. This article explores the scientific literature for evidence of efficacy, safety, and common mechanisms of action of the different forms of manual therapies for potential use in managing acute or chronic pain syndromes in horses. Currently, there is limited evidence supporting the effectiveness of spinal mobilization and manipulation in reducing pain and muscle hypertonicity. Further research is needed to assess the efficacy of specific manual therapy techniques and their contribution to multimodal protocols for managing specific somatic pain conditions in horses.

What is 'manipulation'? A reappraisal

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.

Comparison of the effectiveness of three manual physical therapy techniques in a subgroup of patients with low back pain who satisfy a clinical prediction rule: a randomized clinical trial

STUDY DESIGN

Randomized clinical trial.

OBJECTIVE

The purpose of this randomized clinical trial was to examine the generalizability of 3 different manual therapy techniques in a patient population with low back pain that satisfy a clinical prediction rule (CPR).

SUMMARY OF BACKGROUND DATA

Recently a CPR that identifies patients with LBP who are likely to respond rapidly and dramatically to thrust manipulation has been developed and validated. The generalizability of the CPR requires further investigation.

METHODS

A total of 112 patients were enrolled in the trial and provided demographic information and completed a number of self-report questionnaires including the Oswestry Disability Questionnaire (ODQ) and the Numerical Pain Rating Scale (NPRS) at baseline, 1-week, 4-weeks, and 6-months. Patients were randomly assigned to receive 1 of the 3 manual therapy techniques for 2 consecutive treatment sessions followed by exercise regimen for an additional 3 sessions. We examined the primary aim using a linear mixed model for repeated measures, using the ODQ and NPRS as dependent variables. The hypothesis of interest was the group by time interaction, which was further explored with pair-wise comparisons of the estimated marginal means.

RESULTS

There was a significant group x time interaction for the ODQ (P < 0.001) and NPRS scores (P = 0.001). Pair-wise comparisons revealed no differences between the supine thrust manipulation and side-lying thrust manipulation at any follow-up period. Significant differences in the ODQ and NPRS existed at each follow-up between the thrust manipulation and the nonthrust manipulation groups at 1-week and 4-weeks. There was also a significant difference in ODQ scores at 6-months in favor of the thrust groups.

CONCLUSION

The results of the study support the generalizability of the CPR to another thrust manipulation technique, but not to the nonthrust manipulation technique that was used in this study. In general, our results also provided support that the CPR can be generalized to different settings from which it was derived and validated. However, additional research is needed to examine this issue.

Comparison of surface electromyographic activity of erector spinae before and after the application of central posteroanterior mobilisation on the lumbar spine

Lumbar spine accessory movements, used by therapists in the treatment of patients with low back pain, is thought to decrease paravertebral muscular activity; however there is little research to support this suggestion. This study investigated the effects of lumbar spine accessory movements on surface electromyography (sEMG) activity of erector spinae. A condition randomised, placebo controlled, repeated measures design was used. sEMG measurements were recorded from 36 asymptomatic subjects following a control, placebo and central posteroanterior (PA) mobilisation to L3 each for 2min. The therapist stood on a force platform while applying the PA mobilisation to quantify the force used. The PA mobilisation applied to each subject had a mean maximum force of 103.3N, mean amplitude of force oscillation of 41.1N, and a frequency of 1.2Hz. Surface electromyographic data were recorded from the musculature adjacent to L3, L5 and T10. There were statistically significant reductions of 15.5% (95% CI: 8.0-22.5%) and 17.8% (95% CI: 12.9-22.4%) in mean sEMG values following mobilisation compared with the control and placebo, respectively. This study demonstrates that a central PA mobilisation to L3 results in a statistically significant decrease in the sEMG activity of erector spinae of an asymptomatic population.

The Effects of Thoracic Manipulation on Heart Rate Variability: A Controlled Crossover Trial

OBJECTIVE

The objective of this study was to measure the effects of thoracic spinal manipulation on heart rate variability (HRV) in a cohort of healthy young adults.

METHODS

A controlled crossover trial that was conducted on 28 healthy young adults (23 men and 5 women; age range, 18-45 years; mean age, 29 +/- 7 years) measured HRV before and after a sham procedure and a thoracic spinal manipulation.

RESULTS

In healthy young adults, thoracic spinal manipulation was associated with changes in HRV that were not duplicated by the sham procedure. The ratio of the powers of the low-frequency and high-frequency components increased from 0.9562 +/- 0.9192 to 1.304 +/- 1.118 (P = .0030, Wilcoxon signed rank test). In subjects undergoing sham spinal manipulation, there was no statistically significant change in the low-frequency or the high-frequency component of the power spectrum; neither was there any in the ratio of the two regardless of whether the comparison was made using the paired t test or the Wilcoxon signed rank test.

CONCLUSION

High-velocity and low-amplitude manipulation of the thoracic spine appears to be able to influence autonomic output to the heart in ways that are not duplicated by a sham procedure or by other forms of somatic/physical therapies.

Immediate effects of spinal manipulation on thermal pain sensitivity: an experimental study

Background

The underlying causes of spinal manipulation hypoalgesia are largely unknown. The beneficial clinical effects were originally theorized to be due to biomechanical changes, but recent research has suggested spinal manipulation may have a direct neurophysiological effect on pain perception through dorsal horn inhibition. This study added to this literature by investigating whether spinal manipulation hypoalgesia was: a) local to anatomical areas innervated by the lumbar spine; b) correlated with psychological variables; c) greater than hypoalgesia from physical activity; and d) different for A-delta and C-fiber mediated pain perception.

Methods

Asymptomatic subjects (n = 60) completed baseline psychological questionnaires and underwent thermal quantitative sensory testing for A-delta and C-fiber mediated pain perception. Subjects were then randomized to ride a stationary bicycle, perform lumbar extension exercise, or receive spinal manipulation. Quantitative sensory testing was repeated 5 minutes after the intervention period. Data were analyzed with repeated measures ANOVA and post-hoc testing was performed with Bonferroni correction, as appropriate.

Results

Subjects in the three intervention groups did not differ on baseline characteristics. Hypoalgesia from spinal manipulation was observed in lumbar innervated areas, but not control (cervical innervated) areas. Hypoalgesic response was not strongly correlated with psychological variables. Spinal manipulation hypoalgesia for A-delta fiber mediated pain perception did not differ from stationary bicycle and lumbar extension (p > 0.05). Spinal manipulation hypoalgesia for C-fiber mediated pain perception was greater than stationary bicycle riding (p = 0.040), but not for lumbar extension (p = 0.105).

Conclusion

Local dorsal horn mediated inhibition of C-fiber input is a potential hypoalgesic mechanism of spinal manipulation for asymptomatic subjects, but further study is required to replicate this finding in subjects with low back pain.