Short-term changes in median nerve neural tension after a suboccipital muscle inhibition technique in subjects with cervical whiplash: a randomised controlled trial

The quality of reporting in randomized controlled trials investigating exercise for individuals with whiplash-associated disorders; a systematic review

BACKGROUND

Whiplash-associated disorders are a common sequela of road traffic accidents. Exercise therapy is considered an effective intervention, and it is recommended for the management of such condition. However, the application of research findings to everyday clinical practice is dependent on sufficient details being reported.

OBJECTIVES

To explore the quality of reporting in studies investigating the effectiveness of exercise for whiplash-associated disorders.

METHODS

A literature search was conducted to identify studies testing the effectiveness of exercise for whiplash-associated disorders. Two reporting checklists were used to evaluate reporting completeness. The median positive scores for each study and overall percentage of positive scores for each item were calculated. Percentage agreement and the Cohen's Kappa coefficient were calculated.

RESULTS

Twenty-one studies were included. According to the Template for Intervention Description and Replication checklist, items were reported appropriately with a median of 29% (range 0-95%, IQR 40.5). The median number of adequately reported items per study was 5 (range 1-10, IQR 3). For the Consensus on Exercise Reporting Template checklist, items were reported appropriately with a median of 29% (range 0-57%, IQR 29). The median number of adequately reported items per study was 4 (range 0-16, IQR 8). Percentage agreement ranged from 57% to 100% while Cohen's Kappa from -0.17 to 1.00.

CONCLUSIONS

The study reveals significant gaps in the quality of reporting in studies investigating exercise for whiplash-associated disorders as both checklists showed a median reporting adequacy of only 29%. Overall, the inter-rater agreement for both checklists was acceptable.

Which Portion of Physiotherapy Treatments' Effect Is Not Attributable to the Specific Effects in People With Musculoskeletal Pain? A Meta-Analysis of Randomized Placebo-Controlled Trials

OBJECTIVE: We aimed to quantify the proportion not attributable to the specific effects (PCE) of physical therapy interventions for musculoskeletal pain. DESIGN: Intervention systematic review with meta-analysis. LITERATURE SEARCH: We searched Ovid, MEDLINE, EMBASE, CINAHL, Scopus, PEDro, Cochrane Controlled Trials Registry, and SPORTDiscus databases from inception to April 2023. STUDY SELECTION CRITERIA: Randomized placebo-controlled trials evaluating the effect of physical therapy interventions on musculoskeletal pain. DATA SYNTHESIS: Risk of bias was evaluated using the Cochrane risk-of-bias tool for randomized trials (RoB 2). The proportion of physical therapy interventions effect that was not explained by the specific effect of the intervention was calculated, using the proportion not attributable to the specific effects (PCE) metric, and a quantitative summary of the data from the studies was conducted using the random-effects inverse-variance model (Hartung-Knapp-Sidik-Jonkman method). RESULTS: Sixty-eight studies were included in the systematic review (participants: n = 5238), and 54 placebo-controlled trials informed our meta-analysis (participants: n = 3793). Physical therapy interventions included soft tissue techniques, mobilization, manipulation, taping, exercise therapy, and dry needling. Placebo interventions included manual, nonmanual interventions, or both. The proportion not attributable to the specific effects of mobilization accounted for 88% of the immediate overall treatment effect for pain intensity (PCE = 0.88, 95% confidence interval [CI]: 0.57, 1.20). In exercise therapy, this proportion accounted for 46% of the overall treatment effect for pain intensity (PCE = 0.46, 95% CI: 0.41, 0.52). The PCE in manipulation excelled in short-term pain relief (PCE = 0.81, 95% CI: 0.62, 1.01) and in mobilization in long-term effects (PCE = 0.86, 95% CI: 0.76, 0.96). In taping, the PCE accounted for 64% of disability improvement (PCE = 0.64, 95% CI: 0.48, 0.80). CONCLUSION: The outcomes of physical therapy interventions for musculoskeletal pain were significantly influenced by factors not attributable to the specific effects of the interventions. Boosting these factors consciously to enhance therapeutic outcomes represents an ethical opportunity that could benefit patients. J Orthop Sports Phys Ther 2024;54(6):391-399. Epub 11 April 2024. doi:10.2519/jospt.2024.12126.

Meta-epidemiologic review: blinding and sham treatment in clinical trial design for osteopathic manipulative treatment research

Objective

To analyze the consistency of study designs in osteopathic manipulative treatment (OMT) research, focusing on blinding protocols and the use of sham treatments.

Data Source and Study Selection

PubMed and CINAHL were searched in January 2022. A total of 83 research studies between 2009 and 2021 were selected based on the presence of a double- or single-blind study design and/or sham treatment.

Data Extraction and Analysis

Data regarding the primary outcome measures, blinding design, measures used to determine success of blinding, osteopathic technique used, and sham technique used for each eligible study were extracted and compared among different study designs.

Results

A total of 5968 subjects participated in the 83 trials. The study population mainly consisted of asymptomatic individuals (25%) and chronic back pain patients (19%). Light touch was employed most commonly (49%) as the sham treatment, followed by unrelated sham (20%) and incomplete maneuvers (20%). Most studies blinded the subjects (80%) or the outcome evaluator/data analyzer (71%), while only 20% studies blinded the osteopathic physicians.

Conclusions

Strict double-blinding is achievable for OMT clinical research by blinding the subjects and data collectors/analyzers rather than the osteopaths providing the actual treatment. The use of questionnaires to determine the success of blinding should be considered. Additionally, including OMT-naïve subjects is preferred to enhance blinding success. When designing a sham treatment, careful consideration should be given to blinding the data collector, accounting for the placebo effect, and incorporating an additional no-treatment control group to improve the rigor of the study design.

Massage for neck pain

BACKGROUND

Massage is widely used for neck pain, but its effectiveness remains unclear.

OBJECTIVES

To assess the benefits and harms of massage compared to placebo or sham, no treatment or exercise as an adjuvant to the same co-intervention for acute to chronic persisting neck pain in adults with or without radiculopathy, including whiplash-associated disorders and cervicogenic headache.

SEARCH METHODS

We searched multiple databases (CENTRAL, MEDLINE, EMBASE, CINAHL, Index to Chiropractic Literature, trial registries) to 1 October 2023.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing any type of massage with sham or placebo, no treatment or wait-list, or massage as an adjuvant treatment, in adults with acute, subacute or chronic neck pain.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane. We transformed outcomes to standardise the direction of the effect (a smaller score is better). We used a partially contextualised approach relative to identified thresholds to report the effect size as slight-small, moderate or large-substantive.

MAIN RESULTS

We included 33 studies (1994 participants analysed). Selection (82%) and detection bias (94%) were common; multiple trials had unclear allocation concealment, utilised a placebo that may not be credible and did not test whether blinding to the placebo was effective. Massage was compared with placebo (n = 10) or no treatment (n = 8), or assessed as an adjuvant to the same co-treatment (n = 15). The trials studied adults aged 18 to 70 years, 70% female, with mean pain severity of 51.8 (standard deviation (SD) 14.1) on a visual analogue scale (0 to 100). Neck pain was subacute-chronic and classified as non-specific neck pain (85%, including n = 1 whiplash), radiculopathy (6%) or cervicogenic headache (9%). Trials were conducted in outpatient settings in Asia (n = 11), America (n = 5), Africa (n = 1), Europe (n = 12) and the Middle East (n = 4). Trials received research funding (15%) from research institutes. We report the main results for the comparison of massage versus placebo. Low-certainty evidence indicates that massage probably results in little to no difference in pain, function-disability and health-related quality of life when compared against a placebo for subacute-chronic neck pain at up to 12 weeks follow-up. It may slightly improve participant-reported treatment success. Subgroup analysis by dose showed a clinically important difference favouring a high dose (≥ 8 sessions over four weeks for ≥ 30 minutes duration). There is very low-certainty evidence for total adverse events. Data on patient satisfaction and serious adverse events were not available. Pain was a mean of 20.55 points with placebo and improved by 3.43 points with massage (95% confidence interval (CI) 8.16 better to 1.29 worse) on a 0 to 100 scale, where a lower score indicates less pain (8 studies, 403 participants; I2 = 39%). We downgraded the evidence to low-certainty due to indirectness; most trials in the placebo comparison used suboptimal massage doses (only single sessions). Selection, performance and detection bias were evident as multiple trials had unclear allocation concealment, utilised a placebo that may not be credible and did not test whether blinding was effective, respectively. Function-disability was a mean of 30.90 points with placebo and improved by 9.69 points with massage (95% CI 17.57 better to 1.81 better) on the Neck Disability Index 0 to 100, where a lower score indicates better function (2 studies, 68 participants; I2 = 0%). We downgraded the evidence to low-certainty due to imprecision (the wide CI represents slight to moderate benefit that does not rule in or rule out a clinically important change) and risk of selection, performance and detection biases. Participant-reported treatment success was a mean of 3.1 points with placebo and improved by 0.80 points with massage (95% CI 1.39 better to 0.21 better) on a Global Improvement 1 to 7 scale, where a lower score indicates very much improved (1 study, 54 participants). We downgraded the evidence to low-certainty due to imprecision (single study with a wide CI that does not rule in or rule out a clinically important change) and risk of performance as well as detection bias. Health-related quality of life was a mean of 43.2 points with placebo and improved by 5.30 points with massage (95% CI 8.24 better to 2.36 better) on the SF-12 (physical) 0 to 100 scale, where 0 indicates the lowest level of health (1 study, 54 participants). We downgraded the evidence once for imprecision (a single small study) and risk of performance and detection bias. We are uncertain whether massage results in increased total adverse events, such as treatment soreness, sweating or low blood pressure (RR 0.99, 95% CI 0.08 to 11.55; 2 studies, 175 participants; I2 = 77%). We downgraded the evidence to very low-certainty due to unexplained inconsistency, risk of performance and detection bias, and imprecision (the CI was extremely wide and the total number of events was very small, i.e < 200 events).

AUTHORS' CONCLUSIONS

The contribution of massage to the management of neck pain remains uncertain given the predominance of low-certainty evidence in this field. For subacute and chronic neck pain (closest to 12 weeks follow-up), massage may result in a little or no difference in improving pain, function-disability, health-related quality of life and participant-reported treatment success when compared to a placebo. Inadequate reporting on adverse events precluded analysis. Focused planning for larger, adequately dosed, well-designed trials is needed.

Manual Therapy Effect in Placebo-Controlled Trials: A Systematic Review and Meta-Analysis

PURPOSE

Background: Evaluate whether the design of placebo control groups could produce different interpretations of the efficacy of manual therapy techniques.

METHODS

Nine databases were searched (EMBASE, CINAHL, PsycINFO, MEDLINE, PubMed, SCOPUS, WEB of SCIENCE, COCHRANE, and PEDro). Randomized placebo-controlled clinical trials that used manual therapy as a sham treatment on subjects suffering from pain were included. Data were summarized qualitatively, and meta-analyses were conducted with R.

RESULTS

53 articles were included in the qualitative analysis and 48 were included in the quantitative analyses. Manipulation techniques did not show higher effectiveness when compared with all types of sham groups that were analyzed (SMD 0.28; 95%CI [-0.24; 0.80]) (SMD 0.28; 95%CI [-0.08; 0.64]) (SMD 0.42; 95%CI [0.16; 0.67]) (SMD 0.82; 95%CI [-0.57; 2.21]), raising doubts on their therapeutic effect. Factors such as expectations of treatment were not consistently evaluated, and analysis could help clarify the effect of different sham groups. As for soft tissue techniques, the results are stronger in favor of these techniques when compared to sham control groups (SMD 0.40; 95%CI [0.19, 0.61]). Regarding mobilization techniques and neural gliding techniques, not enough studies were found for conclusions to be made.

CONCLUSIONS

The literature presents a lack of a unified placebo control group design for each technique and an absence of assessment of expectations. These two issues might account for the unclear results obtained in the analysis.

The Impact of Suboccipital Muscle Release on Pain and Range of Motion in the Cervical Spine of Young Adults

Introduction: Limited mobility and pain in the cervical spine affect 50% of the population, leading to disability and a reduction in quality of life. It is important to use effective forms of therapy. One of them, enjoying growing popularity, is deep tissue massage, the stability of which requires confirmation in scientific research. Research objective: The aim of the study was to investigate how a single deep tissue massage therapy aimed at suboccipital muscles reduces pain and improves the range of motion in the cervical spine and how long the improvement lasts. Research materials and methods: The study participants included 41 people aged 20-34. The respondents were randomly divided into 2 groups: study (21 people) and control (20 people). The subjects completed a questionnaire consisting of 14 questions and were subjected to 2 tests for evaluating cervical spine stability: the covering membrane test and the anterior occipital membrane test. Then, the measurements of pain on the VAS scale (0-10) and the range of cervical mobility were collected. Measurements were taken before, immediately after, as well as 2 and 4 weeks following the therapeutic intervention. The therapy in the study group consisted of a single, 10-minute relaxation session of the sub-occipital muscles. In the control group, cervical spine traction, lasting 30 seconds, was performed 3 times. Results: In the study group, the pain decreased statistically significantly (p<0.05), before the therapy it totalled 4.33 ± 1.49, while after the therapy, its value decreased to 2.05 ± 0.86 and lasted up to 2 weeks after the massage – 2.67 ± 1.49. In the control group, the pain level before the therapy was 4.25 ± 0.76, and following the therapy, it decreased to 3 ± 0.95 and then increased to the mean value of 4 ± 1 (after 2 weeks). On average, the level equalled 4.25 ± 0.76 (after 4 weeks). In the study group, the range of flexion motion was, on average, 3.24 ± 1.00 cm, extension, mean 6.90 ± 1.14 cm, lateral flexion to the left, on avg. 4.76 ± 0.62, to the right on avg. 4.90 ± 1.04 cm, left rotation on avg. 8.43 ± 0.81, and right rotation on avg., 8.19 ± 1.08 cm. After deep tissue massage therapy, the results differed from the range of motion results obtained in the control group: flexion totalled 5.67 ± 0.48 cm immediately after therapy and 4.90 ± 1.34 cm 2 weeks post-intervention, extension 8.57 ± 0.87 cm immediately after therapy and 7.62 ± 1.47 cm 2 weeks after therapy, and finally, left lateral flexion 5.52 ± 0.81 directly following the therapy and 5.43 ± 0.93 cm 2 weeks after therapy. Conclusions: 1. Single-session deep tissue massage therapy significantly reduces pain and increases range of motion in the cervical spine. 2. The effects last up to 2 weeks following the therapy.

Exercise therapy for whiplash-associated disorders: a systematic review and meta-analysis

OBJECTIVES

Acute as well as chronic pain syndromes are common after whiplash trauma and exercise therapy is proposed as one possible intervention strategy. The aim of the present systematic review was to evaluate the effect of exercise therapy in patients with Whiplash-Associated Disorders for the improvement of neck pain and neck disability, compared with other therapeutic interventions, placebo interventions, no treatment, or waiting list.

CONTENT

The review was registered in Prospero (CRD42017060356) and conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A literature search in PubMed, Scopus and Cochrane from inception until January 13, 2020 was combined with a hand search to identify eligible randomized controlled studies. Abstract screening, full text assessment and risk of bias assessment (Cochrane RoB 2.0) were conducted by two independent reviewers.

SUMMARY

The search identified 4,103 articles. After removal of duplicates, screening of 2,921 abstracts and full text assessment of 100 articles, 27 articles that reported data for 2,127 patients were included. The included articles evaluated the effect of exercise therapy on neck pain, neck disability or other outcome measures and indicated some positive effects from exercise, but many studies lacked control groups not receiving active treatment. Studies on exercise that could be included in the random-effect meta-analysis showed significant short-term effects on neck pain and medium-term effects on neck disability.

OUTLOOK

Despite a large number of articles published in the area of exercise therapy and Whiplash-Associated Disorders, the current evidence base is weak. The results from the present review with meta-analysis suggests that exercise therapy may provide additional effect for improvement of neck pain and disability in patients with Whiplash-Associated Disorders.

Effects of Instrumental, Manipulative and Soft Tissue Approaches for the Suboccipital Region in Subjects with Chronic Mechanical Neck Pain. A Randomized Controlled Trial

The INYBI is an instrument used to release the suboccipital myofascial area. There is scarce evidence of its efficacy. A randomized controlled, double-blinded, longitudinal and prospective trial was performed. Ninety-six subjects (aged 29.47 ± 5.16 years) (70 women) with chronic neck pain were randomly assigned to the manual suboccipital inhibition technique (MSIT), instrumental suboccipital inhibition (INYBI) or the INYBI plus upper cervical manipulation technique (INYBI + UCMT) groups and received two sessions with a week interval between them. The Neck Disability Index was used before the first intervention and two weeks after the second intervention. Pre- and post-measurements were taken on both intervention days for pressure pain threshold of the upper trapezius and suboccipital muscles, self-perceived pain and cervical range of motion. In spite of a significant general improvement in time that was found for the three groups for all of the outcome measurements (p < 0.05 in all cases), no between-groups differences were found (p > 0.05 in all cases), with the exception of self-perceived pain for left rotation (p = 0.024), with the MSIT group showing the lower improvement. However, the higher degree of within-group improvements was found for the INYBI + UCMT group. It was concluded that the myofascial release therapy in the suboccipital area is effective in patients with chronic neck pain, either through a manual application or by means of the INYBI tool. Moreover, the addition of craniocervical manipulation achieved the higher within-group improvements, but with no statistical significance.

Effects of the Suboccipital Muscle Inhibition Technique on the Range of Motion of the Ankle Joint and Balance According to Its Application Duration: A Randomized Controlled Trial

This study aimed to investigate the effects of suboccipital muscle inhibition technique (SMIT) on active range of motion (AROM) of the ankle joint, lunge angle (LA), and balance in healthy adults, according to the duration of its application. A total of 80 participants were randomly allocated to the 4-min suboccipital muscle inhibition (SMI) group (SMI_4M, n = 20), 8-min SMI group (n = 20), 4-min sham-SMI (SSMI) group (n = 20), and 8-min SSMI group (n = 20). Accordingly, the SMIT and sham SMIT were applied for 4 min or 8 min in the respective groups. AROM of dorsiflexion and LA were assessed, and a single leg balance test (SLBT) was performed before and after the intervention. AROM (4 min, p < 0.001; 8 min, p < 0.001), LA (4 min, p < 0.001; 8 min, p < 0.001), and SLBT (4 min, p < 0.001; 8 min, p < 0.001) significantly improved after SMI application. Compared with the SSMI group, the SMI group showed a significant increase in AROM (p < 0.001), LA (p < 0.001), and SLBT (p < 0.001). Except for SLBT (p = 0.016), there were no significant interactions between intervention and application duration. The results suggest that the SMIT, at durations of both 4 and 8 min, could be effective tools for improving AROM, LA, and balance.

Sham treatment effects in manual therapy trials on back pain patients: a systematic review and pairwise meta-analysis

OBJECTIVE

To assess the effects and reliability of sham procedures in manual therapy (MT) trials in the treatment of back pain (BP) in order to provide methodological guidance for clinical trial development.

DESIGN

Systematic review and meta-analysis.

METHODS AND ANALYSIS

Different databases were screened up to 20 August 2020. Randomised controlled trials involving adults affected by BP (cervical and lumbar), acute or chronic, were included.Hand contact sham treatment (ST) was compared with different MT (physiotherapy, chiropractic, osteopathy, massage, kinesiology and reflexology) and to no treatment. Primary outcomes were BP improvement, success of blinding and adverse effect (AE). Secondary outcomes were number of drop-outs. Dichotomous outcomes were analysed using risk ratio (RR), continuous using mean difference (MD), 95% CIs. The minimal clinically important difference was 30 mm changes in pain score.

RESULTS

24 trials were included involving 2019 participants. Very low evidence quality suggests clinically insignificant pain improvement in favour of MT compared with ST (MD 3.86, 95% CI 3.29 to 4.43) and no differences between ST and no treatment (MD -5.84, 95% CI -20.46 to 8.78).ST reliability shows a high percentage of correct detection by participants (ranged from 46.7% to 83.5%), spinal manipulation being the most recognised technique.Low quality of evidence suggests that AE and drop-out rates were similar between ST and MT (RR AE=0.84, 95% CI 0.55 to 1.28, RR drop-outs=0.98, 95% CI 0.77 to 1.25). A similar drop-out rate was reported for no treatment (RR=0.82, 95% 0.43 to 1.55).

CONCLUSIONS

MT does not seem to have clinically relevant effect compared with ST. Similar effects were found with no treatment. The heterogeneousness of sham MT studies and the very low quality of evidence render uncertain these review findings.Future trials should develop reliable kinds of ST, similar to active treatment, to ensure participant blinding and to guarantee a proper sample size for the reliable detection of clinically meaningful treatment effects.

PROSPERO REGISTRATION NUMBER

CRD42020198301.

INYBI: A New Tool for Self-Myofascial Release of the Suboccipital Muscles in Patients With Chronic Non-Specific Neck Pain: A Randomized Controlled Trial

STUDY DESIGN

A randomized, single-blinded (the outcome assessor was unaware of participants' allocation group) controlled clinical trial.

OBJECTIVE

To investigate the effects of myofascial release therapy (MRT) over the suboccipital muscles, compared with self-MRT using a novel device, the INYBI tool, on pain-related outcomes, active cervical mobility, and vertical mouth opening, in adults with chronic non-specific neck pain (NSNP).

SUMMARY OF BACKGROUND DATA

MRT is used to manage chronic musculoskeletal pain conditions, with purported positive effects. The efficacy of self-MRT, compared with MRT, has been scarcely evaluated.

METHODS

Fifty-eight participants (mean age of 34.6 ± 4.7 yrs; range 21-40 yrs; 77.6% females, 22.4% males) with persistent NSNP agreed to participate, and were equally distributed into an INYBI (n = 29) or a control group (n = 29). Both groups underwent a single 5-minutes intervention session. For participants in the control group, MRT of the suboccipital muscles was performed using the suboccipital muscle inhibition technique, while those in the INYBI group underwent a self-MRT intervention using the INYBI device. Primary measurements were taken of pain intensity (visual analogue scale), local pressure pain sensitivity, as assessed with an algometer, and active cervical range-of-movement. Secondary outcomes included pain-free vertical mouth opening. Outcomes were collected at baseline, immediately after intervention and 45 minutes later.

RESULTS

The analysis of variance (ANOVAs) demonstrated no significant between-groups effect for any variable (all, P > 0.05). In the within-groups comparison, all participants significantly improved pain-related outcomes, and showed similar positive changes for mouth opening. Cervical range-of-movement- mainly increased after intervention for participants in the control group.

CONCLUSION

Both, MRT and self-MRT using the INYBI, are equally effective to enhance self-reported pain intensity, and local pressure pain sensitivity in chronic NSNP patients. For cervical mobility, MRT appears to be slighlty superior, compared with the INYBI, to achieve improvements in this population.

LEVEL OF EVIDENCE

2.

Effects of a Single Myofascial Induction Session on Neural Mechanosensitivity in Breast Cancer Survivors: A Secondary Analysis of a Crossover Study

OBJECTIVES

The purpose of this study was to investigate the short-term effects of myofascial induction on mechanosensitivity of upper limb nerves.

METHODS

In this secondary analysis of a randomized, single-blind, placebo-controlled crossover study, 21 breast cancer survivors with stage I-IIIA cancer were randomly allocated to an experimental group (30 minutes of myofascial induction session) or placebo control group (unplugged pulsed 30 minutes of shortwave therapy), with a 4-week washout period between sessions that occurred in a physical therapy laboratory in the Health Science Faculty (University of Granada, Spain). Range of motion (universal goniometry), structural differentiation, symptoms (yes/no), and pressure pain thresholds (electronic algometry) were assessed during neurodynamic tests and attitude toward massage scale as covariate.

RESULTS

An analysis of covariance revealed significant time × group interactions for range of motion in affected upper limb nerves (median, P < .001; radial, P = .036; ulnar, P = .002), but not for nonaffected upper limb nerves (median, P = .083; radial, P = .072; ulnar, P = .796). A χ2 or Fisher exact test, as appropriate, also revealed a significant difference (P = .044) in sensitivity for the affected upper limb ulnar nerve in the experimental group, whereas the rest of the assessed nerves (affected and nonaffected upper limb nerves) showed no significant changes in either the experimental or control groups (P > .05). An analysis of covariance revealed no significant interactions on pressure pain thresholds over the nerves for affected (all P > .05) and nonaffected (all P > .05) upper limb nerves.

CONCLUSION

A single myofascial induction session may partially improve mechanosensitivity of median, radial, and ulnar nerves and yield positive effects on symptom mechanosensitivity, especially regarding the ulnar nerve in breast cancer survivors.

Reliability and accuracy of the brachial plexus neurodynamic test

STUDY DESIGN

Observational study.

INTRODUCTION

The brachial plexus neurodynamic test (BPNT), based on previous neurodynamic tests, is considered a clinically meaningful tool to objectively assess brachial plexus extensibility. This novel test's psychometric properties have yet to be determined.

PURPOSE OF THE STUDY

The primary study aim was to assess the inter- and intrarater reliability and accuracy of the BPNT, which biases the median nerve and brachial plexus, among clinicians of various professional experience levels and geographic US regions. The secondary study aim was to determine if professional experience or geographic region affects the accuracy levels of this test.

METHODS

In phase 1, inter-rater reliability and accuracy was determined. About 307 participants attending neural mobilization conferences and courses were instructed in the BPNT and asked to score 7 different videos of 14 possible test levels. In phase 2, intrarater reliability was determined via scoring the same test videos twice.

RESULTS

High inter-rater intraclass correlation coefficient (range, 0.98-0.99) and accuracy (range, 0.88-0.94) levels were determined for all clinical experience levels and geographic regions. Intrarater intraclass correlation coefficient values were high (range, 0.96-1.0) among all participants. One-way analysis of variance indicated no significant differences on test accuracy based on professional clinical experience (F = 0.104; P = .958) and geographic region (F = 0.416; P = .416) among all 307 participants.

DISCUSSION

Excellent inter- and intrarater reliability and accuracy levels may allow clinicians to correctly identify BPNT positions regardless of their professional experience or geographic location.

CONCLUSION

The BPNT can reliably and accurately quantify outcomes in neural mobility scoring.

Comparative study of the effects of two inhibitory suboccipital techniques in non-symptomatic subjects with limited cervical mobility

BACKGROUND

Hypomobility on a cervical segment is a frequent finding which is sometimes asymptomatic. The effects of inhibitory suboccipital techniques on cervical mobility have not been evaluated.

OBJECTIVE

To compare the effect on cervical mobility, of pressure maintained suboccipital inhibition manual technique versus a self-treatment using an Occipivot cushion, in asymptomatic subjects with limited mobility assessed by the flexion-rotation test.

METHODS

Before-after randomized uncontrolled trial. Thirty-two subjects were recruited and randomized into two groups: Manual Group and Instrumental Group, receiving a single session of the assigned technique. Upper and overall cervical spine mobility was measured. Subjective sensation during technique application and post-treatment, and number and intensity of headache episodes during the following 15 days after treatment were also registered.

RESULTS

Comparing with the Instrumental Group, the Manual Group showed statistically significant improvements on flexion-rotation test (p< 0.01 to p< 0.03), upper cervical extension (p< 0.01), overall right rotation (p< 0.05) and overall right (p< 0.01) and left (p< 0.01) side-bending.

CONCLUSION

In asymptomatic subjects with limited cervical mobility, pressure maintained suboccipital inhibition manual technique achieves further improvement on cervical range of motion than the technique using the Occipivot cushion.

A Systematic Review of the Soft-Tissue Connections Between Neck Muscles and Dura Mater: The Myodural Bridge

STUDY DESIGN

Systematic review.

OBJECTIVE

To elucidate the existence of soft tissue connections between the neck muscles and cervical dura mater.

SUMMARY OF BACKGROUND DATA

Several studies discuss the existence of a cervical myodural bridge; however, conflicting data have been reported.

METHODS

Searches were conducted in the PubMed, Web of Science, Cochrane Library, and PEDro databases. Studies reporting original data regarding the continuity of non-post-surgical soft tissue between the cervical muscles and dura mater were reviewed. Two reviewers independently selected articles, and a third one resolved disagreements. Another two researchers extracted the methodology of the study, the anatomical findings, and evaluated the quality of the studies using Quality Appraisal for Cadaveric Studies Scale. A different third researcher resolved disagreements.

RESULTS

Twenty-six studies were included. A soft tissue connection between the rectus capitis posterior minor, the rectus capitis posterior major, and the obliquus capitis inferior muscles seems to be proved with a strong level of evidence for each one of them. Controversy exists about the possible communication between the dura mater and the upper trapezius, rhomboideus minor, serratus posterior superior, and splenius capitis by means of the ligamentum nuchae. Finally, there is limited evidence about the existence of a soft tissue connection between rectus capitis anterior muscle and the dura mater.

CONCLUSION

There is a continuity of soft tissue between the cervical musculature and the cervical dura mater; this might have physiological, pathophysiological, and therapeutic implications, and going some way to explaining the effect of some therapies in craniocervical disorders.

LEVEL OF EVIDENCE

N/A.

The paradox of sham therapy and placebo effect in osteopathy: A systematic review

BACKGROUND

Placebo, defined as "false treatment," is a common gold-standard method to assess the validity of a therapy both in pharmacological trials and manual medicine research where placebo is also referred to as "sham therapy." In the medical literature, guidelines have been proposed on how to conduct robust placebo-controlled trials, but mainly in a drug-based scenario. In contrast, there are not precise guidelines on how to conduct a placebo-controlled in manual medicine trials (particularly osteopathy). The aim of the present systematic review was to report how and what type of sham methods, dosage, operator characteristics, and patient types were used in osteopathic clinical trials and, eventually, assess sham clinical effectiveness.

METHODS

A systematic Cochrane-based review was conducted by analyzing the osteopathic trials that used both manual and nonmanual placebo control. Searches were conducted on 8 databases from journal inception to December 2015 using a pragmatic literature search approach. Two independent reviewers conducted the study selection and data extraction for each study. The risk of bias was evaluated according to the Cochrane methods.

RESULTS

A total of 64 studies were eligible for analysis collecting a total of 5024 participants. More than half (43 studies) used a manual placebo; 9 studies used a nonmanual placebo; and 12 studies used both manual and nonmanual placebo. Data showed lack of reporting sham therapy information across studies. Risk of bias analysis demonstrated a high risk of bias for allocation, blinding of personnel and participants, selective, and other bias. To explore the clinical effects of sham therapies used, a quantitative analysis was planned. However, due to the high heterogeneity of sham approaches used no further analyses were performed.

CONCLUSION

High heterogeneity regarding placebo used between studies, lack of reporting information on placebo methods and within-study variability between sham and real treatment procedures suggest prudence in reading and interpreting study findings in manual osteopathic randomized controlled trials (RCTs). Efforts must be made to promote guidelines to design the most reliable placebo for manual RCTs as a means of increasing the internal validity and improve external validity of findings.

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.