Specific manipulative therapy treatment for chronic lateral epicondylalgia produces uniquely characteristic hypoalgesia

Lumbar Spine and Neural Tissue Mobilizations Improve Outcomes in Runners Presenting With Foot/Ankle Pathology: A Case Series

CONTEXT

Foot/ankle pain is common among runners. Inadequate management of runners with foot/ankle pain can lead to lost training time, competition removal, and other activity limitations. Neurodynamics, which refers to the integrated biomechanical, physiological, and structural function of the nervous system during movement, can be overlooked in patients with foot/ankle pain. Although a link between the cervical spine, neurodynamics, and upper quarter pain has been studied, less is known about the relationship between the lumbar spine and lower quarter. This case series describes the successful management of 3 runners with foot/ankle pain.

CASE PRESENTATIONS

Three female runners (ages 23, 24, and 45 y) presented to physical therapy with foot/ankle pain and difficulty running. Each patient had positive examination findings with local foot/ankle testing. A comprehensive lumbar spine examination demonstrated impairments in range of motion and joint mobility that were hypothesized to be contributing. Positive lower quarter neurodynamic tests were also found.

MANAGEMENT AND OUTCOMES

All patients were treated with nonthrust lumbar spine mobilization and lower quarter neural tissue mobilization. Changes in the Patient-Specific Functional Scale, Numerical Pain Rating Scale, Lower Extremity Functional Scale, and Global Rating of Change occurred after intervention targeting the lumbar spine and lower-extremity neurodynamics in all patients.

CONCLUSIONS

This case series demonstrates the importance of including a thorough lumbar spine examination and neurodynamic testing to identify appropriate interventions while managing patients with foot/ankle pain, even when patients have signs indicative of local ankle/foot pathology. These examination procedures should be performed particularly when a patient is not responding to management targeting local foot/ankle structures.

Effects of a novel osteopathic visceral technique for the pancreas on pain and range of motion in a patient with neck pain: Case report

INTRODUCTION

Neck pain is a leading cause of disability worldwide. Visceral referred pain is a common form of disease-induced pain, with visceral nociception being referred to somatic tissues.

OBJECTIVE

The aim of this case report was to evaluate the immediate and long term effects of a novel osteopathic visceral technique (OVT) on pain and cervical range of motion (CROM) in a patient with nonspecific neck pain (NS-NP).

METHOD

A case of a 47-year-old female suffering with NS-NP for four months. The patient had sought physiotherapy treatment several times, and occasionally used anti-inflammatory medication to relieve symptoms. The patient presented muscle cervical tenderness and hyperalgesia over the spinous processes of C3-C4 spinal segments with limited CROM. A novel osteopathic visceral manipulation (OVM) technique was applied in the epigastric region targeting the pancreas. Immediately after the treatment, the patient reported reduction in pain evaluated with the numerical evaluation scale (NRS), and a clinically significant increase in pressure pain threshold (PPT) in C3 spinous process. Improvement in CROM was also observed. The post-treatment improvements have been maintained at 1-month of follow-up assessment.

CONCLUSION

A single OVT was effective in reducing cervical pain and increasing CROM in a patient with NS-NP caused by a viscerosomatic reflex. The results of this case study provides preliminary evidence that OVM can produce hypoalgesia in somatic tissues with segmentally related innervation. This finding encourages future research to gain a better understanding of the mechanisms of regional inhibitory interdependence involving the viscerosomatic reflexes of OVM.

Adverse Events Reported in Trials Assessing Manual Therapy to the Extremities: A Systematic Review

Objective: This review aimed to describe the quality and comprehensiveness of adverse event (AE) reporting in clinical trials incorporating manual therapy (MT) as an intervention for extremity conditions using the Consolidated Standards of Reporting Trials (CONSORT)-Harms extension as the benchmark. The secondary aim was to determine whether the quality of AE reporting improved after the availability of the CONSORT reporting checklist. Design: Systematic review. Methods: A literature search was conducted using multiple databases to identify trials where MT was used to treat extremity conditions. Studies that reported AEs were identified and evaluated using the CONSORT-Harms extension. The frequency of trials reporting study AEs before and after the publication of the updated 2010 CONSORT statement was calculated, along with the categorization of how study AEs were reported. Results: Of the 55,539 studies initially identified, 220 trials met all inclusion criteria. Eighty trials (36.4%) reported AE occurrence. None of the studies that reported AEs adhered to all 10 criteria proposed by the 2010 CONSORT-Harms extension. The most commonly reported criterion was number four, which clarified how AE-related information was collected (30% of trials). The least reported criterion was number six, which describes the participant withdrawals for each arm due to AEs and the experience with the allocated treatment (1.3% of trials). The nomenclature used to describe AEs varied substantially. Fifty-nine of 76 trials (33.3%) were published after the updated CONSORT Harms-checklist was available, compared to 21 of 44 trials (46.7%) published before it was available. Conclusion: Reporting of AEs in trials investigating MT for extremity conditions is poor. Every included trial lacked adherence to all 10 criteria proposed by the CONSORT-Harms Extension. The quality and comprehensiveness of AE reporting did not improve after the most recent CONSORT update recommending AE reporting. Clinicians must obtain informed consent before performing any intervention, including MT, which requires disclosing potential risks, which could be better known with improved tracking, analyzing, and reporting of AEs. The authors recommend improved adherence to best practices for adequately tracking and reporting AEs in future MT trials.

Manual therapy and exercise for lateral elbow pain

BACKGROUND

Manual therapy and prescribed exercises are often provided together or separately in contemporary clinical practice to treat people with lateral elbow pain.

OBJECTIVES

To assess the benefits and harms of manual therapy, prescribed exercises or both for adults with lateral elbow pain.

SEARCH METHODS

We searched the databases CENTRAL, MEDLINE and Embase, and trial registries until 31 January 2024, unrestricted by language or date of publication.

SELECTION CRITERIA

We included randomised or quasi-randomised trials. Participants were adults with lateral elbow pain. Interventions were manual therapy, prescribed exercises or both. Primary comparators were placebo or minimal or no intervention. We also included comparisons of manual therapy and prescribed exercises with either intervention alone, with or without glucocorticoid injection. Exclusions were trials testing a single application of an intervention or comparison of different types of manual therapy or prescribed exercises.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, extracted trial characteristics and numerical data, and assessed study risk of bias and certainty of evidence using GRADE. The main comparisons were manual therapy, prescribed exercises or both compared with placebo treatment, and with minimal or no intervention. Major outcomes were pain, disability, heath-related quality of life, participant-reported treatment success, participant withdrawals, adverse events and serious adverse events. The primary endpoint was end of intervention for pain, disability, health-related quality of life and participant-reported treatment success and final time point for adverse events and withdrawals.

MAIN RESULTS

Twenty-three trials (1612 participants) met our inclusion criteria (mean age ranged from 38 to 52 years, 47% female, 70% dominant arm affected). One trial (23 participants) compared manual therapy to placebo manual therapy, 12 trials (1124 participants) compared manual therapy, prescribed exercises or both to minimal or no intervention, six trials (228 participants) compared manual therapy and exercise to exercise alone, one trial (60 participants) compared the addition of manual therapy to prescribed exercises and glucocorticoid injection, and four trials (177 participants) assessed the addition of manual therapy, prescribed exercises or both to glucocorticoid injection. Twenty-one trials without placebo control were susceptible to performance and detection bias as participants were not blinded to the intervention. Other biases included selection (nine trials, 39%, including two quasi-randomised), attrition (eight trials, 35%) and selective reporting (15 trials, 65%) biases. We report the results of the main comparisons. Manual therapy versus placebo manual therapy Low-certainty evidence, based upon a single trial (23 participants) and downgraded due to indirectness and imprecision, indicates manual therapy may reduce pain and elbow disability at the end of two to three weeks of treatment. Mean pain at the end of treatment was 4.1 points with placebo (0 to 10 scale) and 2.0 points with manual therapy, MD -2.1 points (95% CI -4.2 to -0.1). Mean disability was 40 points with placebo (0 to 100 scale) and 15 points with manual therapy, MD -25 points (95% CI -43 to -7). There was no follow-up beyond the end of treatment to show if these effects were sustained, and no other major outcomes were reported. Manual therapy, prescribed exercises or both versus minimal intervention Low-certainty evidence indicates manual therapy, prescribed exercises or both may slightly reduce pain and disability at the end of treatment, but the effects were not sustained, and there may be little to no improvement in health-related quality of life or number of participants reporting treatment success. We downgraded the evidence due to increased risk of performance bias and detection bias across all the trials, and indirectness due to the multimodal nature of the interventions included in the trials. At four weeks to three months, mean pain was 5.10 points with minimal treatment and manual therapy, prescribed exercises or both reduced pain by a MD of -0.53 points (95% CI -0.92 to -0.14, I2 = 43%; 12 trials, 1023 participants). At four weeks to three months, mean disability was 63.8 points with minimal or no treatment and manual therapy, prescribed exercises or both reduced disability by a MD of -5.00 points (95% CI -9.22 to -0.77, I2 = 63%; 10 trials, 732 participants). At four weeks to three months, mean quality of life was 73.04 points with minimal treatment on a 0 to 100 scale and prescribed exercises reduced quality of life by a MD of -5.58 points (95% CI -10.29 to -0.99; 2 trials, 113 participants). Treatment success was reported by 42% of participants with minimal or no treatment and 57.1% of participants with manual therapy, prescribed exercises or both, RR 1.36 (95% CI 0.96 to 1.93, I2 = 73%; 6 trials, 770 participants). We are uncertain if manual therapy, prescribed exercises or both results in more withdrawals or adverse events. There were 83/566 participant withdrawals (147 per 1000) from the minimal or no intervention group, and 77/581 (126 per 1000) from the manual therapy, prescribed exercises or both groups, RR 0.86 (95% CI 0.66 to 1.12, I2 = 0%; 12 trials). Adverse events were mild and transient and included pain, bruising and gastrointestinal events, and no serious adverse events were reported. Adverse events were reported by 19/224 (85 per 1000) in the minimal treatment group and 70/233 (313 per 1000) in the manual therapy, prescribed exercises or both groups, RR 3.69 (95% CI 0.98 to 13.97, I2 = 72%; 6 trials).

AUTHORS' CONCLUSIONS

Low-certainty evidence from a single trial in people with lateral elbow pain indicates that, compared with placebo, manual therapy may provide a clinically worthwhile benefit in terms of pain and disability at the end of treatment, although the 95% confidence interval also includes both an important improvement and no improvement, and the longer-term outcomes are unknown. Low-certainty evidence from 12 trials indicates that manual therapy and exercise may slightly reduce pain and disability at the end of treatment, but this may not be clinically worthwhile and these benefits are not sustained. While pain after treatment was an adverse event from manual therapy, the number of events was too small to be certain.

Effects of a Conventional Treatment Plus Scapular Exercises Program in Patients With Chronic Lateral Elbow Tendinopathy: A Pre-Post Single-Group Study

BACKGROUND

Weakness of the shoulder girdle muscles has been reported in patients with chronic lateral elbow tendinopathy. The aim of this study was to assess the short- and long-term effects of a conventional treatment plus scapular exercises program in patients with chronic lateral elbow tendinopathy.

METHODS

A single-group prestudy and poststudy were conducted. The primary outcome was the Patient-Rated Tennis Elbow Evaluation questionnaire score. Secondary outcomes were grip strength; Disabilities of the Arm, Shoulder, and Hand questionnaire score; Visual Analogue Scale score at rest and at grip, and presence of scapular dyskinesis.

RESULTS

A total of 65 patients (72.3% females), with a mean age of 41.8 years, were analyzed. At the end of 6 weeks, the results showed clinically and statistically significant differences (P < .05). At 1-year follow-up, the differences were: Patient-Rated Tennis Elbow Evaluation -31 points (P < .001); grip strength +33.6% (P < .001); Disabilities of the Arm, Shoulder, and Hand -34.2 points (P < .001); Visual Analogue Scale at rest -2.5 cm (P < .001); and Visual Analogue Scale at grip -2.3 cm (P < .001).

CONCLUSION

At the end of 6 weeks and at 1-year follow-up, conventional treatment plus scapular exercises program showed statistically and clinically significant differences in all functional outcomes assessed in patients with lateral elbow tendinopathy.

Effectiveness of spinal manipulation in influencing the autonomic nervous system - a systematic review and meta-analysis

BACKGROUND

Spinal manipulation (SM) has been hypothesized to influence the autonomic nervous system (ANS). Further, it has been proposed that the effects may vary depending on the segment manipulated. The aim of this systematic review was to synthesize the current level of evidence for SM in influencing the ANS in healthy and/or symptomatic population.

METHODS

Various databases (n = 8) were searched (inception till May 2023) and 14 trials (n = 618 participants) were included in the review. Two authors independently screened, extracted and assessed the risk of bias in included studies. The data were synthesized using standard mean differences and meta-analysis for the primary outcome measures. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used for assessing the quality of the body of evidence for each outcome of interest.

RESULTS

Overall, there was low quality evidence that SM did not influence any measure of ANS including heart rate variability (HRV), oxy-hemoglobin, blood pressure, epinephrine and nor-epinephrine. However, there was low quality evidence that cervical spine manipulation may influence high frequency parameter of HRV, indicating its influence on the parasympathetic nervous system.

CONCLUSION

When compared with control or sham interventions, SM did not alter the ANS. Due to invalid methodologies and the low quality of included studies, findings must be interpreted with great caution. Future studies are needed which employ rigorous data collection processes to verify the true physiological implications of SM on ANS.

A Clinical Overview of the Natural Course and Management of Lateral Epicondylitis

Lateral epicondylitis (LE), also often called tennis elbow, is a frequent cause of elbow pain. The most characteristic symptom of LE is pain and burning around the lateral epicondyle of the humerus that may radiate to the forearm or to the upper arm. Ultrasonography is a quick and noninvasive tool used to confirm (or exclude) the diagnosis of LE. Management of LE symptoms should be directed to the management of pain, protection of movement, and improvement of arm performance. Treatment of LE includes nonoperative techniques and surgery. [Orthopedics. 2023;46(4):e210-e218.].

[Physiotherapeutic therapy modalities for lateral epicondyopathy]

Physiotherapy interventions can have a positive effect on the symptoms and relief of symptoms of lateral epicondylopathy (LE). However, there is currently no standard physiotherapy protocol for treating LE. Today, a multimodal treatment approach that focuses on progressive exercise therapy is recommended. While in the past, most treatment protocols were based on eccentric training, recent research shows that other forms of training can also improve pain and function in tendinopathies.

Feasibility of Using Detuned Laser as a Placebo In Manual Therapy Research: An Analysis of Participant Perceptions

OBJECTIVE

The purpose of this study was to determine the feasibility of using detuned laser as a placebo intervention in manual therapy research.

METHODS

We performed a secondary data analysis of a randomized controlled trial. In our analysis, 30 participants with chronic ankle instability (manual therapy group: n = 13, age = 33.1 ± 8.1 years, female participants = 50%; detuned laser group: n = 17, age = 31.9 ± 11.8 years, female participants = 72%) were asked to indicate which intervention (manual therapy [active] or detuned laser [placebo]), they thought they had received and to give a confidence rating on their response regarding the received intervention at the conclusion of the course of intervention. Independent t tests were used to compare the groups. Participants in both groups were asked the following open-ended question: "What did you think of the intervention?".

RESULTS

There were 52.9% participants in the detuned laser group and 53.8% participants in the manual therapy group who perceived that they had received the active intervention. The confidence ratings about their perceptions (6.7 ± 2.0, detuned laser group; 6.3 ± 2.4, manual therapy group) (P = .66) and the self-reported recovery ratings (1.9 ± 1.5 and 1.8 ± 1.2, respectively) (P = .77) were similar.

CONCLUSIONS

Participants in this study confidently perceived that detuned laser was an active intervention. They positively rated their recovery following the course of the placebo intervention and perceived that detuned laser was effective in treating their condition. Therefore, it is feasible for detuned laser to be used as a placebo for manual therapy trials.

Treatment, Diagnostic Criteria and Variability of Terminology for Lateral Elbow Pain: Findings from an Overview of Systematic Reviews

Background: Lateral elbow pain (LEP) represents a musculoskeletal disorder affecting the epicondyloid region of the elbow. The terminological framework of this problem in literature, to date, is confusing. This systematic review (SR) aims to analyse the panorama of the scientific literature concerning the pathogenetic framework, treatment, and clinical diagnosis of LEP. Methods: We conducted an SR according to the guidelines of the PRISMA statement. We performed research using the electronic Medline, Epistemonikos, and Cochrane Library databases. The research started on 12 January 2022 and finished on 30 April 2022. We included all systematic reviews and meta-analyses published, in English, between 1989 and 2022. The articles’ selection was based on critical appraisal using Amstar 2. In the selected reviews we obtained the etiopathogenic terminology used to describe the symptoms, treatment, and diagnostic criteria of LEP. Results: Twenty-five SRs met the eligibility criteria and were included in the study. From these SRs, 227 RCT articles were analysed and different treatments proposals were extracted, such as exercise, manipulation corticosteroid injection, and surgery. In the selected articles, 10 different terms emerged to describe LEP and 12 different clinical tests. The most common treatments detected in this SR were a conservative multimodal approach (e.g., eccentric exercises, manual therapy, acupuncture, ultrasound), then surgery or other invasive treatments (e.g., corticosteroid injection, tenotomy). The most common term detected in this SR was “lateral epicondylitis” (n = 95, 51.6%), followed by “tennis elbow” (n = 51, 28.1%) and “lateral epicondylalgia” (n = 18, 9.4%). Among the diagnostic tests were painful palpation (n = 101, 46.8%), the Cozen test (n = 91, 42.1%), the pain-free grip-strength test (n = 41, 19.0%), and the Maudsley test (n = 48, 22.2%). A total of 43.1% of RCTs (n = 96) included subjects with LEP > 3 months, 40.2% (n = 85) included patients with LEP < 3 months, and 16.7% of the items (n = 35) were not specified by the inclusion criteria on the onset of symptoms. Conclusions: In this SR, a considerable terminological heterogeneity emerged in the description of LEP, associated with the lack of clear and recognised diagnostic criteria in evaluating and treating patients with lateral elbow pain.

Lateral epicondylitis: New trends and challenges in treatment

Lateral epicondylitis (LE) is a chronic aseptic inflammatory condition caused by repetitive microtrauma and excessive overload of the extensor carpi radialis brevis muscle. This is the most common cause of musculoskeletal pain syndrome in the elbow, inducing significant pain and limitation of the function of the upper limb. It affects approximately 1-3% of the population and is frequently seen in racquet sports and sports associated with functional overload of the elbow, such as tennis, squash, gymnastics, acrobatics, fitness, and weight lifting. Typewriters, artists, musicians, electricians, mechanics, and other professions requiring frequent repetitive movements in the elbow and wrists are also affected. LE is a leading causation for absence from work and lower sport results in athletes. The treatment includes a variety of conservative measures, but if those fail, surgery is indicated. This review summarizes the knowledge about this disease, focusing on risk factors, expected course, prognosis, and conservative and surgical treatment approaches.

Is Ankle Kinesio Taping Effective to Immediately Change Balance, Range of Motion, and Muscle Strength in Healthy Individuals? A Randomized, Sham-Controlled Trial

Background

The ankle–foot complex plays a key role in maintaining balance because it collects proprioceptive data. Kinesio taping (KT) is a rehabilitative method performed by the cutaneous application of a special elastic tape. The mechanical correction technique of KT was suggested to reposition the joints and alter balance parameters. The aim was to reveal the pure effects of ankle KT on balance, range of motion (ROM), and muscle strength in healthy individuals.

Methods

Forty healthy students were recruited for this randomized, sham-controlled study at a local university. Participants were divided into two groups—experimental and sham application groups. The primary outcome measures were balance parameters. Athlete Single Leg (ASL), Limits of Stability (LoS), and Clinical Test of Sensory Interaction and Balance (CTSIB) were used to measure single-leg dynamic balance, dynamic postural control, and sensory interaction of balance, respectively. Dorsiflexion ROM and dorsiflexor muscle strength were the secondary outcomes.

Results

The ASL score showed significant improvement only in the experimental KT group (P=0.02); however, the LoS score increased significantly in both groups (P<0.05). CTSIB scores, dorsiflexion ROM, and dorsiflexor muscle strength for both ankles did not change in any of the groups after intervention (P>0.05). Moreover, there was no superiority of one intervention over the other in improving any of the variables (P>0.05).

Conclusion

The mechanical correction technique of KT can be useful in providing immediate improvement in single-leg dynamic balance in healthy individuals. However, it may not be effective to significantly change the sensory interaction of balance, dorsiflexion ROM, and muscle strength.

Comparison of an exercise program with and without manual therapy for patients with chronic neck pain and upper cervical rotation restriction. Randomized controlled trial

Background

Cervical exercise has been shown to be an effective treatment for neck pain, but there is still a need for more clinical trials evaluating the effectiveness of adding manual therapy to the exercise approach. There is a lack of evidence on the effect of these techniques in patients with neck pain and upper cervical rotation restriction.

Purpose

To compare the effectiveness of adding manual therapy to a cervical exercise protocol for the treatment of patients with chronic neck pain and upper cervical rotation restriction.

Methods

Single-blind randomized clinical trial. Fifty-eight subjects: 29 for the Manual Therapy+Exercise (MT+Exercise) Group and 29 for the Exercise group. Neck disability index, pain intensity (0–10), pressure pain threshold (kPa), flexion-rotation test (°), and cervical range of motion (°) were measured at the beginning and at the end of the intervention, and at 3-and 6-month follow-ups. The MT+Exercise Group received one 20-min session of manual therapy and exercise once a week for 4 weeks and home exercise. The Exercise Group received one 20-min session of exercise once a week for 4 weeks and home exercise.

Results

The MT+Exercise Group showed significant better values post-intervention in all variables: neck disability index: 0% patient with moderate, severe, or complete disability compared to 31% in the Exercise Group (p = 0.000) at 6-months; flexion-rotation test (p = 0.000) and pain intensity (p = 0.000) from the first follow-up to the end of the study; cervical flexion (p = 0.002), extension (p = 0.002), right lateral-flexion (p = 0.000), left lateral-flexion (p = 0.001), right rotation (p = 0.000) and left rotation (p = 0.005) at 6-months of the study, except for flexion, with significative changes from 3-months of follow up; pressure pain threshold from the first follow-up to the end of the study (p values range: 0.003–0.000).

Conclusion

Four 20-min sessions of manual therapy and exercise, along with a home-exercise program, was found to be more effective than an exercise protocol and a home-exercise program in improving the neck disability index, flexion-rotation test, pain intensity, and pressure pain threshold, in the short, medium, and medium-long term in patients with chronic neck pain and upper rotation restriction. Cervical range of motion improved with the addition of manual therapy in the medium and medium-long term. The high dropout rate may have compromised the external validity of the study.

The analgesic effect of joint mobilization and manipulation in tendinopathy: a narrative review

Objective: To summarize the available literature with regards to the potential analgesic effect and mechanism of joint mobilization and manipulation in tendinopathy. Results: The effect of these techniques in rotator cuff tendinopathy and lateral elbow tendinopathy, applied alone, compared to a placebo intervention or along with other interventions has been reported in some randomized controlled trials which have been scrutinized in systematic reviews. Due to the small randomized controlled trials and other methodological limitations of the evidence base, including short-term follow-ups, small sample size and lack of homogenous samples further studies are needed. Literature in other tendinopathies such as medial elbow tendinopathy, de Quervain's disease and Achilles tendinopathy is limited since the analgesic effect of these techniques has been identified in few case series and reports. Therefore, the low methodological quality renders caution in the generalization of findings in clinical practice. Studies on the analgesic mechanism of these techniques highlight the activation of the descending inhibitory pain mechanism and sympathoexcitation although this area needs further investigation. Conclusion: Study suggests that joint mobilization and manipulation may be a potential contributor in the management of tendinopathy as a pre-conditioning process prior to formal exercise loading rehabilitation or other proven effective treatment approaches.

Effects of Dry Needling of Latent Trigger Points on Viscoelastic and Muscular Contractile Properties: Preliminary Results of a Randomized Within-Participant Clinical Trial

This study aimed to evaluate changes in neuromuscular function and pain perception in latent trigger points (TrPs) in the gastrocnemius muscle after a single session of dry needling. A randomized within-participant clinical trial was conducted. Fifty volunteers with latent TrPs in the gastrocnemius muscles were explored. Each extremity was randomly assigned to a control or experimental (dry needling) group. Viscoelastic parameters and contractile properties were analyzed by tensiomyography. Ankle dorsiflexion range of motion was assessed with the lunge test. Pressure pain thresholds (PPT) and pain perceived were also analyzed. The results observed that three viscoelastic proprieties (myotonometry) showed significant differences in favor of the experimental extremity in the lateral gastrocnemius: stiffness (p = 0.02), relaxation (p = 0.045), and creep (p = 0.03), but not in the medial gastrocnemius. No changes in tensiomyography outcomes were found. The control extremity showed a higher increase in PPTs (i.e., decrease in pressure pain sensitivity) than the experimental extremity (p = 0.03). No significant effects for range of motion or strength were observed. In general, gender did not influence the effects of dry needling over latent TrPs in the gastrocnemius muscle. In conclusion, a single session of dry needling was able to change some parameters of neuromuscular function, such as muscle tone, relaxation, pressure pain sensitivity, and creep in the lateral (but not medial) gastrocnemius but did not improve strength or range of motion.

The Course of Posterior Antebrachial Cutaneous Nerve: Anatomical and Sonographic Study with a Clinical Implication

The course of the posterior antebrachial cutaneous nerve (PACN) was studied via ultrasound (US) and dissection. The aim of this study was to reveal the anatomical relationships of PACN with the surrounding structures along its pathway to identify possible critical points of compression. Nineteen cryopreserved cadaver body donor upper extremities were explored via US and further dissected. During US exploration, two reference points, in relation with the compression of the nerve, were marked using dye injection: (1) the point where the RN pierces the lateral intermuscular septum (LIMS) and (2) the point where the PACN pierces the deep fascia. Anatomical measurements referred to the lateral epicondyle (LE) were taken at these two points. Dissection confirmed the correct site of US-guided dye injection at 100% of points where the RN crossed the LIMS (10.5 cm from the LE) and was correctly injected at 74% of points where the PACN pierce the deep fascia (7.4 cm from the LE). There were variations in the course of the PACN, but it always divided from the RN as an only branch. Either ran close and parallel to the LIMS until the RN crossed the LIMS (84%) or clearly separated from the RN, 1 cm before it crossed the LIMS (16%). In 21% of cases, the PACN crossed the LIMS with the RN, while in the rest of the cases it always followed in the posterior compartment. A close relationship between PACN and LIMS, as well as triceps brachii muscle and deep fascia was observed. The US and anatomical study showed that the course of PACN maintains a close relationship with the LIMS and other connective tissues (such as the fascia and subcutaneous tissue) to be present in its pathology and treatment.

Effects of Manual Therapy on the Diaphragm in the Musculoskeletal System: A Systematic Review

OBJECTIVES

To analyze the effects at the musculoskeletal level of manual treatment of the diaphragm muscle in adults.

DATA SOURCES

Systematic review using 4 databases: PubMed, Science Direct, Web of Science, and Scopus.

STUDY SELECTION AND DATA EXTRACTION

Two independent reviewers applied the selection criteria and assessed the quality of the studies using the Physiotherapy Evidence Database scale for experimental studies. A third reviewer intervened in cases where a consensus had not been reached. A total of 9 studies were included in the review.

DATA SYNTHESIS

Manual therapy directed to the diaphragm has been shown to be effective in terms of the immediate increase in diaphragmatic mobility and thoracoabdominal expansion. The immediate improvement in the posterior muscle chain flexibility test is another of the most frequently found findings in the evaluated studies. Limited studies show improvements at the lumbar and cervical level in the range of motion and in pain.

CONCLUSION

Manual diaphragm therapy has shown an immediate significant effect on parameters related to costal, spinal, and posterior muscle chain mobility. Further studies are needed, not only to demonstrate the effectiveness of manual diaphragm therapy in the long-term and in symptomatic populations, but also to investigate the specific neurophysiological mechanisms involved in this type of therapy.

Epicondylopathia humeri radialis

BACKGROUND

Lateral epicondylitis is a common orthopaedic condition often massively restricting the quality of life of the affected patients. There are a wide variety of treatment options - with varying levels of evidence.

METHOD

The following statements and recommendations are based on the current German S2k guideline Epicondylopathia radialis humeri (AWMF registry number: 033 - 2019). All major German specialist societies participated in this guideline, which is based on a systematic review of the literature and a structured consensus-building process.

OUTCOMES

Lateral epicondylitis should be diagnosed clinically and can be confirmed by imaging modalities. The Guidelines Commission issues recommendations on clinical and radiological diagnostic workup. The clinical condition results from the accumulated effect of mechanical overload, neurologic irritation and metabolic changes. Differentiating between acute and chronic disorder is helpful. Prognosis of non-surgical regimens is favourable in most cases. Most cases spontaneously resolve within 12 months. In case of unsuccessful attempted non-surgical management for at least six months, surgery may be considered as an alternative, if there is a corresponding structural morphology and clinical manifestation. At present, it is not possible to recommend a specific surgical procedure.

CONCLUSION

This paper provides a summary of the guideline with extracts of the recommendations and statements of its authors regarding the pathogenesis, prevention, diagnostic workup as well as non-surgical and surgical management.

The effect of lumbar spine manipulation on pain and disability in Achilles tendinopathy. A case report

BACKGROUND/PURPOSE

Cervical and thoracic spine manipulation has been found to reduce tendon pain and disability in lateral epicondylalgia and rotator cuff tendinopathy. Based on these findings, the application of lumbar spine manipulation may also provide similar improvements in Achilles tendinopathy (AT). Therefore, the purpose of this study was to evaluate the effect of lumbar spine manipulation on pain and disability in a patient experiencing AT.

CASE DESCRIPTION

A 44 years old male ex-football player presented with a 20-year history of persistent Achilles tendon pain (ATP) consistent with AT diagnosis. The patient attended 12 treatment sessions receiving a high-velocity, low amplitude lumbar spine manipulation. Outcome measures were collected at baseline, 2 weeks, 4 weeks, 3 months and 6 months and included pain in visual analogue scale, the American Orthopedic Foot and Ankle Score, the 36-Item Short Form Health Survey and the Victorian Institute of Sport Assessment-Achilles questionnaire. Pressure pain threshold was also assessed using an electronic pressure algometer.

OUTCOMES

Improvement in all outcome measures was noted 6-months post intervention. Outcome measures indicated substantial improvements in both the patient's pain and disability. The patient was able to perform activities of daily living without difficulties, suggesting higher level of function and quality of life at 6-months post initial evaluation.

CONCLUSION

These findings have demonstrated the positive effects of lumbar spine manipulation on ATP and disability. Further studies, specifically clinical trials investigating the effect of lumbar spine manipulation or combining this technique with exercises and functional activities are suggested.

Efficacy of Manual Therapy on Facilitatory Nociception and Endogenous Pain Modulation in Older Adults with Knee Osteoarthritis: A Case Series

Background: manual therapy (MT) has been shown to have positive effects in patients with osteoarthritis (OA)-related pain, and its use in clinical settings is recommended. However, the mechanisms of action for how these positive effects occur are not yet well understood. The aim of the present study was to investigate the influence of MT treatment on facilitatory nociception and endogenous pain modulation in patients with knee OA related pain. Methods: Twenty-eight patients with knee OA were included in this study. Pain intensity using the numerical pain rating scale (NPRS), temporal summation (TS), conditioned pain modulation (CPM), and local (knee) and distant (elbow) hyperalgesia through the pressure pain threshold (PPT), were assessed to evaluate the pain modulatory system. Patients underwent four sessions of MT treatments within 3 weeks and were evaluated at the baseline, after the first session and after the fourth session. Results: the MT treatment reduced knee pain after the first session (p = 0.03) and after the fourth session (p = 0.04). TS decreased significantly after the fourth session of MT (p = 0.02), while a significant increase in the CPM assessment was detected after the fourth session (p = 0.05). No significant changes in the PPT over the knee and elbow were found in the follow-ups. Conclusions: The results from our study suggest that MT might be an effective and safe method for improving pain and for decreasing temporal summation.

Effects of the Manual Therapy Approach of Segments C0-1 and C2-3 in the Flexion-Rotation Test in Patients with Chronic Neck Pain: A Randomized Controlled Trial

Background: Flexion-rotation test predominantly measures rotation in C1-2 segment. Restriction in flexion-rotation may be due to direct limitation in C1-2, but also to a premature tightening of the alar ligament as a result of lack of movement in C0-1 or C2-3. The aim of this study was to compare the effect of a 20-min single cervical exercise session, with or without manual therapy of C0-1 and C2-3 segment in flexion-rotation test, in patients with chronic neck pain and positive flexion-rotation test. Methods: Randomized controlled clinical trial in 48 subjects (24 manual therapy+exercise/24 exercise). Range of motion and pain during flexion-rotation test, neck pain intensity and active cervical range of motion were measured before and after the intervention. Results: Significant differences were found in favour of the manual therapy group in the flexion-rotation test: right (p < 0.001) and left rotation (p < 0.001); pain during the flexion-rotation test: right (p < 0.001) and left rotation (p < 0.001); neck pain intensity: (p < 0.001); cervical flexion (p < 0.038), extension (p < 0.010), right side-bending (p < 0.035), left side-bending (p < 0.002), right rotation (p < 0.001), and left rotation (p < 0.006). Conclusions: Addition of one C0-C1 and C2-C3 manual therapy session to cervical exercise can immediately improve flexion-rotation test and cervical range of motion and reduce pain intensity.

Changes in glenohumeral translation, electromyographic activity, and pressure-pain thresholds following sustained or oscillatory mobilizations in stiff and healthy shoulders: Results of a randomized, controlled laboratory trial

STUDY DESIGN

Randomized Controlled Laboratory Study.

BACKGROUND

Posterior glide glenohumeral (GH) mobilizations are utilized to improve motion and decrease pain in patients with shoulder pathologies, thought to be due to capsular stretch and neurophysiologic effects. However, it remains unclear how different GH mobilizations influence mobility, rotator cuff (RC) activity, and pain processing, or if effects are different in stiff (≥15-degree loss of passive motion in any plane) rather than healthy shoulders.

OBJECTIVES

To compare the effects of oscillatory and sustained posterior GH mobilizations on translation, RC activity, and pressure pain threshold (PPT) in stiff and healthy shoulders.

METHODS

Eighty-eight participants, (44 control, 44 stiff shoulders) were randomly assigned to one of two mobilization conditions. Pre-post intervention measurements of PPT, GH translation via ultrasound imaging, and RC activity assessed via electromyography were performed. Sustained or oscillatory grade III posterior GH mobilizations were then provided to all participants. Data were analyzed using tests of difference and regression modeling.

RESULTS

Sustained glides (2.8 ± 3.3 mm) demonstrated significantly greater changes in translation compared to oscillatory glides (1.1 ± 3.9 mm), p = .028. Stiff shoulders demonstrated higher total RC activity than controls both pre (+24.51%, p = .004) and post-intervention (+23.10%, p = .01). Small changes in PPT occurred across all conditions, none reaching clinically meaningful levels.

CONCLUSION

Sustained mobilizations resulted in greater changes in GH translation. RC activity was higher in the stiff shoulder group, and remained higher post-intervention despite gains in GH translation, suggesting a mechanical rather than neurophysiologic effect. There was no meaningful difference in PPT between modes of mobilization.

LEVEL OF EVIDENCE

Therapy, Randomized Controlled Laboratory Study, Level 1b.

Immediate Effects of Ankle Joint Mobilization With Movement on Postural Control, Range of Motion, and Muscle Strength in Healthy Individuals: A Randomized, Sham-Controlled Trial

CONTEXT

Ankle proprioception is one of the crucial components contributing to postural control. Although the effects of Mulligan's mobilization with movement (MWM) on postural control, ankle dorsiflexion range of motion (DFROM), and muscle strength in people with ankle disorders have previously been investigated, it is still unclear whether ankle MWM had ability to change postural control, DFROM, and muscle strength.

OBJECTIVES

To reveal pure effects of MWM on postural control, ankle DFROM, and muscle strength in healthy individuals.

DESIGN

A prospective, randomized, double-blinded, sham-controlled study.

SETTING

Musculoskeletal laboratory, Dokuz Eylul University, Turkey.

PARTICIPANTS

Forty students in good health recruited from a local university.

INTERVENTIONS

Mulligan's MWM or sham application over ankle joint.

MAIN OUTCOME MEASURES

The primary outcome was postural control and measured using limits of stability (LOS) test. The secondary outcomes were tibialis anterior muscle strength and ankle DFROM, which were measured using handheld dynamometer and weight-bearing lunge test, respectively. All outcomes were assessed before and immediately after intervention.

RESULTS

Left and right ankle DFROM and LOS overall score showed a statistically significant improvement compared with first measurement in both groups (P < .05). However, LOS time was significantly improved only in the MWM group (P < .05). Statistical analyses of between-group mean differences showed that Mulligan's MWM provided significant improvement in the LOS in forward-right direction compared with sham application (P = .03).

CONCLUSIONS

The results of this study suggest that the application of Mulligan's MWM on ankle joint might be beneficial to improve postural control in forward right direction in individuals with healthy ankles. On the other hand, both MWM and sham application were able to increase overall postural control and DFROM, and MWM had no superiority over sham application for increasing these 2 variables.

Spinal Manipulation and Select Manual Therapies: Current Perspectives

Touch is fundamental to the doctor-patient relationship. Touch can produce neuromodulatory effects that mitigate pain and put patients at ease. Touch begins with a confident handshake and continues throughout the physical examination. Touching patients where they hurt is a clear indication that a provider understands their complaint. Touch often continues as a function of treatment. This article updates evidence surrounding human touch and addresses mechanisms of action for manual therapy, the impact of manual therapy on pain management, health care conditions for which manual therapy may be beneficial, treatment plans with dose-response evidence, and the impact of manual therapy on the health care system.

Does the Addition of Manual Therapy Approach to a Cervical Exercise Program Improve Clinical Outcomes for Patients with Chronic Neck Pain in Short- and Mid-Term? A Randomized Controlled Trial

Chronic neck pain is one of today’s most prevalent pathologies. The International Classification of Diseases categorizes four subgroups based on patients’ associated symptoms. However, this classification does not encompass upper cervical spine dysfunction. The aim is to compare the short- and mid-term effectiveness of adding a manual therapy approach to a cervical exercise protocol in patients with chronic neck pain and upper cervical spine dysfunction. Fifty-eight subjects with chronic neck pain and upper cervical spine dysfunction were recruited (29 = Manual therapy + Exercise; 29 = Exercise). Each group received four 20-min sessions, one per week during four consecutive weeks, and a home exercise regime. Upper flexion and flexion-rotation test range of motion, neck disability index, craniocervical flexion test, visual analogue scale, pressure pain threshold, global rating of change scale, and adherence to self-treatment were assessed at the beginning, end of the intervention and at 3- and 6-month follow-ups. The Manual therapy + Exercise group statistically improved short- and medium-term in all variables compared to the Exercise group. Four 20-min sessions of Manual therapy + Exercise along with a home-exercise program is more effective in the short- to mid-term than an exercise protocol and a home-exercise program for patients with chronic neck pain and upper cervical dysfunction.

Short-term Effects of Mulligan's Mobilization With Movement on Pain, Function, and Emotional Aspects in Individuals With Knee Osteoarthritis: A Prospective Case Series

OBJECTIVE

To evaluate the short-term effects of Mulligan's mobilization with movement (MWM) on pain, physical function, emotional aspects, and proprioceptive acuity after a 2-week treatment period and throughout a 3-week follow-up period.

METHODS

A single group of 30 participants (60.96 ± 5.16 years) with symptomatic knee osteoarthritis (KOA) was evaluated. The protocol involved 5 evaluations moments, before (baseline) and after 2 weeks of intervention (24 hours after the last session), and at 3-week follow-up. The intervention included 3 Mulligan's MWM techniques. The variables evaluated were pain (pressure pain threshold and Visual Numeric Scale), physical function (range of motion, proprioceptive acuity, and the Western Ontario and McMaster Universities Osteoarthritis Index) and emotional aspects (Beck Depression Inventory). Analysis of variance for repeated measures was used considering a significance level of 5%.

RESULTS

At the second evaluation (after intervention), the pressure pain threshold presented higher values for rectus femoris, tibialis anterior, and patellar tendon sites and reduced values for the Visual Numeric Scale, Beck Depression Inventory, and Western Ontario and McMaster Universities Osteoarthritis Index compared with baseline. Also, during the follow-up period, all variables returned close to baseline levels. Proprioceptive acuity and range of motion did not present significant changes.

CONCLUSION

Scores for pain relief, physical function, and emotional aspects improved after a course of MWM in this single group of individuals with KOA. Mobilization with movement had limited outcome during follow-up. It suggests that future clinical trials on the use of MWM for KOA should be considered.

Adding mobilisation with movement to exercise and advice hastens the improvement in range, pain and function after non-operative cast immobilisation for distal radius fracture: a multicentre, randomised trial

QUESTION

Does adding mobilisation with movement (MWM) to usual care (ie, exercises plus advice) improve outcomes after immobilisation for a distal radius fracture?

DESIGN

A prospective, multicentre, randomised, clinical trial with concealed allocation, blinding and intention-to-treat analysis.

PARTICIPANTS

Sixty-seven adults (76% female, mean age 60 years) treated with casting after distal radius fracture.

INTERVENTION

The control group received exercises and advice. The experimental group received the same exercises and advice, plus supination and wrist extension MWM.

OUTCOME MEASURES

The primary outcome was forearm supination at 4 weeks (immediately post-intervention). Secondary outcomes included wrist extension, flexion, pronation, grip strength, QuickDASH (Disabilities of Arm, Shoulder and Hand), Patient-Rated Wrist Evaluation (PRWE) and global rating of change. Follow-up time points were 4 and 12 weeks, with patient-rated measures at 26 and 52 weeks.

RESULTS

Compared with the control group, supination was greater in the experimental group by 12 deg (95% CI 5 to 20) at 4 weeks and 8 deg (95% CI 1 to 15) at 12 weeks. Various secondary outcomes were better in the experimental group at 4 weeks: extension (14 deg, 95% CI 7 to 20), flexion (9 deg, 95% CI 4 to 15), QuickDASH (-11, 95% CI -18 to -3) and PRWE (-13, 95% CI -23 to -4). Benefits were still evident at 12 weeks for supination, extension, flexion and QuickDASH. The experimental group were more likely to rate their global change as 'improved' (risk difference 22%, 95% CI 5 to 39). There were no clear benefits in any of the participant-rated measures at 26 and 52 weeks, and no adverse effects.

CONCLUSION

Adding MWM to exercise and advice gives a faster and greater improvement in motion impairments for non-operative management of distal radius fracture.

REGISTRATION

ACTRN12615001330538.

The effects of spinal manipulative therapy on lower limb neurodynamic test outcomes in adults: a systematic review

Objective: Spinal Manipulative Therapy (SMT) is a routinely applied treatment modality for various musculoskeletal conditions, including low back pain. The precise mechanisms by which SMT elicits its effects are largely unknown, but recent research supports a multi-system explanation recognizing both biomechanical and neurophysiological mechanisms. Although the evaluation of changes in clinical presentation is complex, objective neurophysiological measures of sensitivity to movement (e.g. neurodynamic tests) can be a valuable clinical indicator in evaluating the effects of SMT. This review aimed to synthesize current literature investigating the effects of SMT on lower limb neurodynamics.Method: Eight electronic databases were systematically searched for randomized controlled trials (RCT) that applied SMT (against any control) and evaluated lower limb neurodynamics (Passive Straight Leg Raise or Slump Test). Selection and data extraction were conducted by one researcher, reviewed by a second author. Risk of bias (RoB) was assessed using the Cochrane Back Review Group criteria.Results: Eight RCTs were included, one with high RoB. SMT produced a clinically meaningful (≥6⁰) difference in five of these studies compared with inert control, hamstring stretching, and as an adjunct to conventional physiotherapy, but not compared with standard care, as an adjunct to home exercise and advice, or when comparing different SMT techniques. Findings compared to sham were mixed. When reported, effects tentatively lasted up to 6 weeks post-intervention.Conclusion: Limited evidence suggests SMT-improved range of motion and was more effective than some other interventions. Future research, using standardized Neurodynamic tests, should explore technique types and evaluate longer-term effects.Level of Evidence: 1a.

Do joint mobilizations assist in the recovery of lateral elbow tendinopathy? A systematic review and meta-analysis

STUDY DESIGN

Systematic review.

INTRODUCTION

No consensus exists as to which are the most effective methods to treat the symptoms associated with lateral elbow tendinopathy (LET). Research has suggested that joint mobilizations may assist in the recovery of patients with LET.

PURPOSE OF THE STUDY

To determine if joint mobilizations are effective in improving pain, grip strength, and disability in adults with LET.

METHODS

Searches in 3 databases were performed to identify relevant clinical trials. Reviewers independently extracted data and assessed the methodological quality. Summary measures of quantitative data were extracted or calculated where possible. Appropriate data were pooled for meta-analysis using a random-effects model.

RESULTS

A total of 20 studies met the inclusion criteria; 7 were included in the meta-analysis. Studies were broadly classified into 3 groups: mobilization with movement (MWM), Mill's manipulation, and regional mobilization techniques. Pooled data across all time periods demonstrated a mean effect size of 0.43 (95% confidence interval [CI]: 0.15-0.71) for MWM on improving pain rating, and 0.31 (95% CI: 0.11-0.51) for MWM on improving grip strength, 0.47 (95% CI: 0.11-0.82) for Mill's manipulation on improving pain rating. A mean effect size of -0.01 (95% CI: -0.27 to -0.26) shows Mill's manipulation did not improve pain free grip strength. Functional outcomes varied considerably among studies. Pain, grip strength, and functional outcomes were improved with regional mobilizations.

CONCLUSION

There is compelling evidence that joint mobilizations have a positive effect on both pain and/or functional grip scores across all time frames compared to control groups in the management of LET.

The effects of KinesioTape on the treatment of lateral epicondylitis

STUDY DESIGN

Randomized clinical trial.

INTRODUCTION

KinesioTape (KT) is a noninvasive method to treat pain and muscular dysfunction.

PURPOSE

To investigate the effect of KT with and without tension on pain intensity, pain pressure threshold, grip strength and disability in individuals with lateral epicondylitis, and myofacial trigger points in forearm muscles.

METHODS

Thirty women with lateral epicondylitis and myofacial trigger point in forearm muscles were randomly assigned to KT with tension and placebo (KT without tension). The treatment was provided 3 times in one week, and outcome measures were assess pre-post treatment.

RESULTS

The mean score of visual analogue scale (VAS) during activity decreased significantly from 6.4 and 6 pretest to 2.53 and 4.66 posttest, respectively, for the KT with and without tension groups. The mean score of Disabilities of the Arm, Shoulder and Hand decreased significantly from 16.82 and 22.79 pretest to 8.65 and 8.29 posttest, respectively, for the KT with and without tension groups. A paired t-test revealed a significant reduction in VAS during activity and Disabilities of the Arm, Shoulder and Hand before and after treatment in both groups (P < .05). Pain pressure threshold, grip strength, and VAS using an algometer revealed no significant differences. The study showed no significant difference in variables immediately after intervention.

DISCUSSION

Improvements in functional disability were superior when KT was used with tension, than obtained with a placebo-no tension application.

CONCLUSION

The application of KT produces an improvement in pain intensity and upper extremity disability in subjects with LE and MTP in forearm muscles, and KT with tension was more effective than placebo group.

LEVEL OF EVIDENCE

NA.

TRIAL REGISTRATION NUMBER

100-216.

The effect of mobilization with movement on pain and function in patients with knee osteoarthritis: a randomized double-blind controlled trial

BACKGROUND

Few studies have investigated the effects of mobilization with movement (MWM) in patients with knee osteoarthritis (OA) compared to other procedures. Sham procedures are generally more appropriate control than using no or usual treatments. Moreover, studies investigating the widespread hypoalgesic effects of MWM in patients with knee OA are lacking. The aim was to investigate the effect of MWM on function and pain in patients with knee OA compared to sham MWM.

METHODS

This is a randomized double-blind (patients and assessor) controlled trial. Forty adult patients with knee OA of grade II and above were recruited to receive either MWM treatment or sham MWM for the knee. The outcome measures included the following: a visual analogue scale (VAS) for pain, the pressure pain threshold (PPT) test, the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) Index, the timed up and go (TUG) test, knee strength and knee range of motion (ROM). The measurements were taken at baseline, immediately after intervention and 2 days later.

RESULTS

Compared with sham MWM, MWM resulted in greater immediate improvement in pain [mean difference (95% CI): - 2.2 (- 2.8, - 1.6)], PPT at both the knee [176 (97, 254)] and shoulder [212 (136, 288)], TUG time [- 1.6 (- 2.1, - 1.1)], knee flexor strength [2.0 (1.3, 2.7)] and extensor strength [5.7 (4.1, 7.2)] and knee flexion ROM [12.8 (9.6, 15.9)] (all, p < 0.001) but not knee extension ROM [- 0.8 (- 1.6, 0.1)] (p = 0.067). After 2 days of intervention, patients who received MWM also demonstrated a greater improvement in pain [- 1.0 (- 1.8, - 0.1)], PPT at the shoulder [107 (40, 175)], TUG time [- 0.9 (- 1.4, - 0.4)], knee flexor strength [0.9 (0.2, 1.7)] and extensor strength [2.9 (2.1, 3.9)] and knee flexion ROM [8.3 (4.7, 11.9)] (all, p ≤ 0.026). However, WOMAC scores and knee extension ROM showed no evidence of change at any stage after intervention (p ≥ 0.067).

CONCLUSIONS

MWM provided superior benefits over sham MWM in terms of local and widespread pain, physical function (walking), knee flexion and extension muscle strength and knee flexion ROM for at least 2 days in patients with knee OA.

TRIAL REGISTRATION

ClinicalTrials.gov ( NCT02865252 ), registered on August 12, 2016.

Comparison of high, medium and low mobilization forces for reducing pain and improving physical function in patients with hip osteoarthritis: Secondary analysis of a randomized controlled trial

BACKGROUND

Long-axis distraction mobilization (LADM) of the hip has been shown to reduce pain and improve physical function in hip osteoarthritis (OA). The optimal intensity of mobilization force necessary to reduce pain and improve physical function is unknown.

OBJECTIVE

To compare the effects on pain and physical function of three different intensities of LADM mobilization force in hip OA patients.

DESIGN

Randomized controlled trial.

METHODS

Sixty patients with unilateral hip OA were randomized to three groups: low, medium or high force mobilization group. Participants received three treatment sessions of LADM. Pressure pain thresholds (PPT) at hip, knee and heel, physical function (Western Ontario and McMaster Universities physical function subscale, timed up and go and 40 m self-placed walk test) and pain after the physical function tests (visual analogic scale) were assessed before and after the intervention.

RESULTS

The three treatment groups showed significant improvements in pain and in physical function (p < 0.05). The low-force group showed the largest effects size for pain (d = 2.0) and the greatest mean percentage increase in PPTs (hip = 30.3%, knee = 34.6%, heel = 25.6%). The high-force group showed the largest effects size for physical function (d = 0.5-0.7).

CONCLUSION

A low-force LADM produced the largest reduction in pain and a high-force LADM the largest improvement in physical function in hip OA patients. The improvements in pain and physical function after LADM in hip OA patients appear to be modulated by the intensity of the mobilization force.

Combined use of cervical headache snag and cervical snag half rotation techniques in the treatment of cervicogenic headache

[Purpose] Cervicogenic headache is a major problem in patients with upper cervical dysfunction. However, its physical therapy management is a topic of debate. This study aims to determine the effect of C1-C2 Mulligan sustained natural apophyseal glide mobilizations on cervicogenic headache and associated dizziness. [Participants and Methods] This study included 48 patients with cervicogenic headache, who were randomly assigned to three equal groups: Group A (Headache SNAG), group B (C1-C2 SNAG rotation), and group C (combined). Neck Disability Index was used to examine neck pain intensity and cervicogenic headache symptoms. The 6-item Headache Impact Test scale was used to examine headache severity and its adverse effects on social life and functions. Flexion-Rotation Test was used to assess rotation range of motion at the level of C1-C2 and confirmed by a cervical range of motion device. Dizziness Handicap Inventory scale was used to evaluate dizziness. The evaluation was done pre- and post-treatment and compared between the groups. [Results] Group C showed significant improvement in all variables compared with groups A and B. [Conclusion] Sustained natural apophyseal glide mobilizations used in the study were effective in reducing cervicogenic headache and dizziness in all groups with a greater improvement in the combined group. The use of cervical SNAG mobilizations is encouraged as a noninvasive intervention depending on the therapist's assessment, findings, and clinical reasoning.

The effect of massage technique plus thoracic manipulation versus thoracic manipulation on pain and neural tension in mechanical neck pain: a randomized controlled trial

[Purpose] To determine the short-term effects of thoracic manipulation, used alone or in conjunction with the Rungthip massage technique, on pain and neural extensibility in patients with chronic mechanical neck pain. [Participants and Methods] Thirty participants were randomly allocated to the aforementioned two groups. Outcome measures were neck pain at rest assessed using the Visual Analog Scale, and elbow extension range of motion evaluated using Upper Limb Neurodynamic Test 1 prior to treatment and three weeks after it. [Results] A statistically significant reduction in resting neck pain, and an improvement in elbow extension range of motion was reported by both groups shortly after the moment when the pain was first felt (threshold level). However, an improvement in elbow extension range of motion was not observed in either group at the maximum level of pain (tolerance level). A significant reduction in resting neck pain was seen in the thoracic manipulation plus Rungthip massage group, compared to that achieved using thoracic manipulation alone. [Conclusion] The use of thoracic manipulation and Rungthip massage is recommended to reduce resting neck pain and increase pain-free neural tissue extensibility.

The effectiveness of Mulligan's mobilisation with movement (MWM) on peripheral joints in musculoskeletal (MSK) conditions: A systematic review

Musculoskeletal (MSK) conditions are very common and represent a major concern for the society and global health. The manual therapy technique Mulligan's Mobilisation with Movement (MWM) has shown promising results in treating a variety of MSK conditions. The aim of this review was to systematically review the literature to establish whether MWM treatment is effective for improving pain and function in patients with MSK conditions related to peripheral joints.

METHODS

Seven electronic databases (MEDLINE (through Ovid), EMBASE (through ovid), CINAHL (through EBSCO), Cochrane (CENTRAL), Web of Science, SPORTDiscus (through EBSCO) AND PEDro) were searched up to November 2017 for randomized controlled trials (RCTs). The quality of the evidence was rated using the GRADE approach.

RESULTS

Seven published trials were identified in which all trials presented positive clinical outcome in pain and function of MWM. Moderate quality evidence was found for the effectiveness of MWM in pain and function in patients with chronic ankle instability (CAI) and hip osteoarthritis (OA). There was found low quality evidence for shoulder impingement syndrome (SIS) and low and very low quality evidence for lateral epicondylalgia.

CONCLUSION

Overall MWM interventions applied to peripheral joints seems to be superior to placebo and no intervention controls, but not in comparison with other medical or physiotherapy interventions. There is a need for more high quality trials that investigate the short and long-term effect of a series of MWM interventions.

The Effect of Mulligan Mobilization Technique in Older Adults with Neck Pain: A Randomized Controlled, Double-Blind Study

Background

The purpose of this study was to examine the effect of Mulligan mobilization technique (MMT) on pain, range of motion (ROM), functional level, kinesiophobia, depression, and quality of life (QoL) in older adults with neck pain (NP).

Methods

Forty-two older adults with NP were included in the study, and they were randomly divided into two groups: traditional physiotherapy (TP) group and traditional physiotherapy-Mulligan mobilization (TPMM) group. Treatment program was scheduled for 10 sessions. Participants were assessed in terms of pain, ROM, functional level, kinesiophobia, depression, and QoL both pre- and posttreatment.

Results

Pain, ROM, functional level, kinesiophobia, depression, and QoL improved in both groups following treatment (p < 0.05). When comparing effects of these two treatment programs, it was observed that the TPMM group had a better outcome (p < 0.05) in terms of ROM, kinesiophobia, depression, and QoL.

Conclusion

In older adults with NP, MMT has been found to have significant effects on pain, ROM, functional level, kinesiophobia, depression, and QoL as long as it is performed by a specialist. "This trial is registered with NCT03507907".

Effects of eccentric control exercise for wrist extensor and shoulder stabilization exercise on the pain and functions of tennis elbow

[Purpose] This study aimed to conduct experiments to examine the effects of wrist eccentric control exercise or shoulder stabilization exercises after a basic direct treatment of the elbow in the treatment of tennis elbow patients in terms of pain and grip strength. [Subjects and Methods] The subjects were divided into two groups: one group conducted wrist eccentric control exercise and was comprised of 5 male and 4 female subjects, and the other group received shoulder stabilization exercise and was comprised of 5 male and 4 female subjects. [Results] In the intragroup comparison, both groups showed a significant decrease in pain level and a significant increase in the measurement of the tenderness thresholds of the upper trapezius muscle, lateral epicondyle, and grip strength. In the intergroup comparison, the shoulder stabilization exercise group showed a significantly greater increase in the measurement of the tenderness thresholds of the upper trapezius muscle and grip strength, and the differences were not significant in the pain level and tenderness threshold of the lateral epicondyle. [Conclusion] Wrist eccentric control exercise and shoulder stabilization exercises can be useful as intervention methods for relief from pain due to lateral epicondylitis and for the improvement of functions impaired by tennis elbow.

Effectiveness of classic physical therapy proposals for chronic non-specific low back pain: a literature review

INTRODUCTION

Chronic low back pain is a pathological process that compromises the functionality and quality of life worldwide. The objective of the study was to evaluate the effectiveness of classical physiotherapy in the management of non-specific chronic low back pain.

METHODS

A literature search in English electronic databases was performed from November to December of 2015. Only those studies addressing chronic non-specific low back pain by manual therapy and different types of exercises methods were included, and those, which combined acute or subacute pain with systematic reviews and clinical practice guidelines, were excluded. Studies involving cognitive-behavioral approaches were also excluded.

RESULTS

487 studies were identified, 16 were analyzed and 10 were excluded. Of the 6 studies reviewed, 5 of them achieved a moderate quality and 1 of them was of a low quality. Back School exercises and McKenzie's method were all ineffective. Osteopathic spinal manipulation proved effective when performed on the lower back and the thoracic area but only immediately after it was received, and not in the medium or long term. Massages proved effective in the short term too, as well as the global postural reeducation although ultimately this study can be considered of a low methodological quality.

CONCLUSIONS

Based on the data obtained, classical physiotherapy proposals show ineffectiveness in the treatment of chronic non-specific low back pain. More multidimensional studies are needed in order to achieve a better treatment of this condition, including the biopsychosocial paradigm.

Effect of a lateral glide mobilisation with movement of the hip on vibration threshold in healthy volunteers

BACKGROUND

Mulligan's mobilisation-with-movement (MWM) techniques are proposed to achieve their clinical benefit via neurophysiological mechanisms. However, previous research has focussed on responses in the sympathetic nervous system only, and is not conclusive. An alternative measure of neurophysiological response to MWM is required to support or refute this mechanism of action. Recently, vibration threshold (VT) has been used to quantify changes in the sensory nervous system in patients experiencing musculoskeletal pain.

OBJECTIVE

To investigate the effect of a lateral glide MWM of the hip joint on vibration threshold compared to a placebo and control condition in asymptomatic volunteers.

METHODS

Fifteen asymptomatic volunteers participated in this single-blinded, randomised, within-subject, placebo, control design. Participants received each of three interventions in a randomised order; a lateral glide MWM of the hip joint into flexion, a placebo MWM, and a control intervention. Vibration threshold (VT) measures were taken at baseline and immediately after each intervention. Mean change in VT from baseline was calculated for each intervention and then analysed for between group differences using a one-way analysis of variance (ANOVA).

RESULTS

A one-way ANOVA revealed no statistically significant differences between the three experimental conditions (P = 0.812).

CONCLUSION

This small study found that a lateral glide MWM of the hip did not significantly change vibration threshold compared to a placebo and control intervention in an asymptomatic population. This study provides a method of using vibration threshold to investigate the potential neurophysiological effects of a manual therapy intervention that should be repeated in a larger, symptomatic population.

Management of Chronic Lateral Epicondylitis With Manual Therapy and Local Cryostimulation: A Pilot Study

Objective

The purpose of this pilot study was to evaluate the feasibility and efficacy of adding cryostimulation to manual therapy in patients with chronic lateral epicondylitis.

Methods

The control group (n = 19) was treated with manual therapy consisting of soft-tissue therapy and radial head mobilizations. The experimental group (n = 18) received cryostimulation in addition to manual therapy care similar to that for the control group. Both protocols consisted of 8 treatments over a 4-week period. Outcome measures included pain intensity (visual analog scale), pain-free grip strength (handheld dynamometer), and functional index (Patient-Rated Tennis Elbow Evaluation questionnaire). Assessments were performed at baseline, postintervention, and 3-month follow-up. Adherence and dropout rates were also considered.

Results

Both groups exhibited significant improvements in pain intensity and functional index at postintervention assessments, which were maintained at follow-up. All participants attended the prescribed number of treatments, but 27% were lost at follow-up. Minor adverse events were reported after cryostimulation in 4 cases.

Conclusions

This study indicated that it is feasible to complete a clinical trial evaluating the efficacy of adding cryostimulation to manual therapy in patients with chronic lateral epicondylitis. On the basis of these preliminary data, the combination of cryostimulation and manual therapy care did not provide any additional benefits in both the short term and the long term. Manual myofascial point treatment and mobilization techniques yielded positive outcomes in chronic lateral epicondylitis. Further studies should focus on the sole therapeutic effect of cryostimulation in both patients with acute and those with chronic conditions.

Immediate effects of Maitland mobilization versus Mulligan Mobilization with Movement in Osteoarthritis knee- A Randomized Crossover trial

BACKGROUND

Maitland Mobilization or Mulligan Mobilization with Movement (MWM) approaches have been widely used clinically for pain relief and improving mobility in Osteoarthritis knee. However the experimental evidence supporting the usage of these mobilization techniques as sole interventions in management of Osteoarthritis knee is insufficient.

OBJECTIVE

To determine from Maitland Mobilization and Mulligan MWM, which mobilization technique will be more effective in reducing pain and improving mobility and function in OA knee immediately after the intervention.

STUDY DESIGN

Randomized Crossover trial.

MATERIALS AND METHODS

30 subjects with osteoarthritis knee were recruited and 15 each were randomly allocated to two intervention sequences-one sequence was where Maitland was given first followed by Mulligan and the other was where Mulligan was given first followed by Maitland with a washout period of 48 h in between the two interventions. Numeric Pain Rating Scale (NPRS), Timed Up and Go (TUG) test and Pain free Squat Angle were the outcome measures measured before and immediately after both interventions.

RESULTS

Using Repeated Measures ANOVA for analysis of outcomes between and within interventions, no significant differences were seen between Maitland Mobilization and Mulligan MWM, for NPRS, TUG and Pain free Squat Angle (p = 0.18, p = 0.27,p = 0.17) respectively whereas within the interventions both Maitland and Mulligan all outcome measures showed significant changes (p < 0.001).

CONCLUSION

Thus it can be seen that Maitland mobilization and Mulligan MWM, both are equally effective in osteoarthritis knee in reducing pain and improving functional mobility and pain free squat angle immediately post treatment.