Hypoalgesia induced by elbow manipulation in lateral epicondylalgia does not exhibit tolerance

Postural and clinical outcomes of sustained natural apophyseal glides treatment in cervicogenic dizziness patients: A randomised controlled trial

OBJECTIVE

To evaluate how self-report and posturographic measures could be affected in patients with cervicogenic dizziness undergoing sustained natural apophyseal glides.

DESIGN

Randomised controlled single-blind study.

SETTING

Tertiary rehabilitation centre.

SUBJECTS

Patients affected by cervicogenic dizziness, diagnosed by applying accepted criteria. Forty-one patients (19 male, 22 female: mean age 44.3 ± 14.8 years) receiving treatment, and 39 patients (18 male, 21 female: mean age 43.8 ± 13.9 years) receiving placebo were included in the study.

INTERVENTIONS

The treatment group underwent sustained natural apophyseal glides, while the placebo was constituted by a detuned laser. Both groups received their interventions six times over 4 weeks.

MAIN MEASURES

Outcomes were tested by means of self-report measures such as perceived dizziness, neck disability, anxiety and depression. Also, cervical range of motion and posturography testing with power spectra frequency were analysed.

RESULTS

When compared to placebo, treated patients demonstrated a significant decrease in perceived dizziness (post-treatment total Dizziness Handicap Inventory score 20.5 ± 5.3 as compared to 26.2 ± 6 baseline), neck disability and pain (Neck Disability Index and Neck Pain Index post-treatment scores 12.5 ± 4.3 and 45.6 ± 15.1, respectively, as compared to baseline scores of 15.1 ± 4.8 and 62.5 ± 14.3), as well as significant improvement in cervical range of motion and some posturographic parameters.

CONCLUSION

Sustained natural apophyseal glides may represent a useful intervention in reaching short-term beneficial effects in patients with cervicogenic dizziness, with respect to self-perceived symptoms, proprioceptive integration and cervical range of motion improvement.

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.

Clinical comparative effectiveness of acupuncture versus manual therapy treatment of lateral epicondylitis: feasibility randomized clinical trial

Background

Lateral epicondylitis (LE) is a challenging condition for clinicians, and research has yet not proven the superiority of one specific treatment approach. However, manual therapy (elbow mobilization) in addition to eccentric exercise has been found to be superior to exercise alone. As well, acupuncture is effective in short-term pain relief when compared with sham treatment, but there is little knowledge on the comparative effectiveness of manual therapy and acupuncture treatment of LE in terms of pain relief. The primary objective of this pilot trial was to assess the feasibility (retention and adherence rates) of performing a randomized controlled trial (RCT) to explore the clinical effectiveness of acupuncture and manual therapy treatment of LE.

Methods

This pilot trial took place in an outpatient interdisciplinary institute of sports medicine and rehabilitation in Oslo, Norway. Thirty-six adults with clinically diagnosed LE were randomly allocated into one of three groups: eccentric exercise alone, eccentric exercise plus acupuncture, or eccentric exercise plus manual therapy for a 12-week treatment period. Primary outcomes were patient retention and adherence rates. Secondary outcomes included patient-reported pain (NRS), level of disability (Quick-DASH), and participant’s satisfaction with treatment and global perceived effect.

Results

Nine (69%) patients in the acupuncture group completed the 1-year follow-up, compared to eight (67%) in the manual therapy group and five (45%) in exercise alone. Our goal was to demonstrate a retention rate above 80% to avoid serious threats to validity, but the result was lower than expected. The majority of participants (64%) in both treatment groups received only three-treatment sessions; the reasons included non-attendance or recovery from pain. Secondary outcomes support the rationale for conduction of an RCT. There were no adverse advents related to study participation.

Conclusions

Based on differences in pain relief between groups, patient retention, and adherence rates, an RCT seems to be feasible to assess treatment effectiveness more precisely. In a future definitive trial, greater dropout may be reduced by maintaining contact with the participants in the exercise alone group throughout the intervention, and objective assessments might be considered.

Trial registration

ClinicalTrials.gov, NCT02321696

Effects of orthopaedic manual therapy in knee osteoarthritis: a systematic review and meta-analysis

OBJECTIVE

This systematic review to aimed to evaluate the effects of orthopaedic manual therapy (OMT) on pain, improving function, and physical performance in patients with knee osteoarthritis (OA).

DATA SOURCES

Four databases (PubMed, Web of Science, CENTRAL, and CINAHL) were searched.

STUDY SELECTION

Trials were required to compare OMT alone or OMT in combination with exercise therapy, with exercise therapy alone or control.

DATA EXTRACTION

Data extraction and risk assessment were done by two independent reviewers. Outcome measures were visual analogue scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain score, WOMAC function score, WOMAC global score, and stairs ascending-descending time.

RESULTS

Eleven randomized controlled trials were included (494 subjects), four of which had a PEDro score of 6 or higher, indicating adequate quality. The results of the meta-analysis indicated that reduction of VAS score in OMT compared with the control group was statistically insignificant (SDM: -0.59; 95% CI: -1.54 to -0.36; P=0.224). The reduction of VAS score in OMT compared with exercise therapy group was statistically significant (SDM: -0.78; 95% CI: -1.42 to -0.17; P=0.013). The reduction of WOMAC pain score in OMT compared with the exercise therapy group was statistically significant (SDM: -0.79; 95% CI: -1.14 to -0.43; P=0.001). Similarly, the reduction of WOMAC function score in OMT compared with the exercise therapy group was statistically significant (SDM: -0.85; 95% CI: -1.20 to -0.50; P=0.001). However, the reduction of WOMAC global score in OMT compared with the exercise therapy group was statistically insignificant (SDM: -0.23; 95% CI: -0.54 to -0.09; P=0.164). The reduction of stairs ascending-descending time in OMT compared with the exercise therapy group was statistically significant (SDM: -0.88; 95% CI: -1.48 to -0.29; P=0.004).

CONCLUSIONS

This review indicated OMT compared with exercise therapy alone provides short-term benefits in reducing pain, improving function, and physical performance in patients with knee OA.

REVIEW REGISTRATION

PROSPERO 2016:CRD42016032799.

Effect of mobilization with movement on lateral knee pain due to proximal tibiofibular joint hypomobility

This case report describes a 45-year-old female who presented with lateral knee pain over the right proximal tibiofibular joint (PTFJ) managed unsuccessfully with rest, medications, bracing, injection, and physiotherapy. Clinical diagnosis of PTFJ hypomobility was based on concordant symptom reproduction with palpatory tenderness, accessory motion testing, and restricted anterior glide of the fibula. Intervention consisted of Mulligan's mobilization with movement and taping over the right PTFJ with immediate improvements noticed in pain, range of motion, and function. The patient was seen twice a week and was discharged after four treatment sessions. A follow-up after 6 months revealed that the patient was pain free and fully functional.

Effect of a novel mobilization with movement procedure on anterolateral ankle impingement - A case report

This case report describes a 50-year-old male who presented with right anterolateral ankle pain managed unsuccessfully with rest, medications, bracing, injection, physical therapy, and massage therapy. Clinical diagnosis of anterolateral ankle impingement was based on concordant symptom reproduction with palpatory tenderness and a positive lateral synovial impingement test. This case report is a potential first time description of the successful management of anterolateral ankle impingement utilizing a novel Mulligan's mobilization with movement procedure (consisting of internal rotation of the distal tibia) and taping with immediate improvements noted in pain, range of motion, and function. The patient was seen twice a week and was discharged after four treatment sessions. A follow-up after 4 months revealed that the patient was pain free and fully functional.

Novel treatment of lateral ankle sprains using the Mulligan concept: an exploratory case series analysis

Objective

The purpose of this study was to examine the effect of the Mulligan Concept (MC) Mobilization with movement (MWM) in the treatment of clinically diagnosed acute lateral ankle sprains in competitive athletes.

Methods

A prospective case series of 5 adolescent patients, ages ranging from 14 to 18 years (mean = 15.8 ± 1.64), that suffered an acute lateral ankle sprain (LAS). Patients were treated with the MC lateral ankle MWM. Mobilization was directed at the distal fibula or, using a modified MWM, 2-3 inches proximal to the distal fibula. Using paired t-tests and descriptive statistics (mean and standard deviation) results were analyzed.

Results

Treatment lasted an average of 9 days (mean = 9.2, ±SD 3.96) from intake to discharge. During that time frame, patients reported decreases in pain on the numeric pain rating scale (NRS), disability on the Disablement in the Physically Active (DPA) scale and an increase in function on the patient-specific functional scale (PSFS); and an immediate decrease in pain on the NRS within the first treatment. The minimal detectable change for the PSFS and NRS were exceeded from intake to discharge. Additionally, the minimally clinical important differences were exceeded on the NRS and DPA scale.

Discussion

The evidence presented in this Level-4 case series supports the use of the MC lateral ankle MWM to treat patients diagnosed with acute grade II LAS. Patients in this case series reported immediate decreases in pain and immediate increases in function. Therefore, further investigation of the MC lateral ankle MWM is warranted.

The Role of Descending Modulation in Manual Therapy and Its Analgesic Implications: A Narrative Review

Manual therapy has long been a component of physical rehabilitation programs, especially to treat those in pain. The mechanisms of manual therapy, however, are not fully understood, and it has been suggested that its pain modulatory effects are of neurophysiological origin and may be mediated by the descending modulatory circuit. Therefore, the purpose of this review is to examine the neurophysiological response to different types of manual therapy, in order to better understand the neurophysiological mechanisms behind each therapy's analgesic effects. It is concluded that different forms of manual therapy elicit analgesic effects via different mechanisms, and nearly all therapies appear to be at least partially mediated by descending modulation. Additionally, future avenues of mechanistic research pertaining to manual therapy are discussed.

Comparison of Dry Needling versus Orthopedic Manual Therapy in Patients with Myofascial Chronic Neck Pain: A Single-Blind, Randomized Pilot Study

Objective. The aim of this study was to compare the efficacy of three interventions for the treatment of myofascial chronic neck pain. Methods. Thirty-six patients were randomly assigned to one of three intervention groups: orthopedic manual therapy (OMT), dry needling and stretching (DN-S), and soft tissue techniques (STT). All groups received two treatment sessions with a 48 h time interval. Outcome measures included neck pain intensity measured using a visual analogue scale, cervical range of motion (ROM), pressure pain threshold for measuring mechanical hyperalgesia, and two self-reported questionnaires (neck disability index and pain catastrophizing scale). Results. The ANOVA revealed significant differences for the group × time interaction for neck disability, neck pain intensity, and pain catastrophizing. The DN-S and OMT groups reduced neck disability. Only the OMT group showed decreases in mechanical hyperalgesia and pain catastrophizing. The cervical ROM increased in OMT (i.e., flexion, side-bending, and rotation) and DN-S (i.e., side-bending and rotation) groups. Conclusions. The three interventions are all effective in reducing pain intensity. Reduction in mechanical hyperalgesia and pain catastrophizing was only observed in the OMT group. Cervical ROM improved in the DN-S and OMT groups and also neck disability being only clinically relevant for OMT group.

Effects of Lumbosacral Manipulation on Isokinetic Strength of the Knee Extensors and Flexors in Healthy Subjects: A Randomized, Controlled, Single-Blind Crossover Trial

OBJECTIVE

The purpose of this study was to investigate the effect of manual manipulations targeting the lumbar spine and/or sacroiliac joint on concentric knee extension and flexion forces. Torque production was measured during isometric and isokinetic contractions.

METHODS

This was a randomized, controlled, single-blind crossover design with 21 asymptomatic, college-aged subjects who had never received spinal manipulation. During 2 separate sessions, subjects' peak torques were recorded while performing maximal voluntary contractions on an isokinetic dynamometer. Isometric knee extension and flexion were recorded at 60° of knee flexion, in addition to isokinetic measurements obtained at 60°/s and 180°/s. Baseline measurements were acquired before either treatment form of lumbosacral manipulation or sham manipulation, followed by identical peak torque measurements within 5 and 20 minutes posttreatment. Data were analyzed with a repeated measures analysis of variance.

RESULTS

A statistically significant difference did not occur between the effects of lumbosacral manipulation or the sham manipulation in the percentage changes of knee extension and flexion peak torques at 5 and 20 minutes posttreatment. Similar, nonsignificant results were observed in the overall percentage changes of isometric contractions (spinal manipulation 4.0 ± 9.5 vs sham 1.2 ± 6.3, P = .067), isokinetic contractions at 60°/s (spinal manipulation - 4.0 ± 14.2 vs sham - 0.3 ± 8.2, P = .34), and isokinetic contractions at 180°/s (spinal manipulation - 1.4 ± 13.9 vs sham - 5.5 ± 20.0, P = .18).

CONCLUSION

The results of the current study suggest that spinal manipulation does not yield an immediate strength-enhancing effect about the knee in healthy, college-aged subjects when measured with isokinetic dynamometry.

Manipulation in the Treatment of Plantar Digital Neuralgia: A Retrospective Study of 38 Cases

OBJECTIVE

The purpose of this retrospective case series is to describe treatment outcomes for patients with plantar digital neuralgia (PDN) (Morton's neuroma) who were treated using foot manipulation.

METHODS

Charts were reviewed retrospectively for patients with a diagnosis of PDN and who received a minimum of 6 treatments consisting of manipulation alone. Visual analogue pain scales (VAS) and pressure threshold meter readings (PTM) were extracted as outcome measures.

RESULTS

Thirty-eight cases met inclusion criteria. Mean pretreatment duration of pain was 28 months. Mean pretreatment VAS was 69.5/100 mm. Mean pretreatment PTM was 2.54 Kp. By the sixth treatment, 30 (79%) of the 38 patients scored a VAS of 0 mm and a further 4 (10%) were below 10 mm. Contralateral limb PTM showed a mean pre-treatment score of 5.5 Kp, which rose slightly to 5.85 Kp. This compared to a pre-treatment score of 2.54 Kp rising to 5.86 Kp in the affected limb. This represents a 126% increase in the affected side compared to 6.5% in the unaffected limb. Statistical analysis demonstrated a significant linear trend between decreasing VAS and manipulation (P < .001).

CONCLUSION

The patients with PDN who were included in this case series improved with conservative care that included only foot manipulation.

The effect of sustained natural apophyseal glide (SNAG) combined with neurodynamics in the management of a patient with cervical radiculopathy: a case report

This case report describes a 47-year-old female who presented with complaints of pain in the right elbow radiating down to the thumb. Physical examination revealed symptom reproduction with Spurling A test, upper limb neurodynamic testing-1 and right cervical rotation along with reduced symptoms with neck distraction. Clinical diagnosis of cervical radiculopathy (CR) was made based on a clinical prediction rule. This case report speculates a potentially first-time description of successful conservative management of CR in a patient utilizing simultaneous combination of sustained natural apophyseal glide and neurodynamic mobilization. Immediate improvements were seen in pain, cervical range of motion and functional abilities. The patient was discharged from physical therapy by the second week after four treatment sessions with complete pain resolution maintained at a four-month follow-up period.

Ankle joint mobilization affects postoperative pain through peripheral and central adenosine A1 receptors

BACKGROUND

Physical therapists frequently use joint mobilization therapy techniques to treat people with musculoskeletal dysfunction and pain. Several studies suggest that endogenous adenosine may act in an analgesic fashion in various pain states.

OBJECTIVE

The purpose of this study was to investigate the contribution of the adenosinergic system on the antihyperalgesic effect of ankle joint mobilization (AJM).

DESIGN

This was a experimental study.

METHODS

To test the hypothesis that the adrenosinergic system is involved in the antihyperalgesic effect of AJM, mice (25-35 g) submitted to plantar incision surgery were used as a model of acute postoperative pain. The mice were subjected to AJM for 9 minutes. Withdrawal frequency to mechanical stimuli was assessed 24 hours after plantar incision surgery and 30 minutes after AJM, adenosine, clonidine, or morphine treatments. The adenosinergic system was assessed by systemic (intraperitoneal), central (intrathecal), and peripheral (intraplantar) administration of caffeine. The participation of the A1 receptor was investigated using a selective adenosine A1 receptor subtype antagonist. In addition, previous data on the involvement of the serotonergic and noradrenergic systems in the antihyperalgesic effect of AJM were confirmed.

RESULTS

Ankle joint mobilization decreased mechanical hyperalgesia, and this effect was reversed by pretreatment of the animals with caffeine given by intraperitoneal, intraplantar, and intrathecal routes. In addition, intraplanar and intrathecal administrations of 1,3-dipropyl-8-cyclopentylxanthine (DPCPX, a selective adenosine A1 subtype receptor antagonist) or systemic administration of yohimbine or ρ-chlorophenylalanine methyl ester hydrochloride (PCPA) blocked the antihyperalgesia induced by AJM.

LIMITATIONS

The results are limited to animal models and cannot be generalized to acute pain in humans.

CONCLUSIONS

This study demonstrated the involvement of the adenosinergic system in the antihyperalgesic effect of AJM in a rodent model of pain and provides a possible mechanism basis for AJM-induced relief of acute pain.

One-week time course of the effects of Mulligan's Mobilisation with Movement and taping in painful shoulders

Previous research suggests that Mulligan's Mobilisation-with-Movement (MWM) technique for the shoulder produces an immediate improvement in movement and pain. The aims of this study were to investigate the time course of the effects of a single MWM technique and to ascertain the effects of adding tape following MWM in people with shoulder pain. Twenty-five participants (15 males, 10 females), who responded positively to an initial application of MWM, were randomly assigned to MWM or MWM-with-Tape. Range of movement (ROM), pressure pain threshold (PPT) and current pain severity (PVAS) were measured pre- and post-intervention, 30-min, 24-h and one week follow-up. Following a one-week washout period, participants were crossed over to receive a single session of the opposite intervention with follow-up measures repeated. ROM significantly improved with MWM-with-Tape and was sustained over one week follow-up (p < 0.001; 18.8°, 95% confidence intervals (CI) 7.3-30.4), and in PVAS up to 30-min follow-up (38.4 mm, 95% CI 20.6-56.1 mm). MWM demonstrated an improvement in ROM (11.8°, 95% CI 1.9-21.7) and PVAS (40.4 mm, 95% CI 27.8-53.0 mm), but only up to 30-min follow-up. There was no significant improvement in PPT for either intervention at any time point. MWM-with-Tape significantly improved ROM over the one-week follow-up compared to MWM alone (15.9°, 95% CI 7.4-24.4). Both MWM and MWM-with-Tape provide a short-lasting improvement in pain and ROM, and MWM-with-Tape also provides a sustained improvement in ROM to one-week follow-up, which is superior to MWM alone.

Immediate changes in widespread pressure pain sensitivity, neck pain, and cervical range of motion after cervical or thoracic thrust manipulation in patients with bilateral chronic mechanical neck pain: a randomized clinical trial

STUDY DESIGN

Randomized clinical trial.

OBJECTIVES

To compare the effects of cervical versus thoracic thrust manipulation in patients with bilateral chronic mechanical neck pain on pressure pain sensitivity, neck pain, and cervical range of motion (CROM).

BACKGROUND

Evidence suggests that spinal interventions can stimulate descending inhibitory pain pathways. To our knowledge, no study has investigated the neurophysiological effects of thoracic thrust manipulation in individuals with bilateral chronic mechanical neck pain, including widespread changes on pressure sensitivity.

METHODS

Ninety patients (51% female) were randomly assigned to 1 of 3 groups: cervical thrust manipulation on the right, cervical thrust manipulation on the left, or thoracic thrust manipulation. Pressure pain thresholds (PPTs) over the C5-6 zygapophyseal joint, lateral epicondyle, and tibialis anterior muscle, neck pain (11-point numeric pain rating scale), and cervical spine range of motion (CROM) were collected at baseline and 10 minutes after the intervention by an assessor blinded to the treatment allocation of the patients. Mixed-model analyses of covariance were used to examine the effects of the treatment on each outcome variable, with group as the between-subjects variable, time and side as the within-subject variables, and gender as the covariate. The primary analysis was the group-by-time interaction.

RESULTS

No significant interactions were found with the mixed-model analyses of covariance for PPT level (C5-6, P>.210; lateral epicondyle, P>.186; tibialis anterior muscle, P>.268), neck pain intensity (P = .923), or CROM (flexion, P = .700; extension, P = .387; lateral flexion, P>.672; rotation, P>.192) as dependent variables. All groups exhibited similar changes in PPT, neck pain, and CROM (all, P<.001). Gender did not influence the main effects or the interaction effects in the analyses of the outcomes (P>.10).

CONCLUSION

The results of the current randomized clinical trial suggest that cervical and thoracic thrust manipulation induce similar changes in PPT, neck pain intensity, and CROM in individuals with bilateral chronic mechanical neck pain. However, changes in PPT and CROM were small and did not surpass their respective minimal detectable change values. Further, because we did not include a control group, we cannot rule out a placebo effect of the thrust interventions on the outcomes.

LEVEL OF EVIDENCE

Therapy, level 1b.J Orthop Sports Phys Ther 2012;42(9):806-814, Epub 18 June 2012. doi:10.2519/jospt.2012.4151.

Mobilization with movement and kinesiotaping compared with a supervised exercise program for painful shoulder: results of a clinical trial

OBJECTIVE

The purpose of this study was to compare the efficacy of Mobilization with Movement (MWM) and kinesiotaping (KT) techniques with a supervised exercise program in participants with patients with shoulder pain.

METHODS

Twenty subjects with shoulder pain were included if subjects were diagnosed by the referring physician with either rotator cuff lesion with impingement syndrome or impingement shoulder syndrome. Participants were randomly assigned to 1 of 2 groups after clinical and radiologic assessment: group 1 was treated with MWM and KT techniques, whereas group 2 was treated with a supervised exercise program. The main outcome measures were active pain-free shoulder abduction and flexion tested on days 0, 5, and 10.

RESULTS

Improvement in active pain-free shoulder range of motion was significantly higher in the group treated with MWM and KT. Repeated-measures analysis of variance indicated significant effects of treatment, time, and treatment×time interaction.

CONCLUSION

This study suggests that MWM and KT may be an effective and useful treatment in range of motion augmentation of subjects with rotator cuff lesion and impingement syndrome or impingement shoulder syndrome.

The suitability of sham treatments for use as placebo controls in trials of spinal manipulative therapy: a pilot study

Despite the augmented use and dependence on manual therapy (MT), there are still calls from both within and outside the MT professions to provide robust evidence that spinal manipulative therapy (SMT) induces therapeutic effects beyond placebo. To facilitate this, placebo or 'sham' treatments, the development of which is notoriously difficult, must be used in rigorously controlled trials. The aim of this study was to investigate the suitability of different shams as controls in SMT trials. A repeated measures, single-blind, randomised trial was conducted on 10 asymptomatic subjects. Pain pressure thresholds (PPTs) were measured at 2 sites, local and systemic, before and after the application of either high-velocity low-amplitude thrust (HVLAT), sham functional technique (SFT), sham ultrasound (SUS) or no intervention control (NIC) to the cervico-thoracic (CT) junctional area. Treatment credibility was then assessed using a 4-point Likert Scale in response to 4 statements. Results demonstrated no significant change in PPT following any of the interventions, irrespective of site tested. The effect sizes for all interventions were considered small (d = <0.2). There were significant differences in Likert Scale responses for each statement (P < 0.001), with SUS eliciting significantly different responses as compared to SFT and NIC but not, predominantly, with HVLAT. SUS is implicated as being the most effective sham, having high fidelity to subjects' perceptions of a 'real' treatment, whilst being therapeutically inert i.e. results in no significant change in clinical status.

The immediate effects of sigmoid colon manipulation on pressure pain thresholds in the lumbar spine

Visceral manual therapy is increasingly used by UK osteopaths and manual therapists, but there is a paucity of research investigating its underlying mechanisms, and in particular in relation to hypoalgesia. The aim of this study was to investigate the immediate effects of osteopathic visceral mobilisation on pressure pain thresholds. A single-blinded, randomised, within subjects, repeated measures design was conducted on 15 asymptomatic subjects. Pressure pain thresholds were measured at the L1 paraspinal musculature and 1st dorsal interossei before and after osteopathic visceral mobilisation of the sigmoid colon. The results demonstrated a statistically significant improvement in pressure pain thresholds immediately after the intervention (P<0.001). This effect was not observed to be systemic, affecting only the L1 paraspinal musculature. This novel study provides new experimental evidence that visceral manual therapy can produce immediate hypoalgesia in somatic structures segmentally related to the organ being mobilised, in asymptomatic subjects.

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

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

Joint manipulation in the management of lateral epicondylalgia: a clinical commentary

Lateral epicondylalgia or tennis elbow is a prevalent musculoskeletal disorder that is characterized by lateral elbow pain often associated with gripping tasks. The underlying pathology remains to be fully elucidated; however, evidence indicates that the disorder does not involve an inflammatory process but rather impairments of the pain and motor systems as well as morphological changes in the structure of both the extensor carpi radialis brevis muscle and tendon. Although the most efficient management approach remains controversial, there is a growing body of literature reporting the effects and underlying mechanisms of joint manipulation in the management of lateral epicondylalgia. Evidence exists demonstrating that joint manipulation directed at the elbow and wrist as well as at the cervical and thoracic spinal regions results in clinical alterations in pain and the motor system. In addition to presenting this evidence, this paper describes proposed underlying physiological mechanisms of joint manipulation associated with the observed clinical effects. We propose that this information will be useful for the physical therapist in making clinical decisions regarding the selection of treatment technique for the management of patients with lateral epicondylalgia.

A systematic review of the effectiveness of manipulative therapy in treating lateral epicondylalgia

Lateral epicondylalgia is a commonly encountered musculoskeletal complaint. Currently, there is no agreement regarding the exact underlying pathoanatomical cause or the most effective management strategy. Various forms of joint manipulation have been recommended as treatment. The purpose of this study was to systematically review available literature regarding the effectiveness of manipulation in treating lateral epicondylalgia. A comprehensive search of Medline, CINAHL, Health Source, SPORTDiscus, and the Physiotherapy Evidence Database ending in November 2007 was conducted. Thirteen studies, both randomized and non-randomized clinical trials, met inclusion criteria. Articles were assessed for quality by one reviewer using the 10-point PEDro scale. Quality scores ranged from 1-8 with a mean score of 5.15 +/- 1.85. This score represented fair quality overall; however, trends indicated the presence of consistent methodological flaws. Specifically, no study achieved successful blinding of the patient or treating therapist, and less than 50% used a blinded outcome assessor. Additionally, studies varied significantly in terms of outcome measures, follow-up, and comparison treatments, thus making comparing results across studies difficult. Results of this review support the use of Mulligan's mobilization with movement in providing immediate, short-, and long-term benefits. In addition, positive results were demonstrated with manipulative therapy directed at the cervical spine, although data regarding long-term effects were limited. Currently, limited evidence exists to support a synthesis of any particular technique whether directed at the elbow or cervical spine. Overall, this review identified the need for further high-quality studies using larger sample sizes, valid functional outcome measures, and longer follow-up periods.

The influence of expectation on spinal manipulation induced hypoalgesia: an experimental study in normal subjects

Background

The mechanisms thorough which spinal manipulative therapy (SMT) exerts clinical effects are not established. A prior study has suggested a dorsal horn modulated effect; however, the role of subject expectation was not considered. The purpose of the current study was to determine the effect of subject expectation on hypoalgesia associated with SMT.

Methods

Sixty healthy subjects agreed to participate and underwent quantitative sensory testing (QST) to their leg and low back. Next, participants were randomly assigned to receive a positive, negative, or neutral expectation instructional set regarding the effects of a specific SMT technique on pain perception. Following the instructional set, all subjects received SMT and underwent repeat QST.

Results

No interaction (p = 0.38) between group assignment and pain response was present in the lower extremity following SMT; however, a main effect (p < 0.01) for hypoalgesia was present. A significant interaction was present between change in pain perception and group assignment in the low back (p = 0.01) with participants receiving a negative expectation instructional set demonstrating significant hyperalgesia (p < 0.01).

Conclusion

The current study replicates prior findings of c- fiber mediated hypoalgesia in the lower extremity following SMT and this occurred regardless of expectation. A significant increase in pain perception occurred following SMT in the low back of participants receiving negative expectation suggesting a potential influence of expectation on SMT induced hypoalgesia in the body area to which the expectation is directed.

Sustained natural apophyseal glides (SNAGs) are an effective treatment for cervicogenic dizziness

<Cervicogenic dizziness is dizziness described as imbalance occurring together with cervical pain or headache. This study aimed to determine the efficacy of sustained natural apophyseal glides (SNAGs) in the treatment of this condition. A double-blind randomised controlled clinical trial was undertaken. Thirty-four participants with cervicogenic dizziness were randomised to receive four to six treatments of SNAGs (n=17) or a placebo of detuned laser (n=17). Participants were assessed by a blinded assistant before treatment, after the final treatment and at 6- and 12-week follow-ups. The primary outcome measures were severity of dizziness, disability, frequency of dizziness, severity of cervical pain, and global perceived effect; balance and cervical range of motion were secondary measures. At post-treatment, 6- and 12-week follow-ups compared to pre-treatment, the SNAG group had less (P<0.05) dizziness, lower (P<0.05) scores on the Dizziness Handicap Inventory (DHI), decreased (P<0.05) frequency of dizziness, and less (P<0.05) cervical pain. The placebo group had significant (P<0.05) changes only at the 12-week follow-up in three outcome measures: severity of dizziness, DHI, and severity of cervical pain. Compared to the placebo group at post-treatment and 6-week follow-up, the SNAG group had less (P<0.05) dizziness, lower (P < or =0.05) scores on DHI, and less (P<0.05) cervical pain. Balance with the neck in extension improved (P < or =0.05) and extension range of motion increased (P<0.05) in the SNAG group. No improvements in balance or range of motion were observed in the placebo group. The SNAG treatment had an immediate clinically and statistically significant sustained effect in reducing dizziness, cervical pain and disability caused by cervical dysfunction.

Immediate effects on pressure pain threshold following a single cervical spine manipulation in healthy subjects

DESIGN

A placebo, control, repeated-measures, single-blinded randomized study.

OBJECTIVES

To compare the immediate effects on pressure pain threshold (PPT) tested over the lateral elbow region following a single cervical high-velocity low-amplitude (HVLA) thrust manipulation, a sham-manual application (placebo), or a control condition; and to analyze if a different effect was evident on the side ipsilateral to, compared to the side contralateral to, the intervention.

BACKGROUND

Previous studies investigating the effects of spinal manual therapy used passive mobilization procedures. There is a lack of studies exploring the effect of cervical manipulative interventions.

METHODS

Fifteen asymptomatic volunteers (7 male, 8 female; aged 19-25 years) participated in this study. Each subject attended 3 experimental sessions on 3 separate days, at least 48 hours apart. At each session, subjects received either the manipulation, placebo, or control intervention provided by an experienced therapist. The manipulative intervention was directed at the posterior joint of the C5-6 vertebral level. PPT over the lateral epicondyle of both elbows was assessed preintervention and 5 minutes postintervention by an examiner blinded to the treatment allocation of the subject. A 3-way analysis of covariance (ANCOVA) with intervention, side, and time as factors, and gender as covariate, was used to evaluate changes in PPT.

RESULTS

The analysis of variance detected a significant effect for intervention (F = 31.46, P < .001) and for time (F = 33.81, P < .001), but not for side (F = 0.303, P > .5). A significant interaction between intervention and time (F = 15.74, P < .001) was also found. Gender did not influence the comparative analysis (F = 0.252, P > .6). Post hoc analysis revealed that the application of a HVLA thrust manipulation produced a greater increase of PPT in both elbows, as compared to placebo or control interventions (P < .001). No significant changes in PPT levels were found after the placebo and control interventions (P > .6). Within-group effect sizes were large for PPT levels in both elbows after the manipulative procedure (d > 1.0), but small after placebo or control intervention (d < 0.1).

CONCLUSIONS

The application of a manipulative intervention directed at the posterior joint of the C5-6 vertebral level produced an immediate increase in PPT over the lateral epicondyle of both elbows in healthy subjects. Effect sizes for the HVLA thrust manipulation were large, suggesting a strong effect of unknown clinical importance at this stage, whereas effect sizes for both placebo and control procedures were small, suggesting no significant effect.

Mulligan's mobilization-with-movement, positional faults and pain relief: Current concepts from a critical review of literature

There are an increasing number of reports espousing the clinically beneficial effects of Mulligan's mobilization-with-movement (MWM) treatment techniques. The most frequent reported effect is that of an immediate and substantial pain reduction accompanied by improved function. Prompted by these dramatic effects are questions regarding the mechanism(s) of action that underpins MWM. It appears timely that a review of the current literature is performed to synthesize and evaluate claims of the effectiveness of MWM and speculation about the proposed mechanisms of action. This article provides an overview of the literature concerning the clinical efficacy, effects and putative mechanisms of action of the MWM approach in the treatment of musculoskeletal conditions. The literature regarding the mechanisms of action in both the biomechanical and pain science paradigms is covered herein by reviewing all available scientific evidence from laboratory-based studies. Limitations of reported studies and directions for further research are also considered.

The initial effects of a Mulligan's mobilization with movement technique on range of movement and pressure pain threshold in pain-limited shoulders

There is little known about the specific manual therapy techniques used to treat painfully limited shoulders and their effects on range of movement (ROM) and pressure pain threshold (PPT). The objective of this study was to investigate the initial effects of a Mulligan's mobilization with movement (MWM) technique on shoulder ROM in the plane of the scapula and PPT in participants with anterior shoulder pain. A repeated measures, double-blind randomized-controlled trial with a crossover design was conducted with 24 subjects (11 males and 13 females). ROM and PPT were measured before and after the application of MWM, sham and control conditions. Significant and clinically meaningful improvements in both ROM (15.3%, F (2,46)=16.31 P=0.00) and PPT (20.2%, F(2,46)=3.44, P=0.04) occurred immediately after post treatment. The results indicate that this specific manual therapy treatment has an immediate positive effect on both ROM and pain in subjects with painful limitation of shoulder movement. Further study is needed to evaluate the duration of such effects and the mechanism by which this occurs.

Effects of a manual therapy technique in experimental lateral epicondylalgia

In patients with lateral epicondylalgia, mobilization-with-movement (MWM) is used as an intervention aimed at achieving analgesia and enhancing grip force, although the mechanisms underlying these effects are unclear. The present study investigated the acute sensory and motor effects of an MWM intervention in healthy controls with experimentally induced lateral epicondylalgia. Twenty-four subjects were randomly allocated to either a MWM or a placebo group (n=12). In both groups, to generate the model of lateral epicondylalgia, delayed onset muscle soreness (DOMS) was provoked in one arm 24h prior (Day 0) to hypertonic saline-induced pain in the extensor carpi radialis brevis muscle (Day 1). Either a MWM or placebo intervention was applied during the saline-induced pain period. Saline-induced pain intensity (visual analogue scale: VAS), pain distribution and pain quality were assessed quantitatively. Pressure pain thresholds (PPTs) were recorded at the common extensor origin and the extensor carpi radialis brevis muscle. Maximal measures of grip and wrist extension force were recorded. In both groups (pooled data), DOMS was efficiently induced as demonstrated by a significant decrease in pre-exercise to pre-injection PPT at the common extensor origin (-45+/-19%) and at the extensor carpi radialis brevis (-61+/-23%; P<0.05), and a significant decrease in maximal grip force (-25+/-6%) and maximal wrist extension force (-40+/-12%; P<0.001). Moreover, both groups experienced a significant increase in muscle soreness (3.9+/-0.2; P<0.0001) at Day 1 compared to pre-exercise. During saline-induced pain and in response to intervention, there were no significant between-group differences in VAS profiles, pain distributions, induced deep tissue hyperalgesia or force attenuation. These data suggest that the lateral glide-MWM does not activate mechanisms associated with analgesia or force augmentation in subjects with experimentally induced features simulating lateral epicondylalgia.

The Use of Polarized Polychromatic Non-coherent Light as Therapy for Acute Tennis Elbow/Lateral Epicondylalgia: A Pilot Study

OBJECTIVE

The aim of this study was to assess the efficacy of polarized, polychromatic, non-coherent, low energy light (Bioptron 2, Bioptron AG, Switzerland) in the treatment of acute tennis elbow.

BACKGROUND

Tennis elbow, or lateral epicondylitis, is one of the most common lesions affecting the arm. A plethora of treatment regimes have been described for this condition, but no specific therapy has emerged as a gold standard.

METHODS

A pilot study was carried out with 25 patients who had acute tennis elbow. Bioptron 2 device was applied over lateral epicondyle three times per week for 4 weeks. Pain on VAS, function on VAS, and painfree grip strength were measured at the beginning (week 0) and at the end of the study (week 4).

RESULTS

The pain on VAS was reduced at the end of treatment (t(24) = 3.84, p = 0.001). Function on VAS was increased at the end of treatment (t(24) = 4.23, p < 0.001). Pain-free grip strength was increased at the end of treatment (t(24) = 4.23, p < 0.004).

CONCLUSION

Although the results suggested that the Bioptron 2 could reduce patients' symptoms with acute tennis elbow, future controlled studies are needed to establish the relative and absolute effectiveness of Bioptron 2.