'Next steps' for researching orthopedic manual therapy

A critical review of the role of manual therapy in the treatment of individuals with low back pain

The number of low back pain (LBP) cases is projected to increase to more than 800 million by 2050. To address the substantial burden of disease associated with this rise in prevalence, effective treatments are needed. While clinical practice guidelines (CPG) consistently recommend non-pharmacological therapies as first-line treatments, recommendations regarding manual therapy (MT) in treating low back pain vary. The goal of this narrative review was to critically summarize the available evidence for MT behind these recommendations, to scrutinize its mechanisms of action, and propose some actionable steps for clinicians on how this knowledge can be integrated into a person-centered approach. Despite disparate recommendations from CPG, MT is as effective as other available treatments and may be offered to patients with LBP, especially as part of a treatment package with exercise and education. Most of the effects of MT are not specific to the technique. MT and other interventions share several mechanisms of action that mediate treatment success. These mechanisms can encompass patients' expectations, prior experiences, beliefs and convictions, epistemic trust, and nonspecific contextual effects. Although MT is safer than opioids for patients with LBP, this alone is insufficient. Our goal is to encourage clinicians to shift away from outdated and refuted ideas in MT and embrace a person-centered approach rooted in a comprehensive biopsychosocial framework while incorporating patients' beliefs, addressing illness behaviors, and seeking to understand each patient's journey.

A Clinically-Reasoned Approach to Manual Therapy in Sports Physical Therapy

Symptom modification techniques have been recently dichotomously labeled as either passive or active therapies. Active therapy such as exercise has been rightfully advocated for while "passive" therapies, mainly manual therapy have been regarded as low value within the physical therapy treatment spectrum. In sporting environments where physical activity and exercise are inherent to the athletic experience, the utilization of exercise-only strategies to manage pain and injury can be challenging when considering the demands and qualities of a sporting career which include chronically high internal and external workloads. Participation may be impacted by pain and its influence on related factors such as training and competition performance, career length, financial earning potential, educational opportunity, social pressures, influence of family, friends, and other key stakeholders of their athletic activity. Though highly polarizing viewpoints regarding different therapies create black and white "sides," a pragmatic gray area regarding manual therapy exists in which proper clinical reasoning can serve to improve athlete pain and injury management. This gray area includes both historic positive reported short-term outcomes and negative historical biomechanical underpinnings that have created unfounded dogma and inappropriate overutilization. Applying symptom modification strategies to safely allow the continuation of sport and exercise requires critical thinking utilizing not only the evidence-base, but also the multi-factorial nature of sports participation and pain management. Given the risks associated with pharmacological pain management, the cost of passive modalities like biophysical agents (electrical stimulation, photobiomodulation, ultrasound, etc), and the indications from the evidence-base when combined with active therapies, manual therapy can be a safe and effective treatment strategy to keep athletes active.

Level of Evidence

5.

Inter-individual variability in mechanical pain sensation in patients with cervicogenic headache: an explorative study

Currently, evidence for effective physiotherapy interventions in patients with cervicogenic headache (CeH) is inconsistent. Although inter-individual variability in pain response is predictive for successful physiotherapy interventions, it was never explored in patients with CeH. Therefore the objective of the current study was to explore inter-individual variability in mechanical pain sensation, and its association with biopsychosocial-lifestyle (BPSL) characteristics in patients with CeH. A cross-sectional explorative analysis of inter-individual variability in mechanical pain sensation in 18 participants with CeH (29-51 years) was conducted. Inter-individual variability in mechanical pain sensation (standard deviations (SDs), F-statistics, Measurement System Analysis) was deducted from bilateral pressure pain thresholds of the suboccipitals, erector spine, tibialis anterior. BPSL-characteristics depression, anxiety, stress (Depression Anxiety Stress Scale-21), quality of life (Headache Impact Test-6), sleep-quality (Pittsburgh Sleep Quality Index), and sedentary time (hours/week) were questioned. Inter-individual variability in mechanical pain sensation explained 69.2% (suboccipital left), 86.8% (suboccipital right), 94.6% (erector spine left), 93.2% (erector spine right), 91.7% (tibialis anterior left), and 82% (tibialis anterior right) of the total variability in patients with CeH. The significant p-values and large F-statistic values indicate inter-individual differences in SDs. Significant associations between (1) lower quality of life and lower SDs of the suboccipital left PPT (p .005), and (2) longer sedentary time and higher SDs of the suboccipital left PPT (p .001) were observed. Results from our explorative study could suggest inter-individual variability in mechanical pain sensation at the left suboccipitals which associates with quality of life and sedentary time. These novel findings should be considered when phenotyping patients and 'individually' match interventions.