The effects of a cervical mobilisation technique on sympathetic outflow to the upper limb in normal subjects

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

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

Comparative Effects of Neurodynamic Slider and Tensioner Mobilization Techniques on Sympathetic Nervous System Function: A Randomized Controlled Trial

Objective: To investigate the effect of slider and tensioner neurodynamic techniques (NDTs) on the sympathetic nervous system (SNS) activity, aiming to identify which technique more effectively modulates autonomic responses in asymptomatic individuals. Materials and Methods: In this double-blind controlled trial, a total of 90 healthy participants were randomly allocated into three groups: slider, tensioner, and control. Skin conductance (SC) was continuously monitored throughout the entire 20 min experiment, while body temperature and blood pressure were measured pre- and post-intervention. Results: The SC levels significantly increased in both the slider and tensioner groups compared to the control group during the intervention and end rest period on the left leg (slider vs. control: p < 0.001, d = 1.20; tensioner vs. control: p < 0.001, d = 1.64) and on the right leg (slider vs. control: p < 0.001, d = 1.47; tensioner vs. control: p < 0.001, d = 0.73). There were no significant differences between the two NDTs on the left (p < 0.13, d = 0.89) and right legs (p < 1.00, d = 0.36). The body temperature of the slider group showed a significant increase compared to both the control group (p < 0.001, d = 0.95) and the tensioner group (p < 0.001, d = 1.48). There were no significant differences between the groups in systolic (p = 0.95) or diastolic blood pressure (p = 0.06). There were no side-specific effects on SNS activity between the left and right legs (p < 0.019) during all intervention phases. Conclusions: Significant sympathoexcitatory responses were elicited by both slider and tensioner NDTs in asymptomatic participants, demonstrating their efficacy in modulating the SNS. The differences between the two techniques were not statistically significant; however, the tensioner NDT showed a slightly more pronounced effect, suggesting that the tensioner NDT can be considered superior in terms of overall SNS effect. These findings indicate that both techniques may have the potential to enhance autonomic regulation in clinical practice; however, the tensioner NDT may be more effective. The consistent responses across participants highlight the systemic benefits of NDTs, providing a foundation for further research into their application in symptomatic populations. This study contributes to evidence-based practice by providing baseline data that support the development of theoretical frameworks and aid in clinical decision-making.

Autonomic nervous system and endocrine system response to upper and lower cervical spine mobilization in healthy male adults: a randomized crossover trial

BACKGROUND

Cervical spine mobilizations may differentially modulate both components of the stress response, consisting of the autonomic nervous system and hypothalamic pituitary adrenal-axis, depending on whether the target location is the upper or lower cervical spine. To date, no study has investigated this.

METHODS

A randomized, crossover trial investigated the effects of upper versus lower cervical mobilization on both components of the stress response simultaneously. The primary outcome was salivary cortisol (sCOR) concentration. The secondary outcome was heart rate variability measured with a smartphone application. Twenty healthy males, aged 21-35, were included. Participants were randomly assigned to block-AB (upper then lower cervical mobilization, n = 10) or block-BA (lower than upper cervical mobilization, n = 10), separated by a one-week washout period. All interventions were performed in the same room (University clinic) under controlled conditions. Statistical analyses were performed with a Friedman's Two-Way ANOVA and Wilcoxon Signed Rank Test.

RESULTS

Within groups, sCOR concentration reduced thirty-minutes following lower cervical mobilization (p = 0.049). Between groups, sCOR concentration was different at thirty-minutes following the intervention (p = 0.018).

CONCLUSION

There was a statistically significant reduction in sCOR concentration following lower cervical spine mobilization, and between-group difference, 30 min following the intervention. This indicates that mobilizations applied to separate target locations within the cervical spine can differentially modulate the stress response.

[Manual spinal therapy techniques to stimulate the autonomic nervous system: a scoping review]

BACKGROUND

Physical interventions or manual therapeutic techniques (MTTe) such as mobilisation, manipulation or soft tissue techniques not only have an influence on the target tissue with improvement of metabolism or reduction of hypertonic muscles. They are also used for balance regulation in central nervous changes of the autonomic nervous system (ANS). To date, there is a lack of empirical evidence on impact mechanisms and target locations of MTTe on the ANS. This scoping review aims to provide an overview of the evidence on the application of MTTe at diverse levels of the spine with a view to the ANS.

METHOD

A systematic literature search was conducted on CENTRAL, Google Scholar, Osteopathic Research Web, PEDro and PubMed. The scope and content of the literature were documented. The results of the included and referenced studies were summarised in a narrative approach with the focus being on the most significant clinical aspects.

RESULTS

MTTe was described as manipulations, mobilisations, myofascial techniques and cervical traction. In 27 out of 35 studies, therapeutic treatments were carried out on healthy volunteers. Ten studies analysed immediate effects in patients, while two studies were designed as longitudinal studies in patients with hypertension. Over a period of four to eight weeks, the frequency of intervention was between one and three MTTe sessions a week.

CONCLUSION

The study results proved to be heterogeneous. For this reason, it is not possible to draw definitive, explicit and generally valid statements regarding the type and intensity as well as the segmental level at which MTTe should be applied in order to trigger specific positive ANS response mechanisms. Consequently, longitudinal studies with follow-up are recommended for future studies. In addition, comprehensive effects of MTTe should be evaluated in groups of patients with different characteristics.

The effect of manual therapy to the thoracic spine on pain-free grip and sympathetic activity in patients with lateral epicondylalgia humeri. A randomized, sample sized planned, placebo-controlled, patient-blinded monocentric trial

Background

The treatment of first choice for lateral epicondylalgia humeri is conservative therapy. Recent findings indicate that spinal manual therapy is effective in the treatment of lateral epicondylalgia. We hypothesized that thoracic spinal mobilization in patients with epicondylalgia would have a positive short–term effect on pain and sympathetic activity.

Methods

Thirty patients (all analyzed) with clinically diagnosed (physical examination) lateral epicondylalgia were enrolled in this randomized, sample size planned, placebo-controlled, patient-blinded, monocentric trial. Pain-free grip, skin conductance and peripheral skin temperature were measured before and after the intervention. The treatment group (15 patients) received a one-time 2-min T5 costovertebral mobilization (2 Hz), and the placebo group (15 patients) received a 2-min one-time sham ultrasound therapy.

Results

Mobilization at the thoracic spine resulted in significantly increased strength of pain-free grip + 4.6 kg ± 6.10 (p = 0.008) and skin conductance + 0.76 μS ± 0.73 (p = 0.000004) as well as a decrease in peripheral skin temperature by − 0.80 °C ± 0.35 (p < 0.0000001) within the treatment group.

Conclusion

A thoracic costovertebral T5 mobilization at a frequency of 2 Hz shows an immediate positive effect on pain-free grip and sympathetic activity in patients with lateral epicondylalgia.

Clinical trial registration

German clinical trial register DRKS00013964, retrospectively registered on 2.2.2018.

Effects of joint mobilisation on clinical manifestations of sympathetic nervous system activity: a systematic review and meta-analysis

BACKGROUND

A potential mechanism of action of manual therapy is the activation of a sympathetic-excitatory response.

OBJECTIVE

To evaluate the effects of joint mobilisation on changes in clinical manifestations of sympathetic nervous system activity.

DATA SOURCES

MEDLINE, EMBASE, AMED, CINAHL, EBSCO, PubMed, PEDro, Cochrane Collaboration Trials Register, Cochrane Database of Systematic Reviews and SCOPUS databases.

STUDY SELECTION

Randomised controlled trials that compared a mobilisation technique applied to the spine or the extremities with a control or placebo.

DATA EXTRACTION AND DATA SYNTHESIS

Human studies collecting data on skin conductance or skin temperature were used. Data were extracted by two reviewers. Risk of bias was assessed using the Cochrane guidelines, and quality of evidence was assessed using the GRADE approach. Standardised mean differences (SMD) and random effects were calculated.

RESULTS

Eighteen studies were included in the review and 17 were included in the meta-analysis. The meta-analysis found a significant increase in skin conductance [SMD 1.21, 95% confidence interval (CI) 0.88 to 1.53, n=269] and a decrease in temperature (SMD 0.92, 95% CI -1.47 to -0.37, n=128) after mobilisation compared with the control group. An increase in skin conductance (SMD 0.73, 95% CI 0.51 to 0.96, n=293) and a decrease in temperature (SMD -0.50, 95% CI -0.82 to -0.18, n=134) were seen after mobilisation compared with placebo. The risk of bias was generally low, but the heterogenicity of the results downgraded the level of evidence.

LIMITATIONS

Most trials (14/18) were conducted on asymptomatic healthy subjects.

CONCLUSION

There is moderate evidence suggesting a sympatho-excitatory effect of joint mobilisation. Systematic Review Registration Number PROSPERO CRD42018089991.

Effectiveness of an osteopathic treatment on the autonomic nervous system: a systematic review of the literature

OBJECTIVE

The objective of this systematic review was to evaluate the effectiveness of an osteopathic treatment on the autonomic nervous system (ANS). For this purpose, published primary studies were analysed and critically evaluated.

METHOD

To generate this review, 15 electronic databases were systematically searched for studies. Randomized clinical controlled trials (RCT) and clinical controlled trials (CCT) are included in the review and evaluated with appropriate assessment tools (Downs and Black Checklist and the checklist from Kienle and Kiene).

RESULTS

23 published studies (10 RCT, 1 clinic multi-centre study, 1 CCT, 5 randomized cross-over studies, 5 randomized pilot studies and 1 single case study) are included in this review. The studies were evaluated with the assessment tools according to their quality. 3 studies are graded as high quality, 11 as moderate and 8 as low-quality studies.

CONCLUSION

The included published studies represent a good level of evidence. Due to a small number of subjects and no follow-ups, the methodological quality is rated as moderate. A significant change on the ANS was shown in studies including High-Velocity Low-Amplitude Techniques (HVLAT). No statement could be drawn in studies in which they used cranial osteopathic techniques due to the lack of methodological quality. A significant change on the ANS is shown in the treatment of the suboccipital region. In studies which evaluated the effectiveness of mobilization in the cervical and thoracic region, no statement could be displayed due to a low level of evidence. None of the findings in these studies have given statements if ANS activation takes place in the sympathetic or parasympathetic system.

Time-course changes associated with PA lumbar mobilizations on lumbar and hamstring range of motion: a randomized controlled crossover trial

OBJECTIVE

We aimed to compare the post-intervention time-course changes in active knee extension (AKE) and active lumbar flexion (ALF) range of motion in response to unilateral posterior-anterior (UPA) mobilizations of the lumbar spine (L4/5 zygapophyseal).

METHODS

Twenty-four asymptomatic participants (maleness: 0.58, age [mean ± standard deviation]: 32 ± 8 years, body mass index 25.9 ± 2.6 kg m2) were recruited to a fully controlled crossover trial. Following either the intervention (L4/5 zygapophyseal mobilizations) or control, participants immediately performed the AKE and ALF tests, which were also performed at baseline. Subsequent tests were made at intervals of 5, 10, 15, 20, 25, 30, 45 and 60 min.

RESULTS

After adjustment for baseline (mean AKE: 37.2° from full extension, mean ALF: 14.37 cm), sex and age, UPA lumbar mobilizations had a most likely moderate effect on AKE (9.8° closer to full extension; ±1.9) and a likely moderate effect on ALF (1.34 cm; ±90% confidence limits 0.43). The magnitude of the AKE effect became most likely small 20-min posttreatment (5.3; ±1.7) and possibly small/possibly trivial 60-min posttreatment (2.1; ±1.4). For ALF, the magnitude of the effect became most likely small 15-min posttreatment (0.76; ±0.25), possibly small/possibly trivial 25-min posttreatment (0.38; ±0.18) and likely trivial 60-min posttreatment (0.26; ±1.8).

DISCUSSION

UPA lumbar mobilizations increased lumbar Range of Motion and hamstring extensibility by a moderate magnitude, with the effect reducing after 10-20-min posttreatment. Clinicians should consider these time-course changes when applying UPA lumbar mobilizations. Clinical Trials Registry: NCT03273400 Evidence Level: 2b.

The acute effects of joint manipulative techniques on markers of autonomic nervous system activity: a systematic review and meta-analysis of randomized sham-controlled trials

Background

The autonomic nervous system (ANS) interests many chiropractors and manual therapists, because joint manipulative techniques (JMT), e.g. high velocity low amplitude (HVLA) manipulations and mobilizations, appear to produce acute changes in ANS mediated physiology. The complexity of this issue justifies a systematic critical literature review.

Objective

To review the literature comparing the acute changes in markers of ANS activity between JMT applied on spinal or peripheral joints and a sham procedure in healthy or symptomatic subjects.

Method

We searched PsycINFO, PEDro, PubMed, Cochrane library, EMBASE, and Medline up to December 2017. We updated the search with PubMed, Cochrane library, EMBASE, and Medline including July 2018. Inclusion criteria were: randomized sham-controlled trials assessing the effect of JMT on markers of ANS activity; manually applied JMT, regardless of technique, applied on either healthy or symptomatic humans; outcome measurements recorded at baseline and repeated during and/or after interventions. Selection of articles and data extraction were performed independently by two reviewers. The quality of studies was assessed using the Cochrane ‘risk of bias’ tool and a technical check-list. Results were reported narratively with some meta-analyses. The Cochrane GRADE approach was used to assess the certainty of evidence.

Results

Twenty-nine of 2267 studies were included in the synthesis. Mobilizations (oscillatory technique) probably produce an immediate and short-term, bilateral increase in skin sympathetic nerve activity (reflected by an increase in skin conductance) regardless of the area treated (moderate-certainty evidence). It is uncertain whether the sympathetic arousal also explains an increase in respiratory rate (very low-certainty evidence). Our evaluation of the literature suggests that spinal sustained apophyseal glides (SNAGs) mobilization and HVLA manipulation of the spine may have no acute effect on the studied markers of ANS activity (very low- to low-certainty evidence).

Conclusion

Some types of mobilizations probably produce an immediate and short-term, statistically significant increase in skin sympathetic nerve activity when compared to a sham procedure, whereas spinal SNAGs and spinal HVLA techniques may have no acute effect on the studied markers of ANS activity. No region-specific results were noted. The literature suffers from several shortcomings, for which reason we strongly suggest further research.

Electronic supplementary material

The online version of this article (10.1186/s12998-019-0235-1) contains supplementary material, which is available to authorized users.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Autonomic function and pressure pain threshold following thoracic mobilization in asymptomatic subjects: A randomized controlled trial

OBJECTIVE

To compare the effects of two different mobilization techniques and a placebo intervention applied to the thoracic spine on heart rate variability (HRV) and pressure pain threshold (PPT) in asymptomatic individuals.

METHODS

Sixty healthy asymptomatic subjects aged between 18 and 40 years old were randomized to a single session of one of the three interventions: posterior-to-anterior (PA) rotatory thoracic passive accessory intervertebral mobilization (PAIVM) (PA group), unilateral thoracic PA in slump position (SLUMP group) or placebo intervention (Placebo group). HRV and PPT at C7 and T4 spinous process, first dorsal interossei muscles bilaterally, and muscle belly of tibialis anterior bilaterally were measured before and immediately after the intervention. A univariate analysis of covariance (ANCOVA) adjusted for baseline values assessed the effect of "Group". Pairwise comparisons with Bonferroni adjustment for multiple comparisons were performed.

RESULTS

There were no significant between-group differences for HRV. A significant between-group difference for PPT in the ipsilateral tibia was found favoring the SLUMP group in comparison with the PA group. There were no significant between-group differences for PPT in the other landmarks.

CONCLUSION

A single treatment of thoracic PAIVM in prone lying and slump position did not alter PPT and HRV compared to placebo in asymptomatic subjects.

T4 Syndrome: A Scoping Review of the Literature

OBJECTIVE

The purpose of this scoping review was to identify any available evidence regarding T4 syndrome.

METHODS

Databases were searched from inception through October 2015 and included PubMed, CINAHL, PEDro, Google Scholar, Osteomed-DR; Index to Chiropractic Literature, PROSPERO, and Chiroaccess. All studies with information about T4 syndrome that were published in a peer-reviewed journal or textbook were included. The information was organized in the format of the International Classification of Functioning, Disability, and Health. Studies were ranked using Sackett's levels of evidence.

RESULTS

Eight articles met the inclusion criteria. Studied areas included theoretical pathophysiology and symptom etiology, diagnosis, symptoms, treatment, and outcomes of T4 syndrome. The methodological quality of included studies was low.

CONCLUSION

T4 syndrome is a diagnosis of exclusion that appears to be rare. It has been treated conservatively in the literature using mobilization and exercise. There is no high-quality evidence published about T4 syndrome, and we caution clinicians when considering it as a primary means to determine patient care.

An investigation into the effects of applying a lumbar Maitland mobilisation at different frequencies on sympathetic nervous system activity levels in the lower limb

BACKGROUND

Oscillatory Maitland mobilisations are commonly used in the management of lower back pain with research suggesting that mobilisations at 2 Hz may excite the sympathetic nervous system (SNS) more than sustained pressure glides or 0.5 Hz oscillatory mobilisations.

OBJECTIVES

Investigate the effects of increasing the oscillation frequency greater than 2 Hz.

DESIGN

A double-blind, placebo-controlled, independent group experimental design.

METHOD

Sixty healthy male volunteers were randomly allocated to one of four groups; a control group (no contact), placebo group (sustained static pressure to L4 vertebra), and two intervention groups receiving a centrally applied postero-anterior mobilisation applied at either 2 Hz or 3 Hz for three 1-min periods. SNS activity was recorded by a blinded data collector by continuous skin conductance (SC) activity levels in the feet using a Biopac MP35 electrodermal amplifier. Participants were blinded to their group allocation which was further validated by a post-experiment questionnaire (p > 0.05).

RESULTS

The magnitude of sympathoexcitatory response was greatest for the 3 Hz mobilisation (20%) compared with the 2 Hz mobilisation (12%), placebo (-1%) and control conditions (3%). Only the 3 Hz group demonstrated statistical significance when compared to placebo intervention (p = 0.002), and the control group (p = 0.02).

CONCLUSION

SC changes reflect those of previous studies using lumbar mobilisations at 2 Hz, however the 3 Hz group was found to have a greater magnitude of effect worthy of consideration within research and clinical settings. These findings provide preliminary evidence to support the use of 3 Hz oscillatory mobilisations to affect a greater magnitude of SNS activity than those previously reported (0.5, 1.5 and 2 Hz).

A multimodal physical therapy approach to the management of a patient with temporomandibular dysfunction and head and neck lymphedema: a case report

OBJECTIVE AND IMPORTANCE

There is a paucity of research that investigates therapeutic interventions of patients with concurrent head and neck lymphedema and temporomandibular dysfunction (TMD). The purpose of this case report is to describe the management and outcomes of a patient with head and neck lymphedema and TMD using a multimodal physical therapy approach.

CLINICAL PRESENTATION

A 74-year-old male with a past medical history of head and neck lymphedema and TMD was referred to physical therapy with chief complaints of inability to open his mouth in order to eat solid food, increased neck lymphedema, temporomadibular joint pain, and inability to speak for prolonged periods of time.

INTERVENTIONS

The patient was treated for three visits over 4 weeks. Treatment included complete decongestive therapy (CDT), manual therapy, therapeutic exercise, and a home exercise program. Upon discharge, the patient had improved mandibular depression, decreased head and neck lymphedema, improved deep neck flexor endurance, decreased pain, and improved function on the Patient Specific Functional Scale (PSFS).

CONCLUSION

Utilization of a multimodal physical therapy approach to treat a patient with a complex presentation yielded positive outcomes. Further research on outcomes and treatment approaches in patients with TMD and head and neck lymphedema is warranted.

Peripheral response to cervical or thoracic spinal manual therapy: an evidence-based review with meta analysis

OBJECTIVES

Spinal manual therapy (SMT) is commonly used for treatment of musculoskeletal pain in the neck, upper back, or upper extremity. Some authors report a multi-system effect of SMT, including peripheral alterations in skin conductance and skin temperature, suggesting that SMT may initiate a sympathetic nervous system (SNS) response. The focus of this evidence-based review and meta-analysis is to evaluate the evidence of SNS responses and clinically relevant outcomes following SMT to the cervical or thoracic spine.

METHODS

A SYSTEMATIC SEARCH USED THE TERMS: 'manual therapy', 'SMT', 'spinal manipulation', 'mobilization', 'SNS', 'autonomic nervous system', 'neurophysiology', 'hypoalgesia', 'pain pathophysiology', 'cervical vertebrae', 'thoracic vertebrae', 'upper extremity', and 'neurodynamic test'. Data were extracted and within-group and between-group effect sizes were calculated for outcomes of skin conductance, skin temperature, pain, and upper extremity range of motion (ROM) during upper limb neurodynamic tests (ULNTs).

RESULTS

Eleven studies were identified. Statistically significant changes were seen with increased skin conductance, decreased skin temperature, decreased pain, and increased upper extremity ROM during ULNT.

DISCUSSION

A mechanical stimulus at the cervical or thoracic spine can produce a SNS excitatory response (increased skin conductance and decreased skin temperature). Findings of reduced pain and increased ROM during ULNT provide support to the clinical relevance of SMT. This evidence points toward additional mechanisms underlying the therapeutic effect of SMT. The effect sizes are small to moderate and no long-term effects post-SMT were collected. Future research is needed to associate peripheral effects with a possible centrally-mediated response to SMT.

Assessment of skin blood flow following spinal manual therapy: a systematic review

Skin blood flow (SBF) indexes have been used to describe physiological mechanisms associated with spinal manual therapy (SMT). The aims of the current review were to assess methods for data collection, assess how investigators interpreted SBF changes, and formulate recommendations to advance manual medicine research. A database search was performed in PubMed, Cochrane Library, the Physiotherapy Evidence Database, and the Cumulative Index to Nursing and Allied Health Literature through April 2014. Articles were included if at least 1 outcome measure was changes in 1 SBF index following SMT. The database search yielded 344 records. Two independent authors applied the inclusion criteria. Twenty studies met the inclusion criteria. Selected studies used heterogeneous methods to assess short-term post-SMT changes in SBF, usually vasoconstriction, which was interpreted as a general sympathoexcitatory effect through central mechanisms. However, this conclusion might be challenged by the current understanding of skin sympathetic nervous activity over local endothelial mechanisms that are specifically controlling SBF. Evaluation of SBF measurements in peripheral tissues following SMT may document physiological responses that are beyond peripheral sympathetic function. Based on the current use of SBF indexes in clinical and physiological research, 14 recommendations for advancing manual medicine research using laser Doppler flowmetry are presented.

The effects of a modified spinal mobilisation with leg movement (SMWLM) technique on sympathetic outflow to the lower limbs

Physiotherapy management of lumbar disorders, based on Mulligan's mobilization techniques, is a treatment of choice by many physiotherapists, however, there is only limited evidence of any neurophysiological effects and much of this has focused on the cervical spine and upper limbs. This study aims to extend the knowledge base underpinning the use of a modified Mulligan's spinal mobilisation with leg movement technique (SMWLM) by exploring its effects on the peripheral sympathetic nervous system (SNS) of the lower limbs. Using a single blind, placebo controlled, independent groups study design, 45 normal naive healthy males were randomly assigned to one of three experimental groups (control, placebo or treatment; SMWLM). SNS activity was determined by recording skin conductance (SC) obtained from lower limb electrodes connected to a BioPac unit. Validation of the placebo technique was performed by post- intervention questionnaire. Results indicated that there was a significant change in SC from baseline levels (30%) that was specific to the side treated for the treatment group during the intervention period (compared to placebo and control conditions). This study provides preliminary evidence that a modified SMWLM technique results in side-specific peripheral SNS changes in the lower limbs.

The neurophysiological effects of a single session of spinal joint mobilization: does the effect last?

Studies detailing the neurophysiological effects of spinal manual therapy have fueled a paradigm shift away from a strict biomechanical model. However, a recent systematic review of the temporal nature of a single session of spinal thrust manipulation found that the neurophysiological effects were only temporary. The objective of this review was to examine the temporal nature of neurophysiological effects after one session of spinal mobilization. Studies eligible for this review had to report on the temporal component of the neurophysiological effects of a single session of joint mobilization of the spine in human subjects. In order to be sure that the temporal nature of these effects was captured, the studies had to monitor neurophysiological effects for a time beyond the immediate post-treatment period. This systematic review followed the methodology for preferred reporting items for systematic reviews and meta-analyses. In order to assess the quality, strength, and importance of the included studies, the grading of recommendations assessment, development and evaluation system was used. Results of this review showed that the neurophysiological effects of a single session of spinal mobilization are mostly 5 minutes or less. An exception to these findings is hypoalgesia which may last up to 24 hours, based on one study. Continued research on small samples of healthy subjects with irrelevant immediate outcomes like salivary rate, skin conductance, and skin temperature should give way to randomized controlled trials on subjects with pain and decreased function.

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.

Short-term effects of manipulation to the upper thoracic spine of asymptomatic subjects on plasma concentrations of epinephrine and norepinephrine-a randomized and controlled observational study

OBJECTIVE

The purpose of this study was to investigate the short-term effects of spinal manipulation applied to a hypomobile segment of the upper thoracic spine (T1-T6), on plasma concentrations of norepinephrine (NE) and epinephrine (E) in asymptomatic subjects, under strictly controlled conditions.

METHODS

Fifty-six asymptomatic subjects were randomly assigned to receive either a chiropractic manipulative intervention or a sham intervention in the upper thoracic spine. A 20-gauge catheter fitted with a saline lock was used to sample blood before, immediately after, and 15 minutes after intervention. Plasma NE and E concentrations were determined using an enzyme-linked immunosorbent assay. Changes in plasma catecholamine concentrations were analyzed within and between groups using 1- and 2-sample t tests, respectively.

RESULTS

The plasma samples of 36 subjects (18 treatment, 18 control) were used in the analysis. Mean plasma concentrations of NE and E did not significantly differ between the 2 groups at any time point and did not change significantly after either the manipulative or sham intervention.

CONCLUSIONS

The results of this study indicate that a manipulative thrust directed to a hypomobile segment in the upper thoracic spine of asymptomatic subjects does not have a measurable effect on the plasma concentrations of NE or E. These results provide a baseline measure of the sympathetic response to spinal manipulation.

A preliminary investigation into the magnitude of effect of lumbar extension exercises and a segmental rotatory manipulation on sympathetic nervous system activity

Two commonly utilised manual therapy techniques; McKenzie's lumbar extension exercises (EE); and segmental rotational grade V manipulation were investigated to determine their magnitude of neurophysiological effect. Proxy measures of sympathetic nervous system (SNS) activity (skin conductance) were utilised to ascertaining neurophysiological response. This study determined the neurological effects of these two treatment techniques in addition to establishing the Biopac System as a reliable measure of neurophysiological changes. A quasi-experimental, independent group's design was utilised, with random allocation of 50 normal, healthy participants into a manipulation or an EE group. Neurophysiological measurements of skin conductance were taken in the lower limbs before, during and after the administration of the techniques. Results were converted into percentage change calculations for the intervention and the post-intervention periods. Both treatments increased SNS activity during the intervention period, 63% for the manipulation group (p = 0.0005) and 42% for EE group (p = 0.0005) with the manipulative technique having significantly greater effect (p = 0.012). Further analysis of the manipulation group found no difference between the 'opening' and the 'closing' side of the technique (p = 0.76). Biopac System is a reliable method for measuring SNS activity with minimum measurement variability. Preliminary evidence now exists supporting the neurophysiological effects of two lumbar techniques.

A crossover study on the effect of cervical mobilization on motor function and pressure pain threshold in pain-free individuals

OBJECTIVE

Cervical mobilization has been shown to elicit effects on pain perception, autonomic function, and motor function in subjects who experience musculoskeletal pain. The improvement in motor function may be a direct effect of the treatment or secondary to a hypoalgesic effect. This study tested whether it is possible to alter motor function following joint mobilization in situations where motor performance is not impaired by pain.

METHODS

Twenty-four asymptomatic subjects participated in this double-blind, controlled, within-subjects crossover study. Pressure pain thresholds and electromyographic activity of the superficial neck flexor muscles were compared with repeated-measures analysis of variance between a posteroanterior cervical mobilization, manual contact, and noncontact condition.

RESULTS

The results indicate no significant change in the pressure pain threshold (P =.846) after posteroanterior cervical mobilization. There was no significant difference in superficial neck flexor muscle activity during the craniocervical flexion test (P =.713). Post hoc power analysis demonstrated the ability to detect a 15% difference in electromyographic activity with 70% power.

CONCLUSION

The improvement in motor function demonstrated in previous studies was not replicated, suggesting that either it is only possible to produce an effect when motor function is impaired or the change in motor function is secondary to the pain inhibitory effect of the treatment.

An investigation into the effects of a unilaterally applied lumbar mobilisation technique on peripheral sympathetic nervous system activity in the lower limbs

Physiotherapeutic management of lumbar disorders often utilises specific segmental joint mobilisation techniques; however, there is only limited evidence of any neurophysiological effects and much of this has focused on the cervical spine and upper limbs. This study aims to extend the knowledge base underpinning the use of a unilaterally applied lumbar spinal mobilisation technique by exploring its effects on the peripheral sympathetic nervous system (SNS) of the lower limbs. Using a double blind, placebo controlled, independent groups study design and based upon power calculations, 45 normal naïve healthy males were randomly assigned to one of three experimental groups (control, placebo or treatment; a unilaterally applied postero-anterior mobilisation to the left L4/5 zygopophyseal joint). SNS activity was determined by recording skin conductance (SC) obtained from lower limb electrodes connected to a BioPac unit. Validation of the placebo technique was performed by post-intervention questionnaire. Results indicated that there was a significant change in SC from baseline levels (13.5%) that was specific to the side treated for the treatment group during the intervention period (compared to placebo and control conditions). This study provides preliminary evidence that a unilaterally applied postero-anterior mobilisation technique performed, at a rate of 2 Hz, to the left L4/5 lumbar zygopophyseal joint results in side-specific peripheral SNS changes in the lower limbs.

The effects of cervical high-velocity low-amplitude thrust manipulation on resting electromyographic activity of the biceps brachii muscle

There is a gap in the literature regarding the effects of spinal manipulation on extremity muscles that are unconnected to the vertebral column by an origin or insertion. This study investigated the effect of a right C5/6 high-velocity low-amplitude thrust (HVLAT) manipulation on resting electromyographic activity of the biceps brachii muscles bilaterally. A placebo-controlled, single-blind, repeated measures design employed an asymptomatic convenience sample (n=54) investigating three conditions: HVLAT, sham, and control. HVLAT demonstrated an excitatory effect with increased EMG activity of 94.20% (P=0.0001) and 80.05% (P=0.0001) for the right and left biceps respectively. A one-way repeated measures ANOVA revealed a significant difference (P=0.0001) in the mean percentage change of resting EMG activity, as did post hoc analyses (P=0.0001) between all three conditions. Subjects not experiencing cavitation post HVLAT demonstrated greater EMG increases for both right (P=0.0001) and left (P=0.014) biceps than those experiencing cavitation. The magnitude of mean EMG change for the right biceps was significantly greater than the left (P=0.011) post HVLAT. This study demonstrates a single HVLAT to the right C5/6 zygapophyseal joint elicits an immediate increase in resting EMG activity of the biceps bilaterally, irrespective of whether or not cavitation occurs.

Paradigm shift in manual therapy? Evidence for a central nervous system component in the response to passive cervical joint mobilisation

Segmental neurological modulation, neural hysteresis and biomechanical effects have been proposed as mechanisms underpinning the effects of manual therapy. An increasing number of studies hypothesise activation of the central nervous system resulting in a non-segmental hypoalgesic effect with concurrent activation of other neural pathways as a potential mechanism of action. Whether this model is consistent with the current literature is unknown. This systematic review aims to assess the consistency of evidence supporting an involvement of supraspinal systems in mediating the effects of passive cervical joint mobilisation. We searched randomised trials in three electronic databases from inception to November 2007, without language restriction, and checked reference lists of included studies. We assessed study validity and extracted salient features in duplicate. Fifteen studies met our inclusion criteria. The overall quality was high. We found consistency for concurrent hypoalgesia, sympathetic nervous system excitation and changes in motor function. Pooling of data suggested that joint mobilisation improved outcomes by approximately 20% relative to controls. This specific pattern suggests that descending pathways might play a key role in manual therapy induced hypoalgesia. Our review supports the existence of an alternative neurophysiological model, in which passive joint mobilisation stimulates areas within the central nervous system.

Efficacy of a C1-C2 self-sustained natural apophyseal glide (SNAG) in the management of cervicogenic headache

STUDY DESIGN

Randomized, double-blind, placebo controlled trial.

OBJECTIVES

To determine the effect of a C1-C2 self-sustained natural apophyseal glide (SNAG) on cervicogenic headache.

BACKGROUND

Cervicogenic headache is a common condition causing significant disability. Recent studies have shown a high incidence of C1-C2 dysfunction, evaluated by the flexion-rotation test (FRT), in subjects with cervicogenic headache. To manage this dysfunction, Mulligan has described a C1-C2 self-SNAG, though no studies have investigated the efficacy of this intervention approach.

METHODS

A sample of 32 subjects (mean _ SD age, 36 +/- 3 years) with cervicogenic headache and FRT limitation were randomized into a C1-C2 self-SNAG or placebo group. After an initial instruction and practice visit in the clinic, interventions consisted of exercises applied independently by the subject twice daily at home on a continual basis. FRT range was measured twice, before and immediately after the instruction and practice visit. Headache symptoms were determined by a headache index over time, assessed by questionnaire preintervention, at 4 weeks postintervention, and at 12 months postintervention.

RESULTS

No differences were found in baseline measures between groups. Immediately after the initial instruction and practice visit performed with the supervision of the therapist, FRT range increased by 15 degrees (SD, 9) for the C1-C2 self-SNAG group (P < .001), which was significantly more than 5 degrees (SD, 5) for the placebo intervention (P < .001). There was also a significant interaction for the variable headache index between group and time (P < .001), indicating that group difference was dependent on time. There was no difference in headache index scores at baseline between groups. Headache index scores were substantially less in the C1-C2 self-SNAG group (mean +/- SD points at 4 weeks, 31 +/- 9; mean +/- SD points at 12 months, 24 +/- 9) compared to the placebo group (mean +/- SD points at 4 weeks, 51 +/- 15; mean +/- SD points at 12 months, 44 +/- 13) at 4 weeks (P < .001) and 12 months (P < .001), with an overall (+/-SD) reduction of 54% (+/-17%) for the individuals in the C1-C2 self-SNAG group.

CONCLUSIONS

These results provide evidence for the efficacy of the C1-C2 self-SNAG technique in the management of individuals with cervicogenic headache.

A preliminary investigation into the relationship between cervical snags and sympathetic nervous system activity in the upper limbs of an asymptomatic population

Spinal manipulative therapy techniques are commonly employed by physiotherapists in the clinical setting for the management of neuromusculoskeletal pain and dysfunction, although their underlying mechanism is not fully understood. Mulligan's sustained natural apophyseal glides (SNAGs) constitute one of these techniques. This preliminary investigation was undertaken to investigate the relationship between the application of cervical SNAGs to the C5/6 intervertebral joint (with cervical right rotation) and indirect measures of sympathetic nervous system (SNS) activity. Previous investigations have suggested that cervical manipulative therapy techniques, separate to cervical SNAGs, result in a sympatheoexcitatory effect and that this may be instrumental in producing an analgesic response. Sixteen asymptomatic subjects participated in a laboratory-based experiment. A single blind, randomized, within subject, repeated measures study design which included control, placebo and treatment comparisons was used. Measures of skin conductance (SC) and skin temperature (ST) in the right and left upper limbs were used as indicators of SNS activity. The cervical SNAG technique produced a sympathoexcitatory response demonstrated by a significant increase in SC during application of the treatment intervention (P<0.0005) and for a 2-min period after the intervention (P=0.001) compared with control. There was also a significant increase in SC for the placebo condition, both during intervention (P=0.015) and after intervention (P=0.011) compared with control. There was a statistically significant difference in SC between placebo and treatment conditions for the 2-min period after the intervention had been applied (P=0.01). A trend did emerge for ST change, illustrating a decrease in ST for the treatment and placebo conditions compared with control, however this did not reach statistically significant levels. There were no apparent left/right upper limb differences for SC and ST for each condition. The results of this study suggest that cervical SNAG techniques, performed on naïve asymptomatic subjects, have a sympathoexcitatory effect as measured by changes in SC and ST. The importance of this sympathoexcitatory effect in relation to potential mechanisms for manipulation induced analgesia are discussed, and further areas of research proposed.

Naloxone Fails to Antagonize Initial Hypoalgesic Effect of a Manual Therapy Treatment for Lateral Epicondylalgia

BACKGROUND

Recent research has shown that Mulligan's Mobilization With Movement treatment technique for the elbow (MWM), a peripheral joint mobilization technique, produces a substantial and immediate pain relief in chronic lateral epicondylalgia (48% increase in pain-free grip strength).([1]) This hypoalgesic effect is far greater than that previously reported with spinal manual therapy treatments, prompting speculation that peripheral manual therapy treatments may differ in mechanism of action to spinal manual therapy techniques. Naloxone antagonism and tolerance studies, which employ widely accepted tests for the identification of endogenous opioid-mediated pain control mechanisms, have shown that spinal manual therapy-induced hypoalgesia does not involve an opioid mechanism.

OBJECTIVE

The aim of this study was to evaluate the effect of naloxone administration on the hypoalgesic effect of MWM.

METHODS

A randomized, controlled trial evaluated the effect of administering naloxone, saline, or no-substance control injection on the MWM-induced hypoalgesia in 18 participants with lateral epicondylalgia. Pain-free grip strength, pressure pain threshold, thermal pain threshold, and upper limb neural tissue provocation test 2b were the outcome measures.

RESULTS

The results demonstrated that the initial hypoalgesic effect of the MWM was not antagonized by naloxone, suggesting a nonopioid mechanism of action.

CONCLUSIONS

The studied peripheral mobilization treatment technique appears to have a similar effect profile to previously studied spinal manual therapy techniques, suggesting a nonopioid-mediated hypoalgesia following manual therapy.

Somatovisceral response following osteopathic HVLAT: a pilot study on the effect of unilateral lumbosacral high-velocity low-amplitude thrust technique on the cutaneous blood flow in the lower limb

INTRODUCTION

Spinal manipulative treatment is widely used among manual therapists, although knowledge regarding the absolute physiological effects has not been clearly established. In this study, 20 healthy male subjects underwent a unilateral high-velocity low-amplitude thrust (HVLAT) to the lumbosacral junction, while the cutaneous blood flow in the corresponding dermatome of the lower limb was monitored.

METHODS

Subjects underwent a sham manipulation before the actual manipulation and acted as their own control. Laser Doppler flowmetry was used to measure relative changes in the cutaneous blood flow over the L5 dermatome for 5 minutes before the sham manipulation, for 5 minutes between the sham and the actual manipulation, and for 5 minutes after the spinal adjustment. Analysis of variance (ANOVA) and Tukey post hoc analysis was used in the interpretation of the data.

RESULTS

Twelve nonsmoking subjects, who received a successful HVLAT manipulation, showed a significant increase (P <.001) in blood perfusion, both ipsilaterally and contralaterally. Six smokers responded with a significant decrease in blood flow ipsilaterally (P <.01) and contralaterally (P <.001) after HVLAT manipulation.

CONCLUSION

The results from this study support previous published hypotheses that spinal adjustments outside the region of the sympathetic outflow result in an increase in cutaneous blood flow. Further studies will be needed to confirm the outcome of this study, and more knowledge is needed regarding the specific neurophysiological effects of spinal manipulation.

Cervical mobilisation: concurrent effects on pain, sympathetic nervous system activity and motor activity

Recent findings that spinal manual therapy (SMT) produces concurrent hypoalgesic and sympathoexcitatory effects have led to the proposal that SMT may exert its initial effects by activating descending inhibitory pathways from the dorsal periaqueductal gray area of the midbrain (dPAG). In addition to hypoalgesic and sympathoexcitatory effects, stimulation of the dPAG in animals has been shown to have a facilitatory effect on motor activity. This study sought to further investigate the proposal regarding SMT and the PAG by including a test of motor function in addition to the variables previously investigated. Using a condition randomised, placebo-controlled, double blind, repeated measures design, 30 subjects with mid to lower cervical spine pain of insidious onset participated in the study. The results indicated that the cervical mobilisation technique produced a hypoalgesic effect as revealed by increased pressure pain thresholds on the side of treatment (P=0.0001) and decreased resting visual analogue scale scores (P=0.049). The treatment technique also produced a sympathoexcitatory effect with an increase in skin conductance (P<0.002) and a decrease in skin temperature (P=<0.02). There was a decrease in superficial neck flexor muscle activity (P<0.0002) at the lower levels of a staged cranio-cervical flexion test. This could imply facilitation of the deep neck flexor muscles with a decreased need for co-activation of the superficial neck flexors. The combination of all findings would support the proposal that SMT may, at least initially, exert part of its influence via activation of the PAG.

Short-term effects of cervical manipulation on edge light pupil cycle time: a pilot study

BACKGROUND

Edge light pupil cycle time (ELPCT) is one of the eye's light reflexes. Studies have shown ELPCT to be a measurable constant, unaffected by visual acuity, refractive error, eye color, pupil size, or sex. Control of this reflex occurs through the autonomic nervous system. Various authors suggest that spinal manipulative techniques can produce distant effects mediated in part by alterations in autonomic tone after intervention.

OBJECTIVE

To investigate the effects of a C1-2 high-velocity, low-amplitude manipulation on ELPCT.

DESIGN

A single-group, randomized pilot study without a control group.

METHODS

Thirteen men (mean age 24.2 years) without a history of eye disease or central or autonomic nervous system pathologic conditions had their ELPCT measured before and after manipulation. The manipulation comprised a high-velocity, low-amplitude rotatory thrust, localized to the C1-2 joint on the left (n = 6) or right (n = 7) eye, determined randomly.

RESULTS

ELPCT measures demonstrated a significant difference for both eyes before and after manipulation (P = .002; the right eye, P = .027; the left eye, P = .046).

CONCLUSION

This suggests that ELPCT, which is mediated through the autonomic nervous system, can be directly influenced by high-velocity manipulation to the upper cervical spine.