Effect of rehabilitative exercise and spinal manipulative therapy on veteran with chronic diffuse spine pain: A case report

IntroductionPatient is a 57-year-old male veteran with complaints of musculoskeletal origin. The patient was treated with rehabilitative exercise, manual therapy, and spinal manipulative therapy. Treatment helped improve the patient's ability to perform ADLs and is reflected in rehabilitative exercise progression and objective findings.Case presentationThe patient is a 57-year-old male veteran who presented with chronic cervical, thoracic, and lumbar pain. Range of motion was decreased and painful during all active ranges of motion. Each region had degenerative changes at various levels confirmed via radiographs. Rehabilitative exercise was directed with results from a Selective Functional Movement Assessment (SFMA). Patient was treated with manual therapy and spinal manipulative therapy (SMT). Rehabilitative exercises were selected to improve the patient's ADLs based on goals, to target chief complaints, and correct SFMA findings.Management and outcomeThe patient's progress was tracked with progression in rehabilitative exercise. The patient's objective findings continually improved throughout the care plan. At the end of the care plan, the patient underwent the same examination, and the objective findings were compared. There was an improvement across all objective testing.DiscussionThis case demonstrates the classic veteran with chronic diffuse spine pain that interferes with performance in their normal activities of daily living. This case demonstrated that the combination of soft tissue therapy, SMT and rehabilitative exercise can show an improvement in objective findings and help the patient meet their goals.     

Use of thoracic spine manipulation in the treatment of adhesive capsulitis: a case report

Abstract

Adhesive capsulitis (AC) is a common and disabling shoulder condition seen in physical therapy, and there is no clear consensus as to the best treatment approach. Recently there has been emerging evidence that manual therapy directed at the thoracic spine may be beneficial for patients with shoulder pain; however, this has not been examined specifically in patients with AC. The purpose of this paper is to present the case of 59-year-old female referred to physical therapy with a diagnosis of AC. The patient presented with complaints of left shoulder pain and significant limitations in range of motion (ROM) and upper extremity function. The initial treatment included exercises and manual therapy directed at the glenohumeral and scapulothoracic joints, and after 10 visits only minimal progress had been made. Further examination revealed mobility and ROM deficits in the thoracic spine, and manual therapy directed at this region was incorporated into her treatment. After the first session of thoracic spine manual therapy (TSMT) a 25 degree improvement was noted in active shoulder flexion. After four total visits of TSMT substantial improvements in pain, ROM, and function were noted compared to those made during the first 10 visits. This case adds to the emerging evidence that manual therapy directed at the thoracic spine should be considered for patients with shoulder pain.     

Lumbar extension exercises in conjunction with mechanical traction for the management of a patient with a lumbar herniated disc

ABSTRACT

Low back pain resulting from lumbar disc herniation is a common reason for referral for physical therapy. There is no evidence to support the management of lumbar disc herniation and derangement using mechanical traction combined with lumbar extension exercises. Therefore, the purpose of this case report was to describe and discuss the use of mechanical traction in conjunction with lumbar extension exercises for a patient with a lumbar herniated disc. The patient was a 49-year-old male referred to physical therapy with a medical diagnosis of a lumbar herniated disc at L5-S1 with compression of the L5 nerve root confirmed by MRI. The patient's chief complaint was pain over the left lumbosacral and central lumbar region with radiating pain into the left buttock accompanied by numbness and tingling in the left lower leg and foot. The patient was seen for a total of 14 visits. The first 5 days (2 weeks) of therapy consisted of lumbar extension exercises. For the following nine visits (over a 3-week period), mechanical traction was added as an adjunct to the extension exercises. Outcome measures included the Oswestry Disability Questionnaire, Back Pain Function Scale (BPFS), and the Numeric Pain Rating Scale (NPRS). Results from initial evaluation to discharge (Oswestry: 36% to 0%; BPFS: 33/60 to 57/60; NPRS: 7/10 to 0/10) demonstrated that the patient no longer experienced low back pain and improved in terms of functional status and pain-related disability. The patient no longer complained of numbness and tingling in the left lower extremity and the goals for the patient had been attained. The data from this case report suggests lumbar extension exercises in conjunction with mechanical traction facilitated the patient's improvement in pain and return to prior level of function.     

Formative Dynamics: The Pelvic Girdle

Abstract

Altered mechanics and/or forces related to the lumbar/pelvic/hip regions may result in pelvic-girdle dysfunction and or instability, which then may contribute to the development, persistence, or reoccurrence of low back pain (LBP). This series of three case studies outlines an integrated biomechanical clinical evaluation and treatment approach utilizing manual care, education, and exercise in the treatment of patients with chronic pelvic-girdle dysfunction and/or instability.

This integrated approach was used on three patients with a primary diagnosis of sacroiliac joint (SIJ) dysfunction. These patients had similar patterns of altered mechanics, movement patterns, and muscle imbalances. The treatment they received was an integration of three components: 1) restoration of optimal soft tissue/joint mechanics to the thoracic/lumbar/pelvic region and lower quarters; 2) patient education in specific self-stretching/mobilization exercises, spinal/pelvic stabilization exercises, and body mechanics training; 3) pelvic external bracing and/or prolotherapy injections (sclerosing) for those patients with hypermobile/unstable, chronic and recurring pelvic girdle dysfunction. Treatment varied from 24 to 35 visits over a 3-4 month period. The treatment outcomes demonstrated a correlation between improved patient function and pain reduction after restoring optimal mobility, functional strength, and movement patterns. These benefits lasted well beyond the course of treatment. Further research is needed to determine whether patients with chronic pelvic-girdle dysfunction and/or instability who receive this integrated approach will consistently achieve lasting pain relief and restoration of function when compared with no treatment or other treatment approaches.     

Manual therapy and exercise for impingementrelated shoulder pain

Abstract

Background: Shoulder complaints are among the commonest causes of musculoskeletal pain. They are potentially disabling and frequently cause absenteeism from work and claims for sickness benefits. One of the most prevalent subtypes of shoulder pain is impingement. This is often managed physiotherapeutically, with 'hands-on' manual therapy and exercises being mainstays.

Objectives: To assess the effectiveness of manual therapy and exercises to improve pain, disability and function in people with shoulder impingement.

Methods: A systematic review was conducted including systematic reviews, quasi-randomized trials and randomized controlled trials published up to October 2008. Searches included the Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Medline, Embase, Cinahl and PEDro. Methodological quality and risk of bias were assessed with appropriate instruments. All findings were critically analysed and discussed, and summary conclusions formulated.

Results: Eight systematic reviews and six randomized controlled trials were included. Methodological quality and risk of bias as well as population and treatment parameters varied. Clinical heterogeneity prevented meta-analysis, thus all findings were synthesized narratively. The included research provides limited evidence to support the use of manual therapy and exercise interventions for shoulder impingement. This primarily relates to subacute and chronic conditions and short to medium-term effectiveness.

Conclusions: Manual therapy and exercise seem effective for shoulder impingement, but varying methodological quality and risk of bias in reviews and trials warrant caution in the interpretation of the results. There is a need for further good-quality primary research.     

The use of functional and traditional mobilization interventions in a patient with chronic thoracic pain: a case report

Abstract

There is little information in the literature regarding the efficacy of spinal manual therapy (SMT) interventions for patients with chronic thoracic spinal pain. In addition, information regarding the clinical decision-making associated with the application of SMT for this patient population is deficient. The purpose of this case report is to present the rationale for and results of applying specific SMT interventions on a patient with chronic spinal pain. A 51-year-old female with 9 months of significant thoracic, chest, sternal, and left shoulder pain was managed with both mobilization with movement and spinal manipulative procedures. The report offers insight into the decisions that guided the selection of these SMT techniques in this case. The outcome provides preliminary support for using these specific SMT procedures in patients with chronic thoracic spinal pain.     

Physical Therapy Diagnosis and Management of a Patient with Chronic Daily Headache: A Case Report

Abstract

Chronic headaches are a significant health problem for patients and often a clinical enigma for the medical professionals who treat such patients. The purpose of this case report is to describe the physical therapy diagnosis and management of a patient with chronic daily headache. The patient was a 48-year-old woman with a medical diagnosis of combined common migraine headache and chronic tension-type headache. An exacerbation of these long-standing headache complaints had resulted in a chronic daily headache for the preceding eight months. Symptoms included bilateral headache, neck pain, left facial pain, and tinnitus. Outcome measures used included the Henry Ford Hospital Headache Disability Inventory (HDI) and the Neck Disability Index (NDI). Examination revealed myofascial, articular, postural, and neuromuscular impairments of the head and neck region. Treatment incorporated myofascial trigger point dry needling, orthopaedic manual physical therapy, exercise therapy, and patient education. On the final visit, the patient reported no headaches during the preceding month. There was a 31% improvement in the HDI emotional score, a 42% improvement in the functional score, and a 36% improvement in the total score for the HDI, the latter exceeding the minimal detectable change for the total score on this measure. The NDI at discharge showed an 18% improvement with a maximal improvement during the course of treatment of 26%. Both improvements exceeded the minimal clinically important difference for the NDI. This case report indicates that physical therapy diagnosis and management as described may be indicated for the conservative care of patients with chronic headaches.     

Lower extremity thrust and non-thrust joint mobilization for patellofemoral pain syndrome: a case report

A 40-year old female presented to physical therapy with a one-year history of insidious right anteromedial and anterolateral knee pain. Additionally, the patient had a history of multiple lateral ankle sprains bilaterally, the last sprain occurring on the right ankle 1 year prior to the onset of knee pain. The patient was evaluated and given a physical therapy diagnosis of patellofemoral pain syndrome (PFPS), with associated talocrural and tibiofemoral joint hypomobility limiting ankle dorsiflexion and knee extension, respectively. Treatment included a high-velocity low amplitude thrust manipulation to the talocrural joint, which helped restore normal ankle dorsiflexion range of motion. The patient also received tibiofemoral joint non-thrust manual therapy to regain normal knee extension mobility prior to implementing further functional progression exercises to her home program (HEP). This case report highlights the importance of a detailed evaluation of knee and ankle joint mobility in patients presenting with anterior knee pain. Further, manual physical therapy to the lower extremity was found to be successful in restoring normal movement patterns and pain-free function in a patient with chronic anterior knee pain.     

Use of thoracic spine manipulation in the treatment of adhesive capsulitis: a case report

Adhesive capsulitis (AC) is a common and disabling shoulder condition seen in physical therapy, and there is no clear consensus as to the best treatment approach. Recently there has been emerging evidence that manual therapy directed at the thoracic spine may be beneficial for patients with shoulder pain; however, this has not been examined specifically in patients with AC. The purpose of this paper is to present the case of 59-year-old female referred to physical therapy with a diagnosis of AC. The patient presented with complaints of left shoulder pain and significant limitations in range of motion (ROM) and upper extremity function. The initial treatment included exercises and manual therapy directed at the glenohumeral and scapulothoracic joints, and after 10 visits only minimal progress had been made. Further examination revealed mobility and ROM deficits in the thoracic spine, and manual therapy directed at this region was incorporated into her treatment. After the first session of thoracic spine manual therapy (TSMT) a 25 degree improvement was noted in active shoulder flexion. After four total visits of TSMT substantial improvements in pain, ROM, and function were noted compared to those made during the first 10 visits. This case adds to the emerging evidence that manual therapy directed at the thoracic spine should be considered for patients with shoulder pain.     

Traditional physical therapy exercises combined with sensorimotor training: The effects on clinical outcomes for chronic neck pain in a double-blind,randomized controlled trial

ObjectiveThis study examined the effects of combining traditional physical therapy exercises with sensorimotor training on joint position sense, pain, muscle endurance, balance and disability in patients with chronic, non-specific neck pain.DesignDouble-blind, randomized controlled trial.SubjectsA total of 53 patients with chronic non-specific neck pain were randomized to either traditional or combined exercise groups.InterventionsAll patients received 12 sessions of supervised intervention 3 times per week. The traditional group performed traditional exercises, and the combined exercise group performed sensorimotor training in addition to traditional exercises.Outcome measuresJoint position sense, pain, neck flexor muscle endurance test, 10 Meter Walk Test, step test, and the Neck Disability Index.ResultsThe combined exercise group showed significantly greater improvement compared to the traditional group in joint position sense during extension, flexion, right rotation, the 10 m walk test with head turn, and the step test. Pain intensity, muscle endurance, and disability improved in both groups. Additionally, there was a higher degree of effect on muscle endurance in the combined exercise group compared to a moderate effect in the traditional group.ConclusionsA combination of sensorimotor training with traditional physical therapy exercises could be more effective than traditional exercises alone in improving joint position sense, endurance, dynamic balance and walking speed.     

Interventions for preventing hamstring injuries: a systematic review

Objectives

To assess, by systematic review, the effects of interventions used for preventing hamstring injuries in physically active individuals.

Selection criteria

Randomised or quasi-randomised trials of interventions for preventing hamstring injuries were included, as were trials testing interventions for the prevention of lower limb injuries, provided that hamstring injuries were reported. Risk ratios (RRs) and 95% confidence intervals (95% CIs) were calculated for dichotomous variables and are reported for individual and pooled data.

Main results

Seven randomised controlled trials involving 1919 participants were included. Some trials were compromised by poor methodology, including lack of blinding and incomplete outcome data. Four trials, including 287 participants, examined interventions directly targeted at preventing hamstring injuries. Three of these trials, which tested hamstring strengthening protocols, had contradictory findings, with one small trial showing benefit, although the control rate of mainly minor hamstring injury was unusually high. The other two trials found no benefit, with a greater incidence of hamstring injury in the intervention group. One unpublished and underpowered trial provided some evidence that manual therapy may prevent lower limb muscle strain (RR 0.13, 95% CI 0.02 to 0.97), although the finding for hamstring injury did not reach statistical significance (RR 0.21, 95% CI 0.03 to 1.66).

Conclusions

There is insufficient evidence from randomised controlled trials to draw conclusions on the effectiveness of interventions used to prevent hamstring injuries in people participating in football or other high-risk activities. The findings for manual therapy need confirmation.     

Effects of static stretching and strengthening exercises on flexion relaxation ratio in patients with LBP: A randomized clinical trial

IntroductionStretching and strengthening exercises are commonly used to improve muscle shortness. Consequently, the aim of this trial was to compare the flexion-relaxation response (electromyography activities of shortened hamstring and back muscles) in chronic nonspecific LBP patients.MethodsIn this randomized controlled clinical trial, forty-five eligible patients were randomly categorized into three groups; static stretching (n = 15), strengthening exercise in lengthened hamstring position (n = 15) and control (n = 15). All groups received conventional physical therapy for LBP and the two intervention groups received special exercise programs as well. Each group performed three treatment sessions for a week, a total of 12 sessions. The flexion-relaxation ratio (FRR) for knee and back muscles were assessed as the primary outcome measure. Pain and functional disability for participants were also assessed.ResultsThe results indicated non-significant differences between the three groups regarding the changes of FRR (mean between-group differences ranged over 0.69 to 39.1; p > 0.05), pain and disability (mean between-group differences ranged over 0.15 to 5.96; p > 0.05). Within-group analysis for each group, revealed statistically significant improvement in the patients' score of either pain (mean within-group differences ranged over −27.20 to −35.76; p < 0.001) or disability (mean within-group differences ranged over −16.17 to 24.95; p < 0.001) as secondary outcomes. In other words, the scores of pain and disability decreased in all treatment groups as compared to the baseline.ConclusionNeither static stretching nor strengthening exercises in lengthened hamstring position affected FRR more than the control group.     

Manual therapy and eccentric exercise in the management of Achilles tendinopathy

Chronic Achilles tendinopathy (AT) is an overuse condition seen among runners. Eccentric exercise can decrease pain and improve function for those with chronic degenerative tendon changes; however, some individuals have continued pain requiring additional intervention. While joint mobilization and manipulation has not been studied in the management in Achilles tendinopathy, other chronic tendon dysfunction, such as lateral epicondylalgia, has responded well to manual therapy (MT). Three runners were seen in physical therapy (PT) for chronic AT. They were prescribed eccentric loading exercises and calf stretching. Joint mobilization and manipulation was implemented to improve foot and ankle mobility, decrease pain, and improve function. Immediate within-session changes in pain, heel raise repetitions, and pressure pain thresholds (PPT) were noted following joint-directed MT in each patient. Each patient improved in self-reported function on the Achilles tendon specific Victorian Institute for Sport Assessment questionnaire (VISA-A), pain levels, PPT, joint mobility, ankle motion, and single-leg heel raises at discharge and 9-month follow-up. The addition of MT directed at local and remote sites may enhance the rehabilitation of patients with AT. Further research is necessary to determine the efficacy of adding joint mobilization to standard care for AT.

Level of Evidence: Case series. Therapy, Level 4.     

Limited scientific evidence supports the use of conservative treatment interventions for pain and function in patients with subacromial impingement syndrome: randomized control trials

Abstract

Background: Different conservative treatment interventions are often used to decrease pain and improve function in patients with subacromial impingement syndrome (SAIS). However, the current evidence to support the use of these interventions has not been established.

Objectives: To determine the evidence for conservative treatment interventions regarding pain and function compared to any intervention for SAIS patients.

Methods: A systematic review of randomized controlled trials, published in English between 1 January 1999 and 31 May 2010, was performed using PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library and manual searching. The methodological quality (PEDro scale) and evidence grade (SBU) were rated. Eight studies were of high quality, four were medium quality, and eight were low quality. Various conservative treatment interventions were evaluated: acupuncture, electrotherapy modalities, exercises, mixed modalities, changing posture, and use of a functional brace.

Results: Limited scientific evidence (LSE) indicates positive effects of exercise and mixed modalities regarding pain and function and high-intensity laser therapy (HILT) regarding pain in SAIS patients. LSE also indicate no effect of electrotherapy modalities, apart from HILT, as treatment for SAIS.

Conclusions: The lack of high quality interventions limits the ability to draw conclusions regarding efficacy from several of the included studies. However, exercise may be as efficient as surgery, manual therapy in combination with exercise seems to be more effective than exercise alone and high-dose exercises seem to be more effective than low-dose exercises. Furthermore, there is contradictory evidence to support the use of acupuncture.