A randomized clinical trial comparing non-thrust manipulation with segmental and distal dry needling on pain,disability, and rate of recovery for patients with non-specific low back pain

ABSTRACT

Objective: The purpose of this study was to examine the within and between-group effects of segmental and distal dry needling (DN) without needle manipulation to a semi-standardized non-thrust manipulation (NTM) targeting the symptomatic spinal level for patients with non-specific low back pain (NSLBP).

Methods: Sixty-five patients with NSLBP were randomized to receive either DN (n = 30) or NTM (n = 35) for six sessions over 3 weeks. Outcomes collected included the oswestry disability index (ODI), patient specific functional scale (PSFS), numeric pain rating scale (NPRS), and pain pressure thresholds (PPT). At discharge, patients perceived recovery was assessed.

Results: A two-way mixed model ANOVA demonstrated that there was no group*time interaction for PSFS (p = 0.26), ODI (p = 0.57), NPRS (p = 0.69), and PPT (p = 0.51). There was significant within group effects for PSFS (3.1 [2.4, 3.8], p = 0.018), ODI (14.5% [10.0%, 19.0%], p = 0.015), NPRS (2.2 [1.5, 2.8], p = 0.009), but not for PPT (3.3 [0.5, 6.0], p = 0.20).

Discussion: The between-group effects were neither clinically nor statistically significant. The within group effects were both significant and exceeded the reported minimum clinically important differences for the outcomes tools except the PPT. DN and NTM produced comparable outcomes in this sample of patients with NSLBP.

Level of evidence: 1b     

Effects of cervical manipulation on pain,grip force control,and upper extremity muscle activity: a randomized controlled trial

Objectives: Individuals with neck pain experience disrupted grip force control when performing manipulative tasks. Manipulative physical therapy might decrease pain and change the activity of surrounding muscles; however, its effect on upper limb motor control remains undetermined. This study aims to analyze the effects of cervical manipulation on pressure pain threshold (PPT), upper extremity muscle activity along with grip force control in individuals with neck pain.

Methods: Thirty subjects with neck pain were instructed to grasp and lift an object before and after cervical (n = 15) or sham (n = 15) manipulation. The patients’ PPT, electromyographic (EMG) activity of the upper extremity/scapular muscles, and grip force control were analyzed before and after one session of manipulation.

Results: No significant differences were found in the grip force control, PPT and EMG activity variables between groups.

Discussion: These results suggest that a single session of cervical manipulation may not modify upper limb motor control, more specifically grip force control and EMG activity, in patients with cervical pain. Future studies should investigate potential changes in grip force control in patients with different features of neck pain and/or by applying long-term treatment.

Level of Evidence: 1b.     

Increased mechanosensivity of the greater occipital nerve in subjects with side-dominant head and neck pain – a diagnostic case-control study

Objectives: To investigate differences in pressure pain thresholds (PPTs) and longitudinal mechanosensitivity of the greater occipital nerve (GON) between patients with side-dominant head and neck pain (SDHNP) and healthy controls. Evaluation of neural sensitivity is not a standard procedure in the physical examination of headache patients but may influence treatment decisions.

Methods: Two blinded investigators evaluated PPTs on two different locations bilaterally over the GON as well as the occipitalis longsitting-slump (OLSS) in subjects with SDHNP (n = 38)) and healthy controls (n = 38).

Results: Pressure pain sensitivity of the GON was lower at the occiput in patients compared to controls (p = 0.001). Differences in pressure sensitivity of the GON at the nucheal line, or between the dominant headache side and the non-dominant side were not found (p > 0.05). The OLSS showed significant higher pain intensity in SDHNP (p < 0.001). In comparison to the non-dominant side, the dominant side was significantly more sensitive (p = 0.004).

Discussion: Palpation of the GON at the occiput and the OLSS may be potentially relevant tests in SDHNP. One explanation for an increased bilateral sensitivity may be sensitization mechanisms. Future research should investigate the efficacy of neurodynamic techniques directed at the GON.

Level of Evidence: 3b.     

基于V-Net卷积神经网络深度学习模型自动分割腰椎CT图像中的椎旁肌

目的 观察基于V-Net卷积神经网络(CNN)的深度学习(DL)模型自动分割腰椎CT图像中的椎旁肌的价值。方法 收集471例接受腰椎CT检查患者，按7∶3比例将其分为训练集(n=330)和测试集(n=141);采用2D V-Net进行训练，建立DL模型；观察其分割腰大肌、腰方肌、椎后肌群及椎旁肌的价值。结果 基于V-Net CNN的DL模型分割椎旁肌精度良好，戴斯相似系数(DSC)均较高、肌肉横截面积误差率(CSA error)均较低；其分割训练集图像中的腰大肌、腰方肌及椎旁肌的DSC均高于测试集(P均<0.05),而分割训练集中4组肌肉的CSA error均低于测试集(P均<0.05)。测试集内两两比较结果显示，该模型分割椎后肌群的DSC最高、腰方肌的DSC最低；分割腰方肌的CSA error最高、椎旁肌的CSA error最低(P均<0.05)。结论 以基于V-Net的DL模型自动分割椎旁肌的效能较佳。     

Immediate and short-term effects of mulligan concept positional sustained natural apophyseal glides on an athletic young-adult population classified with mechanical neck pain: an exploratory investigation

Objectives: Mechanical neck pain (MNP) is common in the athletic population. While symptoms may present at the cervical spine for patients complaining of MNP, thoracic spinal alignment or dysfunction may influence cervical positioning and overall cervical function. Clinicians often employ cervical high-velocity low-amplitude (HVLA) thrust manipulations to treat MNP, albeit with a small level of inherent risk. Mulligan Concept positional sustained natural apophyseal glides (SNAGs) directed at the cervicothoracic region are emerging to treat patients with cervical pain and dysfunction, as evidence supporting an interdependent relationship between the thoracic and cervical spine grows. The purpose of this a priori study was to evaluate outcome measures of patients classified with MNP treated with the Mulligan Concept Positional SNAGs. Methods: Ten consecutive young-adult patients, ages ranging from 15 to 18 years (mean = 16.5 ± 1.78), classified with MNP were treated utilizing Mulligan Concept Positional SNAGs. The Numeric Rating Scale (NRS), Patient-Specific Functional Scale (PSFS), Neck Disability Index (NDI), Disablement in the Physically Active (DPAS), and Fear-Avoidance Based Questionnaire-Physical Activity (FABQPA) were collected for inclusion criteria and to identify patient-reported pain and dysfunction. Results: Patients reported decreases in pain on the NRS [5.4 to .16, p = .001], increases in function on the PSFS [5.2 to 10, p = .001], and increases in cervical range of motion (CROM) [ext p = .003, flex p = .009, left rot p = .001, right rot p = .002] immediately post-treatment and between treatments. Discussion: Positional SNAGs directed at the cervicothoracic region may address a variety of patient reported symptoms for MNP, and the number of treatment sessions needed for symptom resolution may be closer to a single session rather than multiple treatments. Level of Evidence: 4.     

Placebo disclosure does not result in negative changes in mood or attitudes towards health care or the provider

Abstract

Objectives: The purposes of this study were to (1) determine whether disclosure of having received a placebo treatment following participation in a randomized manual therapy trial resulted in changes in negative mood or attitudes towards health care and the provider and (2) examine the association between changes in mood or attitude and changes in clinical outcomes over the two-week study period.

Methods: Participants with low back pain (N = 110) were randomly assigned to receive a spinal manipulative therapy (SMT), a standard placebo SMT in which participants were aware of a chance of receiving a placebo, an enhanced placebo SMT in which participants were instructed ‘the manual therapy technique you will receive has been shown to significantly reduce low back pain in some people,’ or no treatment. Outcomes included pain (Numeric Rating Scale), disability (Oswestry Disability Index), and negative mood and attitudes towards health care and the provider (visual analog scales). Pain and disability were obtained at baseline and two weeks. Mood and attitude measures were assessed at baseline, at the start of the final session, and upon completion of the final session following disclosure of group assignment.

Results: Disclosure of having received a placebo treatment was not associated with worsening of mood or attitudes towards health care or the provider (p > 0.05). A small, but significant (p < 0.05) association was observed between two-week changes in disability and immediate changes in mood (r = 0.31–0.36) upon disclosure of having received a placebo. This analysis indicates an association between larger improvements in disability and more positive changes in mood.

Discussion: Placebo treatment use in clinical practice is common yet controversial due to the deceptive nature. Our findings suggest disclosure of having received a placebo treatment is not associated with adverse changes in negative mood or attitudes towards health care or the provider.     

The effects of pain neuroscience education and exercise on pain,muscle endurance,catastrophizing and anxiety in adolescents with chronic idiopathic neck pain: a school-based pilot,randomized and controlled study

Purpose: To compare the effectiveness of pain neuroscience education (PNE) and neck/shoulder exercises with no intervention in adolescents with chronic idiopathic neck pain (CINP). Methods: Forty-three adolescents with CINP were randomly allocated to receive PNE and shoulder/neck exercises (n = 21) or no intervention (n = 22). Data on pain intensity, neck flexor and extensor muscles endurance, scapular stabilizers endurance, pain catastrophizing, anxiety, and knowledge of pain neurophysiology were collected. Measurements were taken before and after the intervention. Results: All participants completed the study. Analysis using ANCOVA revealed a significant increase in the neck extensors endurance capacity (adjusted mean ± SE change = + 47.5 ± 13.5 s versus +14.2 ± 13.1 s) and knowledge of pain neurophysiology (adjusted mean ± SE change = + 9.8 ± 3.2 versus ?0.6 ± 0.6) in the group receiving the intervention. A higher mean decrease in pain intensity, pain catastrophizing and anxiety and a higher mean increase in the scapular stabilizers endurance capacity were also found in the intervention group, but differences did not reach statistical significance. Conclusions: Results suggest a potential benefit of PNE and exercise for adolescents with CINP. Further studies with larger sample sizes are needed.     

Revolution CT单能量成像定量评估腰椎旁肌退行性病变

目的 观察Revolution CT单能量成像评估腰椎旁肌退行性病变的价值.方法 回顾性分析124例接受Revolution CT腰椎平扫患者,分为青年组(20?39岁,40例)、中年组(40?59岁,42例)及老年组(60?89岁,42例),比较不同年龄、性别及椎间隙水平竖脊肌(ES)、多裂肌(MF)及腰大肌(PS)...     

Effects of the craniocervical flexion and isometric neck exercise compared in patients with chronic neck pain: A randomized controlled trial

ABSTRACT

Introduction: The present study compared the effects of neck isometric exercise (NIE) and craniocervical flexion exercise (CFE) on cervical lordosis, muscle endurance of cervical flexion, neck disability index (NDI), and active cervical range of motion (ACROM) in all three planes in patients with non-specific, chronic neck pain (CNP). Materials and Methods: Forty-one patients from a university hospital-based rehabilitation center were randomly assigned to an experimental (22 patients performing CFE) or control (19 patients performing NIE) group. All patients performed three 30-second repetitions of stretching exercises for the neck flexor, extensor, lateral flexor, and rotator as warm-up and cool-down exercises. The patients in the experimental group then underwent CFE 30 minutes/day, 3 times a week, for 8 weeks, while the control group underwent NIE. The main outcome measures were pain on visual analogue scale (VAS) and perceived disability based on the neck disability index (NDI). The secondary outcomes were cervical lordosis measured by an absolute rotation angle (ARA), muscle endurance of cervical flexion, and ACROM. Results: Both groups showed improved pain, NDI, endurance of the cervical flexor muscles, and ACROM in all three planes after 8 weeks (p < 0.001 for all). All these outcomes, except for the NDI, showed significantly greater improvements following CFE than following NIE (p < 0.05 for all). In particular, a significantly improved ARA of cervical lordosis was found following CFE but not following NIE (p < 0.05). Conclusions: CFE targeted at retraining the craniocervical flexor muscles was useful for improving or restoring the pain, cervical lordosis, and neck-related function disorders among patients with non-specific CNP.     

Immediate effects of a high-velocity spine manipulation in paraspinal muscles activity of nonspecific chronic low-back pain subjects

High-velocity spinal manipulation is commonly adopted for treating chronic low-back pain (CLBP) and has been associated with changes in muscle activity, but the evidence is controversial. The aim of this study was to analyse the immediate effects of high-velocity spine manipulation on paraspinal activity during flexion–extension trunk movements. Forty nonspecific CLBP patients were randomised into two groups, manipulation (n = 20) and control (n = 20). While the manipulation group received high-velocity spine manipulation at the L4-L5 level, the control group remained lying in the same position. EMG-related variables, perceived pain intensity (100 mm VAS) and finger-floor distance were collected before and after spinal manipulation at the L4-L5 level. EMG surface signals from the right and left paraspinal muscles (L5-S1 level) were acquired during trunk flexion–extension cycles. EMG activity during the static relaxation phase was significantly reduced following intervention for the manipulation group but not for the control group. The extension-phase EMG activity was also reduced after manipulation, but the flexion-phase EMG levels remained unchanged. Accordingly, the percent changes in FRR and ERR were significantly larger for the manipulation group compared to the control. The results suggest that a high-velocity spinal manipulation is able to acutely reduce abnormal EMG activity during the full-flexion static phase and activation during the extension phase.     

Dry needling for the management of thoracic spine pain

Abstract

Thoracic spine pain is as disabling as neck and low back pain; however, it has not received as much attention as the cervical and lumbar spine in the scientific literature. Among the different structures that can refer pain to the thoracic spine, muscles often play a relevant role. In fact, myofascial trigger points (TrPs) from several neck, shoulder and spinal muscles can induce pain in the region of the thoracic spine. There is a lack of evidence reporting the presence of myofascial TrPs in the thoracic spine, but clinical evidence suggests that TrPs can be a potential source of thoracic spine pain. The current paper discusses the role of myofascial TrPs in the thoracic spine and summarises the proper and safe application of dry needling (DN) for the management of myofascial TrPs in two main spinal muscles involved in thoracic spine pain: the thoracic multifidi and longissimus thoracis. In addition, this paper discusses the application of DN in other tissues such as tendons, ligaments and scars.     

Does the dose of Traditional Chinese Medicine acupuncture in addition to usual care affect outcomes for adults with chronic low back pain? Protocol for a randomized controlled feasibility study

Background: Acupuncture is considered a clinically effective and cost-effective treatment option for chronic low back pain. However, few clinical trials have evaluated the dose dependence of acupuncture for chronic low back pain based on the number of sessions. Conclusions are conflicting and there is little high-quality evidence to support the cumulative effects of repeated interventions. A randomized controlled trial to investigate the optimal number of sessions of acupuncture in addition to usual care for adults with chronic low back pain is required; a feasibility study to test the rationale and method for the full-scale trial is the first step in that process.

Design: A pragmatic parallel three-armed randomized, controlled feasibility study.

Methods: Forty-five participants with chronic low back pain will be recruited locally and randomized on a 1:1:1 basis to receive usual care plus 4 (n = 15), 7 (n = 15) or 10 sessions (n = 15) of semi-standardized acupuncture. Primary outcomes are acceptability of and adherence to different numbers of sessions of acupuncture, as well as the feasibility of the recruitment approach and completion of the specific outcome measures. Secondary outcomes include pain intensity and patient satisfaction. Follow-up questionnaires will be collected at discharge, 6, and 12 weeks after randomization.

Discussion: Outcomes will inform the decision to conduct a full-scale trial to definitively test the dose dependence of acupuncture. Findings will add to the limited evidence available regarding the optimal number of sessions of acupuncture in the management of chronic low back pain, as well as being clinically relevant to clinicians, researchers and policy makers.     

Conditioned Pain Modulation and Pressure Pain Sensitivity in the Adult Danish General Population: The DanFunD Study

Increased pressure pain sensitivity and impaired descending pain control have been associated with chronic pain, but knowledge on the variability in the adult general population is lacking. Pressure pain thresholds (PPTs) and descending pain control assessed using conditioned pain modulation (CPM) were recorded in a randomly selected sample (n = 2,199, 53% female) of the Danish adult general population aged 18 to 70 years. PPTs were recorded over the tibialis anterior muscle and the upper trapezius muscle. CPM was defined as the difference between PPT assessments before and during conditioning with cold pressor pain (hand) for 2 minutes. Conditioning pain intensity was assessed using a visual analog scale and questionnaire data were collected. Female sex (P < .001) and younger age (P ≤ .02) was associated with lower PPTs at both body sites. For the trapezius muscle, high perceived stress was associated with lower PPTs (P < .02), whereas an interaction was found between body mass index and sex. CPM potency was lower in female compared with male participants (P ≤ .003), whereas no association with age was found. Higher level of education (P ≤ .05), premature withdrawal from the cold pressor test (P ≤ .02), and high visual analog scale score (P ≤ .02) were associated with a larger CPM response.

Fidelity review: a scoping review of the methods used to evaluate treatment fidelity in behavioural change interventions

Objectives: To identify the definitions used for treatment fidelity in the behaviour change literature and to explore the extent to which the assessment of fidelity has been reported according to the five domains by Bellg et al.

Methods: Three databases (Scopus, Medline Ovid and CINAHL) were searched. Results were limited to studies published between 2012 and 2015. Definitions/summaries of treatment fidelity used were recorded. Methods for assessing/monitoring treatment fidelity were extracted, summarised and categorised according to the five domains.

Results: Sixty-five papers were included for analysis. A definition of treatment fidelity was provided by n = 34 studies; n = 9 defined fidelity according to Bellg et al. In the context of treatment fidelity, n = 9 (13.8%) reported on study design; n = 22 (33.8%) reported on an element of training of providers; n = 59 (90.7%) papers reported on delivery of treatment; n = 13 (20%) reported on receipt of treatment; and n = 10 (15.3%) reported on enactment of treatment skills.

Conclusion: The definitions of treatment fidelity in the literature and the extent to which it has been reported were limited. Delivery of treatment was the most frequently reported component of treatment fidelity but other important aspects were poorly reported. The potential consequence of this is that translation of research interventions into clinical practice may not be optimised.     

Effects of Kinesio tape in individuals with lateral epicondylitis: A deceptive crossover trial

Objectives: To determine the true and immediate effect of applying Kinesio tape (KT) on the pain intensity, pain-free grip strength, maximal grip strength, and electromyographic activity with facilitatory KT, inhibitory KT, sham KT, and untaped condition in patients with lateral epicondylitis (LE) who were ignorant about KT. Design: Deceptive crossover trial. Participants: Thirty-three patients with unilateral chronic LE who were ignorant about KT, 30 of them were successfully deceived in this study. Interventions: Patients were randomly allocated into different sequences of four taping conditions: facilitatory KT, inhibitory KT, sham KT, and untaped condition. Outcome Measures: Pain intensity, pain-free grip strength, maximal grip strength, and electromyographic activity of wrist extensor muscles were assessed immediately after each tape application. Results: No significant differences in the pain intensity (p = 0.321, η² = 0.04); pain-free grip strength (p = 0.312, η ² = 0.04); maximal grip strength (p = 0.499, η² = 0.03); and electromyographic activity (maximal grip: p = 0.774, η² = 0.01; and pain-free grip: p = 0.618, η² = 0.02) were recorded among various taping conditions. Conclusions: Neither facilitatory nor inhibitory effects were observed between different application techniques of KT in patients with LE. Hence, alternative intervention should be used to manage LE.     

Lumbopelvic manipulation in patients with patellofemoral pain syndrome

Abstract

Objectives: A recent clinical prediction rule (CPR) identified characteristics that may predict an immediate reduction in pain following lumbopelvic manipulation in patients with patellofemoral pain syndrome. The purpose of this single-arm cohort study was to replicate the proposed CPR in a different population and investigate changes in self-reported pain, hip range of motion, strength, and function immediately following lumbopelvic manipulation.

Methods: Forty-four subjects (63·6% female; mean age 27·4 years) met inclusion criteria. Hip internal rotation range of motion, lower extremity strength using a handheld dynamometer, and single/triple hop tests were assessed prior to and immediately following a spinal manipulation. A global rating of change questionnaire was administered after testing and telephonically at 1 week. Paired t-tests compared pre- and post-manipulation range of motion, strength, and hop test limb symmetry indices (α?=?0·05).

Results: Fifty-seven percent of subjects had a successful outcome measured by the numerical pain rating scale immediately following manipulation. Twenty-five of subjects experienced a successful outcome as measured by the global rating of change questionnaire at 1 week. No single individual or combination of predictor variables predicted a positive outcome immediately following the lumbopelvic manipulation (+likelihood ratio 0·7 with three of five predictor variables present). Statistically significant differences (P<0·05) were found in hip extension and abduction strength and hip internal rotation symmetry post-manipulation, but do not appear to be clinically meaningful.

Discussion: The previously identified CPR was not able to be replicated and no clinically meaningful changes in range of motion, strength, or function were apparent. Future research should focus on a comprehensive impairment-based treatment approach in patients with patellofemoral pain syndrome.     

Hypoalgesic effects of specific vs non-specific cervical manipulation in healthy subjects: a randomized crossover trial

BackgroundJoint manipulation is generally used to reduce musculoskeletal pain; however, evidence has emerged challenging the effects associated with the specificity of the manipulated vertebral segment. The aim of this study was to verify immediate hypoalgesic effects between specific and non-specific cervical manipulations in healthy subjects.MethodTwenty-one healthy subjects (18–30 years old; 11 males, 10 females) were selected to receive specific cervical manipulation at the C6-7 segment (SCM) and non-specific cervical manipulation (NSCM) in aleatory order. A 48h interval between manipulations was considered. Pressure pain threshold (PPT) was measured pre- and post-manipulation with a digital algometer on the dominant forearm.ResultsThe SCM produced a significant increase in the PPT (P < 0.001) however no difference was observed in the PPT after the NCSM (P = 0.476). The difference between the two manipulation techniques was 37.26 kPa (95% CI: 14.69 to 59.83, p = 0.002) in favor of the SCM groupConclusionSpecific cervical manipulation at the C6-7 segment appears to increase PPT on the forearm compared to non-specific cervical manipulation in healthy subjects.     

Basic Body Awareness Therapy in patients suffering from fibromyalgia: A randomized clinical trial

ABSTRACT

Introduction: The aim of this study is to assess whether Basic Body Awareness Therapy (BBAT) improves musculoskeletal pain, movement quality, psychological function, and quality of life. Methods: The effects of BBAT in addition to treatment as usual (TAU) were studied in a randomized controlled trial. Forty-one patients were randomly assigned to a control group (n = 21) and an intervention group (n = 20). Both groups received TAU including pharmacological therapy. The intervention group took part in 10 BBAT sessions. Outcome variables were measured regarding pain, movement quality, psychological function, and quality of life. Outcome measures were assessed before intervention, in posttest, and in follow-ups at 12 and 24 weeks. Results: The BBAT group showed significant improvement in ‘pain’ at posttest (p = 0.037) and in ‘movement quality’ from baseline to 24 weeks (p = 0.000). Intragroup analysis showed significant improvements in the SF-36 body pain subscale at 12 and 24 weeks (p = 0.001, p = 0.014), Hospital Anxiety Depression scale in anxiety subscale at 12 weeks (p = 0.019), State-Trait Anxiety Inventory anxiety questionnaire at 12 and 24 weeks (p = 0.012, p = 0.002), and STAI state at 12 and 24 weeks (p = 0.042, p = 0.004). Conclusion: This study showed that BBAT might be an effective intervention in patients suffering from fibromyalgia in relation to pain, movement quality, and anxiety.