Subject Index

Abstract

Shoulder pain is a common orthopedic condition seen by physical therapists, with many potential contributing factors and proposed treatments. Although manual physical therapy interventions for the cervicothoracic spine and ribs have been investigated for this patient population, the specific effects of these treatments have not been reported. The purpose of this investigational study is to report the immediate effects of thoracic spine and rib manipulation in patients with primary complaints of shoulder pain. Using a test-retest design, 21 subjects with shoulder pain were treated during a single treatment session with high-velocity thrust manipulation to the thoracic spine or upper ribs. Post-treatment effects demonstrated a 51% (32mm) reduction in shoulder pain, a corresponding increase in shoulder range of motion (30°-38°), and a mean patient-perceived global rating of change of 4.2 (median 5). These immediate post-treatment results suggest that thoracic and rib manipulative therapy is associated with improved shoulder pain and motion in patients with shoulder pain, and further these interventions support the concept of a regional interdependence between the thoracic spine, upper ribs, and shoulder.     

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.     

The Immediate Effects of Thoracic Spine and Rib Manipulation on Subjects with Primary Complaints of Shoulder Pain

Shoulder pain is a common orthopedic condition seen by physical therapists, with many potential contributing factors and proposed treatments. Although manual physical therapy interventions for the cervicothoracic spine and ribs have been investigated for this patient population, the specific effects of these treatments have not been reported. The purpose of this investigational study is to report the immediate effects of thoracic spine and rib manipulation in patients with primary complaints of shoulder pain. Using a test-retest design, 21 subjects with shoulder pain were treated during a single treatment session with high-velocity thrust manipulation to the thoracic spine or upper ribs. Post-treatment effects demonstrated a 51% (32mm) reduction in shoulder pain, a corresponding increase in shoulder range of motion (30°-38°), and a mean patient-perceived global rating of change of 4.2 (median 5). These immediate post-treatment results suggest that thoracic and rib manipulative therapy is associated with improved shoulder pain and motion in patients with shoulder pain, and further these interventions support the concept of a regional interdependence between the thoracic spine, upper ribs, and shoulder.KEYWORDS: Manipulation, Manual Therapy, Shoulder Pain, Thoracic SpineRegional interdependence, as described by Wainner and col-leagues^1,2, “refers to the concept that seemingly unrelated impairments in a remote anatomical region may contribute to, or be associated with, the patient''s primary complaint”. This model suggests that many musculoskeletal disorders may respond more favorably to a regional examination and treatment approach that, in addition to localized treatment, encourages physical therapists to examine and treat distant dysfunctions that may be influencing the patient''s symptoms. Although the specific mechanism (whether neurophysiologic, biomechanical, or other) has yet to be elucidated, several high-quality clinical trials have demonstrated the effective use of this regional examination and treatment approach in achieving positive functional outcomes for patients with a variety of musculoskeletal disorders^3–10.Three of these studies^3–5 have investigated the effects of including cervicothoracic spine and rib manual physical therapy into an overall treatment approach for patients with shoulder pain. Winters et al⁵ found that manipulative therapy applied throughout the shoulder girdle was more effective than physiotherapy in reducing the duration of shoulder pain in a subgroup of 58 patients whose shoulder pain was attributed to dysfunctions within the cervical spine, upper thoracic spine, or upper ribs. Bang and Deyle³ reported improved outcomes in strength, function, and pain when manual physical therapy techniques for the shoulder, cervical spine, and thoracic spine were added to an exercise program for patients with shoulder impingement syndrome. In a more recent clinical trial, Bergman et al⁴ assessed the added benefit of applying cervicothoracic and rib manipulations and mobilizations to a standardized treatment regimen of anti-inflammatory and analgesic medications, corticosteroid injections, and physical therapy (exercises, massage, and modalities) for patients with shoulder pain and dysfunction. The addition of manipulative therapy to this usual medical care resulted in significant improvements in short- and long-term recovery rates and symptom severity for these subjects.Although the overall treatment effect of manual physical therapy has been demonstrated in these studies, the relative contribution of specific manipulative techniques applied to the cervical spine, thoracic spine, and/or ribs towards the improvement in functional outcomes for patients with shoulder pain cannot be determined. The purpose of this preliminary study is to report the immediate effects of thoracic and rib manipulation on subjects with primary complaints of shoulder pain. Exploratory studies of this nature are needed to help define the potential interdependence between anatomic regions such as the thoracic spine, upper ribs, and shoulder.     

Comparison of Forces Exerted by a Chiropractor on Children and Adults During High-Speed,Low-Amplitude Spinal Manipulations: A Feasibility Study

ObjectiveThe aim of this study was to demonstrate that quantification of the forces exerted by a single chiropractor on children and adults during high-velocity, low-amplitude spinal manipulations and the correlation of forces to age was feasible.MethodsThe force-time profiles of high-velocity, low-amplitude spinal manipulations were measured in 48 children (109 manipulations) ranging from 14 weeks to 17 years of age, and 20 adults (49 manipulations) in a clinical setting. The measurements were taken using a thin, flexible pressure pad. Outcome variables (peak forces, preload forces, thrust forces, thrust durations, rates of force application, and thrust impulses) were quantified and compared across age groups using Kruskal-Wallis testing with Dunn post hoc analysis. Outcome variables were fitted with best-fitting linear regressions with age as the dependent variable. The level of significance for all statistical tests was set a priori at α = 0.05.ResultsMost outcome variables increased with the age of the patient. Specifically, peak forces, thrust forces, and the rate of force application were positively correlated with age, while thrust durations remained constant across all ages and preload forces decreased slightly with patient age for cervical spine manipulations.ConclusionFor this single chiropractor in private practice, the forces he used increased with the age of the patient, and he thus used lower forces in children than adults. This study shows that measuring the forces used by a chiropractor in clinical practice on patients with a range of ages was feasible.     

Manipulation under joint anesthesia/analgesia: a proposed interdisciplinary treatment approach for recalcitrant spinal axis pain of synovial joint origin

BACKGROUND: Manipulation under joint anesthesia/analgesia (MUJA) is an approach to treatment for patients with chronic, recalcitrant spinal axis pain of synovial joint origin. MUJA is the synthesis of fluoroscopically and corticosteroid agents with targeted, manual mobilizations and/or manipulations of the injected joint(s). DISCUSSION: MUJA should be viewed with guarded optimism because its success is based solely on anecdotal experience. Many physicians (specializing in targeted intraarticular "blocks" of spinal synovial joints) and chiropractors (specializing in manual mobilization and manipulation of spinal synovial joints) in the Tyler, Texas, area have treated more than 1000 patients over a 7-year period with the MUJA protocol. This protocol includes treatment of the atlanto-occipital and lateral atantoaxial joints of the upper cervical spine, the zygapophysial joints of the cervical spine from C2-3 to C6-7, the thoracic spine and the lumbar spine, and the pelvic sacroiliac joints. CONCLUSION: The following patient types are suitable candidates for MUJA: patients with dominant spinal axis pain who have been unable to progress despite the passage of sufficient time (>2 months) and the delivery of prior treatments, including spinal manipulative therapy; patients with pain so severe that standard manipulative therapy cannot be delivered with technical success; and patients with complex problems in whom the diagnosis of synovial joint-mediated spinal pain must be established before the safe delivery of manipulative therapy.     

Reflex Responses of Neck,Back, and Limb Muscles to High-Velocity,Low-Amplitude Manual Cervical and Upper Thoracic Spinal Manipulation of Asymptomatic Individuals—A Descriptive Study

ObjectiveThe purpose of this research was to determine the extent of reflex responses after spinal manipulative therapy (SMT) of the cervical and upper thoracic spine.MethodsEleven asymptomatic participants received 6 commonly used SMTs to the cervical and upper thoracic spine. Bipolar surface electromyography electrodes were used to measure reflex responses of 16 neck, back, and proximal limb muscles bilaterally. The percentage of occurrence and the extent of reflex responses of these muscles were determined.ResultsReflex responses after cervical SMT were typically present in all neck and most back muscles, whereas responses in the outlets to the arm and leg were less frequent. This trend was similar, although decreased in magnitude, after thoracic SMT.ConclusionReflex responses were greatest after upper cervical SMT and lowest with thoracic SMT.     

Procedure Selection and Patient Positioning Influence Spine Kinematics During High-Velocity,Low-Amplitude Spinal Manipulation Applied to the Low Back

Objectives

This investigation compared indirect 3-dimensional angular kinematics (position, velocity, and acceleration) of the lumbar spine for 2 different high-velocity, low-amplitude (HVLA) spinal manipulation procedures (lumbar spinous pull or push), and altered initial patient lower limb posture.

Manipulation of the cervical spine

In New Zealand, a new approach to manual therapy of the cervical spine has integrated physiotherapy and osteopathy techniques. The combination of the philosophies of these two professions has added a new dimension to the management of cervical spine pain. Emphasis is placed on issues of safety, such as the degree of cervical rotation and comfort for both the patient and the therapist. This is combined with biomechanical considerations, which have made the teaching and learning of these manipulative techniques less complicated and easily progressed from palpation to mobilization and onto manipulation. Appropriate patient screening and selection identified through thorough subjective and objective assessments are important aspects of this approach and reflective interpretation of all clinical findings is essential. The refinement of cervical joint positioning and an increased anatomical awareness have led to the utilization of new upper cervical high-velocity thrust techniques. Consequently, it is envisaged that an increase in the safety and specificity of cervical manipulative techniques is achieved.     

Regional interdependence and manual therapy directed at the thoracic spine

Abstract

Thoracic spine manipulation is commonly used by physical therapists for the management of patients with upper quarter pain syndromes. The theoretical construct for using thoracic manipulation for upper quarter conditions is a mainstay of a regional interdependence (RI) approach. The RI concept is likely much more complex and is perhaps driven by a neurophysiological response including those related to peripheral, spinal cord and supraspinal mechanisms. Recent evidence suggests that thoracic spine manipulation results in neurophysiological changes, which may lead to improved pain and outcomes in individuals with musculoskeletal disorders. The intent of this narrative review is to describe the research supporting the RI concept and its application to the treatment of individuals with neck and/or shoulder pain. Treatment utilizing both thrust and non-thrust thoracic manipulation has been shown to result in improvements in pain, range of motion and disability in patients with upper quarter conditions. Research has yet to determine optimal dosage, techniques or patient populations to which the RI approach should be applied; however, emerging evidence supporting a neurophysiological effect for thoracic spine manipulation may negate the need to fully answer this question. Certainly, there is a need for further research examining both the clinical efficacy and effectiveness of manual therapy interventions utilized in the RI model as well as the neurophysiological effects resulting from this intervention.     

High-Velocity Thrust Technique for Traumatic Onset Lateral Elbow Pain

Abstract

A 35 year-old male presented to physical therapy following a fall onto his outstretched right hand. He developed pain and dysfunction in the right lateral epicondyle region. The patient was assessed and received a physical therapy diagnosis of abducted ulna syndrome. The patient was treated with a high-velocity, low-amplitude manipulation technique to the humeroulnar joint. This technique coincided with a restoration in the patient's normal function, along with an elimination of painful symptoms. This case study suggests that a high-velocity, low-amplitude manipulation technique performed by a physical therapist may play an important role in the successful treatment of traumatically induced lateral epicondyle pain.     

Association of Spinal Manipulative Therapy With Changes in Cervical Motion Segment Interactions in Patients With Neck Pain: An Observational Study With Matched Asymptomatic Controls

ObjectiveThe objectives of this study were to determine (1) if maximal intervertebral range of motion (IV-RoMmax) and laxity interactions exist in the cervical spine during flexion, (2) if there are differences in IV-RoMmax or laxity parameters between baseline and follow-up in both patients with neck pain and asymptomatic controls, and (3) if there is an effect on IV-RoMmax/laxity relationships in patients with neck pain after spinal manipulative therapy.MethodsTwenty-nine patients with subacute or chronic neck pain and 33 asymptomatic controls were imaged during flexion and extension, pre and post a course of cervical chiropractic manipulation (patient group only), using a standardized quantitative fluoroscopy acquisition protocol.ResultsSignificant correlations between IV-RoMs were found in both neck pain and neck pain–free populations at baseline and follow-up. Positive relationships were found between C2-C3 and C3-C4 and C4-C5 and C5-C6 IV-RoM in both populations. A negative correlation was found in the patient group at baseline between C1-C2 and C5-C6, but not at follow-up. Significant relationships were also found for segmental laxity, with a negative correlation found at C1-C2 and C5-C6 in the patient group only and at baseline only.ConclusionDistinct relationships were found between both intraregional IV-RoM and laxity, many of which were present in both groups at baseline and follow-up, suggestive of normal kinematic behaviors. Changes in correlations unique to the patient group may be indicative of a change in regional kinematics resulting from the manipulation intervention. Spinal manipulative therapy may have a therapeutic effect by influencing cervical kinematics at the regional level.     

A rigid body model of the dynamic posteroanterior motion response of the human lumbar spine

BACKGROUND: Clinicians apply posteroanterior (PA) forces to the spine for both mobility assessment and certain spinal mobilization and manipulation treatments. Commonly applied forces include low-frequency sinusoidal oscillations (<2 Hz) as used in mobilization, single haversine thrusts (<0.5 seconds) as imparted in high-velocity, low-amplitude (HVLA) manipulation, or very rapid impulsive thrusts (<5 ms) such as those delivered in mechanical-force, manually-assisted (MFMA) manipulation. Little is known about the mechanics of these procedures. Reliable methods are sought to obtain an adequate understanding of the force-induced displacement response of the lumbar spine to PA forces. OBJECTIVE: The objective of this study was to investigate the kinematic response of the lumbar spine to static and dynamic PA forces. DESIGN: A 2-dimensional modal analysis was performed to predict the dynamic motion response of the lumbar spine. METHODS: A 5-degree-of-freedom, lumped equivalent model was developed to predict the PA motion of the lumbar spine. Lumbar vertebrae were modeled as masses, massless-spring, and dampers, and the resulting equations of motion were solved by using a modal analysis approach. The sensitivity of the model to variations in the spring stiffness and damping coefficients was examined, and the model validity was determined by comparing the results to oscillatory and impulsive force measurements of vertebral motion associated with spine mobilization and 2 forms of spinal manipulation. RESULTS: Model predictions, based on a damping ratio of 0.15 (moderate damping) and PA spring stiffness coefficient ranging from 25 to 60 kN/m, showed good agreement with in vivo human studies. Quasi-static and low-frequency (<2.0 Hz) forces at L3 produced L3 segmental and L3-L4 intersegmental displacements up to 8.1 mm and 3.0 mm, respectively. PA oscillatory motions were over 2.5-fold greater for oscillatory forces applied at the natural frequency. Impulsive forces produced much lower segmental displacements in comparison to static and oscillatory forces. Differences in intersegmental displacements resulting from impulsive, static, and oscillatory forces were much less remarkable. The latter suggests that intersegmental motions produced by spinal manipulation may play a prominent role in eliciting therapeutic responses. CONCLUSIONS: The simple analytical model presented in this study can be used to predict the static, cyclic, and impulsive force PA displacement response of the lumbar spine. The model provides data on lumbar segmental and intersegmental motion patterns that are otherwise difficult to obtain experimentally. Modeling of the PA motion response of the lumbar spine to PA forces assists in the understanding the biomechanics of therapeutic PA forces applied to the lumbar spine and may ultimately be used to validate chiropractic technique procedures and minimize risk to patients receiving spinal manipulative therapy.     

Effects of cervical orthoses on neck biomechanical responses during transitioning from supine to upright

Background

Our objectives were to use a hybrid cadaveric/surrogate model to evaluate the effects of the cervicothoracic orthosis and collar on head and neck biomechanical responses during transitioning from supine to upright.

Methods

The model consisted of an adult-male surrogate dummy with its artificial neck replaced by a human neck specimen (n = 10). The model was transitioned from supine to upright using a rotation apparatus. A high-speed digital camera tracked motions of the head, vertebrae, cervicothoracic orthosis, pelvis, and rotation apparatus. Head load cell data were used to compute occipital condyle loads. Average peak spinal loads and motions were statistically compared (P < 0.05) among experimental conditions (cervicothoracic orthosis: anterior strut locked and unlocked; collar; and unrestricted).

Findings

Loads at the occipital condyles consisted of anterior shear, compression, and extension moment. The most rigid device tested, cervicothoracic orthosis with anterior strut locked, significantly reduced axial compression neck force and increased anterior shear neck force and provided the greatest immobilization by significantly reducing spinal rotations as compared to other experimental conditions. Similar neck biomechanical responses were observed between the cervicothoracic orthosis, anterior strut unlocked, and collar.

Interpretation

The simple maneuver of supine-to-upright transitioning, commonly performed clinically, produced complex neck loads and motions including head protrusion which caused cervical spine snaking. Neck motions consisted of extension at the upper cervical spine and flexion at the subaxial cervical spinal levels. Of the devices tested, the cervicothoracic orthosis, with anterior strut locked, provided the greatest cervical spine immobilization thereby reducing the risk of potential secondary neck injuries.     

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.     

Manuelle Diagnostik und Therapie der Halswirbelsäule

Evidence-based results of therapeutic and diagnostic procedures of manual medicine are well known. Successful diagnostic and therapeutic effects are based on exact undertaking of manual techniques. In this paper therapeutic and diagnostic procedures of manual medicine (chirotherapy) of the cervical spine are presented. Like in other issues devoted to a specific topic the selection of the techniques was also made in accordance with the three German societies for manual medicine/chirotherapy (ÄMM, DGMSM, MWE). Tests from a global orientation to a specific examination of the joint play are described as well as a selection of manipulative treatments of the cervical spine with and without high-velocity thrust. Emphasis is laid on the necessity of carrying out safety tests to identify red flags, i.e. structural lesions or nerve root compressions.     

Auswirkung von thorakalen Manipulationen auf die sagittale Ausrichtung der Wirbels?ule

Background

Sagittal plane alignment of the spine has been implicated in spinal diseases, such as disc degeneration and low back pain. The effects of spinal manipulation (high velocity low amplitude) on the sagittal alignment of the spine are unknown.

Subjects and methods

In this pilot study a total of 44 subjects were examined by means of video raster stereography. The angle of thoracic kyphosis and lumbal lordosis were calculated before and after thoracic spinal manipulation (high velocity low amplitude) in normal and straight posture.

Results

The angle of thoracic kyphosis did not change but the angle of lumbal lordosis increased significantly in straight (p?=?0.004) and normal (p?=?0.001) posture.

Conclusions

Thoracic spinal manipulation can affect the biomechanics of the lumbal spine. This fact shows the interdependence between different regions of the spine which is seen as an important point in manual therapy. Whether the effects of thoracic spinal manipulation are caused by affects of central or segmental regions remains unclear and cannot be answered in this pilot study.     

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.