Interaction between Trigger Points and Joint Hypomobility: A Clinical Perspective

Abstract

The relationship between muscle trigger points (TrPs) and joint hypomobility is frequently recognized by clinicians. Among different manual therapies aimed at inactivating muscle TrPs, ischemic compression and spinal manipulation have shown moderately strong evidence for immediate pain relief. Reduction of joint mobility appears related to local muscles innervated from the segment, which suggests that muscle and joint impairments may be indivisible and related disorders in pain patients. Two clinical studies have investigated the relationship between the presence of muscle TrPs and joint hypomobility in patients with neck pain. Both studies reported that all patients exhibited segmental hypomobility at C3-C4 zygapophyseal joint and TrPs in the upper trapezius, sternocleidomastoid, or levator scapulae muscles. There are several theories that have discussed the relationship between TrP and joint hypomobility. First, increased tension of the taut muscular bands associated with a TrP and facilitation of motor activity can maintain displacement stress on the joint. Alternatively, it may be that the abnormal sensory input from the joint hypomobility may reflexively activate TrPs. It is also conceivable that TrPs provide a nociceptive barrage to the dorsal horn neurons and facilitate joint hypomobility. There is scientific evidence showing change in muscle sensitivity in muscle TrP after spinal manipulation, which suggests that clinicians should include treatment of joint hypomobility in the management of TrPs. Nevertheless, the order in which these muscle and joint impairments should be treated is not known and requires further investigation.     

A Multi-Structural Approach to Treatment of a Patient With Sub-Acromial Impingement: A Case Report

Abstract

Sub-acromial impingement is a condition commonly seen by physical therapists, however little evidence is available regarding the efficacy of this treatment. This case report describes the use of manual therapy and exercise, using a multi-structural approach to manage this condition. The subject was a 48-year-old retired physiotherapist complaining of recurrent shoulder pain during daily activities, although her daily function was not limited. Passive joint mobilization techniques of the cervical spine, costovertebral joints, and the glenohumeral joint as well as soft tissue mobilization techniques of the rotator cuff muscles were used. Exercises were prescribed to “set” the scapula in an optimal position and to facilitate and strengthen the rotator cuff muscles. After two treatments, the patient consulted an orthopaedic surgeon due to imminent decrease in funding for her treatment and a cortisone injection was administered. This decreased her pain immediately by 90%. However, two months later she attended three further physical therapy treatments because of recurrence of the pain. Six months after these treatments she was still pain-free. This case illustrates that physical therapy can be effective in the treatment of sub-acromial impingement, using a multi-structural approach to treatment.     

Abstracts: AAOMPT Conference, 2002

Abstract

Background/Purpose: The purpose of this case report is to describe the clinical management of a patient with sacroiliac joint dysfunction (SIJD) and a concomitant asymmetrical hip-joint rotation range of motion. The patient was a 53-year-old male whose chief complaint was right low back pain (LBP) that interfered with work and leisure activities. Physical therapy consisted of manual therapy, stretching, and postural education to address SIJ and hip motion abnormalities. At the conclusion of 6 visits, the hip-joint rotation range of motion was more symmetrical. The patient reported self-correction of unilateral standing and sitting postures. He returned to full-time work and to playing golf, and he rated pain at 0-1/10. This patient's asymmetrical hip-joint rotation range of motion may have been associated with SIJD, either as a result of trauma or subsequent habitual postural adjustments. Clinician awareness of the possible relationship between SIJD and asymmetrical hip joint rotation range of motion is recommended.     

Effect of Mobilization of the Anterior Hip Capsule on Gluteus Maximus Strength

Abstract

Loss of hip extension is often compensated for by extension of the lumbar spine. This compensation can result in hypermobility and ultimately be a source of low back dysfunction and pain. Joint mobilizations have been known to return physiologic and accessory motion to hypomobile structures. Mobilization has also been demonstrated to improve muscular strength when secondary to joint hypomobility. The purpose of this study was to determine the usefulness of posteroanterior (P-A) hip-joint mobilization in improving strength of the gluteus maximus muscle. Forty subjects were randomly assigned to a control group (Grade I P-A mobilization) and an experimental group (Grade IV P-A mobilization). The subjects performed a pretest/posttest set of five isometric repetitions on the Cybex Norm? isokinetic machine. The peak torque was determined for both pretest and posttest measurements. The data collected were analyzed using an independent t-test with a significance level of p < .05. The results demonstrated a statistically significant difference between the experimental and control groups (t=1.68, p=0.002). This study demonstrated a significant increase in gluteus maximus strength in response to Grade IV P-A mobilizations performed on the anterior hip capsule. Clinicians can utilize these findings in everyday practice to improve muscle strength by integrating manual therapy with therapeutic exercise.     

Differential Diagnosis and Treatment of Chronic Neck and Upper Trapezius Pain and Upper Extremity Paresthesia: A Case Study Involving the Management of an Elevated First Rib and Uncovertebral Joint Dysfunction

Abstract

Diagnosis and effective treatment of patients presenting with cervicobrachial symptoms are often challenging due to the large number of potential pain sources and the high degree of convergence of sensory afference in the cervical region. A 42-year-old female presented in the clinic with a six-month history of neck pain, upper trapezius pain, and upper extremity paresthesia. A careful history, specific functional examination, and selected special tests led to diagnosis-specific orthopedic manual therapy management of this patient. The patient fully recovered within 6 physical therapy treatment sessions, which included management of an elevated first rib, double-crush phenomenon, uncovertebral joint dysfunction, and careful ergonomic intervention with home instructions. Although controlled trials are needed to evaluate the effectiveness of these techniques and allow generalizability of such interventions, the recovery of this patient suggests the efficacy of manual techniques and ergonomic intervention in the management of uncovertebral joint dysfunction and thoracic outlet syndrome associated with a double-crush phenomenon.     

Predictive Factors in Poor Inter-Rater Reliability Among Physical Therapists

Abstract

Manual therapy is a widely used form of treatment among physical therapists and has been shown to be effective in the treatment of musculoskeletal disorders. In numerous studies, the reliability of clinicians performing the four grades of mobilization of manual therapy has been poor. A sample of 23 licensed physical therapists participated in quasi-experimental repeated measures designed to determine if predictive factors such as gender or years of experience contribute to inter-rater reliability variances. In this design, therapists performed Grade I, II, III and IV mobilizations on two asymptomatic volunteers at the level of L3, based on resistance defined Grades of Movement. The Kistler Force Plate ? was used to record mobilization forces for each physical therapist at a rate of 600 data-point measurements per second. Data were assessed to determine if poor inter-rater reliability is reflective of certain predictive variables. The results identified that the independent variables of age, years of experience, gender, frequency of use, education, and background of the rater did not contribute to the overall variance within the study. Further investigation is required as to what determines the poor inter-rater reliability of spinal accessory mobilizations by practicing clinicians.     

Clinical teaching and learning within a preceptorship model in an acute care hospital in Ireland; a qualitative study

BackgroundA preceptorship model of clinical teaching was introduced to support the new all-graduate nurse education programme in Ireland in 2002. Little is known about how this model impacts upon the pedagogical practices of the preceptor or student learning in clinical practice leading to question what constitutes effective teaching and learning in clinical practice at undergraduate level.AimThis study aimed to explore the clinical teaching and learning within a preceptorship model in an acute care hospital in Ireland and identify when best practice, based on current theoretical professional and educational principles occurred.MethodA qualitative research study of a purposively selected sample of 13 students and 13 preceptors, working together in four clinical areas in one hospital in Ireland. Methods were semi-structured interviews, analysed thematically, complemented by documentary analysis relating to the teaching and assessment of the students. Ethical approval was gained from the hospital's Ethics Committee.FindingsPreceptor-student contact time within an empowering student-preceptor learning relationship was the foundation of effective teaching and learning and assessment. Dialoguing and talking through practice enhanced the students' knowledge and understanding, while the ability of the preceptor to ask higher order questions promoted the students' clinical reasoning and problem solving skills. Insufficient time to teach, and an over reliance on students' ability to participate in and contribute to practice with minimal guidance were found to negatively impact students' learning.Conclusions & ImplicationsConcepts such as cognitive apprenticeship, scaffolding and learning in communities of practice can be helpful in understanding the processes entailed in preceptorship. Preceptors need extensive educational preparation and support to ensure they have the pedagogical competencies necessary to provide the cognitive teaching techniques that foster professional performance and clinical reasoning. National competency based standards for preceptor preparation should be developed.     

Can Chiropractors and Evidence-Based Manual Therapists Work Together? An Opinion From a Veteran Chiropractor

Abstract

Use of manual therapy in the form of manipulation and massage is evident in the earliest recordings of history. Today, manual therapy is an evidence-based practice that can be used with predictable results in the treatment of a variety of neuromusculoskeletal problems. However, for some manual therapists, treatment is still based on a belief system that incorporates vitalism, energy healing, and other metaphysical concepts. Cooperation of practitioners in researching the effects of manual therapy would require uniformity based upon the guidelines of science, following rules for selection of an evidence-based therapy that produces predictable and replicable results. Such an approach would not allow contamination by dogma or by an agenda that is designed more to support a belief system than to find the truth. The chiropractic profession, which began with a founding father in 1895, is identified primarily by its use of manipulation. But chiropractic is based upon a vertebral subluxation theory that is generally categorized as supporting a belief system. The words "manipulation" and "subluxation" in a chiropractic context have meanings that are different from the meanings in evidence-based literature. An orthopedic subluxation, a partial dislocation or displacement of a joint, can sometimes benefit from manipulation or mobilization when there are joint-related symptoms. A chiropractic subluxation, however, is often an undetectable or asymptomatic "spinal lesion" that is alleged to be a cause of disease. Such a subluxation, which has never been proven to exist, is "adjusted" by chiropractors, who manipulate the spine to restore and maintain health. The reasons for use of manipulation/ mobilization by an evidence-based manual therapist are not the same as the reason for use of adjustment/manipulation by most chiropractors. Only evidence-based chiropractors, who have renounced subluxation dogma, can be part of a team that would research the effects of manipulation without bias.     

The Effects of Manual Therapy Using Joint Mobilization and Flexion-distraction Techniques on Chronic Low Back Pain and Disc Heights

[Purpose] The purpose of this study was to examine the effects of manual therapy using joint mobilization and flexion-distraction techniques on chronic low back pain and disc heights. [Subjects] This study was conducted with 31 chronic low back pain patients who were divided into a manual therapy group (MTG; n=16) and a spinal decompression therapy group (SDTG; n=15). [Methods] The MTG was treated using joint mobilization techniques and flexion-distraction techniques, and the SDTG was treated using spinal decompression therapeutic apparatuses. Conservative physical therapy was used in both groups, and the therapy was implemented three times per week for 6 weeks. The visual analog scale (VAS) was used to measure patient’s low back pain scores, and a picture archiving and communication system was used to measure disc height by comparing and analyzing the images. [Results] In comparisons of the VAS within each of the two groups, both the MTG and the SDTG showed significant decreases. In comparisons of disc height within each of the two groups, the MTG showed statistically significant increases. [Conclusion] Manual therapy using joint mobilization techniques and flexion-distraction techniques is considered an effective intervention for addressing low back pain and disc heights in patients with chronic low back pain.Key words: Manual therapy, Joint mobilization techniques, Spinal decompression therapy     

Articular dysfunction patterns in patients with mechanical neck pain: A clinical algorithm to guide specific mobilization and manipulation techniques

In view of a didactical approach for teaching cervical mobilization and manipulation techniques to students as well as their use in daily practice, it is mandatory to acquire sound clinical reasoning to optimally apply advanced technical skills. The aim of this Masterclass is to present a clinical algorithm to guide (novice) therapists in their clinical reasoning to identify patients who are likely to respond to mobilization and/or manipulation. The presented clinical reasoning process is situated within the context of pain mechanisms and is narrowed to and applicable in patients with a dominant input pain mechanism. Based on key features in subjective and clinical examination, patients with mechanical nociceptive pain probably arising from articular structures can be categorized into specific articular dysfunction patterns. Pending on these patterns, specific mobilization and manipulation techniques are warranted. The proposed patterns are illustrated in 3 case studies. This clinical algorithm is the corollary of empirical expertise and is complemented by in-depth discussions and knowledge exchange with international colleagues. Consequently, it is intended that a carefully targeted approach contributes to an increase in specificity and safety in the use of cervical mobilizations and manipulation techniques as valuable adjuncts to other manual therapy modalities.     

Reliability of Joint Mobility and Pain Assessment of the Thoracic Spine and Rib Cage in Asymptomatic Individuals

Abstract

Despite the importance of correctly diagnosing a spinal dysfunction, limited research exists related to physical therapists' ability to reliably identify a joint exhibiting signs of dysfunction. The purpose of this investigation was to determine the inter- and intra-examiner reliability of a thoracic spine and rib cage joint mobility and pain assessment between two experienced manipulative physical therapists. Nine healthy subjects (3 male, 6 female; ages 23-35) without history of mid- or low back pain participated. Posterior-to-anterior pressures were applied to the thoracic spine and rib articulations with anterior-to-posterior pressures applied to the costosternal joints of each subject by two examiners to evaluate joint mobility and pain provocation. Both examiners assessed all subjects twice and were blinded to subject identity. Kappa statistics were calculated using a strict and expanded definition of agreement to determine the between- and within-examiner reliability for each outcome. Intra-examiner reliability of joint mobility assessment ranged from slight to fair based on the strict agreement but improved to good when findings were compared across ± 1 spinal/rib level. Pain provocation reliability increased to very good under the expanded agreement; however, this finding should be viewed with caution due to limited pain prevalence in the subject sample. Selected clinical prediction rules, applied to the care of individuals with back pain, characterize the patient's regional mobility simply as hypomobile, normal, or hypermobile; consequently, we feel the results of an expanded definition of agreement may be more appropriate for clinic practice. Further research is needed to determine the reliability in individuals with thoracic spine and rib cage symptoms.     

2003 Manual Therapy Awards and Abstracts

Abstract

Lateral epicondylalgia or tennis elbow is a prevalent musculoskeletal disorder that is characterized by lateral elbow pain often associated with gripping tasks. The underlying pathology remains to be fully elucidated; however, evidence indicates that the disorder does not involve an inflammatory process but rather impairments of the pain and motor systems as well as morphological changes in the structure of both the extensor carpi radialis brevis muscle and tendon. Although the most efficient management approach remains controversial, there is a growing body of literature reporting the effects and underlying mechanisms of joint manipulation in the management of lateral epicondylalgia. Evidence exists demonstrating that joint manipulation directed at the elbow and wrist as well as at the cervical and thoracic spinal regions results in clinical alterations in pain and the motor system. In addition to presenting this evidence, this paper describes proposed underlying physiological mechanisms of joint manipulation associated with the observed clinical effects. We propose that this information will be useful for the physical therapist in making clinical decisions regarding the selection of treatment technique for the management of patients with lateral epicondylalgia.     

Joint mobilization for children with central nervous system disorders: indications and precautions

Because clinicians are introducing joint mobilization into treatment programs for children with cerebral palsy, we felt that a review of the procedure and its scientific basis would be timely. The goals of the introductory section of this article are to define joint mobilization as it has been used for adults with musculoskeletal disabilities, to discuss various rationales for its effects, to describe contraindications and precautions for its use, and to discuss its efficacy as reported in the research literature. The latter part of the article deals with the use of joint mobilization for children with central nervous system (CNS) disorders. In an effort to understand precautions for the use of joint mobilization in children, musculoskeletal development will be described both for typically developing children and for children with spastic cerebral palsy. Indications for using joint mobilization techniques in children with spasticity will be outlined. Specific neurodevelopmental disabilities for which joint mobilization would be strongly contraindicated will be listed. Finally, future research directions in evaluating reliability of assessment of joint dysfunction and efficacy of joint mobilization in children will be discussed.     

Joint Mobilization of the Hands of Patients With Rheumatoid Arthritis: Results From an Assessor-Blinded,Randomized Crossover Trial

ObjectiveThe purpose of this study was to assess the clinical feasibility and effectiveness of manual mobilization of the hands of patients with rheumatoid arthritis (RA).MethodsA total of 320 individual hand joints were evaluated after recruiting an experimental research group of 12 participants with RA and, for clinical comparability, 8 participants with hand osteoarthritis (OA). One hand per participant was randomized to receive weekly low-grade (I-II) Kaltenborn manual mobilization, using passive sustained stretch of the metacarpophalangeal (MCP) joints II to V by licensed manual therapists. After 2 weeks, the randomized treated hand was crossed over to control (untreated) during weeks 3 to 4 and vice versa. Final assessment was at 2 months, which was 1 month after the last treatment at week 4. Primary hand outcomes included pain by visual analog scale, tender or swollen joint count, and presence of Doppler signal or synovial fluid and radiographic joint space by musculoskeletal ultrasound.ResultsIn the RA group, both the initially randomized treated hand and the contralateral hand improved significantly from baseline to crossover to follow-up at 2 months (pain outcomes and Doppler signal, P < .050; synovial fluid and MCP joint space, P ≤ .001). Hand pain and MCP joint space also improved significantly in OA. There were no dropouts or reported adverse events in either the RA or OA group.ConclusionIn this study, manual mobilization of the hands of patients with RA was shown to be feasible, safe, and effective to integrate into specialized healthcare.     

Strategies to overcome size and mechanical disadvantages in manual therapy

The practice of manual therapy (MT) is often difficult when providing care for large patients and for practitioners small in stature or with other physical limitations. Many MT techniques can be modified using simple principles to require less exertion, permitting consistency with standards of practice even in the presence of physical challenges. Commonly used MT techniques are herein described and demonstrated with alternative preparatory and movement methods, which can also be adopted for use in other techniques. These alternative techniques and the procedures used to adapt them warrant discussion among practitioners and educators in order to implement care, consistent with the best treatment evidence for many common musculoskeletal (MSK) conditions. The inclusion in educational curricula and MT training programs is recommended to enrich skill development in physical therapists (PTs), spanning entry-level practitioners to those pursuing advanced manual skills.