Force transmission between thoracic and cervical segments of the spine during prone-lying high-velocity low-amplitude spinal manipulation: A proof of principle for the concept of regional interdependence

BackgroundRegional interdependence is conceptually based on observations that applying manual therapy to a remote anatomical region has an effect in the area of the patient's primary complaint. The current model for regional interdependence depends on force transmissibility within the body. This investigation sought to determine transmissibility between forces applied to the thoracic spine during prone-lying high-velocity low-amplitude spinal manipulative therapy and the cervical spine.MethodsA chiropractic treatment table was modified to allow (or disallow) translation of the headrest in the caudal-cephalad direction when unlocked (or locked). Prone-lying high-velocity low-amplitude spinal manipulative therapy was applied to the thoracic region of 9 healthy participants with the headrest in both configurations. Head and thorax kinematics and kinetics were measured at interfaces between participant and the external environment, which included the clinician's hands. Compressive forces at the cervicothoracic junction and angular kinematics of the cervical spine were derived. Ratios between the clinician-applied forces (input) and the cervical compressive force (output) were also determined.FindingsThe cervical spine extended during all high-velocity low-amplitude spinal manipulative therapy trials. Force input-to-output ratios exceeded 1 for high-velocity low-amplitude spinal manipulative therapy trials performed with the headrest in the locked configuration, which was greater than ratios for the unlocked configuration.InterpretationForces imparted to thoracic spine during high-velocity low-amplitude spinal manipulative therapy were transmitted to the cervical spine, which provided a precursor for the regional interdependence model for manual therapy. Friction between the participant's face and the treatment table's head rest likely amplified cervical compressive forces.     

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.     

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.     

Effects of Tibiofibular and Ankle Joint Manipulation on Hip Strength and Muscle Activation

ObjectivesThe purpose of this study was to determine whether high-velocity, low-amplitude ankle region manipulations could increase force output and muscle activation of hip musculature in individuals with a history of ankle sprain and unilateral tensor fascia latae (TFL) weakness during muscle testing.MethodsThis investigation used a single-arm repeated measures design. Twenty-five participants’ force outputs were tested at three time points (before manipulation, immediately after manipulation, and 48 hours after manipulation), and muscle activation of the rectus femoris, gluteus medius, and TFL was measured before and immediately after manipulation. Manipulations were applied to the talocrural, subtalar, proximal, and distal tibiofibular joints of the weaker limb. No contralateral manipulations were applied. Two-way repeated measures analysis of variance was used to compare maximal and average force production for each limb. In addition, paired t tests were used to compare muscle activation before and after manipulations.ResultsThere was a significant limb × time interaction. The involved limb average force increased from before manipulation (65.7 N) to 48 hours after manipulation (77.8 N; P = .014), maximal force increased (76.9 N) 48 hours after manipulation (87.8 N; P = .030), and gluteus medius activation increased (9.8% maximum, 12.2% average) immediately after manipulation. No significant differences were found in the uninvolved limb.ConclusionThe results of this study suggest that high-velocity, low-amplitude ankle region manipulations might improve hip abductor strength in individuals with a history of ankle sprain and unilateral weakness during a TFL muscle test.     

Spinal manipulation does not affect pressure pain thresholds in the absence of neuromodulators: a randomized controlled trial

Background: Measurement of pressure pain threshold (PPT) is a way to determine one of the many potential treatment effects of spinal manipulative therapy.

Objective: To determine how multiple spinal manipulations administered in a single-session affected PPTs at local and distal sites in asymptomatic individuals.

Methods: Participants were randomly assigned into one of three groups: Group one (n = 18) received a lumbar manipulation followed by a cervical manipulation. Group two (n = 17) received a cervical manipulation followed by a lumbar manipulation. The control group (n = 19) received two bouts of five minutes of rest. At baseline and after each intervention or rest period, each participant’s PPTs were obtained using a handheld algometer. The PPTs were tested bilaterally over the lateral epicondyles of the humerus and over the mid-bellies of the upper trapezius, lumbar paraspinal, and the tibialis anterior muscles. This study was registered with ClinicalTrials.gov, and its Identifier is NCT02828501.

Results: Repeated-measures ANOVAs and Kruskal–Wallis tests showed no significant within- or between-group differences in PPT. Within-group effect sizes in the changes of PPT ranged from ?.48 at the left paraspinal muscles to .24 at the left lateral humeral epicondyle. Statistical power to detect significant differences at α of 0.05 was calculated to be 0.94.

Conclusions: This study suggests that in young adults who do not have current or recent symptoms of spinal pain, multiple within-session treatments of cervical and lumbar spinal manipulation fail to influence PPTs. Changes in PPT that are observed in symptomatic individuals are likely to be primarily influenced by pain-related neuromodulators rather than by an isolated, mechanical effect of spinal manipulation.     

Use of Multifidus Isometric for a Patient with Acute Neck Pain: A Case Report

Abstract

The purpose of this case report is to describe how a simple isometric technique was effective in treating a patient with complaints of acute neck pain. The patient was a 35-year-old female who complained of an acute onset of right cervical pain. She exhibited a significant increase in range of motion (approximately 50 degrees of right rotation) and a 50% reduction in pain level after one treatment. After two treatments, full pain-free cervical range of motion and function was restored. The report suggests that the technique can significantly increase cervical range of motion and decrease pain in one treatment session. Thrust and nonthrust manipulation techniques have been found to be effective in treating neck pain. Nonthrust techniques, however, appear to lessen the risk to the patient. The multifidus isometric is a safe, nonthrust manual therapy technique that can be effective in reducing pain and increasing range of motion in some cases of acute cervical dysfunction in as little as one treatment session.     

Unilateral and Multiple Cavitation Sounds During Lumbosacral Spinal Manipulation

ObjectiveThe purpose of this study was to determine from which side of the spine the popping sound (PS) emanates during side-lying, rotatory high-velocity low-amplitude (HVLA) thrust manipulation directed to the L5-S1 articulation using a time-frequency analysis. Secondary aims were to calculate the average number of PSs, the duration of lumbar thrust manipulation, and the duration of a single PS.MethodsThirty-four asymptomatic participants received 2 lumbar HVLA thrust manipulations targeting the right and left L5-S1 articulations. Two high sampling rate accelerometers were secured bilaterally 25 mm lateral to the midline of the L5-S1 interspace. For each manipulation, 2 audio signals were extracted and singularly processed via spectrogram calculation to obtain the release of energy over time on each side of the lumbosacral junction.ResultsDuring 60 HVLA thrust manipulations, it was measured a total of 320 PSs. Of those PSs, 176 occurred ipsilateral and 144 occurred contralateral to the targeted L5-S1 articulation; that is, the PS was no more likely to occur on the upside than the downside facet after right or left rotatory L5-S1 HVLA thrust manipulation. Moreover, PSs occurring on both sides at the same time were detected very rarely (ie, 2% of cases) with the lumbar HVLA thrust manipulations. The mean number of audible PSs per lumbosacral HVLA thrust manipulation was 5.27 (range 2-9). The mean duration of a single manipulation was 139.13 milliseconds (95% confidence interval: 5.61-493.79), and the mean duration of a single PS was 2.69 milliseconds (95% confidence interval: 0.95-4.59).ConclusionBased on our findings, spinal manipulative therapy practitioners should expect multiple PSs that most often occur on the upside or the downside facet articulations when performing HVLA thrust manipulation to the lumbosacral junction (ie, L5-S1). However, whether the multiple PSs found in this study emanated from the same joint or adjacent ipsilateral or contralateral facet joints remains unknown. A single model may not necessarily be able to explain all of the audible sounds during HVLA thrust manipulation.     

Effect of Spinal Manipulation Thrust Duration on Trunk Mechanical Activation Thresholds of Nociceptive-Specific Lateral Thalamic Neurons

Objective

The objective of this preliminary study was to determine if high-velocity, low-amplitude spinal manipulation (HVLA-SM) thrust duration alters mechanical trunk activation thresholds of nociceptive-specific (NS) lateral thalamic neurons.

Methods

Extracellular recordings were obtained from 18 NS neurons located in 2 lateral thalamic nuclei (ventrolateral [n = 12] and posterior [n = 6]) in normal anesthetized Wistar rats. Response thresholds to electronic von Frey anesthesiometer (rigid tip) mechanical trunk stimuli applied in 3 lumbar directions (dorsal-ventral, 45° caudal, and 45° cranial) were determined before and immediately after the delivery of 3 HVLA-SM thrust durations (time control 0, 100, and 400 milliseconds). Mean changes in mechanical trunk activation thresholds were compared using a mixed model analysis of variance.

Results

High-velocity, low-amplitude spinal manipulation duration did not significantly alter NS lateral thalamic neurons' mechanical trunk responses to any of the 3 directions tested with the anesthesiometer.

Conclusions

This study is the first to examine the effect of HVLA-SM thrust duration on NS lateral thalamic mechanical response thresholds. High-velocity, low-amplitude spinal manipulation thrust duration did not affect mechanical trunk thresholds.     

Medical diagnosis of cubital tunnel syndrome ameliorated with thrust manipulation of the elbow and carpals

Abstract

This case report describes the effectiveness of thrust manipulation to the elbow and carpals in the management of a patient referred with a medical diagnosis of cubital tunnel syndrome (CuTS). The patient was a 45-year-old woman with a 6-week history of right medial elbow pain, ulnar wrist pain, and intermittent paresthesia in the ulnar nerve distribution. Upon initial assessment, she presented with a positive elbow flexion test and upper limb neurodynamic test with ulnar nerve bias. A biomechanical assessment of the elbow and carpals revealed a loss of lateral glide of the humerus on the ulna and a loss of palmar glide of the triquetral on the hamate. After the patient received two thrust manipulations of the elbow and one thrust manipulation of the carpals over the course of four sessions, her pain and paresthesia were resolved. This case demonstrates that the use of thrust manipulation to the elbow and carpals may be an effective approach in the management of insidious onset CuTS. This patient was successfully treated with thrust manipulation when joint dysfunction of the elbow and wrist were appropriately identified. This case report may shed light on the examination and management of insidious onset CuTS.     

Cyriax Physiotherapy Versus Phonophoresis with Supervised Exercise in Subjects with Lateral Epicondylalgia: A Randomized Clinical Trial

Abstract

Cyriax and Cyriax advocated the use of deep transverse friction massage in combination with Mill's manipulation in treating lateral epicondylalgia. Evidence comparing this approach with other physical therapies is lacking. The purpose of this randomized clinical trial was to compare the effectiveness of deep transverse friction massage with Mill's manipulation versus phonophoresis with supervised exercise in managing lateral epicondylalgia. Sixty patients age 30-60, presenting with the teno-periosteal variety of lateral epicondylalgia with symptom duration greater than one month, were randomized into two groups. The control group received phonophoresis with diclofenac gel over the area of the lateral epicondyle for 5 minutes combined with supervised exercise. The experimental group received 10 minutes of deep transverse friction massage followed by a single application of Mill's manipulation. Both groups received treatment 3 times per week for 4 weeks. Outcomes of interest included pain via visual analog scale (VAS), pain-free grip strength, and functional status measured with the Tennis Elbow Function Scale. Data were analyzed using a one-way ANOVA. Whereas both groups improved significantly from the initiation of treatment, a between-group comparison revealed significantly greater (p<0.05) improvements regarding pain, pain-free grip, and functional status for the experimental group compared to the control group. The results of this study demonstrate that Cyriax physiotherapy is a superior treatment approach compared to phonophoresis and exercise in managing lateral epicondylalgia.     

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.

Management of Lumbar Spinal Stenosis through the Use of Translatoric Manipulation and Lumbar Flexion Exercises: A Case Series

Abstract

Lumbar spinal stenosis is a narrowing of the spinal canal or intervertebral foramen that can produce low back pain and leg pain and weakness. Surgical intervention is commonly performed to relieve these symptoms. Symptom reduction and longitudinal management of functional deficits with conservative care is less well documented. The purpose of this case series was to describe the outcomes of a conservative physical therapy program consisting of low- and high-velocity translatoric manipulations of T1-T9 and L1-L3, and two lumbar flexion exercises on 6 subjects diagnosed with lumbar spinal stenosis and neurogenic claudication. A treadmill test was repeated on a weekly basis and at discharge for each patient. All six subjects demonstrated improvements in treadmill walking time prior to the onset of neurogenic claudication (range: 1 min 34 sec to 26 min); in Oswestry Low Back Pain Disability Index scores (range: 7.5% to 64.7%); and in McGill Pain Questionnaire scores (range: 25% to 57%). Five subjects were measured using the Schober technique, and all showed improvement in thoracolumbar flexion mobility. Combined use of translatoric manipulation and spinal flexion exercises may have resulted in improved spinal flexibility, ambulatory abilities, and pain and functional status in six subjects with lumbar spinal stenosis.     

Multimodal physical therapy management of a 48-year-old female with post-stroke complex regional pain syndrome

Abstract

This case report describes a 48-year-old female who presented with complaints of right shoulder pain, hyperesthesias and swelling of the hand along with added symptoms of pain centralization following a cerebrovascular accident. On clinical evaluation, the patient satisfied the Budapest diagnostic criteria for Complex Regional Pain Syndrome (CRPS) type-1. Physical therapy management (1st three sessions) was initially focused on pain neurophysiology education with an aim to reduce kinesiophobia and reconceptualise her pain perception. The patient had an immediate significant improvement in her pain and functional status. Following this, pain modulation in the form of transcutaneous electrical nerve stimulation, kinesio tape application, “pain exposure” physical therapy and exercise therapy was carried out for a period of 7 weeks. The patient had complete resolution of her symptoms which was maintained at a six-month follow-up.     

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.     

Conservative chiropractic care of lateral epicondylitis

OBJECTIVE: To discuss the management of a patient with lateral epicondylitis refractory to previous medical and conservative interventions. CLINICAL FEATURES: A 45-year-old woman had difficulty in supinating her left elbow because of pain from activities at work. Standard tests demonstrated and reproduced pain at the lateral epicondyle with resisted extension of the wrist and fingers. INTERVENTION AND OUTCOME: Specific joint manipulation for relief of lateral epicondylitis was performed. Immobilization of the elbow joint after manipulation was accomplished by means of a sugar tong plaster splint. Follow-up joint manipulation with a progressive rehabilitation program was effective in providing relief of symptoms. CONCLUSION: Resolution of pain and limited elbow motion was demonstrated after Mills' manipulation.     

Lumbar manipulation and exercise for the treatment of acute low back pain in adolescents: a randomized controlled trial

ObjectivesLow back pain (LBP) is a common condition in adolescents. Although much has been written about the efficacy of lumbar manipulation for adults with LBP, little is known about its effectiveness in adolescents. This study had two primary aims: (1) to assess the efficacy of adding lumbar manipulation to an exercise program in adolescents with acute (<90 days) LBP and (2) to report and assess any adverse reactions associated with lumbar manipulation noted in this study.MethodsPatients were randomly assigned to receive lumbar manipulation or sham manipulation. All patients performed 4 weeks of physical therapy exercise. Pain, patient-specific functional scale (PSFS), and global rating of change (GROC) scores were measured at evaluation, 1 week, 4 weeks, and 6 months. Relative risk was calculated for adverse reactions noted.ResultsWe recruited 35 consecutive patients with acute LBP. One patient was excluded after being diagnosed with a spondylolysis, 34 patients remained for analysis. Both groups experienced significant improvement over time in all measures. There were no differences between groups for pain, PSFS, or GROC scores. No increased risk of adverse reaction from lumbar manipulation was noted.DiscussionThe addition of lumbar manipulation to exercise did not benefit adolescents with acute LBP. There was not an increased risk of an adverse reaction noted in this study from lumbar manipulation performed on adolescents. Further research needs to be done to identify factors that predict positive outcomes following lumbar manipulation in adolescents.