Posteroanterior motion test of a lumbar vertebra: accuracy of perception

PURPOSE: The aim of this study was to investigate the accuracy of perception of forces applied to and displacement produced in an electromechanical one vertebral spinal model, among inexperienced and experienced physical, therapists performing posteroanterior pressure on a lumbar vertebra, before and after a training session. METHODS: Ten relatively inexperienced physical therapists and ten experienced manual therapists participated. An electromechanical single level spinal model was used for applying oscillatory posteroanterior pressure and measuring the forces on and displacement of the vertebra. A digital oscilloscope was used to give direct feedback to the therapists while performing mobilization to discern the magnitude of these two variables. RESULTS: The inexperienced group estimated the displacement accurately but the experienced group was significantly inaccurate (p<0.02), and both groups were inaccurate in estimating the force (p<0.001), before training. Following training, the inexperienced group maintained their accuracy on displacement and the experienced group improved their accuracy significantly (p<0.001). Both groups approached significance in improving their accuracy of force estimation. CONCLUSION: An electromechanical spinal model can be used as training tool along with an oscilloscope. Longer training may be needed for the force than the displacement for accurate perception.     

Effect of feedback on learning a vertebral joint mobilization skill

This study was designed to investigate whether concurrent quantitative feedback of performance could improve the learning of a joint mobilization technique. A group of 110 physical therapy students had been randomly divided into two groups for teaching purposes. All students had previously learned mobilization of peripheral joints and were currently learning spinal mobilization. From one of the groups, 22 students volunteered to comprise a control group, which was taught a spinal mobilization technique in the traditional way. Additional concurrent quantitative feedback of the level of force applied to the patient was given to 31 volunteers from the other group. These students formed the experimental group. A force plate was used for force measurement, and the feedback was given via an oscilloscope. The average force applied by the students' instructors was taken as an "ideal" force. The oscilloscope showed both the applied force and the "ideal" force. Consistency was measured by the variance of the group's performance. Accuracy was assessed by calculating the difference between the applied force and the "ideal" force. Results indicated that this feedback was associated with a significant improvement in accuracy and consistency in the application of the mobilizing force. This improvement was still present at a follow-up test conducted one week later. This result supports a greater use of such feedback in the teaching and practice of joint mobilization techniques, although the need for further research is emphasized.     

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     

Naloxone fails to antagonize initial hypoalgesic effect of a manual therapy treatment for lateral epicondylalgia

BACKGROUND: Recent research has shown that Mulligan's Mobilization With Movement treatment technique for the elbow (MWM), a peripheral joint mobilization technique, produces a substantial and immediate pain relief in chronic lateral epicondylalgia (48% increase in pain-free grip strength).([1]) This hypoalgesic effect is far greater than that previously reported with spinal manual therapy treatments, prompting speculation that peripheral manual therapy treatments may differ in mechanism of action to spinal manual therapy techniques. Naloxone antagonism and tolerance studies, which employ widely accepted tests for the identification of endogenous opioid-mediated pain control mechanisms, have shown that spinal manual therapy-induced hypoalgesia does not involve an opioid mechanism. OBJECTIVE: The aim of this study was to evaluate the effect of naloxone administration on the hypoalgesic effect of MWM. METHODS: A randomized, controlled trial evaluated the effect of administering naloxone, saline, or no-substance control injection on the MWM-induced hypoalgesia in 18 participants with lateral epicondylalgia. Pain-free grip strength, pressure pain threshold, thermal pain threshold, and upper limb neural tissue provocation test 2b were the outcome measures. RESULTS: The results demonstrated that the initial hypoalgesic effect of the MWM was not antagonized by naloxone, suggesting a nonopioid mechanism of action. CONCLUSIONS: The studied peripheral mobilization treatment technique appears to have a similar effect profile to previously studied spinal manual therapy techniques, suggesting a nonopioid-mediated hypoalgesia following manual therapy.     

Forces applied during manual therapy to patients with low back pain

BACKGROUND: To date, there is little information available regarding the forces used during mobilization treatment of patients with low back pain (LBP). OBJECTIVE: This study measured such forces and investigated whether the force characteristics could be predicted on the basis of physical therapist and patient characteristics. SUBJECTS: Ten physical therapists applied a central posteroanterior (PA) mobilization treatment to 80 patients with LBP, providing data on treatment of 123 lumbar levels. METHODS: Physical therapists were required to treat their patients while the patients lay on an instrumented couch. This couch has been shown to be highly accurate in its measurement of force in 3 directions (error <2%) and has demonstrated high test-retest reliability (ICC [2, 1], 99% CI = 0.99-1.00). The forces applied by the physical therapists were recorded over a 10-second period. Data on the characteristics of the physical therapists and patients were collected by means of questionnaires. RESULTS: The force used by physical therapists related not only to patient characteristics but also to physical therapist characteristics. Interestingly, current pain intensity and nature of symptoms did not affect the forces used. The overall patterns of the force characteristics were generally consistent with previous studies performed in asymptomatic subjects. However, the magnitude of the force applied and the frequency of each grade used in the present study are relatively higher than in earlier studies. CONCLUSION: These preliminary data provide some useful quantitative information about the forces used during mobilization treatment of patients with LBP. Also, the force characteristics described here may provide useful data for both teaching and research in manual therapy.     

Four Cardinal Principles of Joint Mobilization and Joint Play Assessment

Abstract

The teaching and learning of fundamental principles that guide valid and effective assessment and intervention techniques in joint mobilization is a basic foundation to those health professions that make use of manual therapy. Such principles help establish the specificity of manual therapy techniques, the foremost quality of 'best practice.' However, authors of few textbooks or reference books devote space to establishing such fundamental principles for learners and practitioners of manual therapy techniques. The purpose of this paper is to present four cardinal principles that have impressed us, over our years as educators and clinicians, as the foundation for the teaching and practice of sound manual therapy techniques for either joint play assessment or joint mobilization. These principles are utilized in practice from entry-level to master clinicians, they can guide educators as to how to introduce and monitor effective manual therapy skills among students and colleagues, and they can also serve as a source of refreshment for experienced clinicians who desire continuing education for maintenance of their hands-on skills in manual therapy interventions and assessment.     

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.     

Morphology and kinematics of the atlanto-axial joints and their interaction during manual cervical rotation mobilization

Background data

At present little data are available on the relationship between spinal anatomy and kinematics. No studies have verified the relationship between atlanto-axial kinematics during manual mobilization and the spatial features of the atlanto-axial ligaments and the lateral joints.

Materials and methods

Twenty un-embalmed cervical spine specimens (9 male and 11 female; 80 ± 11 years) were studied. Atlanto-axial kinematics were registered during manual axial rotation mobilization using an ultrasound-based motion tracking system. Anatomical landmarks were digitized and spatial features of the lateral atlanto-axial joint surfaces and alar ligaments were extracted. The relationship between the anatomical features and the spinal kinematics was analyzed using statistical regression analysis.

Results

Only the range of motion of the coupled flexion–extension motion component, the ratio and the time shift between main axial rotation and coupled lateral bending motion components could be predicted for about 52%, 49% and 73%, respectively, by a selected set of anatomical features.

Conclusion

Supposed relationships between anatomical features and joint kinematics are only partially confirmed. The results indicate that the kinematics of the atlanto-axial joint during manual regional axial mobilization are not completely predetermined by the specimens’ specific anatomy.     

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.     

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.     

Inter-clinician and intra-clinician reliability of force application during joint mobilization: A systematic review

Joint mobilizations are commonly used by clinicians to decrease pain and restore joint arthrokinematics following musculoskeletal injury. The force applied during a joint mobilization treatment is subjective to the individual clinician but may have an effect on patient outcomes. The purpose of this systematic review was to critically appraise and synthesize the studies which examined the reliability of clinicians' force application during joint mobilization. A systematic search of PubMed and EBSCO Host databases from inception to March 1, 2013 was conducted to identify studies assessing the reliability of force application during joint mobilizations. Two reviewers utilized the Quality Appraisal of Reliability Studies (QAREL) assessment tool to determine the quality of included studies. The relative reliability of the included studies was examined through intraclass correlation coefficients (ICC) to synthesize study findings. All results were collated qualitatively with a level of evidence approach. A total of seven studies met the eligibility and were included. Five studies were included that assessed inter-clinician reliability, and six studies were included that assessed intra-clinician reliability. The overall level of evidence for inter-clinician reliability was strong for poor-to-moderate reliability (ICC = −0.04 to 0.70). The overall level of evidence for intra-clinician reliability was strong for good reliability (ICC = 0.75–0.99). This systematic review indicates there is variability in force application between clinicians but individual clinicians apply forces consistently. The results of this systematic review suggest innovative instructional methods are needed to improve consistency and validate the forces applied during of joint mobilization treatments. This is particularly evident for improving the consistency of force application across clinicians.     

Force-deformation response of the lumbar spine: a sagittal plane model of posteroanterior manipulation and mobilization

OBJECTIVE: To develop a mathematical model capable of describing the static and dynamic motion response of the lumbar spine to posteroanterior forces. DESIGN: Static, impulsive and oscillatory forces with varying thrust angles and offsets were applied to the model, and the resulting motion responses were compared to experimental data published for spinal mobilization and manipulation of prone-lying subjects. BACKGROUND: Methods are sought to improve understanding of the dynamic force-induced displacement response of the lumbar spine during spinal mobilization and manipulation treatment. METHODS: The thorax, pelvis and five lumbar vertebrae were represented as seven rigid structures and eight flexible joint structures. Flexible joint structures were modeled using spring and damper elements with three displacement degrees-of-freedom (posterior-anterior and axial displacement, and flexion-extension rotation). The resulting 21 degrees-of-freedom lumped parameter model was solved in modal space. RESULTS: The fundamental natural frequency of vibration was 5.24 Hz. Simulations performed using 100 N static and dynamic posteroanterior forces applied to the L3 vertebrae indicated that peak L3 segmental displacements were up to 2.40 mm (impulsive) and 8.23 mm (oscillatory at 2 Hz). Appreciable axial displacements (0.41 mm) and flexion-extension rotations (1.49 degrees ) were also observed for oscillatory forces at L3. The posteroanterior motion response of the lumbar vertebrae was relatively insensitive to both the thrust force angle and thrust force offset, but axial displacements and flexion-extension rotations showed a large change (2-fold or greater) for thrust angles greater than -5 degrees (caudal) in comparison to vertical thrusts. Intersegmental motion responses for static, impulsive and oscillatory loads were more comparable than their segmental counterparts. CONCLUSIONS: The model predicts lumbar segmental and inter-segmental motion responses to manipulative forces that are otherwise difficult to obtain experimentally. RELEVANCE: This study assists clinicians to understand the biomechanics of posteroanterior forces applied to the lumbar spine of prone-lying subjects. Of particular clinical relevance is the finding that greater spinal mobility is possible by targeting specific load-time histories.     

Manual fixation versus locking during upper cervical segmental mobilization. Part 2: an in vitro three-dimensional arthrokinematic analysis of manual axial rotation and lateral bending mobilization of the atlanto-axial joint

BackgroundThree-dimensional kinematic aspects of coupled motion during manual cervical mobilization have not previously been studied. Using an in vitro 3D-motion analysis method, the kinematic effects of two different segmental techniques for axial rotation and lateral bending mobilization of the upper cervical spine were investigated as a second part of the study (in part one, kinematic effects of flexion-extension mobilization have been investigated).MethodsAxial rotation and lateral bending mobilization of the atlanto-occipital and atlanto-axial segments were analysed in vitro using an electromagnetic tracking device. Local reference frames were defined based on bony reference points that were registered using a 3D-digitizing stylus.Five embalmed and one fresh specimen were analysed. Segmental motion was registered simultaneously in the atlanto-occipital and the atlanto-axial joints during manual mobilization through the full range of axial rotation and lateral bending mobility. The 3D-kinematic aspects during regional mobilization were compared with those during segmental mobilization with manual fixation and during segmental mobilization using a locking technique.ResultsDuring both segmental axial rotation techniques of the atlanto-axial joint, a significant reduction of the coupled lateral bending and flexion-extension motion was observed. The locking technique also induced an increase in the main axial rotation component. During lateral bending mobilization of the atlanto-axial joint, the manual fixation technique reduced the effect on the coupled flexion-extension component significantly.InterpretationsThese results suggest that for manual segmental axial rotation and lateral bending mobilization of the upper cervical spine segmental manual fixation or locking may be preferred in different situations depending on the desired effects. This study brings additional information to the data provided by part 1 of this study on the 3D-arthrokinematic effects of flexion-extension mobilization.     

Measurement of accessory motion: critical issues and related concepts.

The term "manual therapy" has traditionally been associated with physical therapists who examine and treat patients who have disorders related to the musculoskeletal system. In addition to using instruments to collect patient data, these therapists use a large variety of manually applied examination procedures. Range-of-motion tests, manual muscle tests, neurological tests, and palpation tests are just a few of the categories of tests these therapists use as part of the clinical decision-making process. The major sources of error that can affect the usefulness of manually obtained measurements are discussed. The literature that provides the theoretical and clinical bases for the assessment of joint surface movement is thoroughly reviewed. Conclusions are made about what is currently known about the usefulness of accessory motion tests. Suggestions are made for future research needs in order to clarify and enhance the usefulness of accessory motion tests and other examination procedures used by manual therapists.     

Knee joint mobilization reduces secondary mechanical hyperalgesia induced by capsaicin injection into the ankle joint.

Joint mobilization is a treatment approach commonly used by physical therapists for the management of a variety of painful conditions. However, the clinical effectiveness when compared to placebo and the neurophysiological mechanism of action are not known. The purpose of this study was to establish that application of a manual therapy technique will produce antihyperalgesia in an animal model of joint inflammation and that the antihyperalgesia produced by joint mobilization depends on the time of treatment application. Capsaicin (0.2%, 50 microl) was injected into the lateral aspect of the left ankle joint and mechanical withdrawal threshold assessed before and after capsaicin injection in Sprague-Dawley rats. Joint mobilization of the ipsilateral knee joint was performed 2 h after capsaicin injection for a total of 3 min, 9 min or 15 min under halothane anaesthesia. Control groups included animals that received halothane for the same time as the group that received joint mobilization and those whose limbs were held for the same duration as the mobilization (no halothane). Capsaicin resulted in a decreased mechanical withdrawal threshold by 2 h after injection that was maintained through 4 h. Both 9 and 15 min of mobilization, but not 3 min of mobilization, increased the withdrawal threshold to mechanical stimuli to baseline values when compared with control groups. The antihyperalgesic effect of joint mobilization lasted 30 min. Thus, joint mobilization (9 or 15 min duration) produces a significant reversal of secondary mechanical hyperalgesia induced by intra-articular injection of capsaicin.     

Influence of elbow flexion angle on mobilization of the proximal radio-ulnar joint: a motion analysis using cadaver specimens

The purpose of this study was to determine the most effective elbow joint flexion angle for mobilization of the proximal radio-ulnar joint. Five fresh-frozen cadaveric elbows were used to measure displacement of the radial head in the antero-medial and postero-lateral directions by traction force of 2kgf and 4kgf, respectively. Simulation of the gliding of the proximal radio-ulnar joint was performed at four elbow flexion angles (0 degrees , 30 degrees , 60 degrees , 90 degrees). Data obtained from those flexion angles were compared using one-way repeated measures analysis of variance. Radial head displacement at 60 degrees and 90 degrees during antero-medial gliding were significantly greater than those at 0 degrees and 30 degrees (p<0.05) There were no significant differences in radial head displacement among four elbow flexion angles during postero-lateral gliding at 2kgf and 4kgf. Our findings suggest that proximal radio-ulnar joint mobilization in the antero-medial direction can be performed effectively at 60 degrees and 90 degrees elbow flexion.     

Reproducibility of global three-dimensional motion during manual atlanto-axial rotation mobilization: an in vitro study

The reproducibility of the three-dimensional (3D) kinematic aspects of motion coupling patterns during manual mobilizing techniques is still a debatable matter. The present in vitro study analysed segmental 3D motion of the atlanto-axial joint during manual axial rotation mobilization. Twenty fresh frozen human cervical specimens were studied in a test–retest situation with two examiners. The specimens were manually mobilized using three different techniques: (1) a regional mobilization technique of the cervical spine; (2) a segmental mobilization technique of the atlas with manual fixation of the axis; and (3) a segmental mobilization of the atlas on the axis applying a locking technique. Segmental atlanto-axial kinematics was registered with a Zebris CMS-20 ultrasound-based tracking system. The Euclidian norm was used as a representation of overall 3D motion. The results indicated good reproducibility (mean intraclass correlation coefficient, ICC: 0.87). Intraobserver reproducibility was slightly higher (mean ICC: 0.91; range: 0.76–0.99) than interobserver reproducibility (mean ICC: 0.85; range: 0.56–0.98) (P < 0.05). The total range of motion expressed as the Euclidean norm of 3D motion components was a parameter with good reproducibility in the study of segmental kinematics of manual atlanto-axial mobilization. Although previous studies have demonstrated poor inter-rater reliability of manual examination and mobilization of segmental motion components, the results of the present study shed a new and more positive light on the reproducibility of techniques for manual mobilization of the upper cervical spine.     

Immediate and Carryover Changes of C5-6 Joint Mobilization on Shoulder External Rotator Muscle Strength

ObjectiveClinical evidence has shown that extremity dysfunction, such as muscle weakness or inhibition, is associated with spinal disorders. Spinal manual therapy is a common therapeutic approach used to address extremity muscle weakness. The purpose of the study was to assess changes in the maximal muscle strength of the shoulder external rotators immediately and at 10, 20, and 30 minutes after cervical joint mobilization at the C5-6 segment.MethodsEighteen participants with existing or a history of neck pain were screened by 2 investigators independently for muscle weakness of shoulder external rotators. Fifteen qualified participants underwent shoulder external rotator strength testing with a handheld dynamometer. Each participant was tested 6 times, twice before, immediately after, and at 10, 20, and 30 minutes after a C5-6 joint mobilization on the involved side. The 2 strength data collected before the mobilization were used to determine intratester reliability.ResultsThe intratester reliability of the shoulder external rotator strength was excellent (intraclass correlation coefficient_3,2 = 0.985). One-way analysis of variance with repeated measures showed a statistical significance in strength data (P = .002). Post hoc tests revealed a significant increase between prejoint mobilization and immediately postjoint mobilization (P = .003) and between pre joint mobilization and 10-minute post joint mobilization (P < .001).ConclusionsThe results of the study suggest that C5-6 joint mobilization increases muscle strength of the shoulder external rotators immediately and its effect carries over for 10 minutes but not after 20 minutes.