补泻手法辨证治疗腰背痛临床观察

根据中医基本理论,将120例腰背痛患者分为虚证和实证两大类,并分组进行疗效对比手法治疗。观察组60例,辩证施治,补虚泻实;对照组60例,平补平泻,不辩证施治。结果显示观察组痊愈率明显高于对照组,疗程也较对照组短(虚证P<0.05,实证P<0.01)。表明手法的补泻作用是客观存在的,且具有一定的临床应用价值。     

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.     

The efficacy of cervical/thoracic active range of motion for detecting changes associated with individuals receiving muscle energy techniques

Abstract

Background: Muscle energy techniques (METs) have been used to treat cervical and thoracic range of motion (ROM) restrictions for over 40 years. Of the trials published on METs, most have examined the effectiveness of METs on ROM in the cervical and thoracic spine.

Objectives: The aim of this systematic review was to investigate the sensitivity of cervical and thoracic rotation active range of motion, as an objective measure of function, for detecting changes associated with individuals receiving METs compared to (1) individuals receiving no treatment and (2) individuals receiving manipulation.

Methods: Relevant databases were searched from January 1970 up to March 2010. Methodological quality of each included study was assessed using the PEDro scale. Effect sizes (Hedges' g) and their 95% confidence intervals were calculated for active rotation ROM scores between and within the MET and comparison groups.

Results: Five randomized controlled trials were included in this review. Four studies addressed the first clinical question and one study answered the second. The average PEDro score was 5.8. In general, between and within group effect sizes were moderate to strong in favour of METs.

Conclusion: There is fair evidence that cervical and thoracic active range of motion is sensitive to changes associated with individuals who receive an MET. The change in ROM was associated with asymptomatic individuals having restricted rotation. Further studies with higher methodological quality are needed to make a stronger clinical conclusion about the effectiveness of METs.     

A History of Manipulative Therapy Through the Ages and Up to the Current Controversy in the United States

Abstract

Joint manipulation is an ancient art and science that can trace its origins to the earliest medical and lay practitioners. Today, it is practiced principally by physical therapists and chiropractors and to a lesser degree, by osteopathic and medical physicians. Self-manipulation of both joint and soft tissues is also a common practice in those who “crack” their own knuckles and spines. This article traces the history and development of manipulation from its origins to the present with a special emphasis on developments in the United States as a background for understanding current licensure and practice issues.

Since the beginning of this century, physical therapy has enjoyed a close relationship with medicine and has developed its knowledge base and practice in spinal and extremity manipulation from the medical profession. Manipulation in physical therapy has become a significant part of its rehabilitation practice, often encompassed in the terms therapeutic exercise, active and passive movement, or manual therapy. Instruction in manipulation begins with pre-professional education; for those who wish to specialize in this field, instruction continues at the post-professional level, following the medical model of specialization. Since the 1960's, physical therapists have developed their own body of knowledge in manipulation, emphasizing pain relief and enhanced physical function.

By contrast, since its independent origins in the late 19th century, chiropractic has practiced manipulation for most of its history as a primary therapeutic tool to correct spinal subluxation. It provides spinal adjustments to facilitate the free flow of nerve energy, which, in turn, relieves many human ailments. Unlike physical therapy, chiropractic has not been practiced in cooperation with medicine but has existed as an alternative during most of its history. In recent years, the chiropractic profession has divided along philosophical lines: those who strongly defend the subluxation theory (straights) to those who do not (mixers), with the later group now holding sway. This change in chiropractic philosophy and practice has brought practitioners into a practice model more closely aligned with the comprehensive model of rehabilitation therapy modeled by physical therapists. Consequently, many chiropractors now use physical therapy procedures even though they are prohibited from calling themselves physical therapists. As a result, competition in the market place has heightened, with concomitant licensure and political challenges.

This article discusses the history and evolution of the practice of manipulation against a background of other key developments in health care; as such, it should provide understanding for today's current practice scene.     

The Use of Upper Thoracic Manipulation in a Patient With Headache

Abstract

This case study describes how thrust manipulation in the upper thoracic spine was effective in reducing symptoms in a patient with complaint of headache; it discusses potential theories and interrelationships. The study describes a 29-year-old female with onset of occipital headaches who noted no change in symptoms after five treatments over a period of three weeks. Treatment included soft tissue mobilization, passive stretching, postural instruction/exercise and nonthrust manipulation to occipito-atlantal (O/A), atlanto axial (A/A) and cervical facet joints. The patient's sixth visit, that occurred 5 days after the fifth treatment session, included a thrust manipulation to the upper thoracic spine (T1/2) after which she noted a significant reduction in symptoms. The patient was then seen for two additional visits which included nonthrust manipulation techniques. Two days after her final visit, the patient noted full resolution of symptoms. The patient continued to note full resolution of symptoms for six weeks. The patient then returned to physical therapy with similar complaints but at approximately 50% of the earlier intensity. Two treatments, over a period of one week, utilizing nonthrust manipulation techniques yielded no relief in symptoms. One week later, the patient received a thrust manipulation at T2/3 after which she noted full resolution of symptoms. At follow up, seven weeks later, the patient remained symptom free.     

Manipulation in the Treatment of Acute Low Back Pain

Abstract

Study Design. This prospective research project statistically analyses the difference between two randomized groups of patients, one receiving manipulation plus exercises for acute low back pain of mechanical origin, the other receiving an exercise program alone. Objectives. To determine if orthopaedic manipulation is beneficial in treating acute low back pain of mechanical origin. Summary of Background Data. Orthopaedic manipulative physiotherapists have frequently observed dramatic results including elimination of pain and restoration of pain-free range of movement following manipulation of the acute locked back. Spinal manipulative therapy is a widely used method of treating lower back pain with millions of patient treatments performed each year, the majority in Western societies. Trials have emphasized the immediate and short-term symptomatic relief of low back pain following manipulation; however, the longterm difference in effects between manipulated and control groups has required further evaluation. Methods. A sample of convenience of acute low back pain participants were randomly assigned to two groups. A pre-test/post-test experimental design approach was used with 29 participants. This design included three dependent variables (pain, range of movement, and disability assessment) and one independent variable (15 participants in Group I received an exercise program with manipulation and 14 participants in Group II received an exercise program only). Participants were assessed for pain, range of movement, and disability before treatment. Participants were reassessed weekly for four weeks, then at two months and three months after initiation of treatment. Results. The findings of this study illustrate a statistically significant difference between the two treatments (p = <0.0005). Univariate post hoc tests concluded that the two treatment regimens had significantly different effects at three months on disability (p = 0.001), pain (p = <0.0005), and ROM (p = <0.0005). As well as being statistically significant, the magnitude of the relationships was strong, with 42.8% of the variability attributed to the disability measure, 64.3% of the variability attributed to the pain measure, and 65.9% of the variability attributed to the ROM measure. Conclusion. Patients who receive orthopaedic manipulation with an exercise program for acute low back pain of mechanical origin are likely to improve more than patients who receive an exercise program alone.     

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.     

Management of Low Back Pain: A Case Series Illustrating the Pragmatic Combination of Treatment- and Mechanism-Based Classification Systems

Abstract

This case series describes the pragmatic use of a treatment-based classification system for the management of four patients with a chief complaint of low back pain. Patients were initially classified into stabilization, manipulation, or specific exercise subgroups based on history and clinical examination. Each patient was reassessed during the course of clinical care to determine whether to continue treating according to the initially assigned subgroup or to alter management and incorporate a mechanism-based classification addressing identified impairments. Patient #1 was initially classified in the manipulation category. Within three visits, he reported being "a great deal better" on the Global Rating of Change (GROC) and had a 6-point improvement in his Oswestry Disability Index (ODI). Patient #2, classified in the specific exercise/extension category, reported being "moderately better" using the GROC and had a 22-point improvement in her ODI within six visits. Patient #3, classified in the stabilization category, reported being "a very great deal better" on the GROC and had a 30-point improvement in his ODI Index within four visits. Patient #4 was categorized initially in the manipulation category and subsequently in the specific exercise category; after five visits, he noted being "quite a bit better" using the GROC and he reported a 58-point improvement on his ODI. All four patients in this study were managed using a dynamic pragmatic treatment-based classification approach that allowed for the change of subgroup classification and treatment of impairments and all achieved a clinically meaningful improvement in pain and disability.     

Randomised Controlled Trials on the Efficacy Of Spinal Manipulation Therapy in The Treatment of Low Back Pain

Abstract

Low back pain presents a major challenge to health care professionals within both primary and secondary care. Spinal manipulation therapy is one option from a range of treatment techniques which until recently has lacked credibility, in part due to a dearth of published, plausible explanations of the mechanisms through which it works. Such explanations are starting to emerge but rigorous evaluations of spinal manipulation therapy over other treatment modalities remain few in number. This paper builds on the review by Mohseni-Bandpei et al. (Mohseni-Bandpei MA, Stephenson R, Richardson B. Spinal manipulation in the treatment of low back pain: a review of the literature with particular emphasis on randomised controlled trials. Phys Ther Rev 1998; 3:185–94), by reviewing literature in particular randomised controlled trials published in the field since that date. It is concluded that the efficacy of manipulation for patients with acute or chronic low back pain remains unconvincing and that the literature remains blighted by inconsistency of definitions of interventions and by methodological flaws.     

Needle EMG Response of Lumbar Multifidus to Manipulation in the Presence of Clinical Instability

Abstract

A proposed mechanism for the persistence of low back pain due to clinical instability is a decrease in control of local spinal musculature, more specifically decreased recruitment of multifidus. Altered segmental mechanoreceptor input has been proposed as a contributing factor responsible for a decrease in local muscle recruitment. In this case report, immediate changes in the recruitment of the deep multifidus following manipulation were examined using needle EMG and isometric testing of trunk rotational force. Trunk rotational force appeared to improve while the multifidus demonstrated a decrease in activity as measured by needle EMG. No specific conclusions can be drawn from this report; however, the results do suggest that immediate multifidus function may be influenced with manipulation, resulting in improved muscular control of the trunk.