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Filed under: Uncategorized
November 26, 2009 • 7:45 pm 1
Interaction between trigger points and joint hypomobility: a clinical perspective
- de las Penas, CF
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.
Journal of Manual & Manipulative Therapy, 2009; 17(2): 74-7 (46 ref) – abstract
MTABC members – permalink (sign in to EBSCO for access)
Filed under: Conservative therapies, Topic review, Trigger points , Joints -- Physiopathology, Manual therapy, Muscles -- Physiopathology, Neck Pain -- Therapy, Trigger Point
October 1, 2009 • 7:19 pm 0
Manual physical therapy and exercise versus electrophysical agents and exercise in the management of plantar heel pain: a multicenter randomized clinical trial.
Cleland JA, Abbott JH, Kidd MO, Stockwell S, Cheney S, Gerrard DF, Flynn TW.
OBJECTIVE:
To compare the effectiveness of 2 different conservative management approaches in the treatment of plantar heel pain.
BACKGROUND:
There is insufficient evidence to establish the optimal physical therapy management strategies for patients with heel pain, and little evidence of long-term effects.
METHODS:
Patients with a primary report of plantar heel pain underwent a standard evaluation and completed a number of patient self-report questionnaires, including the Lower Extremity Functional Scale (LEFS), the Foot and Ankle Ability Measure (FAAM), and the Numeric Pain Rating Scale (NPRS). Patients were randomly assigned to be treated with either an electrophysical agents and exercise (EPAX) or a manual physical therapy and exercise (MTEX) approach. Outcomes of interest were captured at baseline and at 4-week and 6-month follow-ups. The primary aim (effects of treatment on pain and disability) was examined with a mixed-model analysis of variance (ANOVA). The hypothesis of interest was the 2-way interaction (group by time).
RESULTS:
Sixty subjects (mean [SD] age, 48.4 [8.7] years) satisfied the eligibility criteria, agreed to participate, and were randomized into the EPAX (n = 30) or MTEX group (n = 30). The overall group-by-time interaction for the ANOVA was statistically significant for the LEFS (P = .002), FAAM (P = .005), and pain (P = .043). Between-group differences favored the MTEX group at both 4-week (difference in LEFS, 13.5; 95% CI: 6.3, 20.8) and 6-month (9.9; 95% CI: 1.2, 18.6) follow-ups.
CONCLUSION:
The results of this study provide evidence that MTEX is a superior management approach over an EPAX approach in the management of individuals with plantar heel pain at both the short- and long-term follow-ups. Future studies should examine the contribution of the different components of the exercise and manual physical therapy programs.
Journal of Orthopedic Sports Physical Therapy. 2009 Aug;39(8):573-85. – abstract
Power point presentation of the main outcome charts- here
Filed under: Exercise therapy, Foot and ankle, Manual therapy , iontophoresis, manipulation, mobilization, plantar fasciitis, plantar fasciosis
September 17, 2009 • 4:50 am 0
The relationship between pelvic torsion and anatomical leg length inequality: a review of the literature
Robert Cooperstein, Makani Lew
Abstract: Objective: Although it is common to find assertions relating functional leg length inequality (LLI) to pelvic torsion and other states of subluxation, comments and/or data concerning anatomical LLI in this same context are uncommon. This review of the literature synthesizes the evidence on pelvic torsion in relation to anatomical LLI.
Methods: The literature was searched using the PubMed; Manual, Alternative, and Natural Therapy Index System; Allied and Complementary Medicine Database; Cumulative Index to Nursing and Allied Health Literature; and Index to Chiropractic Literature databases for primary studies that related LLI, either artificially created or naturally occurring, to pelvic torsion. Extracted data included natural vs artificial LLI, method of creating or detecting LLI, subject selection, methodology for measuring pelvic torsion, and results.
Results: Nine English-language studies were retrieved published 1936-2004. Seven determined the impact of artificial, transient LLI on pelvic torsion, whereas 2 studied the effect of naturally occurring LLI.
Conclusion: Across varying methodologies for measuring LLI and pelvic torsion, a consistent, dose-related pattern was identified in which the innominate rotates anteriorly on the side of a shorter leg and posteriorly on the side of the longer leg. This finding was contrary to the common assertion that the ilium rotates posteriorly on the side of a short leg and vice versa. Practitioners of manual medicine who derive vectors for intervention based on leg checking procedures should consider the possibility that the direction of pelvic torsion may be variable depending on whether the LLI is of anatomical or functional origin.
Journal of Chiropractic Medicine, Vol 8, Issue 3, Pages 107-118 (September 2009) – abstract
Filed under: Assessment, Hip, Physical examination, Topic review , Ilium, Leg length inequality, Mechanical, Posture, Sacroiliac joint, Torsion
September 4, 2009 • 6:15 pm 0
Most clinical tests cannot accurately diagnose rotator cuff pathology: a systematic review.
Hughes PC, Taylor NF, Green RA
Question: Do clinical tests accurately diagnose rotator cuff pathology?
Design: A systematic review of investigations into the diagnostic accuracy of clinical tests for rotator cuff pathology.
Participants: People with shoulder pain who underwent clinical testing in order to diagnose rotator cuff pathology.
Outcome measures: The diagnostic accuracy of clinical tests was determined using likelihood ratios.
Results: Thirteen studies met the inclusion criteria. The 13 studies evaluated 14 clinical tests in 89 separate evaluations of diagnostic accuracy. Only one evaluation, palpation for supraspinatus ruptures, resulted in significant positive and negative likelihood ratios. Eight of the 89 evaluations resulted in either significant positive or negative likelihood ratios. However, none of these eight positive or negative likelihood ratios were found in other studies. Of the 89 evaluations of clinical tests 71 (80%) did not result in either significant positive or negative likelihood ratio evaluations across different studies.
Conclusion: Overall, most tests for rotator cuff pathology were inaccurate and cannot be recommended for clinical use. At best, suspicion of a rotator cuff tear may be heightened by a positive palpation, combined Hawkins/painful arc/infraspinatus test, Napoleon test, lift-off test, belly-press test, or drop-arm test, and it may be reduced by a negative palpation, empty can test or Hawkins-Kennedy test.
Australian Journal of Physiotherapy 54: 159–170 – full text
“The poor accuracy of clinical tests for rotator cuff pathology could be related to a lack of anatomical validity of the tests or it may be that the close relationships of structures in the shoulder may make it difficult to identify specific pathologies with clinical tests.”
Filed under: Assessment, Physical examination, Shoulder , differential, Review, Rotator cuff; Diagnosis
July 28, 2009 • 6:41 pm 1
Massage for Low Back Pain: An Updated Systematic Review Within the Framework of the Cochrane Back Review Group
Furlan, AD; Imamura, M; Dryden, T; Irvin, E
Abstract
Study Design. Systematic Review.
Objectives. To assess the effects of massage therapy for nonspecific low back pain.
Summary of Background Data. Low back pain is one of the most common and costly musculoskeletal problems in modern society. Proponents of massage therapy claim it can minimize pain and disability, and speed return to normal function.
Methods. We searched MEDLINE, EMBASE, CINAHL from their beginning to May 2008. We also searched the Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, issue 3), HealthSTAR and Dissertation abstracts up to 2006. There were no language restrictions. References in the included studies and in reviews of the literature were screened. The studies had to be randomized or quasi-randomized trials investigating the use of any type of massage (using the hands or a mechanical device) as a treatment for nonspecific low back pain. Two review authors selected the studies, assessed the risk of bias using the criteria recommended by the Cochrane Back Review Group, and extracted the data using standardized forms. Both qualitative and meta-analyses were performed.
Results. Thirteen randomized trials were included. Eight had a high risk and 5 had a low risk of bias. One study was published in German and the rest in English. Massage was compared to an inert therapy (sham treatment) in 2 studies that showed that massage was superior for pain and function on both short- and long-term follow-ups. In 8 studies, massage was compared to other active treatments. They showed that massage was similar to exercises, and massage was superior to joint mobilization, relaxation therapy, physical therapy, acupuncture, and self-care education. One study showed that reflexology on the feet had no effect on pain and functioning. The beneficial effects of massage in patients with chronic low back pain lasted at least 1 year after the end of the treatment. Two studies compared 2 different techniques of massage. One concluded that acupuncture massage produces better results than classic (Swedish) massage and another concluded that Thai massage produces similar results to classic (Swedish) massage.
Conclusion. Massage might be beneficial for patients with subacute and chronic nonspecific low back pain, especially when combined with exercises and education. The evidence suggests that acupuncture massage is more effective than classic massage, but this need confirmation. More studies are needed to confirm these conclusions, to assess the impact of massage on return-to-work, and to determine cost-effectiveness of massage as an intervention for low back pain.
Spine: 15 July 2009 – Volume 34 – Issue 16 – pp 1669-1684 - abstract
doi: 10.1097/BRS.0b013e3181ad7bd6
Full text available in 
through MTABC member only website (link) under the research tab and then library.
through MTABC member only website (link) under the research tab and then library.Filed under: Exercise therapy, Lumbar spine, Massage, Patient education, Topic review , Low back, Lumbar spine, massage therapy, nonspecific low back pain, pain, Systematic review
July 3, 2009 • 11:51 pm 0
Risk Factors for Persistent Problems Following Whiplash Injury: Results of a Systematic Review and Meta-analysis
DM Walton, J Pretty, JC MacDermid, RW Teasell
STUDY DESIGN: Systematic review and meta-analysis. BACKGROUND: Whiplash-associated disorder (WAD) is the most common reported injury following motor vehicle accident. Evidence for prognosis and intervention are difficult to interpret due to differences in inception times, outcomes used, and sample heterogeneity. METHODS: An extensive literature search was conducted to identify published studies of prognosis following whiplash. Rigorous inclusion criteria were applied to allow for meaningful results to be drawn. Data were extracted, transformed where necessary, and pooled to allow estimation of the odds ratio for any factor with at least 3 data points in the literature.
RESULTS: From 11 cohorts (n = 3193), 25 factors were identified with at least 3 data points in the existing literature. Of these, 9 were found to be significant predictors based on the odds ratio and confidence limits: no postsecondary education, female gender, history of previous neck pain,baseline neck pain intensity greater than 55/100, presence of neck pain at baseline, presence of headache at baseline, catastrophizing, WAD grade 2 or 3, and no seat belt in use at time of collision. Neck pain intensity, WAD grade, headache, and no postsecondary education were robust to publication bias.
CONCLUSIONS: Using a rigorous process for the identification and extraction of data from a homogenous subset of the prognostic WAD literature, we were able to identify several factors for which information is easy to collect clinically and could provide clinicians with a good sense of prognosis following whiplash injury. LEVEL OF EVIDENCE: Prognosis, level 1a.
J Orthop Sports Phys Ther 2009;39(5):334-350, Epub 18 July 2008. View Full Article
doi:10.2519/jospt.2009.2765
Filed under: Cervical, Prognosis, Whiplash Injuries , Cervical spine, neck, Prognosis, WAD
• 6:47 pm 0
Measurement Properties of the Neck Disability Index: A Systematic Review
JC MacDermid, DM Walton, S Avery, A Blanchard, E Etruw, C McAlpine, CH Goldsmith
STUDY DESIGN: Systematic review of clinical measurement. OBJECTIVE: To find and synthesize evidence on the psychometric properties and usefulness of the neck disability index (NDI). BACKGROUND: The NDI is the most commonly used outcome measure for neck pain, and a synthesis of knowledge should provide a deeper understanding of its use and limitations. METHODS AND MEASURES: Using a standard search strategy (1966 to September 2008) and 4 databases (Medline, CINAHL, Embase, and PsychInfo), a structured search was conducted and supplemented by web and hand searching. In total, 37 published primary studies, 3 reviews, and 1 in-press paper were analyzed. Pairs of raters conducted data extraction and critical appraisal using structured tools. Ranking of quality and descriptive synthesis were performed.
RESULTS: Horizon estimation suggested the potential for 1 missed paper. The agreement between raters on quality assessments was high(kappa = 0.82). Half of the studies reached a quality level greater than 70%. Failures to report clear psychometric objectives/hypotheses or to rationalize the sample size were the most common design flaws. Studies often focused on less clinically applicable properties, like construct validity or group reliability, than transferable data, like known group differences or absolute reliability (standard error of measurement [SEM] or minimum detectable change [MDC]). Most studies suggest that the NDI has acceptable reliability, although intraclass correlation coefficients (ICCs) range from 0.50 to 0.98. Longer test intervals and the definition of stable can influence reliability estimates. A number of high-quality published (Korean, Dutch, Spanish, French, Brazilian Portuguese) and commercially supported translations are available. The NDI is considered a 1-dimensional measure that can be interpreted as an interval scale. Some studies question these assumptions. The MDC is around 5/50 for uncomplicated neck pain and up to 10/50 for cervical radiculopathy. The reported clinically important difference (CID) is inconsistent across different studies ranging from 5/50 to 19/50. The NDI is strongly correlated (>0.70) to a number of similar indices and moderately related to both physical and mental aspects of general health.
CONCLUSION: The NDI has sufficient support and usefulness to retain its current status as the most commonly used self-report measure for neck pain. More studies of CID in different clinical populations and the relationship to subjective/work/function categories are required.
J Orthop Sports Phys Ther 2009;39(5):400-417.- full text PDF
doi:10.2519/jospt.2009.2930
Filed under: Cervical, Outcome measure , Cervical spine, Outcome measure, reliability
June 11, 2009 • 10:22 pm 0
Special physical examination tests for superior labrum anterior posterior shoulder tears are clinically limited and invalid: a diagnostic systematic review
Calvert, Chambers, Regan et al
Objective
The diagnosis of a superior labrum anterior posterior (SLAP) lesion through physical examination has been widely reported in the literature. Most of these studies report high sensitivities and specificities, and claim to be accurate, valid, and reliable. The purpose of this study was to critically evaluate these studies to determine if there was sufficient evidence to support the use of the SLAP physical examination tests as valid and reliable diagnostic test procedures.
Study Design and Setting
Strict epidemiologic methodology was used to obtain and collate all relevant articles. Sackett’s guidelines were applied to all articles. Confidence intervals and likelihood ratios were determined.
Results
Fifteen of 29 relevant studies met the criteria for inclusion. Only one article met all of Sackett’s critical appraisal criteria. Confidence intervals for both the positive and negative likelihood ratios contained the value 1.
Conclusion
The current literature being used as a resource for teaching in medical schools and continuing education lacks the validity necessary to be useful. There are no good physical examination tests that exist for effectively diagnosing a SLAP lesion.
Journal of Clinical Epidemiology, Volume 62, Issue 5, May 2009, Pages 558-563 – abstract
Filed under: Physical examination, Shoulder, Topic review , Diagnostic accuracy, Physical examination, Sensitivity, Shoulder, Superior labrum anterior posterior (SLAP) lesion, Systematic review
June 8, 2009 • 7:02 pm 0
Nonsurgical interventional therapies for low back pain: a review of the evidence for an american pain society clinical practice guideline
Chou R, Atlas SJ, Stanos SP, et al
STUDY DESIGN: Systematic review.
OBJECTIVE: To systematically assess benefits and harms of nonsurgical interventional therapies for low back and radicular pain.
SUMMARY OF BACKGROUND DATA: Although use of certain interventional therapies is common or increasing, there is also uncertainty or controversy about their efficacy.
METHODS: Electronic database searches on Ovid MEDLINE and the Cochrane databases were conducted through July 2008 to identify randomized controlled trials and systematic reviews of local injections, botulinum toxin injection, prolotherapy, epidural steroid injection, facet joint injection, therapeutic medial branch block, sacroiliac joint injection, intradiscal steroid injection, chemonucleolysis, radiofrequency denervation, intradiscal electrothermal therapy, percutaneous intradiscal radiofrequency thermocoagulation, Coblation nucleoplasty, and spinal cord stimulation. All relevant studies were methodologically assessed by 2 independent reviewers using criteria developed by the Cochrane Back Review Group (for trials) and by Oxman (for systematic reviews). A qualitative synthesis of results was performed using methods adapted from the US Preventive Services Task Force.
RESULTS: For sciatica or prolapsed lumbar disc with radiculopathy, we found good evidence that chemonucleolysis is moderately superior to placebo injection but inferior to surgery, and fair evidence that epidural steroid injection is moderately effective for short-term (but not long-term) symptom relief. We found fair evidence that spinal cord stimulation is moderately effective for failed back surgery syndrome with persistent radiculopathy, though device-related complications are common. We found good or fair evidence that prolotherapy, facet joint injection, intradiscal steroid injection, and percutaneous intradiscal radiofrequency thermocoagulation are not effective. Insufficient evidence exists to reliably evaluate other interventional therapies.
CONCLUSION: Few nonsurgical interventional therapies for low back pain have been shown to be effective in randomized, placebo-controlled trials.
Spine. 2009 May 1;34(10):1078-93 – abstract
Full text available in through MTABC member only website (link) under the research tab and then library.
Filed under: Lumbar spine, Topic review, therapies , interventional, Low back, nonsurgical, radicular pain, therapies
