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Volume 17, Number 4

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Articles in this Issue:

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Editorial	Continuity and Change
Manual Therapy Awards	Manual Therapy Awards
Online Only Article	Anatomical Variations of the Lumbar Plexus: A Descriptive Anatomy Study with Proposed Clinical Implications
Authors	Information for Authors
Letters	Letter To The Editor
Letters	Response To Letter To The Editor
Information	Information For Authors
Indices	Author and Subject Indices

Abstracts:

Editorial: Continuity and Change

MARK SIMON

[no abstract available]
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The Journal of Manual & Manipulative Therapy Vol. 17 No. 4 (2009), 194

Manual Therapy Awards

[no abstract available]
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The Journal of Manual & Manipulative Therapy Vol. 17 No. 4 (2009), 195

An Exploration of Maitland's Concept of Pain Irritability in Patients with Low Back Pain

EDWARD T. BARAKATT, PT, PhD; PATRICK S. ROMANO, MD, MPh; DANIEL L. RIDDLE, PT, PhD; LAUREL A. BECKETT, PhD; RICHARD KRAVITz, MD, MPH

Abstract: Maitland's construct of musculoskeletal pain irritability is widely used by physical therapists for making decisions about the vigor of examination and treatment, but this construct has not been defined to the extent that its measurement properties can be tested. The purposes of this study were to 1) determine if physical therapists utilize low back pain (LBP) irritability judgments to make treatment decisions, 2) identify LBP characteristics appropriate for an LBP irritability construct, and 3) develop a measurement construct of LBP irritability. Physical therapists evaluated and treated 183 subjects with LBP. The therapists judged the subjects’ LBP as irritable or non-irritable, and recorded treatments provided at the initial visit. A principal-components analysis (PCA) was performed on 14 patient-reported LBP characteristics to identify potential components of a measurement construct of LBP irritability. The therapists’ irritability judgments were found to be associated with the types of treatments prescribed. Five dimensions of LBP irritability were identified by the PCA from the 14 LBP characteristics considered. Four of these dimensions were associated with the therapists' LBP irritability judgments. The Roland-Morris Disability Questionnaire, presence of distal symptoms, and forward bending tolerance were found to have a stronger association with the irritability judgments than the dimensions of irritability identified in this study. Validated measures of LBP characteristics in current clinical use may adequately capture Maitland's concept of irritability.

The Journal of Manual & Manipulative Therapy Vol. 17 No. 4 (2009), 196-205

Effectiveness of Manual Physical Therapy for Painful Shoulder Conditions: A Systematic Review

JAMES CAMARINOS, DPT; LEE MARINKO, PT, ScD, OCS, FAAOMPT

Abstract: Multiple disease-specific systematic reviews on the effectiveness of physical therapy intervention for shoulder dysfunction have been inconclusive. To date, there have been two systematic reviews that examined manual therapy specifically but both considered effects within diagnoses. The purpose of this systematic review was to identify the effective- ness of manual therapy to the glenohumeral joint across all painful shoulder conditions. A search of MEDLINE, CINAHL, Web of Science, and Cochrane Central Register of Randomized Controlled Trials for articles dated 1996 to June 2009 was performed. Inclusion for review were manual therapy performed to the glenohumeral joint only; non-surgical painful shoulder disorders; subjects 18-80 years; and outcomes of range of motion, pain, function, and/or quality of life. Quality assessment was performed using the PEDro scale with subsequent data extraction. Seventeen related articles were found with seven fitting the inclusion criteria. The average PEDro score was 7.86, meeting the cutoff score for high quality. Significant heterogeneity in outcome measures prohibited meta-analysis. Five studies demonstrated benefits utilizing manual therapy for mobility, and four demonstrated a trend towards decreasing pain values. Functional outcomes and quality-of-life measures varied greatly among all studies. Manual therapy appears to increase either active or passive mobility of the shoulder. A trend was found favoring manual therapy for decreasing pain, but the effect on function and quality of life remains inconclusive. Future research utilizing consistent outcome measurements is necessary.

The Journal of Manual & Manipulative Therapy Vol. 17 No. 4 (2009), 206-215

A Case Study Examining the Effectiveness of Mechanical Diagnosis and Therapy in a Patient who Met the Clinical Prediction Rule for Spinal Manipulation

JUDY CHEN, DPT; AMY PHILLIPS, DPT; MELISSA RAMSEY, MS, PT; RON SCHENK, PT, PhD, OCS, FAAOMPT, Cert. MDT

Abstract: This single-subject case study was conducted as a part of a randomized trial investigating the efficacy of mechanical diagnosis and therapy (MDT) and spinal thrust manipulation (STM) in patients who meet a clinical prediction rule (CPR) for spinal manipulation. Following initial examination, a patient who met the CPR was treated initially with STM and then eventually with MDT. The Oswestry Disability Questionnaire (ODI), Fear-Avoidance Beliefs Questionnaire, and the Numerical Pain Rating Scale (NPRS) were administered at the initial examination and at a two-week follow-up. Data were analyzed based on changes in the pain rating scale, ODI, and straight leg raise scores from initial examination to discharge. In accordance with a study protocol in which the patient was part of, this patient was changed from STM to MDT after the second physical therapy visit due to failure of overall improvement. The patient received MDT during the third session and continued with this approach until discharge. This patient responded favorably to MDT presenting with a 20° improvement in SLR on the left and 10° on the right, 6 points lower on the NPRS, and a 4% decrease on the OSW after a total of 6 visits.

The Journal of Manual & Manipulative Therapy Vol. 17 No. 4 (2009), 216-220

Inter-tester Reliability in Classifying Acute and Subacute Low Back Pain Patients into Clinical Subgroups: A Comparison of Specialists and Non-Specialists. A Pilot Study

MARKKU PAATELMA, MSc, PT; EIRA KARVONEN, MSc, PT; ARI HEINONEN, PhD, PT

Abstract: Many systems have been suggested for classifying low back pain (LBP); the most commonly used among physiotherapists involves a pathoanatomical/pathophysiolog- ical tissue classification system. Few studies have examined whether this form of classification of LBP disorders can be performed in a reliable manner between specialists with advanced training, or between specialists with advanced training and non-specialists who lack advanced training. The purpose of this paper was to examine the inter-tester reliability of two specialists, and the ability of a specialist and non-specialist to independently classify patients with LBP, utilizing clinical tests and history-based classification methods after a short educational course on the classification system. Subjects were acute or sub-acute patients with LBP who visited their occupational healthcare or municipal healthcare center. Inter-tester reliability between the specialist and non-specialists was at almost the same level: overall Kappa 0.60 (95%CI; 0.40 to 0.85), overall agreement 70%, as between the two specialists: overall Kappa 0.65 (95%CI; 0.33-0.86), overall agreement 77%. The findings suggest that a short educational course can provide rather reliable examination tools to allow non-specialized physiotherapists to classify patients according to tissue origination.

The Journal of Manual & Manipulative Therapy Vol. 17 No. 4 (2009), 221-229

The Immediate Effects of Thoracic Spine and Rib Manipulation on Subjects with Primary Complaints of Shoulder Pain

JOSEPH B. STRUNCE PT, DSc, OCS, FAAOMPT; MICHAEL J. WALKER PT, DSc, OCS, FAAOMPT; ROBERT E. BOYLES PT, DSc, OCS, FAAOMPT; BRIAN A. YOUNG PT, DSc, OCS, FAAOMPT

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 inter- dependence between the thoracic spine, upper ribs, and shoulder.

The Journal of Manual & Manipulative Therapy Vol. 17 No. 4 (2009), 230-236

The Effectiveness of Thoracic Spine Manipulation for the Management of Musculoskeletal Conditions: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

RONALD F. WALSER, PT, DPT; BRENT B. MESERVE, PT, DPT; THOMAS R. BOUCHER, PhD

Abstract: Thoracic spine manipulation (TSM) is an intervention practiced by different professions, and recently an incursion of research using TSM has been published. The pur- pose of this review was to examine the effectiveness of TSM for the management of musculoskeletal conditions and the quality of trials that included TSM techniques. A comprehensive search of online databases was performed, and first authors of studies identified were contacted. Thirteen randomized clinical trials were included in the final review. The methodological quality of all studies was assessed using the 10-point PEDro scale. Seven of the 13 studies were of high quality. Three studies looked at TSM for treatment of shoulder conditions; however, there is limited evidence to support the use of TSM for shoulder conditions. Nine studies used TSM for the management of neck conditions. The meta-analysis identified a subset of homogeneous studies evaluating neck pain. The value of the pooled estimator (1.33) was statistically significant for the treatment effect of TSM in the studies with researcher effect removed (95 % confidence interval: 1.15, 1.52). This analysis suggests there is sufficient evidence to support the use of TSM for specific subgroups of patients with neck conditions. This review also identifies the need for further studies to examine the effectiveness of TSM to treat shoulder conditions and the effectiveness of TSM on neck conditions with long-term follow-up studies.

The Journal of Manual & Manipulative Therapy Vol. 17 No. 4 (2009), 237-246

Management and Treatment of Temporomandibular Disorders: A Clinical Perspective

EDWARD F. WRIGHT, DDS, MS; SARAH L. NORTH, PT, MPT

Abstract: A temporomandibular disorder (TMD) is a very common problem affecting up to 33% of individuals within their lifetime. TMD is often viewed as a repetitive motion disorder of the masticatory structures and has many similarities to musculoskeletal disorders of other parts of the body. Treatment often involves similar principles as other regions as well. However, patients with TMD and concurrent cervical pain exhibit a complex symptomatic behavior that is more challenging than isolated TMD symptoms. Although routinely managed by medical and dental practitioners, TMD may be more effectively cared for when physical therapists are involved in the treatment process. Hence, a listing of situations when practitioners should consider referring TMD patients to a physical therapist can be provided to the practitioners in each physical therapist’s region. This paper should assist physical therapists with evaluating, treating, insurance billing, and obtaining referrals for TMD patients.

The Journal of Manual & Manipulative Therapy Vol. 17 No. 4 (2009), 247-254

Anatomical Variations of the Lumbar Plexus: A Descriptive Anatomy Study with Proposed Clinical Implications

PHILIP A. ANLOAGUE, PT, DHSc, OCS, MTC; PETER HUIJBREGTS, PT, DPT, OCS, FAAOMPT, FCAMT

Abstract: This study used dissection of 34 lumbar plexes to look at the prevalence of anatomical variations in the lumbar plexus and the six peripheral branches from the origin at the ventral roots of (T12) L1-L4 to the exit from the pelvic cavity. Prevalence of anatomical variation in the individual nerves ranged from 8.8–47.1% with a mean prevalence of 20.1%. Anatomical variations included absence of the iliohypogastric nerve, an early split of the genitofemoral nerve into genital and femoral branches, an aberrant segmental origin for the lateral femoral cutaneous nerve, bifurcation of the lateral femoral nerve prior to exiting the pelvic cavity, bifurcation of the femoral nerve into two to three slips separated by psoas major muscle fibers, the presence of a single anterior femoral cutaneous nerve rather than the normal presentation of two separate anterior femoral cutaneous branches, and the presence of an accessory obturator nerve. Comparison with relevant research literature showed a wide variation in reported prevalence of the anatomical variations noted in this study. Clinical implications and directions for future research are proposed.
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The Journal of Manual & Manipulative Therapy Vol. 17 No. 4 (2009), E107-E114