CURRENT ISSUE

Clinical Evaluation of Cervicogenic Headache: A Clinical Perspective

TOBY HALL, MSc, Post-Grad Dip Manip Ther, KATHY BRIFFA, PhD, DIANA HOPPER, PhD

Abstract: Headache is a common complaint that afects the majority of the population at some point in their lives. The underlying pathological bases for headache symptoms are many, diverse, and oten diicult to distinguish. Classiication of headache is principally based on the evaluation of headache symptoms as well as clinical testing. Although manual therapy has been advocated to treat a variety of diferent forms of headache, the current evidence only supports treatment for cervicogenic headache (CGH). This form of headache can be identiied from migraine and other headache forms by a comprehensive musculoskeletal examination. Examination and subsequent diagnosis is essential not only to identify patients with headache where manual therapy is appropriate but also to form a basis for selection of the most appropriate treatment for the identiied condition. The purpose of this paper is to outline, in clinical terms, the classiication of headache, so that the clinician can readily identify those patients with headache suited to manual therapy.

The Journal of Manual & Manipulative Therapy Vol. 16 No. 2 (2008), 73-80

Invited Commentary - Clinical Evaluation of Cervicogenic Headache: A Clinical Perspective

CÉSAR FERNÁNDEZ-DE-LAS-PEAS, PT, DO, PhD , Department of Physical Therapy, Universidad Rey Juan Carlos, Madrid, Spain

[No abstract available]

The Journal of Manual & Manipulative Therapy Vol. 16 No. 2 (2008), 81

Identifying Myelopathy Caused by Thoracic Syringomyelia: A Case Report

BEVERLY RENE HUDSON, DPT , CHAD COOK, PT, PhD, MBA, OCS, FAAOMPT , ADAM GOODE, PT, DPT

Abstract: Myelopathy is a form of neurological disease caused by compression of the spinal cord. Upper and lower quarter screens are commonly used in identifying myelopathy, although most of the screen components demonstrate poor or unstudied diagnostic value. The purpose of this case report is to describe the diagnostic process in detecting syringomyelia, an intramedullary lesion that may cause myelopathy. The patient was a 47-year-old female with a thoracic syrinx that was discovered by spinal magnetic resonance imaging (MRI) following a complicated and delayed clinical diagnostic course. Following surgical intervention and a two-week inpatient rehabilitation stay, the patient was discharged using a rolling walker for ambulation and was performing most transfers with modii ed independence. A complicating pattern of signs and symptoms combined with a diagnostic process guided by poorly studied screen components demonstrates the diagnostic dilemma associated with identifying the cause of myelopathy within the thoracic spine. This also indicates the need for further investigation of individual and clustered components of the neurological screen to improve the ability to identify patients in need of complete imaging studies in a more timely fashion.

The Journal of Manual & Manipulative Therapy Vol. 16 No. 2 (2008), 82-88

Ultrasonographic Measurement of Neck Muscle Recruitment: A Preliminary Investigation

FABIANNA M.R. JESUS, BPT, PAULO H. FERREIRA, BPT, PhD, MANUELA L. FERREIRA, BPT, PhD

Abstract: Chronic cervical pain is a common source of disability in society, and evidence suggests that individuals with neck pain have impairment of the deep cervical flexor (DCF) muscles. This study investigated the recruitment pattern of the neck muscles, particularly the DCF, during the Craniocervical Flexion Test (CCFT), using ultrasound measurement of muscle activity in asymptomatic subjects. In a cross-sectional design, 10 subjects, of both sexes, with no history of neck pain participated in the study. Participants were instructed to perform the CCFT, and changes in thickness from resting baseline values during the five incremental stages of the test were obtained for DCF and sternocleidomastoid (SCM) muscles using ultrasonography. The most significant changes found in DCF thickness were between phase 1 and phases 4 (p<0.001) and 5 (p=<0.001). For SCM, differences were most significant between phases 1 and 3 (p<0.001), 4 (p<0.001), and 5 (p<0.001); and between phases 3 and 5 (p<0.003). No differences were found between DCF and SCM muscles. The present study conifrms the evidence that CCFT increases DCF recruitment. However, the ultrasonography test protocol did not identify differences in recruitment between deep and superficial neck muscles. The present study confirms the evidence that the CCFT challenges the cervical spine and that DCF activity is increased during this maneuver.

The Journal of Manual & Manipulative Therapy Vol. 16 No. 2 (2008), 89-92

The Immediate Effects of Upper Thoracic Translatoric Spinal Manipulation on Cervical Pain and Range of Motion: A Randomized Clinical Trial

JOHN KRAUSS, PT, PhD, OCS, FAAOMPT, DOUG CREIGHTON, DPT, OCS, FAAOMPT, JONATHAN D. ELY PT, MS, FAAOMPT, JOANNA PODLEWSKA-ELY PT, MS, FAAOMPT

Abstract: This study examined the effect of translatoric spinal manipulation (TSM) on cervical pain and cervical active motion restriction when applied to upper thoracic (T1-T4) segments. Active cervical rotation range of motion was measured pre- and post-intervention with a cervical inclinometer (CROM), and cervical pain status was monitored before and at er manipulation with a Faces Pain Scale. Study participants included a sample of convenience that included 32 patients referred to physical therapy with complaints of pain in the mid-cervical region and restricted active cervical rotation. Twenty-two patients were randomly assigned to the experimental group and ten were assigned to the control group. Pre and post-intervention cervical range of motion and pain scale measurements were taken by a physical therapist assistant who was blinded to group assignment. The experimental group received TSM to hypomobile upper thoracic segments. The control group received no intervention. Paired t-tests were used to analyze within-group changes in cervical rotation and pain, and a 2-way repeated-measure ANOVA was used to analyze between-group differences in cervical rotation and pain. Significance was accepted at p = 0.05. Significant changes that exceeded the MDC95 were detected for cervical rotation both within group and between groups with the TSM group demonstrating increased mean (SD) in right rotation of 8.23° (7.41°) and left rotation of 7.09° (5.83°). Pain levels perceived during post-intervention cervical rotation showed significant improvement during right rotation for patients experiencing pain during bilateral rotation only (p=.05). This study supports the hypothesis that spinal manipulation applied to the upper thoracic spine (T1-T4 motion segments) significantly increases cervical rotation ROM and may reduce cervical pain at end range rotation for patients experiencing pain during bilateral cervical rotation.

The Journal of Manual & Manipulative Therapy Vol. 16 No. 2 (2008), 93-99

Immediate Effects of Anterior-to-Posterior Talocrural Joint Mobilization after Prolonged Ankle Immobilization: A Preliminary Study

ELIZABETH L. LANDRUM, MEd, ATC, CDR. BRENT M. KELLN, PhD, PT, OCS, WILLIAM R. PARENTE, DPT, ATC, CHRISTOPHER D. INGERSOLL, PhD, ATC, JAY HERTEL, PhD, ATC

Abstract: Ankle dorsiflexion range of motion (ROM) typically decreases after prolonged immobilization. Anterior-to-posterior talocrural joint mobilizations are purported to increase dorsil exion ROM and decrease joint stiffness after immobilization. The purpose of this study was to determine if a single bout of Grade III anterior-to-posterior talocrural joint mobilizations immediately affected measures of dorsil exion ROM, posterior ankle joint stiffness, and posterior talar translation in ankles of patients who had been immobilized at least 14 days. Ten physically active patients (5 males, 5 females; age=21.4+3.3 years) participated. Each had the ankle immobilized following a lower extremity injury for at least 14 days and presented with at least a 5° dorsil exion ROM deficit compared to the contralateral ankle. A crossover design was employed so that half of the subjects received joint mobilizations first and half of the subjects received the control intervention (no treatment) first. All subjects ultimately received both treatments. Active dorsiflexion ROM was assessed with a bubble inclinometer, and posterior ankle stiffness and talar translation were assessed with an instrumented ankle arthrometer. After a single application of grade III anterior-to-posterior talocrural joint mobilization, dorsiflexion ROM and posterior ankle joint stiffness were significantly increased. There was also a trend toward less posterior talar translation immediately after mobilization. The trend toward decreased posterior talar translation and increased posterior ankle joint stiffness supports the positional fault theory. Correction of an anterior talar positional fault offers a possible explanation for these results.

The Journal of Manual & Manipulative Therapy Vol. 16 No. 2 (2008), 100-105

Changes in Clinical Parameters in Patients with Tension-type Headache Following Massage Therapy: A Pilot Study

ALBERT MORASKA, PhD, CLINT CHANDLER, BS, LMT

Abstract: Complementary and alternative medicine approaches to treatment for tension-type headache are increasingly popular among patients, but evidence supporting its eiffcacy is limited. The objective of this study was to assess short term changes on primary and secondary headache pain measures in patients with tension-type headache (TTH) receiving a structured massage therapy program with a focus on myofascial trigger point therapy. Participants were enrolled in an open label trial using a baseline control with four 3-week phases: baseline, massage (two 3-week phases) and follow-up. Twice weekly, 45- minute massage sessions commenced following the baseline phase. A daily headache diary was maintained throughout the study in which participants recorded headache incidence, intensity, and duration. The Headache Disability Index was administered upon study entry and at 3-week intervals thereatfer. 18 subjects were enrolled with 16 completing all headache diary, evaluation, and massage assignments. Study participants reported a median of 7.5 years with TTH. Headache frequency decreased from 4.7 +/- 0.7 episodes per week during baseline to 3.7 +/- 0.9 during treatment period 2 (P<0.001); reduction was also noted during the follow-up phase (3.2 +/- 1.0). Secondary measures of headache also decreased across the study phases with headache intensity decreasing by 30% (P<0.01) and headache duration from 4.0 +/- 1.3 to 2.8 +/- 0.5 hours (P<0.05). A corresponding improvement in Headache Disability Index was found with massage (P<0.001). This pilot study provides preliminary evidence for reduction in headache pain and disability with massage therapy that targets myofascial trigger points, suggesting the need for more rigorously controlled studies.

The Journal of Manual & Manipulative Therapy Vol. 16 No. 2 (2008), 106-112

Variation in Pelvic Morphology May Prevent the Identification of Anterior Pelvic Tilt

STEPHEN J. PREECE, PhD, PETER WILLAN, PhD, CHRIS J. NESTER, PhD, PHILIP GRAHAM-SMITH, PhD, LEE HERRINGTON, MSc, PhD, PETER BOWKER, PhD

Abstract: Pelvic tilt is ot en quantii ed using the angle between the horizontal and a line connecting the anterior superior iliac spine (ASIS) and the posterior superior iliac spine (PSIS). Although this angle is determined by the balance of muscular and ligamentous forces acting between the pelvis and adjacent segments, it could also be inlfuenced by variations in pelvic morphology. The primary objective of this anatomical study was to establish how such variation may affect the ASIS-PSIS measure of pelvic tilt. In addition, we also investigated how variability in pelvic landmarks may inl uence measures of innominate rotational asymmetry and measures of pelvic height. Thirty cadaver pelves were used for the study. Each specimen was positioned in a fixed anatomical reference position and the angle between the ASIS and PSIS measured bilaterally. In addition, side-to-side differences in the height of the innominate bone were recorded. The study found a range of values for the ASIS-PSIS of 0-23 degrees, with a mean of 13 and standard deviation of 5 degrees. Asymmetry of pelvic landmarks resulted in side-to-side dif erences of up to 11 degrees in ASIS- PSIS tilt and 16 millimeters in innominate height. These results suggest that variations in pelvic morphology may significantly inlfuence measures of pelvic tilt and innominate rotational asymmetry.

The Journal of Manual & Manipulative Therapy Vol. 16 No. 2 (2008), 113-117

Concurrent Criterion-Related Validity of Physical Examination Tests for Hip Labral Lesions: A Systematic Review

M. REBECCA LEIBOLD, MPT, MTC, PETER A. HUIJBREGTS, PT, DPT, OCS, FAAOMPT, FCAMT, RICHARD JENSEN, PT, PhD

Abstract: Hip injuries are prevalent, especially within the athletic population. Of the hip injuries in this population, some 18-55% are lesions to the labrum of the hip. Clinical diagnosis of hip labral lesions is diicult because data on prevalence are varied. In addition, data on the prevalence of internal and external risk factors are absent as are data on the correlation of these risk factors with labral lesions, making it diicult to gauge the diagnostic utility. The mechanism of injury is oten unknown or not speciic to labral lesions. Internal risk factors may remain hidden to physical therapists because in most jurisdictions, ordering imaging tests is not within their scope of practice. Anterior inguinal pain seems highly sensitive for the diagnosis of patients with labral lesions but can hardly be considered specific; data on other pain-related and mechanical symptoms clearly have little diagnostic utility, making these data collected during the patient history almost irrelevant to diagnosis. By way of a comprehensive literature review and narrative and systematic analysis of the methodological quality of the retrieved diagnostic utility studies, this paper aimed to determine a diagnostic physical examination test or test cluster based on current best evidence for the diagnosis of hip labral lesions. Current best evidence indicates that a negative finding for the lexion-adduction-internal rotation test, the lexion-internal rotation test, the impingement provocation test, the lexion-adduction-axial compression test, the Fitzgerald test, or a combination of these tests provides the clinician with the greatest evidence-based conidence that a hip labral lesion is absent. Currently, research has produced no tests with suicient speciicity to help conidently rule in a diagnosis of hip labral lesion. Suggestions for future research are provided.
[ Download the Full Article Free ]

The Journal of Manual & Manipulative Therapy Vol. 16 No. 2 (2008), E24-E41

Chronic Mechanical Neck Pain in Adults Treated by Manual Therapy: A Systematic Review of Change Scores in Randomized Controlled Trials of a Single Session

HOWARD VERNON, DC, PhD, BARRY KIM HUMPHREYS, DC, PhD

Abstract: We report a systematic analysis of group change scores of subjects with chronic neck pain not due to whiplash and without headache or arm pain, in randomized clinical trials of a single session of manual therapy. A comprehensive literature search of clinical trials of chronic neck pain treated with manual therapies up to December 2006 was conducted. Trials that scored above 60% on the PEDro Scale were included. Change scores were analyzed for absolute, percentage change and efect size (ES) whenever possible. Nine trials were identiied: 6 for spinal manipulation, 4 for spinal mobilization or non-manipulative manual therapy (2 overlapping trials), and 1 trial using ischemic compression. No trials were identified for massage therapy or manual traction. Four manipulation trials (five groups) reported mean immediate changes in 100-mm VAS of -18.94 (9.28) mm. ES for these changes ranged from .33 to 2.3. Two mobilization trials reported immediate VAS changes of -11.5 and -4 mm (ES of .36 and .22, respectively); one trial reported no difference in immediate pain scores versus sham mobilization. he ischemic compression study showed statistically signiicant immediate decreases in 100-mm pain VAS (average = -14.6 mm). here is moderate-to-high quality evidence that immediate clinically important improvements are obtained from a single session of spinal manipulation. The evidence for mobilization is less substantial, with fewer studies reporting smaller immediate changes. here is insuicient evidence for ischemic compression to draw conclusions. There is no evidence for a single session of massage or manual traction for chronic neck pain.
[ Download the Full Article Free ]

The Journal of Manual & Manipulative Therapy Vol. 16 No. 2 (2008), E42-E52