PAST ISSUES OF THE JOURNAL OF MANUAL AND MANIPULATIVE THERAPY

Use of Mobilization with Movement in the Treatment of a Patient with Subacromial Impingement: A Case Report

Lucy DeSantis, MS, PT, Scott M. Hasson, EdD, PT, FACSM

Abstract: Mobilization with movement (MWM) is a fairly new therapeutic technique commonly used by physical therapists. The purpose of this case report was to describe the use of MWM in the treatment of a 27-year old left-hand dominant male patient referred to physical therapy with a diagnosis of supraspinatus tendinopathy secondary to impingement. Interventions consisted of MWM and other manual therapy techniques, modalities, and therapeutic exercises. Outcome measures used included goniometric active range of motion (AROM) measurements and manual muscle tests of the shoulder, impingement tests, and the Shoulder Pain and Disability Index (SPADI) and Short Form-36 (SF-36) questionnaires. Specific outcome measures used to describe the response to MWM of the glenohumeral joint included the Numeric Pain Rating Scale (NPRS) and goniometric measurement of abduction AROM. After the first MWM treatment (session 2/12), the 6/10 pre-application NPRS score during shoulder abduction was reduced to 3/10 post-application; however, abduction AROM did not improve (95º). At the final MWM treatment (session 6/12), the pre-application NPRS score during abduction was reduced from 3/10 to 0/10 post-application: abduction AROM increased from 130º to 175º. After 12 sessions, there was a decrease from moderate pain (7/10) to little or no pain (0-1/10) during active shoulder abduction; restricted (95º) to full shoulder abduction active range of motion (180º); and an improvement in the SPADI score from 45% to 8% with no pain or ADL activity difficulty scores >2. This case report indicates that MWM may be an effective treatment intervention for patients with subacromial impingement. Future research is needed to study the efficacy and mechanisms of this treatment technique.

The Journal of Manual & Manipulative Therapy Vol. 14 No. 2 (2006), 77 - 87

Myofascial Trigger Points and Postero-Anterior Joint Hypomobility in the Mid-Cervical Spine in Subjects Presenting with Mechanical Neck Pain: A Pilot Study

César Fernández-de-las-Peñas, PT, Cristina Alonso-Blanco, PT, Isabel Maria Alguacil-Diego, MD, PhD, Juan Carlos Miangolarra-Page, MD, PhD

Abstract: A relationship between muscle and joint impairments has been proposed in the literature; however, the prevalence and the extent of a possible correlation between these disorders in a patient population with mechanical neck pain have been documented in only a few papers. Our aims for this cross-sectional study were to assess the prevalence of myofascial trigger points (TrPs) in the upper trapezius, sternocleidomastoid, and levator scapulae muscles; the prevalence of posterior-anterior (PA) joint hypomobility in the mid-cervical spine (C3-C6); and the correlation of these impairments in patients presenting with mechanical neck pain. Thirty patients with neck pain were examined for the presence of TrPs, according to the diagnostic criteria described by Simons et al and Gerwin et al, and for the presence of mid-cervical spine joint hypomobility as described by Maitland. One clinician first examined for TrPs. A second clinician blinded to the TrP results then examined the patients for PA joint hypomobility. All patients exhibited TrPs. The mean number of TrPs present on each patient was 3.4 (SD±0.9), of which 2.4 (±1.3) were latent and 1.1 (±0.9) were active. PA joint hypomobility was the most prevalent at the C3 vertebra (24 patients or 80%), followed by joint hypomobility at the C4 vertebra (6 subjects or 20%). The relationship between TrPs and cervical PA joint hypomobility did not reach significance (P>0.1). We conclude that all patients with mechanical neck pain exhibited PA joint hypomobility of the mid-cervical spine and TrPs in the cervical musculature. However, correlation between these findings was not statistically significant.

The Journal of Manual & Manipulative Therapy Vol. 14 No. 2 (2006), 88 - 94

Mulligan Traction Straight Leg Raise: A Pilot Study to Investigate Effects on Range of Motion in Patients with Low Back Pain

Toby Hall, MSc, Post Grad Dip Manip Ther (Curtin), Claus Beyerlein, MSc (Curtin), Ulla Hansson, MSc (Curtin), Hun Teck Lim, MSc (Curtin), Merete Odermark, MSc (Curtin), David Sainsbury, MSc (Curtin),

Abstract: Mulligan mobilization techniques are frequently used in clinical practice but there is little evidence underlying their use. The aims of this study were to determine the immediate effects of the Mulligan traction straight leg raise technique (TSLR) on range of straight leg raise (SLR) in subjects with low back pain (LBP). A further aim was to determine whether the presence of lower-quarter mechano-sensitive neural tissue influenced the outcome. Nineteen subjects with LBP with a unilateral limitation of SLR, sub-classified according to the presence or not of mechano-sensitive lower-quarter neural tissue, were included. On the symptomatic side, range of SLR, hip flexion, and posterior pelvic rotation were recorded at the first onset of pain, using goniometers positioned lateral to the knee and pelvis. Following the intervention, there was a significant increase in range of SLR of 11º (95% confidence interval = 9,13) (F [1,16] = 34.28, p<0.001). This increase was attributed to hip flexion rather than pelvic rotation (F [1,16] = 0.79, p = 0.388). In addition, the presence of mechano-sensitive neural tissue did not significantly influence the outcome (F [1,16] = 0.68, p=0.42). These results provide preliminary evidence for the use of the Mulligan TSLR technique in the management of LBP, when a limitation of SLR is present; however, further controlled studies are required to substantiate these findings.

The Journal of Manual & Manipulative Therapy Vol. 14 No. 2 (2006), 95 - 100

Effect of Different Neurodynamic Mobilization Techniques on Knee Extension Range of Motion in the Slump Position

Lee Herrington, MSc, MCSP, SRP, CSCS

Abstract: Mobilization of the nervous system has emerged as a significant adjunct to the treatment of musculoskeletal injuries. Clinical studies have shown that neurogenic symptoms can be resolved by treatment techniques directed at restoring normal neural biomechanics and physiology. Two alternate mobilization techniques have been proposed: the slider and tensioner techniques. A search of the literature revealed no peer-reviewed studies comparing the effects of these two treatment techniques, although a number of studies have investigated these techniques in isolation and found them to have positive effects on range of motion and other outcome measures. The aim of this study was to investigate the effects of these two techniques on knee range of motion of normal subjects (30 females [mean age 21.4+/-1.2 years, range 19-24]) in the slump position. Knee flexion angle of the right leg was measured using a universal 360º goniometer while in a fully slumped position, prior to and after the application of the respective mobilization technique. The tensioner technique brought about a significant decrease in knee flexion angle (P=0.003) with a mean percentage change of 14.7+/-11.8% (3.4+/-2.5º). The slider technique brought about a significant decrease in knee flexion angle (P<0.001) with a mean percentage change of 19.9+/-15% (4.3+/-2.6º). There was a non-significant between-group difference for the effect of the two techniques on range of motion (P=0.075). The findings of this study indicate that in normal female subjects, both the tensioner and slider techniques have a positive and significant effect on improving knee extension range of motion in the slump position. This could decrease the sensitivity of the sciatic nerve and the neuromeningeal structures to mechanical load. The clinical significance of changes of this magnitude on neural tissue and of these techniques in a symptomatic population requires further investigation.

The Journal of Manual & Manipulative Therapy Vol. 14 No. 2 (2006), 101 - 107

Variables Associated with Abandoning the Manual Therapy Approach Learned in Physical Therapy School

Kevin Ramey, MS, PT, Laura Fothergill, MPT, Devyn Hadley, MPT, Amanda Merryman, MPT, Dominic Salazar, MPT, Chad Cook, PT, PhD, MBA, OCS, COMT

Abstract: Numerous manual therapy backgrounds are taught during formal education and continuing education courses within the United States. Many of these approaches employ disparate philosophies for examination and treatment. The purpose of this study was to determine what variables are associated with abandoning the manual therapy approach learned in school. This study surveyed 439 Board-Certified Orthopaedic Specialists (OCS), members of the American Physical Therapy Association. Data were collected through an Internet survey and analyzed using SPSS version 12.0. Logistic regression analysis determined that increased years of experience was associated with the likelihood of abandoning one’s spinal manual therapy approach learned in school. There were no variables associated with the likelihood of abandonment of a peripheral approach. Moreover, clinicians were less likely to report abandonment of an approach if their PT school emphasized the Maitland, eclectic, Osteopathic, McKenzie, Cyriax, Kaltenborn, or Paris approach to the spine. The variables that made a clinician less likely to abandon his or her peripheral manual therapy approach were that a clinician 'feels that the approach is effective' with the additions of the backgrounds of Maitland, Kaltenborn, Cyriax, eclectic, Paris, or Osteopathic approach or "none." All variables with the exception of years of experience were associated with the likelihood of retaining versus abandoning one's manual therapy approach learned during formal education.

The Journal of Manual & Manipulative Therapy Vol. 14 No. 2 (2006), 108 - 117

Can Chiropractors and Evidence-Based Manual Therapists Work Together? An Opinion From a Veteran Chiropractor

Samuel Homola, DC

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.
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Concurrent Criterion-Related Validity of Acromioclavicular Joint Physical Examination Tests: A Systematic Review

Janette W. Powell, PT, BEd (Eng), BAppSc (Pty), OCS, STC, EMT-B, Peter A. Huijbregts, PT, MSc, MHSc, DPT, OCS, MTC, FAAOMPT, FCAMT

Abstract: This article systematically reviews the available research on concurrent criterionrelated validity of physical examination tests for the diagnosis of acromioclavicular joint (ACJ) dysfunction. A literature search yielded four research studies on the topic of concurrent criterion-related validity of physical examination tests of the ACJ. These studies had various methodological shortcomings. Methodological scores on the STARD (Standards for Reporting of Diagnostic Accuracy) criteria yielded scores from 1/22 to 16/22. All studies examined pain provocation tests only. The currently available best research evidence supports the inclusion of a number of tests with a specific interpretation in a physical examination format for the diagnosis of painful ACJ dysfunction. A negative finding on the cross-body adduction test, tenderness on palpation of the ACJ, and the Paxinos sign may serve to rule out a painful ACJ dysfunction. A positive finding on the active compression test, the cross-body adduction test, and the acromioclavicular resisted extension test may serve to rule in a painful ACJ dysfunction. A positive finding on all three tests for the cross-body adduction, active compression, and resisted acromioclavicular extension may be relevant when the physical therapist is considering a medical-surgical referral and associated higher-risk interventions. This review indicates that future research is required 1) to evaluate the diagnostic utility of the gold standard tests used in the studies retrieved; 2) to examine the reliability and concurrent criterion-related validity (with validated gold standard tests) of these and other physical tests and history items commonly used in the diagnosis of ACJ lesions, both isolated and in the form of multi-test regimens; and 3) to study predictive validity of findings on tests and multi-test regimens for ACJ dysfunction coupled to outcomes with diagnosis-specific (orthopedic manual) physical therapy, medical, and surgical interventions.
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