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2009 - Vol. 17, No. 2

Free Content:

Editorial Sub-group Classification of Low Back Related Leg Pain: Is this the Catalyst Needed for Other Challenging Conditions?
Online Only Article Clinimetrics Corner: Analysis of Variance: The Fundamental Concepts
Online Only Article Mulligan's Mobilization with Movement: A Systematic Review
Letter to the Editor with Author Response Evidenced-Based-Diagnosis and Treatment of the Painful Sacroiliac Joint: A Clinical Perspective
Book and Multimedia Reviews Book and Multimedia Reviews
Announcements Manual Therapy Announcements
Information for Authors Information for Authors


Abstracts:

Editorial: Sub-group Classification of Low Back Related Leg Pain: Is this the Catalyst Needed for Other Challenging Conditions?

CHAD COOK PT, PhD, MBA, OCS, FAAOMPT, EDITOR IN CHIEF, JMMT

[no abstract available]
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The Journal of Manual & Manipulative Therapy Vol. 17 No. 2 (2009), 70-72

Interaction between Trigger Points and Joint Hypomobility: A Clinical Perspective

CÉSAR FERNÁNDEZ- DE -LAS-PENAS, PT, DO, PhD

Abstract: 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.


The Journal of Manual & Manipulative Therapy Vol. 17 No. 2 (2009), 74-77

Manual Correction of an Acute Lumbar Lateral Shift: Maintenance of Correction and Rehabilitation: A Case Report with Video

MARK LASLETT, FNZCP, PhD, Dip.MT, Dip.MDT

Abstract: The acute onset lumbar lateral shift, otherwise known as a list or acute scoliosis, is a common clinical observation associated with low back pain. In general orthopaedics, the presence of a lateral shift is associated with a poor prognosis; however, a manual correction method devised by McKenzie is claimed to produce rapid reversal of the deformity and reduction in pain. This single-case report presents the details of the McKenzie Mechanical Diagnosis and Treatment (MDT) management of a major right-sided lateral shift, which includes the manual correction technique, self-correction and management, prophylaxis, pain ablation, and rehabilitation to a high level of athletic function, with longterm follow-up at 9 months. The lateral shift is widely accepted as being associated with disc pathology, but the exact mechanism of shift production remains speculative. Hypotheses include muscle spasm, avoidance of irritation of a spinal nerve, and space-occupying or space-deficient disc mechanics. The hypotheses used to explain the lateral shift phenomena are discussed.


The Journal of Manual & Manipulative Therapy Vol. 17 No. 2 (2009), 78-85

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

ALBERT MORASKA, PhD, CLINT CHANDLER, BS

Abstract: Investigations into complementary and alternative medicine (CAM) approaches to address stress, depression, and anxiety of those experiencing chronic pain are rare. The objective of this pilot study was to assess the value of a structured massage therapy program, with a focus on myofascial trigger points, on psychological measures associated with tension-type headache. Participants were enrolled in an open-label trial using a baseline control with four 3-week phases: baseline, massage (two 3-week periods) and a followup phase. Eighteen subjects with episodic or chronic tension-type headache were enrolled and evaluated at 3-week intervals using the State-Trait Anxiety Inventory, Beck Depression Inventory, and the Perceived Stress Scale. The Daily Stress Inventory was administered over 7-day periods during baseline and the final week of massage. Twice weekly, 45-minute massage therapy sessions commenced following the baseline phase and continued for 6 weeks. A significant improvement in all psychological measures was detected over the timeframe of the study. Post hoc evaluation indicated improvement over baseline for depression and trait anxiety following 6 weeks of massage, but not 3 weeks. A reduction in the number of events deemed stressful as well as their respective impact was detected. This pilot study provides evidence for reduction of affective distress in a chronic pain population, suggesting the need for more rigorously controlled studies using massage therapy to address psychological measures associated with TTH.


The Journal of Manual & Manipulative Therapy Vol. 17 No. 2 (2009), 86-94

Applying Joint Mobilization at Different Cervical Vertebral Levels does not Influence Immediate Pain Reduction in Patients with Chronic Neck Pain: A Randomized Clinical Trial

RAFAELA L. AQUINO, BPhty; PRISCILA M. CAIRES, BPhty; FERNANDA C. FURTADO, BPhty; ALINE V. LOUREIRO, BPhty; PAULO H. FERREIRA, PhD; MANUELA L. FERREIRA, PhD

Abstract: The aim of the present study was to compare the effects of applying joint mobilization at symptomatic and asymptomatic cervical levels in patients with chronic non-specific neck pain. Forty-eight patients aged between 18 and 65 years and presenting non-specific neck pain with a minimum duration of 3 months were recruited for the study. Included patients were randomized to one of two treatment groups: (i) control group: the most symptomatic vertebral level was mobilized; (ii) experimental group: a randomly selected vertebral level was chosen and mobilized. All patients received one treatment session. Pain intensity in resting position during the most painful active cervical movement as well as during vertebral palpation was quantified using an 11-point pain scale. Follow-up measures were taken immediately after intervention by a blinded assessor. The results showed no significant difference in pain intensity immediately after treatment between groups (symptomatic level treated vs. randomly chosen cervical vertebral level treated) during resting position, painful active movement, or vertebral palpation. Within-group comparisons showed significant pain relief after treatment during the most painful active movement as well as during vertebral palpation for both groups, but not during resting position. Significant change in immediate pain intensity during painful active movement and vertebral palpation was achieved after vertebral mobilization. However, both groups presented similar pain reductions suggesting that pain reduction due to joint mobilization is not specific to the vertebral level being mobilized.


The Journal of Manual & Manipulative Therapy Vol. 17 No. 2 (2009), 95-100

The Effect of an Analgesic Mobilization Technique When Applied at Symptomatic or Asymptomatic Levels of the Cervical Spine in Subjects with Neck Pain: A Randomized Controlled Trial

JOCHEN SCHOMACHER, PT, OMT, MCMK, DPT, BSc, MSc Phys

Abstract: The purpose of this single-blinded, randomized controlled trial was to compare the effects of a manual treatment technique on neck pain and movement sensation when applied in different segments of the cervical spine. Consecutive patients with neck pain (n=126) were recruited and randomly allocated to two groups (A or B). Group A received a single 4-minute pain-alleviating traction at the most symptomatic zygopophyseal joint of the cervical segment, where movement was correlated with pain. Group B received the same treatment 3 segments away from the concordant segment. Pain intensity and sensation of movement were assessed with a numeric rating scale (NRS). Statistical analysis included a t-test for paired and unpaired samples. Pre- and post-test findings demonstrated significant improvements in both types of mobilization although there was no significant difference between the two groups. Similar results have been reported in the literature for cervical manipulation. The findings of this study question the necessity of precise symptom localization tests for a pain treatment. However, limitations of the study prevent generalization of these results.


The Journal of Manual & Manipulative Therapy Vol. 17 No. 2 (2009), 101-108

Interrater Reliability of a New Classification System for Patients with Neural Low Back-Related Leg Pain

AXEL SCHÄFER, PT; TOBY M. HALL, MSc,4; KERSTIN LÜDTKE, MSc; JOACHIM MALLWITZ, MD; NOELLE K. BRIFFA, PhD

Abstract: The aim of this study was to investigate the reliability of a new classification system for low back-related leg pain arising from neural tissue dysfunction. Leg pain is a frequent accompaniment to back pain and is an indicator of the severity and prognosis of the disorder. For optimal patient care, treatment should be directed according to the identified pathophysiological mechanisms. The authors have proposed a sub-classification of neural low back-related leg pain into four categories, each requiring a different management strategy: Central Sensitization (CS), comprising major features of sensitization of the somatosensory system; Denervation (D), arising from significant axonal compromise without evidence of major central nervous system changes; Peripheral Nerve Sensitization (PNS), arising from nerve trunk inflammation without clinical evidence of significant denervation; and Musculoskeletal pain (M), referred from non-neural structures such as the disc or facet joints. The purpose of this study was to investigate the interrater reliability of this classification system. Forty consecutive patients with unilateral low back-related leg pain were independently assessed by five pairs of examiners using a physical examination protocol, screening for central sensitization of the somatosensory system, neurological deficit, and nerve tissue mechano-sensitization. Subjects were classified as follows: CS 30%, D 27.5%, PNS 10%, and M 32.5%. Interrater reliability was good with 80% agreement and a k of 0.72 (95% Confidence Interval (CI) .57-.86). The findings of the study demonstrate that patients with low back-related leg pain can be reliably classified to one of the four proposed groups.


The Journal of Manual & Manipulative Therapy Vol. 17 No. 2 (2009), 109-116

Classification of Low Back-Related Leg Pain: Do Subgroups Differ in Disability and Psychosocial Factors?

JEREMY WALSH, BSc (Hons), M Manip Ther; TOBY HALL MSc, Post Grad Dip Manip Ther, FACP

Abstract: ABSTRACT: It has been proposed that patients with low back-related leg pain can be classified according to pain mechanisms into four distinct subgroups: Central Sensitization (CS), Denervation (D), Peripheral Nerve Sensitization (PNS), and Musculoskeletal (M). The purpose of this study was to determine whether there were any differences in terms of disability and psychosocial factors between these four subgroups. Forty-five subjects with low back-related leg pain completed the Oswestry Disability Index, the Hospital Anxiety and Depression Scale, and the Fear Avoidance Beliefs Questionnaire. Subsequently, an examiner blinded to the questionnaire results classified the subjects into one of the four subgroups, according to the findings of the self-administered Leeds Assessment of Neuropathic Signs and Symptoms questionnaire and a physical examination. It was found that the PNS subgroup had significantly greater disability compared to all other subgroups and significantly greater fear avoidance beliefs about physical activity compared to the CS and D subgroups. This highlights the importance of sub-classification but also the need to take into account disability and psychosocial factors in the management of low back-related leg pain.


The Journal of Manual & Manipulative Therapy Vol. 17 No. 2 (2009), 118-123

Invited Commentary: "Interrater Reliability of a New Classification System for Patients with Neural Low Back-Related Leg Pain" and "Classification of Low Back-Related Leg Pain: Do Subgroups Differ in Disability and Psychosocial Factors?"

STEPHEN MAY, MSc

[no abstract available]


The Journal of Manual & Manipulative Therapy Vol. 17 No. 2 (2009), 124

Clinimetrics Corner: Analysis of Variance: The Fundamental Concepts

STEVEN F. SAWYER, PT, PhD

Abstract: ABSTRACT: Analysis of variance (ANOVA) is a statistical test for detecting differences in group means when there is one parametric dependent variable and one or more independent variables. This article summarizes the fundamentals of ANOVA for an intended benefit of the clinician reader of scientific literature who does not possess expertise in statistics. The emphasis is on conceptually-based perspectives regarding the use and interpretation of ANOVA, with minimal coverage of the mathematical foundations. Computational examples are provided. Assumptions underlying ANOVA include parametric data measures, normally distributed data, similar group variances, and independence of subjects. However, normality and variance assumptions can often be violated with impunity if sample sizes are sufficiently large and there are equal numbers of subjects in each group. A statistically significant ANOVA is typically followed up with a multiple comparison procedure to identify which group means differ from each other. The article concludes with a discussion of effect size and the important distinction between statistical significance and clinical significance.
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The Journal of Manual & Manipulative Therapy Vol. 17 No. 2 (2009), E27-E38

Mulligan's Mobilization with Movement: A Systematic Review

WAYNE HING, PhD; RENEE BIGELOW, BHSc; TONI BREMNER, BHSc

Abstract: Mulligan's manual therapy technique at peripheral joints, namely mobilization with movement (MWM), has been well documented in research. The efficacy of MWM has been established in the treatment of joint dysfunction and various pathologies. The purpose of this systematic review was to critically evaluate the literature regarding MWM at peripheral joints and determine the overall efficacy related to MWM prescription. Electronic databases (Cinahl, Medline and Amed via Ovid, Pubmed and Medline via Ebsco Health Databases, Cochrane via Wiley and PEDro) were searched up to August 2008 with no date restriction to identify all studies pertaining to MWM at peripheral joints. The keywords used were mobilization with movement* OR mobilization with movement* OR MWM*; manual therapy AND (mobilization* OR mobilization); mulligan mobilization* OR mulligan mobilization*. Two researchers independently reviewed all papers and crossexamined reference lists for further potential studies. Methodological quality was assessed using the Downs and Black checklist, and tables were compiled to determine study characteristics. Twenty-one studies, which have investigated MWM at peripheral joints, were included for analysis. This review highlights that there is an overall moderate level of methodological quality (mean = 15 (/28), SD ± 4.54, range = 4 - 23 /28). The efficacy of MWM at peripheral joints is well established for various joints and pathologies with 24 out of 25 studies (96%) demonstrating positive effects. It would be advisable that future research have more robust methodology and investigate and/or implement all necessary established parameters of MWM prescription.
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The Journal of Manual & Manipulative Therapy Vol. 17 No. 2 (2009), E39-E66

Letter to the Editor with Author Response: Evidenced-Based-Diagnosis and Treatment of the Painful Sacroiliac Joint: A Clinical Perspective

[no abstract available]
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The Journal of Manual & Manipulative Therapy Vol. 17 No. 2 (2008), E67-E70

Book and Multimedia Reviews

[no abstract available]
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The Journal of Manual & Manipulative Therapy Vol. 17 No. 2 (2008), E71-E72

Manual Therapy Announcements

[no abstract available]
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The Journal of Manual & Manipulative Therapy Vol. 17 No. 2 (2008), E73

Information for Authors

[no abstract available]
[ View Author Guidelines Online ]


The Journal of Manual & Manipulative Therapy Vol. 17 No. 2 (2008), E74