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Background: Neck pain is among the most prevalent and costly musculoskeletal disorders. Manual therapy and exercise are two standard treatment approaches to manage neck pain. In addition, clinical practice guidelines recommend a multi-modal approach, including both manual therapy and exercise for the treatment of neck pain; however, the specific effects of these combined interventions have not recently been reported in the literature. Objective: To perform a systematic review and meta-analysis to determine the effect of manual therapy combined with exercise on pain, disability, and quality of life in individuals with nonspecific neck pain. Design: Systematic Review and Meta-Analysis Methods: Electronic database searches were completed in PubMed, CINAHL, Cochrane, EMBASE, Ovid, and SportDiscus, with publication dates of January 2000 to December 2022. The risk of bias in the included articles was completed using the Revised Cochrane Risk of Bias Tool (RoB 2). Raw data were pooled using standardized mean differences and mean differences for pain, disability, and quality of life outcomes, and forest plots were computed in the metaanalysis. Results: Twenty-two studies were included in the final review. With moderate certainty of evidence, three studies demonstrated no significant difference between manual therapy plus exercise and manual therapy alone in pain (SMD of −0.25 (95% CI: −0.52, 0.02)) or disability (−0.37 (95% CI: −0.92, 0.18)). With a low certainty of evidence, 16 studies demonstrated that manual therapy plus exercise is significantly better than exercise alone for reducing pain (−0.95 (95%CI: −1.38, −0.51)). Similarly, with low certainty of evidence, 13 studies demonstrated that manual therapy plus exercise is significantly better than exercise alone for reducing disability (−0.59 (95% CI: −0.90, −0.28)). Four studies demonstrated that manual therapy plus exercise is significantly better than a control intervention for reducing pain (moderate certainty) (−2.15 (95%CI: −3.58, −0.73)) and disability (low certainty) (−2.39 (95% CI: −3.80, −0.98)). With a high certainty of evidence, four studies demonstrated no significant difference between manual therapy plus exercise and exercise alone in quality of life (SMD of −0.02 (95% CI: −0.21, 0.18)). Conclusion: Based on this systematic review and meta-analysis, a multi-modal treatment approach including exercise and manual therapy appears to provide similar effects as manual therapy alone, but is more effective than exercise alone or other interventions (control, placebo, ‘conventional physical therapy’, etc.) for the treatment of nonspecific neck pain and related disability. Some caution needs to be taken when interpreting these results given the general low to moderate certainty of the quality of the evidence. [ABSTRACT FROM AUTHOR]

To determine if thoracic spine manipulation (TSM) improves pain and disability in individuals with cervicogenic headache (CeH). A randomized controlled crossover trial was conducted on 48 participants (mean age: 34.4 years) with CeH symptoms. Participants were randomized to 6 sessions of TSM or no treatment (Hold) and after 4-weeks, groups crossed over. Outcomes were collected at 4, 8 and 12 weeks and included: headache disability inventory (HDI), neck disability index (NDI), and the global rating of change (GRC). Outcomes were analyzed using a linear mixed-effects model with Bonferroni correction. Odds of achieving the minimal clinically important difference (MCID) on the GRC of +4 or greater were also calculated. Scores at 4 weeks represent the only timepoint where 1 group is fully treated and other group has not received any treatment. Comparing hold to active treatment, HDI were not significantly different between groups (mean difference = 7.39, 95 CI: −4.39 to 19.18; P = 0.214) at any timepoint; the NDI was significant (mean difference = 6.90, 95 CI: 0.05 to 13.75; P = 0.048) at 4 weeks. Odds of achieving the +4 MCID on the GRC (OR = 38.0, 95 CI: 6.6 to 220.0; p < 0.001) favored TSM at 4 weeks. TSM had no effect on headache-related disability but resulted in significant improvements in neck-related disability and participant reported perceived improvement. Future studies are needed to examine the long-term impact of TSM in this population. [ABSTRACT FROM AUTHOR]

The term 'regional interdependence' or RI has recently been introduced into the vernacular of physical therapy and rehabilitation literature as a clinical model of musculoskeletal assessment and intervention. The underlying premise of this model is that seemingly unrelated impairments in remote anatomical regions of the body may contribute to and be associated with a patient's primary report of symptoms. The clinical implication of this premise is that interventions directed at one region of the body will often have effects at remote and seeming unrelated areas. The formalized concept of RI is relatively new and was originally derived in an inductive manner from a variety of earlier publications and clinical observations. However, recent literature has provided additional support to the concept. The primary purpose of this article will be to further refine the operational definition for the concept of RI, examine supporting literature, discuss possible clinically relevant mechanisms, and conclude with a discussion of the implications of these findings on clinical practice and research. [ABSTRACT FROM AUTHOR]

Thoracic spine manipulation has been shown to be effective for the management of neck pain. The purpose of this study was to investigate the immediate effect of a T3-T4 spinal thrust manipulation on autonomic nervous system activity in subjects with chronic cervical pain. An additional aim was to determine if the manipulation resulted in an immediate pain relief in patients with chronic neck pain when compared to a placebo intervention. One hundred subjects with chronic neck pain were randomly assigned to receive either a thoracic thrust manipulation or a placebo intervention. The Friedman's test was used to evaluate the change in pupil diameter within both groups. The Wilcoxen signed-ranks test was used to explore pupil changes over time and to make paired comparisons of the pupil change between the groups. The Mann-Whitney U test was used to compare the change in pain perception for the chronic cervical pain group subjects receiving either the thrust manipulation or the placebo intervention. The results demonstrated that manipulation did not result in a change in sympathetic activity. Additionally, there was no significant difference in the subject's pain perception (P=0.961) when comparing the effects of the thrust manipulation to the placebo intervention within this group of subjects with chronic neck pain. The clinical impression of this study is that manipulation of the thoracic spine may not be effective in immediately reducing pain in patients with chronic neck pain. [ABSTRACT FROM AUTHOR]

An introduction is presented in which the editor discusses various reports within the issue on topics including the dysfunction of thoracic spine, the research evidence of thorax as an integrated system, and the safe and proper dry needling (DN) application for myofascial trigger points management.

The article pays tribute to registered physical therapist Peter A. Huijbregts, who died on November 6, 2010.

Objective: To determine the effect of strain counterstrain (SCS) on dynamic balance and subjective sense of instability in individuals with chronic ankle instability (CAI). Although many studies have been published on CAI, the cause for this common clinical dysfunction remains inconclusive. No studies have assessed the effectiveness of SCS on CAI. Methods: At baseline all participants completed a demographic questionnaire, the star excursion balance test (SEBT), and the foot and ankle ability measure (FAAM). Following the baseline evaluation, participants were randomized into the SCS experimental group (EG) (n=13) or the sham SCS group (SG) (n=14). All participants received the assigned treatment once a week for 4 weeks and participated in a prescribed exercise program. At week 4, all participants repeated the outcome measures and completed a global rating of change (GROC) form. The primary aim was examined with a two-way analysis of variance (ANOVA). Results: A significant group-by-time interaction was found for seven directions in the SEBT (P<0.031). For subjective measures, no significant group-by-time interaction was found for the FAAM (P>0.548), but the GROC revealed a significant difference (P=0.014) in the mean score for the EG (3.92 ± 1.66) when compared to the SG (2.43 ± 1.66). Discussion: Although SCS may not have an effect on subjective ankle function in individuals with CAI, preliminary evidence suggests that SCS may lead to an improvement in dynamic ankle stability and the subjective sense of ankle instability. [ABSTRACT FROM AUTHOR]

Background: Cervical spine manipulation (CSM) is a commonly utilized intervention, but its use remains controversial. Purpose: To retrospectively analyze all available documented case reports in the literature describing patients who had experienced severe adverse events (AEs) after receiving CSM to determine if the CSM was used appropriately, and if these types of AEs could have been prevented using sound clinical reasoning on the part of the clinician. Data sources: PubMed and the Cumulative Index to Nursing and Allied Health were systematically searched for case reports between 1950 and 2010 of AEs following CSM. Study selection: Case reports were included if they were peer-reviewed; published between 1950 and 2010; case reports or case series; and had CSM as an intervention. Articles were excluded if the AE occurred without CSM (e.g. spontaneous); they were systematic or literature reviews. Data extracted from each case report included: gender; age; who performed the CSM and why; presence of contraindications; the number of manipulation interventions performed; initial symptoms experienced after the CSM; and type of resultant AE. Data synthesis: Based on the information gathered, CSMs were categorized as appropriate or inappropriate, and AEs were categorized as preventable, unpreventable, or unknown. Chi-square analysis with an alpha level of 0.05 was used to determine if there was a difference in proportion between six categories: appropriate/preventable, appropriate/unpreventable, appropriate/unknown, inappropriate/ preventable, inappropriate/unpreventable, and inappropriate/unknown. Results: One hundred thirty four cases, reported in 93 case reports, were reviewed. There was no significant difference in proportions between appropriateness and preventability, P=.46. Of the 134 cases, 60 (44.8%) were categorized as preventable, 14 (10.4%) were unpreventable and 60 (44.8%) were categorized as 'unknown'. CSM was performed appropriately in 80.6% of cases. Death resulted in 5.2% (n=7) of the cases, mostly caused by arterial dissection. Limitations: There may have been discrepancies between what was reported in the cases and what actually occurred, since physicians dealing with the effects of the AE, rather than the clinician performing the CSM, published many of the cases. Conclusions: This review showed that, if all contraindications and red flags were ruled out, there was potential for a clinician to prevent 44.8% of AEs associated with CSM. Additionally, 10.4% of the events were unpreventable, suggesting some inherent risk associated with CSM even after a thorough exam and proper clinical reasoning. [ABSTRACT FROM AUTHOR]

Study design: A case series of consecutive patients with chronic low back pain. Background and purpose: In patients with chronic low back pain (CLBP), the importance of impairments at the hip joints is unclear. However, it has been postulated that impairments at the hip joints may contribute to CLBP. The purpose of this case series was to investigate the short-term outcomes in patients with CLBP managed with impairment-based manual therapy and exercise directed at the hip joints. Methods: Eight consecutive patients (mean age: 43.9 years) with a primary report of CLBP (>6 months) without radiculopathy were treated with a standardized approach of manual physical therapy and exercise directed at bilateral hip impairments for a total of three sessions over approximately 1 week. At initial examination, all patients completed a numeric rating pain scale (NPRS), Oswestry disability index (ODI), fear-avoidance beliefs questionnaire (FABQ), and patient-specific functional scale (PSFS). At the second and third treatment sessions, each patient completed all outcome measures as well as the Global Rating of Change (GROC). Results: Five of the eight (62.5%) patients reported 'moderately better' or higher (> + 4) on the GROC at the third session, indicating a moderate improvement in self-reported symptoms. These five individuals also experienced a 24.4% reduction in ODI scores. Discussion: This case series suggests that an impairment-based approach directed at the hip joints may lead to improvements in pain, function, and disability in patients with CLBP. A neurophysiologic mechanism may be a plausible explanation regarding the clinical outcomes of this study. A larger, well-controlled trial is needed to determine the potential effectiveness of this approach with patients with CLBP. [ABSTRACT FROM AUTHOR]