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Background: Neck pain with mobility deficits is a common non-specific disorder often observed in younger individuals. The abnormal position of the scapula has also been identified as a risk factor in individuals with neck pain and mobility deficits. Though literature exists regarding the effects of scapular strengthening exercises, there is a lack of studies that have examined the effects of scapular strengthening exercises in individuals with neck pain and mobility deficits. This randomized controlled trial aims to examine the effects of scapula-focused exercises on pain and disability in individuals with neck pain and mobility deficits., Methods: A single-blind (assessor-blinded) randomized controlled trial will be performed. One hundred and eight participants will be recruited and randomly assigned into two groups. The intervention group will receive scapula-focused exercises, and the control group will receive neckspecific exercises. Both groups will receive supervised sessions 3 days per week for 6 weeks and unsupervised sessions for the remaining weeks. Disability, pain, range of motion, pain pressure threshold, muscle strength, EMG activity, and sensory-motor functions will be assessed at the baseline, the 6th week, and the 12th week., Results: This study aims to provide the effectiveness of scapular-focused exercises and its effect on neck pain with mobility deficits., Conclusion: Analyzing the results can provide insight into how effective scapular-focused exercises are when compared to neck exercises., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

Objective: To evaluate the effectiveness of the neurodynamic mobilization techniques compared with passive robotic physiologic movement in patients with hand osteoarthritis (OA)., Methods: We conducted a randomized controlled trial. A total of 72 patients (mean ± SD age 71 ± 11 years) with dominant symptomatic hand OA were randomized in 2 groups, and both received 12 treatment sessions over 4 weeks. The experimental group received neurodynamic mobilization of the median, radial, and ulnar nerves, and the control group received robotic-assisted passive movement treatment. Both groups also participated in a program of hand stability exercises. Outcome measures included pain intensity, pressure pain thresholds (PPTs), and strength measurements. Group-by-time effects were compared using mixed-model analyses of variance., Results: After the intervention, the experimental group had statistically significant, higher PPTs than the control group at the thumb carpometacarpal joint by 0.7 kg/cm 2 (95% confidence interval [95% CI] 0.6, 0.8), the median nerve by 0.7 kg/cm 2 (95% CI 0.6, 0.7), and the radial nerve by 0.5 kg/cm 2 (95% CI 0.3, 0.6); however, the difference was not statistically significant at 3 months postintervention. Although mean values in the experimental group were higher than in the control group at all PPT sites at both assessments, these differences were not statistically significant. The experimental group experienced a statistically significant reduction in pain immediately postintervention, but this was not present at the 3-month follow-up. There were no statistically significant differences in pinch or grip strength between groups., Conclusion: We found that neurodynamic mobilizations decreased hypersensitivity in patients with hand OA immediately after the intervention; however, differences were no longer present at 3 months. The results suggest that these techniques may have some limited value in the short term but do not have lasting effects., (© 2020, American College of Rheumatology.)

Objective: To examine the short- and long-term effectiveness of dry needling on disability, pain, and patient-perceived improvements in patients with mechanical neck pain when added to a multimodal treatment program that includes manual therapy and exercise., Design: Randomized controlled trial., Methods: Seventy-seven adults (mean ± SD age, 46.68 ± 14.18 years; 79% female) who were referred to physical therapy with acute, subacute, or chronic mechanical neck pain were randomly allocated to receive 7 multimodal treatment sessions over 4 weeks of (1) dry needling, manual therapy, and exercise (needling group); or (2) sham dry needling, manual therapy, and exercise (sham needling group). The primary outcome of disability (Neck Disability Index score) and secondary outcomes of pain (current and 24-hour average) and patient-perceived improvement were assessed at baseline and follow-ups of 4 weeks, 6 months, and 1 year by blinded assessors. Between-group differences were analyzed with a 2-way, repeated-measures analysis of variance. Global rating of change was analyzed with a Mann-Whitney U test., Results: There were no group-by-time interactions for disability (Neck Disability Index: F 2.37,177.47 = 0.42, P = .69), current pain (visual analog scale: F 2.84,213.16 = 1.04, P = .37), or average pain over 24 hours (F 2.64,198.02 = 0.01, P = .10). There were no between-group differences for global rating of change at any time point ( P ≥.65). Both groups improved over time for all variables (Neck Disability Index: F 2.37,177.47 = 124.70, P <.001; current pain: F 2.84,213.16 = 64.28, P <.001; and average pain over 24 hours: F 2.64,198.02 = 76.69, P <.001)., Conclusion: There were no differences in outcomes between trigger point dry needling and sham dry needling when added to a multimodal treatment program for neck pain. Dry needling should not be part of a first-line approach to managing neck pain. J Orthop Sports Phys Ther 2021;51(1):37-45. doi:10.2519/jospt.2021.9864 .

Objective: To (1) evaluate whether exercise therapy is effective for managing neck pain, and (2) investigate the relationship between exercise therapy dosage and treatment effect., Design: Intervention systematic review with meta-analysis and meta-regression., Literature Search: An electronic search of 6 databases was completed for trials assessing the effects of exercise therapy on neck pain., Study Selection Criteria: We included randomized controlled trials that compared exercise therapy to a no-exercise therapy control for treating neck pain. Two reviewers screened and selected studies, extracted outcomes, assessed article risk of bias, and rated the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach., Data Synthesis: Data were pooled using random-effects meta-analysis. We used meta-regression to analyze the effect of exercise dosage on neck pain and disability., Results: Fourteen trials were included in the review. Seven trials were at high risk of bias, 4 were at unclear risk of bias, and 3 were at low risk of bias. Exercise therapy was superior to control for reducing pain (visual analog scale mean difference, -15.32 mm) and improving disability (Neck Disability Index mean difference, -3.64 points). Exercise dosage parameters did not predict pain or disability outcomes., Conclusion: Exercise was beneficial for reducing pain and disability, regardless of exercise therapy dosage. Therefore, optimal exercise dosage recommendations remain unknown. We encourage clinicians to use exercise when managing mechanical neck pain. J Orthop Sports Phys Ther 2020;50(11):607-621. doi:10.2519/jospt.2020.9155 .

Objective: To determine the immediate and short-term effects of adding cervical spine high-velocity, low-amplitude thrust (HVLAT) to behavioral education, soft tissue mobilization, and a home exercise program on pain and dysfunction for people with a primary complaint of temporomandibular disorder (TMD) with myalgia., Design: Randomized clinical trial., Methods: Fifty individuals with TMD were randomly assigned to receive cervical HVLAT or sham manipulation for 4 visits over 4 weeks. Participants in both groups received other treatments, including standardized behavioral education, soft tissue mobilization, and a home exercise program. Primary outcomes included maximal mouth opening, the numeric pain-rating scale, the Jaw Functional Limitation Scale (JFLS), the Tampa Scale of Kinesiophobia for TMD (TSK-TMD), and a global rating of change (GROC). Self-report and objective measurements were taken at baseline, immediately after initial treatment, and follow-ups of 1 week and 4 weeks. A 2-by-4 mixed-model analysis of variance was used, with intervention group as the between-subjects factor and time as the within-subject factor. Separate analyses of variance were performed for dependent variables, and the hypothesis of interest was the group-by-time interaction., Results: There was no significant interaction for maximal mouth opening, the numeric pain-rating scale, or secondary measures. There were significant 2-way interactions for the JFLS ( d = 0.60) and TSK-TMD ( d = 0.80). The HVLAT group had lower fear at 4 weeks and improved jaw function earlier (1 week). The GROC favored the HVLAT group, with significant differences in successful outcomes noted immediately after baseline treatment (thrust, 6/25; sham, 0/25) and at 4 weeks (thrust, 17/25; sham, 10/25)., Conclusion: Both groups improved over time; however, differences between groups were small. There were significant differences between groups for the JFLS, TSK-TMD, and GROC. The additive clinical effect of cervical HVLAT to standard care remains unclear for treating TMD. J Orthop Sports Phys Ther 2020;50(8):455-465. Epub 6 Jan 2020. doi:10.2519/jospt.2020.9175 .

Objectives : To describe the outcomes of 10 patients with chronic biceps tendinopathy treated by physical therapy with the novel approach of dry needling (DN), eccentric-concentric exercise (ECE), and stretching of the long head of the biceps tendon (LHBT). Methods : Ten individuals reporting chronic anterior shoulder symptoms (> 3 months), pain with palpation of the LHBT, and positive results on a combination of tests including active shoulder flexion, Speed's, Hawkins Kennedy, Neer, and Yergason's tests participated in this case series. Validated self-reported outcome measures including the mean numeric pain rating scale (NPRS) and Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) were taken at baseline. Participants were treated with two to eight sessions of DN to the LHBT and an ECE program and stretching of the biceps muscle. At discharge, patients completed the global rating of change (GROC), QuickDASH and NPRS. Results : Patients had an improved mean NPRS of 3.9 (SD, 1.3; p  < 0.001), QuickDASH of 19.01% (SD, 10.8; p  < 0.02) and GROC +5.4 (SD, 1.3). Conclusion : Findings from this case series suggest that DN and ECE may be beneficial for the management of patients with chronic LHBT tendinopathy. Further research on the efficacy of this novel treatment approach is warranted.

Objective: The aim of the study was to investigate the effects of the inclusion of neural mobilization into a motor control exercise program on pain, related disability, neuropathic symptoms, straight leg raise, and pressure pain threshold in lumbar radiculopathy., Design: This is a randomized clinical trial., Methods: Individuals with low back pain, with confirmed disc herniation, and lumbar radiculopathy were randomly assigned to receive eight sessions of either neurodynamic mobilization plus motor control exercises (n = 16) or motor control exercises alone (n = 16). Outcomes included pain, disability, neuropathic symptoms, straight leg raise, and pressure pain threshold at baseline, after four visits, after eight visits, and after 2 mos., Results: There were no between-groups differences for pain, related disability, or pressure pain threshold at any follow-up period because both groups get similar and large improvements. Patients assigned to the neurodynamic program group experienced better improvements in neuropathic symptoms and the straight leg raise compared with the motor control exercise group (P < 0.01)., Conclusions: The addition of neurodynamic mobilization to a motor control exercise program leads to reductions in neuropathic symptoms and mechanical sensitivity (straight leg raise) but did not result in greater changes of pain, related disability, or pressure pain threshold over motor control exercises program alone in subjects with lumbar radiculopathy. Future trials are needed to further confirm these findings because between-groups differences did not reach clinically relevance.

Objective: To determine the short-term effectiveness of thoracic manipulation when compared to sham manipulation for individuals with low back pain (LBP)., Design: Randomized controlled trial., Methods: Patients with LBP were stratified based on symptom duration and randomly assigned to a thoracic manipulation or sham manipulation treatment group. Groups received 3 visits that included manipulation or sham manipulation, core stabilization exercises, and patient education. Factorial repeated-measures analysis of variance and multiple regression were performed for pain, disability, and fear avoidance. The Mann-Whitney U test was used to analyze patient-perceived improvement, via the global rating of change scale, at follow-up., Results: Ninety participants completed the study (mean ± SD age, 38 ± 11.5 years; 70% female; 72% with chronic LBP). The overall group-by-time interaction was not significant for the Modified Oswestry Disability Questionnaire, numeric pain-rating scale, and Fear-Avoidance Beliefs Questionnaire outcomes. The global rating of change scale was not significantly different between groups., Conclusion: Three sessions of thoracic manipulation, education, and exercise did not result in improved outcomes when compared to a sham manipulation, education, and exercise in individuals with chronic LBP. Future studies are needed to identify the most effective management strategies for the treatment of LBP., Level of Evidence: Therapy, level 1b. J Orthop Sports Phys Ther 2020;50(1):24-32. Epub 6 Dec 2019. doi:10.2519/jospt.2020.8928 .

Background: Trigger point dry needling interventions are utilized by physical therapists to manage shoulder pain. Observational studies have shown positive short-term outcomes in patients with subacromial pain syndrome receiving trigger point dry needling. However, little research has been done to evaluate the long-term effectiveness of trigger point dry needling specifically as it compares to other commonly utilized interventions such as exercise and manual therapy. The purpose of this study is to assess the additive short and long-term effectiveness of trigger point dry needling to a standard physical therapy approach of manual therapy and exercise for patients with subacromial pain syndrome., Methods: This multicenter randomized trial with 3 arms was designed following the standard protocol items for randomized interventional trials. Results will be reported consistent with the consolidated standards of reporting trials guidelines. 130 participants will be randomized to receive standard PT interventions alone (manual therapy and exercise), standard PT and trigger point dry needling or standard PT and sham trigger point dry needling. The primary outcome measures will be the Shoulder Pain and Disability Index and Patient Reported Outcomes Measurement Information Systems (PROMIS-57) scores collected at baseline, 6-weeks, 6-months and one year. Healthcare utilization will be collected for 12 months following enrollment and groups analyzed for differences., Discussion: It is not known if trigger point dry needling provides long-term benefit for individuals with subacromial pain syndrome. This study will help determine if this intervention provides additive benefits over those observed with the commonly applied interventions of exercise and manual therapy., Trial Registration: Identifier: NCT03442894 (https://clinicaltrials.gov/ct2/show/NCT03442894) on 22 February 2018., (Copyright © 2018 Associação Brasileira de Pesquisa e Pós-Graduação em Fisioterapia. Publicado por Elsevier Editora Ltda. All rights reserved.)

Objective: To compare the effects of a neck-specific training program to prescribed physical activity with both groups receiving a cognitive behavioral approach, on pain and disability in patients with cervical radiculopathy (CR)., Design: Parallel-group randomized clinical trial with follow-up at 3, 6, 12, and 24 months., Setting: Recruitment and assessments of participants were performed at a university hospital. Interventions were performed in primary care setting at outpatient physiotherapy clinics., Participants: Patients (N=144) with CR were recruited to participate in this clinical trial., Interventions: Patients were randomly assigned to 3 months of either of a neck-specific training program or prescribed physical activity., Main Outcome Measures: Primary outcomes included self-rated neck and arm pain as collected by the visual analog scale (VAS). Secondary outcomes were self-rated headache measured with the VAS, the Neck Disability Index, the EuroQol 5D, the Fear Avoidance Beliefs Questionnaire, and the Hospital Anxiety and Depression Scale. Assessments were performed at baseline and at 3-, 6-, 12-, and 24-month follow-up periods., Results: Intention-to-treat and per-protocol analyses showed no significant interaction (group × time) or group effects. There were, however, significant time effects indicating improvement over time for both groups for all outcomes except for levels of depression., Conclusions: The study revealed that neck-specific training as well as prescribed physical activity both including additional cognitive behavioral approach decreased the pain in patients with CR, that is, participants improved regardless of the intervention received. There is a lack of consensus of how to best manage individuals with CR. However, our findings suggest that CR has a natural favorable long-term outcome when patients are prescribed neck-specific training and exercise in combination with a behavioral approach., (Copyright © 2018 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate the cost-effectiveness of the inclusion of trigger point-dry needling (TrP-DN) into an exercise program for the management of subacromial pain syndrome., Methods: Fifty patients with unilateral subacromial pain syndrome were randomized with concealed allocation to exercise alone or exercise plus TrP-DN. Both groups were asked to perform an exercise program targeting the rotator cuff musculature twice daily for five weeks. Patients allocated to the exercise plus TrP-DN group also received dry needling during the second and fourth sessions. Societal costs and health-related quality of life (estimated by EuroQol-5D-5L) over a one-year follow-up were used to generate incremental cost per quality-adjusted life-year (QALY) ratios for each intervention., Results: Intention-to-treat analysis was possible for 48 (96%) of the participants. Those in the exercise group made more visits to medical doctors and received a greater number of other treatments (P < 0.001). The major contributor to societal costs (77%) was the absenteeism paid labor in favor of the exercise plus TrP-DN group (P = 0.03). The combination of exercise plus TrP-DN was less costly (mean difference cost/patient = €517.34, P = 0.003) than exercise alone. Incremental QALYs showed greater benefit for exercise plus TrP-DN (difference = 2.87, 95% confidence interval = 2.85-2.89). Therefore, the inclusion of TrP-DN into an exercise program was more likely to be cost-effective than an exercise program alone, with 99.5% of the iterations falling in the dominant area., Conclusions: The inclusion of TrP-DN into an exercise program was more cost-effective for individuals with subacromial pain syndrome than exercise alone. From a cost-benefit perspective, the inclusion of TrP-DN into multimodal management of patients with subacromial pain syndrome should be considered.

Study Design Systematic review. Background Therapeutic exercise is commonly used to treat individuals with knee disorders, but dosing parameters for optimal outcomes are unclear. Large variations exist in exercise prescription, and research related to specific dosing variables for knee osteoarthritis, patellar tendinopathy, and patellofemoral pain is sparse. Objectives To identify specific doses of exercise related to improved outcomes of pain and function in individuals with common knee disorders, categorized by effect size. Methods Five electronic databases were searched for studies related to exercise and the 3 diagnoses. Means and standard deviations were used to calculate effect sizes for the exercise groups. The overall quality of evidence was assessed using the Physiotherapy Evidence Database scale. Results Five hundred eighty-three studies were found after the initial search, and 45 were included for analysis after screening. Physiotherapy Evidence Database scale scores were "fair" quality and ranged from 3 to 8. For knee osteoarthritis, 24 total therapeutic exercise sessions and 8- and 12-week durations of exercise were parameters most often associated with large effects. An exercise frequency of once per week was associated with no effect. No trends were seen with exercise dosing for patellar tendinopathy and patellofemoral pain. Conclusion This review suggests that there are clinically relevant exercise dosing variables that result in improved pain and function for patients with knee osteoarthritis, but optimal dosing is still unclear for patellar tendinopathy and patellofemoral pain. Prospective studies investigating dosing parameters are needed to confirm the results from this systematic review. Level of Evidence Therapy, level 1a. J Orthop Sports Phys Ther 2018;48(3):146-161. Epub 10 Jan 2018. doi:10.2519/jospt.2018.7637.

Objective: To evaluate the effectiveness of exercise, ergonomic modification, and a combination of training exercise and ergonomic modification on the scores of pain in office workers with neck, shoulders, and lower back pain., Methods: Participants (N=142) in this randomized controlled trial were office workers aged 20-50 years old with neck, shoulders, and lower back pain. They were randomly assigned to either the ergonomic modification group, the exercise group, the combined exercise and ergonomic modification group, or the control group (no-treatment). The exercise training group performed a series of stretching exercises, while the ergonomic group received some modification in the working place. Outcome measures were assessed by the Cornell Musculoskeletal Disorders Questionnaire at baseline, after 2, 4, and 6 months of intervention., Results: There was significant differences in pain scores for neck (MD -10.55; 95%CI -14.36 to -6.74), right shoulder (MD -12.17; 95%CI -16.87 to -7.47), left shoulder (MD -11.1; 95%CI -15.1 to -7.09) and lower back (MD -7.8; 95%CI -11.08 to -4.53) between the exercise and control groups. Also, significant differences were seen in pain scores for neck (MD -9.99; 95%CI -13.63 to -6.36), right shoulder (MD -11.12; 95%CI -15.59 to -6.65), left shoulder (MD -10.67; 95%CI -14.49 to -6.85) and lower back (MD -6.87; 95%CI -10 to -3.74) between the combined exercise and ergonomic modification and control groups. The significant improvement from month 4 to 6, was only seen in exercise group (p<0.05)., Conclusion: To have a long term effective on MSDs, physical therapists and occupational therapists should use stretching exercises in their treatment programs rather than solely rely on ergonomic modification., Clinical Trial Id: NCT02874950 - https://www.clinicaltrials.gov/ct2/show/NCT02874950., (Copyright © 2017 Associação Brasileira de Pesquisa e Pós-Graduação em Fisioterapia. Publicado por Elsevier Editora Ltda. All rights reserved.)

Objective: To assess the effects of an 8-week aquatic exercise training program on functional capacity, balance, and perceptions of fatigue in women with multiple sclerosis (MS)., Design: Randomized controlled design., Setting: Referral center of an MS society., Participants: Women (N=32; mean age ± SD, 36.4±8.2y) with diagnosed relapsing-remitting MS. After undergoing baseline testing by a neurologist, participants were allocated to either an intervention (aquatic training program, n=17) or a control group (n=15)., Interventions: The intervention consisted of an 8-week aquatic training program (3 supervised training sessions per week; session duration, 45-60min; 50%-75% estimated maximum heart rate)., Main Outcome Measures: Six-minute walk test (6-MWT), balance (Berg Balance Scale [BBS]), and perceptions of fatigue (Modified Fatigue Impact Scale; [MFIS]) at baseline and after the 8-week intervention. Differences over time between the experimental and control groups were assessed by a 2×2 (group by time) repeated-measures analysis of variance., Results: Thirty-two women completed the 8-week aquatic training intervention (experimental group, n=17; control group, n=15). All outcome measures improved in the experimental group: 6-MWT performance (pretest mean ± SD, 451±58m; posttest mean ± SD, 503±57m; P<.001); BBS (pretest mean ± SD, 53.59±1.70; posttest mean ± SD, 55.18±1.18; P<.001), and MFIS (pretest mean ± SD, 43.1±14.6; posttest mean ± SD, 32.8±5.9; P<.01). A significant group-by-time interaction was evident between the experimental and control groups for 6-MWT (P<.001, partial eta 2 [η p 2 ]=.551), BBS (P<.001, η p 2 =.423), and MFIS (P<.001, η p 2 =.679)., Conclusions: Aquatic exercise training improved functional capacity, balance, and perceptions of fatigue in women with MS., (Copyright © 2017 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: The purpose of this review was to identify doses of exercise therapy associated with greater treatment effect sizes in individuals with common musculoskeletal disorders of the foot and ankle, namely, achilles tendinopathy, ankle sprains and plantar heel pain., Methods: AMED, EMBASE and MEDLINE were searched from 2005 to August 2017 for randomized controlled trials related to exercise for these three diagnoses. The Physiotherapy Evidence Database scale was used for methodological quality assessment. Exercise dosing variables and outcome measures related to pain and function were extracted from the studies, and standardized mean differences were calculated for the exercise groups., Results: Fourteen studies met the final inclusion. A majority of the studies showed large effects and two small trends were identified. Patients with plantar heel pain may benefit more from a daily home exercise program than two supervised visits per week (SMD=3.82), but this recommendation is based on weak evidence. In achilles tendinopathy, a relationship was also seen when sets and repetitions of eccentric exercise were performed as tolerated (SMD=1.08 for function, -1.29 for pain)., Conclusions: Session duration, frequency, total number of visits, and overall length of care may all be dosing variables with limited value for determining effective exercise prescription. However, the limited number of studies prevents any definitive conclusions. Further investigation is warranted to improve our understanding of the influence exercise dosing has on treatment effect sizes. Future randomized controlled trials comparing specific exercise dose variables should be conducted to clarify the impact of these variables., (Copyright © 2017 Associação Brasileira de Pesquisa e Pós-Graduação em Fisioterapia. All rights reserved.)

Background: Whiplash Associated Disorders (WAD) is a biopsychosocial problem, education may be an essential part in the treatment and the prevention of chronic WAD. However, it is still unclear which type of educative intervention has already been used in WAD patients and how effective such interventions are., Objective: To examine the effectiveness of a cognitive behavioral exercises approach (CBEA) for self-training of the neck relative to usual care in individuals with WAD in acute phase., Methods: Forty-one patients, 65.9% female (mean ± SD age: 41 ±11 years), with WAD were recruited immediately after the accident (within 48 hours) and assigned according to patient choice to receive a CBEA self-training of the neck or usual care for 15 days. The primary outcome measure was pain intensity and disability as measured with the Neck Disability Index (NDI). Secondary outcome measures included the presence of headaches, dizziness, nausea, and difficulties with concentration and memory. Measurements were taken at pre-treatment, 2 weeks post-treatment and 4- and 12- weeks after the injury., Results: Patients receiving the CBEA intervention experienced a greater reduction in pain as compared to those receiving the usual care at the end as well as 4 and 12 weeks after the intervention (P< 0.001), for the Neck Disability Index (NDI) decreased more in the CBEA than controls over the 15 days and (F=[3.0] 552.383; P= 0.001), and in both groups at all follow-up periods (all, P= 0.001)., Conclusions: This quasi-experimental clinical trial provides evidence that a CBEA for self-training of the neck may be more beneficial in treating pain than usual care in patients with WAD. However, the CBEA had limited value in improving NDI. Future studies should include several therapists, a measure of a long-term outcomes and randomize patients to groups.

Background: Although commonly utilized interventions, no studies have directly compared the effectiveness of cervical and thoracic manipulation to mobilization and exercise in individuals with cervicogenic headache (CH). The purpose of this study was to compare the effects of manipulation to mobilization and exercise in individuals with CH., Methods: One hundred and ten participants (n = 110) with CH were randomized to receive both cervical and thoracic manipulation (n = 58) or mobilization and exercise (n = 52). The primary outcome was headache intensity as measured by the Numeric Pain Rating Scale (NPRS). Secondary outcomes included headache frequency, headache duration, disability as measured by the Neck Disability Index (NDI), medication intake, and the Global Rating of Change (GRC). The treatment period was 4 weeks with follow-up assessment at 1 week, 4 weeks, and 3 months after initial treatment session. The primary aim was examined with a 2-way mixed-model analysis of variance (ANOVA), with treatment group (manipulation versus mobilization and exercise) as the between subjects variable and time (baseline, 1 week, 4 weeks and 3 months) as the within subjects variable., Results: The 2X4 ANOVA demonstrated that individuals with CH who received both cervical and thoracic manipulation experienced significantly greater reductions in headache intensity (p < 0.001) and disability (p < 0.001) than those who received mobilization and exercise at a 3-month follow-up. Individuals in the upper cervical and upper thoracic manipulation group also experienced less frequent headaches and shorter duration of headaches at each follow-up period (p < 0.001 for all). Additionally, patient perceived improvement was significantly greater at 1 and 4-week follow-up periods in favor of the manipulation group (p < 0.001)., Conclusions: Six to eight sessions of upper cervical and upper thoracic manipulation were shown to be more effective than mobilization and exercise in patients with CH, and the effects were maintained at 3 months., Trial Registration: NCT01580280 April 16, 2012.

Background: Patients with cervical radiculopathy often have neck- and arm pain, neurological changes, activity limitations and difficulties in returning to work. Most patients are not candidates for surgery but are often treated with different conservative approaches and may be sick-listed for long periods. The purpose of the current study is to compare the effectiveness of neck-specific training versus prescribed physical activity., Methods/design: The current protocol is a two armed intervention randomised clinical trial comparing the outcomes of patients receiving neck specific training or prescribed physical activity. A total of 144 patients with cervical radiculopathy will be randomly allocated to either of the two interventions. The interventions will be delivered by experienced physiotherapists and last 14 weeks. The primary outcome variable is neck- and arm pain intensity measured with a Visual Analogue Scale accompanied with secondary outcome measures of impairments and subjective health measurements collected before intervention and at 3, 6, 12 and 24 months after base-line assessment., Discussion: We anticipate that the results of this study will provide evidence to support recommendations as to the effectiveness of conservative interventions for patients with cervical radiculopathy., Trial Registration: ClinicalTrials.gov identifier: NCT01831271.

Study Design: Planned secondary analysis of a randomized controlled trial comparing neural tissue management (NTM) to advice to remain active., Objective: To develop a model that predicts the likelihood of patient-reported improvement following NTM., Background: Matching patients to an intervention they are likely to benefit from potentially improves outcomes. However, baseline characteristics that predict patients' responses to NTM are unknown., Methods: Data came from 60 consecutive adults who had nontraumatic, nerve-related neck and unilateral arm pain for at least 4 weeks. Participants were assigned to a group that received NTM (n = 40), which involved brief education, manual therapy, and nerve gliding exercises for 4 treatments over 2 weeks, or to a group that was given advice to remain active (n = 20), which involved instruction to continue their usual activities. The participants' global rating of change at a 3- to 4-week follow-up defined improvement. Penalized regression of NTM data identified the best prediction model. A medical nomogram was created for prediction model scoring. Post hoc analysis determined whether the model predicted a specific response to NTM., Results: Absence of neuropathic pain qualities, older age, and smaller deficits in median nerve neurodynamic test range of motion predicted improvement. Prediction model cutoffs increased the likelihood of improvement from 53% to 90% (95% confidence interval: 56%, 98%) or decreased the likelihood of improvement to 9% (95% confidence interval: 1%, 42%). The model did not predict the outcomes of the advice to remain active group., Conclusion: Baseline characteristics of patients with nerve-related neck and arm pain predicted the likelihood of improvement with NTM. Model performance needs to be validated in a new sample using different comparison interventions and longer follow-up. Australian New Zealand Clinical Trials Registry (ACTRN 12610000446066)., Level of Evidence: Prognosis, level 2b-.

Study Design: Double-blind, randomized controlled trial., Objective: To examine the effectiveness of a manual therapy and exercise approach relative to a placebo intervention in individuals with carpometacarpal (CMC) joint osteoarthritis (OA)., Background: Recent studies have reported the outcomes of exercise, joint mobilization, and neural mobilization interventions used in isolation in patients with CMC joint OA. However, it is not known if using a combination of these interventions as a multimodal approach to treatment would further improve outcomes in this patient population., Methods: Sixty patients, 90% female (mean ± SD age, 82 ± 6 years), with CMC joint OA were randomly assigned to receive a multimodal manual treatment approach that included joint mobilization, neural mobilization, and exercise, or a sham intervention, for 12 sessions over 4 weeks. The primary outcome measure was pain. Secondary outcome measures included pressure pain threshold over the first CMC joint, scaphoid, and hamate, as well as pinch and strength measurements. All outcome measures were collected at baseline, immediately following the intervention, and at 1 and 2 months following the end of the intervention. Mixed-model analyses of variance were used to examine the effects of the interventions on each outcome, with group as the between-subject variable and time as the within-subject variable., Results: The mixed-model analysis of variance revealed a group-by-time interaction (F = 47.58, P<.001) for pain intensity, with the patients receiving the multimodal intervention experiencing a greater reduction in pain compared to those receiving the placebo intervention at the end of the intervention, as well as at 1 and 2 months after the intervention (P<.001; all group differences greater than 3.0 cm, which is greater than the minimal clinically important difference of 2.0 cm). A significant group-by-time interaction (F = 3.19, P = .025) was found for pressure pain threshold over the hamate bone immediately after the intervention; however, the interaction was no longer significant at 1 and 2 months postintervention., Conclusion: This clinical trial provides evidence that a combination of joint mobilization, neural mobilization, and exercise is more beneficial in treating pain than a sham intervention in patients with CMC joint OA. However, the treatment approach has limited value in improving pressure pain thresholds, as well as pinch and grip strength. Future studies should include several therapists, a measure of function, and long-term outcomes., Trial Registration: Current Controlled Trials ISRCTN37143779., Level of Evidence: Therapy, level 1b.

Study Design: Randomized clinical trial., Objective: To investigate the short-term effects of thoracic spine thrust manipulation combined with cervical spine nonthrust manipulation (experimental group) versus cervical spine nonthrust manipulation alone (comparison group) in individuals with mechanical neck pain., Background: Research has demonstrated improved outcomes with both nonthrust manipulation directed at the cervical spine and thrust manipulation directed at the thoracic spine in patients with neck pain. Previous studies have not determined if thoracic spine thrust manipulation may increase benefits beyond those provided by cervical nonthrust manipulation alone., Methods: Sixty-four participants with mechanical neck pain were randomized into 1 of 2 groups, an experimental or comparison group. Both groups received 2 treatment sessions of cervical spine nonthrust manipulation and a home exercise program consisting of active range-of-motion exercises, and the experimental group received additional thoracic spine thrust manipulations. Outcome measures were collected at baseline and at a 1-week follow-up, and included the numeric pain rating scale, the Neck Disability Index, and the global rating of change., Results: Participants in the experimental group demonstrated significantly greater improvements (P<.001) on both the numeric pain rating scale and Neck Disability Index at the 1-week follow-up compared to those in the comparison group. In addition, 31 of 33 (94%) participants in the experimental group, compared to 11 of 31 participants (35%) in the comparison group, indicated a global rating of change score of +4 or higher at the 1-week follow-up, with an associated number needed to treat of 2., Conclusion: Individuals with neck pain who received a combination of thoracic spine thrust manipulation and cervical spine nonthrust manipulation plus exercise demonstrated better overall short-term outcomes on the numeric pain rating scale, the Neck Disability Index, and the global rating of change.

Objectives: The objective of this study was to determine the effects of physical therapy, including massage and exercise, on pain and mood in patients with advanced terminal cancer., Design: The design was a randomized controlled pilot study., Subjects: Twenty-four (24) patients with terminal cancer were randomly assigned to one of two treatment groups., Interventions: Group A received a physiotherapy intervention consisting of several massage techniques, mobilizations, and local and global exercises. Group B received a simple hand contact/touch to areas of pain (cervical area, shoulder, interscapular area, heels, and gastrocnemius), which was maintained for the same period of time as the intervention group. All patients received six sessions of 30-35 minutes in duration over a 2-week period., Outcomes: Outcomes were collected at baseline, at 1 week, and at a 2-week follow-up (after treatment completion) by an assessor blinded to the treatment allocation of the participants. Outcomes included the Brief Pain Inventory (BPI, 0-10 scale), Memorial Pain Assessment Card (0-10 scale), and Memorial Symptom Assessment Scale (MSAS Physical, Psychological, 0-4 scale). Baseline between-group differences were assessed with an independent t-test. A two-way repeated-measures analysis of variance was used to examine the effects of the intervention., Results: There were no significant between-group baseline differences (p>0.2). A significant group × time interaction with greater improvements in group A was found for BPI worst pain (F=3.5, p=0.036), BPI pain right now (F=3.94, p=0.027), and BPI index (F=13.2, p<0.001), for MSAS Psychological (F=8.480, p=0.001)., Conclusions: The combination of massage and exercises can reduce pain and improve mood in patients with terminal cancer. A sustained effect on pain and psychologic distress existed; however, parameters such as physical distress and the least pain were no greater in the intervention group as compared to the sham.

The aim of this post hoc analysis was to develop a preliminary clinical prediction rule (CPR) for identifying patients with lateral epicondylalgia (LE) likely to respond to mobilisation with movement and exercise (PT). Currently practitioners do not have an evidence-based means to identify such patients a priori. Potential predictive factors were recorded at baseline and reference measures at 3 weeks after treatment was initiated. Participants (n=64) received standardised PT. After 3 weeks, participants were categorised as having experienced 'improvement' or 'no improvement' with treatment. Factors with univariate relationship (p<0.15) to 'improvement' were entered into a step-wise logistic regression model. Receiver operator characteristic curves were used to calculate cut-off points for continuous variables. Analyses resulted in a CPR that included: age (<49 years, +LR=2.6) as well as pain free grip strength on the affected (>112N, +LR=2.3) and unaffected side (<336N, +LR=2.1). Probability of improvement rose from 79 to 100% if all three were positive. The CPR did not predict outcome for wait and see (n=57), indicating it was more accurate for PT. This post hoc analysis has created a Level IV CPR that with further validation will help practitioners identify responders. Future studies are required to validate the rule.

Background: To date, optimal strategies for the management of patients with cervical radiculopathy remain elusive. Preliminary evidence suggests that a multimodal treatment program consisting of manual therapy, exercise, and cervical traction may result in positive outcomes for patients with cervical radiculopathy. However, limited evidence exists to support the use of mechanical cervical traction in patients with cervical radiculopathy., Objective: The purpose of this study was to examine the effects of manual therapy and exercise, with or without the addition of cervical traction, on pain, function, and disability in patients with cervical radiculopathy., Design: This study was a multicenter randomized clinical trial., Setting: The study was conducted in orthopedic physical therapy clinics., Patients: Patients diagnosed with cervical radiculopathy (N=81) were randomly assigned to 1 of 2 groups: a group that received manual therapy, exercise, and intermittent cervical traction (MTEXTraction group) and a group that received manual therapy, exercise, and sham intermittent cervical traction (MTEX group)., Intervention: Patients were treated, on average, 2 times per week for an average of 4.2 weeks., Measurements: Outcome measurements were collected at baseline and at 2 weeks and 4 weeks using the Numeric Pain Rating Scale (NPRS), the Patient-Specific Functional Scale (PSFS), and the Neck Disability Index (NDI)., Results: There were no significant differences between the groups for any of the primary or secondary outcome measures at 2 weeks or 4 weeks. The effect size between groups for each of the primary outcomes was small (NDI=1.5, 95% confidence interval [CI]=-6.8 to 3.8; PSFS=0.29, 95% CI=-1.8 to 1.2; and NPRS=0.52, 95% CI=-1.8 to 1.2)., Limitations: The use of a nonvalidated clinical prediction rule to diagnose cervical radiculopathy and the lack of a control group without treatment were limitations of this study., Conclusions: The results suggest that the addition of mechanical cervical traction to a multimodal treatment program of manual therapy and exercise yields no significant additional benefit to pain, function, or disability in patients with cervical radiculopathy.

Objective: The aim of this study was to develop a preliminary clinical prediction rule to identify the potential predictors for identifying patients presenting with ankylosing spondylitis who are likely to respond to a specific exercise program., Design: Consecutive patients with ankylosing spondylitis underwent a standardized examination and then received eight physical therapy sessions during a 2-mo period, which included an exercise program based on the treatment of the shortened muscle chains, following the guideline described by the global posture re-education method. Patients were classified as having experienced a successful outcome at 1 mo after discharge based on a 20% reduction on Bath Ankylosing Spondylitis Functional Index and self-report perceived recovery. Potential predictor variables were entered into a stepwise logistic regression model to determine the most accurate set of variables for identifying treatment success., Results: Data from 35 patients were included, of which 16 (46%) experienced a successful outcome. A clinical prediction rule with three variables (physical role >37, bodily pain >27, and Bath Ankylosing Spondylitis Disease Activity Index >31) was identified. The most accurate predictor of success was if the patient exhibited two of the three variables, and the positive likelihood ratio was 11.2 (95% confidence interval, 1.7-76.0) and the posttest probability of success increased to 91%. The accuracy of prediction declined if either 1/3 (+likelihood ratio = 7.7; 95% confidence interval, 0.52-113.5) or 3/3 (+likelihood ratio = 2.6, 95% confidence interval, 1.6-4.0) variables were present., Conclusions: The present preliminary clinical prediction rule provides the potential to identify patients with ankylosing spondylitis who are likely to experience short-term follow-up success with a specific exercise program. Future studies are necessary to validate the clinical prediction rule.

Study Design: Prospective-cohort/predictive-validity study., Objectives: To develop a clinical prediction rule (CPR) to identify patients who had sustained an inversion ankle sprain who would likely benefit from manual therapy and exercise., Background: No studies have investigated the predictive value of items from the clinical examination to identify patients with ankle sprains likely to benefit from manual therapy and general mobility exercises., Methods and Measures: Consecutive patients with a status of post inversion ankle sprain underwent a standardized examination followed by manual therapy (both thrust and nonthrust manipulation) and general mobility exercises. Patients were classified as having experienced a successful outcome at the second and third sessions based on their perceived recovery. Potential predictor variables were entered into a stepwise logistic regression model to determine the most accurate set of variables for prediction of treatment success., Results: Eighty-five patients were included in the data analysis, of which 64 had a successful outcome (75%). A CPR with 4 variables was identified. If 3 of the 4 variables were present the accuracy of the rule was maximized (positive likelihood ratio, 5.9; 95% CI: 1.1, 41.6) and the posttest probability of success increased to 95%., Conclusions: The CPR provides the ability to a priori identify patients with an inversion ankle sprain who are likely to exhibit rapid and dramatic short-term success with a treatment approach, including manual therapy and general mobility exercises., Level of Evidence: Prognosis, level 2b.

Background and Purpose: The purpose of this multicenter randomized clinical trial was to examine the effectiveness of an extension-oriented treatment approach (EOTA) in a subgroup of subjects with low back pain (LBP) who were hypothesized to benefit from the treatment compared with similar subjects who received a lumbar spine strengthening exercise program., Methods: Subjects with LBP and symptoms distal to the buttocks that centralized with extension movements were included. Forty-eight subjects were randomly assigned to groups that received an EOTA (n=26) or a strengthening exercise program (n=22). Subjects attended 8 physical therapy sessions and completed a home exercise program. Follow-up data were obtained at 1 week, 4 weeks, and 6 months after randomization. Primary outcome measures were disability (modified Oswestry Low Back Pain Disability Questionnaire) and pain (Numeric Pain Rating Scale)., Results: Subjects in the EOTA group experienced greater improvements in disability compared with subjects who received trunk strengthening exercises at 1 week (mean difference between groups from baseline=8.9, 95% confidence interval [CI]=2.0, 15.9), 4 weeks, (mean difference=14.4, 95% CI=4.8, 23.9), and 6 months (mean difference=14.6, 95% CI=4.6, 24.6). The EOTA group demonstrated greater change in pain at the 1-week follow-up only., Discussion and Conclusion: An EOTA was more effective than trunk strengthening exercise in a subgroup of subjects hypothesized to benefit from this treatment approach. Additional research is needed to explore whether an EOTA may benefit other subgroups of patients.

Background and Purpose: To date, no studies have investigated the predictive validity of variables from the initial examination to identify patients with neck pain who are likely to benefit from thoracic spine thrust manipulation. The purpose of this study was to develop a clinical prediction rule (CPR) to identify patients with neck pain who are likely to experience early success from thoracic spine thrust manipulation., Subjects: This was a prospective, cohort study of patients with mechanical neck pain who were referred for physical therapy., Methods: Subjects underwent a standardized examination and then a series of thoracic spine thrust manipulation techniques. They were classified as having experienced a successful outcome at the second and third sessions based on their perceived recovery. Potential predictor variables were entered into a stepwise logistic regression model to determine the most accurate set of variables for prediction of treatment success., Results: Data for 78 subjects were included in the data analysis, of which 42 had a successful outcome. A CPR with 6 variables was identified. If 3 of the 6 variables (positive likelihood ratio=5.5) were present, the chance of experiencing a successful outcome improved from 54% to 86%., Discussion and Conclusion: The CPR provides the ability to a priori identify patients with neck pain who are likely to experience early success with thoracic spine thrust manipulation. However, future studies are necessary to validate the rule.

The purpose of this study was to determine if slump stretching results in improvements in pain, centralization of symptoms, and disability in patients with non-radicular low back pain (LBP) with likely mild to moderate neural mechanosensitivity. Thirty consecutive patients referred to physical therapy by their primary care physician for LBP who met all eligibility criteria including a positive slump test but who had a negative straight-leg-raise test (SLR) agreed to participate in the study. All patients completed several self-report measures including a body diagram, numeric pain rating scale (NPRS), and the modified Oswestry Disability Index (ODI). Patients were randomized to receive lumbar spine mobilization and exercise (n = 14) or lumbar spine mobilization, exercise, and slump stretching (n = 16). All patients were treated in physical therapy twice weekly for 3 weeks for a total of 6 visits. Upon discharge, outcome measures were re-assessed. Independent t-tests were used to assess differences between groups at baseline and discharge. No baseline differences existed between the groups (P > .05). At discharge, patients who received slump stretching demonstrated significantly greater improvements in disability (9.7 points on the ODI, P < .001), pain (.93 points on the NPRS, P = .001), and centralization of symptoms (P < .01) than patients who did not. The results suggest that slump stretching is beneficial for improving short-term disability, pain, and centralization of symptoms. Future studies should examine whether these benefits are maintained at a longer-term follow-up.

Study Design: Case series describing the outcomes of individual patients with hip osteoarthritis treated with manual physical therapy and exercise., Case Description: Seven patients referred to physical therapy with hip osteoarthritis and/or hip pain were included in this case series. All patients were treated with manual physical therapy followed by exercises to maximize strength and range of motion. Six of 7 patients completed a Harris Hip Score at initial examination and discharge from physical therapy, and 1 patient completed a Global Rating of Change Scale at discharge., Outcomes: Three males and 4 females with a median age of 62 years (range, 52-80 years) and median duration of symptoms of 9 months (range, 2-60 months) participated in this case series. The median number of physical therapy sessions attended was 5 (range, 4-12). The median increase in total passive range of motion of the hip was 82 degrees (range, 70 degrees-86 degrees). The median improvement on the Harris Hip Score was 25 points (range, 15-38 points). The single patient who completed the Global Rating of Change Scale at discharge reported being "a great deal better." Numeric pain rating scores decreased by a mean of 5 points (range, 2-7 points) on 0-to-10-point scale., Discussion: All patients exhibited reductions in pain and increases in passive range of motion, as well as a clinically meaningful improvement in function. Although we can not infer a cause and effect relationship from a case series, the outcomes with these patients are similar to others reported in the literature that have demonstrated superior clinical outcomes associated with manual physical therapy and exercise for hip osteoarthritis compared to exercise alone.

Background: Recently a clinical prediction rule (CPR) has been developed and validated that accurately identifies patients with low back pain (LBP) that are likely to benefit from a lumbo-pelvic thrust manipulation. The studies that developed and validated the rule used the identical manipulation procedure. However, recent evidence suggests that different manual therapy techniques may result similar outcomes. The purpose of this study is to investigate the effectiveness of three different manual therapy techniques in a subgroup of patient with low back pain that satisfy the CPR., Methods/design: Consecutive patients with LBP referred to physical therapy clinics in one of four geographical locations who satisfy the CPR will be invited to participate in this randomized clinical trial. Subjects who agree to participate will undergo a standard evaluation and complete a number of patient self-report questionnaires including the Oswestry Disability Index (OSW), which will serve as the primary outcome measure. Following the baseline examination patients will be randomly assigned to receive the lumbopelvic manipulation used in the development of the CPR, an alternative lumbar manipulation technique, or non-thrust lumbar mobilization technique for the first 2 visits. Beginning on visit 3, all 3 groups will receive an identical standard exercise program for 3 visits (visits 3,4,5). Outcomes of interest will be captured by a therapist blind to group assignment at 1 week (3rd visit), 4 weeks (6th visit) and at a 6-month follow-up. The primary aim of the study will be tested with analysis of variance (ANOVA) using the change in OSW score from baseline to 4-weeks (OSWBaseline - OSW4-weeks) as the dependent variable. The independent variable will be treatment with three levels (lumbo-pelvic manipulation, alternative lumbar manipulation, lumbar mobilization)., Discussion: This trial will be the first to investigate the effectiveness of various manual therapy techniques for patients with LBP who satisfy a CPR.

Study Design: Single-case A1-B-A2 design., Objective: To determine if manual physical therapy, therapeutic exercise, and patient education would be an effective management strategy for a patient with a disc displacement without reduction of both temporomandibular joints., Background: A number of conservative management strategies have been proposed for the treatment of temporomandibular disorders. However, little evidence exists to indicate the effectiveness of physical therapy interventions in patients with bilateral disc displacement without reduction., Methods and Measures: Phase A1 of the study consisted of a baseline condition in which no intervention was initiated. Phase B included manual physical therapy, therapeutic exercise, and patient education focusing on the temporomandibular joint and cervical spine. Phase A2 consisted of withdrawal of the intervention. The Steigerwald/Maher disability questionnaire was used to collect data relative to function. A visual analog scale was used to collect pain data and maximal mouth opening measurements were obtained as an indicator of range of motion. Visual analysis and the 2 standard deviation band method of statistical analysis were used to compare data., Results: Following the implementation of the intervention phase, the patient demonstrated significant reductions in pain and improvements in maximal mouth opening and function as measured by the Steigerwald/Maher disability questionnaire. These observed improvements were maintained at the time of a 3-month follow-up., Conclusions: The results of our study suggest that manual physical therapy, therapeutic exercise, and patient education may have been an effective management strategy for a patient with bilateral disc displacement without reduction of the temporomandibular joints. Further outcome studies in the form of randomized controlled trials are needed to determine the clinical utility of this treatment approach in a larger population.

To evaluate the effect of neck-specific exercise (NSE) compared to prescribed physical activity (PPA) on headache and dizziness in individuals with cervical radiculopathy (CR). Also, to investigate associations between headache or dizziness and pain, neck muscle endurance (NME), neck mobility, physical activity, and fear avoidance beliefs. Individuals randomized to either NSE or PPA were selected to a headache subgroup (n = 59) and/or a dizziness subgroup (n = 73). Data were evaluated, according to headache and/or dizziness outcomes at baseline and at 3, 6, and 12-month follow-ups. No significant between-group differences were found between NSE and PPA in either subgroup. In the headache subgroup, significant within-group improvements were seen at all follow-ups for NSE (p <.001) and from baseline to 3 (p =.037) and 12 (p =.003) months for PPA. For dizziness, significant within-group improvements were seen from baseline to 3 months for NSE (p =.021) and from baseline to 3 (p =.001) and 6 (p =.044) months for PPA. Multiple regression models showed significant associations at baseline between headache intensity and neck pain (adjusted R-square = 0.35, p <.001), and for dizziness with neck pain and dorsal NME (adjusted R-square = 0.34, p <.001). NSE and PPA show similar improvements in headache intensity and dizziness in individuals with CR. Headache intensity is associated with neck pain, and dizziness with neck pain and dorsal NME, highlighting the importance of these factors when evaluating headache and dizziness. [ABSTRACT FROM AUTHOR]

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]

Patients with ulnar neuropathy usually experience sensory disturbances, weakness, and decreased function; however, optimal treatment approaches for this condition are not conclusive. A 48-year-old male with cubital tunnel syndrome was previously managed with a multimodal approach including splinting, neural mobilizations, and exercises with no change in symptoms. Approximately 1 year after the initial onset, he received three sessions of ultrasound-guided percutaneous electrical stimulation (PENS) and self-neural glides as a home program. After PENS intervention, the patient experienced a dramatic improvement in function and symptoms as measured by the Disabilities of the Arm, Shoulder and Hand Outcome Measure (DASH) and self-reported version of the Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS) pain scale as outcomes. These improvements were maintained after 1, 3, 6, and 12 months. The patient also experienced self-perceived improvement in his condition as measured by the Global Rating of Change (GROC) at each follow-up. A patient with ulnar nerve entrapment at the elbow did not respond to a multimodal conservative care for the previous year. Once the patient was treated with ultrasound-guided PENS targeting the ulnar nerve, full functional recovery and resolution of symptoms were documented. Future clinical studies should examine the effects of PENS in managing neural entrapment syndromes on a statistically powered sample of patients. [ABSTRACT FROM AUTHOR]

* OBJECTIVES: To identify the most common type and timing of interventions used to initially manage patellofemoral pain (PFP), and whether exercise therapy as an initial treatment was associated with a decreased likelihood of recurrence of PFR. *DESIGN: Retrospective cohort. *METHODS: Active-duty military service members (n = 74408) aged 18 to 50 years and diagnosed with PFP between 2010 and 2011 were included. We identified the type and timing of interventions from electronic medical records and insurance payer claims, and studied the influence of early exercise therapy use on injury recurrence rates. * RESULTS: In this cohort of patients with PFR 62.3% (n = 46338) sought no additional care after the initial visit. The most common initial pharmacological interventions were nonsteroidal anti-inflammatory drugs (4.1%), corticosteroid injections (0.4%), and muscle relaxers (0.3%). The most common initial nonpharmacological treatments were exercise therapy (7.6%), passive modalities (eg, hot packs, electrical stimulation, ultrasound; 0.6%), and manual therapy (joint manipulation and mobilization; 0.5%). Common specialty referrals were to physical therapy (3.3%) and orthopaedic providers (0.8%). If patients received at least 6 exercise therapy visits during the initial episode of care, they were less likely to have a recurrence of knee pain (odds ratio = 0.46; 95% confidence interval: 0.42, 0.49). *CONCLUSION: Two in every 3 patients did not seek additional care after PFP diagnosis. For those who sought additional care, exercise therapy was the most common intervention, and higher doses of exercise therapy were associated with a reduced likelihood of having a recurrent episode of knee pain. [ABSTRACT FROM AUTHOR]

Objective This randomized clinical trial investigated the effects of adding cervico-mandibular manual therapies into an exercise and educational program on clinical outcomes in individuals with tinnitus associated with temporomandibular disorders (TMDs). Methods Sixty-one patients with tinnitus attributed to TMD were randomized into the physiotherapy and manual therapy group or physiotherapy alone group. All patients received six sessions of physiotherapy treatment including cranio-cervical and temporomandibular joint (TMJ) exercises, self-massage, and patient education for a period of one month. Patients allocated to the manual therapy group also received cervico-mandibular manual therapies targeting the TMJ and cervical and masticatory muscles. Primary outcomes included TMD pain intensity and tinnitus severity. Secondary outcomes included tinnitus-related handicap (Tinnitus Handicap Inventory [THI]), TMD-related disability (Craniofacial Pain and Disability Inventory [CF-PDI]), self-rated quality of life (12-item Short Form Health Survey [SF-12]), depressive symptoms (Beck Depression Inventory [BDI-II]), pressure pain thresholds (PPTs), and mandibular range of motion. Patients were assessed at baseline, one week, three months, and six months after intervention by a blinded assessor. Results The adjusted analyses showed better outcomes (all, P  < 0.001) in the exercise/education plus manual therapy group (large effect sizes) for TMD pain (η 2 P = 0.153), tinnitus severity (η 2 P = 0.233), THI (η 2 P = 0.501), CF-PDI (η 2 P = 0.395), BDI-II (η 2 P = 0.194), PPTs (0.363 < η 2 P  < 0.415), and range of motion (η 2 P = 0.350), but similar changes for the SF-12 (P  = 0.622, η 2 P = 0.01) as the exercise/education alone group. Conclusions This clinical trial found that application of cervico-mandibular manual therapies in combination with exercise and education resulted in better outcomes than application of exercise/education alone in individuals with tinnitus attributed to TMD. [ABSTRACT FROM AUTHOR]

Abstract Objectives The purpose of this study was to identify descriptive factors in individuals with a primary complaint of low back pain (LBP) associated with improved pain and function after receiving physical therapy for LBP with or without manual therapy and exercise directed at the femoroacetabular joints. Methods Participants were enrolled in a randomized clinical trial investigating physical therapy interventions for their LBP, with or without interventions directed at the femoroacetabular joints (hips). A participant was deemed recovered if all of the following were met: Numeric Pain Rating Scale (NPRS) score of ≤2 points, ≤10% on the modified Oswestry Disability Index at discharge, and a global rating of change score of +4 at both 2 weeks and discharge. Logistic regression modelling determined descriptor variables that best predicted treatment recovery. Results Data from 90 participants were included in the analysis, with 44% (n = 40) achieving recovery by discharge from physical therapy (average 7.95 [±4.68]) visits. The variables of concurrent hip problems, lower body mass index ≤25.4, an irritable condition, and a baseline NPRS score of 4 points or less were retained in the final model (R2 =.384). Having a concurrent hip problem had the highest odds of achieving recovery in the model (odds ratio: 5.34, 95 % confidence interval: 1.31-21.8). Conclusions The findings for the patients in this study suggest that those with a concurrent hip problem, a lower body mass index, irritable symptoms, and a baseline NPRS score of 4 points or less were associated with greater odds of achieving recovery with multimodal physical therapy interventions. Further research should continue to investigate the interplay between the lumbar spine and hip joints. [ABSTRACT FROM AUTHOR]

* STUDY DESIGN: Randomized controlled trial. * BACKGROUND: Evidence suggests that multi-modal interventions that include exercise therapy may be effective for patellofemoral pain (PFP); however, no study has investigated the effects of trigger point (TrP) dry needling (DN) in people with PFP. * OBJECTIVES: To compare the effects of adding TrP DN to a manual therapy and exercise program on pain, function, and disability in individuals with PFP. * METHODS: Individuals with PFP (n = 60) recruited from a public hospital in Valencia, Spain were randomly allocated to manual therapy and exercises (n = 30) or manual therapy and exercise plus TrP DN (n = 30). Both groups received the same manual therapy and strengthening exercise program for 3 sessions (once a week for 3 weeks), and 1 group also received TrP DN to active TrPs within the vastus medialis and vastus lateralis muscles. The pain subscale of the Knee injury and Osteoarthritis Outcome Score (KOOS; 0-100 scale) was used as the primary outcome. Secondary outcomes included other subscales of the KOOS, the Knee Society Score, the International Knee Documentation Committee Subjective Knee Evaluation Form (IKDC), and the numeric pain-rating scale. Patients were assessed at baseline and at 15-day (posttreatment) and 3-month follow-ups. Analysis was conducted with mixed analyses of covariance, adjusted for baseline scores. * RESULTS: At 3 months, 58 subjects (97%) completed the follow-up. No significant between-group differences (all, P>.391) were observed for any outcome: KOOS pain subscale mean difference, -2.1 (95% confidence interval [Cl]: -4 .6,0 .4 ) ; IKDC mean difference, 2.3 (95% Cl: -0.1,4.7); knee pain intensity mean difference, 0.3 (95% Cl: -0.2, 0.8). Both groups experienced similar moderate-to-large within-group improvements in all outcomes (standardized mean differences of 0.6 to 1.1); however, only the KOOS function in sport and recreation subscale surpassed the prespecified minimum important change. * CONCLUSION: The current clinical trial suggests that the inclusion of 3 sessions of TrP DN in a manual therapy and exercise program did not result in improved outcomes for pain and disability in individuals with PFP at 3-month follow-up. * LEVEL OF EVIDENCE: Therapy, level 1b. Prospectively registered July 27,2015 at www. clinicaltrials.gov (NCT02514005). [ABSTRACT FROM AUTHOR]

STUDY DESIGN: Secondary analysis of a randomized controlled trial. BACKGROUND: Prognostic variables identifying patients with shoulder pain who are likely to respond to cervicothoracic manipulation have been reported: however, they have yet to be validated. OBJECTIVE: To examine the validity of previously reported prognostic variables in predicting which patients with shoulder pain will respond to cervicothoracic manipulation. METHODS: Participants (n = 140) with a report of shoulder pain were randomly assigned to receive either 2 sessions of range-of-motion exercises plus 6 sessions o' stretching and strengthening exercises (exercise group), or 2 sessions of cervicothoracic manipulation and range-of-motion exercises followed by 6 sessions of stretching and strengthening exercise (manipulative-therapy-plus- exercise group). Outcomes of disability (Shoulder Pain and Disability Index, shortened version of the Disabilities of the Arm, Shoulder and Hand Questionnaire) and pain (numeric pain-rating scale) were collected at baseline, 1 week, 4 weeks, and 6 months. Time, treatment group, status of predictor variables, and 2-way and 3-way interactions were analyzed using linear mixed models with repeated measures. RESULTS: There were no significant 3-way interactions for either disability (P = .27) or pain scores (P = .70) for time, group, and predictor status for any of the predictor variables. CONCLUSION: The results of the current study did not validate the previously identified prognostic variables; therefore, we cannot support using these in clinical practice. Further updating of the existing prediction rule may be warranted and could potentially result in new prognostic variables and improved generalizability. Limitations of the study were a mean duration of symptoms of greater than 2 years and a loss to follow-up of 19% at 6 months. LEVEL OF EVIDENCE: Prognosis, level lb. Trial prospectively registered March 30,2012 at www. clinicaltrials.gov (NCT01571674). [ABSTRACT FROM AUTHOR]

* STUDY DESIGN: Multicenter randomized controlled trial. * BACKGROUND: Cervicothoracic manual therapy has been shown to improve pain and disability in individuals with shoulder pain, but the incremental effects of manual therapy in addition to exercise therapy have not been investigated in a randomized controlled trial. * OBJECTIVES: To compare the effects of cervicothoracic manual therapy and exercise therapy to those of exercise therapy alone in individuals with shoulder pain. * METHODS: Individuals (n = 140) with shoulder pain were randomly assigned to receive 2 sessions of cervicothoracic range-of-motion exercises plus 6 sessions of exercise therapy, or 2 sessions of high-dose cervicothoracic manual therapy and range-of-motion exercises plus 6 sessions of exercise therapy (manual therapy plus exercise). Pain and disability were assessed at baseline, 1 week, 4 weeks, and 6 months. The primary aim (treatment group by time) was examined using linear mixed-model analyses and the repeated measure of time for the Shoulder Pain and Disability Index (SPADI), the numeric pain-rating scale, and the shortened version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH). Patient-perceived success was assessed and analyzed using the global rating of change (GROC) and the Patient Acceptable Symptom State (PASS), using chi-square tests of independence. * RESULTS: There were no significant 2-way interactions of group by time or main effects by group for pain or disability. Both groups improved significantly on the SPADI, numeric pain-rating scale, and QuickDASH. Secondary outcomes of success on the GROC and PASS significantly favored the manual therapy-plus-exercise group at 4 weeks (P = .03 and P<.01, respectively) and on the GROC at 6 months (P = .04). * CONCLUSION: Adding 2 sessions of high-dose cervicothoracic manual therapy to an exercise program did not improve pain or disability in patients with shoulder pain, but did improve patient-perceived success at 4 weeks and 6 months and acceptability of symptoms at 4 weeks. More research is needed on the use of cervicothoracic manual therapy for treating shoulder pain. * LEVEL OF EVIDENCE: Therapy, level 1b. Prospectively registered March 30, 2012 at www. ClinicalTrials.gov (NCT01571674). [ABSTRACT FROM AUTHOR]

STUDY DESIGN: Retrospective cohort. OBJECTIVES: The objectives of this study were (1) to examine patients' general expectations for treatment by physical therapists and specific expectations for common interventions in patients with neck pain, and (2) to assess the extent to which the patients' general and specific expectations for treatment, particularly spinal manipulation, affect clinical outcomes. BACKGROUND: Patient expectations can have a profound influence on the magnitude of treatment outcome across a broad variety of patient conditions. METHODS: We performed a secondary analysis of data from a clinical trial of interventions for neck pain. Prior to beginning treatment for neck pain, 140 patients were asked about their general expectations of benefit as well as their specific expectations for individual interventions. Next, we examined how these expectations related to the patients' ratings of the success of treatment at 1 and 6 months after treatment. RESULTS: Patients had positive expectations for treatment by a physical therapist, with more than 80% of patients expecting moderate relief of symptoms, prevention of disability, the ability to do more activity, and to sleep better. The manual therapy interventions of massage (87%) and manipulation (75%) had the highest proportion of patients who expected these interventions to significantly improve neck pain. These were followed by strengthening (70%) and range-of- motion (54%) exercises. Very few patients thought surgery would improve their neck pain (less than 1%). At 1 month, patients who were unsure of experiencing complete pain relief had lower odds of reporting a successful outcome than patients expecting complete relief (odds ratio [OR] = 0.33; 95% confidence interval [Cl]: 0.11, 0.99). Believing that manipulation would help and not receiving manipulation lowered the odds of success (OR = 0.16; 95% Cl: 0.04, 0.72) compared to believing manipulation would help and receiving manipulation. Six months after treatment, having unsure expectations for complete pain relief lowered the odds of success (OR = 0.19; 95% Cl: 0.05,0.7), whereas definitely expecting to do more exercise increased the odds of success (OR = 11.4; 95%: Cl: 1.7, 74.7). Regarding self-reported disability assessed with the Neck Disability Index, patients who believed manipulation would help and received manipulation reported less disability than those who did not believe manipulation would help and both received manipulation (mean difference, -3.8; 95% Cl: -5.9, -1.5; P = .006) and did not receive manipulation (mean difference, -5.7; 95% Cl; -9.3, -2.1; P = .014). There was also an interaction between time and the expectation for complete relief. CONCLUSION: General expectations of benefit have a strong influence on clinical outcomes for , patients with neck pain. LEVEL OF EVIDENCE: Prognosis, level 2b-. J Orthop Sports Phys Ther 2013;43(7):457-465. Epub 18 March 2013. doi:10.2519/jospt.2013.4492 s KEY WORDS: cervical spine, physical therapy techniques, treatment [ABSTRACT FROM AUTHOR]

STUDY DESIGN: Randomized clinical trial. OBJECTIVE: To compare the effectiveness of manual therapy and exercise (MTEX) to a home exercise program (HEP) in the management of individuals with an inversion ankle sprain. BACKGROUND: An in-clinic exercise program has been found to yield similar outcomes as an HEP for individuals with an inversion ankle sprain. However, no studies have compared an MTEX approach to an HEP. METHODS: Patients with an inversion ankle sprain completed the Foot and Ankle Ability Measure (FAAM) activities of daily living subscale, the FAAM sports subscale, the Lower Extremity Functional Scale, and the numeric pain rating scale. Patients were randomly assigned to either an MTEX or an HEP treatment group. Outcomes were collected at baseline, 4 weeks, and 6 months. The primary aim (effects of treatment on pain and disability) was examined with a mixed-model analysis of variance. The hypothesis of interest was the 2-way interaction (group by time). RESULTS: Seventy-four patients (mean ± SD age, 35.1 ± 11.0 years; 48.6% female) were randomized into the MTEX group (n = 37) or the HEP group (n = 37). The overall group-by-time interaction for the mixed-model analysis of variance was statistically significant for the FAAM activities of daily living subscale (P<.001), FAAM sports subscale (P<.001), Lower Extremity Functional Scale (P<.001), and pain (P≤001). Improvements in all functional outcome measures and pain were significantly greater at both the 4-week and 6-month follow-up periods in favor of the MTEX group. CONCLUSION: The results suggest that an MTEX approach is superior to an HEP in the treatment of inversion ankle sprains. Registered at clinicaltrials.gov (NCT00797368). LEVEL OF EVIDENCE: Therapy, level lb- J Orthop Sports Phys Ther 2013;43(7):443-455: Epub 29 April 2013. doi:10.2519/jospt.2013.4792 [ABSTRACT FROM AUTHOR]

STUDY DESIGN: Randomized clinical trial. To compare the effects of thrust and nonthrust manipulation and exercises with and without the addition of myofascial therapy for the treatment of acute inversion ankle sprain. BACKGROUND: Studies have reported that thrust and nonthrust manipulations of the ankle joint are effective for the management of patients post-ankle sprain. However, it is not known whether the inclusion of soft tissue myofascial therapy could further improve clinical and functional outcomes. METHODS: Fifty patients (37 men and 13 women; mean ± SD age, 33 ± 10 years) post-acute inversion ankle sprain were randomly assigned to 2 groups: a comparison group that received a thrust and nonthrust manipulation and exercise intervention, and an experimental group that received the same protocol and myofascial therapy. The primary outcomes were ankle pain at rest and functional ability. Additionally, ankle mobility and pressure pain threshold over the ankle were assessed by a clinician who was blinded to the treatment allocation. Outcomes of interest were captured at baseline, immediately after the treatment period, and at a 1-month follow-up. The primary analysis was the group-by-time interaction. RESULTS: The 2-by-3 mixed-model analyses of variance revealed a significant group-by-time interaction for ankle pain (P<.001) and functional score (P = .002), with the patients who received the combination of nonthrust and thrust manipulation and myofascial intervention experiencing a greater improvement in pain and function than those who received the nonthrust and thrust manipulation intervention alone. Significant group-by-time interactions were also observed for ankle mobility (P<.001) and pressure pain thresholds (all, P<.01), with those in the experimental group experiencing greater increases in ankle mobility and pressure pain thresholds. Between-group effect sizes were large (d>0.85) for all outcomes. CONCLUSION: This study provides evidence that, in the treatment of individuals post-inversion ankle sprain, the addition of myofascial therapy to a plan of care consisting of thrust and nonthrust manipulation and exercise may further improve outcomes compared to a plan of care solely consisting of thrust and nonthrust manipulation and exercise. However, though statistically significant, the difference in improvement in the primary outcome between groups was not greater than what would be considered a minimal clinically important difference. Future studies should examine the long-term effects of these interventions in this population. LEVEL OF EVIDENCE: Therapy, level lb- [ABSTRACT FROM AUTHOR]

A reprint of the article "Neck Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health From the Orthopaedic Section of the American Physical Therapy Association" which appeared in the "Journal of Orthopaedic & Sports Physical Therapy" is presented. It discusses guidelines for the diagnosis, risk factors and interventions for neck pain. Some of interventions are cervical and thoracic mobilization, stretching exercises and traction.

Background. A clinical prediction rule (CPR) purported to identify patients with neck pain who are likely to respond to thoracic spine thrust manipulation has recently been developed, but has yet to be validated. Objective. The purpose of this study was to examine the validity of this CPR. Design. This was a multi-center randomized clinical trial. Methods. One hundred forty patients with a primary report of neck pain were randomly assigned to receive either 5 sessions of stretching and strengthening exercise (exercise-only group) or 2 sessions of thoracic spine manipulation and cervical range of motion exercise followed by 3 sessions of stretching and strengthening exercise (manipulation + exercise group). Data on disability and pain were collected at baseline, 1 week, 4 weeks, and 6 months. The primary aim (treatment group X time X status on the prediction rule) was examined using a linear mixed model with repeated measures. Time, treatment group, and status on the rule, as well as all possible 2-way and 3-way interactions, were modeled as fixed effects, with disability (and pain) as the dependent variable. Effect sizes were calculated for both pain and disability at each follow-up period. Results. There was no 3-way interaction for either disability or pain. A 2-way (group X time) interaction existed for both disability and pain. Pair-wise comparisons of disability demonstrated that significant differences existed at each follow-up period between the manipulation + exercise group and the exercise-only group. The patients who received manipulation exhibited lower pain scores at the 1-week follow-up period. The effect sizes were moderate for disability at each follow-up period and were moderate for pain at the 1-week follow-up. Limitations. Different exercise approaches may have resulted in a different outcome. Conclusions. The results of the current study did not support the validity of the previously developed (-PR. However, the results demonstrated that patients with mechanical neck pain who received thoracic spine manipulation and exercise exhibited significantly greater improvements in disability at both the short- and long- term follow-up periods and in pain at the 1-week follow-up compared with patients who received exercise only. INSET: The Bottom Line. [ABSTRACT FROM AUTHOR]

Study design: A systematic review of clinical trials. Objective: To determine the effectiveness of therapeutic exercise in the treatment of instability-related lumbar spine pain.Background: Segmental instability of the lumbar spine contributes to the overwhelming incidence of back pain and disability. The extensive range of exercises proposed to treat segmental instability is indicative of the lack of agreement as to the most efficacious management approach.Methods: A search of MEDLINE (1966- April 2002), the Cumulative Index of Nursing and Allied Health Literature (CINAHL) (1982- April 2002) databases was performed. The searches were restricted to articles that used human subjects and were published in English. Key words utilized for searches included, "lumbar stability", "segmental instability of the lumbar spine", "spinal stability", "low back exercises", and "treatment of lumbar instability". The aforementioned key words were combined with "clinical trial" in an attempt to locate studies that were primary sources and included original data.Results: The clinical trials analyzed varied considerably in the type of therapeutic exercise evaluated. However, it has been demonstrated that therapeutic exercise can be beneficial in reducing pain and improving function in patients presenting with instability-related lumbar spine pain.Conclusion: Although the reviewed clinical trials have demonstrated the effectiveness of therapeutic exercise in ameliorating pain and disability, the variations in methodologies of the studies reviewed makes it difficult to speculate which specific exercises would be the most beneficial. [ABSTRACT FROM AUTHOR]