Search

Systematically evaluate the comparative effectiveness of dry needling (DN) or local acupuncture to various types of wet needling (WN) for musculoskeletal pain disorders (MPD). Seven databases (PubMed, PEDro, SPORTDiscus, CINAHL, Scopus, Embase, and Cochrane Central Register of Controlled Trials) were searched following PROSPERO registration. Randomized clinical trials were included if they compared DN or local acupuncture with WN for MPD. Primary outcomes were pain and/or disability. The Revised Cochrane Collaboration tool (RoB 2.0) assessed the risk of bias. Twenty-six studies were selected. Wet Needling types included cortisone (CSI) (N = 5), platelet-rich plasma (PRP) (N = 6), Botox (BoT) (N = 3), and local anesthetic injection (LAI) (N = 12). Evidence was rated as low to moderate quality. Results indicate DN produces similar effects to CSI in the short-medium term and superior outcomes in the long term. In addition, DN produces similar outcomes compared to PRP in the short and long term and similar outcomes as BoT in the short and medium term; however, LAI produces better pain outcomes in the short term. Evidence suggests the effectiveness of DN to WN injections is variable depending on the injection type, outcome time frame, and diagnosis. In addition, adverse event data were similar but inconsistently reported. PROSPERO Registration: 2019 CRD42019131826 Dry needling produces similar effects for pain and disability in the short and medium term compared to cortisone, Botox, and platelet-rich plasma injections. Local anesthetic injection may be more effective at reducing short-term pain. Long-term effects on pain and disability are similar between dry needling and platelet-rich plasma injections, but dry needling may produce better long-term outcomes than cortisone injections. The available adverse event data is similar between dry and wet needling. The conclusions from this study may be beneficial for patients and clinicians for considering risk and cost benefit analyses. [ABSTRACT FROM AUTHOR]

Conservative management of lumbar radiculopathy (LR) is the first treatment option. To date, systematic reviews and clinical practice guidelines have not considered the most appropriate timing of management. This study aimed to establish consensus on effective conservative treatment modalities across different stages (i.e., acute, sub-acute, or chronic) of LR. Through an iterative multistage Delphi process, experts rated agreement with proposed treatment modalities across stages of LR and could suggest additional treatment modalities. The agreement was measured using a 5-point Likert scale. Descriptive statistics were used to measure agreement (median, interquartile ranges, and percentage of agreement). Consensus criteria were defined a priori for each round. Fourteen panelists produced a consensus list of effective treatment modalities across stages of LR. Acute stage management should focus on providing patients with information about the condition including pain education, individualized physical activity, and directional preference exercises, supported with NSAIDs. In the sub-acute stage, strength training and neurodynamic mobilization could be added and transforaminal/epidural injections considered. In the chronic stage, spinal manipulative therapy, specific exercise, and function-specific physical training should be combined with individualized vocational, ergonomic and postural advice. Experts agree effectiveness of interventions differs through the evolution of LR. To date clinical guideline for conservative management of lumbar radiculopathy do not consider the evolution of the condition. Acute stage management of lumbar radiculopathy should focus on providing information about the condition and support individualized physical activity with pain medication. Sub-acute management should add neurodynamic mobilization to strength training, while transforaminal and/or epidural injections could be considered. Chronic stage management should consider spinal manipulative therapy and focus on restoring personalized functional capacity. [ABSTRACT FROM AUTHOR]

Lower limb disability is common in chronic stroke patients, and aquatic therapy is one of the modalities used for the rehabilitation of these patients. To summarize the evidence of the effects of aquatic therapy on lower limb disability compared to land-based exercises in post-stroke patients. MEDLINE, PsycInfo, CENTRAL, SPORTDiscus, PEDro, PsycBITE, and OT Seeker were searched from inception to January 2019. The search included only randomized clinical trials. Two reviewers independently examined the full text and conducted study selection, data extraction, and quality assessment. Data synthesis was applied to summarize information from the included studies. The quantitative analysis incorporated fixed-effect models. Of the 150 studies identified in the initial search, 17 trials (629 participants) satisfied the eligibility criteria. Aquatic therapy improved balance based on the Berg Balance Scale (BBS) (standardized mean difference [SMD], 0.72; 95% confidence interval [CI], 0.50–0.94; I2 = 67%) compared with land-based exercises (control). Also, aquatic therapy had a small positive effect on walking speed (SMD, −0.45; 95% CI {-0.71 – (−0.19)}; I2 = 57%), based on the results of the 10-m walking test, compared to controls. Aquatic therapy had a small positive effect on mobility (based on Timed Up and Go), (SMD, −0.43; 95% CI {-0.7-(- 0.17)}; I2 = 71%) compared to land-based exercise (control). Aquatic therapy had a more positive effect on walking speed, balance, and mobility than land-based exercises. Further research is needed to confirm the clinical utility of aquatic therapy for patients following stroke in the long term. [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]

Predictive clinical and radiological factors can potentially identify adolescent idiopathic scoliosis (AIS) most likely to benefit from overcorrection nighttime bracing. These factors can provide helpful information in clinical decision making. However, the relationship between these factors and outcomes of overcorrection nighttime bracing is unclear. This systematic review determined the predictive factors for identifying outcomes of overcorrection nighttime bracing in AIS. A systematic search was conducted on PubMed, MEDLINE, Scopus, and Embase from January 1986 to January 2021. Studies on AIS patients, aged 10–18 years, with a Risser sign of 0–2 and an initial Cobb angle of 20°–45°, who were treated with overcorrection nighttime bracing and for whom at least one predictive factor of treatment outcome (failure and/or success) was assessed were included. Two blinded reviewers independently evaluated the studies using a quality assessment tool. To determine predictive factors, the level of evidence was rated through best-evidence synthesis. A total of nine studies met the inclusion criteria. A Providence brace was used in six of the included studies, while a Charleston bending brace was used in three. Findings from two high-quality studies provided strong evidence of the association between curve flexibility and brace treatment success. In terms of the Risser sign, this evidence was obtained from three high-quality studies. Moderate evidence indicated a positive association between premenarchal status and nighttime bracing failure. Inconclusive evidence indicated that poor brace compliance is associated with treatment failure. Conflicting evidence of treatment failure was indicated for initial curve magnitude, curve type, in-brace correction, age, Risser sign, curve apex, and sex. These findings show that greater curve flexibility and a higher Risser sign are associated with overcorrection nighttime bracing success. [ABSTRACT FROM AUTHOR]

Background/Purpose The COVID-19 pandemic has impacted adolescents across multiple areas of health. While many factors influence outcomes following anterior cruciate ligament reconstruction (ACLR), the impact of the COVID-19 pandemic on early patient outcomes after ACLR is currently unknown in an adolescent population. The purpose of this study was to determine if short-term clinical outcomes were different in adolescents after ACLR for those who underwent surgery pre-COVID versus during the COVID-19 pandemic timeframe. Design Retrospective cohort Methods A retrospective review of records occurred for patients who underwent ACLR with a quadriceps tendon autograft. Two separate review timeframes were defined according to date of surgery (control: September 2017 - October 2019; COVID: March 2020 - May 2021). Patients were classified into pre-COVID (control) and COVID groups by surgical date and were then age- and sex-matched. Three-month postoperative outcomes were included for analysis, including normalized isometric quadriceps and hamstring peak torque, Anterior Cruciate Ligament - Return to Sport after Injury (ACL-RSI), and the Pedi International Knee Documentation Committee Form (Pedi-IKDC) scores. Results Sixty patients met the inclusion criteria (34 females, 56.7%). Follow-up testing occurred at 3.2 months (98.13 ± 14.91 days) postoperative. A significant difference was found between groups for normalized quadriceps peak torque on the uninvolved limb, with the control group (2.03 ± 0.47 Nm/kg) demonstrating decreased peak torque compared to the COVID group (2.49 ± 0.61 Nm/kg) (p =0.002, effect size (d) = 0.84). For the involved limb, no difference in normalized quadriceps peak torque was observed between the control group (1.25 ± 0.33 Nm/kg) and those who underwent surgery during the COVID-19 pandemic (1.49 ± 0.70 Nm/kg) (p = 0.09). No differences were identified between groups for any of the other strength outcomes (p = 0.31 - 0.87). Similarly, no differences in patient reported outcomes were found for Pedi-IKDC or ACL-RSI between groups (p = 0.12 - 0.43). Conclusion At roughly three months after ACLR, normalized quadriceps peak torque on the uninvolved limb was reduced by 18.5% for adolescents who underwent surgery pre-COVID versus during the COVID-19 pandemic timeframe. No group differences were observed for other isometric strength outcomes, Pedi-IKDC, or ACL-RSI scores. [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]

Objective. The purpose of this study was to develop a data-driven Bayesian network approach to understand the potential multivariate pathways of the effect of manual physical therapy in women with carpal tunnel syndrome (CTS). Methods. Data from a randomized clinical trial (n=104) were analyzed comparing manual therapy including desensitization maneuvers of the central nervous system versus surgery in women with CTS. All variables included in the original trial were included in a Bayesian network to explore its multivariate relationship. The model was used to quantify the direct and indirect pathways of the effect of physical therapy and surgery on short-term,mid-term, and long-term changes in the clinical variables of pain, related function, and symptom severity. Results. Manual physical therapy improved function in women with CTS (between-groups difference: 0.09; 95% CI=0.07 to 0.11). The Bayesian network showed that early improvements (at 1 month) in function and symptom severity led to longterm (at 12 months) changes in related disability both directly and via complex pathways involving baseline pain intensity and depression levels. Additionally, women with moderate CTS had 0.14-point (95% CI=0.11 to 0.17 point) poorer function at 12 months than those with mild CTS and 0.12-point (95% CI=0.09 to 0.15 point) poorer function at 12 months than those with severe CTS. Conclusion. Current findings suggest that short-term benefits in function and symptom severity observed after manual therapy/surgery were associated with long-term improvements in function, but mechanisms driving these effects interact with depression levels and severity as assessed using electromyography. Nevertheless, it should be noted that betweengroup differences depending on severity determined using electromyography were small, and the clinical relevance is elusive. Further data-driven analyses involving a broad range of biopsychosocial variables are recommended to fully understand the pathways underpinning CTS treatment effects. Impact. Short-term effects of physical manual therapy seem to be clinically relevant for obtaining long-term effects in women with CTS. [ABSTRACT FROM AUTHOR]

*OBJECTIVE: To determine whether adding hip treatment to usual care for low back pain (LBP) improved disability and pain in individuals with LBP and a concurrent hip impairment. *DESIGN: Randomized controlled trial. *METHODS: Seventy-six participants (age, 18 years or older; Oswestry Disability Index, 20% or greater; numeric pain-rating scale, 2 or more points) with LBP and a concurrent hip impairment were randomly assigned to a group that received treatment to the lumbar spine only (LBO group) (n = 39) or to one that received both lumbar spine and hip treatments (LBH group) (n = 37). The individual treating clinicians decided which specific low back treatments to administer to the LBO group. Treatments aimed at the hip (LBH group) included manual therapy, exercise, and education, selected by the therapist from a predetermined set of treatments. Primary outcomes were disability and pain, measured by the Oswestry Disability Index and the numeric pain-rating scale, respectively, at baseline, 2 weeks, discharge, 6 months, and 12 months. The secondary outcomes were fear-avoidance beliefs (work and physical activity subscales of the Fear-Avoidance Beliefs Questionnaire), global rating of change, the Patient Acceptable Symptom State, and physical activity level. We used mixed-model 2-by-3 analyses of variance to examine group-by-time interaction effects (intention-to-treat analysis). *RESULTS: Data were available for 68 patients at discharge (LBH group, n = 33; LBO group, n = 35) and 48 at 12 months (n = 24 for both groups). There were no between-group differences in disability at discharge (-5.0; 95% confidence interval [CI]: -10.9, 0.89; P = .09), 12 months (-1.0; 95% CI: -4.44, 2.35; P = .54), and all other time points. There were no between-group differences in pain at discharge (-0.2; 95% CI: -1.03, 0.53; P = .53), 12 months (0.1; 95% CI: -0.53, 0.72; P = .76), and all other time points. There were no between-group differences in secondary outcomes, except for higher Fear-Avoidance Beliefs Questionnaire (work subscale) scores in the LBH group at 2 weeks (-3.35; 95% CI: -6.58, -0.11; P = .04) and discharge (-3.45; 95% CI: -6.30, -0.61; P = .02). *CONCLUSION: Adding treatments aimed at the hip to usual low back physical therapy did not provide additional short- or long-term benefits in reducing disability and pain in individuals with LBP and a concurrent hip impairment. Clinicians may not need to include hip treatments to achieve reductions in low back disability and pain in individuals with LBP and a concurrent hip impairment. [ABSTRACT FROM AUTHOR]

Objective Dry needling is commonly used for the management of plantar fasciitis. This meta-analysis evaluated the effects of dry needling over trigger points associated with plantar heel pain on pain intensity and related disability or function. Methods Electronic databases were searched for randomized controlled trials in which at least one group received dry needling, not acupuncture, for trigger points associated with plantar heel pain and in which outcomes were collected on pain intensity and related disability. The risk of bias was assessed with the Cochrane Risk of Bias tool, methodological quality was assessed with the Physiotherapy Evidence Database (PEDro) score, and the level of evidence is reported according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Between-groups mean differences (MD) and standardized mean differences (SMD) were calculated. Results The search identified 297 publications, with six trials eligible for inclusion. The meta-analysis found low-quality evidence that trigger point dry needling reduces pain intensity in the short term (MD −1.70 points, 95% confidence interval [CI] −2.80 to −0.60; SMD −1.28, 95% CI −2.11 to −0.44) and moderate-quality evidence that it improves pain intensity (MD −1.77 points, 95% CI −2.44 to −1.11; SMD −1.45, 95% CI −2.19 to −0.70) and related disability (SMD −1.75, 95% CI −2.22 to −1.28) in the long term, as compared with a comparison group. The risk of bias of the trials was generally low, but the heterogeneity of the results downgraded the level of evidence. Discussion Moderate- to low-quality evidence suggests a positive effect of trigger point dry needling for improving pain intensity and pain-related disability in the short term and long term, respectively, in patients with plantar heel pain of musculoskeletal origin. The present results should be considered with caution because of the small number of trials. [ABSTRACT FROM AUTHOR]

Patients in the chronic phase after a stroke are an underrepresented group in the literature. Therefore, the aim of this study was to compare the effects of cycling and functional electrical stimulation with linear versus interval patterns of timing on gait parameters in patients after stroke. A double blinded, parallel, randomized clinical trial. Neuroscience Institute. Patients with lower limb disability due to stroke (N = 30) with a stroke onset >6 months and <18 months. Twenty-eight minutes of leg cycling with functional electrical stimulation with linear or interval patterns of timing applied to the peroneal and biceps femoris muscles, 3 times/week for 4 weeks. Timed 10-Meter Walk Test and Functional Ambulation Classification were the primary outcome measures. The Modified Modified Ashworth scale, active range of motion, Timed Up and Go Test, and Single Leg Stance Test were the secondary outcome measures. Evaluation was performed at baseline, after 4, and after 8 weeks. Thirty participants completed the 4-week intervention (interval group, n = 16; linear group, n = 14). The Functional Ambulation Classification, Timed 10-Meter Walk Test, and the Timed Up and Go Test improved significantly in both groups. The Modified Modified Ashworth scale scores for quadriceps and plantar flexion statistically decreased after 4-weeks in the interval group. Significant group-by-time interaction was shown for Timed Up and Go Test (p = 0.003, np2=0.228), knee flexion active range of motion (p < 0.001, np2=0.256) and dorsiflexion active range of motion (p < 0.001, np2=0.359). Modified Modified Ashworth scale and active range of motion in both the ankle and knee improved significantly in the interval group. The functional electrical stimulation with cycling protocols improved the Functional Ambulation Classification, Timed 10-Meter Walk Test, active range of motion, Timed Up and Go Test, and Modified Modified Ashworth scale. An interval protocol of timing was more effective than the linear protocol in terms of spasticity and active range of motion. Cycling + functional electrical stimulation training with an interval pattern of timing seems superior to cycling + functional electrical stimulation training with a linear pattern. Interval protocol has positive effects on spasticity and range of motion after 12 sessions in patients post stroke. Cycling + functional electrical stimulation improves functional mobility and speed in stroke survivors and the effects of this intervention lasted in follow-up assessment after one month. [ABSTRACT FROM AUTHOR]

Objective The purpose of this study was to evaluate the effects of trigger point (TrP) dry needling alone or as an adjunct to other interventions on pain intensity and related disability in nontraumatic shoulder pain. Methods Ten databases were searched from inception to January 2020 for randomized clinical trials in which at least 1 group received TrP dry needling for shoulder pain of musculoskeletal origin with outcomes collected on pain intensity and related disability. Data extraction including participant and therapist details, interventions, blinding strategy, blinding assessment outcomes, and results were extracted by 2 reviewers. The risk of bias (Cochrane Risk of Bias, Cochrane Guidelines), methodological quality (Physiotherapy Evidence Database score), and evidence level (Grading of Recommendations Assessment, Development, and Evaluation approach) were assessed. The search identified 551 publications with 6 trials eligible for inclusion. Results There was moderate-quality evidence that TrP dry needling reduces shoulder pain intensity with a small effect (mean difference = −0.49 points, 95% CI = −0.84 to −0.13; standardized mean difference = −0.25, 95% CI = −0.42 to −0.09) and low-quality evidence that TrP dry needling improves related disability with a large effect (mean difference = −9.99 points, 95% CI −15.97 to −4.01; standardized mean difference = −1.14, 95% CI −1.81 to −0.47) compared with a comparison group. The effects on pain were only found at short term. The Cochrane Risk of Bias was generally low, but the heterogenicity of the results downgraded the evidence level. Conclusion Moderate- to low-quality evidence suggests positive effects of TrP dry needling for pain intensity (small effect) and pain-related disability (large effect) in nontraumatic shoulder pain of musculoskeletal origin, mostly at short term. Future clinical trials investigating long-term effects are needed. Impact Dry needling is commonly used for the management of musculoskeletal pain. This is the first meta-analysis to examine the effects of dry needling on nontraumatic shoulder pain. [ABSTRACT FROM AUTHOR]

Background Tendon dry needling is a potential treatment for tendinopathies. Several hypotheses have been proposed to explain its underlying mechanisms. No studies (to the best of our knowledge) have investigated changes in gene expression. Objective To investigate histological and gene expression changes after the application of dry needling to the healthy Achilles tendons of rats. Methods Six Sprague-Dawley male rats were randomly divided into two groups: no intervention or dry needling. Dry needling consisted of three sessions (once per week) to the Achilles tendon. Molecular expression of several genes involved in tendon repair and remodeling (e.g. Cox2 , Mmp2 , Mmp9 , Col1a1 , Col3a1 , Vefg , and Scx) was assessed 7 days after the last needling session (day 28) or 28 days after for the no-intervention group. Histological tissue changes were determined with hematoxylin-eosin analyses. Results The hematoxylin-eosin–stained images revealed no substantial differences in collagen structure or the presence of inflammatory cells between the dry needling and no-intervention groups. A significant increase in the molecular expression of Cox2 , Mmp2 , Col3a1 , and Scx genes was observed in Achilles tendons treated with dry needling when compared with the no-intervention group. Conclusion This animal pilot study found that the application of dry needling to the healthy Achilles tendons of rats is able to increase the expression of genes associated with collagen regeneration and tissue remodeling of the extracellular matrix with no further histological damage to the tendon. [ABSTRACT FROM AUTHOR]

* 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. s 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. [ABSTRACT FROM AUTHOR]

Objective No study to our knowledge has investigated the effects longer than 1 year of manual therapy in carpal tunnel syndrome (CTS). The purpose of this study was to investigate the effects of manual therapy versus surgery at 4-year follow-up and to compare the post-study surgery rate in CTS. Methods This randomized controlled trial was conducted in a tertiary public hospital and included 120 women with CTS who were randomly allocated to manual therapy or surgery. The participants received 3 sessions of physical therapy, including desensitization maneuvers of the central nervous system or carpal tunnel release combined with a tendon/nerve gliding exercise program at home. Primary outcome was pain intensity (mean and the worst pain). Secondary outcomes included functional status, symptom severity, and self-perceived improvement measured using a global rating of change scale. Outcomes for this analysis were assessed at baseline, 1 year, and 4 years. The rate of surgical intervention received by each group was assessed throughout the study. Results At 4 years, 97 (81%) women completed the study. Between-group changes for all outcomes were not significantly different at 1 year (mean pain: mean difference [MD] = −0.3, 95% CI = −0.9 to 0.3; worst pain: MD = −1.2, 95% CI = −3.6 to 1.2; function: MD = −0.1, 95% CI = −0.4 to 0.2; symptom severity: MD = −0.1, 95% CI = −0.3 to 0.1) and 4 years (mean pain: MD = 0.1, 95% CI = −0.2 to 0.4; worst pain: MD = 0.2, 95% CI = −0.8 to 1.2; function: MD = 0.1, 95% CI = −0.1 to 0.3; symptom severity: MD = 0.2, 95% CI = −0.2 to 0.6). Self-perceived improvement was also similar in both groups. No between-group differences (15% physical therapy vs 13% surgery) in surgery rate were observed during the 4 years. Conclusions In the long term, manual therapy, including desensitization maneuvers of the central nervous system, resulted in similar outcomes and similar surgery rates compared with surgery in women with CTS. Both interventions were combined with a tendon/nerve gliding exercise program at home. Impact This is the first study to our knowledge to report clinical outcomes and surgical rates during a 4-year follow-up and will inform decisions regarding surgical versus conservative management of CTS. Lay summary Women with CTS may receive similar benefit from a more conservative treatment—manual therapy—as they would from surgery. [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]

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. [ABSTRACT FROM AUTHOR]

The purpose of this study was to assess the effectiveness of the application of kinesio taping in reducing induced pain after dry needling of active trigger points (TrPs) to the upper trapezius muscle. Consecutive patients had mechanical neck pain (n = 34, 44% female) with active TrPs in the upper trapezius muscle. All participants received dry needling into upper trapezius active TrPs. Then, they were randomly divided into a kinesio taping group, which received an adhesive tape (Kinesio Tex), and a control group, which did not receive the taping. The numeric pain rating scale was assessed (0-10) at post-needling; immediately after; and 24 hours, 48 hours, and 72 hours after needling. Neck- and shoulder-related disability was assessed before and 72 hours after needling with the Neck Disability Index (NDI) and the Shoulder Pain and Disability Index, respectively. The pressure pain threshold (PPT) over the TrP was also assessed post-needling, immediately post-intervention, and 72 hours after needling. The analysis of covariance did not find a significant group × time interaction (P =.26) for post-needling soreness: both groups exhibited similar changes in post-needling induced pain (P <.001). No significant group × time interactions were observed for changes in NDI (P =.62), SPADI (P =.41), or PPTs (P =.52): similar improvements were found after the needling procedure for the NDI (P <.001), Shoulder Pain and Disability Index (P <.001), and PPT (P <.001). The number of local twitch responses and sex (all, P >.30) did not influence the effect for any outcome. The application of kinesio taping after dry needling of active TrPs in the upper trapezius muscle was not effective for reducing post-needling induced pain in people with mechanical neck pain. Further, the application of kinesio taping as a post-needling intervention did not influence short-term changes in disability. [ABSTRACT FROM AUTHOR]

Background: Dizziness is a common condition which may lead to loss of function and disability. Vestibular Rehabilitation Therapy (VRT) may be utilized to affect the vestibular system and reduce dizziness. However, controversy exists regarding the most effective interventions to treat dizziness. Objectives: To examine the effectiveness of VRT compared to other conservative treatments in reducing dizziness and disability. Methods: A literature search was performed using different combinations of the terms: dizziness, physical therapy, vertigo, vestibular, cervicogenic dizziness to identify randomized clinical trials comparing VRT to conservative treatments. The Cochrane Risk of Bias Tool was used to assess the quality of each included study. Additionally, a meta-analysis and qualitative analysis of the evidence was performed. Results: Ten studies were included in the systematic review. Only four studies were included in the meta-analysis due to lack of adequate data reported for continuous outcomes. Eight studies scored less than a 69% on the Cochrane risk of bias tool indicating a low to moderate risk of bias. The meta-analysis revealed that VRT was found to be more effective than conservative treatment for short term outcomes (0–3 weeks) but not long-term outcomes (4 or more weeks). The results from the studies excluded from the meta-analysis but included in the systematic review are inconclusive. Conclusions: VRT was only found to be more effective than other conservative treatments in the short term. [ABSTRACT FROM AUTHOR]

Stroke is one of the leading causes of disability in western countries. A variety of rehabilitation programs for the treatment of patients after stroke have been proposed. We describe the outcomes of a 49-year-old female patient with a 5-year history of right upper extremity hemiparesis after stroke. Physical examination revealed a right wrist extensor strength grade of 1 according to the Medical Research Council Manual Muscle Testing scale, Stage 4 according to the Brunnstrom hand functional recovery, and Grade 1 in finger flexor and in wrist flexor according to the Modified Modified Ashworth Scale system of muscle spasticity. Magnetic resonance imaging taken immediately after the stroke was indicative of an abnormal signal in the left paraventricular and lentiform nucleus. After receiving a single session of dry needling and electrical stimulation, the patient had significant improvement including a strength grade of 3 for the right wrist extensor muscles, Stage 6 according to the Brunnstrom hand functional recovery, and Grade 0 in finger flexor and in wrist flexor according to the Modified Modified Ashworth Scale system of muscle spasticity. This case report found that dry needling combined with electrical stimulation may be effective in hand function recovery, wrist extensor muscles strength, and decreased wrist and finger spasticity. [ABSTRACT FROM AUTHOR]

* BACKGROUND: Patients with lateral elbow pain are often diagnosed with lateral epicondylalgia. Lateral elbow pain is often associated with dysfunction of the wrist extensor muscles; however, in some cases, it can also mimic signs and symptoms of radial nerve dysfunction. * CASE DESCRIPTION: In this case report, a 43-year-old man, who was originally referred with a diagnosis of lateral epicondylalgia as a result of playing table tennis and who previously responded favorably to manual therapy and exercise, presented to the clinic for treatment. An exacerbation while participating in a table tennis match resulted in a return of his lateral epicondylalgia symptoms, which did not respond favorably to the same interventions used in his prior course of therapy. Further examination revealed sensitization of the radial nerve, which was treated with 2 sessions of ultrasound-guided percutaneous electrical nerve stimulation and 4 weeks of a low-load, concentric/eccentric exercise program for the wrist extensors. * OUTCOMES: Following this intervention, the patient experienced clinically meaningful improvement in pain intensity (numeric pain-rating scale), function (Patient-Rated Tennis Elbow Evaluation), and related disability (Disabilities of the Arm, Shoulder and Hand questionnaire). The patient progressively exhibited complete resolution of pain and function, which was maintained at 2 years. * DISCUSSION: This case report demonstrates the outcomes of a patient with lateral elbow pain who did not respond to manual therapy and exercise. Once radial nerve trunk sensitivity was identified and the intervention, consisting of ultrasound-guided percutaneous electrical nerve stimulation targeting the radial nerve combined with a low-load exercise program, was applied, a full resolution of pain and function occurred rapidly. Future clinical trials should examine the effect of percutaneous electrical nerve stimulation in the management of nerve-related symptoms associated with musculoskeletal pain conditions. * LEVEL OF EVIDENCE: Therapy, level 5. [ABSTRACT FROM AUTHOR]

BACKGROUND: One of the leading causes of disability in the world with enormous economic burden is stroke. OBJECTIVE: To quantify the effectiveness of different protocols of cycling with/without functional electrical stimulation on functional mobility after stroke. METHODS: Multiple databases were searched till 2018. Data extraction was performed using a pre-determined data collection form. The quality of the evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation. RESULTS: A total of 14 trials satisfied eligibility criteria and were included. Cycling had a positive effect on the 6-meter walking test performance (SMD, 0.41; 95% CI, 0.11 –0.71; I2 = 0%) compared with no or placebo intervention (control). Compared with control, cycling had a positive effect on 10-meter walking speed (SMD, 0.30; 95% CI, 0.05 –0.55; I2 = 0%), and on balance based on the Berg score (SMD, 0.32; 95% CI, 0.06 –0.57; I2 = 49%). Cycling with functional electrical stimulation had a positive effect on balance (SMD, 1.48; 95% CI, 0.99 –1.97; I2 = 91%) compared with cycling alone. CONCLUSIONS: It appears that cycling has a positive effect on walking speed, walking ability and balance. Functional electrical stimulation combined with cycling has positive effects on balance beyond cycling alone. [ABSTRACT FROM AUTHOR]

Background: Cervicogenic (CGH) and tension-type (TTH) headaches are prevalent conditions that are associated with considerable pain and disability. Joint mobilization and manipulation are common interventions used by physical therapists to manage individuals with musculoskeletal conditions. However, there is controversy surrounding their effectiveness. Objectives: To evaluate the effectiveness of mobilization and manipulation (MM) compared to other conservative treatments on reducing pain, frequency, and disability in patients with CGH and TTH. Methods: A literature search using terms related to mobilization, manipulation, CGH, and TTH was conducted to identify randomized clinical trials comparing MM to conservative treatment in treating CGH and TTH. The overall quality of the evidence was assessed using the Cochrane risk-of-bias tool. Meta-analysis and qualitative synthesis of the evidence were performed. Results: Nine total studies were included in the systematic review. The majority of studies scored lower than a 69% on the Cochrane risk of bias tool indicating a moderate to high risk of bias. MM were found to be equally as effective as conservative treatment in reducing pain, disability, and frequency of headache in individuals with CGH. MM had statistically significant short-term (1–4 weeks) improvements over conservative treatment for TTH on pain and disability, but not frequency. When comparing the effectiveness of MM versus conservative treatment for TTH, both groups exhibited improvement between 1–3 months in all three outcomes. Conclusions: Manipulation and mobilization were only found to be more effective than conservative care at short-term follow up for individuals with TTH. [ABSTRACT FROM AUTHOR]

Objective: Patient expectations are related to treatment outcome across a broad variety of patient conditions. Here we sought to examine factors associated with the expectation of complete relief from treatment for spinal pain. Design: Secondary analysis of data pooled from two randomized controlled trials of conservative rehabilitation interventions. Patients: 252 patients (103 men, 149 women) with neck (n = 140) or back (n = 112) pain. Methods: We used logistic regression model with backward elimination to test which patient clinical or demographic factors were most related to the expectation of complete relief. Main Outcome Measures: The expectation of complete recovery, which was collected at the baseline examination visit in the primary trials. Results: The final model examining the contributions of patient and clinical characteristics to the expectation of complete relief included two significant interactions. First, increasing disability was associated with increased odds of expecting complete recovery in women while there was very little change for men across levels of disability (OR 0.9 [95%CI 0.8, 0.9]). Second, patients with low fear and a sudden onset of pain had higher odds of expecting recovery than patients with a gradual onset of pain (OR 0.7 [95%CI 0.5, 0.97]). A main effect for education level of the patient was also significant with better odds for expecting complete recovery for college educated patients compared to those with graduate school education (OR 5.0 [95%CI 1.9, 13.4]). Conclusion: The results should assist physical therapists to recognize patients who may have lower expectations of recovery and plan pre-treatment education interventions. [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]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

STUDY DESIGN: Randomized clinical trial. BACKGROUND: The comparative effectiveness between nonthrust manipulation (NTM) and thrust manipulation (TM) for mechanical neck pain has been investigated, with inconsistent results. OBJECTIVE: To compare the clinical effectiveness of concordant cervical and thoracic NTM and TM for patients with mechanical neck pain. METHODS: The Neck Disability Index (NDI) was the primary outcome. Secondary outcomes included the Patient-Specific Functional Scale (PSFS), numeric pain-rating scale (NPRS), deep cervical flexion endurance (DCF), global rating of change (GROC), number of visits, and duration of care. The covariate was clinical equipoise for intervention. Outcomes were collected at baseline, visit 2, and discharge. Patients were randomly assigned to receive either NTM or TM directed at the cervical and thoracic spines. Techniques and dosages were selected pragmatically and applied to the most symptomatic level. Two-way mixed-model analyses of covariance were used to assess clinical outcomes at 3 time points. Analyses of covariance were used to assess between-group differences for the GROC, number of visits, and duration of care at discharge. RESULTS: One hundred three patients were included in the analyses (NTM, n = 55 and TM, n = 48). The between-group analyses revealed no differences in outcomes on the NDI (P = .67), PSFS (P = .26), NPRS (P = .25), DCF (P = .98), GROC (P = .77), number of visits (P = .21), and duration of care (P = .61) for patients with mechanical neck pain who received either NTM or TM. CONCLUSION: NTM and TM produce equivalent outcomes for patients with mechanical neck pain. The trial was registered with ClinicalTrials.gov (NCT02619500). LEVEL OF EVIDENCE: Therapy, level 1b. [ABSTRACT FROM AUTHOR]

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. [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]

Risk stratification is a modelling method that is designed to target interventions toward patients with specific needs. The objective of the present study was to identify predictive characteristics related to patients with knee impairments who had a high risk of a bad prognosis (exceptional non-responders) as well as those who were at low risk of a bad prognosis (exceptional responders). A cohort of 4,837 patients with knee pain seen for physical therapy was retrospective analysed using univariate and multivariate multinomial regression analyses. Modelling was used to identify characteristics associated with those who were exceptional responders and those who were exceptional non-responders. Exceptional non-responders were significantly associated with older age, female gender, longer duration of symptoms, surgical history, lower functional status at baseline and a payer type. Exceptional responders were significantly associated with younger age, no previous surgical history, higher functional status at baseline and a payer type. Findings may be used for managing processes involving intensity of care service and in understanding probable prognoses for each patient. Future research should continue to examine variables predictive of treatment response in patients with knee pain. Copyright © 2016 John Wiley & Sons, Ltd. [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: Randomized parallel-group trial. * BACKGROUND: Carpal tunnel syndrome (CTS) is a common pain condition that can be managed surgically or conservatively. * OBJECTIVE: To compare the effectiveness of manual therapy versus surgery for improving self-reported function, cervical range of motion, and pinch-tip grip force in women with CTS. * METHODS: In this randomized clinical trial, 100 women with CTS were randomly allocated to either a manual therapy (n = 50) or a surgery (n = 50) group. The primary outcome was self-rated hand function, assessed with the Boston Carpal Tunnel Questionnaire. Secondary outcomes included active cervical range of motion, pinch-tip grip force, and the symptom severity subscale of the Boston Carpal Tunnel Questionnaire. Patients were assessed at baseline and 1,3,6, and 12 months after the last treatment by an assessor unaware of group assignment. Analysis was by intention to treat, with mixed analyses of covariance adjusted for baseline scores. * RESULTS: At 12 months, 94 women completed the follow-up. Analyses showed statistically significant differences in flavor of manual therapy at 1 month for self-reported function (mean change, -0.8; 95% confidence interval [Cl]: -1.1, -0.5) and pinch-tip grip force on the symptomatic side (thumb-index finger: mean change, 2,0; 95% CI: 1.1,2.9 and thumb-little finger: mean change, 1.0; 95% CI: 0.5,1.5). Improvements in self-reported function and pinch grip force were similar between the groups at 3, 6, and 12 months. Both groups reported improvements in symptom severity that were not significantly different at all follow-up periods. No significant changes were observed in pinch-tip grip force on the less symptomatic side and in cervical range of motion in either group. * CONCLUSION: Manual therapy and surgery had similar effectiveness for improving self-reported function, symptom severity, and pinch-tip grip force on the symptomatic hand in women with CTS. Neither manual therapy nor surgery resulted in changes in cervical range of motion. [ABSTRACT FROM AUTHOR]

STUDY DESIGN: Secondary analysis of a randomized trial. BACKGROUND: A clinical prediction rule to identify patients with carpal tunnel syndrome (CTS) most likely to respond to manual physical therapy has been published but requires further testing to determine its validity. OBJECTIVE: To assess the validity of a clinical prediction rule proposed for the management of patients with CTS in a different group of patients with a variety of treating clinicians. METHODS: A preplanned secondary analysis of a randomized controlled trial investigating the efficacy of manual physical therapies, including desensitization maneuvers of the central nervous system, in 120 women suffering from CTS was performed. Patients were randomized to receive 3 sessions of manual physical therapy (n = 60) or surgical release/decompression of the carpal tunnel (n = 60). Self-perceived improvement with a global rating of change was recorded at 6- and 12-month follow-ups. Pain intensity (mean pain and worst pain on a 0-to-10 numeric pain-rating scale) and scores on the Boston Carpal Tunnel Questionnaire (functional status and symptom severity subscales) were assessed at baseline and at 1,3, 6, and 12 months. A baseline assessment of status on the clinical prediction rule was performed (positive status on the clinical prediction rule was defined as meeting at least 2 of the following criteria: pressure pain threshold of less than 137 kPa over the affected C5-6 joint; heat pain threshold of less than 39.6°C over the affected carpal tunnel; and general health score [Medical Outcomes Study 36-Item Short-Form Health Survey] of greater than 66 points). Linear mixed models with repeated measures were used to examine the validity of the rule. RESULTS: Participants with a positive status on the rule who received manual physical therapy did not experience greater improvements compared to those with a negative status on the rule for mean pain (P = .65), worst pain (P = .86), function (P = .99), or symptom severity (P = .85). Further, the clinical prediction rule performed no better than chance in identifying the individuals with CTS most likely to respond to manual physical therapy or surgery (mean pain, P = .87; worst pain, P = .91; function, P = .60; severity, P = .66). No differences in self-perceived improvement were observed at either 6 (P = .68) or 12 (P = .36) months, according to the rule. CONCLUSION: The results of this study did not support the validity of the previously developed clinical prediction rule for manual physical therapy in women with CTS. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study was to evaluate the effects of including 1 session of trigger point dry needling (TrP-DN) into a multimodal physiotherapy treatment on pain and function in postoperative shoulder pain. Methods: Twenty patients (5 male; 15 female; age, 58 ± 12 years) with postoperative shoulder pain after either open reduction and internal fixation with Proximal Humeral Internal Locking System plate plate or rotator cuff tear repair were randomly divided into 2 groups: physiotherapy group (n = 10) who received best evidence physical therapy interventions and a physical therapy plus TrP-DN group (n = 10) who received the same intervention plus a single session of TrP-DN targeted at active TrPs. The Constant-Murley score was used to determine pain, activities of daily living, range of motion, and strength, which was captured at baseline and 1 week after by an assessor blinded to group assignment. Results: Analysis of variance showed that subjects receiving TrP-DN plus physical therapy exhibited greater improvement in the Constant-Murley total score (P < .001 ) and also activities of daily living (P < .001 ) and strength (P = .019) subscales than those receiving physical therapy alone. Between-group effect sizes were large in favor of the TrP-DN group (0.97 < SMD < 1.45). Both groups experienced similar improvements in pain (P < .001) and range of motion (P < .001 ). Conclusions: Our results suggest that including a single session of TrP-DN in the first week of a multimodal physical therapy approach may assist with faster increases in function in individuals with postoperative shoulder pain. [ABSTRACT FROM AUTHOR]

STUDY DESIGN: A retrospective cohort design was conducted using data from an electronic survey and an existing commercial outcomes database. OBJECTIVE: To compare the clinical outcomes of patients with musculoskeletal conditions treated by physical therapists who had completed residency or fellowship programs versus those who had not. BACKGROUND: There is an increasing focus on specialization through postprofessional education in physical therapy residency and fellowship programs. Scant evidence exists that evaluates the influence of postprofessional clinical education on actual patient outcomes. METHODS: Physical therapists using a national outcomes database were surveyed to determine their level of postprofessional education. Survey responders were categorized into 1 of 3 groups that included no residency or fellowship training, residency trained, or fellowship trained. Outcomes for 25843 patients with musculoskeletal conditions treated by 353 therapists from June 2012 to June 2013 were extracted from the database. These data were analyzed to identify any differences in functional status change and efficiency achieved between the 3 groups. Potentially confounding variables were controlled for statistically. RESULTS: The fellowship-trained group of physical therapists achieved functional status changes and efficiency that were greater than those of the other groups. No difference in functional status change was observed between the residency group and the therapists without residency or fellowship training. The group without residency or fellowship training was more efficient than the residency-trained group. Fellowship-trained therapists were more likely to achieve greater treatment effect sizes than therapists without residency or fellowship training. Residency-trained therapists were less likely to achieve greater treatment effect sizes than the therapists without residency or fellowship training. CONCLUSION: These data demonstrate that fellowship training may contribute to statistically greater patient outcomes. Residency training did not appear to contribute to improved patient functional status change or efficiency. It is unknown whether the statistical differences observed would be clinically meaningful for patients. [ABSTRACT FROM AUTHOR]

Abstract: Objective: The purpose of this study was to compare the effects of thoracic thrust manipulation vs thoracic non–thrust mobilization in patients with bilateral chronic mechanical neck pain on pressure pain sensitivity and neck pain intensity. Methods: Fifty-two patients (58% were female) were randomly assigned to a thoracic spine thrust manipulation group or of thoracic non–thrust mobilization group. Pressure pain thresholds (PPTs) over C5-C6 zygapophyseal joint, second metacarpal, and tibialis anterior muscle and neck pain intensity (11-point Numerical Pain Rate Scale) were collected at baseline and 10minutes after the intervention by an assessor blinded to group allocation. Mixed-model analyses of variance (ANOVAs) were used to examine the effects of the treatment on each outcome. The primary analysis was the group * time interaction. Results: No significant interactions were found with the mixed-model ANOVAs for any PPT (C5-C6: P >.252; second metacarpal: P >.452; tibialis anterior: P >.273): both groups exhibited similar increases in PPT (all, P <.01), but within-group and between-group effect sizes were small (standardized mean score difference [SMD]<0.22). The ANOVA found that patients receiving thoracic spine thrust manipulation experienced a greater decrease in neck pain (between-group mean difference: 1.4; 95% confidence interval, 0.8-2.1) than did those receiving thoracic spine non–thrust mobilization (P <.001). Within-group effect sizes were large for both groups (SMD>2.1), and between-group effect size was also large (SMD = 1.3) in favor of the manipulative group. Conclusions: The results of this randomized clinical trial suggest that thoracic thrust manipulation and non–thrust mobilization induce similar changes in widespread PPT in individuals with mechanical neck pain; however, the changes were clinically small. We also found that thoracic thrust manipulation was more effective than thoracic non–thrust mobilization for decreasing intensity of neck pain for patients with bilateral chronic mechanical neck pain. [Copyright &y& Elsevier]

The purpose of this case series was to describe the outcomes of patients with temporomandibular disorder (TMD) treated with mobilization with movement (MWM) directed at the temporomandibular joint (TMJ) and the cervical spine, thoracic manipulation, and trigger point (TrP) dry needling. Fifteen patients with TMD completed the Steigerwald/Maher TMD disability questionnaire, the Visual Analog Scale (VAS), and maximal mouth opening (MMO) at baseline. The VAS and MMO were also collected at 15 days posttreatment and at a 2-month follow-up, and the Steigerwald/Maher TMD disability questionnaire was completed at the 2-month follow-up. Repeated measure ANOVAs were used to determine the effects of the intervention on each outcome. Within-group effect sizes were calculated in order to assess clinical effectiveness. Fifteen patients participated in this case series. The ANOVA revealed significant decreases (all, p  <  0.01) VAS mean, VAS Worst, and VAS Best between baseline and final visit of 25.7 (95% CI; 17.7, 33.8); 33.2 (95% CI; 23.4, 43.0); 18.4 (12.1, 24.7); and 28.3 (95% CI; 18.8, 37.9); 36.1 (95% CI; 25.0, 47.3); 19.7 (95% CI; 12.8, 26.7) between baseline and the 2-month follow-up periods, respectively. Additionally, the ANOVA revealed significant increases (all, p  <  0.01) in MMO and disability following the physical therapy management strategy between baseline and final visit with a mean of 11.4 (95% CI, 6.9, 15.9) and 10.2 (95% CI, 5.2, 15.2) between baseline and the 2-month follow-up. Within-group effect sizes were large ( d  >  1.0) for all outcomes at both follow-up periods. Patients with TMD treated with a multimodal treatment exhibited significant and clinical improvements in pain intensity, disability, and MMO. [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: Planned secondary analysis o 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). [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]

The article reports a study to examine the effectiveness of a manual therapy and exercise approach relative to a placebo intervention in individuals with carpometacarpal (CMC) joint osteoarthritis (OA). A double blind randomized control trial was conducted and data were analyzed using Statistical Product and Service Solutions (SPSS) version 18.0. This clinical trial provides evidence that a combination of joint mobilization, neural mobilization, and exercise is more beneficial in treating pain.

The article discusses a randomized control trial to find the short-term effects of thoracic spine thrust manipulation combined with cervical spine nonthrust manipulation versus cervical spine nonthrust manipulation (SNM) alone in individuals with mechanical neck pain. It states that both groups received the treatment sessions cervical SNM and a home exercise program. It is concluded that combination of cervical SNM and thoracic spine thrust manipulation and exercise is beneficial.

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. [ABSTRACT FROM AUTHOR]

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]