STUDY DESIGN: Cross sectional cohort study. OBJECTIVE: To investigate the differences in the level of activation of neck-shoulder muscles between elite swimmers with and without shoulder pain during a functional upper limb task. BACKGROUND: Previous studies have reported altered motor control of the neck-shoulder muscles in patients with chronic neck-shoulder pain. Whether the activation of neck-shoulder muscles is altered among elite swimmers suffering from shoulder pain is unknown. METHODS: Surface electromyography (SEMG) from the sternocleidomastoid (SCM), upper trapezius (UT), and anterior scalene (SCL) muscles was recorded bilaterally in 17 elite swimmers (9 men, 8 women; mean ± SD age: 21±3 years) with unilateral shoulder pain, and 17 age- and sex matched elite swimmers without pain. Root mean square (RMS) values were calculated and normalized to assess the level of muscular activation 5 seconds before, 120 seconds and 150 seconds into, and 10 seconds after a functional upper limb task. RESULTS: The repeated measures revealed significant differences between both groups for RMS of both SCL (F=3.733; P=0.016), but not for the SCM and UT muscles. Swimmers with shoulder pain had higher normalised RMS in both SCL muscles at 120s (78% on average) and 150s (86% on average) into and 10s post-task (40% on average) as compared with swimmers without shoulder pain (P<0.05). CONCLUSIONS: The elite swimmers with shoulder pain demonstrated greater activation of the SCL muscles during a functional task and a lower ability to relax the SCL muscles after completion of the task than elite swimmers without shoulder pain. The present findings suggest altered pattern of cervical muscle activation on elite swimmers with shoulder pain during performance of a functional task.

J Orthop Sports Phys Ther, Epub 25 January 2012. doi:10.2519/jospt.2012.3875

KEY WORDS: electromyography, neck, scalene

STUDY DESIGN: A case control, blinded study. OBJECTIVES: To compare the amount of cervical range of motion in women with minimal, mild/moderate, and severe carpal tunnel syndrome (CTS) to that of healthy control participants. We also assessed the relationships between cervical range of motion and clinical variables related to the intensity and temporal profile of pain within each CTS group. BACKGROUND: It is plausible that the cervical spine may be involved in individuals with CTS. No study has investigated the relationship between cervical range of motion and symptoms associated with CTS severity. METHODS: Cervical range of motion was assessed in 71 women with CTS (18 with minimal, 18 with mild/moderate, and 35 with severe signs and symptoms) and in 20 similar, healthy women. Those with CTS were aged 35 to 59 years (mean ± SD, 45 ± 8 years) and those in the healthy group were aged 31 to 60 years (45 ± 8 years). An experienced therapist, blinded to the participants’ conditions, used a cervical range-of-motion (CROM) device to assess cervical range of motion. Mixed-model analyses of variance (ANOVAs) were conducted to evaluate the differences in cervical range of motion among the 3 groups of patients with CTS and healthy controls. A corrected P value of less than .025 was used as threshold for significance (Bonferroni correction). RESULTS: The mixed-model ANOVAs revealed that the individuals with CTS exhibited restricted cervical range of motion compared to healthy controls (P<.001), with no significant differences among the groups with minimal, mild/moderate, or severe CTS (P>.356). A significant negative correlation between pain intensity and cervical spine lateral flexion away from the affected side was identified: the greater the mean pain intensity, the lesser the cervical lateral flexion away from the affected side. CONCLUSIONS: Women with minimal, mild/moderate, or severe CTS exhibited less cervical range of motion compared to women of a similar age, suggesting that restricted cervical range of motion may be a common feature in individuals with CTS, independent of severity subgroups, as defined by electrodiagnosis. Future research should investigate cervical range of motion as a possible consequence or causative factor of CTS and related symptoms.

J Orthop Sports Phys Ther 2011;41(5):305-310, Epub 6 April 2011. doi:10.2519/jospt.2011.3536

KEY WORDS: CTS, electrodiagnosis, median nerve, neck, wrist

STUDY DESIGN: Randomized clinical trial. OBJECTIVE: To determine if patients who met the clinical prediction rule (CPR) criteria for the success of thoracic spine thrust joint manipulation (TJM) for the treatment of neck pain would have a different outcome if they were treated with a cervical spine TJM. BACKGROUND: A CPR had been proposed to identify patients with neck pain who would likely respond favorably to thoracic spine TJM. Research on validation of that CPR had not been completed when this trial was initiated. In our clinical experience, though many patients with neck pain responded favorably to thoracic spine TJM, they often reported that their symptomatic cervical spine area had not been adequately addressed. METHODS: Twenty-four consecutive patients, who presented to physical therapy with a primary complaint of neck pain and met 4 out of 6 of the CPR criteria for thoracic TJM, were randomly assigned to 1 of 2 treatment groups. The thoracic group received thoracic TJM and a cervical range-of-motion (ROM) exercise for the first 2 sessions, followed by a standardized exercise program for an additional 3 sessions. The cervical group received cervical TJM and the same cervical ROM exercise for the first 2 sessions, and the same exercise program given to the thoracic group for the next 3 sessions. Outcome measures collected at 1 week, 4 weeks, and 6 months from start of treatment included the Neck Disability Index, numeric pain rating scale, and Fear-Avoidance Beliefs Questionnaire. RESULTS: Patients who received cervical TJM demonstrated greater improvements in Neck Disability Index (P≤.001) and numeric pain rating scale (P≤.003) scores at all follow-up times. There was also a statistically significant improvement in the Fear-Avoidance Beliefs Questionnaire physical activity subscale score at all follow-up times for the cervical group (P≤.004). The number needed to treat to avoid an unsuccessful overall outcome was 1.8 at 1 week, 1.6 at 4 weeks, and 1.6 at 6 months. CONCLUSION: Patients with neck pain who met 4 of 6 of the CPR criteria for successful treatment of neck pain with a thoracic spine TJM demonstrated a more favorable response when the TJM was directed to the cervical spine rather than the thoracic spine. Patients receiving cervical TJM also demonstrated fewer transient side-effects. LEVEL OF EVIDENCE: Therapy, level 1b.

J Orthop Sports Phys Ther 2011;41(4):208-220, Epub 18 February 2011. doi:10.2519/jospt.2011.3640

KEY WORDS: clinical prediction rule, manual therapy, mobilization, prognosis

STUDY DESIGN: A randomized controlled clinical trial. OBJECTIVE: To investigate the effects of trigger point (TrP) manual therapy combined with a self-stretching program for the management of patients with plantar heel pain. BACKGROUND: Previous studies have reported that stretching of the calf musculature and the plantar fascia are effective management strategies for plantar heel pain. However, it is not known if the inclusion of soft tissue therapy can further improve the outcomes in this population. METHODS: Sixty patients, 15 men and 45 women (mean ± SD age, 44 ± 10 years) with a clinical diagnosis of plantar heel pain were randomly divided into 2 groups: a self-stretching (Str) group who received a stretching protocol, and a self-stretching and soft tissue TrP manual therapy (Str-ST) group who received TrP manual interventions (TrP pressure release and neuromuscular approach) in addition to the same self-stretching protocol. The primary outcomes were physical function and bodily pain domains of the quality of life SF-36 questionnaire. Additionally, pressure pain thresholds (PPT) were assessed over the affected gastrocnemii and soleus muscles, and over the calcaneus, by an assessor blinded to the treatment allocation. Outcomes of interest were captured at baseline and at a 1-month follow-up (end of treatment period). Mixed-model ANOVAs were used to examine the effects of the interventions on each outcome, with group as the between-subjects variable and time as the within-subjects variable. The primary analysis was the group-by-time interaction. RESULTS: The 2 × 2 mixed-model analysis of variance (ANOVA) revealed a significant group-by-time interaction for the main outcomes of the study: physical function (P = .001) and bodily pain (P = .005); patients receiving a combination of self-stretching and TrP tissue intervention experienced a greater improvement in physical function and a greater reduction in pain, as compared to those receiving the self-stretching protocol. The mixed ANOVA also revealed significant group-by-time interactions for changes in PPT over the gastrocnemii and soleus muscles, and the calcaneus (all P<.001). Patients receiving a combination of self-stretching and TrP tissue intervention showed a greater improvement in PPT, as compared to those who received only the self-stretching protocol. CONCLUSIONS: This study provides evidence that the addition of TrP manual therapies to a self-stretching protocol resulted in superior short-term outcomes as compared to a self-stretching program alone in the treatment of patients with plantar heel pain. LEVEL OF EVIDENCE: Therapy, level 1b.

J Orthop Sports Phys Ther 2011;41(2):43-50. doi:10.2519/jospt.2011.3504

KEY WORDS: ankle plantar flexors, plantar fasciitis, triceps surae

STUDY DESIGN: Case-control study with blinded examiner. OBJECTIVE: To investigate if pressure pain sensitivity is related to specific nerve trunks in the upper extremity of patients with either unilateral lateral epicondylalgia (LE) or carpal tunnel syndrome (CTS). BACKGROUND: In the clinical setting, patients with LE tend to exhibit radial nerve trunk tenderness, whereas patients with CTS exhibit median nerve tenderness. No studies have investigated if specific nerve pressure pain hypersensitivity exists in patients with either LE or CTS. METHODS: Sixteen women with unilateral LE (mean ± SD age, 43 ± 7 years), 17 women with unilateral CTS (43 ± 6 years), and 17 healthy women (43 ± 6 years) were included in this study. Pressure pain thresholds (PPT) were bilaterally assessed over the median, ulnar, and radial nerve trunks, as well as over the C5-6 zygapophyseal joints, by an examiner blinded to the subjectsí condition. A mixed-model analysis of variance was used to evaluate differences in PPT among groups (LE, CTS, or controls) and between sides (affected/nonaffected or dominant/nondominant). RESULTS: The individuals in both the LE and CTS groups demonstrated lower PPT bilaterally over the median (group, P<.001; side, P = .437), radial (group, P<.001; side, P = .556), and ulnar (group, P<.001; side, P = .938) nerve trunks as compared to controls. Additionally, radial (P<.001) and ulnar (P = .005) nerves were more sensitive bilaterally in patients with LE than in patients with CTS. The median nerve was more sensitive bilaterally in patients with CTS than patients with LE (P = .002). Lower PPT over the cervical spine (group, P<.001; side, P = .233) were found bilaterally in both the LE and CTS groups. Further, patients with CTS exhibited lower cervical PPT than patients with LE (P<.001). PPT was negatively correlated with both pain intensity and duration of symptoms in both the LE and CTS groups (P<.001). CONCLUSIONS: Bilateral mechanical nerve pain hypersensitivity is related to specific and particular nerve trunks in women with either unilateral LE or CTS. Our results suggest the presence of central and peripheral sensitization mechanisms in individuals with either LE or CTS.

J Orthop Sports Phys Ther 2010;40(11):751-760, Epub 22 October 2010. doi:10.2519/jospt.2010.3331

KEY WORDS: elbow, median nerve, neck, pressure pain threshold, radial nerve, ulnar nerve

STUDY DESIGN: Case report. BACKGROUND: Differential diagnosis for patients with radial wrist pain requires consideration of systemic disease, referred pain to the radial aspect of the wrist, and local dysfunction. The list of possible local dysfunctions should include De Quervain syndrome, as well as entrapment neuropathy of the superficial radial nerve. CASE DESCRIPTION: The patient was a 57-year-old man with right radial wrist pain of 6 months’ duration. The referral diagnosis was De Quervain syndrome, but a previous course of electrophysical agents-based physical therapy management had been unsuccessful. The physical examination ruled out the cervical, shoulder, elbow, and wrist joints as possible sources of pain. In this case, the diagnosis of entrapment neuropathy of the superficial radial nerve, rather than De Quervain syndrome, was primarily based on the symptom provocation resulting from a modified radial bias upper limb nerve tension test. Based on this diagnosis, treatment consisted of active and passive exercises using neurodynamic techniques. OUTCOMES: After 1 treatment session, the patient noted changes with regard to current pain intensity and function that exceeded the minimal clinically important difference and the minimal detectable change, respectively. After only 2 treatment sessions, the patient reported a complete resolution of symptoms and a full return to work. DISCUSSION: This case report critically evaluates the diagnostic process for patients with radial wrist pain and suggests neuropathy of the superficial sensory branch of the radial nerve as a differential diagnostic option. LEVEL OF EVIDENCE: Therapy, level 4.

J Orthop Sports Phys Ther 2010;40(6):361-368, Epub 22 April 2010. doi:10.2519/jospt.2010.3210

KEY WORDS: De Quervain syndrome, neuropathy, superficial sensory branch radial nerve, thumb

DESIGN: A randomized controlled trial. OBJECTIVE: To investigate the immediate effects on pressure pain thresholds over latent trigger points (TrPs) in the masseter and temporalis muscles and active mouth opening following atlanto-occipital joint thrust manipulation or a soft tissue manual intervention targeted to the suboccipital muscles. BACKGROUND: Previous studies have described hypoalgesic effects of neck manipulative interventions over TrPs in the cervical musculature. There is a lack of studies analyzing these mechanisms over TrPs of muscles innervated by the trigeminal nerve. METHODS: One hundred twenty-two volunteers, 31 men and 91 women, between the ages of 18 and 30 years, with latent TrPs in the masseter muscle, were randomly divided into 3 groups: a manipulative group who received an atlanto-occipital joint thrust, a soft tissue group who received an inhibition technique over the suboccipital muscles, and a control group who did not receive an intervention. Pressure pain thresholds over latent TrPs in the masseter and temporalis muscles, and active mouth opening were assessed pretreatment and 2 minutes posttreatment by a blinded assessor. Mixed-model analyses of variance (ANOVA) were used to examine the effects of interventions on each outcome, with group as the between-subjects variable and time as the within-subjects variable. The primary analysis was the group-by-time interaction. RESULTS: The 2-by-3 mixed-model ANOVA revealed a significant group-by-time interaction for changes in pressure pain thresholds over masseter (P<.01) and temporalis (P = .003) muscle latent TrPs and also for active mouth opening (P<.001) in favor of the manipulative and soft tissue groups. Between-group effect sizes were small. CONCLUSIONS: The application of an atlanto-occipital thrust manipulation or soft tissue technique targeted to the suboccipital muscles led to an immediate increase in pressure pain thresholds over latent TrPs in the masseter and temporalis muscles and an increase in maximum active mouth opening. Nevertheless, the effects of both interventions were small and future studies are required to elucidate the clinical relevance of these changes. LEVEL OF EVIDENCE: Therapy, level 1b.

J Orthop Sports Phys Ther 2010;40(5):310-317, Epub 12 April 2010. doi:10.2519/jospt.2010.3257

KEY WORDS: cervical manipulation, muscle trigger points, neck, TMJ, upper cervical

STUDY DESIGN: Case control study. OBJECTIVES: To compare the amount of forward head posture (FHP) and cervical range of motion between patients with moderate carpal tunnel syndrome (CTS) and healthy controls. We also sought to assess the relationships among FHP, cervical range of motion, and clinical variables related to the intensity and temporal profile of pain due to CTS. BACKGROUND: It is plausible that the cervical spine may be involved in patients with CTS. No studies have investigated the possible associations among FHP, cervical range of motion, and symptoms related to CTS. METHODS: FHP and cervical range of motion were assessed in 25 women with CTS and 25 matched healthy women. Side-view pictures were taken in both relaxed-sitting and standing positions to measure the craniovertebral angle. A CROM device was used to assess cervical range of motion. Posture and mobility measurements were performed by an experienced therapist blinded to the subjects’ condition. Differences in cervical range of motion were examined using the nonparametric Mann-Whitney U test. A 2-way mixed-model analysis of variance (ANOVA) was used to evaluate differences in FHP between groups and positions. RESULTS: The ANOVA revealed significant differences between groups (F = 30.4; P<.001) and between positions (F = 6.5; P<.01) for FHP assessment. Patients with CTS had a smaller craniovertebral angle (greater FHP) than controls (P<.001) in both standing and sitting. Additionally, patients with CTS showed decreased cervical range of motion in all directions when compared to controls (P<.001). Only cervical flexion (r_s = –0.43; P = .02) and lateral flexion contralateral to the side of the CTS (r_s = –0.51; P = .01) were associated with the reported lowest pain experienced in the preceding week. A positive association between FHP and cervical range of motion was identified in both groups: the smaller the craniovertebral angle (reflective of a greater FHP), the smaller the range of motion (r values between 0.27 and 0.45; P<.05). Finally, cervical range of motion and FHP were negatively associated with age in the control group but not in the group with CTS. CONCLUSIONS: Patients with mild/moderate CTS exhibited a greater FHP and less cervical range of motion, as compared to healthy controls. Additionally, a greater FHP was associated with a reduction in cervical range of motion. However, a cause-and-effect relationship cannot be inferred from this study. Future research should investigate if FHP and restricted cervical range of motion is a consequence or a causative factor of CTS and related symptoms (eg, pain).

J Orthop Sports Phys Ther 2009;39(9):658-664, Epub 19 March 2009. doi:10.2519/jospt.2009.3058

KEY WORDS: CROM, CTS, neck

DESIGN: Randomized clinical trial. OBJECTIVES: To determine the short-term effects of Kinesio Taping, applied to the cervical spine, on neck pain and cervical range of motion in individuals with acute whiplash-associated disorders (WADs). BACKGROUND: Researchers have begun to investigate the effects of Kinesio Taping on different musculoskeletal conditions (eg, shoulder and trunk pain). Considering the demonstrated short-term effectiveness of Kinesio Tape for the management of shoulder pain, it is suggested that Kinesio Tape may also be beneficial in reducing pain associated with WAD. METHODS AND MEASURES: Forty-one patients (21 females) were randomly assigned to 1 of 2 groups: the experimental group received Kinesio Taping to the cervical spine (applied with tension) and the placebo group received a sham Kinesio Taping application (applied without tension). Both neck pain (11-point numerical pain rating scale) and cervical range-of-motion data were collected at baseline, immediately after the Kinesio Tape application, and at a 24-hour follow-up by an assessor blinded to the treatment allocation of the patients. Mixed-model analyses of variance (ANOVAs) were used to examine the effects of the treatment on each outcome variable, with group as the between-subjects variable and time as the within-subjects variable. The primary analysis was the group-by-time interaction. RESULTS: The group-by-time interaction for the 2-by-3 mixed-model ANOVA was statistically significant for pain as the dependent variable (F = 64.8; P<.001), indicating that patients receiving Kinesio Taping experienced a greater decrease in pain immediately postapplication and at the 24-hour follow-up (both, P<.001). The group-by-time interaction was also significant for all directions of cervical range of motion: flexion (F = 50.8; P<.001), extension (F = 50.7; P<.001), right (F = 39.5; P<.001) and left (F = 3.8, P<.05) lateral flexion, and right (F = 33.9, P<.001) and left (F = 39.5, P<.001) rotation. Patients in the experimental group obtained a greater improvement in range of motion than thosein the control group (all, P<.001). CONCLUSIONS: Patients with acute WAD receiving an application of Kinesio Taping, applied with proper tension, exhibited statistically significant improvements immediately following application of the Kinesio Tape and at a 24-hour follow-up. However, the improvements in pain and cervical range of motion were small and may not be clinically meaningful. Future studies should investigate if Kinesio Taping provides enhanced outcomes when added to physical therapy interventions with proven efficacy or when applied over a longer period. LEVEL OF EVIDENCE: Therapy, level 1b.

J Orthop Sports Phys Ther 2009;39(7):515-521, Epub 24 February 2009. doi:10.2519/jospt.2009.3072

KEY WORDS: cervical spine, neck, taping, WAD

STUDY DESIGN: Randomized clinical trial. OBJECTIVES: To investigate if patients with mechanical neck pain receiving thoracic spine thrust manipulation would experience superior outcomes compared to a group not receiving thrust manipulation. BACKGROUND: Evidence has begun to emerge in support of thoracic thrust manipulation as an intervention in the management of mechanical neck pain. However, to make a strong recommendation for a clinical technique it is necessary to have multiple studies with convergent findings. METHODS AND MEASURES: Forty-five patients (21 females) were randomly assigned to 1 of 2 groups: a control group, which received electro/thermal therapy for 5 treatment sessions, and the experimental group, which received the same electro/thermal therapy program in addition to a thoracic spine thrust manipulation once a week for 3 consecutive weeks. Mixed-model analyses of variance (ANOVAs) were used to examine the effects of treatment on pain (100-mm visual analogue scale), disability (100-point disability scale), and cervical range of motion, with group as the between-subjects variable and time as the within-subjects variable. The primary analysis was the group-by-time interaction for pain. RESULTS: The group-by-time interaction effects for the ANOVA models were statistically significant for pain, mobility, and disability (P<.05), indicating greater improvements in the manipulation group for all the outcome measures. Patients receiving thoracic manipulation experienced greater improvements in pain at the fifth (final) treatment session and at the 2-week and 4-week follow-up periods (P<.001), with pain improvement scores in the manipulation group of 16.8 mm and 26.5 mm greater than those in the comparison group at the 2- and 4-week follow-up periods, respectively. The experimental group also experienced significantly greater improvements in disability with a between-group difference of 8.8 points (95% confidence interval [CI]: 7.5, 10.1; P<.001) at the fifth visit and 8.0 points (95% CI: 5.8, 10.2; P<.001) at the 2-week follow-up. CONCLUSIONS: The results of our study suggest that thoracic spine thrust manipulation results in superior clinical benefits that persist beyond the 1-month follow-up period for patients with acute neck pain. Future studies should continue to investigate the effects of thoracic spine thrust manipulation, as compared to other physical therapy interventions, in a population with mechanical neck pain. LEVEL OF EVIDENCE: Therapy, level 1b.

J Orthop Sports Phys Ther 2009;39(1):20-27, Epub 19 September 2008. doi:10.2519/jospt.2009.2914

KEY WORDS: cervical spine, clinical trial, manual therapy, mobilization, thrust manipulation

DESIGN: Case-control study. OBJECTIVE: To analyze the differences in muscle size and shape of cervical multifidus between patients with bilateral chronic neck pain and healthy subjects. BACKGROUND: Researchers have demonstrated atrophy of lumbar multifidus in patients presenting with low back pain; however, there are only few published reports on cervical multifidus muscle size in individuals with chronic neck pain. METHODS AND MEASURES: Bilateral ultrasound images of multifidus muscle from the third to sixth cervical vertebrae (C3 to C6) were taken in 20 women with bilateral chronic neck pain and 20 healthy women. Cross-sectional area (CSA [cm²]) and muscle shape ratio (ratio between lateral [Lat] and anterior-posterior [AP] dimensions, [Lat/AP]) were measured without knowledge of group assignment. Two separate 3-way (4 x 2 x 2) mixed-model analyses of variance (ANOVAs) with cervical level (C3 to C6) and side (right, left) as within-subject factors and group (patient, control) as the between-subject factor, were used to evaluate differences in CSA and muscle shape ratio between groups, sides, and cervical levels. RESULTS: The ANOVA for CSA indicated a significant effect for cervical level (F = 6.81, P<.001) and group (F = 20.27, P<.001), but not for side (F = 1.26, P = .36). There were no significant interactions among the variables (P>.5). Post hoc analysis showed that the CSA of the C3 multifidus was smaller than the CSA of the C4 (P = .025), C5 (P<.001) or C6 (P<.01) multifidus. There was no significant difference between C4, C5, and C6 multifidus CSA (P>.05). The patients with neck pain had a smaller CSA of the cervical multifidus at all levels compared to controls (P<.001). The ANOVA for muscle shape ratio indicated a significant effect for level (F = 7.84, P<.001) and group (F = 12.501, P<.001), but not for side (F = 0.654, P = .58). There was a significant interaction between level and group (F = 3.651, P = .01). Patients had a wider ovoid shape (greater values in muscle shape ratio) of the C3 (P<.001) and C6 (P<.01) cervical multifidus compared to controls. Further, the C4 multifidus had a smaller shape ratio compared to C6 (P<.001), but was not significantly different than the shape ratio of the C3 and C5 (P>.05) multifidus. CONCLUSIONS: Females with bilateral chronic neck pain had generalized smaller CSA of the cervical multifidus muscles compared to healthy females. LEVEL OF EVIDENCE: Diagnosis, level 5.

J Orthop Sports Phys Ther. 2008;38(4):175-180, published online 7 December 2007. doi:10.2519/jospt.2008.2598

KEY WORDS: cervical spine, rehabilitative ultrasound imaging, ultrasonography

STUDY DESIGN: A placebo, control, repeated measures, single-blinded randomized study. OBJECTIVES: To compare the immediate effects on pressure pain threshold (PPT) tested over the lateral elbow region following a single cervical high-velocity low-amplitude (HVLA) thrust manipulation, a sham-manual application (placebo), or a control condition; and to analyze if a different effect was evident on the side ipsilateral to, compared to the side contralateral to the intervention. BACKGROUND: Previous studies investigating the effects of spinal manual therapy used passive mobilization procedures. There is a lack of studies exploring the effect of cervical manipulative interventions. METHODS: Fifteen asymptomatic volunteers (7 male and 8 female; aged 19 to 25 years) participated in this study. Each subject attended 3 experimental sessions on 3 separate days at least 48 hours apart. At each session, subjects received either the manipulation, placebo, or control intervention provided by an experienced therapist. The manipulative intervention was directed at the posterior joint of the C5-6 vertebral level. PPT over the lateral epicondyle of both elbows was assessed preintervention and 5 minutes postintervention by an examiner blinded to the treatment allocation of the subject. A 3-way analysis of covariance (ANCOVA) with intervention, side, and time as factors, and gender as covariate was used to evaluate changes in PPT. RESULTS: The analysis of variance detected a significant effect for intervention (F = 31.46, P<.001) and for time (F = 33.81, P<.001), but not for side (F = 0.303, P>.5). A significant interaction between intervention and time (F = 15.74; P<.001) was also found. Gender did not influence the comparative analysis (F = 0.252; P>.6). Post hoc analysis revealed that the application of a HVLA thrust manipulation produced a greater increase of PPT in both elbows, as compared to placebo or control interventions (P<.001). No significant changes in PPT levels were found after the placebo and control intervention (P>.6). Within group effect sizes were large for PPT levels in both elbows after the manipulative procedure (d>1.0), but small after placebo or control intervention (d<0.1). CONCLUSIONS: The application of a manipulative intervention directed at posterior joint of the C5-6 vertebral level produced an immediate increase in PPT over the lateral epicondyle of both elbows in healthy subjects. Effect sizes for the HVLA thrust manipulation were large, suggesting a strong effect of unknown clinical importance at this stage, whereas effect sizes for both placebo and control procedures were small, suggesting no significant effect.

J Orthop Sports Phys Ther. 2007;37(6):325-329, Epub 29 May 2007. doi:10.2519/jospt.2007.2542

KEY WORDS: hypoalgesia, manual therapy, neck pain, thrust manipulation

STUDY DESIGN: Case-control, descriptive pilot study. OBJECTIVE: To describe the differences in the performance of the craniocervical flexion test (CCFT) between individuals with chronic tension-type headache (CTTH) and healthy controls. To assess the relationship between the CCFT, forward head posture, and several clinical variables related to the intensity and temporal profile of headache. BACKGROUND: Musculoskeletal impairments of the craniocervical region might play an important role on the pathogenesis of CTTH. Deficits in the performance of the CCFT have been reported in patients with cervicogenic headache, nonspecific neck pain, and whiplash injury, but not in individuals with CTTH. MATERIAL AND METHODS: Ten patients with CTTH and 10 comparable controls without headache were studied. A headache diary was kept for 4 weeks to substantiate the diagnosis and to record the pain history. The CCFT was performed with the subject supine and required performing a gentle head-nodding action of craniocervical flexion. The activation pressure score (pressure that the subject can achieve and hold for 10 seconds), the performance pressure index (calculated by multiplying the activation pressure score by the number of successful repetitions), and the highest pressure score (the highest level that each subject was able to hold for 10 seconds from 20 to 30 mm Hg) were measured. Side-view pictures of each subject were taken in both sitting and standing positions to assess forward head posture (FHP) by measuring the craniovertebral angle. All measures were taken by an assessor blinded to the subject’s condition. RESULTS: Patients with CTTH had significantly lower values in both active pressure score and performance pressure index (P<.001), but not in the highest pressure score (P = .057), compared to controls. Patients with CTTH had a smaller craniovertebral angle (mean ± SD, 42.0° ± 6.6°), indicating a more FHP than controls (48.8° ± 2.5°), in the standing position (P<.01); but not in the sitting position (CTTH, 39° ± 8.9°; controls, 42.8° ± 8.9°, P = .10). No association between FHP and any of the CCFT variables was found (P>.05). Headache intensity and frequency did not seem to be related to the CCFT variables, but there was a positive association between headache duration and activation pressure score (r_s = 0.746, P = .02) and highest pressure score (r_s = 0.743, P = .02). CONCLUSIONS: These findings suggest possible impairments of the musculoskeletal system in individuals with CTTH, although it is not possible to determine if these impairments contributed to the etiology of CTTH or are as a result of the chronic headache condition.  

J Orthop Sports Phys Ther. 2007;37(2):33-39. doi:10.2519/ jospt.2007.2401

KEY WORDS: cervical spine, head, neck, pain

Study Design: Literature review of quality of clinical trials. Objective: To determine the methodological quality of published randomized controlled trials in the last decade that used spinal manipulation and/or mobilization to treat patients with tension-type headache (TTH), cervicogenic headache (CeH), and migraine (M). Background: TTH, CeH, and M are the most prevalent types of headaches seen in adults. Individuals who have headaches frequently use physical therapy, manual therapy, or chiropractic care. Randomized controlled trials are considered an optimal method with which to assess the efficacy of any intervention. Methods: Computerized literature searches were performed in MEDLINE, EMBASE, COCHRANE, AMED, MANTIS, CINHAL, and PEDro databases. Randomized controlled trials in which spinal manipulation and/or mobilization was used for TTH, CeH, and M that were published in a peer-reviewed journal as full text and included at least 1 clinically relevant outcome measure (ie, headache intensity, duration, or frequency) were reviewed. Two reviewers using a set of predefined criteria independently assessed the methodological quality of the studies. Results: Only 8 studies met all the inclusion criteria. One clinical trial evaluated spinal manipulation and mobilization together, and the remaining 7 assessed spinal manipulative therapy. No controlled trials that analyzed exclusively the effects of spinal mobilization were found. Methodological scores ranged from 35 to 56 points out of a theoretical maximum of 100 points, indicating an overall poor methodology of the studies. Only 2 studies obtained a high-quality score (greater than 50 points). No significant differences in quality scores were found based on the type of headache investigated. Methodological quality was neither associated with the year of publication (before 2000, or later) nor with the results (positive, neutral, negative) reported in the studies. The most common flaws were a small sample size, the absence of a placebo control group, lack of blinded patients, and no description of the manipulative procedure. Conclusions: There are few published randomized controlled trials analyzing the effectiveness of spinal manipulation and/or mobilization for TTH, CeH, and M in the last decade. In addition, the methodological quality of these papers is typically low. Clearly, there is a need for high-quality randomized controlled trials assessing the effectiveness of these interventions in these headache disorders.

J Orthop Sports Phys Ther. 2006;36(3):160-169. doi:10.2519/jospt.2006.2126

Key Words: cervical spine, head, manual therapy, neck