STUDY DESIGN: Randomized, controlled trial. OBJECTIVES: To assess the believability of a novel sham intervention for a neurodynamic technique (NDT) in participants with signs and symptoms of carpal tunnel syndrome (CTS). Additionally, we wished to assess a potential mechanism of NDT (hypoalgesia) and to compare outcomes related to clinical pain and upper extremity disability between NDT and a sham intervention. BACKGROUND: Preliminary evidence suggests that NDT is effective in the treatment of CTS. A sham-controlled study is lacking from the literature and could provide insight to the efficacy of NDT, as well as the corresponding mechanisms. METHODS: Participants with signs and symptoms consistent with CTS provided baseline measures of expectation, clinical pain intensity, upper extremity disability, and experimental pain sensitivity. Participants were then randomly assigned to receive either a NDT known to anatomicallystress the median nerve or a sham technique intended to minimize stress to the median nerve. Following brief exposure to the assigned technique, expectation was reassessed to observe for group-dependent changes. Participants received the assigned intervention over 3 weeks. Additionally, all participants received a prefabricated wrist splint for their involved hands, with instructions to sleep in the splint and to wear it during painful activities when awake. Following 3 weeks of the assigned intervention and splint wear, baseline measures were reassessed and participants were asked which intervention they believed they had received. RESULTS: Forty females agreed to participate. Expectations for pain relief and perceived group assignment were similar between the groups. Within-session decreases in clinical pain intensity and pressure pain sensitivity were observed independent of group assignment. Reduction of temporal summation was observed only in participants receiving NDT. Significant improvements in clinical pain intensity and upper extremity disability were observed at 3 weeks, independent of group assignment. CONCLUSION: The sham intervention was successful in blinding the participants. Immediate changes in pain sensitivity and intensity and 3-week changes in clinical pain intensity and upper extremity disability associated with NDT were equivalent to a sham intervention to which the participants were adequately blinded. Conversely, reduction of temporal summation was only observed in participants receiving the NDT, suggesting the potential of a favorable neurophysiological effect. LEVEL OF EVIDENCE: Therapy, level 1b.

J Orthop Sports Phys Ther 2009;39(10):709-723. doi:10.2519/jospt.2009.3117

KEY WORDS: central sensitization, manual therapy, musculoskeletal pain, placebo

STUDY DESIGN: A single-blinded, quasi-experimental, within- and between-sessions assessment. OBJECTIVES: To investigate potential mechanisms of neural mobilization (NM), using tensioning techniques in comparison to sham NM on a group of asymptomatic volunteers between the ages of 18 and 50. BACKGROUND: NM utilizing tensioning techniques is used by physical therapists in the treatment of patients with cervical and/or upper extremity symptoms. The underlying mechanisms of potential benefits associated with NM tensioning techniques are unknown. METHODS AND MEASURES:  Participants (n = 62) received either a NM or sham NM intervention 2 to 3 times a week for a total of 9 sessions, followed by a 1-week period of no intervention to assess carryover effects. A-delta (first pain response) and C-fiber (temporal summation) mediated pain perceptions were tested via thermal quantitative sensory testing procedures. Elbow extension range of motion (ROM) and sensory descriptor ratings were obtained during a neurodynamic test for the median nerve. Data were analyzed with repeated-measures analysis of variance (ANOVA). RESULTS: No group differences were seen for A-delta mediated pain perception at either immediate or carryover times. Group differences were identified for immediate C-fiber mediated pain perception (P = .032), in which hypoalgesia occurred for the NM group but not the sham NM group. This hypoalgesic effect was not maintained at carryover (P = .104). Group differences were also identified for the 3-week and carryover periods for elbow extension ROM (P = .004), and for the participant sensory descriptor ratings (P = .018), in which increased ROM and decreased sensory descriptor ratings were identified in participants in the NM group but not the sham NM group. CONCLUSION: This study provides preliminary evidence that mechanistic effects of tensioning NM differ from sham NM for asymptomatic participants. Specifically, NM resulted in immediate, but not sustained, C-fiber mediated hypoalgesia. Also, NM was associated with increased elbow ROM and a reduction in sensory descriptor ratings at 3-week and carryover assessment times. These differences provide potentially important information on the mechanistic effects of NM, as well as the description of a sham NM for use in future clinical trials. LEVEL OF EVIDENCE: Therapy, level 2b.

J Orthop Sports Phys Ther 2009;39(6):428-438, Epub 19 March 2009. doi:10.2519/jospt.2009.2954

KEY WORDS: manual therapy, neurodynamic testing, temporal summation

STUDY DESIGN: Cross-sectional. OBJECTIVES: This study examined the baseline relationship of pain intensity, physical impairment, and pain-related fear to shoulder function. BACKGROUND: There is no consensus regarding the influence psychological variable have on function and recovery in individuals with shoulder pathologies. While pain-related fear has been shown to predict disability for patients with low-back and cervical pain, this relationship has not been consistently reported for patients with shoulder pain. METHODS AND MEASURES: One hundred forty-two subjects (78 male, 64 female; mean age, 41.4 years) with nonoperative unilateralshoulder disorders were identified from a clinical database of impairment and outcome measures.Demographic information, duration of symptoms, mechanism of injury, pain intensity, pain-related
fear, and range-of-motion (ROM) measures were collected. Self-report of function was measured with the Shoulder Pain and Disability Index (SPADI). Hierarchical regression analysis determinedthe proportions of explained variance in function. RESULTS: Demographic variables (durationof symptoms, sex, age, and mechanism of injury) collectively contributed approximately 9% (P = .003) of the variance in function scores. Average pain intensity and flexion ROM contributed an additional 22% (P<.001) of the variance, and Tampa Scale of Kinesiophobia (TSK-11) scores contributed an additional 3% (P<.001). In the final parsimonious model, presence of symptoms longer than 3 months (ß = .23, P = .003), pain intensity (ß = .25, P = .002), shoulder flexion ROM index (ß = –.35, P = .001), and kinesiophobia (ß = .17, P = .026) explained 33% of the variance in SPADI function score (P<.001). CONCLUSIONS: Presence of symptoms longer than 3 months, average pain intensity, flexion ROM index (strongest contributor in multivariate model), and fear-of-pain scores all contributed to baseline shoulder function. The immediate clinical relevance of these findings is unclear but they do provide direction for prospective studies. LEVEL OF EVIDENCE: Prognosis, level 2b.

J Orthop Sports Phys Ther 2009;39(4):270-277, Epub 15 December 2008. doi:10.2519/jospt.2009.2879

KEY WORDS: disability, kinesiophobia, psychological, physical therapy, shoulder flexion

For some patients, spinal manipulative therapy is an effective treatment for spine pain, yet we really don't fully understand how or why. The mechanisms of spinal manipulative therapy are not well defined, and common explanations for why spinal manipulative therapy works lack supporting evidence. Traditionally, the decision to incorporate spinal manipulative therapy into a plan of care is based on a seductively plausible biomechanical theory. Examination techniques, sometimes quite elaborate in nature, are used to determine painful structures and associated abnormalities related to alignment and mobility. The appropriately matched spinal manipulative therapy treatment techniques are then implemented to correct "pathological" findings. The underlying implication of these approacheds is that success of spinal manipulative therapy is dependent upon correction of biomechanical faults detected on examination.

J Orthop Sports Phys Ther. 2008;38(6):293-295. doi:10.2519/jospt.2008.0118

KEY WORDS: biomechanics, spine

Letters to the Editor-in-Chief of the JOSPT as follows:

• Regional Interdependence: A Musculoskeletal Examination Model Whose Time Has Come. J Orthop Sports Phys Ther. 2008;38(3):159-161. doi:10.2519/jospt.2008.0201
• Authors' response. J Orthop Sports Phys Ther. 2008;38(3):159-161. doi:10.2519/jospt.2008.0202
• Slipped Capital Femoral Epiphysis in a Patient Referred to Physical Therapy for Knee Pain. J Orthop Sports Phys Ther. 2008;38(3):159-161. doi:10.2519/jospt.2008.0203
• Authors' response. J Orthop Sports Phys Ther. 2008;38(3):159-161. doi:10.2519/jospt.2008.0204

STUDY DESIGN: Nonexperimental. OBJECTIVES: To determine interrater and intrarater agreement for 2 methods of evaluating movement quality during 2 lower extremity func­tional tasks, and to descriptively compare levels of agreement between the 2 methods. BACKGROUND: Clinicians typically use observational analysis to evaluate movement quality during functional tasks, but the extent of agreement is unknown. METHODS AND MEASURES: Twenty-five uninjured subjects performed 3 trials of unilateral squat and lateral step-down tasks. Three clinicians evaluated the trunk, pelvis, and hips for coronal plane and transverse plane movement deviations. Two rating methods were used: assessment of the entire movement (“overall method”) and rating each segment individually (“specific method”). Movement deviation severity was rated using basic clinical guidelines and ratings were repeated from videotape. Percent agreement and weighted kappa coefficients were calculated between rater pairs and rating sessions. Generalized kappa coefficients were calculated across raters. RESULTS: Interrater and intrarater percent agreement were higher using the overall method. Interrater weighted kappa coefficients were similar between rating methods (overall method, 0-0.55; specific method, 0.23-0.53). Intrarater weighted kappa coefficients were higher for the specific method (0.38-0.68) compared to the overall method (0.13-0.50). Generalized kappa coefficients were also higher for specific method compared to the overall method (unilateral squat, 0.19 and 0.01, respectively; lateral step-down, 0.22 and 0.18, respectively) and 95% confidence intervals remained above zero. CONCLUSIONS: Rating movement at body segments appears to result in agreement among raters that is better than chance. Neither rating method produced high agreement, indicating a need to develop more explicit criteria for rating movement deviation severity.  

J Orthop Sports Phys Ther. 2007;37(3):122-129. doi:10.2519/jospt.2007.2457 

KEY WORDS: functional testing, hip, knee, movement analysis, neuromuscular, reliability