The Utilization of Joint Mobilization As Part of a Comprehensive Program to Manage Carpal Tunnel Syndrome: A Systematic Review.

OBJECTIVE: The purpose of this review is to identify the role of joint mobilization for individuals with Carpal tunnel syndrome (CTS). METHODS: A systematic search of 5 electronic databases (PubMed, CINAHL, Scopus, Cochrane Central Register of Controlled Trials, and SPORTDiscus) was performed to identify eligible full-text randomized clinical trials related to the clinical question. Joint mobilization had to be included in one arm of the randomized clinical trials to be included. Two reviewers independently participated in each step of the screening process. A blinded third reviewer assisted in cases of discrepancy. The PEDro scale was used to assess quality. RESULTS: Ten articles were included after screening 2068 titles. In each article where joint mobilization was used, positive effects in pain, function, or additional outcomes were noted. In most cases, the intervention group integrating joint mobilization performed better than the comparison group not receiving joint techniques. CONCLUSION: In the articles reviewed, joint mobilization was associated with positive clinical effects for persons with CTS. No studies used joint mobilization in isolation; therefore, results must be interpreted cautiously. This review indicates that joint mobilization might be a useful adjunctive intervention in the management of CTS.

Manual therapy and eccentric exercise in the management of Achilles tendinopathy.

Chronic Achilles tendinopathy (AT) is an overuse condition seen among runners. Eccentric exercise can decrease pain and improve function for those with chronic degenerative tendon changes; however, some individuals have continued pain requiring additional intervention. While joint mobilization and manipulation has not been studied in the management in Achilles tendinopathy, other chronic tendon dysfunction, such as lateral epicondylalgia, has responded well to manual therapy (MT). Three runners were seen in physical therapy (PT) for chronic AT. They were prescribed eccentric loading exercises and calf stretching. Joint mobilization and manipulation was implemented to improve foot and ankle mobility, decrease pain, and improve function. Immediate within-session changes in pain, heel raise repetitions, and pressure pain thresholds (PPT) were noted following joint-directed MT in each patient. Each patient improved in self-reported function on the Achilles tendon specific Victorian Institute for Sport Assessment questionnaire (VISA-A), pain levels, PPT, joint mobility, ankle motion, and single-leg heel raises at discharge and 9-month follow-up. The addition of MT directed at local and remote sites may enhance the rehabilitation of patients with AT. Further research is necessary to determine the efficacy of adding joint mobilization to standard care for AT. LEVEL OF EVIDENCE: Case series. Therapy, Level 4.

The symptomatic and functional effects of manual physical therapy on plantar heel pain: a systematic review.

OBJECTIVES: Plantar heel pain is common and can be severely disabling. Unfortunately, a gap in the literature exists regarding the optimal intervention for this painful condition. Consequently, a systematic review of the current literature regarding manual therapy for the treatment of plantar heel pain was performed. METHODS: A computer-assisted literature search for randomized controlled trials in MEDLINE, EMBASE, Cochrane, CINAHL, and Rehabilitation & Sports Medicine Source, was concluded on 7 January 2014. After identification of titles, three independent reviewers selected abstracts and then full-text articles for review. RESULTS: Eight articles were selected for the final review and underwent PEDro scale assessment for quality. Heterogeneity of the articles did not allow for quantitative analysis. Only two studies scored ≥7/10 on the PEDro scale and included joint, soft tissue, and neural mobilization techniques. These two studies showed statistically greater symptomatic and functional outcomes in the manual therapy group. DISCUSSION: This review suggests that manual therapy is effective in the treatment of plantar heel pain; however, further research is needed to validate these findings given the preponderance of low quality studies.

Regional effects of orthopedic manual physical therapy in the successful management of chronic jaw pain.

OBJECTIVE AND IMPORTANCE: Temporomandibular disorders (TMD) encompass a variety of dysfunction of the maxillofacial region. A strong relationship between TMD and cervical spine pain exists, and widespread hyperalgesia is common in TMD. This case describes the management and reduction in regional hyperalgesia in a patient with chronic TMD. CLINICAL PRESENTATION: A 23-year-old female with a 10-year history of tinnitus and bilateral (B) jaw pain, and 5-year history of intermittent neck pain, presented with pain, which could reach 10/10 on the numeric pain rating scale, locking, tightness and restricted eating habits. Cervical motion testing did not reproduce her jaw pain. Her mouth opening (MO) and B temporomandibular joint (TMJ) accessory glides were limited and painful. Accessory glides at the upper cervical facet joints reproduced her jaw pain. Pressure pain thresholds (PPT) at her B masseters and thenar eminences at the hand were diminished, indicating hyperalgesia. INTERVENTION: Treatment included passive mobilizations at her TMJs and cervical spine. Home exercises included self-mobilization of her TMJs and neck. In six sessions, her MO improved from 30 to 45 mm and average pain improved from 4/10 to 0/10. The jaw pain and function questionnaire improved from 16/52 to 5/52. PPTs at her right/left masseter and thenar eminence improved from 140/106 and 221/230 kPa to 381/389 and 562/519 kPa, respectively. CONCLUSION: This case described the treatment and reduction of upper extremity hyperalgesia of a patient with chronic jaw and neck pain. Manual therapy may be a valuable intervention in the treatment of chronic TMD with distal hyperalgesia.

Manual therapy should not be on the sideline in the game of treating tendinopathy.

Tendinopathy is a common but difficult condition to manage in the orthopedic and sports settings. Despite strong evidence supporting exercise and load-management, a substantial proportion of individuals with the condition do not achieve a satisfactory long-term outcome. Tendinopathy can be associated with a number of impairments, including mobility deficits, muscle performance impairments, pain, and possible altered central pain processing - all of which are indications for manual therapy. Manual therapy has not been well described in the management of tendinopathy, even though its indications match the impairments associated with the condition. In this clinical perspective, the role of manual therapy in the management of tendinopathy is explored, with the intention of expanding possible treatment strategies for this challenging condition.

Mobilization of the lumbar spine in a 76-year-old male with mechanical low back pain and an abdominal aortic aneurysm: A case report.

BACKGROUND: Abdominal aortic aneurysms (AAAs) are found in 1-12% of older males. Low back pain (LBP) is prevalent with incidence increasing with age and can respond to manual therapy (MT). To date, the safety of the application of MT for LBP in the presence of a known AAA has not been reported. This case reports on the short-term effects of MT in a patient with LBP and AAA and pre- and post-therapy imaging. CASE DESCRIPTION: A 76-year-old male presented with mechanical LBP, groin pain, and a known 4.2-cm AAA. A lumbar magnetic resonance imaging showed significant multilevel abnormalities. Abdominal screening did not elicit back or groin pain. Lumbar and hip range of motion and accessory motion testing reproduced his complaints. He was treated with lumbar and hip MT. OUTCOMES: After three visits, he reported that his groin pain resolved, and his back pain could be managed with home exercise. He reported a +6 on the global rating of change. Repeated follow-up imaging of his AAA demonstrated no significant change of his AAA. DISCUSSION: No immediate adverse events were recorded, and repeated follow-up imaging indicated no significant AAA expansion. Considering that mobilization causes similar displacement to active motion, research into the safety of MT in this population is warranted as are guidelines for appropriate initial and ongoing clinical screening during treatment in this population.

JOINT MOBILIZATION IN THE MANAGEMENT OF PERSISTENT INSERTIONAL ACHILLES TENDINOPATHY: A CASE REPORT.

BACKGROUND & PURPOSE: Insertional Achilles tendinopathy (IAT) can be a challenging condition to manage conservatively. Eccentric exercise is commonly used in the management of chronic tendinopathy; however, it may not be as helpful for insertional tendon problems as compared to mid-portion dysfunction. While current evidence describing the physical therapy management of IAT is developing, gaps still exist in descriptions of best practice. The purpose of this case report is to describe the management of a patient with persistent IAT utilizing impairment-based joint mobilization, self-mobilization, and exercise. CASE DESCRIPTION: A 51-year-old male was seen in physical therapy for complaints of posterior heel pain and reduced running capacity. He was seen by multiple physical therapists previously, but reported continued impairment, and functional restriction. Joint-based non-thrust mobilization and self-mobilization exercise were performed to enhance his ability to run and reduce symptoms. OUTCOMES: The subject was seen for four visits over the course of two months. He made clinically significant improvements on the Foot and Ankle Activity Measure and Victorian Institute of Sport Assessment-Achilles tendon outcomes, was asymptomatic, and participated in numerous marathons. Improvements were maintained at one-year follow-up. DISCUSSION: Mobility deficits can contribute to the development of tendinopathy, and without addressing movement restrictions, symptoms and functional decline related to tendinopathy may persist. Joint-directed manual therapy may be a beneficial intervention in a comprehensive plan of care in allowing patients with chronic tendon changes to optimize function. LEVEL OF EVIDENCE: Therapy, Level 4.

Learning Curves Observed in Establishing Targeted Rate of Force Application in Pressure Pain Algometry.

Purpose: To determine whether learning curves can be observed with deliberate practice when the goal is to apply a consistent rate of force at 5 N/second during pressure pain threshold (PPT) testing in healthy volunteers. Methods: In this prospective study, 17 clinician participants completed PPT targeted rate-of-application testing with healthy volunteers using three different feedback paradigms. The resultant performances of ramp rate during 36 trials were plotted on a graph and examined to determine whether learning curves were observed. Results: Clinicians were not consistent in the rate of force applied. None demonstrated a learning curve over the course of 36 trials and three testing paradigms. Conclusion: The results of this study indicate that applying a consistent 5 N/second of force is difficult for practising clinicians. The lack of learning curves observed suggests that educational strategies for clinicians using PPT may need to change.

Objectif : Déterminer si une courbe d'apprentissage se dégage en réponse à un entraînement délibéré visant à appliquer un taux de force constant de 5 newtons par seconde (N/s) lors de tests du seuil de douleur à la pression (PPT pour pressure pain threshold) auprès de participants en santé. Méthodes : Dans cette étude prospective, 17 cliniciens ont réalisé des tests sur des participants en santé au moyen de trois modes de rétroaction. La variation du taux de force observée sur 36 essais a été représentée graphiquement afin de déterminer si une courbe d'apprentissage se dégageait chez les cliniciens. Résultats : Le taux de force appliqué par les cliniciens n'était pas constant. Une courbe d'apprentissage n'a été observée chez aucun d'entre eux au cours des 36 essais, peu importe le mode de rétroaction. Conclusion : Les résultats de cette étude indiquent qu'il est difficile pour les cliniciens praticiens d'appliquer un taux de force constant de 5 N/s. L'absence de courbe d'apprentissage donne à penser qu'il pourrait y avoir lieu de revoir les stratégies de formation des cliniciens appelés à mesurer le seuil de douleur à la pression.

Manual therapy in the management of a patient with a symptomatic Morton's Neuroma: A case report.

Patients with Morton's neuroma are rarely referred to physical therapy. This case reports the resolution of pain, increase in local pressure pain thresholds, and improvement of scores on the Lower Extremity Functional Scale and Foot and Ankle Ability Measure following a course of joint based manual therapy for a patient who had failed standard conservative medical treatment.

Comminuted C2 Articular Pillar Fracture in a Patient With Multiple Sclerosis and Recurrent Falls.

The patient was a 60-year-old woman, with long-standing balance deficits due to multiple sclerosis, referred to physical therapy by her primary care physician secondary to increasing fall frequency. Following evaluation, the physical therapist escorted the patient to her primary care physician's office, where a computed tomography scan was immediately performed, revealing a comminuted C2 articular pillar fracture.

Midshaft humeral fracture following a proximal humeral fracture: a case report.

BACKGROUND AND PURPOSE: Proximal humeral fractures are relatively uncommon injuries. While previous research has led to effective clinical and diagnostic evaluation and treatment of proximal fractures, less is currently known regarding the typical evaluation and treatment of midshaft humeral fractures. The purpose of this case is to describe the clinical reasoning and utilization of diagnostic imaging in the physical therapy management of a midshaft humeral fracture, sustained during the course of rehabilitation of a proximal humerus fracture. CASE DESCRIPTION: A 63-year-old female recreational tennis player presented to physical therapy, progressing well following a proximal humeral fracture, sustained 18 weeks prior. During the course of care, the patient had a significant regression in range of motion and function, with increased pain, following a seemingly trivial injury. Based on a cluster of subjective and objective flags, the therapist was concerned about a new fracture. The therapist communicated findings with a physician and recommended plain film radiographs before continuing therapy. OUTCOMES: Radiographs showed an oblique displaced fracture extending through the midshaft of the humerus. The patient ultimately underwent surgical plating. At one-year post injury e-mail follow up, she had functional mobility of her left arm, and was playing tennis recreationally three times a week. DISCUSSION: In this case, a patient who was progressing well following a proximal humeral fracture sustained a separate displaced fracture of the midshaft of the humerus, not associated with therapy. Her reported mechanism was not consistent with a typical injury. This highlights the need for clinicians, specifically physical therapists, to cluster subjective information, objective data, and the patient's medical history when interpreting patient appropriateness for therapy, and to optimize outcomes. LEVEL OF EVIDENCE: 5 (single case report).