Physical therapy interventions used to treat individuals with biceps tendinopathy: a scoping review.

BACKGROUND: Shoulder pain related to pathology of the long head of the biceps tendon (LHBT) can be debilitating. Chronic LHBT tendinopathy is a common condition that is difficult to treat. Little consensus exists regarding the optimal approach to treating individuals with LHBT tendinopathy. OBJECTIVE: To systematically scope the literature to identify and present the available information regarding physical therapist interventions used for the management of individuals with LHBT tendinopathy including types of interventions used or recommended. METHODS: A scoping review of physical therapist interventions used to treat LHBT was conducted of the CINAHL, Embase, Medline, and SportDiscus databases. Full text records reporting physical therapist-based interventions in individuals with proximal LHBT pathology were included. Articles not written in English were excluded. RESULTS: Of the 4059 records identified, 14 articles met the inclusion criteria. Interventions used to treat LHBT tendinopathy identified in quantitative studies included: extracorporeal shock wave therapy, polarized light, ultrasound, low-level laser, iontophoresis, general exercise, eccentric training, stretching, dry needling, and joint mobilization. Interventions described in literature reviews, clinical commentaries, and a Delphi study included: therapeutic modalities, manual therapy, exercise, dry needling, and patient education. CONCLUSION: This scoping review reported interventions primarily based on therapeutic modalities in quantitative studies while literature reviews, clinical commentaries, and a Delphi study described the addition of manual therapy, patient education, exercise, and dry needling. Overall, there is a dearth of evidence detailing the conservative management of LHBT tendinopathy.

Feasibility of Using Detuned Laser as a Placebo In Manual Therapy Research: An Analysis of Participant Perceptions.

OBJECTIVE: The purpose of this study was to determine the feasibility of using detuned laser as a placebo intervention in manual therapy research. METHODS: We performed a secondary data analysis of a randomized controlled trial. In our analysis, 30 participants with chronic ankle instability (manual therapy group: n = 13, age = 33.1 ± 8.1 years, female participants = 50%; detuned laser group: n = 17, age = 31.9 ± 11.8 years, female participants = 72%) were asked to indicate which intervention (manual therapy [active] or detuned laser [placebo]), they thought they had received and to give a confidence rating on their response regarding the received intervention at the conclusion of the course of intervention. Independent t tests were used to compare the groups. Participants in both groups were asked the following open-ended question: "What did you think of the intervention?". RESULTS: There were 52.9% participants in the detuned laser group and 53.8% participants in the manual therapy group who perceived that they had received the active intervention. The confidence ratings about their perceptions (6.7 ± 2.0, detuned laser group; 6.3 ± 2.4, manual therapy group) (P = .66) and the self-reported recovery ratings (1.9 ± 1.5 and 1.8 ± 1.2, respectively) (P = .77) were similar. CONCLUSIONS: Participants in this study confidently perceived that detuned laser was an active intervention. They positively rated their recovery following the course of the placebo intervention and perceived that detuned laser was effective in treating their condition. Therefore, it is feasible for detuned laser to be used as a placebo for manual therapy trials.

Thoracic Manual Therapy Improves Pain and Disability in Individuals With Shoulder Impingement Syndrome Compared With Placebo: A Randomized Controlled Trial With 1-Year Follow-up.

OBJECTIVE: To investigate whether muscle energy technique (MET) to the thoracic spine decreases the pain and disability associated with shoulder impingement syndrome (SIS). DESIGN: Single-center, 3-arm, randomized controlled trial, single-blind, placebo control with concealed allocation and a 12-month follow-up. SETTING: Private osteopathic practice. PARTICIPANTS: Three groups of 25 participants (N=75) 40 years or older with SIS received allocated intervention once a week for 15 minutes, 4 consecutive weeks. INTERVENTIONS: Participants were randomly allocated to MET to the thoracic spine (MET-only), MET plus soft tissue massage (MET+STM), or placebo. MAIN OUTCOME MEASURES: Primary outcome measure: Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. SECONDARY OUTCOME MEASURES: Shoulder Pain and Disability Index (SPADI) questionnaire; visual analog scale (VAS) (mm/100): current, 7-day average, and 4-week average; Patient-Specific Functional Scale (PSFS); and Global Rating of Change (GROC). Measures recorded at baseline, discharge, 4-week follow-up, 6 months, and 12 months. Also baseline and discharge thoracic posture and range of motion (ROM) measured using an inclinometer. Statistical analysis included mixed-effects linear regression model for DASH, SPADI, VAS, PSFS, GROC, and thoracic posture and ROM. RESULTS: MET-only group demonstrated significantly greater improvement in pain and disability (DASH, SPADI, VAS 7-day average) than placebo at discharge (mean difference, DASH=-8.4; 95% CI, -14.0 to -2.8; SPADI=-14.7; 95% CI, -23.0 to -6.3; VAS=-15.5; 95% CI, -24.5 to -6.5), 6 months (-11.1; 95% CI, -18.6 to -3.7; -14.9; 95% CI, -26.3 to -3.5; -14.1; 95% CI, -26.0 to -2.2), and 12 months (-13.4; 95% CI, -23.9 to-2.9; -19.0; 95% CI, -32.4 to -5.7; -17.3; 95% CI, -30.9 to -3.8). MET+STM group also demonstrated greater improvement in disability but not pain compared with placebo at discharge (DASH=-8.2; 95% CI, -14.0 to -2.3; SPADI=-13.5; 95% CI, -22.3 to -4.8) and 6 months (-9.0; 95% CI, -16.9 to -1.2; -12.4; 95% CI, -24.3 to -0.5). For the PSFS, MET-only group improved compared with placebo at discharge (1.3; 95% CI, 0.1-2.5) and 12 months (1.8; 95% CI, 0.5-3.2); MET+STM at 12 months (1.7; 95% CI, 0.3-3.0). GROC: MET-only group improved compared with placebo at discharge (1.5; 95% CI, 0.9-2.2) and 4 weeks (1.0; 95% CI, 0.1-1.9); MET+STM at discharge (1.2; 95% CI, 0.5-1.9) and 6 months (1.2; 95% CI, 0.1-1.3). There were no differences between MET-only group and MET+STM, and no between-group differences in thoracic posture or ROM. CONCLUSIONS: MET of the thoracic spine with or without STM improved the pain and disability in individuals 40 years or older with SIS and may be recommended as a treatment approach for SIS.

When Treating Coexisting Low Back Pain and Hip Impairments, Focus on the Back: Adding Specific Hip Treatment Does Not Yield Additional Benefits-A Randomized Controlled Trial.

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. J Orthop Sports Phys Ther 2021;51(12):581-601. Epub 16 Nov 2021. 2021. doi:10.2519/jospt.2021.10593.

Author Response to "Are Findings From a Pragmatic Dry Needling Trial Always Applicable in the Real World?"

Author response to the JOSPT Letter to the Editor-in-Chief "Are Findings From a Pragmatic Dry Needling Trial Always Applicable in the Real World?" J Orthop Sports Phys Ther 2021;51(9):471-472. doi:10.2519/jospt.2021.0202-R.

Dry Needling Adds No Benefit to the Treatment of Neck Pain: A Sham-Controlled Randomized Clinical Trial With 1-Year Follow-up.

OBJECTIVE: To examine the short- and long-term effectiveness of dry needling on disability, pain, and patient-perceived improvements in patients with mechanical neck pain when added to a multimodal treatment program that includes manual therapy and exercise. DESIGN: Randomized controlled trial. METHODS: Seventy-seven adults (mean ± SD age, 46.68 ± 14.18 years; 79% female) who were referred to physical therapy with acute, subacute, or chronic mechanical neck pain were randomly allocated to receive 7 multimodal treatment sessions over 4 weeks of (1) dry needling, manual therapy, and exercise (needling group); or (2) sham dry needling, manual therapy, and exercise (sham needling group). The primary outcome of disability (Neck Disability Index score) and secondary outcomes of pain (current and 24-hour average) and patient-perceived improvement were assessed at baseline and follow-ups of 4 weeks, 6 months, and 1 year by blinded assessors. Between-group differences were analyzed with a 2-way, repeated-measures analysis of variance. Global rating of change was analyzed with a Mann-Whitney U test. RESULTS: There were no group-by-time interactions for disability (Neck Disability Index: F2.37,177.47 = 0.42, P = .69), current pain (visual analog scale: F2.84,213.16 = 1.04, P = .37), or average pain over 24 hours (F2.64,198.02 = 0.01, P = .10). There were no between-group differences for global rating of change at any time point (P≥.65). Both groups improved over time for all variables (Neck Disability Index: F2.37,177.47 = 124.70, P<.001; current pain: F2.84,213.16 = 64.28, P<.001; and average pain over 24 hours: F2.64,198.02 = 76.69, P<.001). CONCLUSION: There were no differences in outcomes between trigger point dry needling and sham dry needling when added to a multimodal treatment program for neck pain. Dry needling should not be part of a first-line approach to managing neck pain. J Orthop Sports Phys Ther 2021;51(1):37-45. doi:10.2519/jospt.2021.9864.

A survey of American physical therapists' current practice of dry needling: Practice patterns and adverse events.

OBJECTIVES: To estimate the proportion of physical therapists currently performing dry needling and report current practices patterns. Secondary aims were to report the numbers of minor and major adverse events and determine if these adverse events were related to therapist characteristics. METHODS: An anonymous electronic survey was distributed through special interest groups within the United States to physical therapists. Participant demographics and responses were analyzed using descriptive statistics. Associations between variables were examined using chi-square. RESULTS: The estimated response rate was 14.4% (n = 865, mean age 39.89, SD 11.73 years). More than half (55.0%, n = 461) of respondents perform dry needling; levels of training varied. Most (78.8%, n = 337) performed 0-3 needling sessions per day, usually lasting < 15 min (67.3% of respondents, n = 288). Therapists commonly performed 3-6 sessions over a patient's course of care (82.0% of respondents, n = 350). Minor adverse events were common; respondents estimated this occurred in 39.6% (SD 31.5) of treatments. Major adverse events were rare, typically not requiring emergency care. Being male (X2 = 8.197, P = 0.004), experienced (>4 years; X2 = 34.635, P < 0.001), and having more training (>61 h; X2 = 8.503, P = 0.004) were associated with reporting a major adverse event occurred during their career. CONCLUSIONS: Half of physical therapists surveyed performed dry needling. Practice patterns were consistent with expert opinion. The number of adverse events reported suggests further research is needed to quantify the risks of dry needling. Participant characteristics associated with a major adverse event appear to be related to the number of exposures.

A Pilot Longitudinal Study of 3-Dimensional Head and Neck Kinematics During Functional Tasks in Individuals With Chronic Idiopathic Neck Pain Either Wait-Listed for or Receiving Chiropractic Spinal Manipulative Therapy With Exercise.

OBJECTIVE: The purpose of this study was to determine if there is a relationship between pain and movement kinematics during functional tasks, evaluated over time, in individuals with chronic idiopathic neck pain. METHODS: Ten participants with chronic idiopathic neck pain performed 2 functional tasks (overhead reach to the right and putting on a seatbelt) while evaluated using 8 Oqus 300+ cameras. Kinematic variables included joint angles and range of motion (ROM) (°), head segment relative to neck segment (head-neck [HN]); and head/neck segment relative to upper thoracic segment (head/neck-trunk), velocity (m/s), and time (% of movement phase). Pain was quantified using a 100-mm visual analog scale. Linear mixed effects regression models were used to analyze associations between pain and kinematic variables adjusting for treatment group. RESULTS: For overhead reach, higher pain was associated with less HN peak rotation at baseline (ß = -0.33; 95% CI -0.52 to -0.14, P = .003) and less HN total rotation ROM at 6 months (ß = -0.19; 95% CI -0.38 to -0.003, P = .048). For the seatbelt task, higher pain was associated with less HN peak rotation (ß = -0.52; 95% CI -0.74 to -0.30 to -0.74, P < .001) and less HN total rotation ROM at baseline (ß = -0.32; 95% CI -0.53 to -0.10, P = .006). No other movement variables demonstrated meaningful relationships with pain for the reach or seatbelt tasks. CONCLUSION: Higher pain is associated with less HN peak and total rotation during functional reaching tasks requiring head rotation. Recognizing altered functional kinematics in individuals with chronic neck pain may assist patient management.

Treatment of individuals with chronic bicipital tendinopathy using dry needling, eccentric-concentric exercise and stretching; a case series.

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.

Dry needling in addition to standard physical therapy treatment for sub-acromial pain syndrome: a randomized controlled trial protocol.

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

Variables Describing Individuals With Improved Pain and Function With a Primary Complaint of Low Back Pain: A Secondary Analysis.

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.

Dry Needling for Patients With Neck Pain: Protocol of a Randomized Clinical Trial.

BACKGROUND: Neck pain is a costly and common problem. Current treatments are not adequately effective for a large proportion of patients who continue to experience recurrent pain. Therefore, new treatment strategies should be investigated in an attempt to reduce the disability and high costs associated with neck pain. Dry needling is a technique in which a fine needle is used to penetrate the skin, subcutaneous tissues, and muscle with the intent to mechanically disrupt tissue without the use of an anesthetic. Dry needling is emerging as a treatment modality that is widely used clinically to address a variety of musculoskeletal conditions. Recent studies of dry needling in mechanical neck pain suggest potential benefits, but do not utilize methods typical to clinical practice and lack long-term follow-up. Therefore, a clinical trial with realistic treatment time frames and methods consistent with clinical practice is needed to examine the effectiveness of dry needling on reducing pain and enhancing function in patients presenting to physical therapy with mechanical neck pain. OBJECTIVE: The aim of this trial will be to examine the short- and long-term effectiveness of dry needling delivered by a physical therapist on pain, disability, and patient-perceived improvements in patients with mechanical neck pain. METHODS: We will conduct a randomized, double-blind, placebo-controlled trial in accordance with the CONSORT guidelines. A total of 76 patients over the age of 18 with acute or chronic mechanical neck pain resulting from postural dysfunction, trauma, or insidious onset who are referred to physical therapy will be enrolled after meeting the eligibility criteria. Subjects will be excluded if they have previous history of surgery, whiplash in the last 6 weeks, nerve root compression, red flags, or contraindications to dry needling or manual therapy. Participants will be randomized to receive (1) dry needling, manual therapy, and exercise or (2) sham dry needling, manual therapy, and exercise. Participants will receive seven physical therapy treatments lasting 45 minutes each over a maximum of 4 weeks. The primary outcome will be disability as measured by the Neck Disability Index. Secondary outcomes include the following: pain, patient-perceived improvement, patient expectations, and successful blinding to the needling intervention. Outcome measures will be assessed at 4 weeks, 6 months, and 12 months by an assessor who is blind to the group allocation of the participants to determine the short- and long-term treatment effects. We will examine the primary aim with a two-way, repeated-measures analysis of variance with treatment group as the between-subjects variable and time as the within-subjects variable. The hypothesis of interest will be the two-way group by time interaction. An a priori alpha level of .05 will be used for all analyses. RESULTS: Recruitment is currently underway and is expected to be completed by the end of 2017. Data collection for long-term outcomes will occur throughout 2017 and 2018. Data analysis, preparation, and publication submission is expected to occur throughout the final three quarters of 2018. CONCLUSIONS: The successful completion of this trial will provide evidence to demonstrate whether dry needling is effective for the management of mechanical neck pain when used in a combined treatment approach, as is the common clinical practice. TRIAL REGISTRATION: ClinicalTrials.gov NCT02731014; https://clinicaltrials.gov/ct2/show/NCT02731014 (Archived by WebCite at http://www.webcitation.org/6ujZgbhsq).

The Effectiveness of Trigger Point Dry Needling for Musculoskeletal Conditions by Physical Therapists: A Systematic Review and Meta-analysis.

Study Design Systematic review and meta-analysis. Background An increasing number of physical therapists in the United States and throughout the world are using dry needling to treat musculoskeletal pain. Objective To examine the short- and long-term effectiveness of dry needling delivered by a physical therapist for any musculoskeletal pain condition. Methods Electronic databases were searched. Eligible randomized controlled trials included those with human subjects who had musculoskeletal conditions that were treated with dry needling performed by a physical therapist, compared with a control or other intervention. The overall quality of the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation. Results The initial search returned 218 articles. After screening, 13 were included. Physiotherapy Evidence Database quality scale scores ranged from 4 to 9 (out of a maximum score of 10), with a median score of 7. Eight meta-analyses were performed. In the immediate to 12-week follow-up period, studies provided evidence that dry needling may decrease pain and increase pressure pain threshold when compared to control/sham or other treatment. At 6 to 12 months, dry needling was favored for decreasing pain, but the treatment effect was not statistically significant. Dry needling, when compared to control/sham treatment, provides a statistically significant effect on functional outcomes, but not when compared to other treatments. Conclusion Very low-quality to moderate-quality evidence suggests that dry needling performed by physical therapists is more effective than no treatment, sham dry needling, and other treatments for reducing pain and improving pressure pain threshold in patients presenting with musculoskeletal pain in the immediate to 12-week follow-up period. Low-quality evidence suggests superior outcomes with dry needling for functional outcomes when compared to no treatment or sham needling. However, no difference in functional outcomes exists when compared to other physical therapy treatments. Evidence of long-term benefit of dry needling is currently lacking. Level of Evidence Therapy, level 1a. J Orthop Sports Phys Ther 2017;47(3):133-149. Epub 3 Feb 2017. doi:10.2519/jospt.2017.7096.

Sensorimotor Control in Individuals With Idiopathic Neck Pain and Healthy Individuals: A Systematic Review and Meta-Analysis.

OBJECTIVES: (1) To identify reported tests used to assess sensorimotor control in individuals with idiopathic neck pain and (2) to investigate whether these tests can quantify differences between individuals with idiopathic neck pain and healthy individuals. DATA SOURCES: Allied and Complementary Medicine Database, CINAHL, Cochrane Central Register of Controlled Trials, Embase, MEDLINE, Physiotherapy Evidence Database, Scopus, and SPORTDiscus. STUDY SELECTION: Studies reporting sensorimotor outcomes in individuals with idiopathic neck pain or healthy individuals were identified. There were 1,677 records screened independently by 2 researchers for eligibility: 43 studies were included in the review, with 30 of these studies included in the meta-analysis. DATA EXTRACTION: Methodologic quality was determined using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Data were extracted using a standardized extraction table. DATA SYNTHESIS: Sensorimotor control was most commonly assessed by joint position error and postural sway. Pooled means for joint position error after cervical rotation in individuals with neck pain (range, 2.2°-9.8°) differed significantly (P=.04) compared with healthy individuals (range, 1.66°-5.1°). Postural sway with eyes open ranged from 4.85 to 10.5cm2 (neck pain) and 3.5 to 6.6cm2 (healthy) (P=.16), and postural sway with eyes closed ranged from 2.51 to 16.6cm2 (neck pain) and 2.74 to 10.9cm2 (healthy) (P=.30). Individual studies, but not meta-analysis, demonstrated differences between neck pain and healthy groups for postural sway. Other test conditions and other tests were not sufficiently investigated to enable pooling of data. CONCLUSIONS: The findings from this review suggest sensorimotor control testing may be clinically useful in individuals with idiopathic neck pain. However, results should be interpreted with caution because clinical differences were small; therefore, further cross-sectional research with larger samples is needed to determine the magnitude of the relation between sensorimotor control and pain and to assess any potential clinical significance.

Attentional focus of feedback and instructions in the treatment of musculoskeletal dysfunction: a systematic review.

BACKGROUND: An external focus of attention (EFA) during the learning of a motor task improves performance and retention in healthy individuals. People with musculoskeletal dysfunction also learn motor tasks and could potentially benefit from adopting an EFA during practice. OBJECTIVES: To determine whether instructions and feedback provided to individuals with musculoskeletal dysfunction is more effective in improving function and decreasing pain when inducing an external rather than an internal focus of attention (IFA). DESIGN: Systematic review SEARCH METHODS: MEDLINE, Embase, CINAHL, AMED, the Cochrane Library and five additional databases were searched. SELECTION CRITERIA: Randomised, quasi-randomised and non-randomised controlled trials, cross over trials and observational studies involving participants with any form of musculoskeletal dysfunction, comparing IFA or EFA with a different attentional focus (AF), control, placebo or no focus condition. DATA COLLECTION AND ANALYSIS: Two review authors independently screened titles, abstracts and full texts, then extracted data and appraised the quality of trials using the GRADE system of rating methodological quality. RESULTS: Seven studies were included with a total of 202 participants. Two studies compared an IFA with an EFA, two compared IFA with biofeedback with a different focus condition, and three compared IFA with biofeedback with a no focus condition. Statistically significant improvements in motor performance directly attributable to the focus of attention were only found in the EFA groups. There were no significant improvements in function or pain. CONCLUSION: There is insufficient evidence to draw conclusions regarding the effects of attentional focus of instructions and feedback on outcomes in musculoskeletal dysfunction.

Objective concurrent feedback on force parameters improves performance of lumbar mobilisation, but skill retention declines rapidly.

OBJECTIVE: To determine the optimum practice for students to apply lumbar mobilisations with force parameters consistent with an experienced therapist. DESIGN: Thirty physiotherapy students attended three practice sessions over two weeks where they performed lumbar mobilisations on a fellow student. Students viewed feedback on their applied forces (measured using an instrumented treatment table) in real-time on a computer screen. Performance was tested before and after feedback at each practice session and at follow up sessions one week and three months later. OUTCOME MEASURES: A greater accuracy in manual force application was defined as a smaller difference between each student-applied force parameter (mean peak force (N), force amplitude (N), and oscillation frequency (Hz)), and that previously applied by an expert. Test data from each session was analysed using Friedman's and Wilcoxon signed rank tests to determine student learning and retention. RESULTS: Students were more accurate after feedback at Session 1 (median difference between student and expert force parameters 7.7N, IQR 3.2-15.3) than before feedback (median 17.5, IQR 7.3-33.6, P<0.001). Increased practice improved performance, with the greatest accuracy after feedback at Session 3 (median 7.0, IQR 3.5-11.9, P<0.01). Retention however was poor, with performance at follow-up sessions no different to baseline. CONCLUSIONS: Students apply more consistent and accurate mean peak force, force amplitude and oscillation frequency after practising with objective, concurrent feedback. Additional practice sessions further improve performance, however retention is poor.

Learning lumbar spine mobilization: the effects of frequency and self-control of feedback.

STUDY DESIGN: Controlled laboratory study, longitudinal. OBJECTIVES: To investigate the effects of frequency and self-control of feedback on physiotherapy students learning lumbar spinal mobilization. BACKGROUND: Posterior-to-anterior mobilization is included in most physiotherapy curricula. However, force application varies between therapists and the optimal feedback for learning is unknown. METHODS: Sixty-two physiotherapy students were randomized to 3 feedback groups: constant (100% of practice trials), intermittent (33%), and self-controlled (varied according to student choice) feedback. Students performed 12 practice trials of grade II posterior-to-anterior mobilization to the third lumbar vertebra while receiving real-time feedback. The differences between students' force parameters (mean peak force [N], force amplitude [N], and oscillation frequency [Hz]) and those of a physiotherapist expert were compared between groups posttest and at a follow-up of 5 to 7 days using analysis of covariance. Students completed a survey regarding their perceptions of feedback. RESULTS: Students in the self-controlled group applied mean peak force (mean difference between student and expert, 6.7 N; 95% confidence interval [CI]: 4.4, 9.0) and force amplitude (6.3 N; 95% CI: 4.2, 8.4) that more closely matched the expert's than those applied by the constant group (13.7 N; 95% CI: 8.7, 18.6; P = .021, and 13.1 N; 95% CI: 8.9, 17.4; P = .028) at posttest, with similar results at follow-up for force amplitude only (self-controlled, 9.5 N; 95% CI: 5.8, 18.1; constant, 21.0 N; 95% CI: 13.3, 28.7; P = .018). There were no other significant differences. All students reported a better understanding of manual force application, but feedback preferences varied. CONCLUSION: Self-controlled feedback appears to be more beneficial than constant feedback for students learning to apply forces during lumbar mobilization.

Forces applied to the cervical spine during posteroanterior mobilization.

OBJECTIVE: There is little information on manual forces applied during cervical mobilization, a common treatment technique. Potential variability of applied forces between therapists and treatment occasions, and factors associated with different force applications are unknown. The purpose of this study is to establish the baseline mechanical properties of cervical spine mobilization and to determine if the applied forces are affected by the characteristics of therapists and mobilized subjects. METHODS: Physiotherapists (n = 116) applied 4 grades of posteroanterior mobilization to the premarked C2 and C7 spinous (central technique) and articular processes (unilateral technique, one right and one left) of 1 of 35 asymptomatic subjects. Techniques were performed in randomized order, and the first one was repeated after 20 minutes. Load cells attached to the treatment table recorded forces in 3 directions. Before mobilization, subjects' spinal stiffness at the C2 and C7 spinous processes was measured using a custom device. Analyses of variance with Bonferroni post hoc tests determined technique and grade differences, intraclass correlation coefficients the reliability between therapists, and linear regression the factors associated with forces. RESULTS: Therapists apply distinct manual forces for different techniques and grades (P < .001). Variability between therapists is high, but intratherapist reliability is good (intraclass correlation coefficient [2,1] for different force parameters, 0.84-0.93). Mean peak forces increase from grades I to IV, ranging from 22 to 92 N for resultant forces. Greater vertical and caudad-cephalad forces are applied to C7 than C2 (P < .01), with higher mediolateral forces during unilateral techniques (P < .001). Male sex of the therapist or the mobilized subject is associated with higher forces, and C2 stiffness, thumb pain and postgraduate training with lower (P < .05). CONCLUSIONS: These results quantify cervical mobilization forces, which will inform future research aimed at improving its application and clinical effectiveness.

Calibration of an instrumented treatment table for measuring manual therapy forces applied to the cervical spine.

Manual therapy techniques are commonly used to treat musculoskeletal neck disorders, but little is known about the manual forces applied during cervical spine treatment. Forces may vary between practitioners, and this may affect patient outcomes. This study reports the development of an instrumented treatment table and its calibration for measuring posteroanterior-directed forces applied during cervical spine mobilisation. A treatment table surface was instrumented with seven biaxial load cells to measure manually applied forces in three planes. Accuracy of the system was evaluated using known weights (unloaded and loaded to represent a patient's body weight), selected to be consistent with the level of forces expected to be applied during cervical mobilisation. Recorded force values strongly correlated with known weights (Pearson's r=0.999 to 1.000 for forces applied in different directions and locations, unloaded and loaded). The accuracy of forces in the unloaded condition was very good for vertical forces (mean absolute error 1.1N, SD 1.5), and reasonably good for horizontal forces (2.8N, SD 2.4 for mediolateral, 3.4N, SD 1.5 for caudad-cephalad). In the loaded condition absolute error increased slightly for horizontal forces. The accuracy of measured forces indicates the instrumented table is acceptable for measuring cervical mobilisation forces. Using it allows practitioners to perform manual techniques using their usual clinical technique, however interpretation of force data is limited because it represents force applied to the table rather than at a specific joint.