Clinicians' Ability to Detect a Palpable Difference in Spinal Stiffness Compared With a Mechanical Device.

OBJECTIVE: The purpose of this study was to quantify the threshold at which clinicians can detect a difference in spinal stiffness of the thoracic and lumbar spine via palpation and then determine if this detection threshold would affect a clinician's ability to identify changes in spinal stiffness as measured by an objective instrument. METHODS: In this study, the threshold at which a change in spinal stiffness was detected was quantified in 12 experienced clinicians (physical therapists and doctors of chiropractic) by changing the differential stiffness in 2 inflatable targets until the clinician could no longer identify which was stiffer. In the second part of the study, clinicians then were asked to palpate pre-identified pairs of vertebrae in an asymptomatic volunteer and to identify the stiffer of the pair (T7 and L3, T7 and L4, L3 and L4), and the biomechanical stiffness of each vertebral pair was quantified objectively by a validated instrument. RESULTS: The mean stiffness detection threshold for the clinicians was 8%. Objective measurement of the stiffness differential between vertebral pairs was 30% for T7* and L3, 20% for T7* and L4, and 10% for L3* and L4 (*denotes the stiffer of the pair). Ten of 12 clinicians correctly identified T7 as stiffer when compared with L3 and T7 as stiffer than L4. Alternatively, when the differential vertebral pair stiffness was similar to the stiffness detection threshold (~8%), clinicians were less successful in identifying the stiffer vertebra of the pair; 4 of 12 clinicians correctly identified L3 as being stiffer compared with L4. CONCLUSION: These results suggest that the physiological limits of human palpation may limit the ability of clinicians to identify small alterations in spine stiffness.

Chiropractic treatment including instrument-assisted manipulation for non-specific dizziness and neck pain in community-dwelling older people: a feasibility randomised sham-controlled trial.

Background: Dizziness in older people is a risk factor for falls. Neck pain is associated with dizziness and responds favourably to neck manipulation. However, it is unknown if chiropractic intervention including instrument-assisted manipulation of the neck in older people with neck pain can also improve dizziness. Methods: This parallel two-arm pilot trial was conducted in Melbourne, Australia over nine months (October 2015 to June 2016). Participants aged 65-85 years, with self-reported chronic neck pain and dizziness, were recruited from the general public through advertisements in local community newspapers and via Facebook. Participants were randomised using a permuted block method to one of two groups: 1) Activator II™-instrument-assisted cervical and thoracic spine manipulation plus a combination of: light massage; mobilisation; range of motion exercises; and home advice about the application of heat, or 2) Sham-Activator II™-instrument-assisted manipulation (set to zero impulse) plus gentle touch of cervical and thoracic spinal regions. Participants were blinded to group allocation. The interventions were delivered weekly for four weeks. Assessments were conducted one week pre- and post-intervention. Clinical outcomes were assessed blindly and included: dizziness (dizziness handicap inventory [DHI]); neck pain (neck disability index [NDI]); self-reported concerns of falling; mood; physical function; and treatment satisfaction. Feasibility outcomes included recruitment rates, compliance with intervention and outcome assessment, study location, success of blinding, costs and harms. Results: Out of 162 enquiries, 24 participants were screened as eligible and randomised to either the chiropractic (n = 13) or sham (n = 11) intervention group. Compliance was satisfactory with only two participants lost to follow up; thus, post-intervention data for 12 chiropractic intervention and 10 sham intervention participants were analysed. Blinding was similar between groups. Mild harms of increased spinal pain or headaches were reported by 6 participants. Costs amounted to AUD$2635 per participant. The data showed a trend favouring the chiropractic group in terms of clinically-significant improvements in both NDI and DHI scores. Sample sizes of n = 150 or n = 222 for dizziness or neck pain disability as the primary outcome measure, respectively, would be needed for a fully powered trial. Conclusions: Recruitment of participants in this setting was difficult and expensive. However, a larger trial may be feasible at a specialised dizziness clinic within a rehabilitation setting. Compliance was acceptable and the outcome measures used were well accepted and responsive. Trial registration: Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12613000653763. Registered 13 June 2013.Trial funding: Foundation for Chiropractic Research and Postgraduate Education (Denmark).

Characteristics of Paraspinal Muscle Spindle Response to Mechanically Assisted Spinal Manipulation: A Preliminary Report.

OBJECTIVES: The purpose of this preliminary study is to determine muscle spindle response characteristics related to the use of 2 solenoid powered clinical mechanically assisted manipulation (MAM) devices. METHODS: L6 muscle spindle afferents with receptive fields in paraspinal muscles were isolated in 6 cats. Neural recordings were made during L7 MAM thrusts using the Activator V (Activator Methods Int. Ltd., Phoenix, AZ) and/or Pulstar (Sense Technology Inc., Pittsburgh, PA) devices at their 3 lowest force settings. Mechanically assisted manipulation response measures included (a) the time required post-thrust until the first action potential, (b) differences in mean frequency (MF) and mean instantaneous frequency (MIF) 2 seconds before and after MAM, and (c) the time required for muscle spindle discharge (MF and MIF) to return to 95% of baseline after MAM. RESULTS: Depending on device setting, between 44% to 80% (Pulstar) and 11% to 63% (Activator V) of spindle afferents required >6 seconds to return to within 95% of baseline MF values; whereas 66% to 89% (Pulstar) and 75% to 100% (Activator V) of spindle responses returned to within 95% of baseline MIF in <6 seconds after MAM. Nonparametric comparisons between the 22 N and 44 N settings of the Pulstar yielded significant differences for the time required to return to baseline MF and MIF. CONCLUSION: Short duration (<10 ms) MAM thrusts decrease muscle spindle discharge with a majority of afferents requiring prolonged periods (>6 seconds) to return to baseline MF activity. Physiological consequences and clinical relevance of described MAM mechanoreceptor responses will require additional investigation.

Effect of manual versus mechanically assisted manipulations of the thoracic spine in neck pain patients: study protocol of a randomized controlled trial.

BACKGROUND: Neck pain is a common musculoskeletal condition with a point prevalence of around 15% in males and 23% in females that often presents in physiotherapy practice. Physical therapy and/or manipulation therapy is generally the first management option for patients with mechanical neck pain. Physical therapists treat mechanical neck pain with a number of interventions including joint mobilization and/or manipulation, therapeutic exercises or education. However, manipulation of the cervical spine carries some risks. Treating the thoracic spine for neck pain is an alternative approach. Emerging evidence suggests that it may be effective for treating neck pain without the risks associated with cervical spine manipulation. A new electromechanical device has recently been developed and tested for delivering multiple high velocity, low amplitude thrust manipulations to the spine. This device incorporates both auditory and visual systems that provide real time feedback on the applied treatment. The objective of this study is to compare the short- and long-term effects of manual versus mechanically assisted manipulations of the thoracic spine for neck pain patients. METHODS/DESIGN: A 6-month, randomized controlled trial consisting of 54 patients with acute or chronic neck pain patients will be conducted. Patients with no signs of major pathology and with little or no interference with daily activities will be recruited. Three treatment sessions with 4-day intervals will be carried out. The patients will be randomly assigned to receive either manually performed manipulations or electromechanical manipulations at the thoracic spine. The primary outcome is pain intensity as measured by the Visual Analogue Pain Rating Scale. The secondary outcome measures are neck physical disability using the Neck Disability Index, quality of life measured by the European Quality of Life 5 Dimensions 5 Levels and patients' improvement using the Patient's Global Impression of Change Scale. DISCUSSION: It is expected that both interventions will improve neck pain. This would be a significant finding, as thoracic spine manipulation for neck pain does not carry the same risk of injury as cervical spine manipulation. In addition, the results may provide useful information about therapeutic options for health care providers and patients for the problem of neck pain. TRIAL REGISTRATION: Current Controlled Trials ISRCTN88585962, registered January 2013.

Influencia de la manipulación osteopática cervical sobre el flujo arterial / No disponible

Introducción: La medicina osteopática es uno de los medios de tratamiento más empleados en las dolencias de la columna cervical. Debemos conocer con precisión la relación entre manipulación cervical y valores hemodinámicos arteriales carotideos y vertebrales. Objetivos: Revisar el cuerpo de conocimientos que la literatura científica recoge sobre la relación entre la manipulación cervical osteopática y los posibles cambios en el flujo arterial carotideo. Material y Métodos: Realizamos una revisión bibliográfica en las bases de datos Pubmed, Web of Science y la plataforma EBSCOhost con los términos «spinal», «vertebral», «cervical manipulation», «carotid», «vertebral», «blood flow», «carotid», «vertebral», «blood velocity». Resultados: Obtenemos inicialmente una muestra de 232 estudios (n=232). Tras excluir los estudios que no cumplen los criterios establecidos, obtenemos una muestra de 12 estudios de lectura completa, de los que 5 (n=5) se incluyen en la revisión. Conclusiones: Hay escasa evidencia científica de los efectos postmanipualtivos sobre la circulación arterial cervical (AU)

No disponible

Técnica de dog en extensión bilateral aplicada en una dorsalgia aguda: a propósito de un caso / No disponible

Objetivo: Describir las principales características de aplicación de la técnica de dog en extensión bilateral (TDEB), la cual puede ser utilizada para la reducción de lesiones grupales de flexión bilateral, utilizada para el tratamiento de un paciente con dorsalgia aguda. Material y Métodos: Aplicamos un protocolo de evaluación osteopático en una paciente de 35 años, por un cuadro de dorsalgia aguda, valorada mediante pruebas ortopédicas, de inspección, palpación, movilización global y analítica. Aplicamos como tratamiento la TDEB sobre el segmento en lesión. Resultados: Los resultados obtenidos han sido favorables, dado que se ha restablecido la movilidad, tanto a nivel global como segmentario, y se ha atenuado el dolor percibido por la paciente tras la aplicación de la TDEB. Conclusiones: Una correcta restructuración de la movilidad de los segmentos hipomóviles devuelve la función a los mismos, y produce efectos clínicos favorables, mejorando el estado de salud del paciente (AU)

No disponible

Análisis de la frecuencia cardiaca en hipertensos tras la manipulación con impulso en C7 / Analysis of heart frequency in hypertension after handling with a C7 impulse

Introducción: La hipertensión arterial es la principal causa de morbilidad de la mayoría de los países, afectando al 20% de la población adulta, causando elevados costes a la sociedad. En los últimos años el interés y la sensibilización social en este tema, particularmente en el campo de la osteopatía, han derivado en estudios sobre las variables de frecuencia cardiaca que permitan analizar sus causas y fomentar nuevas técnicas para su tratamiento. Objetivos: Determinar si la manipulación a alta velocidad en el séptimo nivel cervical (C7) en pacientes hipertensos es segura y no modifica la frecuencia cardiaca, tras la intervención. Material y métodos: Estudio aleatorio, experimental, cegado y controlado. Sesenta y uno (n=61) pacientes con hipertensión se distribuyeron aleatoriamente en dos grupos, experimental (n=32) y control (n=29). Se realizó una valoración inicial (Pre-intervención) y una final (Post-intervención) analizando los cambios de la frecuencia cardiaca. Se realizaron evaluaciones previas, mediante los Test de Mitchell, Jackson y Klein. La técnica de intervención aplicada fue la maniobra de impulso (thrust) C7-D1 en decúbito prono, para disfunción en ERS o FRS. Resultados: En los pacientes del grupo experimental, no observamos una reducción significativa tras la manipulación experimental, en la frecuencia cardiaca medida en el brazo izquierdo, en la frecuencia cardiaca pico, en la frecuencia cardiaca de pie, ni en la frecuencia cardiaca en descanso. Conclusiones: La técnica de thrust sobre el segmento cervical C7-D1 aplicada en pacientes hipertensos no reduce significativamente los valores de la frecuencia cardiaca y por tanto es una técnica segura, que podría aplicarse sobre estos pacientes (AU)

Introduction: High blood pressure is the main cause of morbidity in most countries, affecting 20% of the adult population and causing high costs to society. In recent years interest and social awareness in this area, particularly in the field of osteopathy, has led to studies on the variables of heart rate that allow them to analyze their causes and to promote new techniques for treatment. Objective: To determine if high speed manipulation at the seventh cervical level (C7) in hypertensive patients is safe and does not modify the heart rate after intervention. Material and methods: A randomized, experimental, blinded and controlled study. Sixty-one (n = 61) patients with hypertension were randomized into two groups; experimental (n = 32) and control (n = 29). An initial assessment (pre-intervention) and an end assessment (post-intervention) were performed, analyzing changes in heart rate. Previous evaluations were performed using the Mitchell, Jackson and Klein Test. The applied intervention technique was the C7-D1 thrust maneuver in the prone position for dysfunction in ERS or FSR. Results: In patients in the experimental group, we did not observe a significant reduction after experimental manipulation in the heart rate measured in the left arm, the peak heart rate, the standing heart rate, or the resting heart rate. Conclusions: The thrust technique on the cervical segment C7-D1 applied in hypertensive patients does not significantly reduce heart rate values and, therefore, is a safe technique that could be applied to these patients (AU)

Abordajes terapéuticos no farmacológicos para el tratamiento de la cefalea tensional. Revisión bibliográfica / Non-pharmacological therapeutic approaches for the treatment of tension-type headache. Bibliographic review

Introducción: La cefalea tensional (CT) es la más prevalente dentro de las cefaleas primarias. Representa un impacto económico alto y una repercusión importante en la vida de los pacientes que las sufren y en el sistema público de salud. Objetivos: Conocer el número y fechas de publicación de los estudios realizados en el tratamiento de la CT. Material y Métodos: Se procedió a una búsqueda bibliográfica en PubMed recurriendo al uso de las palabras clave contenidas en dichas publicaciones referidas específicamente a CT y se realizó una búsqueda incluyendo los términos tension-type headache y manual therapy, manipulation therapy, physical therapy, vertebral manipulation, cervical manipulation, osteopathy, osteopathic treatment, osteopathic medicine, osteopathic manipulative treatment, osteopathic manipulative. Se encontraron y analizaron un total de 5 estudios que cumplieron los criterios de selección. Resultados: Los resultados encontrados tras la revisión mostraron que respecto a la cefalea tensional (Tension-type headache) existen 2.506 estudios desde 1947 hasta la actualidad. Los resultados mostraron hasta 15 estudios que comenzaron en 1977 hasta el 2009 cuando se asoció a osteopatía (osteopathy) como concepto general resultaron; con tratamiento osteopático (osteopathic treatment) 14 estudios desde 1993 hasta 2011; con medicina osteopática (osteopathic medicine) resultaron 8 estudios desde 1993 hasta 2009; con tratamiento osteopático manipulativo (osteopathic manipulative treatment) 11 estudios desde 1993 hasta 2009; y con osteopatía manipulativa (osteopathic manipulative) 8 estudios desde 1993 hasta 2011. Conclusiones: Existe escasez de estudios que relacionen la terapia osteopática y la CT. Respecto a la aplicación del tratamiento osteopático, junto y por separado, resulta eficaz, pero es necesario que los estudios tengan mayor calidad metodológica (AU)

Introduction: Tension-type headache (TTH) is the most predominant primary headache. It has a high economic impact and a significant consequence for patients whom suffer from it and for the public health system. Objectives: To know how many studies for treating the TTH were performed and when they were published. Material and methods: A bibliographical search was carried out in PubMed, using keywords included in these publications that strictly refer to TTH. This search included terms such as tension-type headache and manual therapy, manipulation therapy, physical therapy, vertebral manipulation, cervical manipulation, osteopathy, osteopathic treatment, osteopathic medicine, osteopathic manipulative treatment, osteopathic manipulative. Five studies were found and analysed that fulfilled the selection criteria. Results: Results that were found after the review showed that regarding the tension-type headache, there are 2,506 studies since 1947 until now. Results showed until 15 studies that started in 1977 until 2009, when osteopathy was associated as general concept; there were 14 studies of osteopathic treatment since 1993 until 2011; 8 studies of osteopathic medicine since 1993 until 2009; 11 studies of osteopathic manipulative treatment since 1993 until 2009 and 8 studies of osteopathic manipulative since 1993 until 2011. Conclusions: There is a lack of studies that link the osteopathic therapy with the TTH. As for the application of an osteopathic treatment, either singly or in conjunction, it is effective, but it is necessary to have more methodological quality in these studies (AU)

Efectos de las técnicas manipulativas de tratamiento comúnmente utilizadas en osteopatía para la cervicalgia / Effects of the manipulative treatment techniques commonly used in osteopathy for cervicalgias

Introducción: Diversas técnicas se han estudiado a lo largo de la historia para proponer tratamientos que optimicen la regeneración del tejido, la resolución de dolor o la limitación, en varias estructuras que podrían ser responsables de la cervicalgia mecánica, considerada de etiología idiopática. Dirigido a las articulaciones inter-apofisarias, con sus efectos neurofisiológicos asociados, encontramos técnicas de manipulación de alta velocidad y corta amplitud (HVLA) y técnicas de movilización descritas por quiroprácticos, osteópatas y terapeutas manuales, con la intención de generar un efecto general en todos los tejidos a través del sistema vascular y del sistema nervioso. En la bibliografía tienen respaldo científico sus efectos tanto en la recuperación de la movilidad, como en la disminución del dolor y la discapacidad. Objetivos: En este estudio la intención será comparar los distintos abordajes manipulativos para determinar cual podría ser más conveniente en el tratamiento de la cervicalgia mecánica. Material y Métodos: Se realizado un comentario crítico tras la revisión bibliográfica de estudios aleatorizados y controlados, analizando los posibles riesgos y beneficios asociados a la manipulación y la movilización en la zona cervical y dorsal. Resultados: Las técnicas de alta velocidad cuentan con mas evidencia científica que apoya su efectividad, tanto aplicadas a la región dorsal como a la cervical, aunque se asocian con riesgos neurovasculares poco frecuentes. Las movilizaciones también resultan efectivas para ese fin. Conclusiones: Tanto las manipulaciones (cervicales y dorsales) como las movilizaciones consiguen analgesia, y mejoran la movilidad de la columna cervical y la satisfacción del paciente, así como su discapacidad a corto, medio y largo plazo, comparado con el uso de medicamentos. Tiene un efecto mayor la manipulación, al menos a corto plazo, en la cervicalgia (AU)

Introduction: Different techniques were studied throughout the history, in order to propose treatments for optimizing tissue regeneration, pain resolution or limitation, in several structures that could responsible for mechanical cervicalgia, which has an idiopathic etiology. Aimed for the interapophyseal joints, with their corresponding neurophysiologic effects, we found high-velocity low-amplitude manipulation techniques (HVLA) and mobilisation techniques described by chiropractors, osteopaths and manual therapists, with the purpose of producing a general effect in all the tissues, through the vascular and nervous system. References reveal the scientific support of their effects for both recovering mobility and decreasing pain and disability. Objectives: In this study, the objective is to compare different manipulative approaches, to be able to choose the most convenient one for treating mechanical cervicalgia. Material and methods: A critical commentary was performed after the bibliographic review of the randomized and controlled trials, analysing the possible risks and benefits associated to manipulation and mobilisation in the cervical and thoracic area. Results: High-velocity techniques have more scientific evidences that support their effectiveness, no matter if they are applied in the cervical or thoracic area, although they are associated with rare neurovascular risks. Mobilisations are also effective for this purpose. Conclusions: Both manipulations (cervical and thoracic) obtain analgesia, like mobilisations, and improve cervical spinal ́s mobility and patient's satisfaction, as well as his/her disability in short, medial and long-term, compared to the use of drugs. Manipulation has a greater effect, at least in short-term, for cervicalgia (AU)

Standardization of spinal manipulation therapy in humans: development of a novel device designed to measure dose-response.

OBJECTIVE: The main objective of this report is to present an innovative research tool that will provide the opportunity to study fundamental aspects of the spinal manipulation dose-physiological response relation in humans. METHODS: A servo-controlled linear actuator motor was developed to simulate spinal manipulative therapy. Coefficient of multiple correlations was calculated to assess the degree of similarity between each measured force curves, whereas precision was obtained by comparing resulting peak force and time-to-peak force to the target curves. RESULTS: The coefficient of multiple correlations calculations showed that repeatability was very high with all correlation values over 0.98. Precision was also very high with average differences in peak force and time-to-peak force of less than 3 N and less than 5 milliseconds. CONCLUSION: The tool was designed to optimize precision, repeatability, and safety in the delivery of force to the spine in humans. It offers a unique opportunity to study dose-response relationship for several spinal manipulation parameters such as peak force, time-to-peak force, and preload.

Changes in pressure pain thresholds and Basal electromyographic activity after instrument-assisted spinal manipulative therapy in asymptomatic participants: a randomized, controlled trial.

OBJECTIVE: The purpose of this study was to investigate the effects of instrument-assisted spinal manipulative therapy (SMT) targeted to the low-back region on changes in pressure pain thresholds (PPTs) and basal electromyographic activity (BEA) in asymptomatic participants. METHODS: A repeated-measures, single-blind, randomized trial was conducted on 30 participants, 19 men and 11 women (mean age, 24.5±3.9 years), without a current history of low-back pain. Each participant attended all 2 treatment group sessions and received instrument-assisted SMT or a sham manipulation procedure. Instrument-assisted SMT was administered using the Activator Method protocol. Bilateral PPT levels over L5-S1 zygapophyseal joints, L5 dermatome, and first dorsal interossei in the hand and bilateral BEA of low back and neck region were assessed pre- and posttreatment by an assessor blinded to the treatment allocation of the participant. A 3-way analysis of variance with time (pre-post) and side (ipslateral, contralateral to the intervention) as within-group variable and intervention (manipulation or sham) as between-group variable was used to evaluate changes in PPT. A paired sample t test was used to analyze the differences between pre- and posttreatment in BEA. RESULTS: The group vs time interaction was statistically significant for PPT irrespective of the site tested or the side treated. Participants receiving the instrument-assisted SMT experienced greater improvement in PPT when compared with the control group. Paired sample t tests for BEA only show an immediate decrease in BEA of the paraspinal muscle on the pelvic deficiency side of the low-back region. CONCLUSIONS: The application of instrument-assisted SMT resulted in an immediate and widespread hypoalgesic effect with local muscle relaxation in asymptomatic participants. It is hypothesized that therapeutic mechanisms, either segmental or central, may be involved in the therapeutic effects of instrument-assisted SMT.

Performance and reliability of a variable rate, force/displacement application system.

OBJECTIVE: Spinal manipulation therapy (SMT), an intervention used to treat low back pain, has been demonstrated to affect the stiffness of the spine. To adequately quantify the effects of SMT on stiffness, a device capable of applying specific parameters of manipulation in addition to measuring force-displacement values has been developed previously. Previously developed indentation techniques that quantify stiffness have been modified for novel use in evaluating SMT parameters. The reliability of stiffness measurements performed by the newly adapted device was assessed in this study. METHODS: Seven springs of varying stiffness were each indented 10 times by a variable rate force/displacement (VRFD) device. Indentations were performed at a rate of 0.5 mm/s to a maximal displacement of 4 mm. The stiffness coefficients for a middle portion of the resulting force-displacement graph and the terminal instantaneous stiffness (stiffness at end displacement) were calculated. The intraclass correlation and confidence interval were calculated for these stiffness measurements to assess device reliability. RESULTS: Repeated spring stiffness measures yielded an intraclass correlation coefficient value of 1.0. The mean stiffness values had narrow 95% confidence intervals ranging from 0.01 N/mm to 0.06 N/mm and small coefficients of variation. CONCLUSION: This VRFD device provides highly reliable stiffness measurements in controlled conditions. Although in vivo reliability remains to be established, the results of this study support the use of the VRFD device in future trials investigating the impact of various SMT parameters on spinal stiffness.

Análise da força aplicada durante a tração manual na coluna lombar e da manutenção da postura pós-tração / Analysis of the force applied during manual traction of the lumbar spine and maintenance of the post-traction posture

Dor lombar é considerada um dos maiores problemas sócioeconômicos por estar associada à incapacidade temporária do indivíduo. Acredita-se que a incidência de desabilidade devido às dores nas costas esteja crescendo exponencialmente pela tendência de um novo estilo de vida sedentário e a baixa tolerância à dor entre a população. Um grande número de estudos mostra que em certo momento da vida 80% da população mundial será afetada por esta patologia. A tração manual aplicada à coluna lombar é entre várias terapias, um dos tratamentos que mais cresce, devido ao seu baixo custo e por ser não invasiva. O propósito deste estudo foi medir a força aplicada pelo examinador durante a tração manual, bem como a pressão resultante da coluna lombar. Os resultados mostraram que a força da tração lombar pode ser facilmente medida por meio do método proposto. A intensidade de força parece depender ligeiramente do peso do sujeito. A mobilização da posição lombar após a tração pode ser monitorada satisfatoriamente medindo a pressão exercida por esta região no arranjo experimental. Um sistema de alerta luminoso foi também desenvolvido a fim de auxiliar o paciente na manutenção pós-tração. Os testes laboratoriais realizados mostraram uma sensibilidade satisfatória, possibilitando uma aplicação clínica deste sistema.

Low back pain is considered as one of the greatest socioeconomic problems due to the associated temporary disability of the subject. The occurrence of disability due to low back pain tends to increase exponentially as a consequence of the sedentary way of life as well as the low pain tolerance of the population. A large number of studies have shown that, at a given stage of life, about 80% of the world population will be affected by this pathology. Manual traction applied to the lumbar spine is, among various therapies, one of the most growing “in popularity” due to its low cost and to thefact of being non-invasive. The purpose of the present study was to measure the force applied by the therapist, during the manual traction, together with the resulting load on the lumbar spine. The results showed that the force of the lumbar traction could be easily measured by means of the simple method proposed; the force intensity seems to be slightly dependent on the subject weight. The mobilization of lumbar position after the traction could by satisfactorily monitored by measuring the local pressure exerted by this region on the manipulative table. An alerting device has also been developed in order to assist the subject to maintain the pos-traction lumbar position. The laboratory tests performed have showed a satisfactory sensitivity of the device, allowing its possible clinical application.

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.

Comparison of posteroanterior spinal stiffness measures to clinical and demographic findings at baseline in patients enrolled in a clinical study of spinal manipulation for low back pain.

OBJECTIVE: A system for measuring posterior-to-anterior spinal stiffness (PAS) was developed for use in clinical trials of manipulation for low back pain (LBP). The current report is an analysis of the baseline PAS data, with particular emphasis on relationships between PAS and clinical and demographic characteristics. METHODS: Posterior-to-anterior spinal stiffness measurements were recorded over the spinous processes of the lumbar spines from patients who had LBP. The system uses electronic sensors to record displacement and force, whereas a human operator provides the force of indentation. Clinical and outcome measures were compared with spinal stiffness. RESULTS: We recruited 192 patients (89 female and 103 male; average age, 40.0 years; SD, 9.4 years). The average Roland-Morris score was 9.7 (SD, 3.2) on a 24-point scale. The Visual Analog Scale pain scores were 55.7 (SD, 20.9) on a 100-mm scale. Stiffness values ranged from 4.16 to 39.68 N/mm (mean, 10.80 N/mm; SD, 3.72 N/mm). Females' lumbar spines were, on the average, 2 N/mm more compliant than males (P < .001). CONCLUSIONS: The PAS system of computer-monitored equipment with human operation performed well in this clinical study of LBP. Spinal stiffness was found to be different between males and females, and age and body mass index were related to PAS. We found no significant relationship between the severity or chronicity of the LBP complaint and spinal stiffness. There was little agreement between the stiff or tender segments identified by the clinicians using palpation and the segment that measured most stiff using the PAS device.

Manual application of controlled forces to thoracic and lumbar spine with a device: rated comfort for the receiver's back and the applier's hands.

PURPOSE: High volumes of manual therapy work can lead to overuse hand and wrist injuries. This study evaluated hand and back comfort in asymptomatic volunteers during spinal mobilization carried out with an instrumented manual therapy tool. METHODS: This crossover design study examined 36 asymptomatic physiotherapy students that were tested in pairs. One participant assumed the role of the simulated therapist and the other the simulated patient, before reversing roles. Posteroanterior mobilization conditions formed by using 2 spinal segments (thoracic/lumbar), 2 force application methods (hands/device), and 3 grades of mobilization were applied in a random order. After each combination, both participants in each pair rated hand or back comfort, respectively, on a 100-mm visual analogue scale. Data were analyzed by analysis of variance. RESULTS: Rated back comfort was greater for hands than for the device and decreased with greater applied force. When the original hard rubber device tip was changed to one of soft molded rubber, both back and hand comfort improved significantly. Although tool mobilization was still rated as significantly less comfortable than mobilization with hands only, this difference was approximately half the discomfort experienced as the grade of mobilization increased from grade I to grade III. For hand comfort when using the softer device tip, the method of force application was no longer a significant determinant of comfort. CONCLUSIONS: The mobilizing tool with a molded rubber tip was acceptably comfortable in use with asymptomatic backs and hands. Further research is indicated in manual therapy settings with therapists who have experienced hand pain.

Development of a hand dynamometer for the control of manually applied forces.

OBJECTIVE: The aim of the study was to develop a prototype tool capable of providing instantaneous feedback about manually applied forces, and to use it to determine (1) whether force constancy can be maintained during different application postures and (2) whether sensitivity to stiffness using the tool is different from sensitivity when assessing stiffness with the hands. METHODS: Subjects were students and staff in a health sciences faculty. A series of grade II and IV mobilizing forces were delivered using a mobilizing tool, a modified JAMAR dynamometer fitted with a molded handle. Forces were executed without feedback at application points on a plinth that were near, midway, and far from the body. Thereafter, discrimination between elastic stiffness was determined with hands alone or using the tool. RESULTS: Force was maintained at grade II when the point of application was moved away from the body, but attempts to replicate grade IV mobilization forces in similar postures showed a decrease despite increased effort. Variation in force produced was substantial both within and between subjects. Stiffness discrimination was not significantly different whether hands or the tool was used. CONCLUSION: There is substantial variation in manually applied forces that could be controlled if instantaneous force readout was available. Reports of hand injury in manual therapists motivate further development of devices that maintain sensitivity and allow for control of applied force and spread the load over a greater surface area on the hands.

A pilot randomized clinical trial on the relative effect of instrumental (MFMA) versus manual (HVLA) manipulation in the treatment of cervical spine dysfunction.

OBJECTIVE: To determine the relative effect of instrument-delivered thrust cervical manipulations in comparison with traditional manual-delivered thrust cervical manipulations in the treatment of cervical spine dysfunction. DESIGN: Prospective, randomized, comparative clinical trial. SETTING: Outpatient chiropractic clinic, Technikon Natal, South Africa. PATIENTS: Thirty patients diagnosed with neck pain and restricted cervical spine range of motion without complicating pathosis for at least 1 month were included in the study. INTERVENTIONS: The patients were randomized into 2 groups. Those in one group received mechanical force, manually assisted (MFMA) manipulation to the cervical spine, delivered by means of a hand-held instrument (Activator II Adjusting Instrument). Those in the other group received specific contact high-velocity, low-amplitude (HVLA) manipulation consisting of standard Diversified rotary/lateral break techniques to the cervical spine. Each group received only the specific therapeutic intervention, no other treatment modalities or interventions (including medication) being used, until asymptomatic status was achieved or a maximum of 8 treatments had been received. MAIN OUTCOME MEASURES: Both treatment groups were assessed through use of subjective (Numerical Pain Rating Scale 101, McGill Short-Form Pain Questionnaire, and Neck Disability Index) and objective (goniometer cervical range of motion) measurement parameters at specific intervals during the treatment period and at 1-month follow-up. The data were assessed through use of 2-tailed nonparametric paired and unpaired analysis, descriptive statistics, and power analysis of the data. RESULTS: The results indicate that both treatment methods had a positive effect on the subjective and objective clinical outcome measures, no significant difference being observed between the 2 groups (P < .025). The subjective data from all 3 questionnaires showed statistically significant changes from initial to final consultations as well as from initial consultation to 1-month follow-up (P < .025). The objective range of motion measures showed statistically significant changes in the MFMA group for left and right rotation and left and right lateral flexion from initial consultation to final consultations and for right rotation and right lateral flexion from initial consultation to 1-month follow-up. The HVLA group showed only the change in left rotation from initial to final consultations and from initial consultation to 1-month follow-up to be statistically significant. CONCLUSIONS: The results of this clinical trial indicate that both instrumental (MFMA) manipulation and manual (HVLA) manipulation have beneficial effects associated with reducing pain and disability and improving cervical range of motion in this patient population. A randomized, controlled clinical trial in a similar patient base with a larger sample size is necessary to verify the clinical relevance of these findings.

Biomechanic evaluation of the Rola Stretcher as a passive distraction device.

INTRODUCTION: Many devices have been marketed claiming to increase the mobility of the articulations of the spine with active or passive distraction. In this study, the Rola Stretcher (Unique Relief, Inc, Davenport, Iowa) and an earlier version, the True Back II (True Back, Inc, Clearwater, Fla), were evaluated to see if they have a measurable biomechanic effect on the spine. METHODS: Two studies were conducted, each with 6 male participants and 6 female participants, using a stadiometer to accurately measure a person's sitting height. The increase in sitting height after using the True Back II or Rola Stretcher for 10 minutes was compared with that after lying supine for 10 minutes. A third intervention, a firm foam block cut to the same size and shape as the True Back II, was also used in this study. RESULTS: The Rola Stretcher had a significantly greater lengthening effect on the spine compared with supine rest (P <0050). The True Back II had a similar but lesser effect (P <.0509). Women demonstrated a greater height gain than men. CONCLUSION: The True Back II and the Rola Stretcher in particular appear to lengthen the spine after a single use of 10 minutes. The observed discrepancy between the effects in men and women may be an experimental artifact occurring as a result of less effective resetting of the posturing mechanisms in men compared with women. A trend showed the Rola Stretcher to be more effective than the foam block.

Standardized initial head position in cervical range-of-motion assessment: reliability and error analysis.

OBJECTIVE: To assess the clinical reliability and precision of the OSI CA-6000 Spinal Motion Analyzer for measurement of range of motion in cervical spines of pain-free subjects by using a novel procedure designed to minimize variability and quantitatively evaluate sources of errors. METHODS: Twenty asymptomatic volunteer subjects were evaluated twice by each of two trained examiners in one session. Subject position was carefully standardized. Rotation, lateral bending, and flexion-extension were evaluated in repeated movements (cycles) from extreme to extreme. ANALYSIS: Descriptive statistics and reliability coefficients (interclass correlation coefficients [ICCs]) were calculated for all full- and half-cycle motions. Possible sources of systematic errors were evaluated, and random errors were estimated. RESULTS: ICCs indicate that the instrument performs very reliably for rotation and lateral bending (0.93-0.97) and acceptably for flexion-extension (0.75-0.93) measurements. Differences in instrument placement, subject posture, or both in different trials correlate neither with differences in measured values nor with variances. Within-trial errors did not correlate with ranges of motion. Standardizing head position resulted in increases in reliability of from 3% to 15% for axial rotation and lateral bending but actually decreased the ICCs for flexion-extension (up to 14%) compared with data collected under a less-stringent protocol. Errors in clinical use are estimated at 4.5 degrees. CONCLUSIONS: By using our modifications to the accessories and standardization of subject position, the CA-6000 is a highly precise and reliable instrument for measuring active cervical motion about the 3 Cartesian axes. Individuals can repeat the same patterns of motion in sequential trials on the same day with very little variation. Ease of repetitious measurement without examiner intervention contributes to the instrument's ability to obtain highly reliable data. Changes in instrument placement or subject body posture between trials do not give rise to systematic errors. Design of the instrument for flexion-extension could be improved.