A modern way to teach and practice manual therapy.

BACKGROUND: Musculoskeletal conditions are the leading contributor to global disability and health burden. Manual therapy (MT) interventions are commonly recommended in clinical guidelines and used in the management of musculoskeletal conditions. Traditional systems of manual therapy (TMT), including physiotherapy, osteopathy, chiropractic, and soft tissue therapy have been built on principles such as clinician-centred assessment, patho-anatomical reasoning, and technique specificity. These historical principles are not supported by current evidence. However, data from clinical trials support the clinical and cost effectiveness of manual therapy as an intervention for musculoskeletal conditions, when used as part of a package of care. PURPOSE: The purpose of this paper is to propose a modern evidence-guided framework for the teaching and practice of MT which avoids reference to and reliance on the outdated principles of TMT. This framework is based on three fundamental humanistic dimensions common in all aspects of healthcare: safety, comfort, and efficiency. These practical elements are contextualised by positive communication, a collaborative context, and person-centred care. The framework facilitates best-practice, reasoning, and communication and is exemplified here with two case studies. METHODS: A literature review stimulated by a new method of teaching manual therapy, reflecting contemporary evidence, being trialled at a United Kingdom education institute. A group of experienced, internationally-based academics, clinicians, and researchers from across the spectrum of manual therapy was convened. Perspectives were elicited through reviews of contemporary literature and discussions in an iterative process. Public presentations were made to multidisciplinary groups and feedback was incorporated. Consensus was achieved through repeated discussion of relevant elements. CONCLUSIONS: Manual therapy interventions should include both passive and active, person-empowering interventions such as exercise, education, and lifestyle adaptations. These should be delivered in a contextualised healing environment with a well-developed person-practitioner therapeutic alliance. Teaching manual therapy should follow this model.

The effectiveness of nerve mechanical interface treatment for entrapment neuropathies in the limbs: A systematic review with metanalysis.

BACKGROUND: Neurodynamic approach employs neural mobilization and mechanical nerve interface techniques. While published studies investigated the efficacy of neural mobilization, it is currently unknown whether manual treatment of the nerve mechanical interface is effective in the treatment of people with entrapment neuropathies. OBJECTIVES: Assess the effectiveness of mechanical interface treatment, including joint and soft tissue techniques, on pain and function in people with peripheral entrapment neuropathies. DESIGN: Intervention systematic review with metanalysis. METHODS: the databases MEDLINE, CINAHL, AMED, APA PsycINFO, SPORTDiscus, PubMed and ScienceDirect were searched from their inception to October 2022. Randomized controlled trials investigating mechanical interface treatment in isolation in patients with peripheral entrapment neuropathies were included. Two independent reviewers performed study selection, data extraction and risk of bias assessment using the Cochrane RoB 2.0 tool. Certainty of evidence for each outcome was judged using the GRADE framework. RESULTS: 11 studies were included in the review, all investigating carpal tunnel syndrome (CTS). Due to high heterogeneity of interventions and comparators, only five studies were pooled in a random-effects meta-analysis. There was evidence of mechanical interface techniques being more effective in reducing pain than sham (MD -2.47 [-3.94;-0.99]) and similarly effective as neural mobilization (MD -0.22 [-0.76; 0.33]) in CTS, albeit with low to very low certainty in the results. CONCLUSION: mechanical interface techniques are effective for improving pain and function in people with CTS. However, the marked heterogeneity of included interventions and comparators prevents clinical recommendation of specific treatments.

Does peripheral neuroinflammation predict chronicity following whiplash injury? Protocol for a prospective cohort study.

INTRODUCTION: Whiplash-associated disorder grade 2 (WAD2) is characterised by musculoskeletal pain/tenderness but no apparent nerve injury. However, studies have found clinical features indicative of neuropathy and neuropathic pain. These studies may indicate peripheral nerve inflammation, since preclinical neuritis models found mechanical sensitivity in inflamed, intact nociceptors. The primary aim of this study is to establish the contribution of peripheral neuroinflammation to WAD2 and its role in prognosis. Participants will be invited to participate in a sub-study investigating the contribution of cutaneous small fibre pathology to WAD2. METHODS AND ANALYSIS: 115 participants within 1 month following whiplash injury and 34 healthy control participants will be recruited and complete validated questionnaires for pain, function and psychological factors. Data collection will take place at the Universities of Sussex and Oxford, UK. Clinical examination, quantitative sensory testing and blood samples will be undertaken. MRI scans using T2-weighted and diffusion tensor images of the brachial plexus and wrist will determine nerve inflammation and nerve structural changes. Skin biopsies from a substudy will determine structural integrity of dermal and intraepidermal nerve fibres. At 6 months, we will evaluate recovery using Neck Disability Index and a self-rated global recovery question and repeat the outcome measures. Regression analysis will identify differences in MRI parameters, clinical tests and skin biopsies between participants with WAD2 and age/gender-matched controls. Linear and logistic regression analyses will assess if nerve inflammation (MRI parameters) predicts poor outcome. Mixed effects modelling will compare MRI and clinical measures between recovered and non-recovered participants over time. ETHICS AND DISSEMINATION: Ethical approval was received from London-Brighton and Sussex Research Ethics Committee (20/PR/0625) and South Central-Oxford C Ethics Committee (18/SC/0263). Written informed consent will be obtained from participants prior to participation in the study. Results will be disseminated through publications in peer-reviewed journals, presentations at national/international conferences and social media. TRIAL REGISTRATION NUMBER: NCT04940923.

This is the day your life must surely change : Prioritising behavioural change in musculoskeletal practice.

Behavioural change is the modification or transformation of behaviour. Health behaviour has been defined as, 'any activity undertaken for the purpose of preventing or detecting disease or for improving health and wellbeing' (Bennell et al., 2019 [1]). For a smoker it is acting on the decision to stop or reduce the number of cigarettes smoked, for someone with a higher than ideal body mass index, it is acting to reduce weight and for someone who isn't achieving ideal levels of exercise (Briggs et al., 2020 [2]) it is the decision and action to increase metabolic activity. With increased understanding of the importance of self-management and impact of lifestyle, clinicians supporting people presenting with musculoskeletal symptoms have recognized that behavioural change is an essential component of the care we need to prioritize. It is about sharing the benefits of lifestyle choices that promote health, discussing how to introduce and maintain them, and supporting people through their journey of change, so the change becomes the new normal. Behavioural change science assumes that (i) morbidity and mortality are due in part to certain behaviours and (ii) these behaviours are modifiable. The aim of this debate article is to discuss reasons why clinicians must include long term behavioural change into their management plan and methods they may use to facilitate the change ensuring recipients are empowered to act and make today the day their 'lives will surely change'.

Management of low back pain: Treatment provision within private practice in the UK in the context of clinical guidelines.

OBJECTIVE: To summarise the combination of treatments private UK-based physiotherapists use with patients who have low back pain (LBP) and the extent to which the treatments used are consistent with clinical guideline recommendations. DESIGN: Cross-sectional observational survey. METHODS: Data were collected from physiotherapists within private UK-based clinics using an online standardised data collection system to record the treatment they provided for patients who had LBP with/without leg pain. Treatment data were classified into those that are 'recommended', 'not recommended' and had 'no recommendation'. RESULTS/FINDINGS: Treatment provided to 8003 patients were included in the analyses. Most patients (95.0%) were provided with a 'recommended' treatment. Approximately half of the patients who received 'recommended' treatment were also provided with other treatments that were either 'not recommended' (16.7%), had 'no recommendation' (16.6%) or a combination of both (13.0%). Few patients were provided with only treatments that were 'not recommended' and/or treatment with 'no recommendation' (4.6%). CONCLUSION: This study provides insight into the self-reported practice of participating physiotherapists and highlights how they generally adopted a multimodal treatment model for patients with LBP. Consistent with the National Institute for Health and Care Excellence guidelines, most patients received information and advice often in conjunction with exercise and manual therapy. Only a small proportion of patients were provided with treatments that are 'not recommended' and/or treatment that had 'no recommendation'. These findings are useful in documenting the implementation of clinical guidelines given the need for practitioners to balance the best available evidence with patient expectation and preference and to facilitate the therapeutic alliance.

Do behaviour change techniques increase adherence to home exercises in those with upper extremity musculoskeletal disorders? A systematic review.

OBJECTIVES: To investigate whether behaviour change techniques (BCTs) can influence adherence to home exercise in people with upper extremity musculoskeletal disorders (UEMD). DESIGN: A systematic review of randomised control trials, non-randomised control trials, case-control studies and cohort studies. Results were presented narratively. Participants were those with UEMD. The intervention was any home exercise programme, alongside a BCT designed to increase exercise adherence. Any duration of intervention was accepted. The main outcome sought was adherence to home exercise. A systematic search was performed on four online databases. Grey literature was searched. RESULTS: The search resulted in 28,755 titles. 77 full-text articles were assessed for eligibility. Six studies were included in the qualitative synthesis. Four studies had Some Concern of Bias, whilst two studies had High Risk of Bias. Three studies found statistically significant differences in exercise adherence (p < 0.05) between the Intervention group and Control group. The BCT 'Social Support (unspecified)' was used within all studies that found significant differences in adherence levels at outcome. However, multiple BCTs were received by the Intervention groups within all studies, making it impossible to identify the effects of any single BCT upon adherence levels. CONCLUSION: Social support may be relevant in patients' adherence levels to HEPs. However, confidence in the results is uncertain given the small number of studies found, and their High RoB. Future studies should validate their measurement and definition of adherence, as well as the number of BCTs they use, to provide reproducible evidence.

Posterior shoulder tightness; an intersession reliability study of 3 clinical tests.

BACKGROUND: Although posterior shoulder tightness (PST) has been associated with shoulder pathology and altered glenohumeral joint kinematics, uncertainty remains regarding its cause and definition. To understand the efficacy of treatments for PST, it must be possible to identify people with PST for the purposes of research and clinical decision-making. Clinical tests for PST must demonstrate acceptable levels of measurement reliability in order to identify the condition and to evaluate the response to intervention. There is currently a lack of research describing intersession reliability for measures of PST. The aim of this study was to quantify the inter-session reliability for three clinical tests used to identify PST over a 6-10 week interval. METHODS: A convenience sample of 26 asymptomatic adult participants (52 shoulders) were recruited from a university setting over a five-month duration. Participants attended the human movement laboratory for measurement of glenohumeral joint internal rotation, horizontal adduction and low flexion on two occasions separated by an interval of 6-10 weeks.Intra-class correlation coefficients were calculated from the mean square values derived from the within-subject, single factor (repeated measures) ANOVA. Test-retest measurement stability was evaluated by calculating the standard error of measurement and the minimum detectable change for each measurement. RESULTS: All 3 tests demonstrated good intersession intra-rater reliability (0.86-0.88), and the standard error of measurement (95%) were 7.3° for glenohumeral horizontal adduction, 9.4° for internal rotation, and 6.9° for low flexion. The minimum detectable change for glenohumeral horizontal adduction was 10.2°, internal rotation was 13.3°, and low flexion was 9.7°. CONCLUSION: In this population of people without symptoms, the 3 measures of PST all demonstrated acceptable inter-session reliability. The standard error of measurement and minimum detectable change results can be used to determine if a change in measures of PST are due to measurement error or an actual change over time.

Sensory descriptors which identify neuropathic pain mechanisms in low back pain: a systematic review.

OBJECTIVE: Descriptors provided by patients with neuropathic low back pain (NLBP) with or without spinally referred leg pain are frequently used by clinicians to help to identify the predominant pain mechanisms. Indeed, many neuropathic screening tools are primarily based on subjective descriptors to determine the presence of neuropathic pain. There is a need to systematically review and analyse the existing evidence to determine the validity of such descriptors in this cohort. METHODS: Ten databases were systematically searched. The review adhered to PRISMA and CRD guidelines and included a risk of bias assessment using QUADAS-2. Studies were included if they contained symptom descriptors from a group of NLBP patients +/- leg pain. Studies had to include a reference test to identity neuropathic pain from other pain mechanisms. RESULTS: Eight studies of 3099 NLBP patients were included. Allodynia and numbness were found to discriminate between NLBP and nociceptive LBP in four studies. Autonomic dysfunction, (changes in the colour or appearance of the skin), was also found to discriminate between the groups in two studies. Dysesthesia identified NLBP in 5/7 respectively. Results from studies were equivocal regarding pain described as hot/burning cold and paroxysmal pain in people with NLBP. CONCLUSION: Subjectively reported allodynia and numbness would suggest a neuropathic pain mechanism in LBP. Dysesthesia would raise the suspicion of NLBP. More research is needed to determine if descriptors suggesting autonomic dysfunction can identify NLBP. There is poor consensus on whether other descriptors can identify NLBP.

Validity of Clinical Small-Fiber Sensory Testing to Detect Small-Nerve Fiber Degeneration.

BACKGROUND: Small-nerve fiber, or small-fiber, degeneration commonly occurs in patients with peripheral neuropathies, resulting in a deterioration of nerve function. Currently, the gold standard to identify small-fiber degeneration is through skin biopsy. Simple clinical tests aim to identify small-fiber degeneration, but their validity remains unknown. OBJECTIVES: To examine the validity of clinical tests to assess small-nerve fiber degeneration, using carpal tunnel syndrome as a model neuropathy. METHODS: One hundred seven participants (22 healthy, 85 with carpal tunnel syndrome) in this prospective, cross-sectional diagnostic accuracy study underwent pinprick testing of the index finger and were assessed for cold detection threshold and warm detection threshold using quantitative sensory testing. In a subgroup of patients with carpal tunnel syndrome (n = 51), cold and warm sensations were also tested, using coins at room and body temperature, respectively. The validity of these clinical tests was established against intra-epidermal nerve fiber density measured in skin biopsies from the index finger. RESULTS: Optimal validity occurred with clusters of tests. Specifically, normal warm or cold sensation is highly sensitive to rule out small-fiber degeneration (sensitivity, 0.98; 95% confidence interval [CI]: 0.85, 0.99), but has a low specificity (0.20; 95% CI: 0.03, 0.52). By contrast, a reduction in pinprick is highly specific (0.88; 95% CI: 0.72, 0.95), and so can be used to rule in small-fiber degeneration. For quantitative sensory testing, the highest specificity (0.83) occurs for warm detection threshold and the highest sensitivity (0.84; 95% CI: 0.72, 0.91) for cold detection threshold or warm detection threshold. CONCLUSION: Pinprick testing, followed by warm and cold tests if pinprick is normal, is a valid and cost-effective method to detect small-fiber degeneration. For quantitative sensory testing, warm detection threshold is useful for ruling in small-fiber degeneration. To rule out small-fiber degeneration, both cold detection threshold and warm detection threshold must be negative. LEVEL OF EVIDENCE: Diagnosis, level 2. J Orthop Sports Phys Ther 2018;48(10):767-774. Epub 22 Jun 2018. doi:10.2519/jospt.2018.8230.

The effects of neurodynamic straight leg raise treatment duration on range of hip flexion and protective muscle activity at P1.

STUDY DESIGN: Randomized, single blind, same subject crossover trial. OBJECTIVES: To compare the effects of two neurodynamic treatment doses on range of hip flexion (ROM HF) and electromyographic (EMG) activity of semitendinosus, at first onset of pain (P1). METHODS: A total of 26 healthy participants without low back or leg pain received each treatment in a random order with at least 48 hours between sessions. Baseline ROM HF and EMG magnitude of semitendinosus at P1 were collected. Subjects then received either 361 or 362 minutes of oscillating end of range (grade IVz) straight leg raise (SLR) neurodynamic treatment and were re-assessed for baseline measures. RESULTS: There was no significant difference between groups in EMG magnitude (P50.190) and ROM HF (P50.739) at P1. There was also no significant difference within groups in EMG magnitude at P1 (P50.182); however, there was a significant improvement in ROM HF at P1 in both groups compared to baseline readings (P50.000), with increases of 6.7u and 5.1u for the 361- and 362-minute groups, respectively. CONCLUSION: Findings indicate that 362 minutes of oscillating grade IVz SLR neurodynamic treatment has no additional benefit over 361 minute, on ROM HF or EMG magnitude of semitendinosus at P1. Using an oscillating SLR treatment may, however, help to increase pain-free ROM HF, although further studies are necessary to confirm this.

The short term effects of straight leg raise neurodynamic treatment on pressure pain and vibration thresholds in individuals with spinally referred leg pain.

BACKGROUND: Limited research exists for the effects of neurodynamic treatment techniques. Understanding short term physiological outcomes could help to better understand immediate benefits or harm of treatment. OBJECTIVES: To assess the short-term effects of a straight leg raise (SLR) tensioner 'intervention' on pressure pain thresholds (PPT) and vibration thresholds (VT), and establish if additional factors influence outcome in individuals with spinally referred leg pain. DESIGN: Experimental, repeated measures. METHODS: Sixty seven participants (mean age (SD) 52.9 (13.3), 33 female) with spinally referred leg pain were divided into 3 sub-groups: somatic referred pain, radicular pain and radiculopathy. Individuals were assessed for central sensitisation (CS) and completed 5 disability and psychosocial questionnaires. PPT and VT were measured pre and post a 3 × 1 min SLR tensioner intervention. RESULTS: No significant differences (p > 0.05) were found between the 3 groups for either outcome measure, or after treatment. Slight improvements in VT were seen in the radiculopathy group after treatment, but were not significant. Only 2 participants were identified with CS. Disability and psychological factors were not significantly different at baseline between the 3 sub-groups, and did not correlate with the outcome measures. CONCLUSIONS: No beneficial effects of treatment were found, but the trend for a decrease in VT indicated that even in individuals with radiculopathy, no detrimental changes to nerve function occurred. Psychosocial factors and levels of disability did not influence short term outcome of SLR treatment.

Sciatic nerve excursion during a modified passive straight leg raise test in asymptomatic participants and participants with spinally referred leg pain.

BACKGROUND: Minimal data exists on in-vivo sciatic nerve motion during straight leg raise (SLR), particularly in symptomatic participants. Such data could help clinicians to better understand nerve mechanic changes following nerve dysfunction. DESIGN: Cross-sectional, controlled laboratory study. OBJECTIVES: To investigate whether individuals with spinally referred leg pain have different nerve excursion patterns compared to healthy participants. METHOD: The sciatic nerve was scanned using ultrasound imaging in the posterior thigh in asymptomatic participants, and individuals with spinally referred leg pain sub-grouped into somatic pain, radicular pain or radiculopathy. Nerve excursion was measured in transverse and longitudinal planes during a side-lying modified SLR. The ultrasound data was analysed off-line using cross correlation software. Longitudinal plane data was collected from 16 asymptomatic and 60 symptomatic participants and transverse plane data from 16 asymptomatic and 56 symptomatic participants. RESULTS: There was no significant difference in longitudinal nerve excursion between the 4 groups. The direction of transverse plane motion altered between groups. These varied movements may be related to protective muscle activation between the groups, although this is speculative at present. CONCLUSION: Longitudinal sciatic nerve excursion at the posterior thigh during a modified SLR is not different between asymptomatic participants and those with spinally referred leg pain. Transverse plane movement appears to be more varied. This may suggest that in individuals with nerve root pain, there is no restriction in nerve excursion. However, as it was not possible to measure excursion at the nerve root, more research is needed to confirm these findings.

Normative sciatic nerve excursion during a modified straight leg raise test.

Minimal data exists on how much sciatic nerve motion occurs during straight leg raise (SLR). The purpose of this study was to report preliminary normative ranges of sciatic nerve excursion using real time ultrasound during a modified SLR. The sciatic nerve was scanned in the posterior thigh in sixteen asymptomatic participants (age range 19-68 years). Nerve excursion was measured in transverse and longitudinal planes during knee extension from 90° to 0°, with the hip flexed to 30° and 60°. The ultrasound data was analysed off-line using cross correlation software. Results demonstrated that most nerves moved superficially during knee extension, a large proportion (10/16) moved laterally. Longitudinal excursion ranged from 6.4 to 14.7 mm (mean (SD) 9.92 mm (2.2)) in 30° hip flexion, and 5.1-20.2 mm (mean (SD) 12.4 mm (4.4)) in 60° hip flexion. Mean nerve excursion was significantly greater in 60° hip flexion (p = 0.02). There is a large between-subject variation in sciatic nerve excursion during this modified SLR in asymptomatic subjects. Mean nerve excursion was found to be higher with the hip pre-positioned in greater flexion, suggesting that pre-loading may not consistently reduce excursion.

Repeatability of measuring sciatic nerve excursion during a modified passive straight leg raise test with ultrasound imaging.

The purpose of this study was to establish the reliability of a frame-by-frame cross correlation method of assessing longitudinal sciatic nerve excursion motion using real time ultrasound imaging during a modified passive straight leg raise (SLR) test. Eighteen asymptomatic participants (age range 19-68 years) lay on their sides on a purpose made jig and the sciatic nerve in the posterior thigh was imaged during knee extension at 30° and then 60° of hip flexion (HF). Participants were re-tested ≥48 h later. The ultrasound images were analysed off-line using cross correlation software. Results demonstrated excellent repeatability of in vivo sciatic nerve excursion during a modified SLR (HF30° ICC 0.92, CI 0.79-0.97, SEM 0.69; HF60° ICC 0.96, CI 0.89-0.99, SEM 0.87). The authors also identify points of good practise to ensure an accurate as possible measurement of nerve excursion using this method. These include breaking down larger movements into sub-components, visually tracking the moving nerve during the tracking procedure, and ensuring the optimal image is captured prior to analysis. The use of ultrasound imaging in lower limb nerve dysfunction will enhance the understanding of how nerves move in vivo during neurodynamic testing, as well as being able to identify possible alteration to nerve movements in patients with neuropathic pain states.

Effect of gender, cadence, and water immersion on ground reaction forces during stationary running.

STUDY DESIGN: Controlled laboratory study. OBJECTIVES: To analyze the vertical and anteroposterior components of the ground reaction force during stationary running performed in water and on dry land, focusing on the effect of gender, level of immersion, and cadence. BACKGROUND: Stationary running, as a fundamental component of aquatic rehabilitation and training protocols, is little explored in the literature with regard to biomechanical variables, which makes it difficult to determine and control the mechanical load acting on the individuals. METHODS: Twenty-two subjects performed 1 minute of stationary running on land, immersed to the hip, and immersed to the chest at 3 different cadences: 90 steps per minute, 110 steps per minute, and 130 steps per minute. Force data were acquired with a force plate, and the variables were vertical peak (Fy), loading rate (LR), anterior peak (Fx anterior), and posterior peak (Fx posterior). Data were normalized to subjects' body weight (BW) and analyzed using repeated-measures analysis of variance. RESULTS: Fy ranged from 0.98 to 2.11 BW, LR ranged from 5.38 to 11.52 BW/s, Fx anterior ranged from 0.07 to 0.14 BW, and Fx posterior ranged from 0.06 to 0.09 BW. The gender factor had no effect on the variables analyzed. A significant interaction between level of immersion and cadence was observed for Fy, Fx anterior, and Fx posterior. On dry land, Fy increased with increasing cadence, whereas in water this effect was seen only between 90 steps per minute and the 2 higher cadences. The higher the level of immersion, the lower the magnitude of Fy. LR was reduced under both water conditions and increased with increasing cadence, regardless of the level of immersion. CONCLUSION: Ground reaction forces during stationary running are similar between genders. Fy and LR are lower in water, though the values are increased at higher cadences.

Effect of straight leg raise examination and treatment on vibration thresholds in the lower limb: a pilot study in asymptomatic subjects.

Individuals who participate in repetitive functional activities may have alteration in large diameter neural activity. It has been proposed that neurodynamic examination and treatment may affect large diameter afferent activity, and that neurological integrity tests should be carried out prior to neurodynamic testing. Vibration threshold testing (VTT) has been shown to be a valid measure of large diameter afferent conduction. The aim of this study was to assess whether examination and treatment of straight leg raise with plantar flexion and inversion (SLR) has an effect on the conduction of large diameter afferents supplying the lower leg in normal subjects and in a group of runners. Twenty sedentary asymptomatic subjects and 10 asymptomatic runners underwent VTT at the second and fourth metatarsals (representing the distribution of the superficial peroneal nerve) before and after examination of the SLR and after a mimicked treatment with SLR (VTT carried out immediately and 10min after treatment). A repeated measures ANOVA revealed no significant baseline differences in VT between runners and non-runners (P=0.171), or between any of the four test conditions in either group (P=0.5). Although not significant there was a trend for runners to have raised mean VT compared to non-runners, and for SLR treatment to cause an elevation in VT in both groups. These results suggest that examination and treatment of SLR may not be detrimental to function of the large diameter afferents in asymptomatic subjects.