Neuromodulation of the Autonomic Nervous System in Chronic Low Back Pain: A Randomized, Controlled, Crossover Clinical Trial.

Chronic pain is a societal concern influencing the autonomic nervous system. This system can be captured with automated pupillometry. The direct connection between the epidermal cells and the brain is presented as part of the central nervous system, reflecting the modulation of the autonomic system. This study's aim was to investigate if tape containing magnetic particles (TCMP) has an immediate effect on the autonomic nervous system (ANS) and influences chronic low back pain. Twenty-three subjects completed this study. Subjects were randomized to either receive the control tape (CT) or TCMP first. Each subject underwent a pain provocative pressure test on the spinous process, followed by the skin pinch test and automated pupillometry. Next, the TCMP/control tape was applied. After tape removal, a second provocative spinous process pressure test and skin pinch test were performed. Subjects returned for a second testing day to receive the other tape application. The results demonstrate that TCMP had an immediate significant effect on the autonomic nervous system and resulted in decreased chronic lower back pain. We postulate that this modulation by TCMP s has an immediate effect on the autonomic system and reducing perceived pain, opening a large field of future research.

Immediate Effects of Long-Axis Talocrural Thrust Manipulation on the Length of the Anterior Talofibular and Calcaneofibular Ligaments Measured With Musculoskeletal Ultrasound Imaging.

OBJECTIVE: The aim of the present study was to measure the immediate effect of a thrust manipulation on the length of the anterior talofibular and calcaneofibular ligaments in healthy patients. METHODS: A convenience sample of 47 healthy patients were recruited for this quasi-experimental study. The patients had an age range from 22 to 54 years, with a mean age of 30.36 years. There were 23 female patients and 24 male patients. Musculoskeletal ultrasound imaging was used to measure the length of the anterior talofibular and calcaneofibular ligaments before and immediately after a high-velocity long-axis thrust manipulation of the talocrural joint during various validated test positions. RESULTS: A single long-axis thrust manipulation did not result in a significant change in the length of the anterior talofibular ligament (P = .325). Additionally, there was no significant difference in calcaneofibular length after a long-axis thrust manipulation (P = .26). CONCLUSION: The results indicate that the length of the anterior talofibular and calcaneofibular ligament did not significantly change after a single long-axis thrust manipulation of the talocrural joint in healthy patients. It appears that the joint capsule of the talocrural joint reached end-range during the manipulation before the ligament undergoes plastic length changes; thus, the increase in joint range of motion after a thrust manipulation was probably not due to increased plastic length changes of the anterior talofibular and calcaneofibular ligaments.

Forces and translation distance during an inferior glide of the shoulder in asymptomatic individuals measured with the novel pliance glove and ultrasound imaging.

BACKGROUND: There has been limited research on how the variance of force affects manual therapy outcomes and what the best practices should be. No specific force threshold necessary to achieve a predetermined translational distance within the joint has been quantified within the literature. PURPOSE: To quantify the amount of force necessary to perform an inferior glide to the glenohumeral joint and reach to end range. A secondary aim was to determine the impact of co-variables, such as gender, height, weight, and age, on the amount of force required to translate the humeral head within the glenohumeral joint. METHODS: A convenience sample of 64 healthy subjects were recruited. Musculoskeletal ultrasound imaging using the GE LogiQe was used to measure the translation of the humeral head. The manipulation force was measured using the novel pliance glove device and software. The ANOVA was used to determine if there was a difference in translation distance and force between trials. The Pearson's correlation was used to correlate translation and force and between covariables. RESULTS: There was no significant difference in translation distance between trials (p = .14). There was no significant difference in the mean force for this translation (p = .45). There was a poor correlation between age and force (r = 0.28) and weight and force (r = 0.12). CONCLUSION: An average force of 14.27 N (n = 61) was needed to displace the humeral head to reach end range. This was the first study using the combination of a flexible force sensor technology and real-time ultrasound imaging to measure humeral head translation.

Evaluation of anterotalofibular and calcaneofibular ligament stress tests utilizing musculoskeletal ultrasound imaging.

STUDY DESIGN: A quasi-experimental. BACKGROUND: The talar tilt test and the anterior drawer test are clinically used to evaluate the length of the anterotalofibular (ATFL) and calcaneofibular (CFL) ligaments. Based on the current literature, there is no clear diagnostic utility or preference for either test. This study investigated ligament lengthening during these special tests and compared the talar tilt test to the long axis distraction test for the CFL length. METHODS: A convenience sample of 47 healthy subjects were recruited for this study. Musculoskeletal ultrasound imaging (MSK US) was used to measure the length of the ATFL and CFL during the talar tilt and anterior drawer tests. Additionally, CFL lengthening during the talar tilt was compared to the long axis distraction test. OUTCOMES: A significant difference was found (p < .001) in ATFL length between the talar tilt and anterior drawer test. This indicates that the talar tilt test is preferred to maximally lengthen the ATFL. There was a significant difference in CFL length (p < .001) between the talar tilt test and the long axis distraction test. DISCUSSION: The results of this study identified that the talar tilt test resulted in more ATFL lengthening than the anterior drawer test and thus is the preferred test to assess ligament length. Additionally, both the long axis distraction test and the talar tilt test cause lengthening of the CFL. Therefore, the long axis distraction test can be used as a differentiation test to determine if either the ATFL or the CFL is the structure with increased laxity.

The Direct Effect of Magnetic Tape® on Pain and Lower-Extremity Blood Flow in Subjects with Low-Back Pain: A Randomized Clinical Trial.

Low-back pain has a high impact on the world population, and solutions are in demand. The behavior of specific physiological processes has been modified using magnetic fields, whether for pain relief, bone consolidation, or improvement of vascularization. The use of tape with magnetic properties could help in these cases. A double-blind randomized clinical trial was designed to use Magnetic Tape® versus placebo Kinesio tape. Blood flow variables were evaluated using pulsed power Doppler ultrasound. Resistance index, pulsatility index, systolic velocity, and diastolic velocity were measured. The pressure pain threshold was measured using algometry in 22 subjects. The results reveal significant differences between the groups for the pulsation index variable (8.06 [5.16, 20.16] in Magnetic Tape® versus 5.50 [4.56, 6.64] in Kinesio tape) and lower (0.98 [0.92, 1.02] for Magnetic Tape® versus 0.99 [0.95, 1.01] for Kinesio tape) in the resistance index variable. The pressure pain threshold variable presented significant differences at multiple levels. The application of Magnetic Tape® causes immediate effects on blood flow and pain and could be a technique of choice for pain modulation. Further studies would be necessary.

Pain Neuroscience Education Delivered by a Student Physical Therapist for a Patient with Persistent Musculoskeletal Pain.

BACKGROUND Persistent pain is one of the most common reasons individuals seek healthcare in the United States, costing $635 billion annually. At present, the medical literature outlines many treatments for persistent pain. Pain neuroscience education (PNE) is described in the literature as an educational intervention for patients with persistent pain that can be applied by a physical therapist. There is limited research on the application of PNE by a student physical therapist; however, this case report offers a unique opportunity to examine outcomes for this intervention when applied by a student physical therapist in conjunction with manual therapy and therapeutic exercise. CASE REPORT This case report examined the outcomes of PNE for a 65-year-old patient with a long-standing history of low back, cervical, shoulder, knee, and foot pain. Interventions included 7 sessions of PNE over 4 weeks delivered by a student physical therapist, in combination with manual therapy and exercise prescribed by a licensed physical therapist. Outcomes measured were fear avoidance belief questionnaire, visual analog scale, Tampa scale of kinesiophobia, neurophysiology of pain questionnaire, neck disability index, and Oswestry disability index. CONCLUSIONS Outcomes included clinically significant decreases in subjective pain level, and kinesiophobia; however, there was only a minimal decrease in fear avoidance and no decrease in perceived disability. This case report provides preliminary evidence that positive outcomes can be achieved when PNE is delivered by a student physical therapist combined with manual therapy and therapeutic exercise from an expert clinician for patients with persistent musculoskeletal pain.

The immediate effect of a single session of pain neuroscience education on pain and the autonomic nervous system in subjects with persistent pain, a pilot study.

BACKGROUND: The autonomic nervous system is a system that operates at the subconscious level and has been associated with neurobehavioral aspects of pain. Overall, persistent pain has a stimulating effect on the sympathetic nervous system. A promising emerging nonpharmacological treatment to manage persistent pain is neuroscience-based pain education. The overarching goal of neuroscience-based pain education is to change cognitions about pain and the pain experience through education. The aim was to determine the immediate and short-term impact of a neuroscience-based pain education video on the autonomic nervous system and pain in a subgroup of individuals with persistent pain. METHODS: A convenience sample of 26 subjects were recruited for this study. Each subject indicated their pain level at the time of testing using a Visual Analogue Scale. Automated pupillometry was utilized to measure pupil diameter. After two minutes of accommodation to the goggles, the pupil was measured continuously for 60 s. Following this a 5-minute video presentation "Understanding Pain" was watched, followed by a continuous pupil measurement for 60 s. Three minutes after this measure, the final pupil diameter measurement was taken for 60 s. After completing the final pupil measure, the subject was asked to fill out a second Visual Analogue Scale and a Global Rate of Change. OUTCOMES: Each subject completed a Global Rating of Change Scale and the mean score was 1.14 (SD = 1.61 and a SEM = 0.), supporting the hypothesis of an overall self-perceived benefit from the intervention. There was a statistically significant difference in pain following the video, P < 0.01. A significant correlation was observed between the self-perceived decrease in pain level and the Global Rating of Change score, p = 0.02. There was no statistically significant difference in the mean pupil diameter following the video with p = 0.76 for the right eye and p = 0.250 for the left eye. DISCUSSION: This pilot study demonstrated that a 5-minute neuroscience-based pain education video reduced perceived pain in a small sample of subjects with persistent pain. Watching the neuroscience-based pain education video did not seem to result in an immediate generalized autonomic nervous system response. However, it resulted in a different reaction on each eye. This unequal response might be the result of the hemispheric lateralization of the ANS. This study supports the fact that the pain experience is determined by the balance between conscious cognitive processes and subconscious processes based on previous psychological experiences.

Musculoskeletal ultrasound imaging and clinical reasoning in the management of a patient with cervicogenic headache: a case report.

Background: Clinical decision-making within the physical therapy treatment process typically follows the hypothetical-deductive method. The accuracy and reliability of clinical tests affect this reasoning process. Musculoskeletal ultrasound imaging (MSK US) is an emerging valid and reliable diagnostic tool in physical therapy. MSK US allows for dynamic visualization of tissues in real time with devices that are often portable.Case Description: The patient was a 55-year-old female, who presented by direct access. She had been suffering from cervicogenic headaches since the age of 18. It was hypothesized that this patient presented with a right rotation positional default of atlas and facet hypomobility at C5-6.Outcomes: After six visits (over 7 weeks) of manual therapy interventions, the patient reported that her headaches and neck pain were no longer present. Her physical therapy goals had been met and she was discharged with the instruction to continue working on her posture correction and self-management.Discussion: This case report describes the use of MSK US imaging as part of the clinical decision-making process when treating a patient with cervicogenic headaches. This case illustrates the successful management using manual therapy to restore position, mobility, decrease muscle tone, and normalize upright posture. Complementary research is necessary to further validate MSK US imaging as the preferred method to objectivize joint mobility and guide decision-making. Additionally, the cause-effect relationship between the treatment and positive outcomes in this case report has to be further validated.

Time effect for in-situ dry needling on the autonomic nervous system, a pilot study.

Study design: Pilot study.Background: Dry needling has been an emerging treatment option for physical therapists over the last decade. Despite the fact that studies have demonstrated the overall benefit of dry needling, there is no clear understanding how long needles should be left in place (situ). This pilot study investigated the effects of needles remaining in situ based on autonomic responses over time.Methods: A convenience sample of 21 subjects were recruited for this study. Automated pupillometry was utilized to obtain a direct measure of autonomic nervous system activity. Directly following a baseline measurement, 8 type J Seirin Acupuncture needles were inserted paravertebral at the C7-T3 segments. A total of 8 post-needling 60 seconds pupil measurements were taken at 3 minutes intervals for 24 minutes post needling.Outcomes: A statistical significant difference in mean pupil diameter was found following the needle intervention (p < .01), which implies an increased sympathetic activity. This subject sample had a statistically significantly larger mean pupil diameter immediately after the needling, which lasted until measure point 7, at 18 minutes (P < .05). At measure point 8 there was no longer a statistical significant difference compared to the premeasurement measure.Discussion: The results of this study provide evidence that dry needling results in a significant increased activity of the sympathetic nervous system for up to 18 minutes. Between 18 and 21 minutes autonomic activity returned to a non-significant difference compared to baseline. The results of this study could assist clinicians in clinical decision making to determine needle placement time.

Anatomy and clinical relevance of sub occipital soft tissue connections with the dura mater in the upper cervical spine.

BACKGROUND: The upper cervical region is a complex anatomical structure. Myodural bridges between posterior suboccipital muscles and the dura might be important explaining conditions associated with the upper cervical spine dysfunction such as cervicogenic headache. This cadaver study explored the upper cervical spine and evaluated the myodural bridges along with position of spinal cord in response to passive motion of upper cervical spine. METHODS: A total of seven adult cadavers were used in this exploratory study. The suboccipital muscles and nuchal ligament were exposed. Connections between the Rectus Capitis Posterior major/minor and the Obliquus Capitis minor, the nuchal ligament, posterior aspect of the cervical spine, flavum ligament and the dura were explored and confirmed with histology. The position of the spinal cord was evaluated with passive motions of the upper cervical spine. OUTCOMES: In all cadavers connective tissues attaching the Rectus Capitis Posterior Major to the posterior atlanto-occipital membrane were identified. In the sagittal dissection we observed connection between the nuchal ligament and the dura. Histology revealed that the connection is collagenous in nature. The spinal cord moves within the spinal canal during passive movement. DISCUSSION: The presence of tissue connections between ligament, bone and muscles in the suboccipital region was confirmed. The nuchal ligament was continuous with the menigiovertebral ligament and the dura. Passive upper cervical motion results in spinal cord motion within the canal and possible tensioning of nerve and ligamentous connections.

THE MANAGEMENT OF PLANTAR FASCIITIS WITH A MUSCULOSKELETAL ULTRASOUND IMAGING GUIDED APPROACH FOR INSTRUMENT ASSISTED SOFT TISSUE MOBILIZATION IN A RUNNER: A CASE REPORT.

BACKGROUND/AND PURPOSE: Musculoskeletal ultrasound imaging (MSK US) is an emerging diagnostic tool in physical therapy, which allows for dynamic visualization of tissues in real time. Plantar fasciitis is a common condition causing heel and arch pain and has been related with degenerative changes in the plantar fascia resulting in tissue thickening. Instrument Assisted Soft Tissue Mobilization (IASTM) is an intervention that allows clinicians deep penetration to treat tissues. The mechanical forces caused by IASTM might cause localized tissue trauma leading to stimulation of the body's natural inflammation and healing processes. The purpose of this case report is to demonstrate the use of ultrasound imaging to guide the decision-making process and to discern the optimal location for the application of IASTM. CASE DESCRIPTION: The subject was a 46-year-old female yoga practitioner and runner, who presented with right foot pain. The clinical impression was formulated based on the combination of traditional physical therapy examination procedures and MSK US imaging findings of the plantar fascia demonstrating thickness and tendinosis like changes within the plantar fascia 3 cm distally from the calcaneus. OUTCOMES: The subject was seen for eight treatment sessions over four weeks, at which time the goals of normal ankle dorsiflexion, no pain with palpation of the plantar fascia, negative windlass test, and no reported pain during gait were achieved. DISCUSSION: This case report illustrates the use of MSK US imaging as a method to objectively assess tissue quality and guide decision-making when managing patients with plantar fascia related pain. MSK US was used to determine the optimal location for the application of IASTM during the conservative management of a runner with plantar fasciitis. LEVEL OF EVIDENCE: Therapy, Level 5.

Immediate effects of the audible pop from a thoracic spine thrust manipulation on the autonomic nervous system and pain: a secondary analysis of a randomized clinical trial.

PURPOSE: This study investigated the immediate effects of audible joint sounds following a supine T3-T4 spinal thrust manipulation on the autonomic nervous system activity using a fully automated pupillometry system in patients with chronic neck pain. An additional aim was to determine if audible sounds as perceived by the therapist were associated with the reduction of pain following manipulation. METHODS: One hundred subjects with chronic neck pain completed the study protocol. The Mann-Whitney U test was used to compare the change scores of the 3 measuring points between the one-pop and multiple-pop groups. Subjects were randomized into either a manipulation or a mobilization group. A method of automated pupillometry was used in this study to capture pupil responsiveness. RESULTS: The analysis showed that there was no significant difference between the 2 groups (P > .05). The Kruskal-Wallis test was used to compare the median change scores between the mobilization, no-pop, and pop groups. The analysis showed that there was no statistically significant difference in the amount of change in pupil diameter between the 3 groups (P > .05).The Mann-Whitney U test demonstrated that the no-pop group (P = .031) and the multiple-pop group (P = .014) had a significant reduction of pain; however, it did not reach the minimal clinically significant level of 13 mm on the visual analog scale. CONCLUSIONS: The results of this study provided evidence that the presence of joint sounds does not influence the overall activity of the autonomic nervous system following a thrust manipulation or contribute to the reduction of pain in patients with chronic neck pain.

Immediate effects of a thoracic spine thrust manipulation on the autonomic nervous system: a randomized clinical trial.

Thoracic spine manipulation has been shown to be effective for the management of neck pain. The purpose of this study was to investigate the immediate effect of a T3-T4 spinal thrust manipulation on autonomic nervous system activity in subjects with chronic cervical pain. An additional aim was to determine if the manipulation resulted in an immediate pain relief in patients with chronic neck pain when compared to a placebo intervention. One hundred subjects with chronic neck pain were randomly assigned to receive either a thoracic thrust manipulation or a placebo intervention. The Friedman's test was used to evaluate the change in pupil diameter within both groups. The Wilcoxen signed-ranks test was used to explore pupil changes over time and to make paired comparisons of the pupil change between the groups. The Mann-Whitney U test was used to compare the change in pain perception for the chronic cervical pain group subjects receiving either the thrust manipulation or the placebo intervention. The results demonstrated that manipulation did not result in a change in sympathetic activity. Additionally, there was no significant difference in the subject's pain perception (P = 0.961) when comparing the effects of the thrust manipulation to the placebo intervention within this group of subjects with chronic neck pain. The clinical impression of this study is that manipulation of the thoracic spine may not be effective in immediately reducing pain in patients with chronic neck pain.