Manipulative/Manual Therapy

in 2013. Julsvoll received the Norwegian Musculosceletal Research Award 2014 for her research on temporomandibular disorders and have presented her research results both at international and national congresses. Julsvoll works at Hans & Olaf Physical therapy clinic, Oslo. She collaborates with other physical therapists and with dentists, oral surgeons and maxillo-facial radiologists. She is also responsible for specialization courses for physiotherapists, manual therapists and chiropractors in Norway and has given support to the Norwegian guidelines for patients with TMD, published by the Norwegian Directorate for Health.

Background: A lumbar lateral shift (LLS) is a common clinical observation in patients with low back pain (LBP), and a shift contralateral to the side of pain is the most common presentation. An LLS that can rapidly alternate sides presents several treatment difficulties and has rarely been described. The purpose of the current case report was to describe the presentation and management of a patient with an alternating LLS. Case Description: A 39-year-old male with a 7-week history of LBP and previous lower extremity radicular pain was referred to physical therapy. An alternating LLS was present. Outcomes: The patient was treated for six visits over 37 days. Treatment included modified self-correction of the LLS, motor control and trunk muscle endurance training, and development of an activity management program. The patient's LLS resolved, his worst pain improved from 3/10 to 0/10, and the Oswestry Disability Index improved from 26% to 4% disability. The patient reported maintenance of improvement at 6-month follow-up. Discussion: The current approach produced a positive outcome in a patient with an alternating LLS. The current understanding of mechanisms and optimal treatment of an alternating LLS is limited.

Research reveals that the primary impairment of the muscular system in individuals with low back pain is not one of strength or functional capacity but rather one of motor control of the deep muscles of the trunk. These deep muscles include the transversus abdominis, the deep segmental fibers of lumbar multifidus, the pelvic floor, and the diaphragm. Advances in knowledge regarding load transfer in the lumbopelvic region have provided the orthopaedic manual therapist with the necessary tools to assess most components of lumbopelvic dysfunction with the exclusion of an evaluation technique for pelvic floor motor control. The use of ultrasound imaging to observe the real-time contraction of muscles is a valuable tool, specifically when the muscles of interest are deep and not readily observable. The author proposes a novel abdominal ultrasound imaging method to assess voluntary pelvic floor motor control and discusses the rationale for its application in a population with lumbopelvic dysfunction.

Objectives: Knee osteoarthritis (OA) causes disability among the elderly and is often associated with impaired balance and proprioception. Perturbation exercises may help improve these impairments. Although manual physical therapy is generally a well-tolerated treatment for knee OA, perturbation exercises have not been evaluated when used with a manual physical therapy approach. The purpose of this study was to observe tolerance to perturbation exercises and the effect of a manual physical therapy approach with perturbation exercises on patients with knee OA. Methods: This was a prospective observational cohort study of 15 patients with knee OA. The Western Ontario and McMaster Universities Arthritis Index (WOMAC), global rating of change (GROC), and 72-hour post-treatment tolerance were primary outcome measures. Patients received perturbation balance exercises along with a manual physical therapy approach, twice weekly for 4 weeks. Follow-up evaluation was done at 1, 3, and 6 months after beginning the program. Results: Mean total WOMAC score significantly improved (P50.001) after the 4-week program (total WOMAC: initial, 105; 4 weeks, 56; 3 months, 54; 6 months, 57). Mean improvements were similar to previously published trials of manual physical therapy without perturbation exercises. The GROC score showed a minimal clinically important difference (MCID)$z3 in 13 patients (87%) at 4 weeks, 12 patients (80%) at 3 months, and 9 patients (60%) at 6 months. No patients reported exacerbation of symptoms within 72 hours following each treatment session. Discussion: A manual physical therapy approach that also included perturbation exercises was well tolerated and resulted in improved outcome scores in patients with knee OA.

ABSTRAK Latar Belakang: Nyeri leher (neck pain) merupakan rasa tidak nyaman di sekitar leher, Nyeri leher juga dapat didefinisikan sebagairasa sakit yang dirasakan di daerah yang dibatasi oleh prosesus spinosus torakal satu dan daerah lateral leher, sedangkan nyeri leher non spesifik merupakan nyeri mekanik yang dirasakan diantara oksiput dan torakal satu dan otot-otot sekitarnya tanpa penyebab yang pasti. Pemberian traksi cervical mampu mengurangi keluhan nyeri pada nyeri leher. Tujuan: Untuk mengetahui pengaruh pemberian traksi cervical terhadap penurunan derajat nyeri pada keluhan nyeri leher di RSUD Bagas Waras Klaten. Metode: Penelitian ini menggunakan metode quasi experiment dengan menggunakan pendekatan single case study pre and post test design. Sampel berjumlah 10 orang diberikan perlakuan berupa pemberian traksi cervical. Uji normalitas menggunakan uji Shapiro Wilk, uji pengaruh menggunakan uji paired sampel t-test. Hasil penelitian: Berdasarkan hasil dari perlakuan yang telah dilakukan peneliti, diperoleh hasil bahwa traksi berpengaruh menurunkan nyeri pada keluhan nyeri leher. Uji statistik untuk uji pengaruh menggunakan Paired Sample T Test didapat p = 0,001 (<0,05). Simpulan: Dari hasil penelitian disimpulkan bahwa terdapat pengaruh Traksi pada penurunan derajat nyeri pada keluhan nyeri leher (Neck Pain). ABSTRACT Background: Neck pain is an uncomfortable feeling around the neck. Neck pain can also be defined as pain that is felt in an area bounded by the thoracic spinous process and the lateral area of the neck, while non-specific neck pain is mechanical pain that is felt between the occiput and thoracic one and the surrounding muscles without a definite cause. Cervical traction can reduce pain in neck pain. Purpose: To determine the effect of cervical traction on the reduction of the degree of pain in neck pain patients at the General Hospital of the Bagas Waras Klaten. Method: This study uses a quasi experiment method using a one group pre and post test design approach. A sample of 10 people was given cervical traction treatment. The normality test uses the Shapiro Wilk test, the effect test uses the paired sample t-test Result: Based on the results of the treatment that has been carried out by researchers, it is found that traction has an effect on reducing pain in neck pain complaints. The statistical test for the effect test using the Paired Sample T Test obtained p = 0.001 (<0.05). Conclusion: From the results of the study it was concluded that there was an effect of traction on reducing the degree of pain in neck pain complaints.

P ostural misalignment of head on trunk (e.g., forward head posture) is associated with complaints of pain in the neck and shoulder region 1-5 and temporomandibular joint dysfunction 6,7 , but is also observed in asymptomatic individuals 8-10 . Attempts to correct this misalignment towards an ideal posture using a combination of strengthening, stretching, and behavioral/biofeedback training represent a significant component of the physical intervention provided to clients with painful neck and/or Abstract: Forward head posture (FHP) is most often described as excessive anterior positioning of the head in relation to a vertical reference line, involving increased cervical spine lordosis (head forward, middle cervical spine extended, lower cervical spine flexed) and rounded shoulders with thoracic kyphosis. Although exercise is routinely used to improve FHP, relatively little data exists on efficacy. The present study was designed to examine the impact of a 10-week targeted and progressive home exercise program on improving FHP. As improvement through exercise of postural alignment depends upon participants adhering to the program, we also looked at issues related to exercise compliance. Seventeen control (C) and 23 exercise (E) participants with a FHP deviation were part of this program. Pre-and post-exercise postural measurements of FHP were obtained from the sagittal plane using the Biotonix TM Postural Analysis System; in addition neck flexion range of motion was measured. Participants were randomly assigned to C or E groups. The E group performed neck extensor and pectoralis major stretches and deep neck flexor and shoulder retractor strengthening exercises for the 10-week period. Two-factor (group, pre-test/post-test) analysis of variance models were used to test main effects and interactions. There were no significant differences (p>0.05) between groups on any pre-test measure. For the E group, there were significant differences and interactions (p<0.05) between pre-and post-tests and also between the E and C groups at post-test for range of motion and one postural measurement. The results demonstrate that a short, home-based targeted exercise program can improve postural alignment related to FHP. These results provide a foundation for further development of postural improvement programs that include an exercise component.

Mulligan mobilization techniques are frequently used in clinical practice but there is little evidence underlying their use. The aims of this study were to determine the immediate effects of the Mulligan traction straight leg raise technique (TSLR) on range of straight leg raise (SLR) in subjects with low back pain (LBP). A further aim was to determine whether the presence of lower-quarter mechano-sensitive neural tissue influenced the outcome. Nineteen subjects with LBP with a unilateral limitation of SLR, sub-classified according to the presence or not of mechano-sensitive lower-quarter neural tissue, were included. On the symptomatic side, range of SLR, hip flexion, and posterior pelvic rotation were recorded at the first onset of pain, using goniometers positioned lateral to the knee and pelvis. Following the intervention, there was a significant increase in range of SLR of IT (95% confidence interval = 9,13) (F [1,16] = 34.28, p<0.001). This increase was attributed to hip flexion rather than pelvic rotation (F [1,16] = 0.79, p = 0.388). In addition, the presence of mechano-sensitive neural tissue did not significantly influence the outcome (F [1,16] = 0.68, p=0.42). These results provide preliminary evidence for the use of the Mulligan TSLR technique in the management of LBP, when a limitation of SLR is present; however, further controlled studies are required to substantiate these findings.

DC ND DO FACN in Bogota, Colombia History and Perspectives What we as doctors learn in medical school about viral infections is summarized within the following course titles: Microbiology, Pathology, and Pharmacology. Following this instruction, the treatments that we use are sanitation, vaccination, and antiviral drugs, respectively. Based on training and my experience with other doctors, I suggest here that most medically-trained doctors are-at least per their formal training-unable to see beyond these blinders and limited options. What I would like to do in this article is broaden those conceptual and therapeutic horizons via a structured antiviral strategy that includes the previously mentioned sanitation, vaccination and antiviral drugs but extends beyond these limited options. Additional citations, support, and clinical details (e.g., dosing and contraindications) for this strategy are available in a digital format constantly updated 1 ; the purpose of this article is to structure the strategy, to shift the paradigm.

Rather than viewing viral infections in a manner that is phenomenalistic and enigmatic, and therefore unwieldy, leading to clumsy prevention and treatment strategies, we should deconstruct the complexity of the infectious process. Doing so – at least in the manner that I have described – gives us four areas upon which we can focus our efforts: 1) targeting the virus directly, 2) blocking viral replication, 3) supporting immune function, and 4) supporting cellular and whole-body health. These are illustrated in the accompanying diagram and briefly described and exemplified in the four respective paragraphs that follow.

Capitolul 1 "Opinia publică" -un concept ambiguu / 17 Precizări terminologice /18 Ce se înţelege prin termenul de "opinie publică"? / 28 Capitolul 2 Din istoricul cunoaşterii opiniei publice / 35 Elogiul şi defăimarea opiniei publice / 35 Cunoaşterea ştiinţifică a opiniei publice / 45 O încercare de identificare a legilor opiniei publice / 52 Capitolul 3 Modelul tridimensional al opiniei publice / 55 Dimensiunea psihologică a opiniei publice^/ 55 "Omul de ştiinţă ingenuu" / 59 "Cauzalitatea fenomenologică" / 60 "Inferenţa corespondenţei" / 60 "Covarianţa" / 61 "Motivaţie şi emoţie" / 63 "Leneşul cognitiv" / 63 Dimensiunea psihosociologică a opiniei publice / 67 Existenţa unei probleme sociale / 67 Natura publicurilor / 68 Exprimarea opiniei / 73 Numărul persoanelor implicate / 73 Modelul "pâlnia cauzalităţii" / 74 Modelul"Foote-Hart" / 76 Dimensiunea sociologică a opiniei publice / 77 Opinia publică -fapt social /78 Opinia publică -metodologia şi deontologia sociologică /81 Capitolul 4 Construirea opiniei publice: rolul mass-media / 85 Teorii ale influenţei mass-media asupra opiniei publice / 87 "Glonţul magic" / 87 "Fluxul comunicării în două trepte" / 89 "Liderii de opinie" / 92 6 OPINIA PUBLICĂ Tipologii ale liderilor de opinie / 94 Metode de identificare a liderilor de opinie / 96 Caracteristici ale liderilor de opinie / 99 "Stabilirea ordinii de zi" / 100 "încadrarea şi reîncadrarea" / 105 "Spirala tăcerii" / 106 "Paza la barieră" /110 Influenţa prezentării în mass-media a sondajelor de opinie publică / 112 Partea a Il-a Persuasiunea şi manipularea opiniilor şi comportamentelor / 123 Capitolul 5 Persuasiunea: teorii, strategii, tehnici / 123 Ce este persuasiunea? / 123 Din istoricul preocupărilor de analiză a persuasiunii / 128 Lista tabelelor 13

This article provides a best evidence-informed review of the current scientific understanding of myofascial trigger points with regard to their etiology, pathophysiology, and clinical implications. Evidence-informed manual therapy integrates the best available scientific evidence with individual clinicians' judgments, expertise, and clinical decision-making. After a brief historical review, the clinical aspects of myofascial trigger points, the interrater reliability for identifying myofascial trigger points, and several characteristic features are discussed, including the taut band, local twitch response, and referred pain patterns. The etiology of myofascial trigger points is discussed with a detailed and comprehensive review of the most common mechanisms, including low-level muscle contractions, uneven intramuscular pressure distribution, direct trauma, unaccustomed eccentric contractions, eccentric contractions in unconditioned muscle, and maximal or sub-maximal concentric contractions. Many current scientific studies are included and provide support for considering myofascial trigger points in the clinical decision-making process. The article concludes with a summary of frequently encountered precipitating and perpetuating mechanical, nutritional, metabolic, and psychological factors relevant for physical therapy practice. Current scientific evidence strongly supports that awareness and working knowledge of muscle dysfunction and in particular myofascial trigger points should be incorporated into manual physical therapy practice consistent with the guidelines for clinical practice developed by the International Federation of Orthopaedic Manipulative Therapists. While there are still many unanswered questions in explaining the etiology of myofascial trigger points, this article provides manual therapists with an up-to-date evidence-informed review of the current scientific knowledge. K e y Wo rd s : M y o f a s c i a l P a i n S y n d r o m e , Tr i g g e r P o i n t s , M y o f a s c i a l , E t i o l o g y, Pathophysiology Jan Dommerholt, PT, MPS, FAAPM Carel Bron, PT Jo Franssen, PT

Thoracic spine manipulation is commonly used by physical therapists for the management of patients with upper quarter pain syndromes. The theoretical construct for using thoracic manipulation for upper quarter conditions is a mainstay of a regional interdependence (RI) approach. The RI concept is likely much more complex and is perhaps driven by a neurophysiological response including those related to peripheral, spinal cord and supraspinal mechanisms. Recent evidence suggests that thoracic spine manipulation results in neurophysiological changes, which may lead to improved pain and outcomes in individuals with musculoskeletal disorders. The intent of this narrative review is to describe the research supporting the RI concept and its application to the treatment of individuals with neck and/or shoulder pain. Treatment utilizing both thrust and non-thrust thoracic manipulation has been shown to result in improvements in pain, range of motion and disability in patients with upper quar...

Background & Purpose Spinal manipulation is used by a variety of healthcare providers in the treatment of neuromusculoskeletal disorders. Its safety is often a topic of debate, despite the infrequent nature of adverse events (less than 1 in 3 million). No one has directly compared the incident of adverse events across professions. The purpose was to identify and compare adverse events between 3 different medical disciplines that use spinal manipulation in standard practice. Methods Patients empaneled to a primary care clinic in the Military Health System (MHS) with an initial spine or shoulder complaint from 1 January to 31 December 2009 were followed for 1 year. Care that included spinal manipulation by physical therapists (PT), chiropractors (DC), or osteopathic physicians (DO) was captured using the MHS Management Analysis and Reporting Tool (M2). Potential adverse events occurring within 7 days of the manipulation event were identified. Results From 6706 initial encounters with potential manipulation procedure codes, 1084 encounter were identified as a potentially adverse event within 45 days, representing 337 unique subjects. Only 43 of these occurred within 7 days (DC=20, DO=14, PT=9). After qualitative analysis of each potential case, none of the potential adverse events could be attributed to spinal manipulation in either group. Discussion-Conclusions There was no evidence of serious harm after the use of spinal manipulation in this cohort. In addition, potential adverse events were not greater in any of the three groups. We encourage future studies to also compare efficacy and healthcare costs.

Background & Purpose Spinal manipulation is used by a variety of healthcare providers in the treatment of neuromusculoskeletal disorders. Its safety is often a topic of debate, despite the infrequent nature of adverse events (less than 1 in 3 million). No one has directly compared the incident of adverse events across professions. The purpose was to identify and compare adverse events between 3 different medical disciplines that use spinal manipulation in standard practice. Methods Patients empaneled to a primary care clinic in the Military Health System (MHS) with an initial spine or shoulder complaint from 1 January to 31 December 2009 were followed for 1 year. Care that included spinal manipulation by physical therapists (PT), chiropractors (DC), or osteopathic physicians (DO) was captured using the MHS Management Analysis and Reporting Tool (M2). Potential adverse events occurring within 7 days of the manipulation event were identified. Results From 6706 initial encounters with potential manipulation procedure codes, 1084 encounter were identified as a potentially adverse event within 45 days, representing 337 unique subjects. Only 43 of these occurred within 7 days (DC=20, DO=14, PT=9). After qualitative analysis of each potential case, none of the potential adverse events could be attributed to spinal manipulation in either group. Discussion-Conclusions There was no evidence of serious harm after the use of spinal manipulation in this cohort. In addition, potential adverse events were not greater in any of the three groups. We encourage future studies to also compare efficacy and healthcare costs.

L ow back pain (LBP) is a costly and troubling phenomenon, affecting 60% to 80% of Americans within their lifetime 1,2 . The one-year prevalence of acute LBP has been estimated to exceed 60% 3 , causing nearly 5% of Americans to lose work and/or require medical intervention 4 . Historically, physical therapist-administered therapeutic exercise has played an essential role in management of LBP 5,6 , a disorder that contributes to 40% of Worker's Compensation-related therapy visits 7 .

Background & Purpose Spinal manipulation is used by a variety of healthcare providers in the treatment of neuromusculoskeletal disorders. Its safety is often a topic of debate, despite the infrequent nature of adverse events (less than 1 in 3 million). No one has directly compared the incident of adverse events across professions. The purpose was to identify and compare adverse events between 3 different medical disciplines that use spinal manipulation in standard practice. Methods Patients empaneled to a primary care clinic in the Military Health System (MHS) with an initial spine or shoulder complaint from 1 January to 31 December 2009 were followed for 1 year. Care that included spinal manipulation by physical therapists (PT), chiropractors (DC), or osteopathic physicians (DO) was captured using the MHS Management Analysis and Reporting Tool (M2). Potential adverse events occurring within 7 days of the manipulation event were identified. Results From 6706 initial encounters with potential manipulation procedure codes, 1084 encounter were identified as a potentially adverse event within 45 days, representing 337 unique subjects. Only 43 of these occurred within 7 days (DC=20, DO=14, PT=9). After qualitative analysis of each potential case, none of the potential adverse events could be attributed to spinal manipulation in either group. Discussion-Conclusions There was no evidence of serious harm after the use of spinal manipulation in this cohort. In addition, potential adverse events were not greater in any of the three groups. We encourage future studies to also compare efficacy and healthcare costs.

The aim of this study was to describe and update current knowledge of manual therapy accuracy in treating cervical and lumbar radiculopathy, to identify the limitations in current studies, and to suggest areas for future research. The study was conducted according to PRISMA guidelines for systematic reviews. A comprehensive literature review was conducted using PubMed and Web of Science databases up to April 2020. The following inclusion criteria were used: (1) presence of radiculopathy; (2) treatment defined as manual therapy (i.e., traction, manipulation, mobilization); and (3) publication defined as a Randomized Controlled Trial. The electronic literature search resulted in 473 potentially relevant articles. Finally, 27 articles were accepted: 21 on cervical (CR) and 6 in lumbar radiculopathy (LR). The mean PEDro score for CR was 6.6 (SD 1.3), and for LR 6.7 (SD 1.6). Traction-oriented techniques are the most frequently chosen treatment form for CR and are efficient in reducing pain and improving functional outcomes. In LR, each of the included publications used a different form of manual therapy, which makes it challenging to summarize knowledge in this group. Of included publications, 93% were either of moderate or low quality, which indicates that quality improvement is necessary for this type of research.

It has been suggested that tight hamstring muscle, due to its anatomical connections, could be a compensatory mechanism for providing sacroiliac (SI) joint stability in patients with gluteal muscle weakness and SIJ dysfunction. The purpose of this study was to determine the relationship between hamstring muscle length and gluteal muscle strength in subjects with sacroiliac joint dysfunction. A total of 159 subjects with and without low back pain (LBP) between the ages of 20 and 65 years participate in the study. Subjects were categorized into three groups: LBP without SIJ involvement (n553); back pain with SIJ dysfunction (n553); and no low back pain (n553). Hamstring muscle length and gluteal muscle strength were measured in all subjects. The number of individuals with gluteal weakness was significantly (P50.02) higher in subjects with SI joint dysfunction (66%) compared to those with LBP without SI joint dysfunctions (34%). In pooled data, there was no significant difference (P50.31) in hamstring muscle length between subjects with SI joint dysfunction and those with back pain without SI involvement. In subjects with SI joint dysfunction, however, those with gluteal muscle weakness had significantly (P50.02) shorter hamstring muscle length (mean5158¡11u) compared to individuals without gluteal weakness (mean5165¡10u). There was no statistically significant difference (P.0.05) in hamstring muscle length between individuals with and without gluteal muscle weakness in other groups. In conclusion, hamstring tightness in subjects with SI joint dysfunction could be related to gluteal muscle weakness. The slight difference in hamstring muscle length found in this study, although statistically significant, was not sufficient for making any definite conclusions. Further studies are needed to establish the role of hamstring muscle in SI joint stability.

Krishna's Kinetikinetic Manual Therapy® (KKMT®) is the latest school of thought in manual therapy founded by Dr. Krishna N. Sharma, a Physiotherapist from India. KKMT® Joint Mobilization is a part of KKMT® as a whole. The KKMT® protocol includes assessment, mobilization and prevention. The mobilization techniques are based on the following principles: 1) Proper arthrokinematic motion and homeostatic kinetic forces are essential for proper and smooth osteokinematic motion. 2) Homeostatic kinetics of the joint is important to maintain static and dynamic alignment of a joint. The homeostatic kinetic forces help the joint come back in its proper alignment after a motion. The factors that produce and govern the homeostatic kinetics of joint are: a) Local/ Intrinsic factors: e.g. ligament, cartilage, meniscus, etc. b) Global/Extrinsic factors: e.g. muscles, fascia, gravity, etc. 3) Limitation or restrictions in the arthrokinematic motion can be restored by facilitating homeostatic kinetics of the intrinsic and extrinsic factors. The techniques to be covered during the 2 days of hands on workshop shall be Joint Gaping®, Functional Articular Rolling® and 3D Gliding® of the peripheral joints. The students will be certified by the Academy of Krishna's Kinetikinetic Manual Therapy, India.

This paper is re-edited.

It publishes a new procedure for treating herniated or bulging spinal discs with the clinical percussion instruments called Trigger Point Hammer (TPH) and TriggerCiser (TC); this therapy is generally referred to as TPH-therapy or TC-therapy.

The basis of the aforementioned therapy is that overloaded (affected/inflamed) tissues are weaker and become protected by natural local muscular contractions locking or diminishing articular motion in order to reduce damaging loads on the tissues. However, these contractions are less needed if patients have a more cautious lifestyle, avoiding producing additional loads in their affected tissues (herniated/bulging spinal discs) while the normal healing processes take place. 

While patients have a more cautious lifestyle, the percussions from the TPH and/or the TC will efficiently produce increased articular motion and circulation stimulating natural healing processes in the affected tissues (cartilage discs); this therapy also reduces pain and the patients feel helped by the treatments.

This publication also explains how this TPH- and TC-therapy may be done in a doggy-style position if  patients have excruciating pain.

Ordinarily, little can be done with herniated/bulging discs, but when using the TPH and/or the TC to produce increase motion and circulation, patients will generally always feel instantly better. The actual healing of a herniated or bulging disc will make the damaged tissue of the injured disc retract gradually away from the nervous tissue in the spinal canal. This healing process generally takes place over an extended period of time, but will finally let the affected disc normalize its size naturally.

Objectives: Upper limb neurodynamic testing (ULNT) can be used clinically to assist in identifying neural tissue involvement in patients with upper quarter pain and dysfunction. Consideration for scapular positioning is a crucial component of ULNT standardization, as variations in positioning may dramatically impact sensory and motor responses. This study aimed to determine if there was a meaningful difference in test outcomes when the ULNT was performed in alternative scapular positions. Methods: This cross-sectional study included 40 asymptomatic individuals. Repeated ULNT testing was performed on the dominant limb with the scapula blocked in neutral (ULNTb) and in scapular depression (ULNTd). Sensory responses, muscle activity, and range of motion outcomes were compared between the two test variations. Results: Pre-positioning in scapular depression (ULNTd) led to reduced elbow extension range of motion, provoked greater upper trapezius muscle activity and an earlier onset and broader area of sensory responses compared to ULNTb. Discussion: During ULNTb, the limbs were taken further into range and elicited reduced muscle activation and more localized sensory response providing a less vigorous version of the test. This study demonstrates that scapular positioning has a meaningful impact on ULNT test outcomes in healthy, asymptomatic individuals. The ULNTd can be considered a more vigorous version that may be appropriate when the cervical motions commonly utilized for structural differentiation are limited or contraindicated.

Rather than viewing viral infections in a manner that is phenomenalistic and enigmatic, and therefore unwieldy, leading to clumsy prevention and treatment strategies, we should deconstruct the complexity of the infectious process. Doing so – at least in the manner that I have described – gives us four areas upon which we can focus our efforts: 1) targeting the virus directly, 2) blocking viral replication, 3) supporting immune function, and 4) supporting cellular and whole-body health. These are illustrated in the accompanying diagram and briefly described and exemplified in the four respective paragraphs that follow.

There appears to be very little in the research literature on the safety of thrust joint manipulation (TJM) when applied to the thoracic spine. To retrospectively analyze all available documented case reports in the literature describing patients who had experienced severe adverse events (AE) after receiving TJM to their thoracic spine. Case reports published in peer reviewed journals were searched in Medline (using Ovid Technologies, Inc.), Science Direct, Web of Science, PEDro (Physiotherapy Evidence Database), Index of Chiropractic literature, AMED (Allied and Alternative Medicine Database), PubMed and the Cumulative Index to Nursing and Allied Health (CINHAL) from January 1950 to February 2015. Case reports were included if they: (1) were peer-reviewed; (2) were published between 1950 and 2015; (3) provided case reports or case series; and (4) had TJM as an intervention. Articles were excluded if: (1) the AE occurred without TJM (e.g. spontaneous); (2) the article was a systemat...

Temporomandibular joint disorders (TMDs) are common and may cause temporomandibular joint (TMJ) locking, pain, and disability. Evidence supports use of manual therapy and exercise for treatment of TMDs including disk displacement limiting full mouth opening, TMJ 'closed lock'. Only limited case studies describe management of TMJ 'open lock', a condition due to posterior disk displacement (PDD) or TMJ anterior dislocation (TMJ-AD). Reported treatment for open lock includes splinting and intraoral joint manipulation. This case report describes a novel extraoral automobilization using the mandibular elevator muscles to treat TMJ open lock in a 22-year-old male after intraoral joint mobilization failed. The exercise program used to restore neuromuscular control for post-reduction management is described. Short term results of automobilization were excellent with restored ability to swallow, speak normally, and achieve occlusion. Long term results at 14 months were good: the patient was pain-free, could swallow and speak normally, had no recurrence of TMJ locking, and minimal disability. Limited right lateral excursion range and left mandibular deviation during mouth opening indicated possible persistence of PDD. This case suggests that mandibular elevator automobilization and masticatory muscle exercise may be useful to treat TMJ open lock and should be considered to treat PDD and TMJ-AD.

In recent years, increased knowledge of the pathogenesis of upper quadrant pain syndromes has translated to better management strategies. Recent studies have demonstrated evidence of peripheral and central sensitization mechanisms in different local pain syndromes of the upper quadrant such as idiopathic neck pain, lateral epicondylalgia, whiplash-associated disorders, shoulder impingement, and carpal tunnel syndrome. Therefore, a treatment-based classification approach where subjects receive matched interventions has been developed and, it has been found that these patients experience better outcomes than those receiving non-matched interventions. There is evidence suggesting that the cervical and thoracic spine is involved in upper quadrant pain. Spinal manipulation has been found to be effective for patients with elbow pain, neck pain, or cervicobrachial pain. Additionally, it is known that spinal manipulative therapy exerts neurophysiological effects that can activate pain modulation mechanisms. This paper exposes some manual therapies for upper quadrant pain syndromes, based on a nociceptive pain rationale for modulating central nervous system including trigger point therapy, dry needling, mobilization or manipulation, and cognitive pain approaches.

Objectives: Neck pain can be evaluated with passive intervertebral motion (PIVM). No study has evaluated the reliability of three-dimensional (3D) segmental PIVM testing of the cervical spine in symptomatic subjects in a functional, seated position. The purpose of this study was to evaluate inter-rater reliability of such 3D PIVM technique for pain provocation, hypomobility, and end-feel detection. Methods: Subjects (n563), age 44¡15.6 years, neck pain 3.4¡1.6 cm with visual analog scale, were evaluated by two of three raters with varied manual therapy education and experience. To perform the test, the rater passively invoked side-bending motion at each cervical joint from C2-C3 to C6-C7, allowing segmental synkinetic rotation and extension to occur. Each joint was assessed for hypomobility, hard endfeel, and pain provocation. Kappa statistics were used to determine the inter-rater reliability for each variable for joints C2-C3 through C6-C7 for both the most painful and least painful sides. Results: Percent agreements for pain provocation, hypomobility, and end-feel ranged 65-83%, 62-84%, and 68-87%, respectively. Kappa values for pain provocation, hypomobility, and end-feel on the most painful side were fair to moderate (0.29-0.53, 0.21-0.48, and 0.25-0.50, respectively), and on the least painful side were fair to substantial (0.43-0.65, 0.33-0.58, and 0.28-0.60, respectively). Discussion: This is the first investigation to assess reliability of 3D cervical segmental testing in sitting and to assess reliability of end-feel. The seated 3D PIVM test has sufficient clinical reliability for use in patients with cervicalgia for the assessment of hypomobility, end-feel, and pain provocation.

This special issue on the coevolution of innovation and public policy is the first issue of Complexity, Governance & Networks to be published by our new publisher, the University of Bamberg Press (UBP). UBP, an academic publisher from Germany, receives financial support from the Otto-Friedrich University of Bamberg and the German science foundation to publish our journal through an open source, open access framework. Because of this support, UBP will be able to publish it open access under the creative commons license and will not charge authors for the articles published in it. In other words: all the articles published in our journal will be freely available to anyone with an internet connection, nothing will be hidden behind paywalls. This way, the articles published in the journal will have greater visibility. Complexity, Governance & Networks will be indexed in all relevant databases (e.g. Scopus and Web of Science) and its contents will be searchable through them. Open access publishing will also give authors greater control over their publications: they can distribute them freely without prior consent. The transition towards an open access journal will not diminish our focus on publishing high-quality papers. All manuscripts submitted to Complexity, Governance & Networks will be subjected to a thorough double-blind review process to ensure that only the best publications will appear in the journal. The back catalogue of our journal has been taken over by UBP and all the articles published in previous issues will be available to download, for free, at the website of Complexity, Governance

Background: There appears to be very little in the research literature on the safety of thrust joint manipulation (TJM) when applied to the thoracic spine. Purpose: To retrospectively analyze all available documented case reports in the literature describing patients who had experienced severe adverse events (AE) after receiving TJM to their thoracic spine. Data Sources: Case reports published in peer reviewed journals were searched in Medline (using Ovid Technologies, Inc.), Science Direct, Web of Science, PEDro (Physiotherapy Evidence Database), Index of Chiropractic literature, AMED (Allied and Alternative Medicine Database), PubMed and the Cumulative Index to Nursing and Allied Health (CINHAL) from January 1950 to February 2015. Study Selection: Case reports were included if they: (1) were peer-reviewed; (2) were published between 1950 and 2015;

Objectives: To investigate the immediate effects of soft tissue mobilization (STM) versus therapeutic ultrasound (US) in patients with neck and arm pain who demonstrate neural mechanical sensitivity. Background: While experts have suggested that individuals with neck and arm pain associated with neural tissue mechanical sensitivity may benefit from STM, there has been little research to investigate this hypothesis. Methods: Twenty-three patients with neck and arm pain and a positive upper limb neurodynamic test (ULNT) were randomly assigned to receive STM or therapeutic US during a single session. Outcome measures were collected immediately before and after treatment, and at 2-4 day follow-up. Primary outcomes were the Global Rating of Change (GROC), range of motion (ROM) during the ULNT, and pain rating during the ULNT. Secondary measures included the Neck Disability Index (NDI), Patient-Specific Functional Scale (PSFS), Numeric Pain Rating Scale (NPRS), and active range of shoulder abduction motion combined with the wrist neutral or wrist extension. Results: A greater proportion of patients in the STM group reported a significant improvement on the GROC immediately after treatment (P50.003, STM575%, US59%), and at 2-4 day follow-up (P50.027, STM558%, US59%). Patients who received STM demonstrated greater improvements in ROM during ULNT (P50.026), PSFS (P50.007), and shoulder active ROM combined with wrist extension (P50.028). Improvements in Numeric Pain Rating Scale and pain during the ULNT were observed only in the STM group. There was no difference between groups for the NDI or shoulder abduction ROM with wrist neutral. Conclusion: Patients with neck and arm pain demonstrated greater improvements in ULNT ROM, GROC, and PSFS, and pain following STM than after receiving therapeutic US. Level of evidence: Therapy, level 1b.

Objective: The purpose of this thesis was to investigate the inter-rater reliability of the McKenzie System of Mechanical Diagnosis and Therapy (MDT) when classifying patients with musculoskeletal knee pain using clinical vignettes. Methods: This study was divided into two phases. First, ten clinicians experienced in the use of MDT were randomly recruited to write a total of 60 clinical vignettes based upon the initial assessment of past patients with knee pain. Second, six different MDT raters were recruited to rate 53 selected vignettes and reliability was determined using Fleiss Kappa. Results: There was "substantial agreement" among six MDT raters classifying the clinical vignettes into one of four categories (kappa=0.72). There was no statistically significant difference between therapists with different levels of training. Significance: These findings indicate that the McKenzie System of MDT is a reliable method of classifying patients presenting with musculoskeletal knee pain when using clinical vignettes.

Muscle energy technique (MET) is a form of manual therapy frequently used to correct lumbopelvic pain (LPP), herein the patient voluntarily contracts specific muscles against the resistance of the clinician. Studies on MET regarding magnitude and duration of effectiveness are limited. This study was a randomized controlled trial in which 20 subjects with self-reported LPP were randomized into two groups (MET or control) after magnitude of pain was determined. MET of the hamstrings and iliopsoas consisted of four 5-second hold/relax periods, while the control group received a sham treatment. Tests for current and worst pain, and pain with provocation were administered at baseline, immediately following intervention and 24 hours after intervention. Separate 2×3 ANOVAs were used to assess results as change scores. Visual analog score (VAS) for worst pain reported in the past 24 hours decreased for the MET group (4.3mm±19.9, p=.03) and increased for the sham (control) group (17.1mm±21.2, p=.03). Subjects receiving MET demonstrated a decrease in VAS worst pain over the past 24 hours, thereby suggesting that MET may be useful to decrease LPP over 24 hours.

Assessment of an individual's functional ability can be complex. This assessment should also be individualized and adaptable to changes in functional status. In the first article of this series, we operationally defined function, discussed the construct of function, examined the evidence as it relates to assessment methods of various aspects of function, and explored the multi-dimensional nature of the concept of function. In this case report, we aim to demonstrate the utilization of a multi-dimensional assessment method (functional performance testing) as it relates to a high-level athlete presenting with pain in the low back and groin. It is our intent to demonstrate how the clinician should continually adapt their assessment dependent on the current functional abilities of the patients.

L ateral epicondylalgia (epicondylitis or tennis elbow) is a clinical enigma characterized by pain over the lateral elbow and limited wrist movement often leading to restricted job performance and restricted activities of daily living 1. It has been reported that nearly 50% of individuals participating in racquet sports will experience lateral epicondylalgia at some point in their life; however, this group only accounts for 9.1-14.1% of all cases seeking medical attention 2-5. The syndrome most often occurs (35-64% of all cases) in professions requiring

Objectives: Knee osteoarthritis (OA) causes disability among the elderly and is often associated with impaired balance and proprioception. Perturbation exercises may help improve these impairments. Although manual physical therapy is generally a well-tolerated treatment for knee OA, perturbation exercises have not been evaluated when used with a manual physical therapy approach. The purpose of this study was to observe tolerance to perturbation exercises and the effect of a manual physical therapy approach with perturbation exercises on patients with knee OA. Methods: This was a prospective observational cohort study of 15 patients with knee OA. The Western Ontario and McMaster Universities Arthritis Index (WOMAC), global rating of change (GROC), and 72-hour post-treatment tolerance were primary outcome measures. Patients received perturbation balance exercises along with a manual physical therapy approach, twice weekly for 4 weeks. Follow-up evaluation was done at 1, 3, and 6 months after beginning the program. Results: Mean total WOMAC score significantly improved (P50.001) after the 4-week program (total WOMAC: initial, 105; 4 weeks, 56; 3 months, 54; 6 months, 57). Mean improvements were similar to previously published trials of manual physical therapy without perturbation exercises. The GROC score showed a minimal clinically important difference (MCID)$z3 in 13 patients (87%) at 4 weeks, 12 patients (80%) at 3 months, and 9 patients (60%) at 6 months. No patients reported exacerbation of symptoms within 72 hours following each treatment session. Discussion: A manual physical therapy approach that also included perturbation exercises was well tolerated and resulted in improved outcome scores in patients with knee OA.

Background & Purpose Spinal manipulation is used by a variety of healthcare providers in the treatment of neuromusculoskeletal disorders. Its safety is often a topic of debate, despite the infrequent nature of adverse events (less than 1 in 3 million). No one has directly compared the incident of adverse events across professions. The purpose was to identify and compare adverse events between 3 different medical disciplines that use spinal manipulation in standard practice. Methods Patients empaneled to a primary care clinic in the Military Health System (MHS) with an initial spine or shoulder complaint from 1 January to 31 December 2009 were followed for 1 year. Care that included spinal manipulation by physical therapists (PT), chiropractors (DC), or osteopathic physicians (DO) was captured using the MHS Management Analysis and Reporting Tool (M2). Potential adverse events occurring within 7 days of the manipulation event were identified. Results From 6706 initial encounters with potential manipulation procedure codes, 1084 encounter were identified as a potentially adverse event within 45 days, representing 337 unique subjects. Only 43 of these occurred within 7 days (DC=20, DO=14, PT=9). After qualitative analysis of each potential case, none of the potential adverse events could be attributed to spinal manipulation in either group. Discussion-Conclusions There was no evidence of serious harm after the use of spinal manipulation in this cohort. In addition, potential adverse events were not greater in any of the three groups. We encourage future studies to also compare efficacy and healthcare costs.

BACKGROUND: Cervical radiculopathy is a common ailment typically confirmed via magnetic resonance imaging. Triage in these patients may be complex as many will be treated conservatively while others will advance to surgical intervention. We describe a case of a pro bono patient with both shoulder and neck pain.

CASE DESCRIPTION: A 52-year-old male satellite dish installer was referred to a pro bono physical therapist 9-weeks status post left rotator cuff repair with complaints of right-sided neck pain. Neck symptoms were chronic for years but worsened after his left rotator cuff repair 9-weeks prior. His neck symptoms were a constant variable sharp pain rated 6/10 on the numeric pain rating scale (NPRS) with intermittent bilateral upper extremity paresthesia. Right cervical lateral flexion and right cervical rotation were aggravating factors. The patient was a 1 pack per day smoker with a 35 pack-year smoking history.

The patient was barrel chested with thoracic hyperkyphosis and a forward head posture. Baseline neck disability index (NDI) score was 36%. Active range of motion in cervical side bending and rotation were restricted bilaterally with reproduction of neck pain. Two-point discrimination testing revealed decreased sensation in the right upper extremity. Biceps brachii and brachioradialis deep tendon reflexes (DTR) were absent bilaterally, and the triceps DTR was absent on the right and 1+ on the left. Passive accessory mobility assessment detected hypomobility centrally at C4-5 and right unilaterally at C6-7 with concordant pain. Same-day treatment of thrust manipulation to the cervicothoracic junction, mid, and upper thoracic spine, and manual traction improved left shoulder mobility but neck impairments were unchanged.

OUTCOMES: Due to concern for cervical radiculopathy, the physical therapist requested magnetic resonance imaging (MRI) which revealed nerve root impingement of the exiting bilateral C5 and C6 nerve roots, and the right C7 nerve roots. Following the MRI results, physical therapy interventions included thrust manipulation to the mid and upper thoracic spine, cervicothoracic junction thrust manipulation, and manual traction targeted at the C4-5 segment. After 7 physical therapy sessions over 6-weeks, the patient regained full cervical active range of motion, the patient’s NPRS improved to 0/10, NDI score improved to 20%, and upper extremity paresthesias were reportedly reduced.

DISCUSSION: Cervical radiculopathy in patients with post-operative shoulders can be diagnostically challenging as myotomal testing can be inconclusive. Furthermore, diagnosis may be confounded as post-operative distal neuropathies are not uncommon. MRI in this case was indicated by variant 2 of the American College of Radiology Appropriateness Criteria for cervical radiculopathy. Findings were utilized in both diagnosis and treatment selection to expedite and maximize patient recovery.