Clair Hebron

The initial effects of different rates of lumbar mobilisations on pressure pain thresholds in asymptomatic subjects

Lumbar mobilisations are commonly used in clinical practice to reduce pain and increase function. Mobilisations to the cervical spine have been shown to reduce pain using pressure pain thresholds (PPTs). Yet there is no evidence to confirm that this happens in the lumbar spine. Furthermore little is known about the effects of different treatment doses on the amount of hypoalgesia produced. It is unknown if changing the rate of application of mobilisations has an effect on hypoalgesia. The aim of this study was to investigate the immediate effects of lumbar posteroanterior mobilisations performed at different rates on PPT and the extent of the hypoalgesia. A repeated measures, single blind, randomised-trial was conducted on 30 asymptomatic subjects. PPTs were measured at 4 sites in the upper and lower quadrants, before and after the application of lumbar posteroanterior mobilisations performed at 2 Hz, 1 Hz and quasi-static. The results demonstrated an immediate and significant improvement in PPT measures (P = 0.000) irrespective of the rate or site tested. The effects were both local and widespread. There was no significant difference in PPT between the rates of mobilisations. This study provides new experimental evidence that lumbar posteroanterior mobilisations produce an immediate and significant widespread hypoalgesic effect, regardless of the rates of mobilisation in asymptomatic subjects.

An investigation into the potential hypoalgesic effects of different amplitudes of PA mobilisations on the lumbar spine as measured by pressure pain thresholds (PPT).

Mobilisation of the spine is a common technique used in clinical practice. Studies have shown that mobilisation to the spine can decrease pain. The optimum treatment dose for achieving this has not so far been investigated. Previous studies that demonstrate the pain relieving effects of mobilisations have used large amplitude of oscillations. The importance of amplitude on pain relief has not been established. The current study aims to: a) Investigate the importance of amplitude as part of the treatment dose. b) To explore the extent of any pain reliving effects seen following mobilisations. The study employed a randomised, single blind, within-subjects repeated measure design. Thirty asymptomatic subjects participated. The subjects completed three experimental conditions on three separate occasions. The conditions were: large amplitude of oscillations (forces between 50 and 200N), small amplitude of oscillations (150N-200N) and quasi-static (maintained at 200N). Each condition involved a 3x1minute central PA mobilisation at a frequency of 1.5Hz on the lumbar spine. Pressure pain thresholds (PPT) were measured immediately before and after each intervention at 4 different sites. The sites were chosen to determine the extent of the hypoalgesic response. Results demonstrated a significant increase in PPT following lumbar mobilisations (p=0.013) at all measured sites. However, no significant difference was found between amplitude conditions (p=0.864). This study suggests that in asymptomatic subjects a systemic hypoalgesic response is caused by lumbar mobilisation regardless of amplitude.

The effect of increasing sets (within one treatment session) and different set durations (between treatment sessions) of lumbar spine posteroanterior mobilisations on pressure pain thresholds

UNLABELLED Spinal mobilisations are a common form of treatment intervention applied by physiotherapists in clinical practice to manage musculoskeletal pain and/or dysfunction. Previous research has demonstrated that mobilisations cause a hypoalgesic effect. However, there is very little research investigating the optimal treatment dose inducing this effect. AIM To investigate the effect of the number of sets (up to 5) and different durations (30 vs. 60 s) on pressure pain thresholds (PPTs) at different sites. METHODS This single-blinded, randomised, same subject repeated measures crossover design included 19 asymptomatic healthy volunteers. The participants received 5 sets of either 30 or 60 s of postero-anterior mobilisations to L4 on different days. PPTs were measured immediately before, between and after the intervention at 4 different standardised sites. RESULTS A 4-way ANOVA analysis revealed that there was no statistically significant difference between 30 versus 60 s of mobilisations. However, there was a tendency for PPT values to be higher for the 60 s intervention. All PPT measurements after the interventions were significantly higher than the baseline. Only the measurement after the 4th set of mobilisations was significantly higher than the measurement after the 1st set (p = 0.035). CONCLUSIONS The results suggest that in order to induce the greatest local hypoalgesia, at least 4 sets of mobilisations are required. The different durations of 30 versus 60 s of mobilisation may not change the extent of the hypoalgesic effect.

The outcome of hip exercise in patellofemoral pain: A systematic review

Patellofemoral pain (PFP) is one of the most common lower extremity conditions seen in clinical practice. Current evidence shows that there are hip strength deficits, delayed onset and shorter activation of gluteus medius in people with PFP. The aim of this review was to systematically review the literature to investigate the outcome of hip exercise in people with PFP. METHOD AMED, CINAHL, Cochrane, EMBASE, PEDro, Pubmed, Science direct and SPORTDiscus databases were searched from inception to November 2014 for RCTs, non-randomised studies and case studies. Two independent reviewers assessed each paper for inclusion and quality. RESULTS Twenty one papers were identified; eighteen investigating strengthening exercise, two investigating the effect of neuromuscular exercise and one study investigated the effect of hip exercise for the prevention of PFP. Hip and knee strengthening programmes were shown to be equally effective. Limited evidence indicates that the addition of hip exercise to an exercise programme is beneficial. Limited evidence demonstrates that motor skill retraining in a participant group who displayed abnormal hip alignment in running improves pain. CONCLUSION The evidence consistently demonstrated that both hip strengthening and neuromuscular exercise has a beneficial effect on pain and function in people with PFP. Strengthening exercise predominantly addressed abductor and external rotator muscle groups. A consensus from PFP researchers for standardisation of methodology is recommended to enable meaningful comparison between trials.

Physiotherapists’ experiences of managing upper limb movement impairments due to breast cancer treatment

ABSTRACT Background: Physiotherapy is recommended for upper limb movement impairments (ULMI) following breast cancer treatment. There is limited research into the pathophysiology and management of ULMI. Care is provided in different health-care contexts by specialist and nonspecialist physiotherapists, with referrals set to increase. This study explores physiotherapists’ experiences of managing ULMI. Design: Qualitative study using a hermeneutic phenomenological approach. Method: We interviewed six physiotherapists from various UK treatment settings. The data were analyzed using interpretative phenomenological analysis. Findings: Four master themes were identified: (1) lack of confidence surrounds various aspects of practice, influenced by limited evidence to guide treatment of ULMI, fear of causing harm, and working in a less-established area of physiotherapy; (2) increasing confidence in practice develops with experience, reinforcing perceptions of the benefits of physiotherapy; (3) physiotherapy is understood to empower and enable patients to regain their sense of self and quality of life; and (4) provision of care is perceived to be subject to many barriers. Conclusion: Physiotherapy for ULMI has professional challenges but is seen as beneficial, encompassing psychosocial and physical effects. Experiences in this area of practice suggest a need for increased professional support, further research to guide treatment, and better patient and health professional awareness of ULMI and the role of physiotherapy.

The intra-rater reliability of a revised 3-point grading system for accessory joint mobilizations

Abstract Objectives: Joint mobilizations are often quantified using a 4-point grading system based on the physiotherapist’s detection of resistance. It is suggested that the initial resistance to joint mobilizations is imperceptible to physiotherapists, but that at some point through range becomes perceptible, a point termed R1. Grades of mobilization traditionally hinge around this concept and are performed either before or after R1. Physiotherapists, however, show poor reliability in applying grades of mobilization. The definition of R1 is ambiguous and dependent on the skills of the individual physiotherapist. The aim of this study is to test a revised grading system where R1 is considered at the beginning of range, and the entire range, as perceived by the physiotherapists maximum force application, is divided into three, creating 3 grades of mobilization. Method: Thirty-two post-registration physiotherapists and nineteen pre-registration students assessed end of range (point R2) and then applied 3 grades of AP mobilizations, over the talus, in an asymptomatic models ankle. Vertical forces were recorded through a force platform. Intra-class Correlation Coefficients, Standard Error of Measurement, and Minimal Detectable Change were calculated to explore intra-rater reliability on intra-day and inter-day testing. T-tests determined group differences. Results: Intra-rater reliability was excellent for intra-day testing (ICC 0.96–0.97), and inter-day testing (ICC 0.85–0.93). No statistical difference was found between pre- and post-registration groups. Discussion: Standardizing the definition of grades of mobilization, by moving R1 to the beginning of range and separating grades into thirds, results in excellent intra-rater reliability on intra-day and inter-day tests. Level of Evidence: 3b.