Laurent Pitance

Effectiveness of Manual Therapy and Therapeutic Exercise for Temporomandibular Disorders: Systematic Review and Meta-Analysis

Background Manual therapy (MT) and exercise have been extensively used to treat people with musculoskeletal conditions such as temporomandibular disorders (TMD). The evidence regarding their effectiveness provided by early systematic reviews is outdated. Purpose The aim of this study was to summarize evidence from and evaluate the methodological quality of randomized controlled trials that examined the effectiveness of MT and therapeutic exercise interventions compared with other active interventions or standard care for treatment of TMD. Data Sources Electronic data searches of 6 databases were performed, in addition to a manual search. Study Selection Randomized controlled trials involving adults with TMD that compared any type of MT intervention (eg, mobilization, manipulation) or exercise therapy with a placebo intervention, controlled comparison intervention, or standard care were included. The main outcomes of this systematic review were pain, range of motion, and oral function. Forty-eight studies met the inclusion criteria and were analyzed. Data Extraction Data were extracted in duplicate on specific study characteristics. Data Synthesis The overall evidence for this systematic review was considered low. The trials included in this review had unclear or high risk of bias. Thus, the evidence was generally downgraded based on assessments of risk of bias. Most of the effect sizes were low to moderate, with no clear indication of superiority of exercises versus other conservative treatments for TMD. However, MT alone or in combination with exercises at the jaw or cervical level showed promising effects. Limitations Quality of the evidence and heterogeneity of the studies were limitations of the study. Conclusions No high-quality evidence was found, indicating that there is great uncertainty about the effectiveness of exercise and MT for treatment of TMD.

Delivery efficacy of a vibrating mesh nebulizer and a jet nebulizer under different configurations.

BACKGROUND Jet nebulizers coupled to spacers are frequently used to promote drug lung deposition, but their clinical efficacy has not been established. Few in vivo studies have been performed with mesh nebulizers, commonly used to nebulize antibiotics. Our study compared inhaled mass and urinary drug concentration of amikacin by using three different nebulizer delivery configuration systems: a standard unvented jet nebulizer (Sidestream(®)) used alone or coupled to a 110-mL corrugated piece of tubing and a vibrating mesh nebulizer (e-Flow rapid(®)). METHOD The inhaled mass of amikacin was assessed using the residual gravimetric method. Delivery efficacy was evaluated by assessing amikacin urinary drug concentration in six healthy spontaneously breathing volunteers. Urinary amikacin was monitored by fluorescent polarization immunoassay then cumulative excreted amount and antibiotic elimination rate were calculated. RESULTS AND CONCLUSIONS The total daily amount of amikacin urinary excretion (Cu) was almost twice as high with eFlow rapid(®) compared to Sidestream(®) used alone; intermediate values being observed when the device was coupled to a corrugated piece of tubing. The latter configuration was also associated with a higher total daily amount of amikacin urinary excretion. In vivo drug output rate was around threefold higher with the eFlow Rapid(®) than with the Sidestream(®) used in any configuration. These results were concordant to those obtained with in vitro analysis comparing inhaled mass of amikacin for the three nebulizers. The elimination constant (Ke) and the mass median aerodynamic diameter (MMAD) did not differ between the three devices. In conclusion, the vibrating mesh nebulizer is more efficient, promoting larger urinary drug concentration and drug output. Coupling a corrugated piece of tubing to the standard jet nebulizer favors delivery efficacy.

Deposition of aerosols delivered by nasal route with jet and mesh nebulizers

PURPOSE To quantify the amount of aerosol deposited in different parts of the airways with a commercially available nasal sonic jet nebulizer (NJN) using a sound effect, and to compare its performance with a new nasal mesh nebulizer (NMN). METHODS Seven healthy non-smoking male volunteers aged 21-36 years with a mean weight of 77±10 kg were included in this single-center study. Both nebulizer systems were loaded with (99m)Tc-DTPA and scintigraphies were performed with a gamma camera. Particle size distribution of the aerosols produced by the two nebulizer systems was measured. RESULTS There was no statistical difference between the two nebulizers in terms of fraction of particles smaller than 5 μm (44±4% vs 45±2%) (p>0.9). Aerosol deposition in the nasal region was 73±10% (% of aerosol deposited in airways) with the NJN, and 99±3% with the NMN (p=0.01). Total nasal deposition was 9.6±1.9% of the nebulizer charge with the NJN and 28.4±8.9% with the NMN (p=0.01). 0.5±0.3% of the nebulizer charge was deposited in the maxillary sinuses with the NJN, compared to 2.2±1.6% with the NMN (p=0.01). CONCLUSION Although the two nebulizers had the same particle size, NMN significantly improved aerosol deposition in nasal cavity and prevents deposition into the lungs.

Aerosol delivery through tracheostomy tubes: an in vitro study.

BACKGROUND Our study investigated the influence of the cannulas inner diameter (ID) and of its removal on the expected respiratory dose of amikacin, using three different jet nebulizer configurations (Sidestream(®)): vented (N1), unvented with a piece of corrugated tubing attached to the expiratory limb of the T attachment (N2), and unvented alone (N3). METHODS The jet nebulizer was filled with amikacin (500 mg/4 mL) and was attached to the tracheostomy tube. A lung model simulating spontaneous breathing was connected to the tracheostomy tube. A filter was connected between the nebulizer and the tracheostomy tube to measure the inhaled dose, and between the tracheostomy tube and the lung model to measure the respiratory dose. Different cannula IDs were tested (6.5, 8, 8.5, and 10 mm), and aerosol lost in the cannulas was determined. RESULTS AND CONCLUSIONS Respiratory dose varied between 96±1 mg and 44±3 mg, with higher values observed with N2. The aerosol lost in the cannula was significant and represented up to 63% of the inhaled dose. There was a negative correlation between the cannulas ID and the aerosol lost in the cannula. After removal of the internal cannula, an increase in the respiratory dose of up to 31.3% was observed. We recommend removing the inner tracheostomy cannula to nebulize a larger amount of drug through a tracheostomy tube. Among the three jet nebulizer configurations studied, we recommend the unvented one with a piece of corrugated tubing attached to the expiratory limb of the T attachment.

Sonic aerosol therapy to target maxillary sinuses

AIM Intranasal aerosol administration of drugs is widely used by ENT specialists. Although clinical evidence is still lacking, intranasal nebulization appears to be an interesting therapeutic option for local drug delivery, targeting anatomic sites beyond the nasal valve. The sonic nebulizer NL11SN associates a 100Hertz (Hz) sound to the aerosolization to improve deposition in the nasal/paranasal sinuses. The aim of the present study was: to evaluate in vivo the influence of associating a 100Hz sound on sinus ventilation and nasal and pulmonary aerosol deposition in normal volunteers, and; to quantify in vitro aerosol deposition in the maxillary sinuses in a plastinated head model. MATERIAL AND METHODS Scintigraphic analysis of (81m)Kr gas ventilation and of sonic aerosol ((99m)Tc-DTPA) deposition using the NL11SN was performed in vivo in seven healthy volunteers. In parallel, NL11SN gentamicin nebulization was performed, with or without associated 100Hz sound, in a plastinated human head model; the gross amount of gentamicin delivered to the paranasal sinuses was determined by fluorescence polarization immunoassay. RESULTS Associating the 100Hz sound to (81m)Kr gas ensured paranasal sinus ventilation in healthy volunteers. (99m)Tc-DTPA particles nebulized with the NL11SN were deposited predominantly in the nasal cavities (2/3, vs 1/3 in the lungs). In vitro, the use of NL11SN in sonic mode increased gentamicin deposition threefold in the plastinated model sinuses (P<0.002); the resulting antibiotic deposit would be sufficient to induce a local therapeutic effect. CONCLUSION The NL11SN nebulizer ensured preferential nasal cavity aerosol deposition and successfully targeted the maxillary sinuses.

Dimensionality and Reliability of the Central Sensitization Inventory in a Pooled Multicountry Sample

Central sensitization (CS) involves the amplification of neural signaling within the central nervous system, which evokes pain hypersensitivity. The Central Sensitization Inventory (CSI) assesses 25 overlapping health-related symptom dimensions that have been reported to be associated with CS-related disorders. Previous studies have reported satisfactory test-retest reliability and internal consistency, but factor analyses have exhibited conflicting results in different language versions. The purpose of this cross-sectional study was to thoroughly examine the dimensionality and reliability of the CSI, with pooled data from 1,987 individuals, collected in several countries. The principal component analysis suggested that 1 general factor of CS best described the structure. A subsequent confirmatory factor analysis revealed that a bifactor model, which accounted for the covariance among CSI items, with regard to 1 general factor and 4 orthogonal factors, fit the CSI structure better than the unidimensional and the 4-factor models. Additional analyses indicated substantial reliability for the general factor (ie, Cronbach α = .92; ω = .95; and ω hierarchical = .89). Reliability results for the 4 specific factors were considered too low to be used for subscales. The results of this study clearly suggest that only total CSI scores should be used and reported. PERSPECTIVE As far as we know, this is the first study that has examined the factor structure and reliability of the CSI in a large multicountry sample. The CSI is currently considered the leading self-report measure of CS-related symptoms worldwide.

Short-Term Effects of Mulligan Mobilization With Movement on Pain, Disability, and Kinematic Spinal Movements in Patients With Nonspecific Low Back Pain: A Randomized Placebo-Controlled Trial

OBJECTIVE The purpose of this clinical study was to compare the immediate- and short-term effects of lumbar Mulligan sustained natural apophyseal glides (SNAGs) on patients with nonspecific low back pain with respect to 2 new kinematic algorithms (KA) for range of motion and speed as well as pain, functional disability, and kinesiophobia. METHODS This was a 2-armed randomized placebo-controlled trial. Subjects, blinded to allocation, were randomized to either a real-SNAG group (n = 16) or a sham-SNAG group (n = 16). All patients were treated during a single session of real/sham SNAG (3 × 6 repetitions) to the lumbar spine from a sitting position in a flexion direction. Two new KA from a validated kinematic spine model were used and recorded with an optoelectronic device. Pain at rest and during flexion as well as functional disability and kinesiophobia was recorded by self-reported measures. These outcomes were blindly evaluated before, after treatment, and at 2-week follow-up in both groups. RESULTS Of 6 variables, 4 demonstrated significant improvement with moderate-to-large effect sizes (ES) in favor of the real-SNAG group: KA-R (P = .014, between-groups ES Cliff δ = -.52), pain at rest and during flexion (visual analog scale, P < .001; ES = -.73/-.75), and functional-disability (Oswestry Disability Index, P = .003 and ES = -.61). Kinesiophobia was not considered to be significant (Tampa scale, P = .03) but presented moderate ES = -.46. Kinematic algorithms for speed was not significantly different between groups (P = .118) with a small ES = -.33. All 6 outcome measures were significantly different (P ≤ .008) during within-group analysis (before and after treatment) only in the real-SNAG group. No serious or moderate adverse events were reported. CONCLUSION This study showed evidence that lumbar spine SNAGs had a short-term favorable effect on KA-R, pain, and function in patients with nonspecific low back pain.

The efficacy of manual therapy and exercise for treating non-specific neck pain: A systematic review

OBJECTIVE: To review and update the evidence for different forms of manual therapy (MT) and exercise for patients with different stages of non-specific neck pain (NP). Data sources: MEDLINE, Cochrane-Register-of-Controlled-Trials, PEDro, EMBASE. METHOD: A qualitative systematic review covering a period from January 2000 to December 2015 was conducted according to updated-guidelines. Specific inclusion criteria only on RCTs were used; including differentiation according to stages of NP (acute – subacute [ASNP] or chronic [CNP]), as well as sub-classification based on type of MT interventions: MT1 (HVLA manipulation); MT2 (mobilization and/or soft-tissue-techniques); MT3 (MT1 + MT2); and MT4 (Mobilization-with-Movement). In each sub-category, MT could be combined or not with exercise and/or usual medical care. RESULTS: Initially 121 studies were identified for potential inclusion. Based on qualitative and quantitative evaluation criteria, 23 RCTs were identified for review. Evidence for ASNP: MODERATE-evidence: In favour of (i) MT1 to the cervical spine (Cx) combined with exercises when compared to MT1 to the thoracic spine (Tx) combined with exercises; (ii) MT3 to the Cx and Tx combined with exercise compared to MT2 to the Cx with exercise or compared to usual medical care for pain and satisfaction with care from short to long-term. Evidence for CNP: STRONG-evidence: Of no difference of efficacy between MT2 at the symptomatic Cx level(s) in comparison to MT2 on asymptomatic Cx level(s) for pain and function. MODERATE to STRONG-evidence: In favour of MT1 and MT3 on Cx and Tx with exercise in comparison to exercise or MT alone for pain, function, satisfaction with care and general-health from short to moderate-terms. MODERATE-evidence: In favour (i) of MT1 as compared to MT2 and MT4, all applied to the Cx, for neck mobility, and pain in the very short term; (ii) of MT2 using sof-tissue-techniques to the Cx and Tx or MT3 to the Cx and Tx in comparison to no-treatment in the short-term for pain and disability. CONCLUSION: This systematic review updates the evidence for MT combined or not with exercise and/or usual medical care for different stages of NP and provides recommendations for future studies. Two majors points could be highlighted, the first one is that combining different forms of MT with exercise is better than MT or exercise alone, and the second one is that mobilization need not be applied at the symptomatic level(s) for improvements of NP patients. These both points may have clinical implications for reducing the risk involved with some MT techniques applied to the cervical spine.

Reliability and Reproducibility of Chest Wall Expansion Measurement in Young Healthy Adults

OBJECTIVE The purposes of this study were to (1) evaluate the reliability and reproducibility of chest expansion (CE) measurement on 2 different levels and (2) observe relationships between upper and lower CE measurements and lung function. METHODS Fifty-three healthy subjects aged between 18 and 39 years were recruited. Chest expansion measurements were taken with a cloth tape measure at 2 levels of the rib cage (upper and lower). Reproducibility of the measurement was measured for 2 physiotherapists and on 2 different days. Lung function (ie, forced expiratory volume in 1 second [FEV1], forced vital capacity (FVC), vital capacity and, inspiratory capacity) was measured for all subjects by a spirometer (MEC Pocket-spiro USB100, Medical Electronic Construction, Brussels, Belgium). RESULTS Upper CE was less than lower CE (5.4 cm and 6.4 cm, respectively; P < .001). Intrarater and interrater reliability were good for upper and lower CE. Reproducibility between physiotherapists was verified for both CE measurements. Reproducibility between days was only verified for upper CE. Sex influenced lower CE. Upper and lower CE values were correlated (r = 0.747; P < .01). Lower and upper CE were significantly and positively correlated with all lung function parameters and inspiratory muscle strength (moderately and weakly, respectively) except to inspiratory capacity for upper CE (P = .051) and for FEV1/FVC for both CE measurements. CONCLUSION Upper and lower CE measurements showed good intra- and interrater reliability and reproducibility in healthy subjects. Although both measurements were correlated with lung functions (ie, FEV1, FVC, and vital capacity), the findings of this study showed that upper CE measurements may be more useful in clinical practice to evaluate chest mobility and to give indirect information on lung volume function and inspiratory muscle strength.

Hip abductor, trunk extensor and ankle plantar flexor endurance in females with and without patellofemoral pain

BACKGROUND Previous studies have reported strength deficit in hip abduction, extension and external rotation in females with patellofemoral pain (PFP) when compared with healthy control; however, there is conflicting evidence for a decrease in hip muscle endurance. Therefore, it seems important to evaluate hip muscle endurance in females with PFP. Moreover, trunk extensor and ankle plantar flexor endurance have not yet been evaluate in females with PFP. OBJECTIVE To compare hip abductor, trunk extensor and ankle plantar flexor endurance between females with and without PFP. METHODS Twenty females with PFP (mean age, 21.1 years) and 76 healthy females (mean age, 20.5 years) were recruited. Subject performed three endurance clinical tests: (1) The hip abductor isometric endurance test, (2) The Sorensen test and (3) The heel rise test. Group differences were assessed using an independent t tests, or Mann-Whitney U tests for non-normally distributed data. RESULTS Subjects with PFP exhibited significantly lower hip abductor, trunk extensor and ankle plantar flexor endurance than healthy controls. On average, subjects with PFP had deficits of 16% in hip abduction, 14% in trunk extension and 26% in ankle plantar flexion. CONCLUSION Females with PFP exhibited diminished hip abductor, trunk extensor and ankle plantar flexor endurance compared to healthy controls.