Robert E. Boyles

The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement syndrome

The study was an exploratory, one group pretest/post-test study, with the objective of investigating the short-term effects of thoracic spine thrust manipulations (TSTMs) on patients with shoulder impingement syndrome (SIS). There is evidence that manual physical therapy that includes TSTM and non-thrust manipulation and exercise is effective for the treatment of patients with SIS. However, the relative contributions of specific manual therapy interventions are not known. To date, no published studies address the short-term effects of TSTM in the treatment of SIS. Fifty-six patients (40 males, 16 females; mean age 31.2+/-8.9) with SIS underwent a standardized shoulder examination, immediately followed by TSTM techniques. Outcomes measured were the Numeric Pain and Rating Scale (NPRS) and the Shoulder Pain and Disability Index (SPADI), all collected at baseline and at a 48-h follow-up period. Additionally, the Global Rating of Change Scale (GRCS) was collected at 48-h follow-up to measure patient perceived change. At 48-h follow-up, the NPRS change scores for Neer impingement sign, Hawkins impingement sign, resisted empty can, resisted external rotation, resisted internal rotation, and active abduction were all statistically significant (p<0.01). The reduction in the SPADI score was also statistically significant (p<0.001) and the mean GRCS score=1.4+/-2.5. In conclusion, TSTM provided a statistically significant decrease in self reported pain measures and disability in patients with SIS at 48-h follow-up.

Responsiveness of the Neck Disability Index in patients with mechanical neck disorders

PURPOSE Report the test-retest reliability, construct validity, minimum clinically important difference (MCID), and minimal detectable change (MDC) for the Neck Disability Index (NDI). STUDY DESIGN/SETTING Cohort study of patients presenting to outpatient physical therapy clinics. PATIENT SAMPLE Ninety-one subjects with a primary complaint of neck pain, with or without concomitant upper extremity (UE) symptoms, who were participants in a randomized clinical trial. OUTCOME MEASURES NDI and the 15-point Global Rating of Change (GRC) self-report measures. METHODS All subjects completed the NDI at baseline and at a 3-week follow-up. Additionally, subjects completed the GRC scale, which was used to dichotomize patients into improved or stable groups. Changes in the NDI were used to assess test-retest reliability, construct validity, MCID, and MDC. RESULTS Test-retest reliability was moderate for the NDI (intraclass correlation coefficient, 0.64; 95% confidence interval, 0.19-0.84). For the NDI, the MCID was 7.5 points and the MDC was 10.2 points. CONCLUSIONS The NDI appears to demonstrate adequate responsiveness based on statistical reference criteria when used in a sample that approximates the high percentage of patients with neck pain and concomitant UE referred symptoms. Because the MCID is within the bounds of measurement error, a 10-point change (the MDC) should be used as the MCID.

The Effectiveness of Manual Physical Therapy and Exercise for Mechanical Neck Pain : A Randomized Clinical Trial

Study Design. Randomized clinical trial. Objective. To assess the effectiveness of manual physical therapy and exercise (MTE) for mechanical neck pain with or without unilateral upper extremity (UE) symptoms, as compared to a minimal intervention (MIN) approach. Summary of Background Data. Mounting evidence supports the use of manual therapy and exercise for mechanical neck pain, but no studies have directly assessed its effectiveness for UE symptoms. Methods. A total of 94 patients referred to 3 physical therapy clinics with a primary complaint of mechanical neck pain, with or without unilateral UE symptoms, were randomized to receive MTE or a MIN approach of advice, motion exercise, and subtherapeutic ultrasound. Primary outcomes were the neck disability index, cervical and UE pain visual analog scales (VAS), and patient-perceived global rating of change assessed at 3-, 6-, and 52-weeks. Secondary measures included treatment success rates and post-treatment healthcare utilization. Results. The MTE group demonstrated significantly larger reductions in short- and long-term neck disability index scores (mean 1-year difference −5.1, 95% confidence intervals (CI) −8.1 to −2.1; P = 0.001) and short-term cervical VAS scores (mean 6-week difference −14.2, 95% CI −22.7 to −5.6; P = 0.001) as compared to the MIN group. The MTE group also demonstrated significant within group reductions in short- and long-term UE VAS scores at all time periods (mean 1-year difference −16.3, 95% CI −23.1 to −9.5; P = 0.000). At 1-year, patient perceived treatment success was reported by 62% (29 of 47) of the MTE group and 32% (15 of 47) of the MIN group (P = 0.004). Conclusion. An impairment-based MTE program resulted in clinically and statistically significant short- and long-term improvements in pain, disability, and patient-perceived recovery in patients with mechanical neck pain when compared to a program comprising advice, a mobility exercise, and subtherapeutic ultrasound.

The Immediate Effects of Thoracic Spine and Rib Manipulation on Subjects with Primary Complaints of Shoulder Pain

Abstract Shoulder pain is a common orthopedic condition seen by physical therapists, with many potential contributing factors and proposed treatments. Although manual physical therapy interventions for the cervicothoracic spine and ribs have been investigated for this patient population, the specific effects of these treatments have not been reported. The purpose of this investigational study is to report the immediate effects of thoracic spine and rib manipulation in patients with primary complaints of shoulder pain. Using a test-retest design, 21 subjects with shoulder pain were treated during a single treatment session with high-velocity thrust manipulation to the thoracic spine or upper ribs. Post-treatment effects demonstrated a 51% (32mm) reduction in shoulder pain, a corresponding increase in shoulder range of motion (30°-38°), and a mean patient-perceived global rating of change of 4.2 (median 5). These immediate post-treatment results suggest that thoracic and rib manipulative therapy is associated with improved shoulder pain and motion in patients with shoulder pain, and further these interventions support the concept of a regional interdependence between the thoracic spine, upper ribs, and shoulder.

Development of a clinical prediction rule for diagnosing hip osteoarthritis in individuals with unilateral hip pain.

STUDY DESIGN Prospective cohort/predictive validity study. OBJECTIVE To determine the diagnostic accuracy of common clinical examination items and to construct a preliminary clinical prediction rule for diagnosing hip osteoarthritis (OA) in individuals with unilateral hip pain. BACKGROUND The current gold standard for the diagnosis of hip OA is a standing anteroposterior (AP) radiograph of the pelvis. Other than for Altmans criteria, little research has been done to determine the accuracy of clinical examination findings for diagnosing hip OA. METHODS AND MEASURES Seventy-two subjects completed the study. Each subject received a standardized history, physical examination, and standing AP radiograph of the pelvis. Subjects with a Kellgren and Lawrence score of 2 or higher based on the radiographs were considered to have definitive hip OA. Likelihood ratios (LRs) were computed to determine which clinical examination findings were most diagnostic of hip OA. Potential predictor variables were entered into a logistic regression model to determine the most accurate set of clinical examination items for diagnosing hip OA. RESULTS Twenty-one (29%) of the 72 subjects had radiographic evidence of hip OA. A clinical prediction rule consisting of 5 examination variables was identified. If at least 4 of 5 variables were present, the positive LR was equal to 24.3 (95% confidence interval: 4.4-142.1), increasing the probability of hip OA to 91%. CONCLUSION The preliminary clinical prediction rule provides the ability to a priori identify patients with hip pain who are likely to have hip OA. A validation study should be done before the rule can be implemented in routine clinical practice.

Effectiveness of manual physical therapy in the treatment of cervical radiculopathy: a systematic review

Abstract Study design: Systematic review of randomized clinical trials. Objective: Review of current literature regarding the effectiveness of manual therapy in the treatment of cervical radiculopathy. Background: Cervical radiculopathy (CR) is a clinical condition frequently encountered in the physical therapy clinic. Cervical radiculopathy is a result of space occupying lesions in the cervical spine: either cervical disc herniations, spondylosis, or osteophytosis. These affect the pain generators of bony and ligamentous tissues, producing radicular symptoms (i.e. pain, numbness, weakness, paresthesia) observed in the upper extremity of patients with cervical nerve root pathology. Cervical radiculopathy has a reported annual incidence of 83·2 per 100 000 and an increased prevalence in the fifth decade of life among the general population. Results: Medline and CINAHL via EBSCO, Cochrane Library, and Google Scholar were used to retrieve the randomized clinical trial studies for this review between the years of 1995 and February of 2011. Four studies met inclusion criteria and were considered to be high quality (PEDro scores of ⩾5). Manual therapy techniques included muscle energy techniques, non-thrust/thrust manipulation/mobilization of the cervical and/or thoracic spine, soft-tissue mobilization, and neural mobilization. In each study, manual therapy was either a stand-alone intervention or part of a multimodal approach which included therapeutic exercise and often some form of cervical traction. Although no clear cause and effect relationship can be established between improvement in radicular symptoms and manual therapy, results are generally promising. Conclusion: Although a definitive treatment progression for treating CR has not been developed a general consensus exists within the literature that using manual therapy techniques in conjunction with therapeutic exercise is effective in regard to increasing function, as well as AROM, while decreasing levels of pain and disability. High quality RCTs featuring control groups are necessary to establish clear and effective protocols in the treatment of CR.

The Short-Term Effects of Treating Plantar Fasciitis With a Temporary Custom Foot Orthosis and Stretching

STUDY DESIGN Prospective single-group cohort study. OBJECTIVES To identify the effectiveness of a temporary custom foot orthosis (TCFO), followed by a stretching program, for the treatment of plantar fasciitis (PF). BACKGROUND PF, a common cause of heel pain, often leads to disability. Optimal treatment for this often challenging clinical condition is still unknown. METHODS Fifteen individuals with PF were recruited from the general public. All participants received a TCFO and were instructed to wear it for 2 weeks while weight bearing. Following the initial 2 weeks, participants were weaned off of the TCFO and instructed to begin a daily stretching program. Follow-up appointments occurred at 2, 4, and 12 weeks. The primary outcome measures included first-step heel pain via numeric pain rating scale (NPRS), the Foot and Ankle Ability Measure activities of daily living subscale (FAAM-A), and the Foot and Ankle Ability Measure sports subscale (FAAM-S). Secondary outcome included the global rating of change (GRC) score. RESULTS Individuals with a primary complaint of plantar foot pain entered and completed this study. Repeated-measures ANOVAs for the NPRS, FAAM-A, and FAAM-S showed statistically significant changes (P<.001). Post hoc analysis using paired t tests demonstrated statistically and clinically significant change at all follow-up times, compared to the initial intervention (P<.001). Mean GRC scores at 2, 4, and 12 weeks were 4.4, 4.5, and 4.2, respectively. CONCLUSION In treating PF, a TCFO used for 2 weeks, followed by a stretching program, provided preliminary evidence that first-step heel pain and foot and ankle function improve in the short term and up to 12 weeks. LEVEL OF EVIDENCE Therapy, level 2b.

Effectiveness of trigger point dry needling for multiple body regions: a systematic review

Background: Trigger point dry needling (TDN) is commonly used to treat musculoskeletal pain related to myofascial trigger points (MTrPs). To date, no systematic review of high-quality randomised controlled trials (RCTs) investigating TDN to multiple body regions exists. Purpose: The aim of this review is to determine the effectiveness of TDN based on high-quality RCTs for all body regions. Methods: To ensure thorough reporting, Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed as the methodological basis for this systematic review. PubMed, Physiotherapy Evidence Database (PEDro), Cinahl, Cochrane and reference lists were searched for the years 2000–2014 and the terms ‘TDN’, ‘dry needling NOT trigger point’, ‘functional dry needling’ and ‘intramuscular manual therapy’. Inclusion criteria: RCTs with PEDro scores 6–10 investigating TDN. Exclusion criteria: duplicates, non-human participants, non-English language, exclusive focus on acupuncture or medicinal injections. Three investigators searched databases, applied criteria, read and assigned PEDro scores to every RCT. Nineteen studies met the criteria. As compared to either baseline or control groups, significant differences were found for pain (14 studies), range of motion (ROM) (five studies) and at least one item on function and quality of life measures (six studies). Limitations: This review was limited by inclusion criteria, timeframe, language and databases searched. Conclusion: The majority of high-quality studies included in this review show measured benefit from TDN for MTrPs in multiple body areas, suggesting broad applicability of TDN treatment for multiple muscle groups. Further high-quality research is warranted to standardise TDN methods to determine clinical applicability.

The Addition of Cervical Thrust Manipulations to a Manual Physical Therapy Approach in Patients Treated for Mechanical Neck Pain: A Secondary Analysis

STUDY DESIGN Secondary analysis of a randomized clinical trial (RCT). OBJECTIVES To perform a secondary analysis on the treatment arm of a larger RCT to determine differences in treatment outcomes, adverse reactions, and effect sizes between patients who received cervical thrust manipulation and those who received only nonthrust manipulation as part of an impairment-based, multimodal treatment program of manual physical therapy (MPT) and exercise for patients with mechanical neck pain. BACKGROUND A treatment regimen of MPT and exercise has been effective in patients with mechanical neck pain. Limited research has compared the effectiveness of cervical thrust manipulations and nonthrust mobilizations for this patient population, and no studies have investigated the added benefit of cervical thrust manipulations as part of an overall MPT treatment plan. METHODS Treatment outcomes from 47 patients in the treatment arm of a larger RCT, with a primary complaint of mechanical neck pain, were analyzed. Twenty-three patients (49%) received cervical thrust manipulations as part of their MPT treatment, and 24 patients (51%) received only cervical nonthrust mobilizations. All patients received up to 6 clinic sessions, twice weekly for 3 weeks, and a home exercise program. Primary outcome measures were the Neck Disability Index (NDI), 2 visual analog scales for cervical and upper extremity pain, and a 15-point global rating of change scale. Blinded outcome measurements were collected at baseline and at 3-, 6- and 52-week follow-ups. RESULTS Consistent with the larger RCT, both subgroups in this secondary analysis demonstrated improvement in short- and long-term pain and disability scores. Low statistical power (beta< or =.28) and the resultant small effect size indices (-0.21 to 0.17) preclude the identification of any between-group differences. No serious adverse reactions were reported by patients in either subgroup. CONCLUSIONS Clinically meaningful and statistically significant improvements in both subgroups of patients over time suggest that cervical thrust manipulation, as part of the MPT treatment plan, did not influence the results of the treatment arm of the larger RCT from which this study was drawn. Although no between-group differences can be identified, the small observed effect sizes in this study may benefit future studies with sample size estimation for larger RCTs and indicate the need to incorporate clinical prediction rule criteria as a means to improve statistical power. LEVEL OF EVIDENCE Therapy, level 4.

A manual physical therapy approach versus subacromial corticosteroid injection for treatment of shoulder impingement syndrome: a protocol for a randomised clinical trial

Introduction Corticosteroid injections (CSI) are a recommended and often-used first-line intervention for shoulder impingement syndrome (SIS) in primary care and orthopaedic settings. Manual physical therapy (MPT) offers a non-invasive approach with negligible risk for managing SIS. There is limited evidence to suggest significant long-term improvements in pain, strength and disability with the use of MPT, and there are conflicting reports from systematic reviews that question the long-term efficacy of CSI. Specifically, the primary objective is to compare the effect of CSI and MPT on pain and disability in subjects with SIS at 12 months. Design This pragmatic randomised clinical trial will be a mixed-model 2×5 factorial design. The independent variables are treatment (MPT and CSI) and time with five levels from baseline to 1 year. The primary dependent variable is the Shoulder Pain and Disability Index, and the secondary outcome measures are the Global Rating of Change and the Numeric Pain Rating Scale. For each ANOVA, the hypothesis of interest will be the two-way group-by-time interaction. Methods and analysis The authors plan to recruit 104 participants meeting established impingement criteria. Following examination and enrolment, eligible participants will be randomly allocated to receive a pragmatic approach of either CSI or MPT. The MPT intervention will consist of six sessions, and the CSI intervention will consist of one to three sessions. All subjects will continue to receive usual care. Subjects will be followed for 12 months. Dissemination and ethics The protocol was approved by the Madigan Army Medical Center Institutional Review Board. The results may have an impact on clinical practice guidelines. This study was funded in part by the Orthopaedic Physical Therapy Products Grant through the American Academy of Orthopaedic Manual Physical Therapists. Trial Registration http://clinicaltrials.gov/ NCT01190891.