Manual Physical Therapy

It is a chiropractic method that includes an instrument-assisted soft tissue mobilization technique to reduce pain. This method is mostly practised by chiropractors, physical therapists, occupational therapists, licensed massage therapists and athletic trainers.

Comparative analysis between orthopaedic manual therapy and osteopathy : focus on the Belgian situation Summary : Orthopaedic manual therapy (OMT) and osteopathy have been coexisting since a long time in Belgium to manage musculoskeletal disorders (MSDs). There are millions of consultations per year in these both disciplines. Both of them offer good clinical outcomes as well as patient satisfaction with care, good cost-effectiveness , as well as minor side effects. Nevertheless, a major misunderstanding remains in Belgium concerning these both professions. A narrative review by Belgian experts in osteopathy and/or in OMT has been undertake. In Belgium, both professions present several major differences concerning the primary first care access, the recognition as health care profession, tailored reimbursement systems, types and organization of education, the use of rehabilitation and motor control, the integration of evidence based practice concept, the reasons/indications of consultation, the degree of confidence within the therapeutic touch concept. In the meantime, several similarities also exist including the integration of the bio-psycho-social model, the evaluation of the neuromusculoskeletal system and the treatment of MSDs using sometimes identical manual techniques, as well as the use of therapeutic education of the patient and specific clinical reasoning. This analysis may help health professionals, students and patients to better understand the convergences and divergences between these both disciplines of musculoskeletal care in Belgium Résumé : La thérapie manuelle orthopédique (TMO) et l'ostéopathie coexistent depuis longtemps en Belgique pour prendre en charge les troubles musculosquelet-tiques (TMS). On comptabilise des millions de consultations par an pour ces deux disciplines. Chacune offre, à la fois, une bonne satisfaction des patients et une bonne efficacité clinique, un bon rapport coût-efficacité, ainsi que des effets secondaires mineurs. Néanmoins, une mécon-naissance majeure demeure en Belgique au sujet de ces approches thérapeutiques. Une revue narrative rédigée par des experts Belges en ostéopathie et/ou en thérapie manuelle a été réalisée. La TMO et l'ostéopathie pré-sentent plusieurs différences majeures en Belgique. Elles concernent l'accès direct, la reconnaissance comme profession de santé, les systèmes de remboursement, les types et l'organisation de l'enseignement, l'utilisation de la rééducation et du contrôle moteur, l'intégration du concept d' «evidence-based-practice», les motifs/indications de consultation, le degré de confiance dans le toucher à des fins diagnostiques et thérapeutiques. Cependant, plu-sieurs similitudes existent également, dont l'intégration du modèle bio-psycho-social, l'évaluation du système neuro-musculo-squelettique, l'utilisation de techniques manuelles parfois identiques pour le traitement des TMS, une édu-cation thérapeutique du patient ainsi que l'utilisation d'un raisonnement clinique, propre, cependant, à chacune des disciplines. Cette analyse devrait aider les professionnels de la santé, les étudiants, ainsi que les patients à mieux comprendre les convergences et les divergences entre ces deux disciplines en Belgique. Mots-clés : Revue-Thérapie manuelle orthopédique-Kinésithérapie-Ostéopathie-Musculo-squelettique.

Before the term "physical therapy" was coined in the early 20th century by the British Medical Journal, its practices and techniques had already started evolving in different ways throughout the world. The earliest known use dates back to 400 BCE, and has continued firmly in its exercise and massage foundations. Rehabilitative healing does have deep historical roots, but it's importance was not recognized until the latter part of the 18th century. Physical therapy, also known as physiotherapy in other parts of the world, was founded on two major events in the early part of the 19th century: World War I and the polio epidemic. Women were trained by the Army in rehabilitation, loyalty to self and country, and to hold steadfast in their values and contribution to the medical field. The American Medical Association(AMA) dictated the majority of health fields at this time, deciding which professions were legitimate in education and competency and would be beneficial in patient treatment. The professionalization of physical therapy did not occur until the mid-1930s.

Background: In 2016, a systematic review was conducted to examine the effects of physical therapy interventions on individuals with subjective tinnitus. However, the research study investigated subjective tinnitus that may not have had a somatic origin. In addition, only one of the included studies specifically assessed the effectiveness of manual therapy. Objectives: The purpose of this systematic review was to examine the effects of manual therapy techniques on individuals with somatic tinnitus. Methods: A search was performed using the following databases: CINAHL Complete, ProQuest Medical Library, and PubMed. The search terms were "somatic tinnitus" OR "somatosensory tinnitus" AND "manual therapy". An evaluation of the evidence level for each included article was conducted using the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence, and an evaluation of the methodological rigor for each included article was conducted using criteria adapted by Medlicott and Harris. Results: A qualitative synthesis was ultimately performed on eight articles. The manual therapy techniques included in this systematic review were cervical mobilizations, myofascial techniques, osteopathic manipulations, soft tissue techniques, and manual therapy as developed by the School of Manual Therapy Utrecht. This systematic review also included complementary treatment approaches such as patient education, therapeutic exercise, transcutaneous electrical neurostimulation, and home exercise programs. Conclusion: Manual therapy appears to be an effective intervention for individuals with somatic tinnitus, especially if they have co-varying tinnitus or tinnitus sensitization. In addition, a multimodal intervention approach may be the ideal way in which to positively impact an individual's activities of daily living.

Objective: The purpose of this scoping review was to identify any available evidence regarding T4 syndrome. Methods: Databases were searched from inception through October 2015 and included PubMed, CINAHL, PEDro, Google Scholar, Osteomed-DR; Index to Chiropractic Literature, PROSPERO, and Chiroaccess. All studies with information about T4 syndrome that were published in a peer-reviewed journal or textbook were included. The information was organized in the format of the International Classification of Functioning, Disability, and Health. Studies were ranked using Sackett's levels of evidence. Results: Eight articles met the inclusion criteria. Studied areas included theoretical pathophysiology and symptom etiology, diagnosis, symptoms, treatment, and outcomes of T4 syndrome. The methodological quality of included studies was low. Conclusion: T4 syndrome is a diagnosis of exclusion that appears to be rare. It has been treated conservatively in the literature using mobilization and exercise. There is no high-quality evidence published about T4 syndrome, and we caution clinicians when considering it as a primary means to determine patient care. (J Manipulative Physiol Ther 2017;40:118-125)

STUDY DESIGN:
Systematic literature review and meta-analysis.
OBJECTIVE:
IN SYMPTOMATIC SUBJECTS TO: (1) examine the effects of a single session of joint mobilization on pain at rest and with most painful movement, and (2) compare the effects when joint mobilization is provided to a specific or non-specific spinal level.
BACKGROUND:
Joint mobilization is routinely used for treating spinal pain in conjunction with other interventions, but its unique effect is not well understood. Further, there is controversy about the role of 'specific level' techniques in producing benefit.
METHODS:
Searches were performed for randomized controlled trials (RCTs) using electronic databases (MEDLINE, CINAHL, and PEDro) from 1966 through November 2010. Methodological quality was assessed using previously detailed criteria. Meta-analysis and meta-regression were conducted on eligible studies.
RESULTS:
Eight RCTs with a mean methodological score of 10/12 were included. Significant heterogeneity (P = 0.075) was found in the overall meta-analysis estimate. When stratified by body location, no significant individual effect was found for pain at rest. However, there was a statistical mean difference [0.71 (95% confidence interval: 0.13-1.28)] between pain at rest for the cervical and lumbar individual means.
CONCLUSIONS:
We found multiple studies which provided evidence that a single session of joint mobilization can lead to a reduction of pain at rest and with most painful movement. When using joint mobilization, the need for specific versus non-specific level mobilization may be influenced by anatomical region; the direction of effect in the cervical spine was toward specific mobilization and in the lumbar spine towards non-specific mobilization.
KEYWORDS:
Pain; Specific level; Spinal mobilization

Έργα του ιδίου : α. Ανάκτορα των Μεγάλων Κομνηνών στην Τραπεζούντα -«ıç kale» (Η οχύρωση -Τα ερείπια) -Σωζόμενες τοιχογραφίες στα παρεκκλήσια της Ακροπόλεως (επιτόπια έρευνα) β. «Άλωσις της Μητροπόλεως Τραπεζούντος» -Κείμενο -Σχόλια (Από τον Κτητορικό Κώδικα της Μονής Βαζελώνος του 1665) γ. Τα Βυζαντινά Μνημεία της Τραπεζούντος -Περιγραφή -Οδηγός πρόσβασης δ. Στα βήματα των Περιηγητών -στα 'χνάρια των Αποστόλων -Οδοιπορικό στα Μεγάλα Κέντρα της Μικράς Ασίας: -Πόντος, Ιωνία, Κιλικία, Καππαδοκία, -Ευφράτης, Ahtamar, Nemrüd (βιντεοκασέτες μικρού μήκους προς εκπαδευτική χρήση ) ε. Ανύτης της Τεγεάτιδος Επιγράμματα -Εισαγωγή -Κείμενα -Μετάφραση -Σχόλια στ. Το Άσμα του Αρμούρη και η Κάθοδος των Σλάβων -Εισαγωγή -Κείμενο -Μετάφραση (από τα χειρόγραφα Ιβήρων και Κουτλουμουσίου) ζ. Η Πολιορκία της Κωνσταντινούπολης από τους Αβάρους και ο «Ακάθιστος Ύμνος» -Άρθρο στο Διαδίκτυο Τα μεν καλώς γραφέντα, φθόνου μη μετεχέτω. Τα δε αγνοηθέντα διορθώσεως υπό των δυνατοτέρων τυγχανέτω (Διόδωρος Σικελιώτης) ΠΕΡΙΕΧΟΜΕΝΑ Έργα του ιδίου 3 Έγκριση του ΥΠΕΠΘ 4 Περιεχόμενα 5 Βιβλιογραφία 6 Αντί Προλόγου 7 Α ΕΙΣΑΓΩΓΙΚΑ 8 Β ΠΑΣΧΑΛΙΝΕΣ «ΑΚΟΛΟΥΘΙΕΣ» ΜΕ ∆ΡΑΜΑΤΙΚΗ ∆ΟΜΗ 13 1 Πρόδρομοι του Λειτουργικού ∆ράματος 15 α. ∆ρώμενα στο Μυστήριο του Βαπτίσματος 15 β.∆ρώμενα στο Μυστήριο του Βαπτίσματος 15 γ. Απόπειρες ∆ραματοποίησης της Λειτουργίας 16 δ.∆ρώμενα στο Μυστήριο του Βαπτίσματος 15 2 Απ την «Εις Άδου Κάθοδο» στα «Συμπόσια» 19 α. Η«Εις Άδου Κάθοδος» και το ∆ράμα «Άρατε Πύλας»19 β. Η Τελετή της «Πρώτης Ανάστασης» 20 γ. Από την Μεγάλη Είσοδο στα «Συμπόσια» ή «Μυστήρια» 21 δ. Το κείμενο «Συμπόσιο των ∆έκα Παρθένων» 22 ε. Οι «∆ιαλέξεις» ως ∆ραματικά Κείμενα 23 3 Παρακμή των «Συποσίων» Ο «Κύκλος των Παθών» 27 α. Παντομίμες και ∆ρώμανα σε επαρχίες της Ανατολής 27 β. «Τελετή του Ιερού Νιπτήρα» πρώτο Λειτουργικό ∆ράμα 27 γ. «∆ίκη και Καταδίκη του Χριστού» ως Λειτουργικό ∆ράμα 29 δ. «Πομπή μέχρι τον Γολγοθά»-Πρώιμο Λειτουργικό ∆ράμα 29 ε. Αρμενία, Πόντος, Καππαδοκία, Κρήτη 30 4 Απ την Πομπή του Επιταφίου στο «Μη μου Άπτου» 33 α. ∆ρώμενα στη Λιτάνευση του Επιταφίου 33 β. Από τον Κύκλο των Μυροφόρων στο «Μη μου Άπτου» 33 γ. Από το «Μη μου Άπτου» στο «Quem quaeritatis» 35 δ. Το Πεντάπρακτο της Μ. Τετάρτης «Η Αμαρτωλή» 36 ε. Από την «Ανάταση του Λαζάρου» στη «Βαϊοφόρο» 38 5 Απ τους «Θρήνους» στα δραματοποιημένα σενάρια 42 α. «Θρήνος»: αυτοσχέδιο θρηνητικό τραγούδι 42 β.Το «Κοσμοσωτήριον Πάθος -Τραγωδία κατ' Ευριπίδην» 42 γ. Επίδραση του «Κοσμοσωτηρίου Πάθους» σε Ανατολή και ∆ύση 44 δ. Από τους «Θρήνους» στο «Καταλόι της Παναγιάς» 45 ε. Αρμενία, «Βυζαντιακή Σκηνική ∆ιάταξις των Παθών» 45 στ. Ο «Κύκλος των Παθών» στη ∆υτική Ευρώπη 46 Γ ΘΕΜΑΤΑ ΑΠΟ ΤΗΝ ΑΓΙΑ ΓΡΑΦΗ ΚΑΙ ΤΗ ΖΩΗ ΤΗΣ ΕΚΚΛΗΣΙΑΣ ΜΕ ∆ΡΑΜΑΤΙΚΗ ∆ΟΜΗ 48 1 Θέματα απ την Παλαιά ∆ιαθήκη 49 α. «Τρεις Παίδες», «∆ανιήλ», «Σωσάνα» 49 β.Τα Σενάρια της «Οκτατεύχου» και η «Εξαγωγή» 50 γ. Το ∆ράμα «Στίχοι εις Αδάμ» 52 δ.»Θυσίες» στην Π.∆. -«Η Θυσία του βραάμ» 53 ε.»Ανάληψη του Προφήτη Ηλιού» 54 2 Ο «Κύκλος των Ακινήτων Εορτών» του ενιαυτού 56 α. Το «∆ωδεκαήμερο» και ο ∆εσποτικός Κύκλος»56 β. Ο «Θεομητορικός Κύκλος» 58 3 «Μαρτύρια» -«Βίοι» -«Θαύματα» («miracles») 62 α. ∆ραματοποιημένοι «»Βίοι Αγίων» 62 β. Τριλογία «Κυπριανός και Ιουστίνα» 63 γ. Από τους «Βίους» στα «Θαύματα» 63 δ. Hroswitha: Το Βυζαντινό Λειτουργικό ∆ράμα στη ∆ύση 64 ∆ ΠΕΡΙΕΧΟΜΕΝΟ ΚΑΙ ∆ΟΜΗ ΤΟΥ «ΛΕΙΤΟΥΡΓΙΚΟΥ ∆ΡΑΜΑΤΟΣ» 66 1 Ένα Καινούργιο Είδος -με Αρχαίες Ρίζες 67 α. ∆ιαφορετικές συνθήκες -Νέο Περιεχόμενο του «∆ράματος» 67 β.Ομοιότητες και ∆ιαφορές στη δομή 68 γ. Εκφρασιτά μέσα (κωμικοί διάλογοι -χωρίς προσωπείο) 69 δ.Σκευοφυλακεία -Σεκρέτα 70 ΛΙΓΑ ΛΟΓΙΑ ΩΣ ΕΠΙΛΟΓΟΣ 73 SUMMARY 74

Background and Purpose:
Chronic lateral hip and thigh pain is regularly treated by the physical therapist. Many issues can cause
pain in this region, and trigger points may contribute to pain. Dry Needling (DN) is an intervention used by physical therapists
where a monofilament needle is inserted into soft tissue to reduce pain thereby facilitating return to prior level of function. The purpose of this case series is to report the outcomes of DN and conventional physical therapy as a treatment intervention for
subjects with chronic lateral hip and thigh pain.

Case Descriptions:
Four subjects with chronic lateral hip and thigh pain attended between four and eight sixty-minute sessions
of dry needling and stretching/ strengthening activities over a four to eight week intervention course. Outcomes were tested at
baseline and upon completion of therapy. A long-term follow up averaging 12.25 months (range 3 to 20 months) was also performed.
The outcome measures included the Visual Analog Scale (VAS) and the Lower Extremity Functional Scale (LEFS).

Outcomes:
The LEFS and VAS indicated clinically meaningful improvements in disability and pain in the short term and upon long
term follow up for each subject. The LEFSmean for the four subjects improved from 50.75 at baseline to 66.75 at the completion of treatment. At long-term follow-up, the LEFSmean was 65.50. Each subject met the minimal clinically important difference (MCID) and
minimal detectable change (MDC) for the LEFS and the VAS. The VAS was broken down into best (VASB), current (VASC), and worst
(VASW) rated pain levels and averaged between the four subjects. The VASB improved from 20 mm at the initial assessment to 0 mm
upon completion of the intervention duration. The VASC improved from 25.75 mm to 11.75 mm, and the VASW improved from 85 mm to 32.5 mm. At the long-term follow up (average 12.25 months), the VASB, VASC, and VASW scores were 0 mm, 14.58 mm, and 43.75 mm respectively.

Discussion:
Clinically meaningful improvements in pain and disability were noted. Subjects reported improved sleep and functional
mobility, which were commensurate with their different age ranges and initial reported limitations in mobility. The results
of this case series show promising outcomes for the use of dry needling in the treatment of chronic lateral hip and thigh pain.
Further controlled clinical trials are recommended to determine the effectiveness of adding dry needling as compared to other
interventions for chronic lateral hip and thigh pain.

Level of Evidence: Level 4.

Keywords: Dry Needling, hip pain, iliotibial band, trochanteric bursitis

Spinal manipulation (SMT) is commonly used for treating individuals experiencing musculoskeletal pain. The mechanisms of SMT remain unclear; however, pain sensitivity testing may provide insight into these mechanisms. The purpose of this systematic review is to examine the literature on the hypoalgesic effects of SMT on pain sensitivity measures and to quantify these effects using meta-analysis. We performed a systematic search of articles using CINAHL, MEDLINE, PsycINFO, and SPORTDiscus from each databases' inception until May 2011. We examined methodological quality of each study and generated pooled effect size estimates using meta-analysis software. Of 997 articles identified, 20 met inclusion criteria for this review. Pain sensitivity testing used in these studies included chemical, electrical, mechanical, and thermal stimuli applied to various anatomical locations. Meta-analysis was appropriate for studies examining the immediate effect of SMT on mechanical pressure pain threshold (PPT). SMT demonstrated a favorable effect over other interventions on increasing PPT. Subgroup analysis showed a significant effect of SMT on increasing PPT at the remote sites of stimulus application supporting a potential central nervous system mechanism. Future studies of SMT related hypoalgesia should include multiple experimental stimuli and test at multiple anatomical sites.

Neck pain is a common complaint treated by the physical therapist. Trigger points (TrPs) have been studied as a source of neuromusculoskeletal pain, though the ability of clinicians to accurately locate a TrP is not well supported. Dry needling (DN) is an intervention utilized by physical therapists where a monofilament needle is inserted into soft tissue in order to reduce pain thereby facilitating return to prior level of function. The purpose of this case report is to report the outcomes of DN as a primary treatment intervention for acute, non-specific cervical region pain.

Global posture is a good indicator of general musculoskeletal health. Prevalence and incidence of musculoskeletal disorders and injuries, and in particular low back pain, is rapidly rising on a global scale. The tightness or spasm Quadratus Lumborum muscle is a common cause for non-specific low back pain and is also closely connected to postural deviations and faulty movement patterns. Having a more complete, holistic and encompassing view of postural deviations will give the clinician more information to put into the clinical reasoning process. A more efficient and effective treatment plan with long-term results is usually the result. We propose Global Posture Systems Therapeutic Pathways as possible solution to more effectively and efficiently treat musculoskeletal disorders and injuries. In this paper we explain the concept in more detail using a case of a chronically tight Quadratus Lumborum muscle that causes low back pain and functional issues. It is also the cause of important postural deviations. At the centre of the GPS Therapeutic Pathways concept lies a thorough static posture assessment. This provides the clinician information on which systems affect posture and how this affects an injury or injury risk. It forms the basis for choosing the right GPS Therapeutic Pathway. A first pathway focusses on autogenic relaxation, breathing techniques, myofascial release and stretching using the innovative therapeutic couch, Mi.TO/Sinthesi. In a second phase we stimulate pain modulation and cellular regeneration with a capacitive and resistive energy transfer technology, TCare. A third pathway assists the clinician in being able to suit each type of therapeutic exercise exactly to the patient's needs using various configurations of suspension slings and pulleys; the Archimedes Pulley System with BlueCord Exercise System. Lastly new and healthy movement and posture patterns are integrated in every day living activities using a variety of proprioceptive and integrative exercise tools. Conclusion: When comparing the before and after digital images recorded with the GPS Postural Lab we can clearly see improvement in the patient's posture indicating that the chronically tight Quadratus Lumborum muscle has been effectively released and lengthened. We conclude that GPS Therapeutic Pathways is a very interesting concept that is cost-effective, able to be applied to many different types of neuromusculoskeletal disorders and can be integrated in modern rehabilitation and physical therapy centres.

Background & Purpose: The Physical Therapy (PT) profession has undergone a significant evolution both in education and scope of practice over the last 4 decades.  Healthcare policy within the United States (US) typically restricts PTs from ordering imaging.  However, it is unknown how healthcare policy in the US compares to other World Confederation for Physical Therapy (WCPT) member nations (MN).  We aimed to investigate the rights of PTs to order imaging studies and to evaluate its association to direct access policy within WCPT MNs. 
Methods: 111 WCPT MNs were polled via email or Facebook on the healthcare policy of PTs ordering diagnostic imaging within their nation.  A secondary analysis was performed to see if multiple variables (including direct access authorization) were associated with diagnostic imaging privileges. 
Results: 81 MNs provided information on their diagnostic imaging policies.  31 (39.2%) of MNs reported having some level of diagnostic imaging authority while 48 (60.8%) denied such authority.  MNs with direct access authorization were significantly more likely to allow diagnostic imaging.  MNs with PT diagnostic imaging spent significantly less per capita on healthcare compared with MNs that restricted imaging.  Diagnostic imaging was significantly more likely to be authorized in MNs with a male majority PT profession. 
Discussion: Advancements in US PT scope of practice have been realized in recent years including an expansion of direct access legislation.  While the WCPT tracks many data points including direct access, it currently does not report on its members’ ability to order diagnostic imaging.  It is notable the calculations within this manuscript are associative in nature and are not meant to indicate causation. 
Conclusion: This is the first study to report diagnostic imaging policy within the WCPT MNs.  We recommend the WCPT begins to track diagnostic imaging policy within their MNs.

Trigger  points  in  cervical  region  muscles  is  mostly  associated  with  tension  type  headache
(T.T.H).Trigger points can be managed immediately by Ischemic compression and positional release
therapy (PRT). A 62 year female who was suffering tension type headache from last 14 months was
treated by combined positional release therapy and ischemic compression in 6 sessions. She had
constant dull pain aggravated by the activities that include neck side bending and neck side rotation
either on left or right side.  At the completion of last session patient has reported her headache
stopped completely. During the duration following 10 months of treatment she had no pain and did
not use any medication for headache. Ischemic compression and PRT are effective in treating
cervicogenic headache that have underlying cause of trigger points.

A 63-yr-old woman reported to an outpatient physical therapy clinic with a 1-yr history of right-sided neck pain that was insidious at onset. The patient's symptoms presented as an intermittent ache with numbness and tingling radiating down the right upper limb to the dorsal aspect of the hand. In the previous month, the patient had developed transient weakness of both arms affecting the right side greater than the left. Her symptoms were exacerbated by lying on her right side, right cervical rotation, overhead extension of arms, and use of a computer mouse. She also had a 1-yr history of globus sensation that was noted initially at the same time as her onset of neck pain. She described these symptoms as a "lump in her throat," hoarseness, and tightness/pressure. The globus sensation was worse when lying supine on a pillow and was intermittently associated with dysphagia.

The patient's previous medical history included hypertension, gastroesophageal reflux disease, and vertigo. Laboratory values for thyroxine and thyroid-stimulating hormone were within reference limits. Previous laryngoscopy was significant for erythema and edema of the posterior commissure and the arytenoid complex. The patient was prescribed Omeprazole, which alleviated the burning symptoms from her gastroesophageal reflux disease but did not change the globus sensation.

Cervical active range of motion was within functional limits in all planes. Strength testing, sensation, and deep tendon reflexes for the upper or lower limbs were within normal limits. Clonus, Babinski sign, and Hoffmann's reflex were not present. Gait and hand dexterity were normal. Posterior-to-anterior pressure applied to the C4 spinous process was significant for instant reproduction of the globus sensation. The latent reproduction of neck pain and right upper limb numbness was appreciated after the C4 palpation.

Cervical radiographs demonstrated multilevel spondylosis contributing to a grade I to II anterolisthesis of C4 on C5 vertebrae (Fig. 1A). Magnetic resonance imaging also demonstrated a grade I to II anterolisthesis of C4 on C5 vertebrae, a grade I retrolisthesis of C5 on C6 vertebrae, and an associated broad disc bulging causing mild central canal narrowing (Fig. 1B). The patient was referred to a spinal surgeon but ultimately refused surgical intervention.

Cervical induced deglutition disorders have been widely reported in the literature, stemming from both anterior vertebral osteophytosis1,2 and thickness of the anterior cervical fusion hardware.3 To our knowledge, we are not aware of any reports of globus sensation arising from a cervical spondylolisthesis. It is reasonable to assume that sagittal displacement of the cervical spine is capable of altering esophageal alignment, thus inducing a globus sensation or a deglutition disorder. Cervical pathology including anterior osteophytosis and spondylolisthesis should be considered in the differential diagnosis of patients with a globus sensation or deglutition disorders.

STUDY DESIGN:
Single-blind randomized trial.
OBJECTIVES:
To compare the effects of cervical and shoulder thrust manipulation (TM) and exercise on pain sensitivity, and to explore associations with clinical outcomes in patients with shoulder pain.
BACKGROUND:
Experimental studies indicate that spinal TM has an influence on central pain processes, supporting its application for treatment of extremity conditions. Direct comparison of spinal and peripheral TM on pain sensitivity has not been widely examined.
METHODS:
Seventy-eight participants with shoulder pain (36 female; mean ± SD age, 39.0 ± 14.5 years) were randomized to receive 3 treatments of cervical TM (n = 26), shoulder TM (n = 27), or shoulder exercise (n = 25) over 2 weeks. Twenty-five healthy participants (13 female; mean ± SD age, 35.2 ± 11.1 years) were assessed to compare pain sensitivity with that in clinical participants at baseline. Primary outcomes were changes in local (eg, shoulder) and remote (eg, tibialis anterior) pressure pain threshold and heat pain threshold occurring over 2 weeks. Secondary outcomes were shoulder pain intensity and patient-rated function at 4, 8, and 12 weeks. Analysis-of-variance models and partial-correlation analyses were conducted to examine comparative effects and the relationship between measures.
RESULTS:
At baseline, clinical participants demonstrated lower local (mean difference, - 1.63 kg; 95% confidence interval [CI]: -2.40, -0.86) and remote pressure pain threshold (mean difference, -1.96 kg; 95% CI: -3.09, -0.82) and heat pain threshold (mean difference, -1.15°C; 95% CI: -2.06, -0.24) compared to controls, suggesting enhanced pain sensitivity. Following intervention, there were no between-group differences in pain sensitivity or clinical outcome (P>.05). However, improvements were noted, regardless of intervention, for pressure pain threshold (range of mean differences, 0.22-0.32 kg; 95% CI: 0.03, 0.43), heat pain threshold (range of mean differences, 0.30-0.58; 95% CI: 0.06, 0.96), pain intensity (range of mean differences, -1.79 to -1.45; 95% CI: -2.34, -0.94), and function (range of mean differences, 3.15-3.82; 95% CI: 0.69, 6.20) at all time points. We did not find an association between pain sensitivity changes and clinical outcome (P>.05). Conclusion Clinical participants showed enhanced pain sensitivity, but did not respond differently to cervical or peripheral TM. In fact, in this sample, cervical TM, shoulder TM, and shoulder exercise had similar pain sensitivity and clinical effects. The lack of association between pain sensitivity and clinical pain and function outcomes suggests different (eg, nonspecific) pain pathways for clinical benefit following TM or exercise.
LEVEL OF EVIDENCE:
Therapy, level 1b.

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.

Purpose / Hypothesis:
The Physical Therapy profession has undergone a significant evolution in education and scope of practice over the last 4 decades. Multiple studies have shown physical therapists (PTs) to have superior knowledge of orthopedic diagnosis and treatment when compared to other health care professions. When authorized, PTs tend to order imaging more appropriately and with reduced costs compared to traditional care. Despite this, health care policy within the United States (US) typically restricts PTs from ordering imaging; however, it is unknown how this compares to other World Confederation for Physical Therapy (WCPT) member nations (MN). We aimed to investigate the rights of PTs to order imaging studies and to search for associations within WCPT MNs.
Subjects:
111 WCPT Member Nations.
Materials / Methods:
All 111 WCPT MNs were electronically polled on the health care policy of PTs ordering diagnostic musculoskeletal (MSK) imaging within their nation. A secondary analysis was performed to see if multiple variables were associated with MSK imaging privileges. A binary logistic regression model was developed to determine if there were any independent variables which were associated with a country’s policy regarding physical therapists ordering MSK imaging procedures. Data were entered into the model with a forward stepwise regression procedure, using the likelihood ratio method. The Hosmer-Lemeshow goodness-of-fit test was used to evaluate the fit of the model.
Results:
81 MNs responded to the poll. 31 (39.2%) of MNs reported having some level of MSK imaging authority while 48 (60.8%) denied such authority. 39 countries had a complete data set for all possible variables included in the stepwise analysis. Completion of the regression found two variables to be significant predictors for MSK imaging rights. Using 67 countries which contained the full data-set for these predictors, it was found that per capital healthcare costs, (p < .05, Exp(β) 0.683, 95% C.I. 0.495, 0.941) and direct access rights (p < .05, Exp(β) 7.397, 95% C.I. 1.928, 28.379) were both significant predictors of MSK imaging authority.
Conclusions:
These results represent the first report of a substantial international mapping of MSK imaging rights to PTs. While lower health care expenditures were significantly associated in MNs that allowed PTs to order MSK imaging, it is unclear why this association exists. Similarly, direct access privileges and MSK imaging privileges showed a significant association, though it is unclear which privilege might be a catalyst for the other. Looking within the MNs that have both of these privileges and the order in which they were authorized may give better perspective on how to advance physical therapy practice.

Clinical Relevance:
Our study shows that PTs in many WCPT MNs are unable to order MSK imaging, despite overwhelming evidence to show the superiority of the PT profession in managing orthopedic conditions. Future studies should consider a more comprehensive questionnaire on musculoskeletal imaging policy to include issues such as origin of restrictive policies (i.e. governmental vs. healthcare institute), insurance reimbursement, private vs. public sector policy, and limitations on imaging modality.

Background: Muscle-biased therapies (MBT) are commonly used to treat pain, yet several reviews suggest evidence for the clinical effectiveness of these therapies is lacking. Inadequate treatment parameters have been suggested to account for inconsistent effects across studies. Pain sensitivity may serve as an intermediate physiologic endpoint helping to establish optimal MBT treatment parameters. The purpose of this review was to summarize the current literature investigating the short-term effect of a single dose of MBT on pain sensitivity in both healthy and clinical populations, with particular attention to specific MBT parameters of intensity and duration. Methods: A systematic search for articles meeting our prespecified criteria was conducted using Cumulative Index to Nursing and Allied Health Literature (CINAHL) and MEDLINE from the inception of each database until July 2012, in accordance with guidelines from the Preferred Reporting Items for Systematic reviews and Meta-Analysis. Relevant characteristics from studies included type, intensity, and duration of MBT and whether short-term changes in pain sensitivity and clinical pain were noted with MBT application. Study results were pooled using a random-effects model to estimate the overall effect size of a single dose of MBT on pain sensitivity as well as the effect of MBT, dependent on comparison group and population type. Results: Reports from 24 randomized controlled trials (23 articles) were included, representing 36 MBT treatment arms and 29 comparative groups, where 10 groups received active agents, 11 received sham/inert treatments, and eight received no treatment. MBT demonstrated a favorable and consistent ability to modulate pain sensitivity. Short-term modulation of pain sensitivity was associated with short-term beneficial effects on clinical pain. Intensity of MBT, but not duration, was linked with change in pain sensitivity. A meta-analysis was conducted on 17 studies that assessed the effect of MBT on pressure pain thresholds. The results suggest that MBT had a favorable effect on pressure pain thresholds when compared with no-treatment and sham/inert groups, and effects comparable with those of other active treatments. Conclusion: The evidence supports the use of pain sensitivity measures by future research to help elucidate optimal therapeutic parameters for MBT as an intermediate physiologic marker.

There is evidence that temporomandibular disorder (TMD) may be a contributing factor to cervicogenic headache (CGH), in part because of the influence of dysfunction of the temporomandibular joint on the cervical spine. The purpose of this randomized controlled trial was to determine whether orofacial treatment in addition to cervical manual therapy, was more effective than cervical manual therapy alone on measures of cervical movement impairment in patients with features of CGH and signs of TMD. In this study, 43 patients (27 women) with headache for more than 3-months and with some features of CGH and signs of TMD were randomly assigned to receive either cervical manual therapy (usual care) or orofacial manual therapy to address TMD in addition to usual care. Subjects were assessed at baseline, after 6 treatment sessions (3-months), and at 6-months follow-up. 38 subjects (25 female) completed all analysis at 6-months follow-up. The outcome criteria were: cervical range of movement (including the C1-2 flexion-rotation test) and manual examination of the upper 3 cervical vertebra. The group that received orofacial treatment in addition to usual care showed significant reduction in all aspects of cervical impairment after the treatment period. These improvements persisted to the 6-month followup, but were not observed in the usual care group at any point. These observations together with previous reports indicate that manual therapists should look for features of TMD when examining patients with headache, particularly if treatment fails when directed to the cervical spine.

Background: Mechanical neck pain is soreness that rises from the posterior element of the cranium and travels toward the decrease cervical spine and shoulders. In this discomfort, vertebral arrangements are disturbed and the joints of the cervical spine and ribs fail to perform the correct biomechanical movements resulting in reduced mobility, which creates pain. In this study, Mulligan sustained natural apophyseal glides (SNAGS) and natural apophyseal glides (NAGS) will be applied in mechanical neck pain subjects to reduce the immobility and relieve pain. Aims & Objectives: The main objective of the research is to compare the effectiveness of Mulligan SNAGs and NAGs in reducing immobility and relieving pain in patients suffering from mechanical neck pain. Methodology: A randomized clinical trial with simple random sampling by random number table was conducted. A sample size of 50 (n=50) subjects was taken from physiotherapy department of Madinah Teaching Hospital, who fulfilled the selection criteria and was distributed into two equal groups of (A-B) twenty-five (25) each. The researcher signed a prior informed consent from all participants before any inspection or examination. The base line treatment is same for both groups, which is the range of motion, strengthening exercises and group A will receive Mulligan SNAGS while group B will receive Mulligan NAGS. Treatment frequency was three times per week for two weeks. Subjects were assessed at the start of the management and at the completion of second week. Whole data was collected using Wong-Baker faces pain scale (WBFPS) and Neck disability index (NDI) to asses change in pain intensity and data was analyzed by SPSS version 20. Results: Pain intensity after treatment with SNAGs (df = 48, p<0.05). Pain intensity with NAGs has (df = 48, p<0.05). Pain intensity after treatment with SNAGs was lower (Mean=3.16) than after NAGs treatment (Mean=3.36) this proves that Mulligan's SNAGs is more effective in case of mechanical neck pain than Mulligan's NAGs. Conclusion: The study concluded that Mulligan's SNAGs are more effective than in comparison to Mulligan's NAGs but at some point, both techniques gave significant results.

• Incidence: Hip/groin pain are among the most common
causes of lost playing time in soccer players.
• Differential Diagnosis: Intrinsic hip-region etiologies
are common, however, hip pain and weakness can also
present with somatic referrals of the lumbar spine.
Lumbar mediated neurogenic inhibition of the hip
musculature can lead to an intrinsic hip injury.
• Purpose: To describe a patient with hip-region pain
whose symptoms did not respond to hip-centric
treatment but improved with lumbar spine intervention.

Background In patients with chronic nonspecific low back pain (NCLBP), brain function changes due to the neuroplastic changes in different regions. Aim The current study aimed to evaluate the brain metabolite changes after spinal manipulation, using proton magnetic resonance spectroscopy (1 H-MRS). Methods In the current study, 25 patients with NCLBP aged 20-50 years were enrolled. Patients were randomly assigned to lumbopelvic manipulation or sham. Patients were evaluated before and 5 weeks after treatment by the Numerical Rating Scale (NRS), the Oswestry Disability Index (ODI), and 1 H-MRS. Results After treatment, severity of pain and functional disability were significantly reduced in the treatment group vs. sham group (p < 0.05). After treatment, N-acetyl aspartate (NAA) in thalamus, insula, dorsolateral prefrontal cortex (DLPFC) regions, as well as choline (Cho) in the thalamus, insula, and somatosensory cortex (SSC) regions, had increased significantly in the treatment group compared with the sham group (p < 0.05). A significant increase was further observed in NAA in thalamus, anterior cingulate cortex (ACC), and SCC regions along with Cho metabolite in thalamus and SCC regions after treatment in the treatment group compared with the baseline measures (p < 0.05). Also, a significant increase was observed in Glx (glutamate and glutamine) levels of thalamus (p = 0.03). There was no significant difference in terms of brain metabolites at baseline and after treatment in the sham group. Conclusion In the patient with low back pain, spinal manipulation affects the central nervous system and changes the brain metabolites. Consequently, pain and functional disability are reduced.

Study Design: Experimental same subject design. Objective: To determine the efficacy of addition of horizontal waist strap to the traditional double shoulder strap school bag on cervical and shoulder posture in Indian school going children. Methods: A total of 60 school children aged 10-16 years were randomly selected from CBSE affiliated schools in Delhi, which participated in this study. Each child's body weight, height, and school bag weight were measured. Posture was measured in the form of three angles: (1) CVA, (2) CHA, (3) SSP, from the sagittal plane and recorded photographically under two different types of backpacks: (1) Double Shoulder Strap Backpack and, (2) Additional Waist Strap Backpack, each backpack had three conditions: (1) unloaded 0% body weight, (2) Static with 10% body weight, (3) post dynamic with 10% body weight. Data analysis: Comparison of postural angles was done between the two types of backpacks and between the three types of loading conditions. The significance of changes in data for the loading conditions was estimated using repeated measure analysis of variance on each angle with which planned contrast were made of the unloaded condition with each of two other loaded condition. The significance of changes in data for the two types of backpacks was estimated using paired t-test on each angle with which planned contrast were made of similar loading conditions between the backpacks. Statistical test were considered significant if p=0.05. Results: The changes in the postural angles with backpack loading were found to be less significant in backpack with additional waist strap as compared to double shoulder strap backpack. A significant change in postural angle was found in 2 loading conditions, static loading (10% BW) and dynamic loading (10% BW) when comparing with unloaded condition. Results revealed that using a backpack with additional waist strap to a traditional double shoulder strap backpack can bring significantly less changes in cervical and shoulder posture. Conclusion: The results of the study suggests that addition of horizontal waist strap to the traditional double shoulder strap backpack loading with 10% body weight reduces the changes in cervical and shoulder postures as compared with the traditional double shoulder strap backpack loading with 10% body weight.

To cite this article: Steve Karas, Paul Mintken & Jean-Michel Brismée (2018) We need to debate the value of manipulative therapy and recognize that we do not always understand from what to attribute our success, Journal of Manual & Manipulative Therapy, 26:1, 1-2,

Objective: The purpose of this scoping review was to identify any available evidence regarding T4 syndrome. Methods: Databases were searched from inception through October 2015 and included PubMed, CINAHL, PEDro, Google Scholar, Osteomed-DR; Index to Chiropractic Literature, PROSPERO, and Chiroaccess. All studies with information about T4 syndrome that were published in a peer-reviewed journal or textbook were included. The information was organized in the format of the International Classification of Functioning, Disability, and Health. Studies were ranked using Sackett's levels of evidence. Results: Eight articles met the inclusion criteria. Studied areas included theoretical pathophysiology and symptom etiology, diagnosis, symptoms, treatment, and outcomes of T4 syndrome. The methodological quality of included studies was low. Conclusion: T4 syndrome is a diagnosis of exclusion that appears to be rare. It has been treated conservatively in the literature using mobilization and exercise. There is no high-quality evidence published about T4 syndrome, and we caution clinicians when considering it as a primary means to determine patient care.

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, EM-BASE. 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.

Low back pain (LBP) is associated with dysfunction of global and local muscle systems, feedback and feedforward postural control mechanisms. Physiotherapists include the use of feedback as part of treatment protocols. Such feedback can focus on a variety of neuromuscular impairments, although the literature related to feedback on the management of LBP has focused mainly on local muscle system impairments. Furthermore, there are various characteristics of feedback that can lead to motor control enhancement or deterioration. The aim of this manuscript is to present a rationale for feedback provision as a rehabilitation tool on the management of LBP. Feedback provision should focus on the main neuromuscular impairment presented by the patient. The suggested rationale describes decision-making stages for the use and progress of feedback interventions. Local muscle system impairment might benefit more from parameter feedback provision, while global muscle system and feedback mechanism im...

Background: Hamstring tightness is one of the musculoskeletal disorders emerging due to shift in life style. The current life styles leave the community with extensibility of body systems at risk of decline and deconditioning including muscular system. Aim: To compare effect of Mulligan Bent Leg Raise Technique and Mulligans' Traction Straight Leg Raise Technique in improving the performance of hamstring muscle. It was a quasi-experimental study. Methodology: Total 20 patients were recruited in each group based on sample of convenience. The Inclusion criteria was 20 to 45 years of age, male and female, failing to fully raise straight leg more than 60 degree were included. Exclusion criteria was subjects having hamstring tightness, but with history of recent trauma, surgery or any neuromuscular deficit. Data were collected; pre and post intervention SLR values were recorded using standard Goniometers. Results: Results of paired sample statistics showed a mean difference and standard deviation of 8.45+3.051 for bent leg raise technique while that of 9.80+2.56 for traction straight leg raise technique, while significant difference as showed by p value to be 0.000. Independent samples T-test and paired samples T-test were applied to measure the outcomes. P-value less than .05 was considered significant. Conclusion: Both of the Mulligan techniques i.e. Bent Leg Raise Technique and Traction Straight Leg Raise Technique were found equally effective.

Objectives: The objective of this research is to discover the trends of work-related musculoskeletal disorders that are prevalent in the linemen population, as well as the occupational activities that put linemen at risk of developing WRMDs. Methodology: The study included 50 male linemen employed in FASCO, who performed various fi eld tasks in a Faisalabad city Pakistan. Age group included in the study between 20 to 40 years. Chi square test was applied to check association between daily life and incidence of symptoms. Results: There is no signifi cance associations were founded between age and tasks of linemen with p-value 0.431. There is signifi cance association was founded between comfort and their tasks with p-value 0.002. There is signifi cance association was founded between body region and their tasks with p-value 0.001. Conclusion: MSDs in body areas other than the back were found in our investigation, particularly in the shoulders and knees. We also identifi ed high-risk tasks that would require more investigation and management.

Various methods of manual therapy, kinesiatrics and combined programmes are used in osteoarthritis (OA) and other joint and spine diseases. According to reviews, manual therapy, exercise and their combinations provide relief for non-specific neck pain at least in the short term. However, the role of placebo effect is sometimes difficult to assess. The patients' perception of outcome is important, especially for the assessment of subjective symptoms, disability and quality of life. The aim of this letter is to express caution concerning manual therapy, used in the former Soviet Union (SU), of conditions with degenerative changes and insufficient regeneration: OA and spine lesions, for example, after professional activities such as heavy weight bearing, those with vertebrobasilar insufficiency, functional compromise of the vertebral artery or chronic pain. More examples include manual therapy of osteochondrosis (the term was used within the meaning of OA) by the pressure with the therapist's thumbs up to the feeling of pain in the C1–C7 area, back- and side-wards (up to 60° from vertical) movements and turning (up to 90°) of the patient's head, and manual therapy of 'cervical spondyloarthritis aggravated by vertigo' by pushing with the therapist's knuckles.] Finally, the 'ultra-rapid' therapy of alcoholism, known in the former SU as coding, should be commented. This method was started during the anti-alcohol campaign (1985–1989); it has been criticised because of mystification, verbal intimidation and unpleasant procedures, for example, massage of trigeminal nerve branches and backwards movements of the patient's head. The latter manipulation may be associated with risk, especially for patients with spine abnormalities. Adverse events following manual treatments to the spine are common, although serious complications are rare. In particular, cervical spine manipulations may carry a small risk for neurovascular complications. There is an opinion that the non-superiority to other treatments, coupled with concerns regarding safety, renders cervical spine manipulations inadvisable. Certainly, the maintenance of an optimum level of the physical fitness is favourable. In particular, daily exercises to maintain mobility and functionality are essential . However, the balance between exercise and rest should be moderate, especially in degenerative diseases, wear and tear conditions in aged people as well as certain posttraumatic lesions. Obviously, in conditions of insufficient regeneration, cartilaginous structures should be protected from further damage.

Effective intervention for low back pain (LBP) can include feedback in one form or other. Although extrinsic feedback (EF) can be provided in a number of ways, most research has not considered how different EF characteristics (e.g. timing and content) influence treatment outcomes. A systematic search related to feedback and LBP was performed on relevant electronic databases. This narrative review aims to describe the forms of feedback provision in the literature regarding management of LBP, and to discuss these in light of previously recommended principles for the use of extrinsic feedback. The present review found support for the provision of EF that focuses on content characteristics including program feedback, summary results feedback, and external focus of attention. Temporal characteristics should enhance the use of intermittent or self-selected feedback. The literature does not support the provision of concurrent or constant EF. As much of the literature related to EF in the management of LBP has not considered content and timing characteristics we have identified future research directions that will clarify the use of content and timing characteristics of EF relative to the management of LBP.

Background &amp;amp; Purpose: The Physical Therapy (PT) profession has undergone a significant evolution both in education and scope of practice over the last 4 decades. Healthcare policy within the United States (US) typically restricts PTs from ordering imaging. However, it is unknown how healthcare policy in the US compares to other World Confederation for Physical Therapy (WCPT) member nations (MN). We aimed to investigate the rights of PTs to order imaging studies and to evaluate its association to direct access policy within WCPT MNs. Methods: 111 WCPT MNs were polled via email or Facebook on the healthcare policy of PTs ordering diagnostic imaging within their nation. A secondary analysis was performed to see if multiple variables (including direct access authorization) were associated with diagnostic imaging privileges. Results: 81 MNs provided information on their diagnostic imaging policies. 31 (39.2%) of MNs reported having some level of diagnostic imaging authority while 48 (60.8%) denied such authority. MNs with direct access authorization were significantly more likely to allow diagnostic imaging. MNs with PT diagnostic imaging spent significantly less per capita on healthcare compared with MNs that restricted imaging. Diagnostic imaging was significantly more likely to be authorized in MNs with a male majority PT profession. Discussion: Advancements in US PT scope of practice have been realized in recent years including an expansion of direct access legislation. While the WCPT tracks many data points including direct access, it currently does not report on its members’ ability to order diagnostic imaging. It is notable the calculations within this manuscript are associative in nature and are not meant to indicate causation. Conclusion: This is the first study to report diagnostic imaging policy within the WCPT MNs. We recommend the WCPT begins to track diagnostic imaging policy within their MNs.

Objectives: Medical evidence largely supports PTs in expanded roles, however, healthcare policy within the United States (USA) typically restricts PTs from ordering musculoskeletal (MSK) imaging. It is unknown how MSK imaging policy in the USA compares to other World Confederation for Physical Therapy (WCPT) member nations. The primary objective of our study was to investigate the authority of PTs to order MSK imaging. A secondary objective was to identify factors associated with the authority for PTs to order MSK imaging. Methods: 111 WCPT member nations were surveyed over a 2-month period on the authority of PTs ordering MSK imaging within their nation. A secondary analysis utilizing a step-wise binary regression compared member nation demographic statistics to MSK imaging authority. Results: 81 member nations responded to the survey. 31 (38.3%) of member nations reported having some level of PT MSK imaging authority while 50 (61.7%) did not. Member nations with lower per capita healthcare costs were significantly more likely to allow PTs to order MSK imaging (p = 0.02). Those with direct access authority were 7.4 times more likely to authorize PTs to order MSK imaging (p &amp;lt; 0.01). Entry-level clinical degree and years of entry-level collegiate credit were not associated with imaging authority. Conclusion: This is the first study to report MSK imaging policy within the WCPT member nations. While many nations within the WCPT allow PTs to order MSK imaging, the majority of nations still restrict PTs from such practice. Lower per capita healthcare costs and direct access authority were significant predictors of MSK imaging authority, however, causation cannot be established within the confines of this study. Future studies should consider issues such as restrictive policy origin (i.e. governmental vs. institutional), insurance reimbursement (i.e. private vs. public sector policy), and limitations on imaging modality. Keywords: diagnostic imaging; direct access; medical legislation; radiography.

Effective intervention for low back pain (LBP) can include feedback in one form or other. Although extrinsic feedback (EF) can be provided in a number of ways, most research has not considered how different EF characteristics (e.g. timing and content) influence treatment outcomes. A systematic search related to feedback and LBP was performed on relevant electronic databases. This narrative review aims to describe the forms of feedback provision in the literature regarding management of LBP, and to discuss these in light of previously recommended principles for the use of extrinsic feedback. The present review found support for the provision of EF that focuses on content characteristics including program feedback, summary results feedback, and external focus of attention. Temporal characteristics should enhance the use of intermittent or self-selected feedback. The literature does not support the provision of concurrent or constant EF. As much of the literature related to EF in the m...

Spinal manipulation (SMT) is commonly used for treating individuals experiencing musculoskeletal pain. The mechanisms of SMT remain unclear; however, pain sensitivity testing may provide insight into these mechanisms. The purpose of this systematic review is to examine the literature on the hypoalgesic effects of SMT on pain sensitivity measures and to quantify these effects using meta-analysis. We performed a systematic search of articles using CINAHL, MEDLINE, PsycINFO, and SPORTDiscus from each databases' inception until May 2011. We examined methodological quality of each study and generated pooled effect size estimates using meta-analysis software. Of 997 articles identified, 20 met inclusion criteria for this review. Pain sensitivity testing used in these studies included chemical, electrical, mechanical, and thermal stimuli applied to various anatomical locations. Meta-analysis was appropriate for studies examining the immediate effect of SMT on mechanical pressure pain threshold (PPT). SMT demonstrated a favorable effect over other interventions on increasing PPT. Subgroup analysis showed a significant effect of SMT on increasing PPT at the remote sites of stimulus application supporting a potential central nervous system mechanism. Future studies of SMT related hypoalgesia should include multiple experimental stimuli and test at multiple anatomical sites.