High-velocity Low-amplitude Thrust Manipulation Research Articles

Diagnosis and Management of Knee Arthrofibrosis and Associated Pain-Related Fear Using Multidimensional Clinical Reasoning and Exposure In Vivo Concept: A Case Report

BACKGROUND: A plethora of treatment approaches are used to manage persistent pain, disability, and fear associated with restricted knee range of motion following knee surgery. We used the pain and disability driver model and exposure in vivo concepts to manage pain-related fear and disability. CASE PRESENTATION: A 68-year-old male who underwent arthroscopic partial meniscectomy presented to physical therapy with a medical diagnosis of Complex Regional Pain Syndrome Type I and knee range-of-motion restriction. Despite extensive medical care and physical therapy for 3 years (202 visits), he continued to experience debilitating knee pain and demonstrated a high level of fear. To ambulate, he wore a knee brace and used a trekking pole. OUTCOME AND FOLLOW UP: Interventions to address the knee stiffness included combined tibiofemoral joint mobilization and high-velocity low-amplitude thrust manipulation targeting tibial internal rotation and low-load long-duration sustained capsular stretching using total end range time principle for extension. His fear was managed using techniques inspired by in vivo exposure concepts. Total knee range of motion improved 110 degrees and the patient was able to ambulate for 30 minutes (0.5 mile) without an assistive device with <2/10 pain intensity. DISCUSSION: Outside-the-box clinical reasoning suggested that poor outcomes with previous interventions were likely due to hypervigilance and pain-related fear. This case delineates the value of nonreductionist clinical reasoning in diagnosis and management of musculoskeletal conditions. It also outlines how the exposure in vivo approach helped the patient overcome his long-established avoidance behaviors. JOSPT Cases 2024;4(3):121-132. Epub 2 July 2024. doi:10.2519/josptcases.2024.0034

Throwing performance after high-velocity low-amplitude thrust manipulation at the cervicothoracic and thoracolumbar junction in elite female water polo players: a randomized blind cross-over study.

The effect of high-velocity low-amplitude (HVLA) thrust manipulation at the cervicothoracic and thoracolumbar junction in healthy elite female water polo players on throwing performance is unknown. Ten healthy members of the Dutch National female water polo team participated in this randomized blind cross-over study. All received a HVLA manipulation and a sham manipulation at the cervicothoracic and thoracolumbar junction. Hereafter maximum throwing speed, range of motion and isometric strength were measured at 1 hour, 48 hours and 4 weeks follow-up. No significant differences in maximum throwing speed was found between HVLA and sham manipulation. In the non-dominant shoulder external rotation increased significantly (5.3±6.7°) 48 hours after sham manipulation, this effect was not considered clinically significant and diminished after four weeks. Our results suggest that HVLA and sham manipulation had no effect on shot velocity or shoulder mobility and the same effect on shoulder strength in healthy elite female water polo players. The common use of cervicothoracic and thoracolumbar HVLA manipulation for improving performance in this specific group of athletes is therefore questionable.

Effect of High-Velocity Low-Amplitude Thrust Manipulation of Upper Cervical Spine on Pulmonary Function Test and Headache Disability Index in Patients with Migraine Headache

Abstract Introduction. Migraine is a common debilitating disorder of neurovascular origin which affects younger adults, especially women. Material and Methods. It was an experimental study design. A convenience type of sampling was used for recruitment of the subjects. A total of 21 participants diagnosed with migraine (6 males and 15 females) fulfilling the inclusion criteria were taken for this study and assigned to one of the two groups (experimental or control group). PFT measured with PFT apparatus (Spirolab 111, Serial No. A23-053 13974) and HDI score were calculated before the start of the intervention and after the intervention. Afterwards, PFT was performed by each participant followed by HVLA thrust manipulations to the migraine patients and an equal period of rest to the control group. Results. There are no significant differences between baseline and post-intervention outcome variables and in mean changes between the two groups. One-way ANOVA was used to analyze the change in HDI score which was calculated three times (pre- prior to intervention, post- after the intervention and 1 month after the intervention). The experimental group showed a significant reduction in the score after the manipulation. It was found that FVC and PEF were positively correlated to FEV1, and FVC was also positively correlated to PEF. Conclusions. The findings of the study revealed that high-velocity thrust manipulations of upper cervical spine were not effective in improving pulmonary functions of migraine patients although it was found effective in improving subjective symptoms of the patients evaluated through HDI.

Does Thoracic Manipulation Cause Extravasation at Joint Following Facet Injections?

Facet injections and other pain management interventions are commonly performed in combination with conservative therapy to address spinal pain. Joint mobilizations are a highly utilized intervention for manual practitioners to treat patients with spinal pain. Clinical reasoning and decision making models have not been well described in the literature assessing if and when joint mobilizations are appropriate interventions immediately or shortly following facet injection procedures. It has not been well studied if joint mobilizations immediately following facet injections negatively impact the injected solution at the respective joint and thus influence therapeutic effect. More specifically, there is a paucity of evidence assessing this at the thoracic spine. The purpose of this study was to assess if thoracic joint high-velocity low amplitude thrust manipulations caused extravasation of injected radiolucent material at respective thoracic facet joints on a cadaver. This study included an expert physician performing ultrasound-guided facet injections, an experienced manual physical therapist performing joint mobilization techniques, and fluoroscopic assessment of radiolucent material pre- and post-manipulation by a board-certified radiologist with experience in this field of study. Imaging interpretation confirmed that extravasation at respective joints did not occur following manipulation. This basic research can help guide clinical reasoning for practitioners considering implementing manual therapy techniques following facet injections and help guide further research.

Comparison between high-velocity low-amplitude manipulation and muscle energy technique on pain and trunk neuromuscular postural control in male workers with chronic low back pain: A randomised crossover trial.

BackgroundA therapeutic recommendation for restoring function in individuals with chronic low back pain (CLBP) is manual therapy through manipulative spinal or muscle energy techniques.ObjectivesTo compare the effectiveness of two osteopathic manipulative techniques on clinical low back symptoms and trunk neuromuscular postural control in male workers with CLBP.MethodTen male workers with CLBP were randomly allocated to two groups: high-velocity low-amplitude (HVLA) manipulation or muscle energy techniques (MET). Each group received one therapy per week for both techniques during 7 weeks of treatment. Pain and function were measured by using the Numeric Pain-Rating Scale, the McGill Pain Questionnaire and the Roland Morris Disability Questionnaire. The lumbar flexibility was assessed by Modified Schober Test. Electromyography (EMG) and force platform measurements were used for evaluation of trunk muscular activation and postural balance, respectively at three different times: baseline, post intervention, and 15 days later.ResultsBoth techniques were effective (p < 0.01) in reducing pain with large clinical differences (-1.8 to -2.8) across immediate and after 15 days. However, no significant effect between groups and times was found for other variables, namely neuromuscular activation and postural balance measures.ConclusionBoth techniques (HVLA thrust manipulation and MET) were effective in reducing back pain immediately and 15 days later. Neither technique changed the trunk neuromuscular activation patterns nor postural balance in male workers with LBP.Clinical implicationsThese results may facilitate clinical decision-making for CLBP management in physiotherapy programs.

Psychological context effects of participant expectation on pain pressure thresholds as an adjunct to cervicothoracic HVLA thrust manipulation: A randomised controlled trial

BackgroundChronic pain is a growing global and economically costly problem leading the National Health Service (NHS) in the UK to actively search for novel strategies to improve health outcomes. Some trials have shown a benefit when practitioners use a positive communication style, however, much of the available literature investigating the use of positive language to alter patient expectation utilises subjective reports from patients. ObjectivesTo demonstrate whether positive and negative communication before a high-velocity low amplitude (HVLA) thrust spinal manipulation of the C7-T1 spine segments, and within an osteopathic consultation setting, increases and decreases (respectively) pain pressure thresholds (PPT) to form contextual placebo and nocebo effects. Study designpre-test, post-test randomised controlled design. Methods35 asymptomatic participants were recruited and randomised into three separate condition arms using a repeated measures cross-over design; negative communication (NegC), neutral communication (NeuC), or positive communication (PosC). Each condition included spinal manipulation (HVLA thrust) to the C7-T1 segments. PPTs were measured by an algometer over the spinous process of C7 pre and post each condition setting. ResultsThere was a significant effect of language style on PPT for the three conditions. Post-hoc tests demonstrated that positive communication had a significant effect on PPT (i.e., placebo effect), but the negative communication demonstrated no significant effect (i.e., no nocebo). ConclusionThese results were discussed in the context of communication style used during an osteopathic clinical consultation to potentially improve health outcomes in NHS and other clinical settings (Clinical trial registry https://clinicaltrials.gov/number: NCT03855254).

Unilateral and Multiple Cavitation Sounds During Lumbosacral Spinal Manipulation

ObjectiveThe purpose of this study was to determine from which side of the spine the popping sound (PS) emanates during side-lying, rotatory high-velocity low-amplitude (HVLA) thrust manipulation directed to the L5-S1 articulation using a time-frequency analysis. Secondary aims were to calculate the average number of PSs, the duration of lumbar thrust manipulation, and the duration of a single PS. MethodsThirty-four asymptomatic participants received 2 lumbar HVLA thrust manipulations targeting the right and left L5-S1 articulations. Two high sampling rate accelerometers were secured bilaterally 25 mm lateral to the midline of the L5-S1 interspace. For each manipulation, 2 audio signals were extracted and singularly processed via spectrogram calculation to obtain the release of energy over time on each side of the lumbosacral junction. ResultsDuring 60 HVLA thrust manipulations, it was measured a total of 320 PSs. Of those PSs, 176 occurred ipsilateral and 144 occurred contralateral to the targeted L5-S1 articulation; that is, the PS was no more likely to occur on the upside than the downside facet after right or left rotatory L5-S1 HVLA thrust manipulation. Moreover, PSs occurring on both sides at the same time were detected very rarely (ie, 2% of cases) with the lumbar HVLA thrust manipulations. The mean number of audible PSs per lumbosacral HVLA thrust manipulation was 5.27 (range 2-9). The mean duration of a single manipulation was 139.13 milliseconds (95% confidence interval: 5.61-493.79), and the mean duration of a single PS was 2.69 milliseconds (95% confidence interval: 0.95-4.59). ConclusionBased on our findings, spinal manipulative therapy practitioners should expect multiple PSs that most often occur on the upside or the downside facet articulations when performing HVLA thrust manipulation to the lumbosacral junction (ie, L5-S1). However, whether the multiple PSs found in this study emanated from the same joint or adjacent ipsilateral or contralateral facet joints remains unknown. A single model may not necessarily be able to explain all of the audible sounds during HVLA thrust manipulation.

3-Dimensional Cervical Movement Characteristics and the Influence of Thoracic Treatment on a Subgroup of Acute Neck Pain Patients

ObjectiveThe purpose of this study was to investigate the influence of thoracic high-velocity low-amplitude thrust (HVLAT) manipulation on quantitative and qualitative 3-dimensional cervical spine kinematic patterns in a subgroup of patients with acute neck pain. MethodsThirty patients with acute neck pain, aged 20 to 59, received a thoracic HVLAT manipulation. Three-dimensional kinematics of the cervical spine were registered pretreatment and posttreatment using an electromagnetic tracking system. Quantitative and qualitative parameters were calculated for axial rotation, lateral bending, and flexion-extension movement. Subjective pain ratings were measured with the visual analogue scale and the Neck Disability Index and were collected pretreatment and posttreatment. ResultsAfter treatment, the range of motion of the main motion improved significantly for axial rotation (P = .034), lateral bending (P < .001), and flexion-extension (P = .031). Although for axial rotation as the main motion, the smoothness of the flexion-extension movement improved significantly after treatment (P = .036), the reverse was true for flexion-extension as the main motion. Visual analogue scale scores exhibited a statistically (P < .001) and clinically significant reduction of pain sensation. The mean change in Neck Disability Index scores only exhibited a statistically significant improvement 1 week after treatment. ConclusionThoracic HVLAT manipulation led to positive changes in quantitative and qualitative aspects of 3-dimensional cervical spine kinematics. Because of the 1-intervention group design, external factors influencing the healing process could not be eliminated.

Changes in Shoulder Pain and Disability After Thrust Manipulation in Subjects Presenting With Second and Third Rib Syndrome

ObjectiveThe purpose of this preliminary study was to investigate changes in shoulder pain, disability, and perceived level of recovery after 2 sessions of upper thoracic and upper rib high-velocity low-amplitude (HVLA) thrust manipulation in patients with shoulder pain secondary to second and third rib syndrome. MethodsThis exploratory study evaluated 10 consecutive individuals with shoulder pain, with or without brachial pain, and a negative Neer impingement test, who completed the Shoulder Pain and Disability Index (SPADI), the numeric pain rating scale (NPRS), and the global rating of change. Patients received 2 sessions of HVLA thrust manipulation targeting the upper thoracic spine bilaterally and the second and third ribs on the symptomatic side. Outcome measures were completed after the first treatment session, at 48 hours, 1 month, and 3 months. ResultsPatients showed a significant decrease in SPADI (F = 59.997; P = .001) and significant decrease in resting shoulder NPRS (F = 63.439; P = .001). For both NPRS and SPADI, there were significant differences between the pretreatment scores and each of the postintervention scores through 3-month follow-up (P < .05). Large within-group effect sizes (Cohen's d ≥ 0.8) were found between preintervention data and all postintervention assessments in both outcomes. Mean global rating of change scores (+6.8 at 3 months) indicated “a very great deal better” outcome at long-term follow-up. ConclusionThis group of patients with shoulder pain secondary to second and third rib syndrome who received upper thoracic and upper rib HVLA thrust manipulations showed significant reductions in pain and disability and improvement in perceived level of recovery.

Thoracic spinal manipulation for musculoskeletal shoulder pain: Can an instructional set change patient expectation and outcome?

Study designPlanned secondary analysis of a randomized clinical trial. ObjectivesTo examine: 1) patients' baseline expectations for treatment outcome of thoracic high velocity low amplitude thrust manipulations (HVLATM) to the thoracic spine for shoulder pain; 2) if the message conveyed by the clinician changed the patients' expectation; 3) any differences in outcome based on expectation independent of messaging.; and 4) any differences in outcome for those patients whose expectations significantly changed as a result of the messaging. BackgroundThoracic HVLATM may be an effective intervention for patients suffering from musculoskeletal shoulder pain. The role of expectation in the treatment effectiveness of this intervention has not been established. MethodsSubjects' expectations regarding the effectiveness of HVLATM on shoulder pain were recorded at baseline. This was reassessed immediately following the provision of positive or neutral instructional set. The subjects then received a thoracic or scapular HVLATM. The Shoulder Pain and Disability Index (SPADI) and the numeric pain rating scale (NPRS) were used as outcomes measures. ResultsThere was a 10 subject change (23%) in positive expectation that was statistically significant (p = 0.019) following a positive message. There was no statistically significant difference in pain and function when these subjects were compared to all other subjects. ConclusionAlthough patients' expectations of positive outcome significantly changed when providing a positive instructional set, these changes did not translate into clinically significant short term changes in shoulder pain and function.Level of Evidence: 1b.

The role of the descending inhibitory pain mechanism in musculoskeletal pain following high-velocity, low amplitude thrust manipulation: a review of the literature.

Although the antinociceptive effect of high-velocity, low amplitude thrust manipulation (HVLAM) has been recognized by numerous systematic reviews, the underlying mechanism for manipulation-related pain relief remains poorly understood. An increasing number of studies have explored its analgesic mechanism suggesting that the excitation of the descending inhibitory pain mechanism (DIPM) might play the most important role for musculoskeletal pain relief. The objective of this review is to investigate the role of the DIPM in musculoskeletal pain following HVLAM as well as to identify the pain-relieving importance of this technique within clinical practice. English literature databases were searched to find studies related to the objective of the present review. Findings from current literature support that HVLAM has a profound influence on nociceptive stimulus via the possible activation of the DIPM. It seems that the application of this technique activates the periaqueductal gray region area of the midbrain, stimulates the noradrenergic descending system and at the level of the spinal cord, the nociceptive afferent barrage is reduced and mechanical hypoalgesia is induced. However, the literature on HVLAM induced-analgesia is still problematic regarding the methodological design of the existing research. Despite these limitations, the clinical importance of the activation of the DIPM should not be ignored since the resulted analgesic effect of this technique can provide a window of opportunity to restore impaired physical performance and disability.

Short-term effects of thoracic spinal manipulations and message conveyed by clinicians to patients with musculoskeletal shoulder symptoms: a randomized clinical trial

Study design:Randomized clinical trial.Objectives:To evaluate the effects of high-velocity, low-amplitude thrust manipulations (HVLATMs) and various messages on patients with musculoskeletal shoulder symptoms.Background:Previous studies indicated that HVLATM directed at the thoracic spine and ribs resulted in improvements of shoulder range of motion, pain, and disability in patients with musculoskeletal shoulder symptoms. These studies did not explore if the outcome was dependent on thrust location, clinician communication with the patient, or if there were any lasting effects.Methods:A consecutive sample of 100 patients with shoulder pain was randomized into four groups. Patients received one intervention session including: six thoracic HVLATM (spine versus scapula), a message about HVLATM (neutral versus positive), and standardized home exercises. Outcome measures included shoulder Numeric Pain Rating Scale (NPRS), NPRS with impingement testing, and Shoulder Pain and Disability Index (SPADI). Measurements were recorded prior to intervention, immediately following intervention, and at short-term follow-up. Kruskal–Wallis statistics were used for between-group comparisons and Wilcoxon signed ranks for within-group comparisons.Results:Eighty-eight patients (22 per group) completed the study. Statistically significant differences were found for within-group comparisons for most time points assessed. No statistical differences were found for between-group comparisons.Conclusion:Patients improved following the interventions. Neither the type of HVLATM nor the message conveyed to the patients had a significant effect on the patients’ improvements.Level of evidence:1b

High-velocity low-amplitude thrust manipulation of the lumbar spine immediately modifies soleus T reflex in asymptomatic adults

BackgroundHigh-velocity low-amplitude thrust manipulations (HVLAM) are routinely used in osteopathic treatment. Despite the large number of studies that have been realized till now, the effects of spinal HVLAM on the physiological properties of muscles and nerves are not fully characterized. ObjectiveThe present study was designed to investigate the effects of a spinal lumbar L4/L5 HVLAM on the functional properties of the soleus T reflex in asymptomatic young adults. DesignControlled pre/post measures experimental design. MethodsRight and left soleus T reflexes were elicited by striking right and left Achilles tendons with an instrumented reflex hammer and the electromyographic (EMG) signals were monitored in right and left soleus muscles. The amplitude and latency of EMG responses were measured before and after the delivery of a HVLAM targeting the L4/L5 segment. The conduction velocity was calculated from the latency value. Subjects50 asymptomatic adults met all inclusion criteria. They were randomly allocated to either group a) receiving a sham manipulation (SM), or b) a HVLAM. Because of subject loss, the final size of SM and HVLAM groups was 24 and 18, respectively. ResultsOur data show that the conduction velocity, but not the amplitude of the T reflex, is significantly increased by HVLAM in both soleus muscles with small to medium effect size. SM neither changes the amplitude nor modifies the conduction velocity. ConclusionOur data show that a lumbar L4/L5 HVLAM modifies the electrophysiological properties of the soleus T reflex.

Can a high-velocity low-amplitude thrust manipulation of C1-2 affect active depression of the temporomandibular joint in a symptomatic population?

BackgroundThe temporomandibular joint (TMJ) is arguably one of the most complex joints in the human body but its intricate structure and mobile nature make dysfunction in this region extremely common. With a reported prevalence of up to 85% of the general population experiencing at least one sign of temporomandibular dysfunction (TMD) at some point in their lives, a wide range of treatment options must be available to manage the array of disorders that may occur at this joint, in order to provide a tailored approach to suit the individuality of patients. The TMJ has a close topographical and functional relationship with the upper cervical spine (Csp) and dysfunction in one area is often concomitant with reduced function in the other. There is significant research supporting the use of physical therapy for Csp dysfunction but more definitive research needs to objectively assess the effectiveness of cervical treatment for TMD and the reciprocal approach. AimTo investigate whether it is possible to affect active depression of the TMJ via a High-Velocity Low-Amplitude Thrust (HVLAT) technique of the C1-2 spinal segment within a symptomatic population, in order to contribute to the current knowledge base. MethodsA pilot study for a single-blind, randomised controlled trial (RCT), was carried out using 30 volunteers with current TMD symptoms, as defined by the National Health Service. The volunteers were randomly assigned to either the intervention or control group and their TMJ and upper Csp range of motion (ROM) were assessed three times pre- and post-intervention. The Csp was assessed via expert palpation and passive range of motion (PROM) testing and the TMJ was assessed using Silicon Coach video analysis software. The treatment consisted of an HVLAT technique of the C1/2 spinal segment and the control group did not receive any treatment. The data was analysed using Statistical Package for Social Sciences (SPSS) software via parametric t-tests. ResultsThe results of the study demonstrated a statistically significant increase in TMJ AROM from baseline to post intervention (p < 0.01) in both dimensions of measurement (nose to chin and mandibular angle) for those in the treatment group. There was no change in TMJ AROM in either dimension in those assigned to the control group. ConclusionThis study demonstrated that an HVLAT of the C1/2 spinal segment significantly increases active depression of the TMJ in a symptomatic population. Larger RCTs of this nature are recommended, with the use of a TMD assessment tool in order to investigate the effect of this technique on particular sub-groups of TMD.

Bilateral and multiple cavitation sounds during upper cervical thrust manipulation

BackgroundThe popping produced during high-velocity, low-amplitude (HVLA) thrust manipulation is a common sound; however to our knowledge, no study has previously investigated the location of cavitation sounds during manipulation of the upper cervical spine. The primary purpose was to determine which side of the spine cavitates during C1-2 rotatory HVLA thrust manipulation. Secondary aims were to calculate the average number of pops, the duration of upper cervical thrust manipulation, and the duration of a single cavitation.MethodsNineteen asymptomatic participants received two upper cervical thrust manipulations targeting the right and left C1-2 articulation, respectively. Skin mounted microphones were secured bilaterally over the transverse process of C1, and sound wave signals were recorded. Identification of the side, duration, and number of popping sounds were determined by simultaneous analysis of spectrograms with audio feedback using custom software developed in Matlab.ResultsBilateral popping sounds were detected in 34 (91.9%) of 37 manipulations while unilateral popping sounds were detected in just 3 (8.1%) manipulations; that is, cavitation was significantly (P < 0.001) more likely to occur bilaterally than unilaterally. Of the 132 total cavitations, 72 occurred ipsilateral and 60 occurred contralateral to the targeted C1-2 articulation. In other words, cavitation was no more likely to occur on the ipsilateral than the contralateral side (P = 0.294). The mean number of pops per C1-2 rotatory HVLA thrust manipulation was 3.57 (95% CI: 3.19, 3.94) and the mean number of pops per subject following both right and left C1-2 thrust manipulations was 6.95 (95% CI: 6.11, 7.79). The mean duration of a single audible pop was 5.66 ms (95% CI: 5.36, 5.96) and the mean duration of a single manipulation was 96.95 ms (95% CI: 57.20, 136.71).ConclusionsCavitation was significantly more likely to occur bilaterally than unilaterally during upper cervical HVLA thrust manipulation. Most subjects produced 3–4 pops during a single rotatory HVLA thrust manipulation targeting the right or left C1-2 articulation; therefore, practitioners of spinal manipulative therapy should expect multiple popping sounds when performing upper cervical thrust manipulation to the atlanto-axial joint. Furthermore, the traditional manual therapy approach of targeting a single ipsilateral or contralateral facet joint in the upper cervical spine may not be realistic.

The effect of thoracic spine high-velocity low-amplitude thrust manipulation on myoelectric activity of the lower trapezius and posterior deltoid muscles during treadmill walking

Objectives To investigate the effect of thoracic spine thrust manipulation on the EMG activity of posterior deltoid and lower trapezius during treadmill walking. Methods Volunteers ( n = 40; 19 males and 21 females) were randomly assigned to a ‘sham ultrasound’ control group ( n = 20) or a thoracic spine high-velocity thrust (HVLAT) manipulation group ( n = 20). Surface EMG recordings were collected from the right posterior deltoid and lower trapezius muscles whilst participants walked on a treadmill for 2 min, at 2.8 mph, both prior to and immediately post-intervention. EMG recordings were analysed by evaluating the difference of integral values for pre and post data using repeated measures ANOVA. Results Both control (sham ultrasound) and experimental groups (HVLAT) exhibited small non-significant reductions in post-intervention EMG activity of lower trapezius ( p = 0.201) and a significant reduction in posterior deltoid ( p = 0.003) during treadmill walking. No significant difference was found in the integrated EMG (IEMG) power between control and experimental group in either the ‘before’ or ‘after’ measurements for both target muscles. Conclusions Manipulation of the thoracic spine does not significantly alter the myoelectric activity of lower trapezius and posterior deltoid muscles during treadmill walking.

Upper Cervical and Upper Thoracic Thrust Manipulation Versus Nonthrust Mobilization in Patients With Mechanical Neck Pain: A Multicenter Randomized Clinical Trial

Randomized clinical trial. To compare the short-term effects of upper cervical and upper thoracic high-velocity low-amplitude (HVLA) thrust manipulation to nonthrust mobilization in patients with neck pain. Although upper cervical and upper thoracic HVLA thrust manipulation and nonthrust mobilization are common interventions for the management of neck pain, no studies have directly compared the effects of both upper cervical and upper thoracic HVLA thrust manipulation to nonthrust mobilization in patients with neck pain. Patients completed the Neck Disability Index, the numeric pain rating scale, the flexion-rotation test for measurement of C1-2 passive rotation range of motion, and the craniocervical flexion test for measurement of deep cervical flexor motor performance. Following the baseline evaluation, patients were randomized to receive either HVLA thrust manipulation or nonthrust mobilization to the upper cervical (C1-2) and upper thoracic (T1-2) spines. Patients were reexamined 48-hours after the initial examination and again completed the outcome measures. The effects of treatment on disability, pain, C1-2 passive rotation range of motion, and motor performance of the deep cervical flexors were examined with a 2-by-2 mixed-model analysis of variance (ANOVA). One hundred seven patients satisfied the eligibility criteria, agreed to participate, and were randomized into the HVLA thrust manipulation (n = 56) and nonthrust mobilization (n = 51) groups. The 2-by-2 ANOVA demonstrated that patients with mechanical neck pain who received the combination of upper cervical and upper thoracic HVLA thrust manipulation experienced significantly (P<.001) greater reductions in disability (50.5%) and pain (58.5%) than those of the nonthrust mobilization group (12.8% and 12.6%, respectively) following treatment. In addition, the HVLA thrust manipulation group had significantly (P<.001) greater improvement in both passive C1-2 rotation range of motion and motor performance of the deep cervical flexor muscles as compared to the group that received nonthrust mobilization. The number needed to treat to avoid an unsuccessful outcome was 1.8 and 2.3 at 48-hour follow-up, using the global rating of change and Neck Disability Index cut scores, respectively. The combination of upper cervical and upper thoracic HVLA thrust manipulation is appreciably more effective in the short term than nonthrust mobilization in patients with mechanical neck pain. Therapy, level 1b.

Treatment of Patients With Degenerative Cervical Radiculopathy Using a Multimodal Conservative Approach in a Geriatric Population: A Case Series

Retrospective clinical case series. To describe the management of 10 patients with advanced cervical spondyloarthrosis with radiculopathy, using manual therapy, intermittent mechanical cervical traction, and home exercises. Predictors and short-term outcomes of cervical radiculopathy have been published. These predictors have not been developed for, or applied to, geriatric patients with spondylitic radiculopathy. A series of 10 patients (aged 67 to 82 years) were referred to a physical therapist for medically prediagnosed cervical spondyloarthrosis and radiculopathy, as determined by magnetic resonance imaging. Neck Disability Index (NDI), numeric pain rating scale (NPRS), upper limb tension testing, Spurling's test, and the cervical distraction test were all completed on each patient at initial examination and at discharge. NDI and NPRS data were also collected at 6 months posttreatment. Intervention included manual therapy (including high-velocity low-amplitude thrust manipulation) of the upper thoracic and cervical spine, intermittent mechanical cervical traction, and a home program (including deep cervical flexor strengthening) for 6 to 12 sessions over a period of 3 to 6 weeks. All 10 patients had substantial improvement in NPRS and NDI scores. The mean NPRS score was less than 1/10, and the mean NDI score was 6/50 at discharge, compared to the original mean NPRS and NDI scores of 5.7 and 27.4, respectively. All patients reported maintaining those gains for 6 months. A multimodal approach for patients diagnosed with cervical spondyloarthrosis with radicular symptoms was useful in this geriatric population to reduce pain, minimize radicular symptoms, and improve functional outcomes. Therapy, level 4.

The effects of cervical high-velocity low-amplitude thrust manipulation on resting electromyographic activity of the biceps brachii muscle

There is a gap in the literature regarding the effects of spinal manipulation on extremity muscles that are unconnected to the vertebral column by an origin or insertion. This study investigated the effect of a right C5/6 high-velocity low-amplitude thrust (HVLAT) manipulation on resting electromyographic activity of the biceps brachii muscles bilaterally. A placebo-controlled, single-blind, repeated measures design employed an asymptomatic convenience sample ( n = 54) investigating three conditions: HVLAT, sham, and control. HVLAT demonstrated an excitatory effect with increased EMG activity of 94.20% ( P = 0.0001) and 80.05% ( P = 0.0001) for the right and left biceps respectively. A one-way repeated measures ANOVA revealed a significant difference ( P = 0.0001) in the mean percentage change of resting EMG activity, as did post hoc analyses ( P = 0.0001) between all three conditions. Subjects not experiencing cavitation post HVLAT demonstrated greater EMG increases for both right ( P = 0.0001) and left ( P = 0.014) biceps than those experiencing cavitation. The magnitude of mean EMG change for the right biceps was significantly greater than the left ( P = 0.011) post HVLAT. This study demonstrates a single HVLAT to the right C5/6 zygapophyseal joint elicits an immediate increase in resting EMG activity of the biceps bilaterally, irrespective of whether or not cavitation occurs.

The effects of high-velocity low-amplitude thrust manipulation and mobilisation techniques on pressure pain threshold in the lumbar spine

Objective To compare changes in pressure pain threshold (PPT) following spinal high-velocity low-amplitude thrust manipulation (HVLAT) and spinal mobilisation. Design Fifty asymptomatic subjects (mean age 27 (6) years; 29 males and 21 females) volunteered to participate in a randomised controlled, singled blinded design study. Subjects were screened for suitability and were randomly allocated into one of three intervention groups where they received either a unilateral spinal HVLAT or a spinal mobilisation of the lumbar spine, or a sham ‘laser’ procedure (control). PPT measurements were made immediately pre- and post-intervention, using a hand-held algometer which was positioned directly over the lumbar spinous process. A two-way ANOVA with repeated measures was conducted to determine PPT changes between the groups. Statistical significance was set at the 0.05 level. Results There were no significant differences in PPT across time for each of the groups ( P = 0.584). The mobilisation group displayed a small increase, though not a significant change in the mean pressure pain threshold (0.434(0.55) kg/cm 2), although effect size was considered to be large (ES = 0.78). The HVLAT group demonstrated a decrease in the mean PPT (−0.173(0.48)) (ES = 0.36, small), and a smaller decrease was noted for the control group (0.105(0.425) kg/cm 2) (ES = 0.25, small). Conclusion Neither spinal HVLAT nor mobilisation had a significant effect on PPT of the lumbar spine in asymptomatic subjects. Only spinal mobilisation appeared to have a greater mean increase in PPT and effect size than the control group. Further investigation into the hypoalgesic effects of these techniques on symptomatic subjects is suggested.