Manual Therapy Practice Research Articles

Clinical Leadership Perspectives: Advancements in Manual Physical Therapy Practice with the Pakistani Context

Physical therapy is a healthcare discipline that is dedicated to help individuals and patients in maintaining their health while optimizing their strength, function, and movements. Pakistan being a developing country, experiences a slower pace in the establishment of advancements in the medical professions. Whereas physical therapy is significantly improving day by day in Pakistan; additionally, this study aims to discuss the advances, in manual therapy concerning the physical therapy profession in Pakistan. This study aimed to evaluate the perception of clinical leadership and its recent advancements concerning the manual physical therapy practice in Pakistan for the preceding year. For this purpose, semi-structured interviews were conducted with 10 physical therapists from 5 different cities in Pakistan. Physical therapists with at least 10 years of clinical practice were included in the data collection. The interviews were audio/video recorded, data verbatim transcribed, and analyzed manually by open coding and in-vivo coding. Furthermore, thematic analysis was done to identify different elements of recent advancements concerning manual physical therapy by finding the appropriate patterns in the gathered data. The results showed that advancements occurred in the last decade, such as international certifications, workshops, hands-on practice and master programs. There is lack of awareness, gender barriers, and financial constraints in adopting new advancements. The focus was shifted more toward muscle energy technique and myofascial release. Modalities were preferred in the past for pain relief; however, in the recent decade, they have been replaced by manual therapy techniques. Pain management and prognosis are better with manual therapy. These advancements will be cost-effective for the patient. This study concluded that manual therapy in Pakistan has undergone a significant transformation during the last preceding years. There is still great potential for more advancement in manual therapy techniques in Pakistan.

Evidence implementation in Australian manual therapy practice: A cross-sectional study

BackgroundFew studies have explored the determinants of evidence implementation in complementary manual therapy professions. Exploring the factors that impede or enable evidence implementation in complementary manual therapy professions is critical to determining the most appropriate strategies to optimise this practice, and enhance the quality of care. MethodsThe study used a cross-sectional study design to examine Australian complementary medicine manual therapists’ attitudes, skills, training, use, barriers and enablers to evidence implementation. Eligible therapists were invited to self-administer the 84-item Evidence-Based practice Attitude and utilization Survey online. ResultsThe survey was completed by 294 manual therapists (77% female; 65% aged ≥50 years). Participants were mostly supportive of, and reported a moderate to moderate-high level of skill in evidence implementation. However, the level of engagement in evidence implementation was low. The leading barriers to evidence implementation were lack of time, and lack of clinical evidence. While few participants reported skill-level as a barrier, most indicated a desire to develop the skills necessary to improve their engagement in evidence implementation. Participants also supported a range of other enabling strategies to foster evidence implementation in their practice, with most of these strategies targeting access to evidence. ConclusionsAlthough participants reported few barriers to evidence implementation, there was a low level of engagement in this activity. The barriers to evidence implementation therefore warrant further exploration. This ongoing work will help better understand how to optimise evidence implementation in complementary manual therapy practice, and help drive improvements in patient care.

Identifying Patient Characteristics Associated With the Occurrence of Post Treatment Non-serious Adverse Events After Cervical Spine Manual Therapy Treatment in Patients With Neck Pain

ObjectivesTo compare prevalence rates of serious and non-serious adverse events after manipulation and mobilization and to identify risk factors of serious and non-serious adverse events following 4 types of manual therapy treatment in patients with neck pain. DesignA prospective cohort study in primary care manual therapy practice. ParticipantsPatients with neck pain (N=686) provided data on adverse events after 1014 manipulation treatments, 829 mobilization treatments, 437 combined manipulation and mobilization treatments, and 891 treatments consisting of “other treatment modality”. InterventionsUsual care manual therapy. Main Outcome MeasuresA chi-square test was performed to explore differences in prevalence rates. Logistic regression analysis was performed within the 4 treatment groups. A priori we defined associations between patient-characteristics and adverse events of odds ratio (OR)>2 or OR<0.5 as clinically relevant. ResultsNo serious adverse events, such as cervical artery dissection or stroke, were reported. With regard to non-serious adverse events, we found that these are common after manual therapy treatment: prevalence rates are ranging from 0.3% to 64.7%. We found a statistically significant difference between the 4 types of treatments, detrimental to mobilization treatment. Logistic regression analysis resulted in 3 main predictors related to non-serious adverse events after manual therapy treatment: smoking (OR ranges from 2.10 [95% confidence interval [CI] 1.37-3.11] to 3.33 [95% CI 1.83-5.93]), the presence of comorbidity (OR ranges from 2.32 [95% CI 1.22-4.44] to 3.88 [95% CI 1.62-9.26]), and female sex (OR ranges from 0.22 [95% CI 0.11-0.46] to 0.49 [95% CI 0.28-0.86]). ConclusionThere is a significant difference in the occurrence of non-serious adverse events after mobilization compared with manipulation or a combination of manipulation and mobilization. Non-serious adverse events in manual therapy practice are common and are associated with smoking and the presence of comorbidity. In addition, women are more likely to report non-serious adverse events.

Patient Satisfaction with Manual Physical Therapy Care

Patient centered approach is the cornerstone in health care facility. Therefore, patient satisfaction is of utmost importance. Factors related to satisfaction of patient in connection with manual therapy practice are not evaluated. Objective: The purpose of this survey was to evaluate satisfaction of patient receiving manual therapy for their musculoskeletal disorders in Ali Hospital Lahore, Pakistan. Methods: A retrospective survey of 82 male and female patients in the range of 18 and above years was conducted in 2021 for the patient who had availed the services from Ali Hospital. These patients were recruited through simple random sampling only to refrain from biasness. Patients were enrolled according to inclusion and exclusion criteria. Results: In current study, among 82 patients almost 31 will undoubtedly and 31 will most likely suggest manual therapy treatment to people close to them. While the remaining 20 participants did not show any interest of suggesting this therapy. 37.80% participants showed more satisfaction towards manual therapy treatment and close association found between patient satisfaction and experience of physical therapist. Patients showed higher level of satisfaction when treatment was done by experienced skilled Physical Therapist. Conclusion: Current study reveals that there is higher customer satisfaction from the skill of Physical Therapist but the follow up exercise plan at home is considered worthless by the recipient. Manual therapy provides more relish. Similarly, the results demonstrate that female recipients are more satisfied from physical therapy in this scenario as compared to males.

Level of Knowledge and Practice of Manual Therapy among Physiotherapy Practitioners at the University Teaching Hospital, Lusaka, Zambia

Level of Knowledge and Practice of Manual Therapy among Physiotherapy Practitioners at the University Teaching Hospital, Lusaka, Zambia

Manual Therapy Research Methods in Animal Models, Focusing on Soft Tissues.

Manual therapies have been practiced for centuries, yet little research has been performed to understand their efficacy and almost no animal research has been performed to inform mechanisms of action. The methods of manual therapy practice are quite varied and present a challenge for scientists to model the treatments and perform research using rodents. In this perspective we present a descriptive analysis of the complexity of the treatments, highlighting the role of tissue mechanics and physics. With these complexities in mind, we compare using manual therapy as clinically practiced, to attempts to develop machinery to model or mimic manual therapy. We propose that because of the complexities of manual therapy as practiced, having therapists perform the treatments on research animals just as they would on humans is the most scientific approach. Our results using this approach have supported its practicality.

Development and internal validation of prognostic models for recovery in patients with non-specific neck pain presenting in primary care

ObjectivesDevelopment and internal validation of prognostic models for post-treatment and 1-year recovery in patients with neck pain in primary care. DesignProspective cohort study. SettingPrimary care manual therapy practices. ParticipantsPatients with non-specific neck pain of any duration (n=1193). InterventionUsual care manual therapy. Outcome measuresRecovery defined in terms of pain intensity, disability, and global perceived improvement directly post-treatment and at 1-year follow-up. ResultsAll post-treatment models exhibited acceptable discriminative performance after derivation (AUC≥0.7). The developed post-treatment disability model exhibited the best overall performance (R2=0.24; IQR, 0.22–0.26), discrimination (AUC=0.75; 95% CI, 0.63–0.84), and calibration (slope 0.92; IQR, 0.91–0.93). After internal validation and penalization, this model retained acceptable discriminative performance (AUC=0.74). The five other models, including those predicting 1-year recovery, did not reach acceptable discriminative performance after internal validation. Baseline pain duration, disability, and pain intensity were consistent predictors across models. ConclusionA post-treatment prognostic model for disability was successfully developed and internally validated. This model has potential to inform primary care clinicians about a patient’s individual prognosis after treatment, but external validation is required before clinical use can be recommended.

Approaches to cervical spine mobilization for neck pain: a pilot randomized controlled trial

Study designPilot randomized controlled trial.BackgroundBetter understanding of the relative effectiveness of different approaches to cervical spine mobilization has been identified as a research priority in manual therapy practice. Two distinct approaches to the practice of mobilization have emerged in recent years, based on different reasoning models for selection of mobilization techniques. The objective of this pilot study was to assess feasibility aspects for a future randomized clinical trial by exploring short-term pain and disability outcomes after a single treatment with pragmatic versus prescriptive approaches to cervical mobilization for people with recent-onset neck pain at 48-h follow-up after randomization.MethodsTwenty adults with a new episode of mechanical neck pain were randomly allocated to either pragmatic or prescriptive mobilization intervention groups. The pragmatic group received a single treatment of cervical mobilization with the technique, target segment, and grade selected by their treating therapist. The prescriptive group received a single treatment of standardized mobilization with techniques similar to a previous mobilization clinical trial. Feasibility outcomes were recruitment rates, randomization audit and completion of treatment and follow-up per protocol. The primary clinical outcome of interest was disability level measured at 48-h follow-up after randomization.ResultsRecruitment rates were approximately 2.5 participants per week and 100% of eligible participants were deemed suitable for treatment with cervical mobilization. There was sufficient variety in the range of pragmatic treatments selected and the data collection process imposed minimal burden on participants.ConclusionsOur results provide supporting evidence for the feasibility of a future larger scale randomized clinical trial.Trial registrationTrial registration: Australian New Zealand Clinical Trials Registry (ACTRN12616000446460). Registered 6th April 2016. https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=370448&isReview=true

Effects of cranial osteopathic techniques in the symptoms of benign positional paroxistic vertical

Background: The benign paroxysmal positional vertigo (BPPV) is the most common cause of dizziness among the population. The osteopathy is a practice of manual therapy which is guided by a holistic perspective of human being, the cranial osteopathy affirms that the respective bones of the cranium represent mobility. Objective: To investigate the effect of the cranial osteopathy techniques on the benign paroxysmal positional vertigo. Methods: The current study included 20 female subjects, each one of them with benign paroxysmal positional vertigo, distributed in two groups, an intervention group and a control group (placebo); in order to detect the BPPV, was applied the Dix-Hallpike test before and after the interventions. Three techniques of cranial osteopathy were used on the structures related to vestibule and to the temporal bones: mobilization of temporal bones, tensioning of cerebellar tentorium and mobilization of eyeball. All statistical analyzes were performed using the GraphPad Prism 6.0 software (GraphPad Software, CA).Results: Among the intervention group, 7 of 10 individuals were negative to the Dix-Hallpike test, whilst individuals of the control group remained positive to the test. In the statistical analysis verified that the intervention with osteopathic techniques had a significant effect in compared to the control group, with a value p=0.0261. Conclusion: The cranial osteopathy appears to be able of produce effects on the vestibular activity, whereas were able to reduce, in a significant means, the symptoms concerning to BPPV.

COVID 19 and manual therapy: international lessons and perspectives on current and future clinical practice and education

ABSTRACT Background The COVID-19 pandemic has altered clinical practice and education in manual therapy globally. Social distancing has limited in-person care and changed health-care provision. Education in manual therapy has moved to online platforms with in-person instruction restricted. The global impact on the clinical practice of manual therapy and education has to date not been explored. Methods a questionnaire survey methodology was used. A sample of convenience of global leaders in manual therapy practice and education received an electronic link to two surveys: one on clinical practice and one on education. Contributors could complete one or both surveys. Results Twenty-five surveys were received on clinical practice and 23 on education in manual therapy, representing the six major continents. Global themes in clinical practice demonstrated a sudden and dramatic shift away from patient contact, with limited modifications to manual therapy in patient care currently adopted. Themes in education were of a major shift to online learning, development of new modes of student instruction including video-based assessment and virtual case-based instruction. Conclusion The international perspectives provided demonstrate a major change in manual therapy practice and education globally. Various approaches have been taken in practice and education without a uniform approach being demonstrated.

The degenerative lumbar disc: not a disease, but still an important consideration for OMPT practice: a review of the history and science of discogenic instability

ABSTRACT Background A recent AAOMPT position paper was published that opposed the use of the term ‘degenerative disc disease’ (DDD), in large part because it appears to be a common age-related finding. While common, there are significant physiologic and biomechanical changes that occur as a result of discogenic degeneration, which are relevant to consider during the practice of manual therapy. Methods A narrative review provides an overview of these considerations, including a historical perspective of discogenic instability, the role of the disc as a pain generator, the basic science of a combined biomechanical and physiologic cycle of degeneration and subsequent discogenic instability, the influence of rotation on the degenerative segment, the implications of these factors for manual therapy practice, and a perspective on an evidence-based treatment approach to patients with concurrent low back pain and discogenic degeneration. Conclusions As we consider the role of imaging findings such as DDD, we pose the following question: Do our manual interventions reflect the scientifically proven biomechanical aspects of DDD, or have we chosen to ignore the helpful science as we discard the harmful diagnostic label?

Prospective Cohort Study of Patients With Neck Pain in a Manual Therapy Setting: Design and Baseline Measures

ObjectivesThe purpose of this study was to describe the design and baseline measurements of a prospective multicenter cohort study in patients with neck pain treated by Dutch manual therapists. Objectives of the study were to determine which patients seek help from a manual therapist, to describe usual care manual therapy in patients with neck pain, to examine the occurrence of nonserious adverse events after treatment, to describe predictors of adverse events, and to determine whether the occurrence of nonserious adverse events affect outcome after manual therapy care. MethodsDuring a 3-month inclusion period, consecutive patients aged between 18 and 80 years presenting with neck pain in manual therapy practices in The Netherlands were included in the study. Baseline questionnaires included the Numeric Rating Scale, Neck Disability Index (NDI), Neck Bournemouth Questionnaire, Fear Avoidance Beliefs Questionnaire (FABQ), and Patient Expectancy List. Within the treatment episode, manual therapist clinical reasoning and applied interventions were registered and patients reported on adverse events. At the end of the treatment episode and at 12-month follow-up, pain intensity (Numeric Rating Scale), functional outcomes (NDI, Neck Bournemouth Questionnaire), personal factors (FABQ), and global perceived effect were measured. ResultsDuring the 3-month inclusion period, 263 participating manual therapists collected data on 1193 patients with neck pain. Most patients (69.4%) were female. The mean age was 44.7 (±13.7) years. The NDI showed overall mild disability (mean score 26%). Mean scores in pain intensity were moderate (4.8), and there was low risk of prolonged disability owing to personal factors (FABQ). ConclusionThis study provides information on baseline characteristics of patients visiting manual therapists for neck pain. In The Netherlands, patients seeking care of manual therapists are comparable to patients in other countries regarding demographics and neck pain characteristics.

Common Manual Therapy Practices in the Netherlands for Infants With Upper Cervical Dysfunction: A Prospective Cohort Study

ObjectiveThe purpose of this study was to describe common clinical practices of manual therapists (MTs) in the Netherlands for infants with indications of upper cervical dysfunction (UCD). MethodsA prospective observational cohort study was conducted to gain insight into characteristics, reasons for seeking care, and common clinical practice for infants (<27 weeks) with indications of UCD, referred to MTs. Pre- and posttreatment self-reported questionnaires were used to collect data from parents and MTs. Parents reported on infant characteristics and perceived effect of treatment. Manual therapists reported on diagnostics, therapeutic procedures, and outcomes. ResultsBetween 2006 and 2007, data regarding 307 referred infants (mean age: 11.2 weeks) were collected by parents and 42 MTs. The most frequent reasons for seeking care were positional preference, restlessness, and/or abnormal head position. Manual therapists observed active, spontaneous, and provoked mobility and passive upper cervical mobility. Of the 307 infants, 295 were diagnosed with UCD based on positive outcomes on the flexion-rotation test and/or lateral flexion test. After treatment with mobilization techniques, positive outcomes on the flexion-rotation test decreased from 78.8% to 6.8%. For the lateral flexion test, the positive outcomes decreased from 91.5% to 6.2%. All parents perceived positive treatment effects. No serious adverse events were reported during this study. ConclusionsThis is the first study to describe common clinical practice for infants referred for manual therapy. Infants with UCD were treated mainly with upper cervical mobilization techniques, and the greatest perceived effect was observed after approximately 2 treatment sessions.

Quantifiable Soft Tissue Manipulation (QSTM): A Requisite to Advance the Field of Manual Therapy

Quantifiable soft tissue manipulation (QSTM) that can characterize the motion and forces delivered during soft tissue examination and treatment of common musculoskeletal (MS) conditions in a real-time and clinically applicable manner is needed to achieve optimal outcomes. Soft tissue manipulation (STM), e.g. massage, is a type of mechanotherapy that has been used with benefit frequently by clinicians worldwide since ancient times. Instrument-assisted STM (IASTM) is a type of STM that uses rigid devices to assess and treat soft tissue abnormalities in a targeted and precise manner. Remarkably, however, the forces delivered during STM approaches have not been adequately quantified. Unlike other mechano-therapeutic approaches, e.g. ultrasound, traction, exercise, electrical stimulation, current manual therapy practice relies mostly on subjective description of STM evaluation findings and treatment parameters. This makes documentation, analysis, comparison, progression and optimization of this non-invasive intervention difficult to establish and validate. It is the authors’ strong opinion that there is need for QSTM to objectively measure, characterize and record the 3-dimensional (3D) forces and motion trajectories of STM evaluation and intervention. Innovative technology aimed to help address this void in research, educational and clinical practice has been developed by our research team and introduced in this article. The QSTM system has two components: an electronic, handheld device (applicator) for 3D characterization of force and a computer with software for data acquisition and analysis. Preliminary testing has demonstrated that the QSTM prototype can provide accurate sensed values and good intra-, inter-rater reliability. Device revisions are in progress and further testing is planned in animals and humans. QSTM is an essential technology needed for the standardization, comparison and optimization of STM therapies and a requisite to advance the field of manual therapy.

Manual Therapy Practices of Sobadores in North Carolina.

This analysis provides a description of the manual-therapy elements of sobadores practicing in North Carolina, using videotapes of patient treatment sessions. Three sobadores allowed the video recording of eight patient treatment sessions (one each for two sobadores, six for the third sobador). Each of the recordings was reviewed by an experienced chiropractor who recorded the frequencies of seven defined manual-therapy elements: (1) treatment time; (2) patient position on treatment surface; (3) patient body part contacted by the sobador; (4) sobador examination methods; (5) primary treatment processes; (6) sobador body part area referencing patient; and (7) adjunctive treatment processes. The range of treatment time of 9-30 min was similar to the treatment spectra that combine techniques used by conventional massage and manipulative practitioners. The patient positions on the treatment surface were not extraordinary, given the wide variety of treatment processes used, and indicated the sobadores treat patients in multiple positions. The patient body part contacted by the sobadores indicated that they were treating each of the major parts of the musculoskeletal system. Basic palpation dominated the sobadores' examination methods. The sobadores' primary treatment processes included significant variety, but rubbing was the dominant practice. The hands were the sobador body area that most often made contact with the patient. They all used lubricants. Sobadores' methods are similar to those of other manual-therapy practitioners. Additional study of video-recorded sobador practices is needed. Video-recorded practice of other traditional and conventional manual therapies for comparative analysis will help delineate the specific similarities and differences among the manual therapies.

Cervico-cephalalgiaphobia: a subtype of phobia in patients with cervicogenic headache and neck pain? A pilot study

Objectives: The term ‘cephalalgiaphobia’ was introduced in the mid-1980s and defined as fear of migraine (attacks). We hypothesized that a specific subtype of cephalalgiaphobia affects patients with cervicogenic headache (CEH). This study aimed to: (1) define the term ‘cervico-cephalalgiaphobia’; (2) develop a set of indicators for phobia relevant to patients with CEH; and (3) apply this set to a practice test in order to estimate the frequency of cervico-cephalalgiaphobia in the Dutch primary care practice of manual physical therapy.Methods: A systematic approach was used to develop a definition and potential indicators for cervico-cephalalgiaphobia. An expert group appraised the definition and the set of indicators (score per indicator: never; sometimes; often/always). An invitation to participate in the practice test was sent to Dutch manual physical therapy practices (n = 56) representing 134 manual physical therapists (MPTs). The cut-off point for percentages of scores for coverage of the indicators was set at ≥ 60%.Results: The expert group agreed with the proposed definition of cervico-cephalalgiaphobia. A set of eight indicators for cervico-cephalalgiaphobia was selected from 10 initial indicators. Thirty-six MPTs provided data from 46 patients diagnosed with CEH. The coverage of ‘often/always’ was substantial for the indicators, ‘Short-term positive results in previous manual physical therapeutic treatment’, ‘Shorter interval between treatment sessions’, ‘Fear of “locked facet joints” of the neck’, ‘More frequent manipulation’, and ‘Fear of increase in headaches’. Coverage was also substantial for ‘never’ regarding ‘Long-term positive results in previous manual physical therapeutic treatment’. ‘Confirmation of “locked facet joints” of the cervical spine by MPT as a cause for increase of CEH’ scored ‘often/always’ in all patients. Coverage for ‘Increased use of medication with insufficient effect’ was substantial, scoring as ‘sometimes’ in 39 (84.8%) patients.Discussion: Cervico-cephalalgiaphobia was defined and a set of eight indicators formulated based on the literature and clinical expertise. The practice test provides valuable information on the frequency of indicators for cervico-cephalalgiaphobia in the Dutch manual physical therapy practice, suggesting that cervico-cephalalgiaphobia is common in patients with CEH.

Tensegrity and manual therapy practice: a qualitative study

BackgroundTensegrity has been proposed as a unifying mechanism between structures at cellular, connective tissue and whole body level. Originating in the fields of sculpture and architecture, tensegrity has recently received increasing attention from practitioners and researchers of manual therapy. Notwithstanding this, evidence regarding the role of the tensegrity principle to manual therapy practice is lacking. ObjectiveThis qualitative study explored the conception of tensegrity amongst manual therapy practitioners and how knowledge of the physical principle of tensegrity may influence manual therapy practitioners' clinical decision-making. MethodsEight semi-structured interviews were conducted with participants from manual therapy, fascia research and/or manual therapy education fields, and analysed using grounded theory methods. ResultsData from this study indicates that tensegrity may inform clinical decision-making in manual therapy. A theory has been constructed that may help to explain aspects of manual therapy practitioners' approaches to tensegrity. Four such approaches to tensegrity were identified and elaborated on. ConclusionThis study suggests that apart from being of importance as a scientific model in the fields of architecture, engineering and biology, tensegrity may also be useful to the practice of manual therapy. Here, tensegrity may serve as a theoretical underpinning of previously conceived clinical models and subjective clinical experience, and may also inform decision-making processes by providing a biomechanical model of the human body.

Cervicogenic somatosensory tinnitus: An indication for manual therapy plus education? Part 2: A pilot study

ObjectivesThe aim of this study was to evaluate the efficacy of Manual Therapy Utrecht (MTU) plus education in patients with cervicogenic somatosensory tinnitus (CeT). Study designPretest–posttest design. MethodFive hundred and six patients were referred or referred themselves. A subgroup of patients was identified with CeT, and within this a subgroup with tinnitus sensitization (TS). Two CeT groups were created based on the presence or absence of TS. Both groups underwent manual therapy combined with tinnitus education. Tinnitus intensity (VAS-tin 0–100 mm) was the primary outcome measure. Number of treatments and adverse effects were the secondary outcome measures. ResultsA total of 122 patients with CeT (24.1%) were included (average age 53.3 years [±9.8], female 38.5% and duration of tinnitus 7.3 years [±8.9]). Patients were divided into two groups: 55 patients (45.1%) with TS (CeT + TS group) and 67 patients (54.9%) without TS (CeT − TS group). Pretest to posttest differences on the VAS-tin were statistically significant within both groups (CeT − TS group: difference VAS-tin 5.9 [p = 0.01]; CeT + TS group: difference VAS-tin 18.2 [p = 0.00]), and between the groups in favor of the CeT + TS group (difference VAS-tin 12.3 [p = 0.01]). Pretest to posttest differences were clinically significant for the CeT + TS group (difference VAS-tin 18.2 [MCIC = ≥10 mm VAS-tin]) and between the groups (difference VAS-tin 12.3 in favor of the CeT + TS group). The average number of treatment sessions was 9.6 (±2.6) for the CeT − TS group and 10.3 (±2.5) for the CeT + TS group, a non-significant difference. There were no adverse effects in either group. ConclusionsDespite its limitations, this study provides valuable information on both the characteristics of patients with CeT and TS in a Dutch primary care manual therapy practice and on the potential effectiveness of MTU combined with tinnitus education for the subgroup of CeT + TS patients.

Strategies to overcome size and mechanical disadvantages in manual therapy

The practice of manual therapy (MT) is often difficult when providing care for large patients and for practitioners small in stature or with other physical limitations. Many MT techniques can be modified using simple principles to require less exertion, permitting consistency with standards of practice even in the presence of physical challenges. Commonly used MT techniques are herein described and demonstrated with alternative preparatory and movement methods, which can also be adopted for use in other techniques. These alternative techniques and the procedures used to adapt them warrant discussion among practitioners and educators in order to implement care, consistent with the best treatment evidence for many common musculoskeletal (MSK) conditions. The inclusion in educational curricula and MT training programs is recommended to enrich skill development in physical therapists (PTs), spanning entry-level practitioners to those pursuing advanced manual skills.

Measureable changes in the neuro-endocrinal mechanism following spinal manipulation

The autonomic nervous system and the hypothalamic–pituitary–adrenal axis have been shown to be dysfunctional in a number of chronic pain disorders. Spinal manipulation is a therapeutic technique used by manual therapists, which may have widespread neuro-physiological effects. The autonomic nervous system has been implicated to modulate these effects. A theory is proposed that spinal manipulation has the potential to be used as a tool in restoring the autonomic nervous system balance. Further, it is also hypothesised that through its anatomical and physiological connections, the autonomic nervous system activity following a thoracic spinal manipulation may have an effect on the hypothalamic–pituitary–adrenal axis and therefore pain and healing via modulation of endocrine and physiological processes. To substantiate our hypothesis we provide evidence from manual therapy studies, basic science and animal studies. According to the proposed theory, there will be measurable changes in the neuro-endocrinal mechanisms following a thoracic spinal manipulation. This has far-reaching implications for manual therapy practice and research and in the integration of spinal manipulation in the treatment of a wide array of disorders.