A Single-Blind Pilot Study to Determine Risk and Association Between Navicular Drop, Calcaneal Eversion, and Low Back Pain

Objective: Syndromes causing mechanical low back pain (MLBP) continue to plague the US health care system. One hypothesis is that flatfeet are a risk factor for MLBP. This pilot study evaluated whether subjects with flatter feet are at greater risk for MLBP than subjects without flatter feet. Methods: Fifty-eight subjects (16-70 years old) were allocated to a group diagnosed with 2 or more episodes of MLBP or with no history of MLBP. A blind assessor measured navicular drop (ND) using navicular height (NH) and calcaneal eversion (CE). Based on a range of reported data, flatfoot was defined as a possible risk factor for MLBP with ND greater than 3, 8, and/or 10 mm, and/or greater than 6° CE. Results: According to χ2 analysis, risk of MLBP appeared similar between groups (P > .05). There was no significant difference (P > .05) between continuous variables (t tests, Pearson r and r2) with one exception, correlation of increasing CE with increasing ND (P = .0001). Power was generally low (10 mm ND), and lesser back pain severity make these data tentative. Further research is needed

A structured protocol of evidence-based conservative care compared with usual care for acute nonspecific low back pain: A randomized clinical trial

Objective: To compare a protocol of evidence-based conservative care with usual care for acute nonspecific low back pain (LBP) of less than 6 weeks' duration. Design: Parallel-group randomized trial. Setting: Three practices in the United Kingdom. Participants: Convenience sample of 149 eligible patients were invited to participate in the study, with 118 volunteers being consented and randomly allocated to a treatment group. Interventions: The experimental group received evidence-based treatments for acute nonspecific LBP as prescribed in a structured protocol of care developed for this study. The control group received usual conservative care. Participants in both groups could receive up to 7 treatments over a 4-week period. Main Outcome Measures: Oswestry Low Back Disability Index (ODD, visual analog scale (VAS), and Patient Satisfaction Questionnaire, alongside estimation of clinically meaningful outcomes. Results: Total dropout rate was 14% (n=16), with 13% of data missing. Missing data were replaced using a multiple imputation method. Participants in both groups received an average of 6 treatments. There was no statistically significant difference in disability ODI scores at the end of week 4 (P=.33), but there was for pain (VAS) scores (P <.001). Interestingly, there were statistically significant differences between the 2 groups for both disability and pain measures at the midpoint of the treatment period (P <.001). Patient satisfaction with care was equally high (85%) in both groups. Minimally clinically important differences in scores and number needed to treat scores (NNT < 6) indicated that the experimental treatment (protocol of care) offered a clinically meaningful benefit over the control treatment (usual care), particularly at the midpoint of the treatment period. Conclusions: Overall, the 2 treatment groups were similar based on primary or secondary outcome measure scores for the full treatment period (4 weeks, with up to 7 treatments). However, there were statistically significant and clinically meaningful differences in both disability and pain scores at week 2 (midpoint) with 4 treatments, suggesting that the protocol of care had a more rapid effect than usual care

The comparative effect of muscle energy technique vs. manipulation for the treatment of chronic recurrent ankle sprain

Background: Ankle injuries account for 23,000 inversion sprains daily. Lateral ankle sprains are predisposed by previous injury and a decrease in balance. This prospective randomized clinical trial compared the use of high-velocity, low-amplitude (HVLA) manipulation and Muscle Energy Technique mobilization in the treatment of chronic ankle sprains Methods: Forty candidates diagnosed with chronic recurrent ankle sprain were randomized into the trial. The primary outcome measures were the One Leg Standing Test and the Numerical Pain Rating Scale-101. Results: The One Leg Standing Test and Numerical Pain Rating Scale-101 had statistically significant and clinically meaningful intra-group changes. The One Leg Standing Test eyes closed showed an increase with High Velocity Low Amplitude manipulation of 10.24 seconds and with Muscle Energy Technique mobilization of 10.05 seconds, both t-tests p=.003 suggestive of a centrally mediated positive neurological effect on the function of the locomotive system. The Numerical Pain Rating Scale-101 showed significant decrease in High Velocity Low Amplitude manipulation of 37.1 points and Muscle Energy Technique of 39.6 points, both t-tests p<0.000. Conclusion: Both High Velocity Low Amplitude manipulation and Muscle Energy Technique mobilization significantly increased balance, range of motion, and function while decreasing shortterm pain. These promising results merit further research with a fully powered trial

Manipulative therapy and rehabilitation for recurrent ankle sprain with functional instability: A short-term, assessor-blind, parallel-group randomized trial

Objective The purpose of this study was to compare manipulative therapy (MT) plus rehabilitation to rehabilitation alone for recurrent ankle sprain with functional instability (RASFI) to determine short-term outcomes. Methods This was an assessor-blind, parallel-group randomized comparative trial. Thirty-three eligible participants with RASFI were randomly allocated to receive rehabilitation alone or chiropractic MT plus rehabilitation. All participants undertook a daily rehabilitation program over the course of the 4-week treatment period. The participants receiving MT had 6 treatments over the same treatment period. The primary outcome measures were the Foot and Ankle Disability Index and the visual analogue pain scale, with the secondary outcome measure being joint motion palpation. Data were collected at baseline and during week 5. Missing scores were replaced using a multiple imputation method. Statistical analysis of the data composed of repeated-measures analysis of variance. Results Between-group analysis demonstrated a difference in scores at the final consultation for the visual analogue scale and frequency of joint motion restrictions (P ≤ .006) but not for the Foot and Ankle Disability Index (P = .26). Conclusions This study showed that the patients with RASFI who received chiropractic MT plus rehabilitation showed significant short-term reduction in pain and the number of joint restrictions in the short-term but not disability when compared with rehabilitation alone

Manipulative therapy for lower extremity conditions: Update of a literature review

Objective: The purpose of this study is to update a systematic review on manipulative therapy (MT) for lower extremity conditions. Methods: A review of literature was conducted using MEDLINE, MANTIS, Science Direct, Index to Chiropractic Literature, and PEDro from March 2008 to May 2011. Inclusion criteria required peripheral diagnosis and MT with or without adjunctive care. Clinical trials were assessed for quality using a modified Scottish Intercollegiate Guidelines Network (SIGN) ranking system. Results: In addition to the citations used in a 2009 systematic review, an additional 399 new citations were accessed: 175 citations in Medline, 30 citations in MANTIS, 98 through Science Direct, 54 from Index to Chiropractic Literature, and 42 from the PEDro database. Forty-eight clinical trials were assessed for quality. Conclusions: Regarding MT for common lower extremity disorders, there is a level of B (fair evidence) for short-term and C (limited evidence) for long-term treatment of hip osteoarthritis. There is a level of B for short-term and C for long-term treatment of knee osteoarthritis, patellofemoral pain syndrome, and ankle inversion sprain. There is a level of B for short-term treatment of plantar fasciitis but C for short-term treatment of metatarsalgia and hallux limitus/rigidus and for loss of foot and/or ankle proprioception and balance. Finally, there is a level of I (insufficient evidence) for treatment of hallux abducto valgus. Further research is needed on MT as a treatment of lower extremity conditions, specifically larger trials with improved methodology

Manipulative and multimodal therapy for upper extremity and temporomandibular disorders: A systematic review

Objective The purpose of this study was to complete a systematic review of manual and manipulative therapy (MMT) for common upper extremity pain and disorders including the temporomandibular joint (TMJ). Methods A literature search was conducted using the Cumulative Index of Nursing Allied Health Literature, PubMed, Manual, Alternative, and Natural Therapy Index System (MANTIS), Physiotherapy Evidence Database (PEDro), Index to Chiropractic Literature, Google Scholar, and hand search inclusive of literature from January 1983 to March 5, 2012. Search limits included the English language and human studies along with MeSH terms such as manipulation, chiropractic, osteopathic, orthopedic, and physical therapies. Inclusion criteria required an extremity peripheral diagnosis (for upper extremity problems including the elbow, wrist, hand, finger and the (upper quadrant) temporomandibular joint) and MMT with or without multimodal therapy. Studies were assessed using the PEDro scale in conjunction with modified guidelines and systems. After synthesis and considered judgment scoring was complete, evidence grades of “A, B, C and I” were applied. Results Out of 764 citations reviewed, 129 studies were deemed possibly to probably useful and/or relevant to develop expert consensus. Out of 81 randomized controlled or clinical trials, 35 were included. Five controlled or clinical trials were located and 4 were included. Fifty case series, reports and/or single-group pre-test post-test prospective case series were located with 32 included. There is Fair (B) level of evidence for MMT to specific joints and the full kinetic chain combined generally with exercise and/or multimodal therapy for lateral epicondylopathy, carpal tunnel syndrome, and temporomandibular joint disorders, in the short term. Conclusion The information from this study will help guide practitioners in the use of MMT, soft tissue technique, exercise, and/or multimodal therapy for the treatment of a variety of upper extremity complaints in the context of the hierarchy of published and available evidence

Manual and manipulative therapy compared to night splint for symptomatic hallux abducto valgus: An exploratory randomised clinical trial

Context Hallux abducto valgus (HAV) is a frequent cause of great toe pain and disability, yet common treatments are only supported by mixed or equivocal research findings. Surgery often only provides modest improvement and post-surgery complications may significantly hamper outcomes, implying the need for trials testing conservative treatment, such as manual and manipulative therapy, particularly in cases where surgery may be contraindicated or premature. The purpose of this exploratory trial was to test an innovative protocol of manual and manipulative therapy (MMT) and compare it to standard care of a night splint(s) for symptomatic mild to moderate HAV, with a view gather insight into the effectiveness of MMT and inform the design of a definitive trial. Design Parallel-group randomised trial set in an out-patient teaching clinic. Participants A convenience sample of 75 patients was assessed for eligibility, with 30 participants (15 per group) being consented and randomly allocated to either the control group (standard care with a night splint) or the experimental group (MMT). Intervention Participants in the control group used a night splint(s) and those in the experimental group (MMT) received a structured protocol of MMT, with the participants in the experimental group receiving 4 treatments over a 2-week period. Outcome measures Visual analogue scale (HAV-related pain), foot function index (HAV-related disability) and hallux dorsiflexion (goniometry). Results There were no participant dropouts and no data was missing. There were no statistical (p < 0.05) or clinically meaningful differences (MCID < 20%) between the two groups based on outcome measure scores. However, the outcome measure scores in the control group (night splint) regressed between the 1-week follow-up and 1-month follow-up, while the scores in the experimental group (MMT) were sustained up to the 1-month follow-up. The within-group data analysis produced statistically and clinically significant changes from baseline to the 1-week flow-up across all outcome measures. Post hoc power analysis and sample size calculations suggest that the average between group power of this trial was approximately 60% (ES = 0.33) and that a definitive trial would require a minimum of 102 participants per group (N = 204) to achieve satisfactory power of ≥80%. Conclusions The trend in results of this trial suggest that an innovative structured protocol of manual and manipulative therapy (experimental group) is equivalent to standard care of a night splint(s) (control group) for symptomatic mild to moderate HAV in the short term. The protocol of MMT maintains its treatment effect from 1-week to 1-month follow-up without further treatment, while patients receiving standard care seem to regress when not using the night splint. Insights from this study support further testing of MMT for symptomatic mild to moderate HAV, particularly where surgery is premature or where surgical outcomes may be equivocal, and serve to inform the design of a future definitive trial

Manual and manipulative therapy in addition to rehabilitation for osteoarthritis of the knee: Assessor-Blind randomized pilot trial

Objectives The purpose of this study was to examine the methodological integrity, sample size requirements, and short-term preliminary clinical outcomes of manual and manipulative therapy (MMT) in addition to a rehabilitation program for symptomatic knee osteoarthritis (OA). Methods This was a pilot study of an assessor-blinded, randomized, parallel-group trial in 2 independent university-based outpatient clinics. Participants with knee OA were randomized to 3 groups: 6 MMT sessions alone, training in rehabilitation followed by a home rehabilitation program alone, or MMT plus the same rehabilitation program, respectively. Six MMT treatment sessions (provided by a chiropractic intern under supervision or by an experienced chiropractor) were provided to participants over the 4-week treatment period. The primary outcome was a description of the research methodology and sample size estimation for a confirmatory study. The secondary outcome was the short-term preliminary clinical outcomes. Data were collected at baseline and 5 weeks using the Western Ontario and McMasters Osteoarthritis Index questionnaire, goniometry for knee flexion/extension, and the McMaster Overall Therapy Effectiveness inventory. Analysis of variance was used to compare differences between groups. Results Eighty-three patients were randomly allocated to 1 of the 3 groups (27, 28, and 28, respectively). Despite 5 dropouts, the data from 78 participants were available for analysis with 10% of scores missing. A minimum of 462 patients is required for a confirmatory 3-arm trial including the respective interventions, accounting for cluster effects and a 20% dropout rate. Statistically significant and clinically meaningful changes in scores from baseline to week 5 were found for all groups for the Western Ontario and McMasters Osteoarthritis Index (P ≤ .008), with a greater change in scores for MMT and MMT plus rehabilitation. Between-group comparison did not reveal statistically significant differences between group scores at week 5 for any of the outcome measures (P ≥ .46). Conclusions This pilot trial suggests that a confirmatory trial is feasible. There were significant changes in scores from baseline to week 5 across all groups, suggesting that all 3 treatment approaches may be of benefit to patients with mild-to-moderate knee OA, justifying a confirmatory trial to compare these interventions

Late Occupation of the High-Elevation Northern Tibetan Plateau Based on Cosmogenic, Luminescence, and Radiocarbon Ages

International audience10Be-26Al cosmogenic surface exposure, optically stimulated luminescence, and radiocarbon dates from the site of Xidatan 2 (∼4300 m above sea level [asl] in the Kunlun Pass, northern Tibetan Plateau) suggest the site was in- termittently and briefly occupied approximately 9200-6400 yr B.P. This age is substantially younger than expected given the late Upper Paleolithic character of the lithic assemblage, which is dominated by microlithic and unique dis- coidal prepared core technologies. Comparisons between Xidatan 2 and known surface lithic assemblages in the Kekexili and Chang Tang regions of the central high Plateau show not only that the latter are technologically similar to Xidatan 2, but also that they are demonstrably connected to Xidatan 2 through utiliza- tion of the same stone raw materials, which includes a chemically distinctive obsidian. Contrary to most accounts of Tibetan Plateau colonization, our re- sults suggest that the earliest substantial occupations on the interior Tibetan Plateau above 4000 m asl may date to the Pleistocene/Holocene transition

Full kinetic chain manual and manipulative therapy plus exercise compared with targeted manual and manipulative therapy plus exercise for symptomatic osteoarthritis of the hip: A randomized controlled trial

Objective: To determine the short-term effectiveness of full kinematic chain manual and manipulative therapy (MMT) plus exercise compared with targeted hip MMT plus exercise for symptomatic mild to moderate hip osteoarthritis (OA). Design: Parallel-group randomized trial with 3-month follow-up. Setting: Two chiropractic outpatient teaching clinics. Participants: Convenience sample of eligible participants (N=111) with symptomatic hip OA were consented and randomly allocated to receive either the experimental or comparison treatment, respectively. Interventions: Participants in the experimental group received full kinematic chain MMT plus exercise while those in the comparison group received targeted hip MMT plus exercise. Participants in both groups received 9 treatments over a 5-week period. Main Outcome Measures: Western Ontario and McMasters Osteoarthritis Index (WOMAC), Harris hip score (HHS), and Overall Therapy Effectiveness, alongside estimation of clinically meaningful outcomes. Results: Total dropout was 9% (n=10) with 7% of total data missing, replaced using a multiple imputation method. No statistically significant differences were found between the 2 groups for any of the outcome measures (analysis of covariance, P=.45 and P=.79 for the WOMAC and HHS, respectively). Conclusions: There were no statistically significant differences in the primary or secondary outcome scores when comparing full kinematic chain MMT plus exercise with targeted hip MMT plus exercise for mild to moderate symptomatic hip OA. Consequently, the nonsignificant findings suggest that there would also be no clinically meaningful difference between the 2 groups. The results of this study provides guidance to musculoskeletal practitioners who regularly use MMT that the full kinematic chain approach does not appear to have any benefit over targeted treatment