Manipulation-induced hypoalgesia in musculoskeletal pain populations: A systematic critical review and meta-analysis

Background Manipulation-induced hypoalgesia (MIH) represents reduced pain sensitivity following joint manipulation, and has been documented in various populations. It is unknown, however, whether MIH following high-velocity low-amplitude spinal manipulative therapy is a specific and clinically relevant treatment effect. Methods This systematic critical review with meta-analysis investigated changes in quantitative sensory testing measures following high-velocity low-amplitude spinal manipulative therapy in musculoskeletal pain populations, in randomised controlled trials. Our objectives were to compare changes in quantitative sensory testing outcomes after spinal manipulative therapy vs. sham, control and active interventions, to estimate the magnitude of change over time, and to determine whether changes are systemic or not. Results Fifteen studies were included. Thirteen measured pressure pain threshold, and four of these were sham-controlled. Change in pressure pain threshold after spinal manipulative therapy compared to sham revealed no significant difference. Pressure pain threshold increased significantly over time after spinal manipulative therapy (0.32 kg/cm2, CI 0.22–0.42), which occurred systemically. There were too few studies comparing to other interventions or for other types of quantitative sensory testing to make robust conclusions about these. Conclusions We found that systemic MIH (for pressure pain threshold) does occur in musculoskeletal pain populations, though there was low quality evidence of no significant difference compared to sham manipulation. Future research should focus on the clinical relevance of MIH, and different types of quantitative sensory tests

Pressure pain thresholds in a real-world chiropractic setting: Topography, changes after treatment, and clinical relevance?

Background Changes in pain sensitivity are a commonly suggested mechanism for the clinical effect of spinal manipulative therapy (SMT). Most research has examined pressure pain thresholds (PPT) and has primarily been conducted in controlled experimental setups and on asymptomatic populations. Many important factors are likely to differ between research and clinical settings, which may affect PPT changes following SMT. Therefore, we planned to investigate PPT before and after clinical chiropractic care and investigate relationships with various potentially clinically-relevant factors. Methods We recruited participants from four Danish chiropractic clinics between May and August 2021. A total of 129 participants (72% of the invited) were included. We measured PPT at eight pre-determined test sites (six spinal and two extra-spinal) immediately before (pre-session) and immediately after (post-session) the chiropractic consultation. We used regression analyses to investigate PPT changes, including the following factors: (i) vertebral distance to the nearest SMT site, (ii) rapid clinical response, (iii) baseline PPT, (iv) number of SMTs performed, (v) at the region of clinical pain compared to other regions, and (vi) if other non-SMT treatment was provided. We also performed topographic mapping of pre-session PPTs. Results After the consultation, there was a non-significant mean increase in PPT of 0.14 kg (95% CIs = − 0.01 to 0.29 kg). No significant associations were found with the distance between the PPT test site and nearest SMT site, the clinical response of participants to treatment, the pre-session PPT, the total number of SMTs performed, or the region/s of clinical pain. A small increase was observed if myofascial treatment was also provided. Topographic mapping found greater pre-session PPTs in a caudal direction, not affected by the region/s of clinical pain. Conclusions This study of real-world chiropractic patients failed to demonstrate a substantial local or generalized increase in PPT following a clinical encounter that included SMT. This runs counter to prior laboratory research and questions the generalizability of highly experimental setups investigating the effect of SMT on PPT to clinical practice

Pressure pain threshold and temporal summation in adults with episodic and persistent low back pain trajectories: A secondary analysis at baseline and after lumbar manipulation or sham

Background People with chronic low back pain (LBP) typically have increased pain sensitivity compared to healthy controls, however its unknown if pain sensitivity differs based on LBP trajectory at baseline or after manual therapy interventions. We aimed to compare baseline pressure pain threshold (PPT) and temporal summation (TS) between people without LBP, with episodic LBP, and with persistent LBP, and to compare changes over time in PPT and TS after a lumbar spinal manipulation or sham manipulation in those with LBP. Methods Participants were aged 18–59, with or without LBP. Those with LBP were categorised as having either episodic or persistent LBP. PPT and TS were tested at baseline. LBP participants then received a lumbar spinal manipulation or sham, after which PPT and TS were re-tested three times over 30 min. Generalised linear mixed models were used to analyse data. Results One hundred participants (49 female) were included and analysed. There were 20 non-LBP participants (mean age 31 yrs), 23 episodic LBP (mean age 35 yrs), and 57 persistent LBP (mean age 37 yrs). There were no significant differences in PPT or TS between groups at baseline. There was a non-significant pattern of lower PPT (higher sensitivity) from the non-LBP group to the persistent LBP group at baseline, and high variability. Changes in PPT and TS after the interventions did not differ between the two LBP groups. Discussion We found no differences between people with no LBP, episodic LBP, or persistent LBP in baseline PPT or TS. Changes in PPT and TS following a lumbar manual therapy intervention do not appear to differ between LBP trajectories

Changes in pressure pain threshold and temporal summation in rapid responders and non-rapid responders after lumbar spinal manipulation and sham: A secondary analysis in adults with low back pain

Background People with LBP who experience rapid improvement in symptoms after spinal manipulative therapy (SMT) are more likely to experience better longer-term outcomes compared to those who don't improve rapidly. It is unknown if short-term hypoalgesia after SMT could be a relevant finding in rapid responders. Objectives We aimed to explore whether rapid responders had different short-term pressure pain threshold (PPT) and temporal summation (TS) outcomes after SMT and sham compared to non-rapid responders. Methods This was a planned secondary analysis of a randomised controlled trial that recruited 80 adults with LBP (42 females, mean age 37 yrs). PPT at the calf, lumbar spine, and shoulder and TS at the hands and feet were measured before and three times over 30 min after a lumbar SMT or sham manipulation. Participants were classified as rapid responders or non-rapid responders based on self-reported change in LBP over the following 24 h. Results Shoulder PPT transiently increased more in the rapid responders than non-rapid responders immediately post-intervention only (between-group difference in change from baseline = 0.29 kg/cm2, 95% CI 0.02–0.56, p = .0497). There were no differences in calf PPT, lumbar PPT, hand TS, or foot TS based on responder status. Conclusions Hypoalgesia in shoulder PPT occurred transiently in the rapid responders compared to the non-rapid responders. This may or may not contribute to symptomatic improvement after SMT or sham in adults with LBP, and may be a spurious finding. Short-term changes in TS do not appear to be related to changes in LBP

Feasibility of using the Neuropen for temporal summation testing

Aim: This pilot study aimed to assess the feasibility of measuring pinprick temporal summation (TS) with the Neuropen, a cheap and accessible device. Methods: Ten asymptomatic participants underwent TS testing using the Neuropen and answered a tolerability questionnaire. Results were compared against reference values, averaging three and five TS tests. Tolerability was assessed qualitatively. Results: The TS results were similar to reference values, with less overall variability. Averaging three versus five tests produced similar results with high correlation. The mean unpleasantness score was low. Conclusion: The Neuropen appears to be suitable for eliciting TS, using an average of three measurements, and has acceptable tolerability. This pilot study was used to inform the use of the Neuropen for measuring TS in subsequent clinical studies

No difference in pressure pain threshold and temporal summation after lumbar spinal manipulation compared to sham: A randomised controlled trial in adults with low back pain

Background Changes in quantitative sensory tests have been observed after spinal manipulative therapy (SMT), particularly in pressure pain thresholds (PPT) and temporal summation (TS). However, a recent systematic review comparing SMT to sham found no significant difference in PPT in patients with musculoskeletal pain. The sham-controlled studies were generally low quality, and conclusions about other quantitative sensory tests could not be made. Objectives We aimed to perform a sham-controlled study with the specific objective of investigating changes in PPT and TS short-term after lumbar SMT compared to sham manipulation in people with low back pain. Methods This was a double-blind randomised controlled trial comparing high-velocity low-amplitude lumbar SMT against sham manipulation in participants with low back pain. Primary outcome measures were PPT at the calf, lumbar spine and shoulder, and TS at the hands and feet. These were measured at baseline, then immediately, 15 min and 30 min post-intervention. Results Eighty participants (42 females) were included in the analyses (mean age 37 years), with 40 participants allocated to each intervention group. Significant between-group differences were only observed for calf PPT, which could be explained by a decrease in PPT (increased sensitivity) after SMT and an increase after sham. Feet TS decreased significantly over time after both SMT and sham, and any other changes over time were inconsistent. Conclusions Our results suggest that lumbar SMT does not have a short-term hypoalgesic effect, as measured with PPT and TS, when compared to sham manipulation in people with low back pain

EFEITO DE ÉPOCAS DE DEFICIÊNCIA HÍDRICA NA EFICIÊNCIA DO USO DO NITROGÊNIO DA CULTURA DO FEIJÃO cv. IMBABELLO

Visando identificar estádios da cultura de feijão que apresentam a menor sensibilidade ao estresse de água no solo, nos quais a irrigação pode ser omitida sem um significativo decréscimo na eficiência de uso de nitrogênio e na produtividade final, foi realizado experimento em um solo franco arenoso (Typic Haplustoll) na Estação Experimental da Universidade Central do Equador, "La Tola", em Tumbaco-Pichincha, Equador, entre julho e novembro de 1994. Os tratamentos consistiram da combinação de sete regimes de irrigação, incluindo irrigação ótima durante todo o ciclo, irrigação deficiente durante todo o ciclo, irrigação tradicional da região, deficiência hídrica no período vegetativo, na floração e formação de vagens, no enchimento de vagens e na maturidade; e de dois níveis de adubação nitrogenada (20 kg N/ha e 80 kg N/ha). Os quatorze tratamentos resultantes foram arranjados e analisados num esquema de parcelas sub-divididas com quatro repetições. O tamanho da parcela experimental foi de 33,6 m2 (8 linhas de 7 metros de comprimento, distantes entre si 0,6 m) com uma população de 120.000 plantas/ha. O nitrogênio fixado do ar pelo feijoeiro foi calculado pelo método de diluição isotópica do 15N, no tratamento com adubação de 20 kg N/ha. A solução marcada foi de sulfato de amônio, com abundância de 5% de átomos de 15N. Como planta-controle, foi utilizado o trigo, semeado no sulco central. Da análise dos resultados obtidos, concluiu-se que: A deficiência de água no solo, durante a fase vegetativa, não afetou a eficiência de uso de nitrogênio, a fixação biológica do nitrogênio, nem a produção de sementes, permitindo uma economia de água de 30%. A deficiência de água durante a floração e enchimento de vagens, afetou drasticamente a fixação biológica do nitrogênio, que comparativamente ao controle, foi reduzida 2,2 vezes.<br>To identify specific growth stages of the common bean crop at which the plant is less sensitive to water stress, in which irrigation could be omitted without significant decrease in biological nitrogen fixation and final yield, a field experiment was conducted at "La Tola" University Experiment Station, Tumbaco, Pichincha, Ecuador, on a sandy loam soil (Typic Haplustoll). The treatments consisted of the combinations of seven irrigation regimes, including normal watering, full stress, traditional practice, single stress at vegetation, at flowering, at yield formation and at ripening, and two levels of applied N (20 and 80 kg/ha). These fourteen treatment combinations were arranged and analysed in a split-plot design with four replications. The plot size was 33.6 m2 (8 rows, 7 m long) with a population of 120,000 plants/ha. Irrigation treatments were started after uniform germination and crop establishment. Soil moisture was monitored with neutron probe down to the 0.50 m depth, 24 hours before and after each irrigation. Nitrogen Fixation was calculated using the 15N methodology for the 20 kg N/ha treatment. Yield data show that treatments which had irrigation deficit had lower yield than those with supplementary irrigation. Nitrogen fertilization significantly increased the number of pods and grain yield. Biological Nitrogen Fixation was significantly affected by water stress at the flowering and yield formation stages