5th National Congress of the Italian Society of Physiotherapy

42 Pages·2016·3.68 MB·English

by  Alessandro Aina

ArchivesofPhysiotherapy2016,6(Suppl1):11
DOI10.1186/s40945-016-0022-4
MEETING ABSTRACTS Open Access
5th National Congress of the Italian Society
of Physiotherapy
Milan,Italy.3–4October2015
Published:14October2016
S1 S2
Criteriaforexercisesselectioninsubjectswithlowbackpain Recentadvancesinpathophysiologyandtreatmentofmyofascial
AlessandroAina([email protected]) triggerpoints
Physiotherapist,Dip.MDT,privatepractice,Milan,Italy MarcoBarbero([email protected])
ArchivesofPhysiotherapy2016,6(Suppl1):S1 RehabilitationResearchLaboratory,DepartmentofBusinessEconomics,
HealthandSocialCare,UniversityofAppliedSciencesandArtsof
Fromthe'70suntilthe'90s,inclinicaltrialsaimedatstudyingtheef- SouthernSwitzerland,SUPSI,Manno,Switzerland
fectsofconservativeinterventionsinpeoplewithlowbackpain,par- ArchivesofPhysiotherapy2016,6(Suppl1):S2
ticipants were randomly allocated to different treatment groups
without a preliminary assessment that went beyond symptoms Theoriginalandthemostcommonlyaccepteddefinitionofmyofas-
localization.Theinitialassumptionwasthatpatientsexhibitingsimi- cial pain syndrome has been formulated by Simons and Travell in
lar symptoms localization should be considered as a unique group. the first volume of The Trigger point Manual edited in 1983 [1]. The
Consequently, theeffectsof differentinterventions weresimilarand authors defined the myofascial pain syndromes as a regional pain
guidelinesmerelysuggested“Stayactive”. characterized by the presence of one or more myofascial trigger
Sincethe'80ssomephysiotherapistsbegantodevelopanumberof points (MTrP). A MTrP is a distinctive clinical characteristic of this
evaluationtestsinordertoidentifyspecificsubgroupsamongpeople painfulsyndromeand it is defined asa hyperirritable palpablenod-
with low back pain and develop targeted treatments for each sub- ule contained in the skeletal muscle fibers. It can produce referred
group.However,intheearly2000s,theAssessmentDiagnosisTreat- pain, either on digital compression or spontaneously. If stimulated
mentOutcome(ASTO)model,developedbyK.Spratt[1],statedthat with dry needling or snapping palpation it may exhibit a typical
eachstepmustbevalidatedbeforeproceedingtothenext. musclefasciculationorjumpsign.
Thistalkwill: The literature suggests that MTrPs are extremely common and can
be considered both a primary cause of a MPS or a secondary pain
generatorinpatientsaffectedbyaprincipalmusculoskeletaldisorder
1. Illustratethefollowingassessmentandclassification
[2]. Before the mid-1990s, key elements regarding the pathophysi-
approaches:A)Mechanicaldiagnosisandtherapy[2],B)
ologywereunrecognized.Subsequentlyresearchstudieshavemade
Treatmentbasedclassification[3],C)Movementsystem
the pathophysiology of myofascial pain syndrome much better
impairment[4],D)Cognitivefunctionaltherapy[5],E)Patho-
understood.Threemainhypotheseshavebeenprovided:energycri-
anatomicbasedclassification[6].
sis theory, muscle spindle concept and the motor endplate hypoth-
2. Providecriteriafortheselectionoftherapeuticexercises.
esis [3]. Additionally, recently Mense et al. presented an integrated
3. Highlightthepossibleoverlapsandsynergiesamongdifferent
hypothesiswhichisaworkinprogressandupdatedasnewevidence
approaches[7].
emerges [4]. This combines recent electrophysiological and histo-
pathologicalresearchfindings.
References Various methods of MTrP treatment are available but currently no
1. SprattK,Statisticalrelevance,inOrthopaedicKnowledgeUpdate:Spine2, clinicalguidelinesareavailableandcliniciansarerequiredtobalance
e.a.D.F.Fardon,Editors,Editor.2002,TheAmericanAcademyof the available evidence, their clinical experience and the patient’s
OrthopaedicSurgeons:Rosemont,Illinois,p.497–505;inDonelsonR. preferences. Treatment approaches can be considered as invasive
Rapidlyreversablelowbackpain.SelfCareFirst,LLC,Hanover,New andnon-invasive.Dryneedlingorintramuscularstimulation,isanin-
Hampshire,Firstedition,2007. vasivetechniqueinwhichathinneedleisusedtopenetratetheskin
2. McKenzie RA, May S. The lumbar spine: mechanical diagnosis and andstimulatetheMTrP.
therapy.2ndedition.Waikanae,NewZealand:SpinalPublications,2003. The expected therapeutic effect is to release the taut band and re-
3. Delitto A, et al. A treatment-based classification approach to low back duce the irritability of the spot tenderness. Together with injections
syndrome:identifyingandstagingpatientsforconservativetreatment. (localanaesthetics,steroids,BotulinumtoxinA)theseareamongthe
PhysTher.1995;75(6):470–489. mostcommontreatmentsformyofascialpainsyndrome.
4. Sahrmann S. Diagnosis and treatment of movement impairment Recentlydryneedlinggainedpopularityamongphysiotherapistsand
syndromes.St.Luis,MO:Mosby,Inc.,2002. threesystematicreviewsontheefficacyhavebeencompleted[5–7].
5. O'Sullivan P. Diagnosis and classification of chronic low back pain Accordingtotheavailablesystematicreviewsdryneedlingshouldbe
disorders:maladaptivemovementandmotorcontrolimpairmentas consideredthefirstchoicetreatmentbutduetothesmallnumberof
underlyingmechanism.ManTher.2005;10(4):242–255. high quality trials additional research requires to be undertaken.
6. PetersenT,etal.Diagnosticclassificationofnon-specificlowbackpain.A Non-invasive treatments include various manual techniques such as
newsystemintegratingpatho-anatomicandclinicalcategories.Physi- ischemiccompressionormanualstretching,andmodalitieslikeultra-
otherTheoryPract.2003;19:213–37. sound and low-level laser therapy. No systematic reviews are avail-
7. Karayannis NV et al., Movement-based subgrouping in low back pain: able for these treatments. However, some trials indicated that
synergyanddivergenceinapproaches.Physiotherapy.2015Jul3[Epub manualtreatmentofMTrPsmightreducethepressurepainthreshold
aheadofprint]. ofspottendernessandtheVASscore[8,9].
©2016TheAuthor(s).OpenAccessThisarticleisdistributedunderthetermsoftheCreativeCommonsAttribution4.0
InternationalLicense(http://creativecommons.org/licenses/by/4.0/),whichpermitsunrestricteduse,distribution,and
reproductioninanymedium,providedyougiveappropriatecredittotheoriginalauthor(s)andthesource,providealinkto
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ArchivesofPhysiotherapy2016,6(Suppl1):11 Page2of42
References these results may be justified by their poor methodological quality
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pointmanual.Baltimore;London:Williams&Wilkins,1983. Despitetheabovebackground,theaimofourstudyistoanalyzeifa
2. FrictonJR.Clinicalcareformyofascialpain.DentClinNorthAm.1991;35:1–28. manual therapy approach is effective for improving the respiratory
3. Simons DG. Clinical and etiological update of myofascial pain from mechanicsofpatientswithdiagnosisofamyotrophiclateralsclerosis
triggerpoints.JMusculoskelPain.1996;4:97–125. (ALS). Respiratory issues are a common cause of comorbidities and
4. MenseS,SimonsDGandRussellIJ.Musclepain:understandingitsnature, mortality in patients affected by this disease [4]. The decreased pa-
diagnosis,andtreatment.Philadelphia:LippincottWilliams&Wilkins,2001. tient’sbreathingcapacityis,inpart,duetotheprogressivemotoneu-
5. CotchettMP,LandorfKBandMunteanuSE.Effectivenessofdryneedling rons degeneration. The increase of the chest stiffness, because of
andinjectionsofmyofascialtriggerpointsassociatedwithplantarheel adaptation of bone and ligamenttissues to a prolongedhypomobi-
pain:asystematicreview.JFootAnkleRes.2010;3:18. lity, further worsens this clinical presentation of restrictive nature
6. KietrysDM,PalombaroKM,AzzarettoE,HublerR,SchallerB,SchlusselJM [5,6]. Strongly supported clinical procedures are the non-invasive
andTuckerM.EffectivenessofDryNeedlingforUpperQuarter ventilation(NIV),themechanicinspiration-expirationtechniques,the
MyofascialPain:ASystematicReviewandMeta-analysis.JOrthopSports coughassistedtechniquesandclearanceoftherespiratorysecretions
PhysTher.2013Sep;43(9):620–34. [7]. Based on our knowledge no articles so far investigated the effi-
7. Tough EA, White AR, Cummings TM, Richards SH and Campbell JL. cacyofmanualtechniquesappliedonthespinalthoracicjointswith
Acupunctureanddryneedlinginthemanagementofmyofascialtrigger theaimtoreducethestiffnessaroundthisanatomicalareawiththe
pointpain:asystematicreviewandmeta-analysisofrandomisedcontrolled final goal to improve the breathing capacity. This modality of treat-
trials.EurJPain.2009;13(1):3–10. ment has already been studied in patients affected by chronic ob-
8. Llamas-Ramos R, Pecos-Martin D, Gallego-Izquierdo T, Llamas-Ramos I, structivepulmonarydisease[5].
Plaza-ManzanoG,Ortega-SantiagoR,ClelandJandFernandez-de-Las- Some preliminary results of a single-center randomized controlled
PenasC.Comparisonoftheshort-termoutcomesbetweentriggerpoint pilotstudyarepresented.Atpresent18subjectshavebeenrecruited
dryneedlingandtriggerpointmanualtherapyforthemanagementof and randomized either in the experimental group or control group.
chronicmechanicalneckpain:arandomizedclinicaltrial.JOrthopSports All subjectsreceived2 daily sessionsof conventional physiotherapy;
PhysTher.2014;44(11):852–61. eachsessionlastedfor1hour.Inaddition,thesubjectsoftheexperi-
9. Cagnie B, Dewitte V, Coppieters I, Van Oosterwijck J, Cools A and mentalgroupweretreatedwithmanualtechniquesfor30minutesdaily
DanneelsL.Effectofischemiccompressionontriggerpointsintheneck for 10 days. Dataof breathing capacity, functional vital capacity(FVC)
andshouldermusclesinofficeworkers:acohortstudy.JManipulative and peak-cough expiratory flow (PCF) were recorded before the first
PhysiolTher.2013;36(8):482–9. treatmentandimmediatelyafterthelastone.Differencespre-postinter-
ventionwereanalyzedwithinthesamegroupandbetweengroups.
S3 The two groups were homogeneous at baseline. The statistical ana-
Rehabilitationofscapulardyskinesia lysis conducted showed a statistically significant change in FVC in
BarbaraCagnie([email protected]) the experimental group after the first treatment of thoracic
DepartmentofRehabilitationSciencesandPhysiotherapy,Ghent mobilization(p=0,012).Moreover,changesintheexperimentalgroup
University,Ghent,Belgium weresignificantlyhigher(p=0.01)thaninthecontrols.Ifthesedata
ArchivesofPhysiotherapy2016,6(Suppl1):S3 willbeconfirmed,additionaltreatmentbasedonmobilizationofthe
thoracic spine maybe useful in the management of respiratory im-
In this lecture, based on her previous work,1,2 Dr. Cagnie highlights pairmentsinthispopulationofpatients.
thecriticalroleofthescapulainprovidingbothmobilityandstability
of the neck/shoulder region and illustrates a science based clinical References
reasoningalgorithmwithpracticalguidelinesfortherehabilitationof 1. Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ. The
scapulardyskinesis. MechanismsofManualTherapyintheTreatmentofMusculoskeletal
Pain:AComprehensiveModel.ManTher.200914(5):531–8.
2. PöllmannW,FenebergW.Currentmanagementofpainassociatedwith
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4. KurianKM,ForbesRB,ColvilleS,SwinglerRJ.Causeofdeathandclinical
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Rehabilitationofscapulardyskinesis:fromtheofficeworkertotheelite gradingcriteriainacohortofamyotrophiclateralsclerosiscases
overheadathlete.BrJSportsMed.2014Apr;48(8):692–7. undergoingautopsyfromtheScottishMotorNeuroneDiseaseRegister.J
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5. Heneghan NR, Adab P, Balanos GM, Jordan RE. Manual therapy for
S4
chronicobstructiveairwaysdisease:asystematicreviewofcurrent
Musculoskeletalrehabilitationinsubjectsaffectedbyneurological evidence.ManTher.2012;17(6):507–18.
disorders
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7. Kirsten L. G, Noah L. Respiratory therapies for amyotrophic lateral
sclerosis:aprimer.Muscle&Nerve2012;46(3):313–331.
Few studies considered the manual therapy techniques applied to
patientsaffectedbyneurologicaldisorders.Itiscommonlyaccepted
thatmanualtherapytreatmentscanaddressandresolvemanymuscle- S5
skeletalpathologies[1]anditisalsowellknowhowtheseconditions Whichexaminationtestssuggestthebestcandidatesformanual
maybeaggravatedbythepresenceofimpairmentsofneurologicalna- therapy
ture(patella-femoraljointpainorlowbackpaininpatientswithdiag- ChadCook([email protected])
nosis of multiple sclerosis [2], shoulder sub-luxation in patients after DivisionofPhysicalTherapy,DukeUniversity,NCUSA
stroke[3]etc.)buttheirtreatmentmodalityisstilluncharted. ArchivesofPhysiotherapy2016,6(Suppl1):S5
Afterascientificliteraturereview,29articlesincluding11RCTabout
theuseofmanualtechniques,suchasspinalandjointmanipulation, Ithasbeenassumedthatonedeterminesapatientisacandidatefor
soft tissue techniques and osteopathic approaches, in patients af- manual therapy during a clinical examination, and that the findings
fected by neurological diseases, have been selected. Overall, the are specificfor the demandof a manual therapyintervention. Trad-
mentionedstudiesshowapoorclinicalefficacyofthesetreatments; itionally, this process (determining candidacy for manual therapy)
ArchivesofPhysiotherapy2016,6(Suppl1):11 Page3of42
hasbeenassociatedwithconclusionsfromthephysicalexamination. PSE is considered a relevant mediator in the relationship between
Forexample,findingssuchaspositionalfaults,abnormalmovement pain and disability in chronic lower back pain (LBP) [2]. The various
patterns, and range of motion loss during movement, all identified outcomes employed were questionnaires and physical clinical tests.
during the physical examination are suggested triggers for manual ThequestionnairesusedweretheOswestryDisabilityIndex(ODI-I)to
therapyuse.In reality,this concept hasbeenwoefully understudied measuredisability[3],the0/10NumericalRatingScale(NRS)tomeas-
and may or may not yield value when determining manual therapy ure pain [4] and the Pain Self Efficacy Questionnaire (PSEQ-I) to
candidacy. Threegeneralphilosophieshave beenadvocated:1) Bio- measure personal belief about how successfully one can cope with
mechanical assumptions (coupling, stiffness, restrictions, patterns of difficultpainfulsituations[5].Thechoiceoftheseoutcomeshasbeen
pain, etc.), 2) Regression based assumptions (modeling and use of achieved with the knowledge of their psychometric properties (in-
clinicalpredictionrules),and3)Withinandbetween-sessionchanges ternalconsistency,reproducibility,validityandsensibilityindetecting
(from patient response). Of the three concepts, identifying change clinical changes after conservative treatment for subacute and
(within but mostly, between session) during the clinical physical chronicLBP)andvalidityinItalianlanguage.
examinationhasprovidedthegreatestamountofevidenceinsupport Thephysicalclinicaltestsusedtodetectsegmentallumbarinstability
butfailstotrulydetermineifsomeonecouldalsobenefitfromanalter- were the Aberrant Movements test (AMs) (Fig. 1) and the Passive
nativeintervention.Thisplatformdiscussesthepresentstateoflitera- Lumbar Extension test (PLE) (Fig. 2). The Active Straight Leg Raise
ture associating physical examination testing and manual therapy (ASLR)wasperformedtoassesslumbo-pelvicmotorcontrol,andthe
outcomesanddiscussesthefutureneedsforimprovedevidence. Supine Bridge Test (SBT) (Fig. 3) was performed to measure lumbar
muscles endurance. The choice of these outcomes has been made
References becausetheseclinicaltestshavebeenusedandtheirvalidityinvesti-
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chiropracticmanipulationofthecervicalspine.JManipulativePhysiol Cognitiveandbehaviouralprincipleswereintegratedineachindivid-
Ther.2008;31(3):172–83. ual program and a functional and graded approach was performed
2. Garrison JC,ShanleyE,ThigpenC,HegedusE,CookC.Between-session toincreasetheactivitylevelandimprovestrength,endurance,range
changespredictoverallperceptionofimprovementbutnotfunctional ofmotion,balance,coordinationandself-efficacy.
improvementinpatientswithshoulderimpingementsyndromeseenfor Todeterminewhetherthemaingoalswereachieved,weconsidered
physicaltherapy:anobservationalstudy.PhysiotherTheoryPract. as Minimal Clinically Important Difference (MCID) results at least 2
2011;27(2):137–45. points score reduction for NRS, 10 points score reduction for ODI-I
3. HahneAJ,KeatingJL,WilsonSC.Dowithin-sessionchangesinpainintensity [8]andascoreimprovementofatleast11forPSEQ-I[9].Weconsid-
andrangeofmotionpredictbetween-sessionchangesinpatientswithlow eredapatientdefinitelyimprovedwhenallMCIDwereattained,par-
backpain?AustJPhysiother.2004;50(1):17–23. tially improved when at least two MCID were attained, and not-
4. TuttleN.Dochangeswithinamanualtherapytreatmentsessionpredict improved when only one or no MCID was attained. Concerning in-
between-sessionchangesforpatientswithcervicalspinepain?AustJ stability and endurance clinical tests (secondary goals), we consid-
Physiother2005;51(1):43–8. ered a patient definitely improved when all instability tests were
5. TuttleN,LaaskoL,BarrettR.Changeinimpairmentsinthefirsttwotreatments negative and SBT reached a score higher than 170 seconds (mean
predictsoutcomeinimpairments,butnotinactivitylimitations,insubacute durationinasymptomaticpeople)[10].
neckpain:anobservationalstudy.AustJPhysiother2006;52(4):281–5. At the end of the treatment, 7 out of 10 patients were considered
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treatmentasaguidetoongoingclinicalreasoning?JManipulative efficacy.Inanycase,PSEwasthemostimproveddomainandalways
PhysiolTher.2009;32(5):396–403. related to significant disability reduction. Clinical improvement ap-
7. WrightAA,AbbottJH,BaxterD,CookC.Theabilityofasustainedwithin- peared coherent with instability and endurance test changes (9 out
sessionfindingofpainreductionduringtractiontodictateimproved of10patientsimproved).
outcomesfromamanualtherapyapproachonpatientswithosteoarthritis Takehomesuggestions:thevalidityandresponsivenessoftheout-
ofthehip.JManManipTher2010;18(3):166–72. comes must be known. To have objective data reflecting changes
8. Saavedra-Hernandez M, Castro-Sánchez AM, Fernández-de-Las-Peñas C, thataremeaningfulforthepatientafteraclinicalintervention,itis
ClelandJA,Ortega-SantiagoR,Arroyo-MoralesM.Predictorsforidentify- basicforphysiotherapistswhendeterminingthepatient’sresponse
ingpatientswithmechanicalneckpainwhoarelikelytoachieveshort- to treatment and to guide clinical decision-making during the
termsuccesswithmanipulativeinterventionsdirectedatthecervicaland courseoftreatment.
thoracicspine.JManipulativePhysiolTher.2011;34(3):144–52. Consentforpublication
9. CookC,LawrenceJ,MichalakK,DhiraprasiddhiS,DonaldsonM,Petersen TheauthorshavewritteninformedconsentfromthepeopleinFigs.1,2
S,LearmanK.Istherepreliminaryvaluetoawithin-and/orbetween- and3,andconsenttopublishthephotographs.Therelevantdocuments
sessionchangefordeterminingshort-termoutcomesofmanualtherapy canbeprovidedonrequest.
onmechanicalneckpain?JManManipTher.2014;22(4):173–80.
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Fig.3(abstractS6)SupineBridgetest
S7
Assessmentofjointmobility:stateoftheart
AndreaFoglia,PaoloBizzarri
Physiotherapists,OrthopaedicManualTherapists(OMT),Private
practitioners,CivitanovaMarche
Correspondence:AndreaFoglia([email protected])–
Physiotherapists,OrthopaedicManualTherapists(OMT),Private
practitioners,CivitanovaMarche
ArchivesofPhysiotherapy2016,6(Suppl1):S7
More than 90% of the general population will experience at least a
musculoskeletal disorder during their lifetime. These types of joint
disordersareoftencharacterizedbymultipleclinicalfindings,inpar-
ticularpainandreductionofjointrangeofmotion(ROM).Insucha
physical therapy setting where the sole radiological investigations
Fig.1(abstractS6)AberrantMovements
and the medical diagnosis are often not enough to assess the pa-
tient’s health status, the need to develop new procedures aimed at
defining and documenting the patient’s health status and his/her
clinicalcoursehasbroughtaboutanincreasinginterestinthisissue.
Overthelastyearsthemainfocushasbeenonestablishingandonval-
idating new tools to assess the joint mobility. Although some of the
procedures have had a positive effect on the clinical setting,thepro-
posedassessment tools wereoften correctfroma biomechanicaland
methodologicalstandpoint,butpoorlyapplicableintheclinicalpractice.
Moreover,suchmeasurementshaveoftenprovedpartialaccordingto
anideabasedonthebiopsycosocialmodel(InternationalClassification
of Functioning, Disability and Health - ICF), where the clinical signifi-
cance of joint mobility data directly depends on its relation with the
person’sreducedactivityandparticipation.Therefore,inthissettingitis
possibletospeakoffunctionalrangeofmotion(functionalROM).
Thispresentationaimsatdescribingourapproachtotheassessment
of the functional ROM, applicable to the clinical setting. This ap-
proach is based on the best evidence available in the literature
anditisalsobasedonfourcrucialsteps:medicalcasehistory,vis-
ual inspection/observation, manual mobility testing, self-reported
Fig.2(abstractS6)PassiveLumbarExtensiontest
measures.
ArchivesofPhysiotherapy2016,6(Suppl1):11 Page5of42
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BlomAW.Doesmeasuringtherangeofmotionofthehipandkneeadd activityandintra-abdominalpressure.IntUrogynecolPelvicFloorDys-
totheassessmentofdisabilityinpeopleundergoingjointreplacement? funct.2002;13:125–32.
OrthopTraumatolSurgRes.2014Apr;100(2):183–6. 5. Sapsford R, Hodges P. Contraction of the pelvic floor muscles during
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IndexisabetterindicatoroflumbarmotionthantheVisualAnalogue 6. JungingerB,BaesslerL,SapsfordR.Effectofabdominalandpelvicfloor
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Arm,ShoulderandHandQuestionnaire(DASH)canmeasuretheimpair- 7. SmithM,RussellA,HodgesP.Doincontinence,breathingdifficulties,and
ment,activitylimitationsandparticipationrestrictionconstructsfromthe gastrointestinalsymptomsincreasetheriskoffuturebackpain?JPain.
InternationalClassificationofFunctioning,DisabilityandHealth(ICF). 2009;10(8):876–86.
BMCMusculoskeletDisord.2008Aug20;9:114. 8. HodgesP,RichardsonC.Inefficientmuscularstabilizationofthelumbarspine
10. RoeY,LundegaardSobergH,Bautz-HolterE,OstensjoS.Asystematicre- associatedwithlowbackpain.Spine(PhilaPa1976).1996;21:2640–50.
viewofmeasuresofshoulderpainandfunctioningusingtheInter- 9. Eisenstein S, Engelbrecht D, El Masry W. Low back pain and urinary
nationalclassificationoffunctioning,disabilityandhealth(ICF).BMC incontinence.Spine(PhilaPa1976).1994;19:1148–52.
MusculoskeletDisor.2013,14:73. 10. O’SullivanP,BealesD,AveryA.Normalisationofaberrantmotorpatterns
insubjectswithsacroiliacjointpainfollowingamotorrelearning
intervention:amultiplesubjectcasestudyinvestigatingtheASLRtest.
S8 FourthInterdisciplinaryWorldCongressonLowBackandPelvicPain,
Corestabilizationexercisesinthetreatmentofurinary Montreal,2001.
incontinence
DonatellaGiraudo([email protected])
SanRaffaeleTurroHospital,Milan,Italy
ArchivesofPhysiotherapy2016,6(Suppl1):S8
The functional relationship between the respiratory diaphragm, the
abdominalmusclesandthepelvicflooriswell-established:thelatter
represents the connective element between the abdominal cavity
and the lower limbs, and a correct postural relationship between
these two - the abdominal cavity and the thoracic cavity - ensures
optimum volume of the "core", optimizing abdominal-pelvic
function.
Controlofthecontractionofthepelvicfloor,whichifattainedauto-
matically on the increaseof intraabdominal pressureoccurs prior to
thecontractionoftheabdominalwallmuscles,isamechanismpre-
venting the onset of stress urinary incontinence and prolapse. To-
gether with the stabilizing action provided by the transverse
abdominalmuscle,thepelvicfloorandthediaphragm,theposterior Fig.4(abstractS8)Relationshipbetweenrespiratorydiaphragm,
muscles of the spine also contribute to stabilization of the "core", abdominalwall,pelvicfloormusclesandrachisinincorrect
thuscounteractingpossibledestabilizationcausedbydysfunction. expiratorypatternwithincompetenceofabdominalwall
Many actions which involve the pelvic floor (defecation, urination,
pregnancy and childbirth) pose a hazard due to the increase in
intraabdominalpressure,whichmustbecounteredwithanappropri- S9
atebreathingpatternandrhythm;simultaneously,themoderatecon- Preventingsurgicalsubacromialdecompressionthroughrotator
traction of the abdominal wall directs expiratory pressure towards cuffrehabilitation
the glottis and not towards the pelvic floor. On the increase of ChrisLittlewood([email protected])
intraabdominal pressure, contraction of the pelvic floor allows the UniversityofSheffield,Sheffield,UK
correctpositionoftheureterovesicaljunctiontobemaintainedand, ArchivesofPhysiotherapy2016,6(Suppl1):S9
togetherwiththecounterthrustprovidedbytheintactfascialsystem,
thedevelopmentofforceswhichcontributetotheincreaseinureth- Shoulder pain is one of the most common musculoskeletal symp-
ralpressure. tomsandsubacromialimpingementsyndromeanditsvarioussyno-
Thecontractionofthepelvicfloor,inturn,affectsthecontractionof nyms including rotator cuff tendinopathy, subacromial pain etc. are
theabdominalmuscles.Theroleplayedbythetransverseabdominal widelyregardedasthemostcommoncause.
ArchivesofPhysiotherapy2016,6(Suppl1):11 Page6of42
There are a range of treatment options available, both conservative which repetitive movements in a specific direction have the ef-
andsurgical.Inrecentyearsthenumberofsubacromialdecompres- fect of reducing pain and symptoms. The most important symp-
sions, a widely used surgical treatment approach for this condition, tom is considered the centralization of pain. The group is made
hasrisenexponentially.Butwhyisthis? up of specific exercises: Group Extension (symptoms more distal
Conservative treatment approaches, particularly exercise, are widely buttock; symptoms that centralize extension lumbar; symptoms
regardedaseffectiveinterventionsforthistypeofmechanicalshoul- periferalization during lumbar bending; directional preference:
der pain. Recent studies have shown that such conservative ap- extension); Group Flexion [age not younger (>50 years); direc-
proaches are comparable to surgical interventions. Also, patients on tional preference: bending; positive imaging for lumbar stenosis];
a surgical waiting list who undertake a structured exercise Group Lateral Shift (visible deviation of the shoulders than the
programmemightrespondsufficientlytoelectnottohavetheoper- pelvis in the frontal plane; directional preference: shifting motions
ation.So,itseemsthatifallpatientsareexposedtoastructuredex- of the pelvis in the frontal plane).
erciseprogrammepriortobeingconsideredforsurgerythenagood CPR4–GroupTraction-Signsandsymptomsofcompressiontothe
proportionwillnotrequiresuchinvasiveintervention.But,ifconser- nerveroot;nomovementwhichcentralizesthesymptoms.
vativetreatmentisatleastasgoodasoperativetreatmentthenwhy Based on all the above considerations, it can be helpful to develop
areweevenbotheringtoconsidersurgeryatallconsideringthatitis an algorithm with some therapeutic indications to help guide the
a more invasive, risky and expensive procedure than conservative clinicianintheprocessofdecision-makinginLBP.
care?
Suchaquestioncanonlybeaddressedbyposinganotherquestion; References
ifconservativetreatment‘fails’,whatthen? 1. CurrierLL,FroehlichPJ,CarowSD,McAndrewRK,CliborneAV,BoylesRE,
Thistalkwillcovertheresearchinrelationtotheeffectivenessofdif- MansfieldLT,WainnerRS.Developmentofaclinicalpredictionruleto
ferenttreatmentapproachesforsubacromialimpingementsyndrome identifypatientswithkneepainandclinicalevidenceofknee
(mechanical shoulder pain without movement restriction) before osteoarthritiswhodemonstrateafavorableshort-termresponsetohip
considering the principles that physiotherapists should follow when mobilization.PhysTher.2007Sep;87(9):1106–19.
designing rehabilitation programmes for their patients with the aim 2. Delitto A, Erhard RE, Bowling RW. A treatment-based classification ap-
ofmaximisingclinicaloutcomeandreducingtheneedforsurgery. proachtolowbacksyndrome:identifyingandstagingpatientsforcon-
servativetreatment.PhysTher.1995Jun;75(6):470–85.
3. FritzJM,ClelandJA,ChildsJD.Subgroupingpatientswithlowbackpain:
S10
evolutionofaclassificationapproachtophysicaltherapy.JOrthop
MethodologicalaspectsofClinicalPredictionRulesinthe SportsPhysTher.2007Jun;37(6):290–302.Review.Erratumin:JOrthop
rehabilitationofLowBackPain
SportsPhysTher.2007Dec;37(12):769.
PaoloPillastrini([email protected])
4. HaskinsR,Osmotherly PG,Rivett DA.Diagnostic clinicalprediction rules
DepartmentofBiomedicalandNeuromotorSciences,Universityof
forspecificsubtypesoflowbackpain:asystematicreview.JOrthop
Bologna,Bologna,Italy SportsPhysTher.2015Feb;45(2):61–76,A1-4.
ArchivesofPhysiotherapy2016,6(Suppl1):S10
5. McGinn TG, Guyatt GH, Wyer PC, Naylor CD, Stiell IG, Richardson WS.
Users'guidestothemedicalliterature:XXII:howtousearticlesabout
ClinicalPredictionRule(CPR)isatooltoassisttheprocessofclassifi-
clinicaldecisionrules.Evidence-BasedMedicineWorkingGroupJAMA.
cation and improve clinical decision making, using the evidence to 2000Jul5;284(1):79–84.
determine which patients will more easily benefit from a specific
6. Sutlive TG, Lopez HP, Schnitker DE, Yawn SE, Halle RJ, Mansfield LT,
treatment strategy. Depending on the model proposed by McGinn,
BoylesRE,ChildsJD.Developmentofaclinicalpredictionrulefor
development and evaluation of CPR is done through a process di-
diagnosinghiposteoarthritisinindividualswithunilateralhippain.J
videdintothreephases:DerivationofCPR,ValidationofCPR,CPRIm- OrthopSportsPhysTher.2008Sep;38(9):542–50.
pactAssessmentontheclinicalbehavior.
7. Vicenzino B, Smith D, Cleland J, Bisset L. Development of a clinical
TherearediagnosticandtherapeuticCPR.
predictionruletoidentifyinitialresponderstomobilisationwith
DiagnosticCPRS
movementandexerciseforlateralepicondylalgia.ManTher.2009
RobinHaskins,inhisscientificresearchtitled"Diagnosticclinicalpre- Oct;14(5):550–4.
dictionrulesforspecificsubtypesoflowbackpain:Asystematicre-
8. Wainner RS, Fritz JM, Irrgang JJ, Delitto A, Allison S, Boninger ML.
view",presentedareviewofthemaindiagnosticCPRpublished.The
Developmentofaclinicalpredictionruleforthediagnosisofcarpal
search found that 13 diagnostic CPRS for LBP have been derived. tunnelsyndrome.ArchPhysMedRehabil.2005Apr;86(4):609–18.
Onethatassistsintheidentificationoflumbarspinalstenosis,and2
whichassistinthescreeningofinflammatorybackpainhaveunder-
gone validation. No impact analysis studies were identified. Most S11
diagnostic CPRS for LBP are in their initial development phase and Interpretabilityofoutcomemeasuresinmusculoskeletal
cannotberecommendedforuseinclinicalpracticeatthistime. rehabilitation
TherapeuticCPRS DanielePiscitelli([email protected])
ThetherapeuticCPRSinLBPhavebeendefinedforthefirst timein Ph.D.CandidateinNeuroscience,DepartmentofTranslationalMedicine
2007 by Julie Fritz, when she presented a Clinical Commentary in andSurgery,UniversityofMilano-Bicocca,Milano,Italy
which,fromtheclassificationofCrimeof2005,shesoughttobetter ArchivesofPhysiotherapy2016,6(Suppl1):S11
definethe4subgroups,describingforeachofthemthestateofthe
art with respect to the effectiveness of the therapeutic procedures A health outcome measure has been described as a measure of
adopted. health change, at a defined time, as a result of one or more health
CPR1-GroupManipulation-Nosymptomsbelowtheknee;onsetof care processes [1]. In order to identify relevant problems directly
recent (<16 days); low score to FABQ-W (Fear-Avoidance Beliefs frompatients,rehabilitationcliniciansandresearchersneedtoassess
Questionnaire-Work Subscale) (<19); hypomobility lumbar spine patient-reported outcomes that may not be directly measurable; for
(evaluated withtheSpringtest);ROMofinternalrotationofthe hip example, disability, quality of life, satisfaction, or pain intensity. The
greaterthan35°inatleastonehipjoint. InternationalClassificationof Functioning, Disabilityand Health(ICF)
CPR2-Groupstabilization-Themostimportantvariableswere:age, framework catalogues these features, consequently the assessment
straight-legraise,proneinstabilitytest,aberrantmotions,lumbarhy- can be performed at different levels including body functions and
permobility, and fear-avoidance beliefs. Basically, they found: age structures, activities and participation. The majority of outcome re-
younger than 40; average SLR> 91°; aberrant trunk movement lated to activity limitations and participation restrictions are often
present;proneinstabilitytestpositive. measured indirectly by their manifestations and are referred to as
CPR3-Groupspecificexercises-TheywereratedaccordingtoMcKen- “latent variables”, “latent traits” or “constructs” [2]. Therefore, we
zie’sapproach,whoidentifiedasmoreappropriateinterventiononein needtotransformthemanifestationsofthese“latent”variablesinto
ArchivesofPhysiotherapy2016,6(Suppl1):11 Page7of42
numbers using questionnaire or scale. Such patient-reported out- problem, which remains unknown. Eachtype of surgical, orthoticor
comes(PRO)canbetakenasmeasurements,andtheassessmentof exercise-based treatment must act exclusively upon the effects of
thepsychometricpropertiesoftheseinstrumentsiscrucial. thediseaseandthusminimizethem.
Clinicians need to be aware of the characteristics of outcome mea- Focusing the reasoning on the conservative treatment approaches,
surestoselecttheappropriateoneandinterpretcorrectlytheresults. thefirstconcepttoconveyisthat,untiltoday,theonlyreliablestrat-
Inthepsychometricfieldhasbeenproposedtwomaintesttheories egiesarethebraceandthespecificexercises.Theuseofalternative
[1]: the classical test theory (CTT) and item response theory (IRT). treatmentapproachessuchasdentalbite,heellift,electricalstimula-
Recently, an international Delphi study has proposed a Consensus‐ tion,manualapproach[1]orfoodtipshaveneverbeenshownable
based Standards for the selection of health Measurement Instru- tomodifythenaturalhistoryofthedisease.
ments(COSMIN)[3]aimedatprovidingataxonomyofpsychometric Typically, all over the world, excluding Europe, the most accepted
properties, pointing out the measurement properties of PRO instru- therapeutic approach for the treatment of a vertebral misalignment
ments assessed by CTT and IRT methods. COSMIN distinguished was the surgery and the conservative treatment has almost always
threedomains:reliability,validity,andresponsiveness.Reliabilityhad been considered if not harmful, at least useless. This is due to the
three measurement properties: internal consistency, reliability, and scarcityofexperimentaltrialsthathadbeenpublisheduntilthen.In
measurementerror.Validityhadthreemeasurementproperties:con- therecentyearsthesituationchangedallowingthedevelopmentof
tentvalidity,criterionvalidityandconstructvalidity.Thelastdomain two Cochrane Reviews: one consacreted on Scoliosis and Brace [2]
includedonlyoneproperty,theresponsiveness. andthesecondoneonScoliosisandSpecificExercises[3].Ithasjust
The interpretability was not taken into account as a measurement beenreleasedanupdateofTheCochraneReviewonbraceswiththe
property, but it was considered an important characteristic of a conclusionsabsolutelyinfavouroftheeffectivenessofthistool,con-
measurement instrument. It was defined as “the degree to which trary to what is always said by the SRS (Scoliosis Research Society),
one can assign qualitative meaning to an instrument’s quantitative theAmericanassociation ofspinesurgeonsspecializedinspinesur-
scoresor changeinscores”[4].Themeaningoftheresultsmustbe geryforscoliosisdisease.Adecisiveblowtotheabsoluteconviction
interpreted carefully. Indeed, the predominant types of outcomes ofthesurgeonshadalreadybeeninflictedbythepublicationofthe
measure are ordinal scale. In PRO tools, by definition, the intervals article"EffectsofBracingwithIdiopathicScoliosisinAdolescents",[4]
between categories are separated by unknown quantities, and con- a RCT of 2013, led by the SRS that compared the results of two
clusions may, therefore, be misleading; e.g., the calculation of min- groupsofpatients:onegrouptreatedwithbraceandcontrolgroup,
imal (clinically) importantdifferencesis compromisedby the lack of totesttheeffectivenessofthebracetolowertheriskofsurgery.The
interval scaling [5]. IRT models such Rasch analysis (RA) [6] allow a firstfollowup,absolutelyinfavourofthebrace,haspromptedtheeth-
transformation of the ordinal score into a linear, interval scores be- icscommitteetomodifythe research,stoppingthe randomization of
causewithRaschtransformationthelocationofitems,aswellaspa- patientsbasedontheeffectivenessofonecomparativeprotocol.
tients,arepresentedonthesamescale[7]. Another review on Scoliosis and Specific Exercises has been pub-
Aproperknowledgeoftheabove-citiedmeasurementpropertiesisa lished.Theconclusionwasthattheevidencefortheeffectivenessof
prerequisite for use toolin clinicalpractice and researchin order to the exercises as a treatment are too weak. As for the Cochrane Re-
prevent inappropriate conclusion and to improve clinical decision view concerning the brace, it is also expected an update of this
makingprocess[8]. paper.Consideringtheitemsthatwillbeintroducedinthenewver-
sion,theconclusionswilldefinitelyincreasethedemonstrableeffect-
References iveness of this approach for the treatment of scoliosis. Worldwide,
1. Streiner DL, Norman GR. Health measurement scales : a practical guide the methodsfor scoliosis treatment basedon specificexercisesthat
totheirdevelopmentanduse(4thed.).Oxford;NewYork:Oxford have proven effectiveness, with the publication of some articles are
UniversityPress,2008. veryfewandarelittleknowninItaly,withtheexceptionoftheSEAS.
2. TesioL.Measuringbehavioursandperceptions:Raschanalysisasatool Oneofthe mostinterestingtreatmentstrategiesfor thefuturecon-
forrehabilitationresearch.JRehabilMed.2003;35(3):105–115. sistsintheintegrationofself-correctionintheactivitiesofdailylife,
3. MokkinkLB,TerweeCB,PatrickDL,AlonsoJ,StratfordPW,KnolDL,etal. totrainaneffectivecontrasttotheviciouscircleofStokes[5],repre-
TheCOSMINstudyreachedinternationalconsensusontaxonomy, sentingthelinkedcorrelationbetweentheprogressiveworseningof
terminology,anddefinitionsofmeasurementpropertiesforhealth- thecurvesandthevertebraedeformation.
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etal.Qualitycriteriawereproposedformeasurementpropertiesof 1. Romano M, Negrini S. Manual therapy as a conservative treatment for
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MinimalClinicallyImportantDifferenceasAppliedinRheumatology:An 2. Negrini S, Minozzi S, Bettany-Saltikov J, Chockalingam N, Grivas TB,
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lookforinaRaschpaper?ArthritisRheum.2007;57(8):1358–1362. CochraneDatabaseSystRev.2012Aug15;8.
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healthcare.BMJ.2013Jan28;346,f167.
S13
S12 Balancetraininginsubjectswithmusculoskeletaldisorders
Conservativetreatmentofthemisalignmentofthespine:stateof AndreaTettamanti([email protected])
theartandperspectives LaboratoryofAnalysisandRehabilitationofMotorFunction,
MicheleRomano([email protected]) NeuroscienceDivision,SanRaffaeleHospital,Milan,Italy
ISICO,IstitutoScientificoItalianoColonnaVertebrale,Milan,Italy ArchivesofPhysiotherapy2016,6(Suppl1):S13
ArchivesofPhysiotherapy2016,6(Suppl1):S12
Balance and proprioceptive deficits are present in most of the sub-
The biggest problem in the treatment of a patient with idiopathic jectswithneurologicaldiseasesandinmanyolderpeople.Theeffect
scoliosis is the impossibility of working directly on the cause of the of balance training in these subjects is quite well established [1–3].
ArchivesofPhysiotherapy2016,6(Suppl1):11 Page8of42
Although they are few considered, balance deficits are present also 7. Smith BE, Littlewood C, May S. An update of stabilisation exercises for
inmanysubjectswithmusculoskeletaldiseases.Alesionoftheknee lowbackpain:asystematicreviewwithmeta-analysis.BMCMusculoskelet
or ankle could lead to a balance deficit, and the effects of balance Disord.2014Dec9;15:416.
training is a reduction in the recurrence of ankle sprains in chronic 8. Jull G, Falla D, Treleaven J, Hodges P, Vicenzino B. Retraining cervical
ankle instability, a reduction in giving way episodes in ACL injured jointpositionsense:theeffectoftwoexerciseregimes.JOrthopRes.
people,areductionofriskoffallinginelderlypeople,andareduced 2007Mar;25(3):404–12.
incidence of knee and ankle injuries [4]. Less evident is that also in
subjects with low back pain (LBP) or neck pain balance deficit is
S14
present.
Dosageofmanualtherapy:principlesforclinicalpractice
In recent years it has been documented that individuals with acute
CarlaVanti([email protected])
andchronicLBPshowchangesintrunkmusclesactivity(transversus
DepartmentofBiomedicalandNeuromotorSciences,Universityof
abdominis and multifidus particularly). A consistent finding is a de-
Bologna,Bologna,Italy
layedactivationoftrunkmusclesduringbothunpredictableandpre-
ArchivesofPhysiotherapy2016,6(Suppl1):S14
dictable trunk perturbations. Trunk balance deficits and muscle
activationimpairmentscouldalsooriginatefrompoorpositionsense,
The dosage of manual therapy techniques refers to the optimal
whichhasbeenreportedtobepresentinindividualswithCLBP[5].
therapeutic dose(e.g. the amountof treatment thatmayproducea
Alsoinpeoplewithneckpainthecoordinationofheadmovements,
therapeutic effect) and the optimal interval betweendoses (e.g. the
the coordination of the movement of the vertebrae of the cervical
sessions’ scheduling). About each session, the main parameters in-
spine,andposturalbalancewereshowntobeimpaired[6].Consider-
volved in the dosage are: the starting position, the force/pressure
ing the prevalence of these two conditions, the number of people
exerted,therhythmandspeed,thetypeoftechnique,theRangeof
suffering of balance deficits secondary to musculoskeletal disorder
Motion (ROM), the stadium of healing, the number of repetitions,
couldberelevant.
andthetotaldurationofthesession.
Despitethedocumentedbalancedeficits,rehabilitativeprotocolsfor
Anon-specific/neutral/painlesspositionisacommonchoicetoapply
improving muscle activation in subjects with LBP are primarily fo-
antalgic techniques, whereas a specific/end of range position is ap-
cused on feedforward mechanisms, using exercises that emphasize
plied to perform the techniques aiming to improve the ROM. The
the maintaining of static postures (i.e. squat exercises, curl up, side
amountofforce/pressureexerteddependsonthetypeoftechnique,
and front support). These kinds of exercises, including trunk muscle
the treated area, the type of pathology/dysfunction, and the mor-
strengtheningexercises,areincludedinprotocolsusingtheconcept
phologicaltypeofpatientandtherapist.However,theforceusedby
ofcorestabilizationtraining.Nevertheless,arecentsystematicreview
physical therapists relates not only to patient, but also to physical
statedthattheyarenotsuperiortootheractiveexercisesinthelong
therapist characteristics (academic qualification, sex, weight and
term[7].Insubjectswithneckpainexercisesforimprovingposition
height). Nevertheless, it was demonstrated that clinicians can suc-
sense and muscle activations rely principally on neck coordination
cessfullydeliverprescribedtractionforceswhiletreatingpatients.
andrepositioningexercises[8].
Concerning the rhythm/speed, a high rhythm is used to stimulate
Onlyfewstudiesinvestigatetheroleofbalanceexercisesinrestoring
the β-receptors and improve the movement of fluids, whilst a slow
sensorimotorfunctionandalleviatesymptomsinsubjectswithback
rhythm is preferred to provoke a tissue deformation. It was shown
orneckpain.TheefficacyofbalancetraininginindividualswithCLBP
that HVLA manipulation induces an initial mechanical, non-opioid
andneckpainwasstudiedintworecenttrials[4,5].Thesekindsof
hypoalgesia(superiortoplaceboandcontrol)andthatpassivepain-
exercisesaredifferentfromtheclassicalexercisesofcorestabilityfor
less techniques induce the H-reflex inhibition. The sympathetic ner-
low back pain or exercises of neck coordination. Balance exercises
vous system activation is also related to the type of technique (e.g.
are focused on the improvement of feedback mechanics of motor
HVLAvsmobilization).
control, while classical core training or neck coordination exercises
ConcerningtheGradesofMovement,manualtherapyliteraturesug-
aremainlyfocusedonfeedforwardmuscularactivations.Thesestud-
geststo use intermittentGradeI and II to managepainand induce
ieson balance trainingsupport the idea thatthiskind of trainingis
relaxation, and Grade III, IV and V to treat hypomobility. However,
effective and can be practiced easily. In subjects with neck pain it
thefrequencyandamplitudeoftheoscillationforcesingradesIand
can effectively improvecervical sensorimotor function and decrease
IV are poorly reproducible. Moreover, the higher the grade of
neckpainintensityandinsubjectswithLBPitreducesdisabilityand
mobilization,thegreatertheforceappliedbyphysicaltherapists.
improvesqualityoflife.
About the total number of sessions, data from clinical trials are ex-
tremelyvariable.Whenapatientisinacutephase,normallyatreat-
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2. Gudavalli MR, Vining RD, Salsbury SA, Corber LG, Long CR, Patwardhan strongly questioned [6,7], and the strongest predictors of persistent
AG,GoertzCM.Clinicianproficiencyindeliveringmanualtreatmentfor painafterTKAaremorerelatedtocatastrophizing,mentalhealth,or
neckpainwithinspecifiedforceranges.SpineJ.2015;15(4):570–6. preoperativekneepainthanexerciseintensity.Third,theingredients
3. Haas M, Vavrek D, Peterson D, Polissar N, Neradilek MB.Dose–response should not be too many, preferringthe few exercisesthat will have
andefficacyofspinalmanipulationforcareofchroniclowbackpain:a thegreatestchanceoftransferfromstrengthgaintoimprovedfunc-
randomizedcontrolledtrial.SpineJ.2014Jul1;14(7):1106–16. tional performance. Fourth, the exercises should be well described,
4. Jeffrey JE, Foster NE. A qualitative investigation of physical therapists' including - whenever it is possible - the indication of the relative
experiencesandfeelingsofmanagingpatientswithnonspecificlow load/repetitionmaximum.
backpain.PhysTher.2012;92(2):266–78. Arewereadytotrythisathome?
5. Jull G, Moore A. What is a Suitable Dosage of Physical Therapy
Treatment?ManTher.2002;7(4):181–2. References
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jointmobilizationskill.PhysTher.1990;70(2):97–102. Ther.2005;35:50–51.
7. Pentelka L, Hebron C, Shapleski R, Goldshtein I.The effect of increasing 2. RoiGS,CretaD,NanniG,MarcacciM,ZaffagniniS,Snyder-MacklerL.Return
sets(withinonetreatmentsession)anddifferentsetdurations(between to official italian first division soccer games within 90 days after
treatmentsessions)oflumbarspineposteroanteriormobilisationson anterior cruciate reconstruction:a case report. J Orthop Sports Phys
pressurepainthresholds.ManTher.2012;17(6):526–30. Ther. 2005;35:52–61.
8. SandmanL.etal.Adherence,shareddecision-makingandpatientauton- 3. Shelbourne D. Invited commentary. J Orthop Sports Phys Ther.
omy.MedHealthCarePhilos.2012;15(2):115–27. 2005;35:61–62.
9. Threlkeld AJ. The effects of manual therapy on connective tissue. 4. Internetsite:www.choosingwisely.org[accessedSeptember15,2015].
Physiotherapy.1992;72(12):893–902. 5. Bandholm T, Kehlet H. Physiotherapy exercise after fast-track total hip
10. WilliamsJM,Cuesta-VargasA.Quantificationofpronethoracicmanipula- andkneearthroplasty:timeforreconsideration?ArchPhysMedRehabil.
tionusinginertialsensor-derivedaccelerations.JManipulativePhysiol 2012;93:1292–1294.
Ther.2014;37(4):230–5. 6. Jacobsen TL, Husted H, Kehlet H, Bandholm T. Progressive strength
training(10RM)commencedimmediatelyafterfast-tracktotalknee
arthroplasty:isitfeasible?DisabilRehabil.2012;34:1034–1040.
S15
7. van der Weegen W, Kornuijt A, Das D. Do lifestyle restriction and
Aretherespeedlimitsinpost-surgerylowerlimbrehabilitation?
precautionspreventdislocationaftertotalhiparthroplasty?Asystematic
StefanoVercelli([email protected])
reviewandmeta-analysisoftheliterature.ClinRehabil.2015,Mar31
UnitofOccupationalRehabilitationandErgonomics,SalvatoreMaugeri
[Epubaheadofprint].
Foundation,IRCCS,Veruno(NO),Italy
ArchivesofPhysiotherapy2016,6(Suppl1):S15
S16
Exactlytenyearsago,KevinWilkwroteaneditorial,whereinheques-
Classificationofpredominantneuropathic,nociceptiveorcentral
tionedthe possibility of identifyingspeedlimitsin rehabilitation [1].
sensationpain
In that issue of JOSPT, the accelerated philosophy was applied to a
LennardVoogt([email protected])
famous Italian soccer player, who returned to official first division
RotterdamUniversityofAppliedSciences,Rotterdam,TheNetherlands
soccer games within (only) 90 days after anterior cruciate ligament
ArchivesofPhysiotherapy2016,6(Suppl1):S16
reconstruction [2]. Donald Shelbourne commented this exceptional
success by encouraging all surgeons and physical therapists to find
Over the last decade we have witnessedimpressive progress in the
their surgical procedure and rehabilitation protocol limits [3]. How-
understanding of neurophysiologic mechanisms underlying chronic
ever,thisencouragementdoesnotseemtohavebeenputintoprac-
musculoskeletal pain. What we have learned from this scientific re-
ticebymostphysicaltherapistsyet.Therefore,in2015,theAPTAfelt
searchis thatpainshould beseen asthe outcomeof verycomplex
theneedtolaunchacampaignagainstthebadpracticeofprescrib-
interactions between biological, psychological and sociological pro-
ing under dosed strength training programs. In essence, it was ad-
cessesandthatthebrainplaysa centralroleintheintegrationand
vised against the use of physical agents except when necessary, as
processingofavarietyofinputsintothecreationofaconcretecon-
wellastheuseofcontinuouspassivemotionmachinesforthepost-
sciousexperienceofpain.Onecharacteristicofthisprocessingisthat
operative management of patients following uncomplicated total
inputsintothebraincanbemodulatedinseveralways,whichmeans
kneereplacement[4].
that the relation between tissue damage and pain experience is
Thetypeofphysiotherapyexerciseinterventionsaftermajorsurgery
certainlynotlinearperse.Besidesthis,wehavelearnedthatitisof
of lower limb (such as total hip or knee arthroplasty, THA and TKA)
primary importance that caregivers in the field of chronic musculo-
has often been based on treatment tradition or time-progression,
skeletalpainhaveathoroughunderstandingoftheneurophysiology
andnotonfirmscientificevidence,basicexercisephysiologyprinci-
ofpainandthattheytaketheseinsightsintoaccountwhiletheyin-
ples, or both [5]. Patients are not all equal, so it is imperative the
form, advice and treat their patients. This is even more important
needtoshiftthefocusfromthetime-basedprotocolstowardanin-
whenweconsiderthefactthatabout20%ofthehumanpopulation
dividualized and evaluation-based approach. Recent meta-analyses
is now suffering from some form of chronic pain and that our
on the effectiveness of physiotherapy exercise after THA and TKA
treatment-effectsaremoderateatbest.
generallyconcludethatphysiotherapyexerciseeitherdoesnotwork
or is it very effective.5 In line with the recent claims from APTA [4], Some scholars in the field of musculoskeletal pain point to the im-
portance of a connection between pain-mechanisms and interven-
thereasonforthismaybethattherehabilitationwasoftoolittlein-
tions in order to improve treatment effects in the near future.
tensityorofferedatthewrongtime,toolateaftersurgery[5].
Current research shows that we can distinguish between different
Recently, Bandholmand Kehlet[5]set foursimplerulestofollowin
clinical practice and in future studies within physiotherapy exercise pain mechanisms and that it is valid to make distinctions between
afterTHAandTKA.First,thetimingshouldberight.Thismeansthat nociceptive,neuropathicand‘centralised’pain.Knowledgeofthedif-
interventionshouldstartbeforethedeficitsareatthegreatest,ifthe ferent physiological mechanisms underlying these three different
goal is a fast recovery. Second, the ingredients should be right and forms of pain is important from a clinical perspective because it
basedondocumenteddeficits.Functionalrehabilitationmustbesup- makes it possible to think more effectively about the relation be-
plementedbymusclestrengthening(withtherightdose)andrange tween pain-physiology and our (physical therapy) interventions. It
of motion recovery. Tradition and fear of symptoms exacerbation seems logical to suppose that nociceptive pain-forms require differ-
have typically precluded progressive strength training early after enttreatmentstrategiesthanneuropathicor‘centralised’pain-forms.
surgery, and lifestyle restriction are commonly applied after THA to Todosoitisimportantforclinicianstomakevalidinterpretationsre-
prevent dislocation. However, both these precautions have been gardingthepain-mechanismsdrivingthepainoftheirpatients.
ArchivesofPhysiotherapy2016,6(Suppl1):11 Page10of42
Although the pain laboratory is not the same as the clinical en- Balance Scale score (+6%, p<0.01) and Fatigue Severity Scale score
counter, we think that it is indeed possible to translate physio- (−14%,p<0.03)atT1.Placebogroupshowedonlyanincreaseofthe
logical knowledge of pain-mechanisms to the clinical encounter time of right double support at T1 (+46%, p=0.05), while no signifi-
andthatproperinterpretationsofsignsandsymptomsofpatients cantresultswerefoundforalltheothermeasures.
with chronic musculoskeletal pain can be made. For this purpose Conclusions
we proposed a clinical algorithm with which clinicians can make This study showed that people with MS treated with Equistasi®,
substantiated distinctions between predominant nociceptive, achieved improvements in balance disorders, especially when
neuropathicor‘centralised’painintheirpatients.Thealgorithmis assessedthroughGaitAnalysis, comparedtoplacebo.Thispilottrial
based on both scientific research and the clinical experience of shows that a physiotherapy program for training balance in associ-
specialistsinthefieldof(chronic)musculoskeletalpain.Duringthe ationwithfocalmechanicalvibrationmightbeanhelpfulrehabilita-
lecture the algorithm will be presented and discussed in light of tivesupportinimprovingpatients’balance.
patientswithlowbackpain.Thewayinwhichthealgorithmshould
beusedanddecisionsshouldbemadeisthemainobjectiveofthe References
lecture. 1. Volpe D, Giantin MG, Fasano A. A Wearable Proprioceptive Stabilizer
(Equistasi)forRehabilitationofPosturalInstabilityinParkinson’sDisease:
References APhaseIIRandomizedDouble-Blind,Double-Dummy,ControlledStudy.
1. NijsJ,ApeldoornA,HallegraefH,ClarkJ,SmeetsR,MalflietA,GirbésEL, PlosOne.2014Nov17;9(11):e112065.
DeKooningM,IckmansK.Lowbackpain:guidelinesfortheclinical 2. Brunetti O, Botti FM, Roscini M et al. Focal vibration of quadriceps
classificationofpredominantneuropathic,nociceptive,orcentral muscle enhances leg power and decreases knee joint laxity in
sensitisationpain.PainPhysician.2015;18:E333-E346. female volleyball players. J Sports Med Phys Fitness. 2012
2. NijsJ,Torres-CuecoR,VanWilgenCP,GirbésEL,StruyfF,RousselN,Van Dec;52(6):596–605.
OosterwijckJ,DaenenL,KuppensK,VanderweeënL,HermansL,Beckwée 3. MartinCL,PhillipsBA,KilpatrickTJ,etal.Gaitandbalanceimpairmentin
D,VoogtL,ClarkJ,MoloneyN,MeeuwsM.Applyingmodernpainneurosci- earlymultiplesclerosisintheabsenceofclinicaldisability.MultScler.
enceinclinicalpractice:criteriafortheclassificationofcentralsensitization 2006Oct;12(5):620–8.
pain.PainPhysician.2014;18:447–457. 4. Pearson OR, Busse ME, Van Deursen RWM, Wiles CM. Quantification
of walking mobility in neurological disorders. QJM. 2004
Aug;97(8):463–475.
P1
5. Katusic A, Alimovic S, Mejaski-Bosnjak V. The effect of vibration therapy
Awearableproprioceptivestabilizer(Equistasi®)forrehabilitation
onspasticityandmotorfunctioninchildrenwithcerebralpalsy:aran-
ofbalancedisordersinmultiplesclerosispatients:preliminary domizedcontrolledtrial.NeuroRehabilitation.2013;32(1):1–8.
resultsofarandomized,double-blind,versusplacebocontrolled
study
AcetoMaria1,SpinaEmanuele1,PaonePaolo2,SilvestreFrancesco1, P2
CarotenutoAntonio1,CerilloIlaria1,OreficeGiuseppe1 Effectofrepeatedneckretractionmovementsonstrengthand
1DepartmentofNeuroscience,ReproductiveSciencesandDentistry, EMGactivityoftheupperlimbs,rangeofmotionandcervical
FedericoIIUniversity,Napoli,Italy;2Statistician,PacalConsultingSas, posture
Milan,Italy BassiRaffaele1,FioritoSerena2,AinaAlessandro3
Correspondence:AcetoMaria([email protected])–Departmentof 1Vita-SaluteSanRaffaeleUniversity,Milan,Italy;2NEMOClinicalCentre,
Neuroscience,ReproductiveSciencesandDentistry,FedericoII NiguardaHospital,Milan,Italy;3Physiotherapist,Dip.MDT,private
University,Napoli,Italy practice,Milan,Italy
ArchivesofPhysiotherapy2016,6(Suppl1):P1 Correspondence:BassiRaffaele([email protected])–Vita-
SaluteSanRaffaeleUniversity,Milan,Italy
Background ArchivesofPhysiotherapy2016,6(Suppl1):P2
Recentstudieshave stated thatfocal mechanicalvibrationcouldbe
aneffectivetoolinthetreatmentofsomeneurologicaldisorders.We Backgroundandaim
performed a pilot study to test the feasibility and effectiveness of a Neck pain is a common clinical condition in result of different
balancetrainingprograminassociationwithawearablepropriocep- factors including changes in cervical posture [1] and mobility [2].
tive stabilizer (Equistasi®) that emits focal mechanical vibrations in The McKenzie method of Mechanical Diagnosis and Therapy
patientswithmultiplesclerosis(MS). (MDT) deals also with neck disorders. Repeated cervical move-
Methods ments are the main diagnostic and therapeutic strategy used in
Twentypatientswithbalanceandgaitdisordersaffectedbyclinically MDT [3]. The most used is the neck retraction movement, which
defined MS were randomly divided into two groups wearing an ac- involves pulling the head and neck posteriorly into a position in
tive or inactive device. All patients received a 3 weeks program of which the head is aligned on the thorax, while maintaining the
balance training. Assessments were performed at baseline, after the look ahead [4] (Fig. 5). In scientific literature, neck retraction is
rehabilitation period (T1), and 3 weeks after (T2) using posturo- poorly investigated even if it has been described as an effective
graphicmeasures,dynamicgaitindex,clinicalscalesforbalanceand method to treat symptoms, achieve pain centralization [5], im-
fatigue. prove ROM and correct head posture. To date, no articles have
Results analyzed the effect of repeated retraction on strength perform-
Bothgroupswerematchedforage,sex, EDSSanddiseaseduration. ance and few have dealt with related EMG activity of the upper
Therewerenosignificantdifferencesbetween-groupsintheareaof limbs muscles. The aim of this study is to investigate the effect
the center of pressure with both opened or closed eyes. Equistasi of 30 repeated neck retractions on upper limbs strength perform-
group showed an increased first right step length at T1 (+18%, ance, posture and cervical spine mobility in healthy subjects.
p<0.02)andT2(p<0.04)andanincreasedfirstleftsteplenghtatT1 Materialsandmethods
(+17%.p=0.05)comparedtoT0withanincreasedaveragestepatT1 50 healthy subjects were recruited and randomly assigned to two
(+9%,p<0.03)andT2. groups: CTRL (control), INT (intervention). 25 subjects (CTRL) per-
Wealsofoundadecreaseintimeofbothrightandleftdoublesup- formed in sitting position 3 series of 10 flexion-extension cervical
port at T1 (−27%, p<0.03; −36%, p<0.01, respectively) and an im- movements, while 25 subjects (INT), in the same position, com-
provement in the Functional Reach Test (+19%. p<0.02), Berg pleted 3 series of 10 neck retractions. Each subject was assessed