Other

Author Names

Valenzuela, P. Mchiro, S. Lucia, A. Germain, F.

Reviewer Name

Alexandra Yeardley, SPT

Reviewer Affiliation(s)

Duke University, Doctor of Physical Therapy division

Paper Abstract

Study Design.  A randomized, double blind, parallel groups, sham-controlled trial.  Objective.  The aim of this study was to analyze the acute effects of spinal manipulative therapy (SMT) on performance and autonomic modulation.  Summary of Background Data.  The use of SMT is progressively spreading from the clinical to the sporting context owing to its purported ergogenic effects. However, its effects remain unclear.  Methods.  Thirty-seven male recreational athletes (aged 37 ± 9 years) who had never received SMT were assigned to a sham (n = 19) or actual SMT group (n = 18). Study endpoints included autonomic modulation (heart rate variability), handgrip strength, jumping ability, and cycling performance [8-minute time trial (TT)]. Differences in custom effects between interventions were determined using magnitude-based inferences.  Results.  A significant and very likely lower value of a marker of sympathetic modulation, the stress score, was observed in response to actual compared with sham SMT [P = 0.007; effect size (ES) = -0.97]. A trend toward a significant and likely lower sympathetic:parasympathetic ratio (P = 0.055; ES = -0.96) and a likely higher natural logarithm of the root-mean-square differences of successive heartbeat intervals [(LnRMSSD), P = 0.12; ES = 0.36] was also found with actual SMT. Moreover, a significantly lower mean power output was observed during the TT with actual compared with sham SMT (P = 0.035; ES = -0.28). Nonsignificant (P > 0.05) and unclear or likely trivial differences (ES < 0.2) were found for the rest of endpoints, including handgrip strength, heart rate during the TT, and jump loss thereafter.  Conclusion.  A single pre-exercise SMT session induced an acute shift toward parasympathetic dominance and slightly impaired performance in recreational healthy athletes.  Level of Evidence: 2

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

1. Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT?

• Yes

2. Was the method of randomization adequate (i.e., use of randomly generated assignment)?

• Yes

3. Was the treatment allocation concealed (so that assignments could not be predicted)?

• Yes

4. Were study participants and providers blinded to treatment group assignment?

• Yes

5. Were the people assessing the outcomes blinded to the participants’ group assignments?

• No

6. Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

• Yes

7. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

• Cannot Determine, Not Reported, or Not Applicable

8. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

• Cannot Determine, Not Reported, or Not Applicable

9. Was there high adherence to the intervention protocols for each treatment group?

• Cannot Determine, Not Reported, or Not Applicable

10. Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

• Cannot Determine, Not Reported, or Not Applicable

11. Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

• Yes

12. Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

• No

13. Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

• Cannot Determine, Not Reported, or Not Applicable

14. Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

• Yes

Key Finding #1

A single Spinal manipulative therapy session induced an acute shift toward parasympathetic dominance and slightly decreased cycling performance. The state of relaxation induced by increased parasympathetic activity by spinal manipulative therapy can decrease exercise performance on those that have never received spinal manipulative therapy before.

Key Finding #2

A single spinal manipulative therapy session decreased power output during an 8 minute time trial on a cycle ergometer as well as jumping height ability on those that had never received spinal manipulative therapy before.

Paper Summary:

This study was only done on a total of 37 subjects which is not a large population. However, the methods used to administer the spinal manipulative therapy were consistent and measurable as they used an Activator IV adjusting instrument set to transmit different levels of force throughout the spine for the experimental group and they used the same device with a level 0 of force for the control group with the machine still making the same noise as it would if it was transmitting force. Analysis of autonomic regulation included HR before the start of each testing session as well as parasympathetic modulation calculated while looking at successive heartbeat intervals (LnRMSSD), an analysis of Poincare-plot was performed to calculate stress score, a measure of sympathetic modulation and sympathetic; parasympathetic ratio was measured as an indicator of autonomic balance. Handgrip strength was used as an indicator of muscular strength. Performance was measured after a warm up looking at an 8-minute time trial on a cycle ergometer due to the participant population consisting of criteria specific to local triathlon and cycling participants. Jumping ability was also assessed immediately before and after treatment in which specific instructions were provided.  A lower sympathetic to parasympathetic ratio and higher parasympathetic modulation in the experimental group was found. A lower power output during the minute time trial was observed with nonsignificant or unclear results regarding handgrip.  There are many studies regarding spinal manipulative therapy and athletic performance, many that are contrary to this study which indicates the need for increased research.

Clinical Interpretation: how this study may impact clinical practice and how the results can be implemented:

This study supports not using spinal manipulative therapy for recreational athletes before competition. This could decrease it’s use during this time of an athletes competing period. However, due to it’s parasympathetic effects, spinal manipulative therapy could be more beneficial when implemented in an athletes recovery phase in which there is a specific time period before competition begins. A lot of athletes will receive treatment before and after competition, and this study could create a better guideline of when it is appropriate and not appropriate to use spinal manipulative therapy for athletes or induce more research to help with this.  When treating a patient that is hypersensitive but responds well to spinal manipulative therapy, incorporating a Activator IV adjusting instrument to administer spinal manipulations may be beneficial because it can prevent administering too much force which is often variable when administered manually. This could potentially increase therapeutic effects and create an objective measurement in which a physical therapist can use to not induce pain. It could also offer more objective measurements for how much a patient can tolerate from one treatment session to another.

Author Names

Milne, N. , Longeri, L. , Patel, A. , Pool, J. , Olson, K. , Basson, A. , Gross, A.

Reviewer Name

Sophia Razzi, SPT

Reviewer Affiliation(s)

Duke University School of Medicine Doctor of Physical Therapy Division

Paper Abstract

Purpose: To i) identify and map the available evidence regarding effectiveness and harms of spinal manipulation and mobilisation for infants, children and adolescents with a broad range of conditions; ii) identify and synthesise policies, regulations, position statements and practice guidelines informing their clinical use.  Design: Systematic scoping review, utilising four electronic databases (PubMed, Embase, CINHAL and Cochrane) and grey literature from root to 4th February 2021.  Participants: Infants, children and adolescents (birth to < 18 years) with any childhood disorder/condition.  Intervention: Spinal manipulation and mobilisation OUTCOME MEASURES: Outcomes relating to common childhood conditions were explored.  Method: Two reviewers (A.P., L.L.) independently screened and selected studies, extracted key findings and assessed methodological quality of included papers using Joanna Briggs Institute Checklist for Systematic Reviews and Research Synthesis, Joanna Briggs Institute Critical Appraisal Checklist for Text and Opinion Papers, Mixed Methods Appraisal Tool and International Centre for Allied Health Evidence Guideline Quality Checklist. A descriptive synthesis of reported findings was undertaken using a levels of evidence approach.  Results: Eighty-seven articles were included. Methodological quality of articles varied. Spinal manipulation and mobilisation are being utilised clinically by a variety of health professionals to manage paediatric populations with adolescent idiopathic scoliosis (AIS), asthma, attention deficit hyperactivity disorder (ADHD), autism spectrum disorder (ASD), back/neck pain, breastfeeding difficulties, cerebral palsy (CP), dysfunctional voiding, excessive crying, headaches, infantile colic, kinetic imbalances due to suboccipital strain (KISS), nocturnal enuresis, otitis media, torticollis and plagiocephaly. The descriptive synthesis revealed: no evidence to explicitly support the effectiveness of spinal manipulation or mobilisation for any condition in paediatric populations. Mild transient symptoms were commonly described in randomised controlled trials and on occasion, moderate-to-severe adverse events were reported in systematic reviews of randomised controlled trials and other lower quality studies. There was strong to very strong evidence for ‘no significant effect’ of spinal manipulation for managing asthma (pulmonary function), headache and nocturnal enuresis, and inconclusive or insufficient evidence for all other conditions explored. There is insufficient evidence to draw conclusions regarding spinal mobilisation to treat paediatric populations with any condition.  Conclusion: Whilst some individual high-quality studies demonstrate positive results for some conditions, our descriptive synthesis of the collective findings does not provide support for spinal manipulation or mobilisation in paediatric populations for any condition. Increased reporting of adverse events is required to determine true risks. Randomised controlled trials examining effectiveness of spinal manipulation and mobilisation in paediatric populations are warranted.

NIH Risk of Bias Tool

Quality Assessment of Systematic Reviews and Meta-Analyses

1. Is the review based on a focused question that is adequately formulated and described?

• Yes

2. Were eligibility criteria for included and excluded studies predefined and specified?

• Yes

3. Did the literature search strategy use a comprehensive, systematic approach?

• Yes

4. Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?

• Yes

5. Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?

• Yes

6. Were the included studies listed along with important characteristics and results of each study?

• Yes

7. Was publication bias assessed?

• Yes

8. Was heterogeneity assessed? (This question applies only to meta-analyses.)

• Cannot Determine, Not Reported, Not Applicable

Key Finding #1

Through the synthesis of 87 articles, it was found that there is insufficient evidence to support the use of spinal manipulation and mobilization in the pediatric population.

Key Finding #2

Although there is insufficient evidence to support the use of spinal mobilization and manipulation in addressing many pediatric diagnoses, it was determined that there is strong to very strong evidence that proposes that these interventions are not beneficial for managing headaches, nocturnal enuresis, and asthma in the pediatric population.

Key Finding #3

There is a great need for high-level RCTs to determine the risks and benefits of spinal mobilization and manipulation in the pediatric population.

Paper Summary:

This systematic scoping review synthesized the findings of 87 articles to determine the effects of spinal manipulation and mobilization in the management of various pediatric conditions such as adolescent idiopathic scoliosis, asthma, ADHD, ASD, back/neck pain, breastfeeding difficulties, dysfunctional voiding, CP, headaches, excessive crying, infantile colic, nocturnal enuresis, kinematic imbalance due to suboccipital strain (KISS), otitis media, plagiocephaly, and torticollis. It was found that there is insufficient evidence to support the use of spinal manipulation and mobilization in the pediatric population for the majority of conditions examined; however, there is strong evidence that these techniques are not effective in managing headaches, nocturnal enuresis, and asthma. Additionally, four systematic reviews included in this article outlined the adverse effects of utilizing spinal manipulation and mobilization in the pediatric population and these adverse events ranged from mild (e.g. muscle soreness) to severe (e.g. death). More research needs to be conducted in this area to determine the risks and benefits of the use of this intervention in the pediatric population.

Clinical Interpretation: how this study may impact clinical practice and how the results can be implemented:

Due to the fact that the majority of the literature examining the effects of spinal manipulation and mobilization in the pediatric population is established on the basis of low-level studies (e.g. case reports), their findings are unable to be generalized to larger populations. However, the findings of these studies do outline various safety concerns that should be taken into account in clinical practice. Due to the lack of research as well as reported risks, the majority of clinicians may not feel comfortable utilizing spinal manipulation or mobilization in pediatric clinical practice. However, if through more research it was determined that spinal manipulation and mobilization are effective in the treatment or management of various pediatric diagnoses, thorough medical screening would be warranted to determine the presence of underlying pathologies that may lead to a contraindication of these techniques. It is evident that additional research must be conducted prior to the widespread implementation of spinal manipulation and mobilization in pediatric clinical practice.

Author Names

Castro-Sánchez A.M., Aguilar-Ferrándiz M.E., Matarán-Peñarrocha G.A., Sánchez-Joya Mdel M., Arroyo-Morales M., Fernández-de-las-Peñas C.

Reviewer Name

Natalia Hanabergh, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

1. Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT?

• Yes

2. Was the method of randomization adequate (i.e., use of randomly generated assignment)?

• Yes

3. Was the treatment allocation concealed (so that assignments could not be predicted)?

• Yes

4. Were study participants and providers blinded to treatment group assignment?

• Yes

5. Were the people assessing the outcomes blinded to the participants’ group assignments?

• Yes

6. Were the groups similar at baseline on important characteristics that could affect
   outcomes (e.g., demographics, risk factors, co-morbid conditions)?

• Yes

7. Was the overall drop-out rate from the study at endpoint 20% or lower of the number
   allocated to treatment?

• Yes

8. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage
   points or lower?

• Yes

9. Was there high adherence to the intervention protocols for each treatment group?

• Yes

10. Were other interventions avoided or similar in the groups (e.g., similar background
    treatments)?

• Yes

11. Were outcomes assessed using valid and reliable measures, implemented consistently
    across all study participants?

• Yes

12. Did the authors report that the sample size was sufficiently large to be able to detect a
    difference in the main outcome between groups with at least 80% power?

• No

13. Were outcomes reported or subgroups analyzed prespecified (i.e., identified before
    analyses were conducted)?

• Cannot Determine, Not Reported, or Not Applicable

14. Were all randomized participants analyzed in the group to which they were originally
    assigned, i.e., did they use an intention-to-treat analysis?

• Yes

Key Finding #1

Patients with FMS receiving the experimental protocol exhibited greater improvements in pain, tender point count, sleep quality, and depressive symptoms than those receiving the control condition.

Key Finding #2

Women and men get similar improvements in quality of sleep and tender point count after manual therapy.

Key Finding #3

Women showed a greater reduction in pain and impact of FMS symptoms than men

Key Finding #4

Men reported higher decreases in depressive symptoms and pressure hypersensitivity than women.

Please provide your summary of the paper

The purpose of this study was to determine the short-term therapeutic effects of a manual therapy (MT) protocol for improving pain unction, pressure pain thresholds (PPT), quality of sleep, and depressive symptoms in women and men with fibromyalgia syndrome (FMS). 89 patients, male and female, previously diagnosed with fibromyalgia syndrome were recruited. Inclusion criteria included being between the ages of 18-70 years, no regular physical activity limitations of activities due to pain in the recent 30 days, and agreement to evening therapy sessions. Patients were divided into either an experimental group or control group. The experimental group underwent manual therapy for 45-minutes/week for 5 weeks. Intervention protocol included Suboccipital release, Release of the pectoral region, Diaphragm release, Lumbosacral decompression, Release of the psoas fascia, and Thoracic spine extension manipulation in prone (high- velocity low-amplitude). The control group received not intervention. Patient reported outcome measures and tools included Pressure Pain Thresholds (digital pressure algometer), Impact of FMS Symptoms (FIQ-Spanish version), Pain (McGill Pain Questionnaire), Quality of Sleep (PSQI), and Depression (CES-D). These reported measures were recorded at baseline prior to intervention commencement and 48 ours following the final session at the 5-week mark. This RCT did find the application of a MT protocol to be a positive tool to improve pain intensity, widespread pressure pain sensitivity, impact of FMS symptoms, sleep quality, and depressive symptoms in individuals with FMS. Sex differences were also identified: both men and women get similar improvements in quality of sleep and tender point count with an MT protocol; however, women showed a greater reduction in pain and impact of FMS symptoms compared to men, but men reported higher decreased in depressive symptoms and pressure hypersensitivity compared to women.

Clinical Interpretation: how this study may impact clinical practice and how the results can be implemented:

The application of a manual therapy protocol can be beneficial to a patient with fibromyalgia syndrome to improve quality of life. As noted in the study, both sexes with fibromyalgia syndrome found improvements in various aspects of their condition experience. Being a chronic pain condition, and one with no known cure, finding that adding manual therapy to treatment sessions may improve an individual’s experience, whether it be pain level, pressure sensitivity, impact of FMS symptoms, sleep quality and /or depressive symptoms is hopeful for symptom management. It is an additional tool that can assist with a treatment plan and one that offers various approaches and outcomes. Additional research is needed to identify the differences in responses towards interventions on sex-specific psychological and sociological circumstances.

Article: Iñaki Pastor-Pons, César Hidalgo-García, María Orosia Lucha-López, Marta BarrauLalmolda, Iñaki Rodes-Pastor, Ángel Luis Rodríguez-Fernández, José Miguel Tricás-Moreno. Effectiveness of pediatric integrative manual therapy in cervical movement limitation in infants with positional plagiocephaly: a randomized controlled trial. Ital J Pediatr. 2021 Feb 25;47(1):41.

Full Article

Study Design: Randomized Controlled Trial Abstract: Positional plagiocephaly (PP) is a cranial deformation frequent amongst children and consisting in a flattened and asymmetrical head shape. PP is associated with excessive time in supine and with congenital muscular torticollis (CMT). Few studies have evaluated the efficiency of a manual therapy approach in PP. The purpose of this parallel randomized controlled trial is to compare the effectiveness of adding a manual therapy approach to a caregiver education program focusing on active rotation range of motion (AROM) and neuromotor development in a PP pediatric sample.

Thirty-four children with PP and less than 28-week-old were randomly distributed into two groups. AROM and neuromotor development with Alberta Infant Motor Scale (AIMS) were measured. The evaluation was performed by an examiner, blinded to the randomization of the subjects. A pediatric integrative manual therapy (PIMT) group received 10-sessions involving manual therapy and a caregiver education program. Manual therapy was addressed to the upper cervical spine to mobilize the occiput, atlas and axis. The caregiver educational program consisted in exercises to reduce the positional preference and to stimulate motor development. The control group received the caregiver education program exclusively. To compare intervention effectiveness across the groups, improvement indexes of AROM and AIMS were calculated using the difference of the final measurement values minus the baseline measurement values. If the distribution was normal, the improvement indexes were compared using the Student t-test for independent samples; if not, the Mann-Whitney U test was used. The effect size of the interventions was calculated using Cohen’s d.

All randomized subjects were analysed. After the intervention, the PIMT group showed a significantly higher increase in rotation (29.68 ± 18.41°) than the control group (6.13 ± 17.69°) (p = 0.001). Both groups improved the neuromotor development but no statistically significant differences were found. No harm was reported during the study.

The PIMT intervention program was more effective in increasing AROM than using only a caregiver education program.

NIH Risk of Bias Score: 13/14 (Low Risk of Bias) Key Findings of the Study: 1. The addition of manual therapy to a caregiver educational program is associated with increased active cervical rotation range of motion after 10 weeks of treatment in infants with positional plagiocephaly.

Key Findings of the Study:

1. The addition of manual therapy to a caregiver educational program is associated with increased active cervical rotation range of motion after 10 weeks of treatment in infants with positional plagiocephaly.

2. No outcome differences in neuromotor development were found by adding manual therapy to a caregiver educational program after 10 weeks of treatment in infants with positional plagiocephaly.

3. Static photography measuring the head position of children showed good reliability comparable to other studies of children with torticollis in which photography was used to measure range of motion.

Reviewer Summary:

This study examined the effects of manual therapy in infants with positional plagiocephaly. The aims were two-fold, assessing the effect of manual intervention on both active cervical rotation and neuromotor development in 34 infants. The control group received an educational program for caregivers, while the intervention group received ten sessions of manual therapy in addition to the program.

Mobilizations targeted the occiput, atlas, and axis with the goal of restoring motion. The increase in right rotation was notably larger in the intervention group than the increase in left rotation potentially due to a lower baseline for right rotation measures. While there is no significant increase between groups for left rotation, there is a significant increase for right and total cervical rotation. Therefore, mobilizations addressing the upper cervical spine should be considered as a primary treatment option and feasible alternative to more risky interventions like surgery or chiropractic manipulation.

No long-term data was collected, and therefore, outcomes greater than 10 weeks cannot be analyzed at this time.

Author Names

Joshi, D., Shah S., Shinde, S., Patil S.

Reviewer Name

Erik Furseth SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

Paper Abstract

Background: Breast surgery, Axillary Lymph Node Dissection (ALND), radiation and chemotherapy may develop several complications such as axillary web syndrome, frozen shoulder, numbness, shoulder pain and range of motion restriction, lymphostasis, and lymphedema. Up to 77% report sensory disturbance in the breast or arm after breast surgery. These short- and long-term consequences have dramatic impact on physical function and quality of life in this population. Aims: The aim of the study was to determine the effect of neural tissue mobilization on sensory-motor impairments in breast cancer survivors with lymphedema. Subjects and Methods: This study was carried out by analyzing total 100 breast cancer survivor women, with lymphedema aged between 30-65 years of age who had undergone breast surgery mostly lumpectomy along with chemotherapy or radiation therapy. Participants were divided into two groups by random allocation. One group underwent neurodynamic mobilization and the other group conventional physiotherapy.The treatment protocol was given for 6 weeks. Parameters such ROM, pain, lymphedema and sensory-motor impairments were assessed at the baseline before the treatment and 6 weeks after the treatment.Result: The result from this study shows that there is significant improvement (p<0.0001, t-value 4.69) in mTNS of patients undergoing neural tissue mobilization, whereas there was no significant improvement (p=0.05, t-value 1.951) seen in patients undergoing conventional physiotherapy. Conclusion: This study concludes that effect of neural tissue mobilization has significant impact on sensory motor impairments as compared to conventional treatment protocol in breast cancer survivors with lymphedema.Pain and ROM showed similar difference with both the treatment protocols. It was also observed that patients with mild and moderate lymphedema showed significant improvement as compared to patients with severe lymphedema.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

1. Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT

• Yes

2. Was the method of randomization adequate (i.e., use of randomly generated assignment)?

• Yes

3. Was the treatment allocation concealed (so that assignments could not be predicted)?

• Yes

4. Were study participants and providers blinded to treatment group assignment?

• No

5. Were the people assessing the outcomes blinded to the participants’ group assignments?

• Cannot Determine, Not Reported, or Not Applicable

6. Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

• Yes

7. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

• Cannot Determine, Not Reported, or Not Applicable

8. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

• Cannot Determine, Not Reported, or Not Applicable

9. Was there high adherence to the intervention protocols for each treatment group?

• Yes

10. Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

• Yes

11. Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

• Yes

12. Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

• Yes

13. Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

• Yes

14. Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

• Yes

Key Finding #1

The use of neural tension treatments is significant for those with mild to moderate lymphadema swelling, but there still shows some benefit with severe.

Key Finding #2

The use of neural tissue mobilization has a significant impact on sensory motor impairments when compared to conventional treatment protocols in breast cancer survivors with lymphedema.

Key Finding #3

Pain scores significantly improved with conventional physical therapy as well as neural tissue mobilizations, but there was no significant differences between the two.

Paper Summary:

The purpose of this study was to determine the effects of neural tissue mobilization of sensory-motor impairments in breast cancer survivors with lymphedema. 100 women who were survivors of breast cancer and had lymphedema, between 30-65 years old, and who had breast surgery along with chemotherapy or radiation therapy. The patients were divided into 2 groups, 1 group that did the neural tissue mobilization technique and the other did conventional physical therapy techniques to treat pain, ROM, lymphedema and sensory-motor impairments. Pain was reported using a 10-point scale to assess their intensity of axillary/shoulder pain. Shoulder flexion and abduction ROM was assessed. Lymphedema was assessed on the effected limb and subsequently compared to the non-affected side. The modified Total Neuropathy Score was used to assess sensory-motor impairments. All impairments were assessed before and after the 6-week interventions. In conclusion to the study, they found a significant difference in both groups for pain level and ROM post intervention. The patients that had mild and moderate lymphedema saw a significant decrease in lymphatic swelling, but the patients with severe swelling still saw some decreases in arm-to-arm measurements.

Clinical Interpretation: how this study may impact clinical practice and how the results can be implemented:

The use of neural tissue mobilization should be used in breast cancer survivors as a therapeutic exercise to help reduce pain, increase ROM, and help to decrease lymphedema. Although patients in this study had specific requirements, since the results showed significant increases in many aspects, neurodynamic mobility could be used in a more broad population and monitored for similar effects. The results found could help with patient buy-in, reduce pain to allow for more physical therapy interventions, potentially increasing the patient’s recovery. More research should be done to determine the effects of using neurodynamic treatment in addition to conventional physical therapy to determine if there are greater effects seen when both are done simultaneously.

Author Names: Shorouk Elshennawy, Ahmed Ali Zahreldin, Hossam Mortada, Menna Hozien, Ahmed S A Youssef, Amira Galal, Mostafa Shahien, Amr Elfeky, Abdelrahman Elaraby, Maged Hamed

Reviewer Name: Kiley Doerzbacher, SPT

Reviewer Affiliation(s): Duke University School of Medicine

Paper Abstract

Objective: To evaluate the efficacy of different physical therapy interventions that could validate decisions taken by health care providers in the field of rehabilitation of patients with hemophilia according to the International Classification of Functioning, Disability and Health (ICF), including body functions and structures, activity, and participation.

Data Sources: Seven databases—PubMed, Cochrane Library, Scopus, Web of Science, Physiotherapy Evidence Database, Google Scholar, and Clinicaltrials.gov—were systematically searched for randomized controlled trials evaluating any physical therapy modality to manage hemophilia.

Study Selection: After abstract and full-text filtration, a methodological quality assessment was performed using the Physiotherapy Evidence Database scale for the studies that met the eligibility criteria.

Data Extraction: Relevant data were extracted from eligible studies and outcomes were categorized according to the ICF.

Data Synthesis: Using Review Manager and Microsoft Excel, a quantitative analysis using standardized mean differences with the 95% confidence interval was completed. Statistical heterogeneity between studies was explored using the I2 test. A fixed effect model was applied to all data analyses. If heterogeneity was statistically significant, the Der Simonian and Laird random effects models were used instead.

Results: 35 randomized controlled trials with 1216 participants were included in this systematic review; 13 of them dealt with pediatric patients. Most of the studies were of good quality; 12 studies were of low quality. Meta-analysis showed a significant difference in favor of manual therapy, laser, and therapeutic exercises on selected outcomes of body function and structure, activity, and participation categories of the ICF model.

Conclusion: This systematic review recommends using manual therapy and therapeutic exercise modalities to improve join health status in combination with educational sessions to improve the quality of life of patients with hemophilic arthropathy. For pediatric patients with hemophilic arthropathy, using laser therapy is promising for improving functional capacity.

Quality Assessment of Controlled Intervention Studies

Is the review based on a focused question that is adequately formulated and described?

Yes

Were eligibility criteria for included and excluded studies predefined and specified?

Yes

Did the literature search strategy use a comprehensive, systematic approach?

Yes

Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?

Yes

Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?

Yes

Were the included studies listed along with important characteristics and results of each study?

Yes

Was publication bias assessed?

Yes

Was heterogeneity assessed? (This question applies only to meta-analyses.)

Yes

Key Finding #1

Combination skilled physical therapy including MT, therapeutic exercise, and patient education can improve QoL and joint health.

Key Finding #2

Pediatric patients did not receive MT, however, laser treatment may prove effective in improving QoL and functional capacity.

Key Finding #3

Individuals with Hemophilia at varying severity levels can handle comprehensive sessions including a variety of MT modalities safely with notable outcomes.

Please provide your summary of the paper

The study aims to analyze the effect of physical therapy modalities individually or combined including: manual therapy (MT), therapeutic exercise, physical modalities, treadmill or isokinetics, sensorimotor interventions, and whole-body vibration, on patients with hemophilic arthropathy. Selected criteria include pediatric and adult patients with any type and severity of hemophilia and any physical therapy intervention compared to conventional therapy or no treatment groups. MT techniques include fascial therapy, soft tissue mobilization, joint traction, and Mulligan’s mobilization of the knee, ankle, or elbow. 35 RCTs are included in the systematic review and 10 articles are included in the meta-analysis due to PEDro scores between 6-8.

Under the ICF body function and structure category, outcomes include frequency of bleeding, joint health status, pain, functional capacity, range of motion, muscle power, edema and swelling, and radiological assessment. Of these items, joint health status, pain, and functional capacity showed statistical significance with MT interventions alone. In one study each, the combined use of MT and therapeutic exercise showed significant difference in functional capacity and muscle power. Under the ICF activity and participation categories, no MT techniques were used to address limitations.

Majority of studies state physical therapy interventions, including MT, are safe to use for hemophilic arthropathy management. The results using MT and therapeutic exercise in this review are compatible with The World Federation of Hemophilia guidelines and are recommended for treating adults with hemophilic arthropathy (types A or B) of the knee, ankle, and elbow.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

This study has potential to encourage more studies relating to the effects of MT on patients with varying severities of hemophilia, including pediatric populations. Results have the potential to change the treatment approach for patients with hemophilia and provide faster, more comprensive relief and recovery.

Author Names

Engel, M.; Gonski, P.; Vemulpad, S.; Graham, P.

Reviewer Name

Maia Hoshino, SPT

Reviewer Affiliation(s)

Duke University SOM, Physical Therapy Division

Paper Abstract

Purpose: Chronic obstructive pulmonary disease (COPD) is characterized by decreasing exercise capacity and deteriorating quality of life (QoL). Recent evidence indicates that combining exercise with manual therapy (MT) delivers greater improvements in exercise capacity than exercise alone in moderate COPD. The aim of this study was to investigate whether this combination delivers similar results in mild COPD. Methods: A total of 71 participants aged 50-65 yr with mild COPD were randomly allocated to two groups: exercise only (Ex) or MT plus exercise (MT + Ex). Both groups received 16 wk of exercise with the MT + Ex group also receiving 8 MT sessions. Lung function (forced vital capacity [FVC] and forced expiratory volume in the 1 st sec [FEV 1 ]), exercise capacity (6-min walk test [6MWT]), and QoL (St George’s Respiratory Questionnaire [SGRQ] and Hospital Anxiety and Depression Scale [HADS]) were measured at baseline, 4, 8, 16, 24, 32, and 48 wk. Results: Although there was no difference in the mean effect over time between groups for lung function (FEV 1 , P = .97; FVC, P = .98), exercise capacity (6MWT, P = .98), and QoL (SGRQ, P = .41; HADS anxiety, P = .52; and HADS depression, P = .06), there were clinically meaningful improvements at 48 wk for 6MWT (30 m; 95% CI, 10-51 m; P < .001), SGRQ (6.3 units; 95% CI, 2.5-10.0; P < .001), and HADS anxiety (1.5 units; 95% CI, 0.3-2.8 units; P = .006) across the entire cohort. Conclusions: While adding MT to Ex did not produce any additional benefits, exercise alone did deliver sustained modest improvements in exercise capacity and QoL in mild COPD.

Quality Assessment of Controlled Intervention Studies

Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT

Yes

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Yes

Was the treatment allocation concealed (so that assignments could not be predicted)?

Yes

Were study participants and providers blinded to treatment group assignment?

Yes

Were the people assessing the outcomes blinded to the participants’ group assignments?

No

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Yes

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Yes

Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Yes

Was there high adherence to the intervention protocols for each treatment group?

Cannot conclude

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

Yes

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

Yes

Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

Cannot conclude

Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Cannot conclude

Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

Yes

Key Finding #1

A combination of manual therapy and exercise did not produce any additional benefits for patients with COPD when compared to solely performing exercise

Key Finding #2

Although not having any added benefits when performing exercise and manual therapy with patients with COPD, there also were not any adverse effects with the additional intervention

Please provide your summary of the paper

This study provided insight into the effects of manual therapy when combined with exercise versus solely performing exercise with patients who have COPD. This study chose patients that were 50-65 y/o and had FEV1/FVC ratios of <0.7 as well as a FEV1% predicted of 60-80%. Those who were sorted into the manual therapy and exercise group were treated with spinal manipulation and soft tissue therapy to the thoracic spine and ribs. While not showing any significant difference between the two groups in improvement in lung function, exercise capacity, or quality of life, manual therapy did not appear to produce any adverse effects.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

While this study did not illustrate that manual therapy would be useful for treating patients with COPD to improve lung function, it did show that it would generally be considered safe to perform manual therapy if necessary. In clinical practice, the use of manual therapy with COPD patients may not increase, but clinicians may feel more at ease as it was shown that patients who do have decreased lung function will not decline further due to the use of this intervention.

Author Names

Traxler, K., Baum, E., Klotz, E., Reindl, M., Schinabeck, F., & Seebacher, B.

Reviewer Name

Virginia Loke, SPT

Reviewer Affiliation(s)

Duke University

Paper Abstract

Purpose: In absence of existing studies, to describe changes in balance and mobility, following specific task-oriented training (TOT), its combination with talocrural manual therapy (MT-TOT) or no intervention, in chronic stroke patients. To explore the feasibility of a full-scale randomised controlled trial (RCT) based on criteria of recruitment, retention and adherence rates, adverse events, falls and acceptability of the intervention. Materials and methods: Using an assessor-blinded pilot RCT, 36 stroke patients were allocated to either MT-TOT, TOT, or controls. Supervised interventions were performed 45 min, 2x/weekly, for 4 weeks, and home-based practice 20min, 4x/weekly for 4weeks. Qualitative interviews evaluated intervention acceptability. Outcomes of balance, mobility, ankle dorsiflexion range of motion (ROM), falls and health-related quality of life (HRQoL) were assessed at baseline, post-intervention and 4-week follow-up. Results: Preliminary efficacy of MT-TOT and TOT was shown in improving balance (effect size 0.714), walking speed (0.683), mobility (0.265), dual-tasking mobility (0.595), falls (0.037), active and passive talocrural ROM (0.603; 0.751) and activities and social participation related HRQoL domains (0.332–0.784) in stroke patients. The feasibility of a larger RCT was confirmed. Conclusions: Specific MT-TOT and TOT appeared effective and are feasible in stroke patients. A larger RCT is needed to validate the results.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT

Yes

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Yes

Was the treatment allocation concealed (so that assignments could not be predicted)?

Yes

Were study participants and providers blinded to treatment group assignment?

No

Were the people assessing the outcomes blinded to the participants’ group assignments?

Yes

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Yes

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Yes

Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Yes

Was there high adherence to the intervention protocols for each treatment group?

Yes

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

Cannot Determine, Not Reported, or Not Applicable

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

Yes

Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

No

Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Yes

Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

Yes

Key Finding #1

There was an improvement in dynamic balance for MT-TOT and TOT compared to controls. Both experimental groups also performed better on functional mobility and walking speed at post-intervention and follow-up, with MT-TOT performing better than TOT.

Key Finding #2

MT-TOT and TOT showed improvements in active ankle dorsiflexion while there were no improvements in the control group, and active dorsiflexion ROM was better in MT-TOT than TOT. Improvements were found in passive ankle dorsiflexion for MT-TOT but not for the other two conditions.

Key Finding #3

The experimental groups also reported improvements in the disability and HRQoL domains of strength, mobility, and recovery compared to control. MT-TOT reported greater improvements in ADL/IADL and social participation.

Key Finding #4

Analyses demonstrated that a larger RCT is feasible.

Please provide your summary of the paper

This study examined the effects of specific task-oriented training (TOT) alone compared to TOT with talocrural manual therapy (MT) on balance, functional mobility, ankle dorsiflexion ROM, number of falls, and health-related quality of life (HRQoL) in patients who had had a stroke at least 6 months prior. The results indicate that specific task-oriented training and ankle manual therapy may help improve dynamic balance, mobility, walking speed, ankle dorsiflexion ROM, disability, and HRQoL in patients with chronic stroke. This study utilized two experimental conditions and one control condition. Compared to both control and the TOT group, the MT-TOT group demonstrated greater improvements in dynamic balance, walking speed, ADL/IADLs, and social participation. These findings suggest that the addition of MT may enhance or add to the benefits of TOT for patients with chronic stroke. Limitations of this study included the small sample size, lack of ability to assess the participants’ home programs objectively, and too short of a study duration to determine any long-term effects of the intervention. Additionally, the MT-TOT group engaged in 30 minutes of TOT and 15 minutes of MT, whereas the TOT group engaged in 45 minutes of TOT during their sessions with the physical therapist. Although unlikely, it is possible that some of the between-group differences the researchers found could be due to the difference in TOT duration rather than the addition of MT. The authors also did not mention if they controlled for participants receiving other interventions, which could potentially introduce bias.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

Despite its limitations, this study helped me understand that utilizing TOT and TOT plus MT for patients with chronic stroke may be beneficial. At first glance, it may seem irrelevant or unnecessary to perform MT on patients with stroke, but those patients often develop ROM limitations or other orthopedic issues that can affect their balance, mobility, walking speed, and quality of life. I think that this study provides a good starting point for investigating the use of MT in patients with chronic stroke and other neurological conditions, and for helping physical therapists to appreciate the co-occurrence of neurological and orthopedic issues.

Aguilar-Rodríguez M., Espí-Lopez G., Inglés M., López-Martínez S., Serra-Añó P.

Chad Fortin

Duke University DPT

Objectives: To compare the effectiveness of a specific Manual Therapy (MT) protocol applied to field hockey players (FHP), versus a Proprioceptive Neuromuscular Facilitation (PNF) protocol, in the improvement of dynamic balance, active range of movement and lumbar flexibility one-week and four weeks after the treatment. Design: Randomized controlled trial. Participants were assigned to 2 groups: MT and PNF. 30 min’ sessions were performed once a week for three weeks. Three evaluations were performed: basal, one-week and four-weeks post-treatment. Setting: University of Valencia (Spain). Participants: 22 in MT group and 20 in PNF group. Main outcome measures: Dynamic Balance, measured with Star Excursion Balance Test; Active Range of Motion (ROM), using a manual goniometer and Lumbar Flexibility, assessed with Fingertip-to-floor test. Results: Both groups significantly improved in lateral and medial dynamic balance one-week post-treatment (p < 0.05); but the improvement in the MT group lasted until the fourth-week after treatment in both reaches (lateral and medial) (p < 0.05). MT group also obtained significant improvements in dorsal flexion of the ankle in the fourth-week post-treatment (p < 0.05) and in lumbar flexibility oneweek post-treatment (p < 0.05). Conclusions: MT and PNF improve dynamic balance one-week post-treatment; however, the improvement obtained through MT is maintained four-weeks later. Only MT improves dorsal flexion of the ankle four-weeks post-treatment and lumbar flexibility one-week post-treatment.

Quality Assessment of Controlled Intervention Studies

Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT

Yes

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Yes

Was the treatment allocation concealed (so that assignments could not be predicted)?

Yes

Were study participants and providers blinded to treatment group assignment?

No

Were the people assessing the outcomes blinded to the participants’ group assignments?

No

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Yes

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

No

Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

No

Was there high adherence to the intervention protocols for each treatment group?

No

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

Yes

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

Yes

Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

No

Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Yes

Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

Yes

Key Finding #1

Manual therapy led to significant improvements in lateral and medial dynamic balance one-week post-treatment, with these improvements maintained at the four-week follow-up

Key Finding #2

Participants in the manual therapy group experienced significant enhancements in lumbar flexibility one week after treatment.

Key Finding #3

The manual therapy group showed significant increases in ankle dorsiflexion range of motion at the four-week post-treatment assessment.

Key Finding #4

Manual therapy proved to yield more long-term benefits than PNF when assessing at the four-week mark.

Please provide your summary of the paper

This randomized controlled trial compared the effects of manual therapy (MT) and proprioceptive neuromuscular facilitation (PNF) on dynamic balance, mobility, and flexibility in field hockey players. Both interventions significantly improved all outcomes, with MT showing slightly greater gains in flexibility and mobility, likely due to direct soft tissue manipulation, while PNF excelled in enhancing dynamic balance through improved neuromuscular coordination. The findings suggest both methods are effective, with the choice depending on specific performance or rehabilitation goals.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

This study suggests that manual therapy (MT) can be effectively used to improve flexibility, mobility, and joint range of motion, while proprioceptive neuromuscular facilitation (PNF) is particularly beneficial for enhancing dynamic balance in athletes. Clinicians can implement these findings by tailoring interventions to address specific deficits, such as using MT for flexibility and PNF for balance. Both techniques can be integrated into training or recovery routines for athletes, with follow-up assessments to ensure sustained improvements and optimize performance.

Author Names

Cabrea-Martos, I

Reviewer Name

Max Francisco- Duke DPT SPT

Reviewer Affiliation(s)

Duke DPT

Paper Abstract

Purpose:

Despite growing evidence regarding nonsynostotic plagiocephaly and their repercussions on motor development, there is little evidence to support the use of manual therapy as an adjuvant option. The aim of this study was to evaluate the effects of a therapeutic approach based on manual therapy as an adjuvant option on treatment duration and motor development in infants with severe nonsynostotic plagiocephaly.

Methods:

This is a randomised controlled pilot study. The study was conducted at a university hospital. Forty-six infants with severe nonsynostotic plagiocephaly (types 4–5 of the Argenta scale) referred to the Early Care and Monitoring Unit were randomly allocated to a control group receiving standard treatment (repositioning and an orthotic helmet) or to an experimental group treated with manual therapy added to standard treatment. Infants were discharged when the correction of the asymmetry was optimal taken into account the previous clinical characteristics. The outcome measures were treatment duration and motor development assessed with the Alberta Infant Motor Scale (AIMS) at baseline and at discharge.

Results:

Asymmetry after the treatment was minimal (type 0 or 1 according to the Argenta scale) in both groups. A comparative analysis showed that treatment duration was significantly shorter (p < 0.001) in the experimental group (109.84 ± 14.45 days) compared to the control group (148.65 ± 11.53 days). The motor behaviour was normal (scores above the 16th percentile of the AIMS) in all the infants after the treatment.

Conclusions:

Manual therapy added to standard treatment reduces the treatment duration in infants with severe nonsynostotic plagiocephaly.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT

Yes

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Yes

Was the treatment allocation concealed (so that assignments could not be predicted)?

Yes

Were study participants and providers blinded to treatment group assignment?

Yes

Were the people assessing the outcomes blinded to the participants’ group assignments?

No

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Yes

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Yes

Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Yes

Was there high adherence to the intervention protocols for each treatment group?

Yes

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

Yes

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

Yes

Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

Cannot determine

Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

Cannot determine

Key Finding #1

On average, the group of children who got the standard therapy as well as the manual therapy were discharged in 109.84 days (±14.45), while the average for the control group who just got the standard treatment of helmet orthotic and repositioning was 148.65 days (± 11.53).

Key Finding #2

Although the experimental group was discharged quicker on average than the treatment group, all children in both groups achieved normal motor behavior, as scored as above the 16th percentile on the Alberta Motor Infant Scale (AIMS).

Please provide your summary of the paper

This paper documents a randomized control study done looking at treatment duration and improvements in motor behavior of children with severe nonsynostotic plagiocephaly. Severe nonsynostotic plagiocephaly was defined as either a 4, a deformity of the posterior skull, malposition of the ipsilateral ear, ipsilateral frontal asymmetry and ipsilateral facial asymmetry, or a 5, a deformity of the posterior skull, malposition of the ears, forehead asymmetry, facial asymmetry and temporal bulging of the posterior skull. The participants of the study were excluded from the study if they had synostotic plagiocephaly, if they suffered from a respiratory disease or a neurological concomitant condition, if they were born preterm with less than 36 weeks gestation or if they had a concomitant deformation such as torticollis. Out of the 48 infants whose parents entered them in the study 46 were approved, as two of the infants were born premature and did not fit the inclusion criteria. The 46 infants were randomly divided evenly by an offsite statistician who was not aware of the study between a control group and an experimental group. The control group received standardized care of orthotic helmeting for 23 hours a day and parental repositioning education. The treatment group received standardized care of orthotic helmeting for 23 hours a day and parental repositioning education, as well as 45 minutes per week of manual therapy from a trained physical therapist. Each group had monthly follow ups to review at home positional treatments, orthic helmets, and overall correction of the asymmetries. The infants were discharged when their nonsynostotic plagiocephaly was graded a 0, no asymmetries, or a 1, most minimal form of asymmetries, as well as the infant achieving at least the 16th percentile on the Alberta Motor Infant Scale (AIMS). Both assessments were done by a pediatric neurologist who was unaware of which treatment group the infant was in.

The results of the study show that manual therapy may be a viable option in decreasing treatment time for infants with nonsynostotic plagiocephaly. On average, the group of children who got the standard therapy as well as the manual therapy were discharged in 109.84 days (±14.45), while the average for the control group who just got the standard treatment of helmet orthotic and repositioning was 148.65 days (± 11.53). Both groups began the study with similar AIMS scores—14.28 (± 3.48) for the experimental group and 14.23 (± 4.62) for the control group. However, the experimental group achieved significantly higher final scores, averaging 52.29 (± 2.75) compared to the control group’s 47.22 (± 4.13). It is important to note that each infant in both the control and the experimental group achieved normal motor behavior, as defined as greater than or equal to the 16th percentile of the Alberta Motor Infant Scale.

The experiment does point out saw flaws in its design and gives advice to anyone trying to replicate it. The authors of the paper point out that there were no follow-ups after discharge, not allowing the researchers to know the differences between the two groups over time. Also, the authors acknowledge that they were not able to ensure adherence to the protocols of the positioning and the time spent wearing the orthotic helmet at home. Finally, the authors pointed out that to prove manual therapy as an effective treatment in reducing the treatment time for children with nonsynostotic plagiocephaly, a larger sample size is needed.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

This paper suggests that manual therapy can and should be a viable treatment for infants with nonsynostotic plagiocephaly. Additionally, this study was designed in a way that reduces tester bias and seems to be a valid study that is easily repeatable. One recommendation that can be done, as seen in other manual therapy studies, is the introduction of sham manual therapy techniques on the control group to decrease familial bias. Knowledge of the benefits that manual therapy can have on children with nonsynostotic plagiocephaly will allow me, as a clinician, to best serve my patients by integrating evidence based manual therapy techniques into my treatment plans. Additionally, what I have seen so far in my shadowing and steps experiences is that wait times for many pediatric physical therapists is astronomical. Recommending something that may lead to a decrease in treatment time is something that could be very influential and be a partial solution to a large problem that many pediatric physical therapists have.

Author Names

Pinheiro da Silva, F., Maria Moreira, G., Zomkowski, K., Amaral de Noronha, M., Flores Sperandio, F.

Reviewer Name

Greysee Floyd, SPT

Reviewer Affiliation(s)

Duke University Doctorate of Physical Therapy Program

Paper Abstract

Objective: The purpose of this systematic review was to investigate the effectiveness of manual therapy (MT) for chronic musculoskeletal pain (CMP) in the upper limbs and thorax of female breast cancer survivors and to investigate the changes in the quality of life and function of these patients.

Methods: Systematic searches were performed in the databases MEDLINE/PubMed, Cumulative Index of Nursing and Allied Health/EBSCO, Web of Science, and Physiotherapy Evidence Database, through March 2018, to identify randomized controlled trials investigating whether MT was effective to treat CMP pain in female breast cancer survivors (PROSPERO number CDR42017074175).

Results: The database searches retrieved 1562 titles, and after screening, 5 papers were included for full analysis. The manual therapy techniques described in the included studies involved myofascial induction, myofascial release, classic massage, ischemic compression of trigger points, and myofascial therapy. A meta-analysis, using a fixed-effects model, found that MT decreased CMP intensity (standardized mean difference: 0.32; 95% CI 0.06-0.57), but no significant difference was observed in quality of life after the MT intervention in comparison with a control condition (standardized mean difference: 0.14; 95% CI 0.17-0.46).

Conclusion: Current evidence suggests that MT is considered effective for treating CMP in the upper limbs and thorax of female breast cancer survivors.

Quality Assessment of Systematic Reviews and Meta-Analyses

Is the review based on a focused question that is adequately formulated and described?

Yes

Were eligibility criteria for included and excluded studies predefined and specified?

Yes

Did the literature search strategy use a comprehensive, systematic approach?

Yes

Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?

Yes

Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?

Yes

Were the included studies listed along with important characteristics and results of each study?

Yes

Was publication bias assessed?

Yes

Was heterogeneity assessed? (This question applies only to meta-analyses.)

Yes

Key Finding #1

Manual therapy can effectively decrease the intensity of chronic musculoskeletal pain in the upper limbs and thorax for female breast cancer survivors.

Key Finding #2

Manual therapy is not correlated to improved quality of life in female breast cancer survivors, despite improvements in pain intensity.

Key Finding #3

The mechanisms of manual therapy are believed to be a result of a combination of physiological, biomechanical, and psychological effects in this patient population.

Please provide your summary of the paper

This article analyzed five randomized controlled trials that investigated the effect of manual therapy in females with a history of breast cancer and chronic musculoskeletal pain in the upper limbs and thorax, specifically focusing on the changes in quality of life and function. According to the authors of the RCTs, females with a history of breast cancer present with decreased pressure pain threshold, increase in pain intensity in the neck, shoulder, and axilla, and points of myofascial strain due to hypertonic muscles. The included papers utilized different manual therapy techniques like myofascial induction, myofascial release, ischemic compression of myofascial trigger points, classical massage, and myofascial therapy as treatment methods for the listed impairments. The results showed that manual therapy can reduce pain but it didn’t lead to significant improvements in overall quality of life. Some studies found better range of motion and arm function, but these results lacked consistency. The authors attribute the mechanisms of manual therapy to a combination of physiological (gate control theory of pain), biomechanical (repeated articular movements through mobilization), and psychological (physical contact from therapist) effects.The limitations of this systematic review include small sample sizes, number of articles included, variability in study designs, and a lack of detailed reporting on pain characteristics and tissue response after specific techniques. In conclusion, manual therapy is safe and may produce positive results in this population, but requires further research to study the differences between techniques, methods, and dosage.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

Manual therapy can be used as an effective treatment for reducing chronic musculoskeletal pain in female breast cancer survivors, particularly in the upper limbs and thorax. While manual therapy decreases pain intensity, its lack of impact on quality of life shows the need for an individualized, comprehensive approach. Physical therapists should continue to use conventional approaches to treatment such as exercise and stretching, but can incorporate techniques discussed in the article like myofascial release and trigger point compression to alleviate pain and improve mobility for optimal results. Manual therapy is a safe intervention that can be easily implemented in clinical settings, but requires therapists to be educated on proper technique as well as provide patient education on strategies to maintain benefits and consider combining manual therapy with other pain management methods.

Author Names

Wong, C., Youdan, G., and Chihuri, S.

Reviewer Name

Reghan Flores, SPT

Reviewer Affiliation(s)

Duke University School of Medicine – Doctor of Physical Therapy Division

Paper Abstract

Background: Most people with lower-limb loss (PLL) have musculoskeletal conditions and range-of-motion and muscle performance impairments. Such impairments limit potential for functional movement but can be reduced with manual therapy. Manual therapy, however, is rarely used for PLL. This case demonstrated how integrating manual therapy, exercise, and functional training led to lasting benefits for one low functioning PLL.

Case Description: A 54-year-old woman more than 1 year after transtibial amputation due to peripheral artery disease presented with multiple comorbidities and yellow flags. Her function remained limited to the Medicare K-1 household walking level with slow gait speed <0.25 m/s. Treatment included four weekly sessions each beginning with manual therapy, followed by exercise and functional training.

Outcomes: After 1 month, performance-based strength, balance, walking speed, and physical activity increased. She advanced to the K-2 limited community walking level and maintained her functional level without further treatment after 3 months.

Discussion: Improvements maintained without treatment expanded upon research that lacked follow-up and excluded K-1 level walkers. Marked improvement after only four sessions was noteworthy since exercise protocols require ≥4 sessions.

Conclusion: Manual therapy followed by exercise and functional training may optimize movement.

Quality Assessment Tool for Before-After (Pre-Post) Studies With No Control Group

Was the study question or objective clearly stated?

Yes

Were eligibility/selection criteria for the study population prespecified and clearly described?

Yes

Were the participants in the study representative of those who would be eligible for the test/service/intervention in the general or clinical population of interest?

Yes

Were all eligible participants that met the prespecified entry criteria enrolled?

NA

Was the sample size sufficiently large to provide confidence in the findings?

No

Was the test/service/intervention clearly described and delivered consistently across the study population?

Yes

Were the outcome measures prespecified, clearly defined, valid, reliable, and assessed consistently across all study participants?

Yes

Were the people assessing the outcomes blinded to the participants’ exposures/interventions?

No

Was the loss to follow-up after baseline 20% or less? Were those lost to follow-up accounted for in the analysis?

Yes

Did the statistical methods examine changes in outcome measures from before to after the intervention? Were statistical tests done that provided p values for the pre-to-post changes?

No

Were outcome measures of interest taken multiple times before the intervention and multiple times after the intervention (i.e., did they use an interrupted time-series design)?

No

If the intervention was conducted at a group level (e.g., a whole hospital, a community, etc.) did the statistical analysis take into account the use of individual-level data to determine effects at the group level?

NA

Key Finding #1

A female patient over a year post transtibial amputation progressed from a K-1 household ambulator to a K-2 limited community ambulator after four sessions of a combined manual therapy and functional mobility program.

Key Finding #2

After implementation of the study, there were improvements in the patient’s balance, gait, physical activity, and strength, of which balance and gait were maintained and physical activity and strength demonstrated further improvement by the three-month follow-up.

Key Finding #3

Compared to self-report of falls three months prior to the study, the patient reported a decrease from five falls to one fall at the three-month follow-up.

Please provide your summary of the paper

In an effort to understand the impact of manual therapy on lower limb loss recovery, this case study identified a K-1 level female who was over a year post-amputation and presented with multiple morbidities. Utilizing the Charlson Comorbidity Index, Gait Speed, 2-Minute Walk Test, Berg Balance Scale, and 30 Second Sit-to-Stand as baseline for change, a protocol was designed and sequenced as follows: manual therapy of passive structures, isometric muscle contractions during key phases of gait, neuromuscular facilitation during gait and sit-to-stands, balance and gait practice, independent walking, activity monitoring for home and community ambulation, and education to encourage weight-bearing through prosthetic. The specific manual therapy techniques included non-thrust spinal manipulation of L2-L5, hip mobilization to facilitate extension, and soft-tissue mobilization of the psoas and TFL for contracture prevention.

After four treatment sessions, the patient was re-tested on the above-mentioned outcome measures and had notable improvements across the board, which were maintained at the three-month follow-up post-study. Additionally, the patient’s frequency of falls over three months decreased, and her average steps-per-day, assessed during the final week of the study, quadrupled post-treatment and remained double the initial measurement three-months post. Within a short-time period, manual therapy combined with exercise resulted in significant functional gains for a previously low-functioning person with K-1 amputee status, which points to the potential added value of manual therapy versus exercise-based interventions alone. Furthermore, the study maintains that by beginning sessions with manual therapy, passive impairments can be reduced to facilitate optimal movement potential, which was not contraindicated by the study’s positive findings. Overall, the study demonstrated that manual therapy technique can be performed safely in the case of lower limb loss, particularly in a low-function, complex case, as well as may enhance rehabilitation outcomes and accelerate performance gains.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

Research addressing manual therapy techniques within the lower-limb loss population is a developing field. This paper presents a hopeful direction for improving rehabilitation outcomes especially for those with lower functioning K-levels, who present with greater risk of secondary musculoskeletal impairment and limited community independence. The participating patient demonstrated positive performance gains based on baseline and post-treatment values, which were maintained, with the exception of balance confidence and prosthetic mobility, at the three-months follow-up.

When considering methods of change assessment, it should be noted that the minimal detectable change (MDC) for the 2-Minute Walk Test and the minimal clinically important difference (MCID) for the Berg Balance Scale were based on older adults despite the patient being 54 years old. Although, it is important to consider that there is not a standard MDC or MCID for lower-limb amputees for the above-mentioned tests. The patient’s progress and maintenance of performance gains after just four sessions is promising, but the values used to evaluate change were not always patient-applicable in this study. On the other hand, percent increase in gait achieved with exercise alone, from a 2014 systematic review, was surpassed by the patient’s walking speed, which could give validity to the added benefit of manual therapy combined with exercise. Once again, however, there are limitations with the individual-specific nature of this study and the risk of bias within the systematic review itself.

While a causal relationship cannot be determined due to the study design, the incorporation of three different data points (pre, post, and follow-up) added an additional level of strength to the results’ validity for a combined manual therapy and functional exercise rehabilitation program. The concluded safe effect of manual therapy as an additive intervention for lower-limb loss, could pave the way for future studies to further assess its efficacy without fear of complicating prognosis. Additionally, it is an exciting possibility that a person presenting at the K-1 level over a year post-amputation could advance to higher levels of function if manual therapy is introduced as a movement primer to enhance rehabilitation potential. With the case-specific nature of this study, it is important to recognize its limitations in terms of generalizability and need for further research. However, the findings themselves identify a positive direction for the future of lower limb loss rehabilitation, one that may include manual therapy.

Author Names: Traxler K, Baum E, Klotz E, Reindl M, Schinabeck F, Seebacher, B.

Reviewer Name: Michael Hils

Reviewer Affiliation(s): Duke University, Doctor of Physical Therapy Class of 2026

Paper Abstract

Purpose: In absence of existing studies, to describe changes in balance and mobility, following specific task-oriented training (TOT), its combination with talocrural manual therapy (MT-TOT) or no intervention, in chronic stroke patients. To explore the feasibility of a full-scale randomised controlled trial (RCT) based on criteria of recruitment, retention and adherence rates, adverse events, falls and acceptability of the intervention. Materials and methods: Using an assessor-blinded pilot RCT, 36 stroke patients were allocated to either MT-TOT, TOT, or controls. Supervised interventions were performed 45 min, 2×/weekly, for 4 weeks, and home-based practice 20 min, 4x/weekly for 4 weeks. Qualitative interviews evaluated intervention acceptability. Outcomes of balance, mobility, ankle dorsiflexion range of motion (ROM), falls and health-related quality of life (HRQoL) were assessed at baseline, post-intervention and 4-week follow-up. Results: Preliminary efficacy of MT-TOT and TOT was shown in improving balance (effect size 0.714), walking speed (0.683), mobility (0.265), dual-tasking mobility (0.595), falls (0.037), active and passive talocrural ROM (0.603; 0.751) and activities and social participation related HRQoL domains (0.332-0.784) in stroke patients. The feasibility of a larger RCT was confirmed. Conclusions: Specific MT-TOT and TOT appeared effective and are feasible in stroke patients. A larger RCT is needed to validate the results.

1. Was the study described as randomized, a randomized trial, a randomized
clinical trial, or an RCT

YES

2. Was the method of randomization adequate (i.e., use of randomly
generated assignment)?

YES

3. Was the treatment allocation concealed (so that assignments could not be
predicted)?

YES

4. Were study participants and providers blinded to treatment group
assignment?

YES

5. Were the people assessing the outcomes blinded to the participants’ group
assignments?

YES

6. Were the groups similar at baseline on important characteristics that could
affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

YES

7. Was the overall drop-out rate from the study at endpoint 20% or lower of
the number allocated to treatment?

YES

8. Was the differential drop-out rate (between treatment groups) at endpoint
15 percentage points or lower?

YES

9. Was there high adherence to the intervention protocols for each treatment
group?

YES

10. Were other interventions avoided or similar in the groups (e.g., similar
background treatments)?

YES

11. Were outcomes assessed using valid and reliable measures, implemented
consistently across all study participants?

YES

12. Did the authors report that the sample size was sufficiently large to be able
to detect a difference in the main outcome between groups with at least
80% power?

NO

13. Were outcomes reported or subgroups analyzed prespecified (i.e.,
identified before analyses were conducted)?

YES

14. Were all randomized participants analyzed in the group to which they were
originally assigned, i.e., did they use an intention-to-treat analysis?

YES

Key Finding #1

A larger scale RCT assessing task-oriented training combined with talocrural manual therapy [MT- TOT] and task-oriented training alone [TOT] in chronic stroke patients is possible, based on this effective execution of this study.

Key Finding #2

Preliminary data from this study indicates that both MT-TOT and TOT may improve balance (i.e. greater sensory orientation, anticipatory postural control, and dynamic gait on the miniBESTest), mobility (TUG), and dual-tasking mobility (TUG cognitive), immediately following intervention and at 4-week follow-up.

Key Finding #3

Preliminary data from this study indicates that MT-TOT can improve passive dorsiflexion, both post-intervention and at 4-week follow-up, where TOT alone made negligible difference to passive dorsiflexion. (A similar trend was shown with active dorsiflexion, but the gains to AROM for the MT-TOT group were arguably insignificant given that the group’s average dorsiflexion goniometric measurement only improved by ~3 degrees.)

Key Finding #4

TOT, MT-TOT, and the control group had no significant differences in fall rates; although 10MWT gait speed improved in the TOT and MT-TOT groups post-intervention, with a smaller improvement noted at the 4-week follow-up.

Please provide your summary of the paper

This mixed methods pilot study aimed to compare task-oriented training alone [TOT] with task-oriented training combined with talocrural manual therapy [MT- TOT] and a control group, with regards to balance (miniBESTest), gait speed (10MWT), ankle dorsiflexion ROM, mobility (TUG), dual-task mobility (TUG cognitive), falls rate, and health quality of life measures (stroke impact scale) in patients who are in the chronic phase of stroke recovery. This study also aimed to assess the feasibility of a larger scale RCT. 36 adult participants who had a stroke (ischemic or hemorrhagic) at least 6 months prior, who had limited dorsiflexion ROM (active and passive), had the ability to sit-to-stand without any AD (use of hands was allowed), the ability to walk 10 meters without any AD, and no contraindications to manual therapy were included in the study. The MT-TOT group participated in 30 minutes of specific TOT and received 15 minutes of talocrural manual therapy geared towards dorsiflexion, 2x/week, over 4 weeks. The TOT group participated in 45 minutes of specific TOT at the same frequency and over the same time frame. Additionally, participants in the MT-TOT and TOT group were asked to perform 20 minutes of a home exercise plan (HEP) 4x/week on the days they weren’t seeing a physiotherapist. The MT-TOT group was taught an ankle dorsiflexion self-mobilization to perform at home. All groups (including the control group) received their usual medical care and medications during the study. The following manual therapy techniques were performed on the MT-TOT group: “Initially, a talus-on-tibia technique at a Maitland joint mobilisation grade III was used at the submaximally dorsiflexed ankle joint. A grade I tibial distraction followed, alternating with anterior-posterior gliding. Then, a tibia-on-talus technique with a posterior-anterior force at a Maitland joint mobilisation grade III was performed in the same joint position. This was combined with active knee joint forward movements and intermittent talocrural mobilisation at Maitland grades ranging from III + to III++.” Preliminary data from this study indicates that both MT-TOT and TOT alone can improve balance (i.e. greater sensory orientation, anticipatory postural control, and dynamic gait on the miniBESTest) and 10MWT gait speed, both post-intervention and 4 weeks later at follow-up. The improvement from baseline to 4-week follow-up was less significant (in both MT-TOT and TOT) when compared to the improvements made from baseline to post-intervention assessment. MT-TOT and TOT groups also had improved TUG and TUG cognitive times, indicating mobility improvements. Preliminary data also suggests that MT-TOT can improve passive dorsiflexion, both post-intervention and at 4-week follow-up, where TOT alone did not make a difference. The MT-TOT group also reported higher scores in the ADL/IADL and social participation domains of the stroke impact scale (validated German version) than the TOT group. Notably, TOT and MT-TOT had no significant difference in fall rates when compared to the control group.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

Given that task-oriented therapy has already been well-established for the treatment of medical conditions which involve a neurologic aspect like stroke, it is not surprising that both TOT and MT-TOT were advantageous to the control group (which seemingly did not receive any sort of intervention or current best-practice physical therapy treatment). For this reason, the larger scale RCT would be beneficial to confirm any potential benefits, ideally with the control group receiving some form of placebo or accepted best-practice intervention. However, the addition of manual therapy to task-orientation training for chronic stroke patients is intriguing nonetheless, given that additional benefits may exist with regards to ROM, the ADL/IADL domain, and the social participation domain of health-related quality of life measures.

Author Names: Austin Sheldon, Steve Karas
Reviewer Name: Mason Kosik
Reviewer Affiliation(s): Duke DPT CO 2026

Paper Abstract
Methods:
We performed a systematic review of potential adverse events (AEs) of manual therapy to peripheral joints using PubMed, CINAHL, PEDro, AMED, and Google Scholar with a single term for each peripheral body region (shoulder, elbow, wrist, hand, hip, knee, ankle, foot). Inclusion criteria included articles that examined or reported the occurrence of AEs. Exclusion criteria included literature discussing treatment other than manual therapy or surgery.

Results:
Twenty total articles meeting the inclusion criteria were found. A total of fifty-three adverse events were analyzed. Most AEs were benign. Little evidence exists for serious AEs with manual therapy. Scant serious AEs were reported with acupuncture or massage near the shoulder, hip, and knee.

Discussion:
AEs with manual therapy to the spine have garnered ample attention in literature. Traditional manual therapy consists of joint mobilization, thrust manipulation, and a variety of soft tissue techniques. However, with the popularity of other “manual therapies,” outside the traditional definition, the practitioner and client should be aware of the risks.

Conclusion:
AEs occurring with most manual therapy techniques to the peripheral joints are transient and mild. It is difficult to attribute true AEs to manual therapy in multi-modal treatment paradigms with numerous single-session interventions. Since there are no international definitions or classifications of AEs, and the definition of manual therapy remains broad, further standardization is necessary.

Quality Assessment of Systematic Reviews and Meta-Analyses
Is the review based on a focused question that is adequately formulated and described?
Yes

Were eligibility criteria for included and excluded studies predefined and specified?
Yes

Did the literature search strategy use a comprehensive, systematic approach?
Yes

Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?
Not reported

Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?
Not reported

Were the included studies listed along with important characteristics and results of each study?
Yes

Was publication bias assessed?
Not reported

Key Finding #1:
There is little evidence of major or moderate adverse events following mobilization/manipulation to the upper extremity.

Key Finding #2:
No noted major or moderate AEs from mobilization/manipulation to the hip and/or knee.

Key Finding #3:
In studies on manual therapy applied to the foot, transient AEs (primarily soreness) have been reported. No evidence of major or moderate AEs has been reported.

Key Finding #4:
Major adverse events have been reported following dry needling, acupuncture, cupping, fine-wire EMG, and vigorous massage. These include pneumothorax, infection, nerve damage, blood vessel damage, and syncope. Reported AEs are from case studies, and rates of occurrence are not clear.

Summary
Reviews on adverse events (AEs) from manual therapy (MT) have been published; however, these reviews are primarily focused on MT to the spine and have not distinguished spine-focused MT from MT to the peripheral joints. Because MT to peripheral joints is commonly used in physical therapy clinics, it is important to understand the risk for AEs. This systematic review aimed to identify AEs from manual therapy specifically to peripheral joints. The initial literature search was broad, identifying 1628 articles. Of these, 640 were reviewed, and 20 met the criteria to be included in the review.

In these studies, no major or moderate adverse events were reported following mobilization/manipulation to the peripheral joints. Occasionally, mild adverse events were reported, most commonly in the foot/ankle. Mild adverse events resulting from mobilization/manipulation treatment were transient in nature and generally involved soreness of the body part that received treatment. Some major/moderate adverse events have been reported following other manual therapy modalities, such as dry needling and acupuncture; however, the occurrence rates of these are not clear. The most common serious AEs reported are pneumothorax following dry needling or acupuncture to the shoulder, and infection following treatment with needles.

Clinical Interpretation
The first major takeaway from this article for clinicians is that mobilizations/manipulations to the peripheral joints appear safe, as there is no evidence of serious adverse events occurring following these treatments. In cases where mobilizations/manipulations are appropriate, they can be utilized without much risk of any adverse events. Soreness in the affected areas is possible, so clinicians should make patients aware of this possibility and provide options to alleviate soreness, such as icing.

Second, the risk of serious adverse events is higher using other treatments, specifically dry needling and acupuncture to the shoulder area. Though the risk is likely still quite low (reported AEs came from a few case studies), these treatment options should only be used by skilled, licensed professionals, and they should not be the first line of treatment. As pneumothorax was the most commonly reported major AE, extra caution should be used when using dry needling or acupuncture in the shoulder, upper chest, or upper back, and needles should never be angled such that they can puncture the lungs. Clinicians using these treatments must also always be vigilant about sanitation in order to prevent infection.

Authors: Isidro Fernandez-Lopez, PT, MSc, PhD, David Pena-Otero, RN, MSc, PhD, María de los Angeles Atín-Arratibel, MD, MSc, PhD, María Eguillor-Mutiloa, RN, MSc

Reviewer Name: Torri Tippett

Reviewer Affiliation(s): Duke University

Paper Abstract
Objectives:
To analyze the effects at the musculoskeletal level of manual treatment of the diaphragm muscle in adults.

Data Sources:
Systematic review using 4 databases: PubMed, Science Direct, Web of Science, and Scopus.

Study Selection and Data Extraction:
Two independent reviewers applied the selection criteria and assessed the quality of the studies using the Physiotherapy Evidence Database scale for experimental studies. A third reviewer intervened in cases where a consensus had not been reached. A total of 9 studies were included in the review.

Data Synthesis:
Manual therapy directed to the diaphragm has been shown to be effective in terms of the immediate increase in diaphragmatic mobility and thoracoabdominal expansion. The immediate improvement in the posterior muscle chain flexibility test is another of the most frequently found findings in the evaluated studies. Limited studies show improvements at the lumbar and cervical level in the range of motion and in pain.

Conclusion:
Manual diaphragm therapy has shown an immediate significant effect on parameters related to costal, spinal, and posterior muscle chain mobility. Further studies are needed, not only to demonstrate the effectiveness of manual diaphragm therapy in the long-term and in symptomatic populations, but also to investigate the specific neurophysiological mechanisms involved in this type of therapy.

Paper Summary
The Effects of Manual Therapy on the Diaphragm in the Musculoskeletal System: A Systematic Review reviews the effects of manual therapy on the diaphragm in adults over 9 studies. It compares adults with clinical conditions such as chronic low back pain, respiratory diseases, or musculoskeletal restrictions. The paper results indicated that manual therapy on the diaphragm improved diaphragm mobility, thoracic cage and abdominal excursion, posterior chain flexibility, and spinal parameters. Incorporating manual therapy targeting the diaphragm into rehabilitation programs could benefit patients with musculoskeletal and respiratory conditions. The studies demonstrated significant benefits in both mobility and flexibility, with the highest quality studies providing the most evidence. The study supports the potential integration of this approach into clinical practice, highlighting the need for further high-quality research to confirm its effectiveness and optimize treatment protocols.

Key Findings
In studies with clinical conditions, manual therapy improved diaphragm mobility.

The studies that examined immediate effects for diaphragm manual therapy saw results within 5-7 minutes.

Long-term effects showed improvements after multiple sessions.

Clinical Interpretation
The study showing positive signs of manual therapy for diaphragm mobility, thoracic cage mobility, abdominal excursion, and flexibility of the posterior chain can inform treatment for various conditions. Patients with chronic nonspecific low back pain, respiratory disease, sedentary adults, etc., can have restricted movement and muscle tightness that can benefit from manual therapy treatment. Therapists could use these techniques and the evidence to develop more targeted treatments.

NIH Scale
Is the review based on a focused question that is adequately formulated and described?
Yes

Were eligibility criteria for included and excluded studies predefined and specified?
Yes

Did the literature search strategy use a comprehensive, systematic approach?
Yes

Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?
Yes

Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?
Yes

Were the included studies listed along with important characteristics and results of each study?
Yes

Was publication bias assessed?
N/A

Was heterogeneity assessed? (This question applies only to meta-analyses.)
N/A

Author Names

Yu Wen Chao, PT, MS, iu Jenq Lin, PT, PhD, Jing Lan Yang, MS , Wendy Tzyy-Jiuan Wang, PhD

Reviewer Name

Lauren Ciuba

Reviewer Affiliation(s)

Duke DPT Class of ’26

Paper Abstract

Study design: Randomized controlled trial.

Introduction: Myofascial pain syndrome is characterized by myofascial trigger points (MTrPs) and fascia tenderness.

Purpose of the study: We investigated the effects of manual pressure release (MPR) alone or in combination with taping (MPR/MKT) in subjects with MTrPs.

Methods: Fifteen and 16 subjects received MPR and MPR/MKT respectively. Outcomes including pressure, pain threshold, muscle stiffness, mechanomyography were assessed at baseline, post-intervention and 7-days later.

Results: Pressure pain threshold improved significantly (d ¼ 1.79, p < 0.005) in both groups. Significant improvement in muscle stiffness in the MPR/MKT group (0.27e0.49 mm) as compared to the MPR group (0.02e0.23 mm). Mechanomyography amplitude in the MPR/MKT group was significantly higher than that of the MPR group (p < 0.05).

Conclusion: MPR and MPR/MKT are effective in reducing pain in these subjects. MPR/MKT has a greater effect on muscle stiffness

NIH Risk of Bias Tool

Randomized Controlled Trial

Quality Assessment of Controlled Intervention Studies

1. Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT

Randomized controlled trial

2. Was the method of randomization adequate (i.e., use of randomly generated assignment)?

The article does mention random assignment, though it does not specify whether it was computer-generated or another method. However, it is generally assumed that the randomization was adequate in such clinical trials.

3. Was the treatment allocation concealed (so that assignments could not be predicted)?

The article does not specifically mention whether allocation concealment was implemented. However, in many trials, allocation concealment is considered best practice and should be assumed unless otherwise stated.

4. Were study participants and providers blinded to treatment group assignment?

The article does not mention blinding of either the participants or the providers. The lack of blinding could be a limitation of the study.

5. Were the people assessing the outcomes blinded to the participants’ group assignments?

The article does not explicitly mention whether outcome assessors were blinded. However, blinding is important to prevent bias in outcome assessment.

6. Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

The study does not provide detailed information about the baseline characteristics. Ideally, the groups should have been similar, but the study does not clarify this.

7. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

The study does not provide specific details on the dropout rate.

8. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

The article does not mention differential dropout rates between treatment groups.

9. Was there high adherence to the intervention protocols for each treatment group?

The article does not mention adherence rates explicitly, but high adherence is often assumed in well-conducted RCTs.

10. Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

The study does not specify if other interventions were avoided or controlled for, so it’s unclear whether the groups received similar background treatments.

11. Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

Yes, the outcomes were assessed using pressure pain threshold, muscle stiffness, and mechanomyography, which are valid and reliable measures for the study’s aims.

12. Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

The article does not mention a sample size calculation, so it’s unclear whether the study had adequate power.

13. Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

The outcomes were clearly defined in the study design, but the article does not explicitly mention prespecifying subgroups or outcomes.

14. Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

The study does not mention using an intention-to-treat analysis, but this should ideally be done in RCTs.

Key Finding #1

Both the manual pressure release (MPR) and the combination of MPR with Kinesio taping (MPR/MKT) groups showed significant improvements in the pressure pain threshold (PPT)

Key Finding #2

The combination treatment (MPR/MKT) led to a greater reduction in muscle stiffness compared to MPR alone

Key Finding #3

The combination of MPR and Kinesio taping enhanced muscle contraction and function more effectively than MPR alone.

Key Finding #4

Both MPR and MPR/MKT were effective in managing pain associated with myofascial trigger points, with MPR/MKT providing additional benefits in terms of muscle function and stiffness

Please provide your summary of the paper

The study looked at the short-term effects of manual pressure release (MPR) and MPR combined with Kinesio taping (MPR/MKT) on individuals with myofascial trigger points (MTrPs). Both treatments led to improvements in pressure pain threshold, with MPR/MKT showing greater reductions in muscle stiffness and improved muscle function. The results suggest that combining MPR with Kinesio taping provides enhanced benefits in managing pain and muscle function compared to MPR alone.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

The study demonstrates that both manual pressure release (MPR) and the combination of MPR with Kinesio taping (MPR/MKT) are effective in managing myofascial trigger points, with the combination of MPR and Kinesio taping showing great benefits. The article described significant improvements in pressure pain threshold and muscle stiffness, especially with the addition of Kinesio taping. This shows the potential for a multidimensional approach in treating musculoskeletal pain and dysfunction associated with trigger points. Clinically, this suggests that combining hands-on manual therapy with Kinesio taping could provide a more comprehensive treatment, addressing both pain and muscle function. By incorporating both techniques, clinicians can offer a treatment plan that not only relieves pain but also improves muscle stiffness and overall function, which is essential for rehabilitation. Implementation in the clinic will have to begin with training on proper taping techniques. This combination may be beneficial for patients who have not responded to standard treatments, offering a non-invasive approach to pain management and muscle rehabilitation

Author Names: Donatella Bagagiolo, DO1 Claudio G. Priolo, MD2 Alessia Didio, DO1 Marco Sbarbaro, MSc, DO1 Paolo Manzoni, MD, PhD2,5 Daniele Farina, MD2 Elena M. Favre, PT, DO1 Antonella Pangallo, DO1 Tiziana Borro, PT2 Silvia Daccò, MSc, PsyD3,4

Reviewer Name: Hannah Dougherty

Reviewer Affiliation(s): Duke University Doctor of Physical Therapy Program

Paper Abstract: Objective This study aimed to compare the efficacy of osteopathic manipulative therapy (OMTh) versus light touch therapy (LTT) in reducing cranial asymmetries in infants with nonsynostotic plagiocephaly (NSP). Study Design A prospective, parallel-group, single-center, LTT-controlled randomized clinical trial was conducted in the Department of Neonatology of Sant’Anna Hospital in Turin, Italy, from September 6, 2016 to February 20, 2020. We enrolled infants of 1 to 6 months of age with NSP, who were then randomly assigned to the study group (repositioning therapy plus six sessions of OMTh) or the control group (repositioning therapy plus six sessions of LTT). The outcome was the reduction of the oblique diameter difference index (ODDI) score <104%, which was assessed at the end of the intervention protocol (at 3 months) and at 1 year of age. Results A total of 96 infants were randomized, 48 in the OMTh group and 48 in the LTT group, with mean ages of 3.1 versus 3.2 months, and baseline ODDI score of 110.2 versus 108.7%. In the OMTh group, a significant reduction of the ODDI score <104%, compared with the LTT group, was observed in the intension-to-treat (ITT) and per- protocol (PP) analyses. The ITT analysis revealed an ODDI score <104% in the OMTh group at 3 months (risk difference: 0.41; 95% confidence interval [CI]: 0.25–0.53; p < 0.001) and at the follow-up at 1 year of age (risk difference: 0.47; 95% CI: 0.31–0.64; p < 0.001). The PP analysis at 3 months reported a risk difference of 0.44 (95% CI: 0.27– 0.60; p < 0.001), and at 1 year of age, a risk difference of 0.54 (95% CI: 0.36–0.72; p < 0.001). Conclusion In infants with NSP, a course of six OMTh sessions significantly reduced cranial asymmetries at both the 3-month and 1-year follow-up assessments, compared with LTT. This study is registered with ClinicalTrial.gov (identifier: NCT03970395; www. clinicaltrials.gov).

NIH Risk of Bias Tool: Answer Only the Questions Specific to Tool Used, Delete All Other Tool Items, THEN DELETE THIS HIGHLIGHTED INSTRUCTIONS.

Quality Assessment of Controlled Intervention Studies

Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT

Yes

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Yes

Was the treatment allocation concealed (so that assignments could not be predicted)?

Yes

Were study participants and providers blinded to treatment group assignment?

Yes

Were the people assessing the outcomes blinded to the participants’ group assignments?

Yes

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Unsure – majority the same with exceptions of gestational age, birth weight, and presentation at birth.

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Yes

Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Unsure

Was there high adherence to the intervention protocols for each treatment group?

Yes

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

Yes

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

Yes

Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

Yes

Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Yes

Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

Yes

Key Finding #1

“At the 3-month assessment, a reduction of the ODDI score <104% occurred in 20 of 45 infants in the OMTh group and 3 of 44 infants in the LTT group.”  

Key Finding #2

“The PP analysis revealed that at the follow-up at 1 year of age, the ODDI score was <104% in 28 of 41 infants in the OMTh group, and only in 5 of 36 infants in the LTT group.”

Key Finding #3

“OMTh significantly decreased the risk of NSP and its severity compared with LTT after 3 months of treatment, and also at the follow-up at 1 year of age.”

Key Finding #4

“Of note, in the OMTh group, the risk reduction occurred throughout all categories of severity of NSP (namely, 12% in mild, 21% in moderate, and 25% in severe cases), with some 58% of infants achieving the target of having an ODDI score below 104%. In contrast, only 4% of the infants in the LTT group achieved an ODDI score below 104% after 3 months of treatment.”

Please provide your summary of the paper:

In the study by Bagagiolo and colleagues, they aimed to compare the effects of osteopathic manipulative therapy (OMTh) versus light touch therapy (LTT) in reducing cranial asymmetries in infants discharged from the NICU with nonsynostotic plagiocephaly.1 As a result of the “Back to Sleep” campaign to reduce sudden infant death syndrome (SIDS), pediatricians and pediatric physical therapists have seen a steady rise in cases of infant torticollis resulting in plagiocephaly, hence the relevance of this study. This randomized controlled trial was performed in Sant’Anna Hospital in Turin, Italy including 96 infants in total aged one to six months. The infants were randomly allocated to one of two groups- the OMTh group or the LTT group. Both groups received routine management involving repositioning therapy in addition to their allocated treatment. The infants completed a total of six interventions throughout the trial: first at baseline, second and third at 1 and 3 weeks from the baseline, respectively, and three adjunctive sessions every 3 weeks from the third intervention.1 The infants were then evaluated at both three months and one year of age. As a result of the treatment, researchers found that OMTh in addition to the repositioning therapy significantly decreased the risk and severity of nonsynostotic plagiocephaly compared to LTT and repositioning therapy. The oblique diameter difference index (ODDI) was an outcome measure used to determine the severity of NSP. The OMTh group experienced 58% of infants achieving the target of having an ODDI score of less than 104% which is considered “normal shape” in contrast to the LTT group where only 4% of the infants achieved the targeted ODDI score.1  Reductions in the severity of NSP by use of OMTh and repositioning therapy highlight significant benefits for infants at risk of positionally dependent cranial deformities and asymmetries and should be investigated further as the mainstream treatment protocol for infants experiencing NSP.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

Clinically, the evidence in this paper is highly applicable to everyday practice and the treatment of infant non-synostotic plagiocephaly (NSP). As a future clinician, I am hopeful that we can incorporate additional early intervention approaches to prevent the progression of NSP and reduce the need for helmet therapy. Based on the results of this study, there are significant developmental benefits to implementing effective management strategies for NSP. The findings suggest that adding osteopathic manual therapy (OMTh) to routine repositioning therapy can further reduce the risk and severity of plagiocephaly, offering a more comprehensive approach to care.

Author Names

Pastor-Pons, I., Lucha-López, M., Barrau-Lalmolda, M., Rodes-Pastor, I.,Luis Rodríguez-Fernández, A., Hidalgo-García, C., Tricás-Moreno, J.

Reviewer Name

Greysee Floyd, SPT

Reviewer Affiliation(s)

Duke University Doctorate of Physical Therapy Program

Paper Abstract

Background: Positional plagiocephaly frequently affects healthy babies. It is hypothesized that manual therapy tailored to pediatrics is more effective in improving plagiocephalic cranial asymmetry than just repositioning and sensory and motor stimulation.

Methods: Thirty-four neurologically healthy subjects aged less than 28 weeks old with a difference of at least 5 mm between cranial diagonal diameters were randomly distributed into 2 groups. For 10 weeks, the pediatric integrative manual therapy (PIMT) group received manual therapy plus a caregiver education program, while the controls received the same education program exclusively. Cranial shape was evaluated using anthropometry; cranial index (CI) and cranial vault asymmetry index (CVAI) were calculated. Parental perception of change was assessed using a visual analogue scale (− 10 cm to + 10 cm).

Results: CVAI presented a greater decrease in PIMT group: 3.72 ± 1.40% compared with 0.34 ± 1.72% in the control group (p = 0.000). CI did not present significant differences between groups. Manual therapy led to a more positive parental perception of cranial changes (manual therapy: 6.66 ± 2.07 cm; control: 4.25 ± 2.31 cm; p = 0.004).

Conclusion: Manual therapy plus a caregiver education program improved CVAI and led to parental satisfaction more effectively than solely a caregiver education program.

Quality Assessment of Controlled Intervention Studies

Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT

Randomized Control Trial

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Yes

Was the treatment allocation concealed (so that assignments could not be predicted)?

Yes

Were study participants and providers blinded to treatment group assignment?

No

Were the people assessing the outcomes blinded to the participants’ group assignments?

Yes

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Yes

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Yes

Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Yes

Was there high adherence to the intervention protocols for each treatment group?

Yes

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

Yes

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

Yes

Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

Yes

Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Yes

Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

Yes

Key Finding #1

Infants who received manual therapy had a much greater reduction in cranial asymmetry than those who only received caregiver education.

Key Finding #2

Significant increases in cranial length and overall head circumference suggest that manual therapy may encourage natural skull development.

Key Finding #3

There was no major difference in cranial index between groups, which means that while asymmetry improved, the overall shape and proportions of the skull remained the same.

Please provide your summary of the paper

This study explored whether pediatric integrative manual therapy (PIMT) could improve head shape in infants with positional plagiocephaly more effectively than caregiver education alone. 34 infants under 28 weeks old with moderate-to-severe positional plagiocephaly were divided into two groups: one received PIMT along with an education program for parents, while the other group only received education. They compared changes in head shape using the cranial vault asymmetry index, cranial index, and other growth markers. They also utilized parent perceptions of head changes. The manual therapy interventions included neuromeningeal tissue mobilization at the lumbosacral level to promote tissue response, cervical spine traction and mobilization, cranial base molding of the flattened occipital area, and intracranial membrane balancing and suture decompression to relieve tension and encourage normal skull development. Infants who received manual therapy showed significantly greater improvements in cranial symmetry compared to those who only had repositioning and education. Parents also reported noticing more positive changes in their child’s head shape. However, overall skull proportions, or cranial index, improved with no difference between the groups. Overall, manual therapy could be a helpful treatment for positional plagiocephaly but would benefit from further research that includes long-term followup and more comprehensive assessment of facial symmetry to track change.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

The positive changes in cranial asymmetry and parental satisfaction suggest that physical therapists should consider manual therapy as an addition to early intervention strategies for infants. PIMT techniques may help facilitate cranial growth, improve tissue mobility, and facilitate symmetrical development. It is important that physical therapists continue to provide parent education including head repositioning strategies and tummy time encouragement at home. Integrating manual therapy into treatment for infants with moderate-to-severe plagiocephaly may provide an alternative or supplement to helmet therapy, the current gold standard, if parents are hesitant about orthotic intervention. The main takeaway for clinical practice is while manual therapy may or may not change overall head shape, it can safely improve asymmetry, which is often the concern with infants who have plagiocephaly.

Author(s): Maria Jose Guzman-Pavon, Ivan Cavero-Redondo, Vicente Martinez-Vizcaino, Ana Isabel Torres-Costoso, Sara Reina-Gutierrez, Celia Alvarez-Bueno

Reviewer Name: Jessica Fullerton

Reviewer Affiliation: Duke University, Doctor of Physical Therapy Program

Abstract:

Objective: Patients with myofascial trigger points (MTPs) frequently manifest restricted range of motion (ROM) during physical evaluation. Multiple manual therapy interventions have been developed for the treatment of MTPs, but their effect on ROM has not been clarified through a systematic review and meta-analysis. Thus, this systematic review aimed to assess the effect of manual therapy interventions on ROM among individuals with MTPs. Methods: A systematic search was conducted in PubMed, Web of Science, Cochrane, Scopus, and Clinical Trials.gov. Articles analyzing the effect of manual therapy interventions on ROM were included. The risk of bias was assessed with the Cochrane Risk of Bias (RoB) 2 tool. The DerSimonian-Laird method was used to compute the pooled effect size (ES) and its 95% confidence interval (95% CI) for ROM. Results: A total of 13 randomized controlled trials were included in this systematic review and meta-analysis. The pooled ES for ROM was 0.52 (95% CI: 0.42–0.63). The pooled ES for ROM evaluated in centimeters was 0.36 (95% CI: 0.14–0.59), and the pooled ES for ROM evaluated in degrees was 0.57 (95% CI: 0.47–0.68). Conclusion: Manual therapy interventions may be an effective approach for improving ROM among individuals with MTPs.

Key words: Systematic Review; Myofascial Trigger Points; Manual Therapy

Quality Assessment of Systematic Reviews and Meta-Analyses

Is the review based on a focused question that is adequately formulated and described?

Yes

Were eligibility criteria for included and excluded studies predefined and specified?

Yes

Did the literature search strategy use a comprehensive, systematic approach?

Yes

Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?

Yes

Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?

Yes

Were the included studies listed along with important characteristics and results of each study?

Yes

Was publication bias assessed?

Yes

Was heterogeneity assessed? (This question applies only to meta-analyses.)

Yes

Key Findings:

Manual therapy can be used as a cost-effective and noninvasive technique to improve ROM in individual’s with MTPs.

“The main characteristic of myofascial pain syndrome are myofascial trigger points (MTPs), which are hyperirritable regions placed in the taut bands of skeletal muscles that become painful when stimulated by compression or other mechanical stimulations and can induce a typical pattern of referred pain, motor dysfunction, and autonomic responses. Other characteristic effects are increased tension, muscle shortening, impaired muscle activation pattern, weakness, increased muscle fatigue, and restriction of mobility.”

Manual therapy techniques that have proven to be effective for ROM alterations include ischemic compression, stretching, strain-counterstain technique, pressure release, muscle energy technique, positional release technique, transverse friction massage, joint mobilizations, and soft tissue mobilizations.

Future research should elucidate the most effective manual therapy technique for the treatment of MTPs along with confirming the effectiveness of manual therapy on joint mobility alterations.

Reviewer Summary:

Previous research has shown manual therapy’s effectiveness in the management of MTPs, but this study aimed to assess manual therapy’s efficacy for increasing ROM in individuals with MTPs. While there is not a cause-effect relationship between MTPs and ROM alterations, ROM restrictions are significant in patients with MTPs versus their healthy counterparts. The study found that manual therapy interventions may be an effective approach in increasing ROM in adult patients with MTPs which is not limited by the manual therapy technique or ROM measuring tool. Multiple mechanisms of manual therapy techniques targeting MTPs can be hypothesized due to the mechanical effect. Normalization in sarcomere length and function from compression or massage techniques might result in reactive hyperemia and blood supply recovery allowing for drainage in the MTP area. The strain-counterstain technique can aid in storing the mechanism of the affected muscle spindle to help sarcomere length and MTP tone. Isometric contraction of muscle energy techniques can help improve ROM due to post-isometric relaxation. Furthermore, descending pain modulation from the stimulation of mechanoreceptors and modulation of nociceptive impulses in the dorsal horn can aid in further improvements. Only short-term improvements were documented, so further research should be done to assess the longevity of ROM improvements following manual therapy interventions in individuals with MTPs. There is also limited variability in study designs and intervention methods which can make drawing firm conclusions about the best treatment technique difficult, so this should be further assessed and narrowed down. Including manual therapy in the treatment of patients with MTPs can improve those patients’ quality of life by providing patients with adequate movement for functional movements.

Clinical Interpretation:

While pharmacological interventions and dry needling have proven to be effective when treating MTPs, the increased cost, adverse drug effects, and illegality of dry needling in some states, shows the importance and benefits of using manual therapy. Manual therapy is non-invasive and cost-effective when compared to other inventions targeting MTPs which makes it an appropriate alternative intervention that can be implemented in many clinics. While the study had limitations, further research should be done to determine which manual therapy technique is most effective for better clinical efficiency along with the long-term effects of these techniques. Upon determining the most effective technique, which may vary among patients, manual therapy can be used in conjunction with other interventions for the treatment of MTPs. In the clinic, it would be beneficial to take a goniometric measurement of ROM restrictions in patients with MTPs, and test retest the same motions prior to and following manual therapy techniques to determine the level of effectiveness and most effective technique for that patient. Clinical practice can be greatly improved with the implementation of the manual therapy techniques listed earlier to improve ROM restrictions in individuals with MTPs.

Author Names: Andreas Leonard Amons,Rene Franciscus Castien, Johannes C. van der Wouden, Willem De Hertogh, Joost Dekker, and Henriëtte Eveline van der Horst

Reviewer Name: Samantha Kim

Reviewer Affiliation(s): Duke University DPT

Paper Abstract: Background: People with migraine often experience disability with serious consequences for their social life and work productivity. The pharmacological prophylactic management of migraine is effective in reducing migraine attacks. However, many people are reluctant to use daily prophylactic medication, leading to a demand for non-pharmacological treatment options. We present the design for and discuss the feasibility of a pragmatic, randomized controlled trial on the effectiveness of a multimodal manual therapy (MT) treatment compared to usual care by the general practitioner (GP) for the prophylactic treatment of migraine. Methods: Eligible participants will be recruited in primary care using the International Classification of Headache Disorders III criteria for migraine of the International Headache Society. Participants will be randomized to either multimodal MT treatment or usual care provided by the GP. GPs will be asked to treat the usual care group according to the Dutch GP guideline for headache. The multimodal MT intervention will include manual pressure techniques, neck muscle-strength exercises and mobilization of the cervical and thoracic spine. The trial will consist of a 12-week treatment period and follow-up measurements at 12, 26 and 52 weeks. The primary outcome measure is the number of migraine days per 4 weeks, assessed with a headache diary. Secondary outcome measures are the number of migraine attacks, medication use, disability due to headache, headache intensity, number of participants reporting a 50% migraine reduction, measurement of cervical pressure pain thresholds, presence of allodynia, endurance of cervical flexor muscles, days of absence of work and global perceived effect. Discussion: The results of the trial will show whether a multimodal MT intervention is an effective non-pharmacological treatment option for people with migraine.

Quality Assessment of Controlled Intervention Studies

Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT

Randomized controlled trial (RCT)

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Yes

Was the treatment allocation concealed (so that assignments could not be predicted)?

Yes

Were study participants and providers blinded to treatment group assignment?

No

Were the people assessing the outcomes blinded to the participants’ group assignments?

Yes

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Yes

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Yes

Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Yes

Was there high adherence to the intervention protocols for each treatment group?

Yes

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

Yes

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

Yes

Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

Yes

Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Yes

Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

Yes

Key Finding #1

This study showed the 15% of the participants preferred the MT treatment over pharmacological methods.

Key Finding #2

This study did not have a placebo or sham treatment but compared the two active treatments side by side and the effectiveness.

Key Finding #3

Experienced manual therapist were trained in the specific treatment protocol before the start of the study.

Key Finding #4

The multimodal manual treatment focus was to restoring cervical function so to reduce nociceptive cervical afferent output.

Please provide your summary of the paper: This paper explores the options of more holistic management when it comes to migraines. Historically, patients and physicians have used and depended on solely on pharmacological prophylactic management to address migraines, but this research paper focuses of manual therapy as a tool for pain management. Participant that were selected were recruited from International Classification of Headache Disorders III criteria. Participants were randomized with multimodal MT treatment or usual care from their general practitioner for 12 week treatment and follow-ups at 12, 26 and 52 weeks. The MT treatment group included manual therapy techniques such as manual pressure techniques, neck muscle strength exercises and mobilizations of cervical and thoracic spine. The Results showed that the multimodal MT treatment showed promising benefits for participants, but researchers did not that further research and strengthen of the studied needed to be pursued.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

I believe this research paper tapped into a hard and unknown territory of the mysteries of migraines. I feel that migraines can be so debilitating for participants yet there are so many unknows about the cause or best intervention. I believe this paper is just the beginning to more holistic approaches to help resolve or intervene with the impact migraines have. I think it is tricking when trying to do a research project on participants who might not have consist of episodes of migraines and with manual therapy, we know to determine if it is effective we have to test, retest. So, I think as we keep pursuing the impact manual therapy has on migraines, knowing the multimodal MT treatment could bring benefit to patient who have been suffering from migraines.

Author Names

Ángela González-Mena, PT, Raquel Leirós-Rodríguez, PhD, Pablo Hernandez-Lucas, MSc

Reviewer Name

Neha Patel

Reviewer Affiliation(s)

Duke DPT

Paper Abstract

Objective

The objective of this study was to evaluate the efficacy of electrotherapy and manual therapy for the treatment of women with primary dysmenorrhea.

Methods

Systematic searches were conducted in Scopus, Web of Science, PubMed, CINAHL, and MEDLINE. The articles must have been published in the last 10 years, had a sample exclusively of women with primary dysmenorrhea, had a randomized controlled trial design, and used interventions that included some form of manual therapy and/or electrotherapy techniques. Two reviewers independently screened articles for eligibility and extracted data. Difference in mean differences and their 95% CIs were calculated as the between-group difference in means divided by the pooled standard deviation. The I2 statistic was used to determine the degree of heterogeneity.

Results

Twelve selected studies evaluated interventions, with 5 evaluating electrotherapy techniques and 7 evaluating manual therapy techniques. All studies analyzed identified improvements in pain intensity and meta-analysis confirmed their strong effect.

Conclusions

Manual therapy and electrotherapy are effective for the treatment of women with primary dysmenorrhea. Transcutaneous electrical nerve stimulation combined with thermotherapy and effleurage massage stands out for its effects on the intensity and duration of pain with the application of a few sessions and their long-term effects.

Impact

Manual therapy techniques and electrotherapy methods reduce the pain intensity of women with primary dysmenorrhea. Quality of life and degree of anxiety improved significantly with manual therapy interventions. Transcutaneous electrical nerve stimulation combined with thermotherapy and effleurage massage are the interventions with which positive effects were achieved with fewer sessions.

Quality Assessment of Systematic Reviews and Meta-Analyses

Is the review based on a focused question that is adequately formulated and described?

Yes

Were eligibility criteria for included and excluded studies predefined and specified?

Yes

Did the literature search strategy use a comprehensive, systematic approach?

Yes

Were titles, abstracts, and full-text articles dually and independently reviewed for inclusion and exclusion to minimize bias?

N/a

Was the quality of each included study rated independently by two or more reviewers using a standard method to appraise its internal validity?

Yes

Were the included studies listed along with important characteristics and results of each study?

Yes

Was publication bias assessed?

Yes

Was heterogeneity assessed? (This question applies only to meta-analyses.)

Yes

Key Finding #1

Both treatment interventions were found to be effective in relieving pain in patients in comparison to placebo interventions or drugs.

Key Finding #2

Transcutaneous electrical nerve stimulation in combination with thermotherapy and effleurage massage stand out for effects on intensity and duration of pain.

Please provide your summary of the paper

This study is a systematic review and meta-analysis with the aim to evaluate the efficacy of electrotherapy and manual therapy for the treatment of women with primary dysmenorrhea. The study used systematic searches conducted in multiple databases. The inclusion criteria included that the articles must have been published in the last 10 years, used samples exclusively of women with primary dysmenorrhea, had a randomized control design, and used interventions including manual therapy and/or electrotherapy techniques. In total, the study used 12 selected studies. All studies that were analyzed found improvement in pain intensity, confirmed by meta-analysis. Overall, both manual and electrotherapy were found to be effective for the treatment of women with primary dysmenorrhea.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

Clinically, this paper indicates that the interventions of manual therapy and electrotherapy reduce pain intensity of women with primary dysmenorrhea. Furthermore, this study may impact clinical practice because this study also found quality of life and degree of anxiety to improve significantly with manual therapy interventions. Additionally, this study shows that when transcutaneous electrical nerve stimulation, thermotherapy, and effleurage massage are combined, positive effects were achieved with fewer sessions.

Author Names:

Ana Sedano-Vidal, Fidel Hita-Contreras, Maria Alharilla Monitlla-Ibanez

Reviewer Name:

Dillan Rowley

Reviewer Affiliation(s)

Duke University Doctor of Physical Therapy Program

Paper Abstract:

(1) Objective: To determine the effect of a directed vestibular rehabilitation therapy (VRT) program with manual therapy (MT) on dizziness-related disability and imbalance symptoms among patients with peripheral unilateral vestibular dysfunction. (2) Methods: Eighty patients (54.75 ± 1.34 years) were allocated either to a control group (n = 40), who underwent a directed VRT program, or to an experimental group (n = 40), who received the same program plus MT once a week/4 weeks. We assessed their level of disability (Dizziness Handicap Inventory, DHI), balance confidence (the Activities-specific Balance Confidence scale—16 items), postural balance (resistive multisensor platform), and the frequency and intensity of dizziness symptoms (visual analog scale). (3) Results: Post-intervention between-group improvements were observed regarding DHI total score and intensity in the experimental group (p < 0.001), as well as four weeks later. Six months after, the experimental group exhibited improvements in the center of pressure velocity with eyes open (p = 0.019), DHI total score (p = 0.001) and subscales (all p < 0.05), and intensity (p = 0.003) and frequency (p = 0.010) of dizziness. Balance confidence improvements were observed 1 month (p = 0.035) and 6 months (p = 0.038) post-intervention. (4) Conclusions: Directed VRT plus MT is a safe and beneficial intervention that speeds up recovery for patients suffering from dizziness and instability derived from unilateral vestibular dysfunction. Keywords: dizziness; vestibular rehabilitation; physical therapy; postural balance; unilateral vestibular hypofunction

Quality Assessment of Controlled Intervention Studies

Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT

Yes

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Yes

Was the treatment allocation concealed (so that assignments could not be predicted)?

Yes

Were study participants and providers blinded to treatment group assignment?

Yes

Were the people assessing the outcomes blinded to the participants’ group assignments?

Yes

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Yes

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Yes

Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Yes

Was there high adherence to the intervention protocols for each treatment group?

Yes

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

Yes

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

Yes

Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

Yes

Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Yes

Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

Yes

Key Finding #1

Vestibular Rehab Therapy has a significant effect on disability in those with unilateral vestibular hypofunction

Key Finding #2

The use of high velocity low amplitude (HVLA) manual therapy, specifically at the C1-C2 level, can be beneficial in improving the frequency of dizziness when combined with vestibular rehab therapy.

Key Finding #3

Manual therapy can also be beneficial when combined with vestibular rehab therapy at reducing the severity and disability experienced by those with unilateral vestibular hypofunction more so than those who only receive vestibular rehab therapy.

Please provide your summary of the paper

80 participants with unilateral vestibular hypofunction (UVH) were randomly assigned to either a control group or to a treatment group. Both groups were assigned to receive vestibular rehab therapy once weekly, however the treatment group was also assigned to a manual therapy treatment session once per week. This rehab went on for four weeks when they reassessed the symptoms experienced by the participants. During the following 6 months participants were given an exercise program to do on their own as well as encouraged to live an active lifestyle. Follow-up was then done again at 1 month and at 6 months when they concluded the study.

The manual therapy treatment was comprised of a C1-C2 HVLA thrust manipulation technique, as well as a myofascial release and inhibition of the suboccipital muscles. The techniques themselves were not described in detail which does not allow them to be reproduceable.

The outcome measures used were self-report outcomes such as, the dizziness handicap index, activity specific confidence scale, and the frequency of dizziness kept through a journal. They also used a system that measured sway with eyes open and eyes closed.

Both the control group and the treatment group experienced improvement in all outcome measures. It was seen however that a significantly better outcome was seen in the treatment group who received the manual therapy and the vestibular rehab.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

This study has some good findings that show the benefit or manual therapy for those who are experiencing UVH. It is important to know that the inclusion criteria was very specific and it should be noted that it may not hold external validity. It is also important to note that there was only one physician who was conducting the therapy for all participants and the protocol for the manual therapy techniques was not provided. It can be beneficial to provide manual therapy to your patients experiencing UVH when using the test, treat, retest method as this study may not be inclusive for all patients with UVH.