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The International Federation of Orthopedic Manipulative Physical Therapists (IFOMPT) describes Orthopedic Manual Therapy (OMT) as a specialist field in physiotherapy for the treatment of neuromusculoskeletal conditions based on clinical reasoning. The aim of this study was to explore how students in a OMT physiotherapy master programme describe their clinical reasoning. Nine participants were included in the study. Data was collected using a semi-structured interview guide and were analyzed with qualitative content analysis. The analysis resulted in one main category: “A multidimensional picture of clinical reasoning” and three categories: 1) Confidence in the role as physiotherapist; 2) Decision making, a cognitive analytical process 3) Creating alliance and involving the patient in the clinical reasoning. The participants described a multidimensional picture of clinical reasoning which gradually developed and eventually encompassed several aspects in the subcategories. The conclusion of the study is that all the parts above are needed in the clinical reasoning and it takes years to develop effective clinical reasoning. For future studies, it would be of interest to explore how recently graduated physiotherapists with a bachelor degree describe their clinical reasoning.

Bakgrund: Smärta som lokaliseras till ländryggen drabbar upp till 80% av alla människor någon gång under livet och är således ett stort problem för både individ och samhälle. Manuell terapi (MT) och olika typer av träningsinterventioner (TI) är två vanligt förekommande behandlingar som fysioterapeuter världen över använder sig av. Långtidseffekten av manuell terapi är ett relativt outforskat område vilket denna litteraturstudie hoppas kunna bidra med ny kunskap till. Syfte: Att undersöka och sammanställa manuella terapiers långtidseffekter på ospecifik ländryggssmärta (LBP) i jämförelse mot olika träningsinterventioner. Kvalitetsgranska inkluderade studier med PEDro samt bedöma tillförlitligheten med GRADEstud. Metod: Genomförande av en systematisk litteraturöversikt genom formulering av PICO. Systematisk sökning i databaserna Pubmed och PEDro. Totalt inkluderades 7 studier som kvalitetsbedömdes med PEDro och granskades med GRADEstud för bedömning av resultatens tillförlitlighet. Resultat: Kvaliteten enligt PEDro varierade mellan medelgod och hög. Samtliga studier observerade positiva effekter av både manuell terapi och träningsinterventioner. 5 av 7 studier fann en signifikant skillnad vid kortidsuppföljning och 2 av 3 studier fann signifikanta långtidseffekter. Den sammanvägda tillförlitligheten till resultatet enligt GRADEstud ansågs vara av mycket låg (+) till låg (++) kvalitet. Slutsats: Resultatet i studien pekar på att både MT och TI kan ha positiva effekter gällande smärtlindring på både kort och lång sikt med svag evidens. Mer högkvalitativ och homogen forskning behövs inom området innan tydliga och välgrundade rekommendationer kan göras. / Background: Low back pain (LBP) affects up towards 80% of people during their life and constitute a problem for both the individual and society. Manual therapy (MT) and different exercise interventions are two common interventions used by physiotherapists. The long-term effect of manual therapy is a rather unstudied area, which this study aims to contribute to with new information. Objective: To research and compile manual therapy’s long-term effects on non-specific low back pain compared to different types of exercise interventions. Also examine the quality of included studies using PEDro and to assess the reliability using GRADEstud. Method: This systematic review implemented and structured questions according to PICO. A systematic search through two databases, Pubmed and PEDro. A total of 7 studies where included whose quality was assessed using PEDro. GRADEstud was used to assess the reliability. Results: The quality of the studies ranged through average to high quality. All studies observed positive effects of both manual therapy and exercise interventions. 5 out of 7 studies found significant differences on short-term outcomes while 2 out of 3 found significant long-term differences. The reliability was considered low (++) to very low (+). Conclusion: The result of this systematic review indicates that both manual therapy and exercise interventions can produce positive effects on pain in short and long-term outcomes with low quality evidence. More high-quality evidence and homogenous research is needed on this area before any clear or well-grounded recommendations can be made.

EFFECTS OF THORACIC SPINAL MANIPULATIVE THERAPY ON THORACIC SPINE AND SHOULDER KINEMATICS, THORACIC SPINE FLEXION/EXTENSION EXCURSION, AND PRESSURE PAIN SENSITIVITY IN PATIENTS WITH SUBACROMIAL PAIN SYNDROME By Joseph R. Kardouni, Ph.D., PT A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy, at Virginia Commonwealth University. Virginia Commonwealth University, 2013. Major Director: Lori A. Michener, PhD, PT, ATC, Professor, Department of Physical Therapy In patients with shoulder pain, the use of manual therapy directed at the spine and shoulder have been reported to provide superior outcomes to exercise based interventions or usual care without the use of manual therapy. Clinical trials have also reported improved pain and disability after thoracic spinal manipulative therapy (SMT) as a stand-alone treatment for shoulder pain. Although clinical efficacy is reported for the use of thoracic SMT for the treatment of shoulder pain, the mechanisms underlying the clinical benefits are not well understood. This limits the directed use of SMT. The benefits could be due to changes in spine or shoulder motion or neurophysiologic mechanisms of pain modulation. Elucidating the mechanism of manual therapy will aid the directed use of thoracic SMT for treating patients with shoulder pain. The research described in chapters 3 and 4 was performed to assess the effects of thoracic SMT in patients with subacromial pain syndrome with regard to biomechanical changes at the thoracic spine and shoulder and effects on central and peripheral pain sensitivity. Subjects with shoulder impingement pain symptoms were randomly assigned to receive 1 visit of thoracic SMT or sham SMT, applied to the lower, middle, and upper (cervicothoracic junction) thoracic spine. A 3-dimensional electromagnetic tracking system was used to measure thoracic and scapular kinematics during active arm elevation, and thoracic excursion at end-range of flexion and extension pre- post-treatment. Pressure pain threshold (PPT) was measured at the painful shoulder (deltoid) and unaffected regions (contralateral deltoid and bilateral lower trapezius areas) immediately pre- and post-treatment. PPT measures at the painful shoulder were used to assess peripheral and/or central pain sensitivity, and PPT at unaffected regions measured central pain sensitivity. Patient-rated outcomes measures of pain (Numeric Pain Rating Scale-NPRS), function (Pennsylvania Shoulder Score-Penn), and global rating of change (GROC) were used to assess changes in clinical symptoms following treatment. No significant differences were found between treatment groups for the thoracic kinematics or excursion, shoulder kinematics, PPT measures, or patient-rated outcomes. No differences were noted pre- to post-treatment in either group for thoracic kinematics or excursion or PPT measures. In both groups, there was a decrease in mean scapular external rotation over time during ascending arm elevation, but the change was less than measurement error. Outcome measures of NPRS, Penn and GROC indicated clinical improvements in both groups following treatment, but there were no differences between the thoracic SMT or sham SMT groups. There were no meaningful correlations between thoracic and scapular kinematics or thoracic excursion with the outcome measures of NPRS, Penn, or GROC. There was a significant positive correlation (r=0.52 , p=0.009) between change in PPT at the lower trapezius on the unaffected side and baseline Penn scores. Biomechanically, thoracic spine extension and excursion did not change following thoracic SMT, and the SMT group had no greater changes in shoulder kinematics or patient-rated pain and function than the sham SMT group. Additionally, thoracic SMT did not improve peripheral or central pain sensitivity as measured by PPT. Furthermore, improvements in patient-rated outcomes were not found to be related to changes in thoracic spine mobility, or shoulder kinematics with SMT. The single correlation between change in PPT and baseline Penn may indicate a neurophyciologic effect of SMT in patients with higher baseline function scores, but the since no other significant relationships between PPT and outcome were seen, the implications of this finding are limited. Overall, alterations in thoracic spine mobility and pressure pain sensitivity do not appear to be responsible for improved outcomes in patients with subacromial pain syndrome. Future studies should explore the effects of SMT using other measures of thoracic spine motion and experimental pain modalities, as well as greater dosing of SMT over a longer follow-up.

O ser humano, durante a postura ortostática, apresenta oscilações posturais aleatórias em relação à vertical que são controladas pelo sistema nervoso central com base em informações sensoriais provenientes dos sistemas visual, vestibular e somatossensorial. Mecanoreceptores e fusos neuromusculares localizados na coluna cervical transmitem informações aferentes tanto para o sistema vestibular quanto para o sistema proprioceptivo, contribuindo significativamente para controle postural. Vários autores têm proposto intervenções baseadas em terapia manual, sugerindo que manobras de manipulação da coluna vertebral podem ser benéficas para o tratamento da tontura e vertigem de origem cervical. No entanto, a maioria desses estudos tem focado em sintomas gerais como medidas clínicas de dor, severidade do acometimento, ocorrência de episódios agudos, etc. Portanto, fica clara a necessidade de um estudo acerca dos efeitos de uma manobra de manipulação vertebral, em nível cervical, sobre o controle postural de sujeitos saudáveis. A hipótese do presente estudo foi que uma liberação das estruturas cervicais (causada pela manobra de manipulação) geraria uma melhora no influxo de informações sensoriais, e, consequentemente, uma melhora no sistema de controle postural. Sete sujeitos foram instruídos a permanecer, durante 60 segundos, sobre uma plataforma de força, o mais quietos possível, em apoio unipodal, proporcionando assim medidas extraídas do sinal da trajetória do centro de pressão, do centro de massa e variações na posição angular das articulações do tornozelo, joelho e quadril. Cada sujeito participou de duas sessões experimentais, sendo que em uma delas realizou testes de equilíbrio antes e depois da manobra de manipulação cervical (sessão experimental, EXP) e no outro dia realizou os mesmos testes de equilíbrio antes e depois de uma intervenção placebo (sessão controle, CTRL). Os resultados sugerem um efeito agudo da manobra de manipulação cervical, já que foi observada redução das oscilações posturais durante as primeiras tentativas realizadas após a intervenção. Nas sessões CTRL, o mesmo efeito não foi observado, pois o sistema de controle postural se mostrou estável durante todo o experimento / Human subjects during upright stance show a random postural sway with respect to vertical, which is controlled by the central nervous system on the basis of information from sensory inputs applied to the visual, vestibular and proprioceptive systems. Mechanoreceptors and muscle spindles in the cervical spine provide afferent information for both the vestibular and the proprioceptive systems, thereby contributing to postural control. Several authors have proposed interventions based on manual therapy, suggesting that manipulation of the spine can be beneficial for treating dizziness and vertigo of cervical origin. However, few studies have investigated the effect of the spinal manipulation on postural control, as most have focused on more general symptoms such as clinical measures of pain, severity and occurrence of acute episodes, etc. Given the importance of the structures of the neck for controlling upright stance, there is a clear need for a study on the effects of cervical spinal manipulation on postural control of healthy subjects. The hypothesis of this work was that a release of the cervical structures (caused by cervical manipulation) would enhance the influx of sensory information, thereby improving postural control. Seven subjects were asked to remain for 60 seconds on a force platform, as quiet as possible, on single-leg stance. Measurements associated with the center of pressure and center of mass trajectories were assessed, as well as information about the ankle, knee and hip positions (i.e. angle variation). Two experimental conditions were tested: before (5 trials) and after (5 trials) cervical manipulation. Each subject participated in two experimental sessions, the first one with balance tests before and after the cervical manipulation (experimental session, EXP) and the other one with the same balance tests before and after a placebo intervention (control session, CTRL). The results suggest an acute effect of the cervical manipulation, as reduced postural sway was observed during the first trials after the intervention. Such an effect was not observed in the CTRL sessions, as the postural control system remained stable throughout the experiment

Bakgrund: Ländryggen består av fem kotor som är omgiven av en avancerad ligamentapparat samt muskler som ska stabilisera denna instabila konstruktion av leder. Ländryggens främsta funktioner är att vara viktbärande och stötdämpande samt att skydda ryggmärgskanalen och nervrötterna. Orsaker till ländryggssmärta är svaga muskler, senor, ligament, degenerativa förändringar, artros etc. Det är 80% av alla personer som har haft eller kommer att ha ont i ryggen, av dessa utvecklar 20% kroniska besvär. Kronisk smärta är det om personen har haft besvär mer än tre månader. Det finns olika sätt att behandla ländryggssmärta, både med manuella behandlingsformer och träning, det är inte känt vilken behandlingsform som är den mest effektiva. Förutom individerna som drabbas, drabbas också samhället av kronisk ländryggssmärta, 2009 var sjukförsäkringskostnaderna 4144 miljoner kronor. Syfte: Syftet med denna systematiska litteraturstudie var att sammanställa resultat av interventionsstudier och undersöka om manuella terapiformer har ett mervärde vid behandling av personer i arbetsför ålder med kronisk ländryggsmärta. Metod: En litteratursökning genomfördes i de medicinska databaserna PubMed, CINAHL och PEDro. Sökningen resulterade i åtta inkluderade studier som motsvarade inklusions- och exklusionskriterierna. Samtliga studier granskades via SBU:s granskningsmall för randomiserade studier. Resultat: Vid granskning av studierna avseende smärta visade fyra signifikanta resultat till förmån för interventionsgruppen, två var av medelhögt bevisvärde och två av svagt bevisvärde. Vid granskning av studierna avseende funktion var det fyra som visade signifikanta resultat till förmån för interventionsgruppen, en studie erhöll högt bevisvärde och en annan med medelhögt bevisvärde. Vid granskning av studierna avseende livskvalitet var det två studier som visade signifikanta resultat till förmån för interventionsgruppen, båda erhöll medelhögt bevisvärde. Konklusion: Det finns indikationer på att manuella behandlingsformer kan ha ett mervärde vid behandling av individer med kronisk ländryggssmärta i arbetsför ålder. Ytterligare forskning inom ämnet efterfrågas. / Background: The lumbar spine consist of five vertebrae surrounded by an advanced ligament device and muscles that will stabilize this unstable construction of joints. The lumbar spines main functions are to be weight-bearing and shock absorption, and protection of the spinal cord and the nerve roots. Causes of low back pain are weak muscles, tendons, ligaments, degenerative changes, osteoarthritis etc. There is 80% of all people who have had or will have low back pain, of which 20% of these will develop chronic problems. Chronic pain is if the person has had pain for more than three months. There are different ways of treating low back pain, both with manual therapies and exercise, it is not known which treatment is the most efficient. In addition to the affected individuals, the society also suffers from chronic low back pain. In 2009, health insurance costs were SEK 4144 million. Purpose: The purpose of this systematic literature study was to compile the results of intervention studies and to investigate whether manual therapies have added value in the treatment in people of working age with chronic lumbar pain. Method: A search for literature was made in the medical databases PubMed, CINAHL and PEDro. The search resulted in eight included articles that corresponded to the inclusion and exclusion criterias. All articles were examined through the SBU template for randomized studies. Results: In examination the studies on pain, four of the included articles showed significant differences in favor of the intervention group, two were of moderate level of evidence and two were of weak level of evidence. In examination the studies on function, four of the included articles showed significant differences in favor of the intervention group, one study received high level of evidence and another with moderate level of evidence. In examination the studies on quality of life, two of the included articles showed significant differences in favor of the intervention group, both receiving moderate level of evidence. Conclusion: There are indications that manual treatments may have added value in the treatment of individuals with chronic low back pain in working age. Further research on the subject is requested.

O ser humano, durante a postura ortostática, apresenta oscilações posturais aleatórias em relação à vertical que são controladas pelo sistema nervoso central com base em informações sensoriais provenientes dos sistemas visual, vestibular e somatossensorial. Mecanoreceptores e fusos neuromusculares localizados na coluna cervical transmitem informações aferentes tanto para o sistema vestibular quanto para o sistema proprioceptivo, contribuindo significativamente para controle postural. Vários autores têm proposto intervenções baseadas em terapia manual, sugerindo que manobras de manipulação da coluna vertebral podem ser benéficas para o tratamento da tontura e vertigem de origem cervical. No entanto, a maioria desses estudos tem focado em sintomas gerais como medidas clínicas de dor, severidade do acometimento, ocorrência de episódios agudos, etc. Portanto, fica clara a necessidade de um estudo acerca dos efeitos de uma manobra de manipulação vertebral, em nível cervical, sobre o controle postural de sujeitos saudáveis. A hipótese do presente estudo foi que uma liberação das estruturas cervicais (causada pela manobra de manipulação) geraria uma melhora no influxo de informações sensoriais, e, consequentemente, uma melhora no sistema de controle postural. Sete sujeitos foram instruídos a permanecer, durante 60 segundos, sobre uma plataforma de força, o mais quietos possível, em apoio unipodal, proporcionando assim medidas extraídas do sinal da trajetória do centro de pressão, do centro de massa e variações na posição angular das articulações do tornozelo, joelho e quadril. Cada sujeito participou de duas sessões experimentais, sendo que em uma delas realizou testes de equilíbrio antes e depois da manobra de manipulação cervical (sessão experimental, EXP) e no outro dia realizou os mesmos testes de equilíbrio antes e depois de uma intervenção placebo (sessão controle, CTRL). Os resultados sugerem um efeito agudo da manobra de manipulação cervical, já que foi observada redução das oscilações posturais durante as primeiras tentativas realizadas após a intervenção. Nas sessões CTRL, o mesmo efeito não foi observado, pois o sistema de controle postural se mostrou estável durante todo o experimento / Human subjects during upright stance show a random postural sway with respect to vertical, which is controlled by the central nervous system on the basis of information from sensory inputs applied to the visual, vestibular and proprioceptive systems. Mechanoreceptors and muscle spindles in the cervical spine provide afferent information for both the vestibular and the proprioceptive systems, thereby contributing to postural control. Several authors have proposed interventions based on manual therapy, suggesting that manipulation of the spine can be beneficial for treating dizziness and vertigo of cervical origin. However, few studies have investigated the effect of the spinal manipulation on postural control, as most have focused on more general symptoms such as clinical measures of pain, severity and occurrence of acute episodes, etc. Given the importance of the structures of the neck for controlling upright stance, there is a clear need for a study on the effects of cervical spinal manipulation on postural control of healthy subjects. The hypothesis of this work was that a release of the cervical structures (caused by cervical manipulation) would enhance the influx of sensory information, thereby improving postural control. Seven subjects were asked to remain for 60 seconds on a force platform, as quiet as possible, on single-leg stance. Measurements associated with the center of pressure and center of mass trajectories were assessed, as well as information about the ankle, knee and hip positions (i.e. angle variation). Two experimental conditions were tested: before (5 trials) and after (5 trials) cervical manipulation. Each subject participated in two experimental sessions, the first one with balance tests before and after the cervical manipulation (experimental session, EXP) and the other one with the same balance tests before and after a placebo intervention (control session, CTRL). The results suggest an acute effect of the cervical manipulation, as reduced postural sway was observed during the first trials after the intervention. Such an effect was not observed in the CTRL sessions, as the postural control system remained stable throughout the experiment

The Efficacy of Kinesio Taping as an Adjunct Intervention to Traditional Physical Therapy in the Treatment of Nonspecific Acute Low Back Pain: A Prospective Randomized Controlled Trial Background: Acute low back pain (LBP) is a significant health problem worldwide and is one of the leading causes of disability. Objective: The purpose of this study was to examine the effect of Kinesio Taping (KT) on disability, fear-avoidance beliefs, and pain intensity in patients with acute, nonspecific LBP. Research Design and Methods: A prospective, randomized controlled study of consecutive patients referred to physical therapy with a primary complaint of LBP. Seventy-eight patients with acute, nonspecific LBP were randomized to an experimental group that received traditional physical therapy plus KT and a control group that received traditional physical therapy alone. Interventions were administered twice a week for 4 weeks. Assessment tools used were Ronald Morris Disability Questionnaire (RMDQ) for disability, Fear-Avoidance Beliefs Questionnaire (FABQ) for fear-avoidance beliefs, and Numerical Pain Rating Scale (NPRS) for pain intensity. Assessments were conducted at baseline, end of week 1, end of week 2, end of week 3, and end of week 4. Analysis: Repeated measures mixed model analysis of variance (ANOVA) was used to examine the effect of treatment on each variable. The group type was the between-subjects variable and the time was the within-subjects variable. A significance level of .05 was used in the analyses. Results: Both groups showed statistically significant lower disability, fear-avoidance beliefs, and pain levels over time compared with baseline scores (p < .0001). The experimental group showed statistically significant lower RMDQ scores at week 2, 3, and 4 (p < .05), statistically significant lower FABQ-physical activity subscale scores at the end of week 1 (p < .01), at the end of week 2 (p < .01), at the end of week 3 (p < .01), and at the end of week 4 (p < .05), statistically significant lower FABQ-work subscale scores at week 3 (p < .05) and week 4 (p < .01), and statistically significant lower NPRS scores at week 1, 2, 3, and 4 (p < .05). Conclusion: Kinesio Taping can be considered a useful adjunct intervention to reduce disability and pain and to modulate fear-avoidance beliefs in patients with acute, nonspecific LBP.

Background: Temporomandibular disorder (TMD) is a common and costly problem often leading to chronic pain. There exists moderate evidence for physical therapy (PT) interventions in the management of TMD. A known relationship between TMD and the cervical spine exists with some evidence to support cervical intervention treatments. Cervical spine thrust joint manipulation (TJM) is an effective PT intervention explored in a limited fashion for this population. Objectives: To determine the immediate and short term (1 and 4 week) effects of cervical TJM on pain, dysfunction, and perception of change in individuals with a primary complaint of TMD. Methods: In this single blind randomized clinical trial, individuals with TMD (n=50) were randomly assigned to receive cervical TJM or sham manipulation in 4 PT visits over 4-weeks. All participants also received behavioral education, a home exercise program, and soft tissue mobilization. Primary outcomes included jaw range of motion (ROM), Numeric Pain Rating Scale (NPRS), TMD Disability Index, Jaw Functional Limitation Scale (JFLS), Tampa Scale of Kinesiophobia (TSK-TMD), and Global Rating of Change (GROC). Self-report and objective measurements (with blinded assessor) were taken at baseline, immediately after baseline treatment, 1-week, and 4-weeks. A 2 x 4 mixed model ANOVA was used with treatment group as the between-subjects factor and time as the within-subjects factor. Separate ANOVAs were performed for dependent variables and the hypothesis of interest was the group by time interaction. Results: Statistically significant 2-way interactions were noted in JFLS (p = .026) and TSK-TMD (p = .008), favoring the thrust manipulation group. Both groups showed statistically significant main effects in all measures over time. GROC and PASS favored the thrust manipulation group with statistically significant differences in successful outcomes noted immediately after baseline treatment (NNT = 5) and at 4-weeks (NNT = 4). Conclusion: Both groups received identical multi-modal treatments with the addition of the randomized intervention: cervical TJM or sham manipulation. Differences between groups were small, however, improvements favored the TJM on all measures. Cervical TJM may be beneficial in the treatment of TMD.

Background: The use of manual therapy for the management of lumbar spinal stenosis (LSS) has not been adequately systematically reviewed in an attempt to determine its effectiveness on patients with LSS. The lack of evidence in support ofcommonly used conservative interventions continues to result in a lack of clarity regarding what interventions should be used to manage patients with LSS. Objective: To use a randomized comparative trial to compare the functional clinical outcomes achieved by patients with LSS receiving two different physical therapy interventions. Methods: In this randomized controlled trial, a total of40 participants diagnosed with LSS were randomized into two groups. Both groups received 6 weeks of treatment. Participants assigned to group 1 (EX Group) received impairment-based exercises. Participants assigned to group 2 (EXMT Group) received impairment-based exercises as well as manual physical therapy techniques. The evaluation parameters included (1) McGill Pain Questionnaire, (2) the original version of the Oswestry Low Back Pain Disability Questionnaire (ODQ), (3) double inclinometer measurement for measuring thoracolumbar flexion and extension, (4) self-pace walking test, (5) hip abductor and extensor strength, and (6) hip external rotation and extension range of motion. All participants were evaluated before starting treatment, once at the end of 6 weeks of treatment, and again at 6 weeks following the completion of treatment. Results: In terms of overall treatmentefficacy, there were notable improvements observed over time regardless of treatment group. Results indicated significant improvement in perceived disability using ODQ in the EXMT treatment group in comparison to the EX group at follow-up. For the EXMT group, there were notable improvements in comparison to the EX group in multiple objective functional improvement measures. Conclusion: Results of this study suggest that a multimodal approach using manual therapy and therapeutic exercises is an effective treatment option for providing clinically significant short-term reduction in back pain and disability, as well as improvements in back mobility in patients with LSS. Physical therapists should strongly consider the impairment-based approachof manual therapy and specific exercises program for lumbar spine and hips as a treatment option for patients with lumbarspinal stenosis.