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The Effectiveness of Cupping Therapy on Relieving Chronic Neck and Shoulder Pain: A Randomized Controlled Trial

Lee-Mei Chi, Li-Mei Lin, Chien-Lin Chen, Shu-Fang Wang, Hui-Ling Lai, and Tai-Chu Peng. (2016). Evidence-Based Complementary and Alternative Medicine, 1-7.

Article Summary by Isaac Ervin, MS, SPT from Missouri State University, Springfield, MO

The goal of this single-blind, randomized controlled trial is to assess the effects cupping therapy has on improving chronic neck and shoulder pain in full-time members of the work force.  The cupping therapy was specifically utilized on three sites commonly treated in acupuncture therapy to relieve neck and shoulder pain.  These three sites are SI 15, GB 21, and LI 15.  SI 15 is located 3-4 cm lateral to the 7th cervical vertebrae on the upper trapezius musculature.  GB 21 is located midway between the SI 15 location and the acromion on the upper trapezius musculature.  LI 15 is located laterally on the middle deltoid musculature.  

The study included 62 participants.  The inclusion criteria for the study was 1) had to work at least 40 hours per week and 2) had to have work-related neck 2) shoulder pain continuously for at least the previous three consecutive months and 3) a pain intensity of at least a 3 on the VAS.  The exclusion criteria for the study included 1) infection, injury, or bleeding surrounding the cupping area, 2) cervical neuropathy, 3) analgesic ingestion 4 hours or less before treatment, 4) had ingested coffee, tea, or any caffeinated beverage 4 hours or less before treatment, and 5) no tobacco products smoked 30 minutes or less before treatment.  The subjects were broken up into a resting or cupping group, and the subjects received a 10-minute treatment to both the right and left sites independently.  

Skin surface temperatures were measured at each cupping site pre-treatment, 5 minutes into treatment, post-treatment, and 5 minutes post-treatment using the FLIR infrared camera.  The results indicated that there were significant temperature differences between both groups during treatment and at both post-treatment measures, with the cupping group having higher skin surface temperatures.  The VAS was recorded pre-treatment and post-treatment.  When comparing the two groups, the cupping group’s average pain measures significantly decreased (8.5 to 2.6) compared to the resting group (8.5 to 7.9).  Overall, the authors concluded that cupping therapy could be used to treat chronic neck and shoulder pain with minimal side effects.

Personal Commentary:

Cupping is a treatment method utilized by physical therapists to alleviate musculoskeletal pain by relieving trigger points and acupuncture sites as well as increasing blood flow to the affected area (Kim et al, 2011).  In the above study by Chi et al, there was a significant decrease in pain after one cupping treatment.  One of the issues with this trial is there were no follow-up measurements to assess the long lasting effects of treatment.  While cupping may have a short-term effect on pain modulation, this treatment may not fully address the primary issue.  In this case, I would expect the pain to increase in intensity post-treatment if the underlying issue is not addressed and cupping is not continued.

Another issue with this article is the absence of a clinical examination to identify the pain generator.  Through performance of the basic physical therapy examination, we would be able to narrow our potential diagnoses and identify the primary issues causing pain generation.  Identifying and treating the primary cause of neck and shoulder pain will not only allow us to improve the patient’s symptoms, but also allows physical therapists to provide them with the education and a specific treatment protocol that could potentially prevent pain from reoccurring.  While there is clinical evidence to support the use of cupping therapy for neck and shoulder pain in these specific sites, it would be best to first identify the primary issue and then utilize cupping therapy, when it is indicated, as a beneficial tool in an individualized, holistic treatment approach.

References

  • Lee-Mei Chi, Li-Mei Lin, Chien-Lin Chen, Shu-Fang Wang, Hui-Ling Lai, and Tai-Chu Peng, “The Effectiveness of Cupping Therapy on Relieving Chronic Neck and Shoulder Pain: A Randomized Controlled Trial,” Evidence-Based Complementary and Alternative Medicine, vol. 2016, Article ID 7358918, 7 pages, 2016. doi:10.1155/2016/7358918
  • Jong-IN Kim, Myeong Soo Lee, Dong-Hyo Lee, Kate Boddy, and Edzard Ernst. “Cupping for Treating Pain: A Systematic Review.” Evidence-Based Complementary and Alternative Medicine, vol. 2011, Article ID 467014, 7 pages, 2011, doi: 10.1093/ecam/nep035.

CLINICAL PEARL Dizziness with Neck Pain

Becky Sherwin MPT, COMT

The vast majority of my caseload consists of patients with spinal impairments, and most of these are patients with neck pain.  Many of these people have been in motor vehicle accidents and  have complaints of headaches and dizziness.  Kristjansson states that “cervical induced dizziness is characterized by subjective complaints of unsteadiness, insecurity and lightheadedness. Some patients also complain about a feeling of … ‘spinning in their head.’”1,2,3  This is a question that I have begun asking my patients that are dizzy:  Do they experience spinning in their head? (indicating a cervicogenic origin) or is the room spinning? (indicating more of a vestibular impairment).2,4

Oculomotor disturbances can also occur with neck pain.  Patients can present with complaints of “symptoms relating to the visual system such as blurred vision, reduced visual field, grey spots appearing in the visual field, temporary blinding, photophobia, and disordered fusion.” 1,5,6  However, “diplopia, which is common in patients with vertebrobasilar insufficiency, is rare in somatic neck dysfunctions.” 5

I have found that I can gain useful information that guides my treatment in cases of chronic pain or patients who have been in an MVA by utilizing the following tests.

Smooth Pursuit — The patient is asked to smoothly follow a slow-moving target with the eyes while keeping the head still.  Kristjansson suggests moving the object horizontally; however, I usually test horizontal, vertical, and diagonal directions.1  According to their deficits, I use this information in developing a HEP for the patient. Quick saccadic eye movements to catch up to the target rather than smooth eye movement, especially during midrange eye movement, are an indication of impairment in the task.7 Reproduction of dizziness and blurred vision may also occur.  Deterioration of eye follow (increase in catch-up saccades), when the patient’s trunk is subsequently turned to 45 degrees (in either direction), while the head is kept still, suggests a cervical afferent component to the deficits as seen on the Smooth-Pursuit Neck Torsion Test (SPNTT).8 If a poor performance is noted when the head is in neutral, and is unchanged by adding neck torsion by rotating the trunk 45 degrees, this would imply CNS disorder.9

Gaze Stability — The patient is asked to focus on a point directly in front of them and then moves the head horizontally, vertically, and in diagonal directions.  I will take note of the patient’s deficits and where they are in the ROM when deficits occur.  This provides information that can be compared at a reassessment.  I am also looking at their ability to perform the ROM correctly.

Per the article:  Patients may “deviate into cervical lateral flexion.  Reproduction of dizziness and / or blurred vision may occur.  This is similar to the dynamic visual acuity test used for those with vestibular disorders; however, head movement is performed actively and slowly rather than passively and quickly.  This approach is better suited to cervical-related gaze disorders, as the cervical afferents are stimulated at lower movement frequencies compared to fast movements that stimulate the vestibular afferents (references).”9

Saccadic Eye Movement — Two targets are placed in front of a patient.  The patient is then asked to move their eyes quickly between the targets.  Take note of deficits.  Again, I test horizontally, vertically, and in diagonal directions.  I have noted clinically that my patients with deficits in the upper cervical area will have difficulty with the upward diagonal patterns on the side of their dysfunction.  “Inability to fixate on target, overshooting the target, and taking more than 2 eye movements to reach to the target might indicate a poor performance.  Again, reproduction of dizziness and or blurred vision may also occur.”9

Eye-Head Coordination — Using the same two targets used with saccadic eye movement,  the patient will look at a target first moving their eyes, then move the head even with the target.  Again, I test in all directions:  horizontal, vertical, and all diagonal directions.  “Often, patients with neck pain are unable to keep their head still while their eyes move or lose focus during the head movement.”10 Clinically, this will also reproduce the patient’s dizziness and / or blurred vision.

I incorporate these tests during my upper cervical evaluation in order to gather more data and in order to reproduce my patients’ symptoms.  These tests assist me in educating my patients on their symptoms, which in turn, helps to decrease their anxiety about them.

References

  1. Kristjansson E, Trelevan J. Sensorimotor Function and Dizziness in Neck Pain: Implicationsfor Assessment and Management. JOSPT. 2009;39(5):364-377.
  2. Hülse M, Holzl M. [Vestibulospinals reactions in cervicogenic disequilibrium. Cervicogenic imbalances].  HNO. 2000; 48:295-301.
  3. Karlberg M. The Neck and Human Balance:  A Clinical and Experimental Approach to “Cervical Vertigo”  [dissertation].  Lund, Sweden:  University Hospital of Lund; 1995.

The Reliability of the Cervical Relocation Test on People with and Without a History of Neck Pain

Burke S, Lynch K, Moghul Z, Young C, Saviola K, Schenk R. The reliability of the cervical relocation test on people with and without a history of neck pain. J Man Manip Ther. 2016;24(4):210-214.

Abstracted by:  Rebecca Sherwin, PT, COMT, West Monroe, LA – Fellowship Candidate, IAOM-US Fellowship Program & Jean-Michel Brismée, PT, ScD, IAOM-US Fellowship Program Director

Neck pain is a common disorder in the United States.  This complaint affects millions of people per year with costs equaling billions of dollars in the United States alone.1  Neck pain can be present due to a chronic problem as well as acute dysfunction from whiplash.  With neck pain, a dysfunction in the proprioceptive sense of the neck and errors in repositioning of the head on the neck can occur.2,3  According to Manchikanti et al, “54-60% of people present with chronic neck pain following a whiplash injury.”4 Changes in position sense of the head and neck is clearly evident in whiplash injury patients as well as other dysfunctions.5  While people seek treatment for the pain, the position sense may remain an untreated condition.  

One test that is utilized to assess position sense in the cervical spine is the Cervical Relocation Test (CRT).3,6  Many studies have been performed to assess position sense with the ability to return the head to a neutral position; however, none have looked at the utilization of a CROM device with this test.  Studies have shown the ability of utilizing the cervical relocation test with various instruments in assessing position sense.  There are many studies that have shown the differences between the position sense of subjects with and without symptoms when utilizing the cervical relocation test (CRT).  One study was performed with the use of a CROM in order to assess cervical position sense and found that relocation accuracy differed between symptomatic and asymptomatic subjects.7  Another study found that a relative head on trunk rotation, which activated cervical proprioceptors without activating the vestibular afferents, produced more position errors for those with symptoms versus the asymptomatic subjects with use of the laser and Fastrak measurement tools.8  Treatment for the neck for not only pain relief but for improving the proprioceptive system seems to be indicated due to the increase in joint position sense in those with neck pain.  Much research has been done on the laser, Fastrak and US measurement tools; however, there is limited research on the reliability of the use of CROM with the cervical relocation test with either intertester or intratester reliability.  

This study was performed to determine the intertester and intratester reliability of utilization of the CROM device in comparison with a laser for measuring cervical relocation in those with and without neck pain. The CROM is an inexpensive and easily accessible tool in the clinic.  

This study included two groups of 25 subjects.  The groups were split into two groups based on convenience.  Each group was paired with each tester to perform the following tests utilizing the CROM and a laser. The 25 subjects in each group were analyzed independently of the other subjects.  The exclusion criteria were:  1) being under the age of 18; 2) previous spinal surgery; 3) pregnant currently; 4) receiving care for neck pathology.  The groups were split and tested with 2 testers where one tester utilized a laser and the other tester utilized the CROM.  The subject was blindfolded (not in picture – subject is with her eyes closed) to inhibit visual input thereby forcing the subject to utilize their proprioception system in the cervical spine.  The test began with the utilization of the CROM.  The subject was asked to turn the head to the right (figure 1), pause at end-range (to allow documentation of the ROM) then return to their perceived neutral head position (NHP) and a recording of this rotation ROM was documented.  Three trials were documented to the right then performed and documented to the left.

The same test was repeated with a laser system.  The subject was blindfolded (not in picture – subject is with her eyes closed) then the laser was placed on the subject’s head with the light at the forehead (figure 2). The subject was placed 3 feet from a wall with a target placed in front of the them.  The return to perceived neutral position was recorded based on the laser projection on the target. This was done with 3 trials to the right and then 3 trials to the left with a brief pause at end-range and then returning to NHP.  

The reliability of the CRT to assess position sense has been established throughout the literature as previously discussed.  This study determined that the interrater reliability using the CROM to measure CRT had ICC values > 0.75 showing a good reliability between testers with the same instrument.  The intertester reliability with the laser was not as good as the CROM with an ICC value of 0.67.  This could possibly be due to the challenging equipment fit of the laser as it was attached in the study with a one-sized bike helmet.   A paired t-test showed no difference in the accuracy to relocate using the CROM in subjects with and without a history of neck pain.  The CROM is a relatively inexpensive and accurate tool to utilize in the clinic to measure a patient’s proprioceptive sense in the cervical spine after trauma.

IAOM Commentary:

Many patients present to the clinic with neck pain after various types of injuries whether traumatic or non-traumatic events.  These patients will usually present with changes in their cervical position sense due to these painful events.  When there is a dysfunction of the position sense in the cervical spine, there will be dysfunction up and down the chain, which can lend to multiple dysfunctions ranging from stiffness, headaches, ROM deficits, muscular tightness and dizziness to name a few.  There are many exercises that can improve position sense in the cervical spine.  Peterson et al report that position sense can be improved through DNF activity, coordination exercises, including eye-head-neck exercises, as well as manual therapy techniques for improving segmental mobilization with the coordination exercises producing the largest effects on position sense.9  The following pages give various exercises as examples of what will improve these different areas previously mentioned.

Figure : Deep Neck Flexion with Beach Ball Roll – Instructions are to perform DNF then rotate the head left and right.

 

Figure : Deep Neck Flexion with Inclinometers – Pt head is rotated in 10˚, 20˚ and 30˚ degree increments in one direction and patient is asked to replicate this motion. The move is then increased to a full arc from left to right.

 

Figure: Laser with Figure 8 motion — moving in a clockwise and counterclockwise direction.

 

Figure: Laser with Clover with a clockwise and counterclockwise movement.

 

Figure: Laser with horizontal movement; and with vertical movement

 

Progression with utilization of various surfaces:

Figure: Challenges with various surfaces or positions — from left to right. Top row: single leg stance with rows, squat with rows, wedge surface with rows. Bottom row: theradisc with rows, theradisc squat with rows, BOSU with lats

 

Segmental Mobilization:

Figure: Segmental Extension Gliding — Lock the caudal segment by stabilizing it (pushing it in a ventral direction), then bring cranial segment into rotation and side-bending away from the treating clinician. Mobilization force through the cranial hand is in a caudal and dorsal direction with rotation away from the treating clinician.

 

Figure: Segmental Flexion Gliding — Lock the caudal segment with a 90˚ angle from the line of the zygapophyseal joint (pushing in a ventral and caudal direction), then bring cranial segment into rotation and side-bending towards the treating clinician. Mobilization force through the cranial hand is in a cranial and ventral and rotation towards the treating clinician.

References

  1. Gaskin DJ, Richard P. The economic costs of pain in the United States. J Pain Off J Am Pain Soc. 2012;13(8):715-724.
  2. Armstrong BS, McNair PJ, Williams M. Head and neck position sense in whiplash patients and healthy individuals and the effect of the cranio-cervical flexion action. Clin Biomech. 2005;20(7):675-684.
  3. Pinsault N, Vuillerme N, Pavan P. Cervicocephalic Relocation Test to the Neutral Head Position: Assessment in Bilateral Labyrinthine-Defective and Chronic, Nontraumatic Neck Pain Patients. Arch Phys Med Rehabil. 2008;89(12):2375-2378.
  4. Manchikanti L, Singh V, Rivera J, Pampati V. Prevalence of cervical facet joint pain in chronic neck pain. Pain Physician. 2002;5(3):243–249.
  5. Sizer PS, Poorbaugh K, Phelps V. Whiplash associated disorders: pathomechanics, diagnosis, and management. Pain Pract. 2004;4(3):249–266.
  6. Pinsault N, Vuillerme N. Degradation of cervical joint position sense following muscular fatigue in humans. Spine. 2010;35(3):294–297.
  7. Wibault J, Vaillant J, Vuillerme N, Dedering Å, Peolsson A. Using the cervical range of motion (CROM) device to assess head repositioning accuracy in individuals with cervical radiculopathy in comparison to neck- healthy individuals. Man Ther. 2013;18(5):403-409.
  8. Chen X, Treleaven J. The effect of neck torsion on joint position error in subjects with chronic neck pain. Man Ther. 2013;18(6):562-567.
  9. Petersen CM, Zimmermann CL, Tang R. Proprioception interventions to improve cervical position sense in cervical pathology. Int J Ther Rehabil. 2013;20(3):154-163.

What’s wrong with this picture?

By Theresa Parry OTR MS CHT COMT

This is an example of a midcarpal joint dorsal intercalated segment instability (DISI). Note how the moon-shaped lunate in facing in a dorsal direction. Also, notice the arthritic changes taking place on the dorsal lip of the lunate from the malaligned loading of the capitate. Yikes!

How do I know if I am dealing with a tendinopathy or a tenosynovitis?

By Theresa Parry OTR, CHT, COMT

We hear so many different words when it comes to tendon issues. Tendonitis, tendinosis, tendinopathy, tenosynovitis…..

So, what means what? And why do we care?

Tendinopathy is a term used to encompass all issues with the tendon proper. Within this category, we find both tendonitis (an actively inflamed tendon) and tendinosis (a chronically inflamed tendon that has undergone degenerative changes and no longer has active inflammation). Tenosynovitis is inflammation of the tendon sheath.

How do I know which is which?

When we complete our basic clinical exam, we always perform resistance to a muscle followed by passive stretch. For example, if we are testing flexor carpi radialis (FCR), we will provide resistance to wrist flexion combined with radial deviation and listen for complaints of pain. We will them complete passive stretch to FCR into wrist extension and ulnar deviation and yes, listen for complaints of pain!  If they have pain with resistance, we are thinking they have a tendinosis or tendinitis. If they have pain with passive stretch, we are thinking there is a tenosynovitis and the sheath is inflamed.

               

Why do we care?

It is important to know which problem the patient has so you can treat is most effectively! When we use our transverse friction massage technique, the surface area you treat will be small – the size of only one fingertip – for a tendonitis or tendinosis. For a tenosynovitis will be broader – the width of 2-3 fingertips – so that we are frictioning a larger portion of the tendon sheath.

The distinction between tendon and sheath issues is also important for your patient education. If they have a tendinitis or tendinosis, we instruct them to avoid resistance. For an FCR tendonitis or tendinosis, we would instruct them to avoid wrist flexion with radial deviation activities such as racket sports. If they have a tenosynovitis, we instruct them to avoid passive wrist extension and ulnar deviation such as weight-bearing with the wrist in extension.

In summary, issues with the tendon itself are referred to as a tendinosis or tendinosis, and their pain will be most provoked with resistance. Issues with the tendon sheath is referred to as a tenosynovitis and pain will be most provoked with passive stretch.

Restoring External Rotation in the Shoulder

By Dustin Silhan, PT, ScD, COMT

When we look at our shoulder patient population, whether we are dealing with the post-op case, adhesive capsulitis, or other cases where we have capsular restrictions, external rotation (specifically at 90 degrees abduction) is often the most difficult and painful to restore.

During external rotation, when the shoulder is in the lower levels of elevation, we have an arthrokinematic roll posteriorly and glide anteriorly, which means our direction of mobilization would be anterior.  This can be an effective technique to restore motion, however, many patients do not tolerate this technique due to pain.  With these patients, I will prepositioning the shoulder in external rotation at varying degrees of flexion, scaption, or abduction, and will perform a posterior mobilization.

Early in the process, I will have the shoulder prepositioned in the 0-45 degree range of flexion (with external rotation), and will progressively move to higher degrees of flexion as pain allows.  I will also progress to prepositions in scaption, and finally abduction as pain allows.  As we get more toward the frontal plane in abduction, with endrange external rotation, this often becomes a position that is not well tolerated by the patient, but nonetheless, is a functional and important position for many of our patients to acquire.

In summary, the progression of preposition from least to most aggressive is as follows: flexion –> scaption–> abduction, and low levels of elevation à 90 degrees of elevation in those respective planes.

In the clinic, I can recall countless times that as I go to move into shoulder abduction/external rotation and the beads of sweat form on their face, as soon as I apply the posterior mobilization, they have a sigh of relief… “that’s better” they say.  It not only relieves their pain, but I also can move them further into external rotation.  What’s going on in the joint that causes this?  My opinion is that the abducted/externally rotated position is placing the joint in a vulnerable position. This position puts stress on the anterior capsule as the humeral head attempts to migrate anteriorly.  This is what occurs in the apprehension test for instability patients.

So maybe the pain relief and improved mobility that occurs with the posterior mobilization is brought on by re-centering the anterior migrated humeral head on the glenoid.  This is what occurs in the “relocation” phase of the apprehension-relocation test for instability patients.  Though these patients are not unstable, I make the analogies to the apprehension-relocation test, just to make a comparison as to what stresses may be going on in the joint and capsule.  I like to know why something is working.

I hope this spurs on some thought in how you treat your “stiff shoulders,” and if you haven’t tried posterior mobs in these patients, I hope you will give them a try.

Kinematics of fast cervical rotations in persons with chronic neck pain: a cross-sectional and reliability study

Roijezon U, Djupsjobacka M, Bjorklund M, et al.  Kinematics of fast cervical rotations in persons with chronic neck pain: a cross-sectional and reliability study.  BMC Musculoskel Dis. 2010; 11:222.

Abstracted by Kevin Browne ScD TTUHSC

While sensorimotor deficits have been demonstrated in chronic neck sufferers in a number of metrics, most investigations have measured self-paced or slow movements.  Two studies have investigated maximum speed, but neither has looked at test-retest reliability or attempted to link them to symptoms or self-rated function.  The purpose of this study was to assess kinematics and reliability in women with chronic neck pain during maximum speed neck rotation and to link results to patient-report characteristics.  The authors used a combined cross-sectional and test-retest design, conducted at a musculoskeletal research lab in Sweden.  They recruited two samples. The first being 16 women (aged 20-55) with non-traumatic, non-specific neck pain (NS) of at least 3 months duration along with 16 controls (CON) from local advertisement.  The second group of 120 NS and 33 CON subjects (aged 20-65) were recruited from health care entities. The age of NS was a mean of 4.5 years higher than CON, and were controlled for in the analysis.   Excluded were those with neurologic, vestibular, radicular or psychiatric disorders   Kinematic data was gathered from FASTRAK, an electromagnetic system, with a receiver place on the forehead and spinous process of T2, measuring speed and along with range of motion (ROM).  Subjects were instructed to outwardly rotate their necks as quickly as possible in a seated position, right and left, alternating directions for a total of 6 trials. Sample 2 used a numerical rating scale (NRS), while Sample 1 used VAS to measure pain prior to and after testing was completed.  Questionnaires, used to assess correlation with kinematic measurements, included Short Form Health Survey, Neck Disability Index, and Tampa Scale of Kinesiophobia   As a majority of patients had bilateral or central neck pain, trials from each direction were pooled for analysis.  Intraclass correlation coefficients (ICC) were used to calculate reliability in Sample 1.  Reliability proved to be high for Peak Speed and ROM in both groups with ICC ranging from 0.64 to 0.86.    Partial Least Squares regression was used to analyze self-rated characteristics with kinematics and group significance was set below 0.05.  NS group had decreased Peak Speed compared with CON (P=<0.01) but greater than those with concurrent LBP (P=0,024).  Linear discriminant analyses was used calculate Sensitivity and Specificity to predict NS and CON.  Peak Speed and ROM had Sensitivities of 74.6% and 64.4%, and Specificities of 73.5% and 71.4% respectively.  Mean pain ratings for the NS group was 4.4 before and 4.7 immediately after the test in Sample 2 (P=<0.01).  Associated variables predicted decreased Peak Speed in the NS group were strongest for Car Driving and Running  (-.37 and -.35, respectively).  The authors concluded that fast rotation speed was most negatively affected by NS and that those differences were heightened in those with concurrent lower back pain. The authors urged further research to examine this phenomenon.  

Personal Application:

There is a lot of face validity to speed and range of motion deficits being associated with chronic neck pain. And while the speed tests are interesting, I don’t have a way to measure it in everyday clinic practice.  I would like to see a study done where chronic neck patients undergo PT, demonstrate a clinically meaningful difference in pain, and find out whether peak speed improves.  The two items of particular interest to me were the association of particularly worsened performance with concurrent lower back pain and the association of running and driving a car ability being negatively associated with chronic neck pain.  Looking back to my experience in the Neuroscience course, this just screams sensitization.  What they didn’t say was whether the lower back pain with chronic as well, though I assume it was.  It would be interesting to see if concurrent chronic lateral epicondylitis had the same effect.  The point of course being that central sensitization is a condition to be co-managed when treating chronic neck pain when at all possible.  Using thoracic spine mobility, such as a foam roller should help.  Teaching ADIM for those with recurrent lower back pain can be a valid use of clinical time, as local (neck) performance is affected.  Teaching strategies to mitigate the driving and running difficulties (where needed) should be addressed and can be improved, even if the neck pain is slow to improve.   

Two different courses of impaired cervical kinaesthesia following a whiplash injury. A one-year prospective study

Oddskottir GL, Kistjansson E.  Two different courses of impaired cervical kinaesthesia following a whiplash injury. A one-year prospective study.  Manual Therapy.  doi:10.1016/j.math.2011.08.009.

Abstracted by Kevin Browne ScD TTUHSC

It is thought that kinaesthesia in the cervical spine after a whiplash injury is an important consideration for recovery from neck pain.  Early identification of those patients that eventually develop cervical kinaesthesia deficits might help with treatment management. The purpose of this year-long prospective study was to determine the course of cervical kinaesthesia in whiplash injury subjects through two movement control tests and to determine test association with patient-reported questionnaires. Seventy-four subjects from the age of 18 to 65, suffering whiplash associated disorder (WAD) I, II or III, were recruited from a University Hospital emergency room in Iceland from December of 2006 to September of 2009 via phone contact 3 weeks after motor vehicular collision (MVC).  Participating subjects underwent movement control and questionnaire (VAS scale, Neck Disability Index: NDI, and TAMPA: measuring fear of movement) testing at 1, 3, 6 and 12 months after MVC, of which 47 subjects completed all testing.   Subjects were classified as improvers and non-improvers with respect to each control test.  The Fly test was administered to measure tracking accuracy using a cursor on a computer screen and the Head-Neck Relocation (HNR) test was administered using Fastrak device to assess active relocation accuracy to neutral from fully rotated positions right and left.  Three movement patterns were traced on the Fly test, repeating 3 times with a 10 second rest between trials in random order.  HNR was completed with the patient being instructed to relocate as accurately as possible from left to neutral and right to neutral 3x alternately.  The authors hypothesized that those subjects who developed cervical kinaesthesia by the 1st month would develop persistent deficits at 6 and 12 months.  Paired t-tests were used with significance set to P=0.05, measuring mean error for the Fly test and HNP, calculated as a sum of the 3 patterns and the sum of right and left sides, since there was no difference between patterns and sides.  ANOVA was used to assess measurement difference over time.  Two-way ANOVA and Pearson’s correlation coefficient was used to determine associations between movement tests and questionnaire findings.  Twenty-five participants improved and 24 worsened accuracy on the Fly test, while 25 improved and 22 worsened accuracy on the HNR test.  Between group (improved and not improved) accuracy differences were not significant at 1 months, but were at 12 months on the Fly test (P=0.004). For the HNR test, the non-improvement group had less relocation error (P=0.002) at one month, but worse after 12 months (P=0.019).  Significant association was found only on NDI results for the non-improving Fly and the improving NIG groups.  The authors note that about ½ of MVC subjects with WAD improved their kinaesthesia accuracy over a one year timeframe, and that there was generally poor correlation between improvement/non-improvement groups with patient-reported pain, disability and fear questionnaires.  The authors highlighted the need to develop better ways to prospectively identify patients likely to develop cervical kinaesthesia.   

Personal Application:

Once again, WAD demonstrates its unique ability to defy prediction and to prove non-cooperative to simple classification.   The first thing that came to mind on the test-re-test results from one to twelve months is that , given a novel motor task, maybe it isn’t surprising that about ½ improved and ½ did not.  It seems perplexing that the non-improvers had better scores to start with, until you consider that taking all 47 subjects results, there was no difference from one to twelve months.  Maybe we can then argue that, as a whole, we are witnessing a reversion to the mean.  I think that makes the most sense.  This study ultimately suggests that tracking and relocation accuracy is not useful in terms of predicting outcomes in WAD.  I would like to see a couple of things.  What does the research say about accuracy for normals?  What is the two test’s reliability? If the data is out there, I find it strange that it isn’t presented here.  Moreover, it is fascinating that only ½ of subjects demonstrated improved or worsened accuracy in both tests, while there was divergence in the other ½.  Again, I think this argues for reversion to the mean.  The authors felt that the tests represent two different kinematic variables. If that was the case, one might expect to see some pattern emerge, but this was not so.  The study illustrates the difficulty in motor control investigation, particularly for subjects as potentially complicated as those suffering from WAD.   

Management of a patient with acute acetabular labral tear and femoral acetabular impingement with intra-articular steroid injection and a neuromotor training program

Narveson, JR, Haberl, MD, Grabowski, PJ. Journal of Orthopedic & Sports Physical Therapy, 2016.

Abstracted by: Paige Koebbe, SPT at Missouri State University, Springfield, Missouri.

This study was done to investigate conservative treatment methods for patients with femoroacetabular impingement and acetabular labral tears, concluding intra-articular injections accompanied by conservative physical therapy can improve symptoms, strength, mobility, and functional activity tolerance.

This study utilized one female student-athlete with a diagnosis of an elevated center-edge angle and alpha angle, crossover sign, subtle cam impingement, and an acute anterior superior acetabular labral tear. The patient received an intra-articular hip injection, including a corticosteroid and a local anesthetic, thirty-two days following the injury date. The injection reduced the patient’s pain immediately, while still presenting with an abnormal gait pattern, reduced hip corrective strategies, range of motion and strength deficits, and pain when the hip was flexed, internally rotated, and adducted. A graded neuromotor training program was used for treatment intervention. This training program was broken down into four phases; muscular activation and hip corrective strategy, muscular endurance, static and dynamic postural control, return to running and skill-specific tasks, and return to sport and plyometric training (see Table 1 below). The labral tear was used to guide this intervention, but the patient’s symptoms origin was unclear. The intervention described was utilized to return to function and re-establish neuromotor control of the affected hip. This patient initiated a running program on day 3, beginning with running until symptoms begin. A difference in ER strength and hip correction strategies was noted post run as well as muscular flexibility. By focusing on patient symptom production, an individualized treatment intervention was developed to facilitate patient progression with activity-specific training without pain.

In conclusion, the findings revealed success with combined intervention for this patient with a femoroacetabular impingement and anterior superior acetabular labral tear. However, this was a case study utilizing only one participant, which reduces the strength of the results. These authors also noted a high level of self-motivation and rigorous compliance with home exercise program.

 

Table 1  
Visit Number Interventions
Day 1
  • Multiple angle isometrics of the hip (IR/ER in 3 positions)
  • SLB, eyes closed  
  • Sidelying quadriceps and TFL stretch
Day 2
  • Elliptical warm up
  • Multiple angle isometrics of hip
  • SLB, eyes closed
  • Half-kneeling balance with eyes closed  
  • Half-kneeling chops with eyes open
  • SLB on foam with dynamic hip flexion and extension
Day 3
  • Treadmill walking and running
  • Standing hip abduction-extension
  • SLB, eyes closed on foam
  • Half-kneeling balance with eyes closed with chops and on foam
  • SLB on foam with dynamic hip flexion and extension and eyes closed
  • Initiated return-to-running program
Day 4
  • Running on treadmill
  • Standing hip abduction-extension eyes closed on foam
  • SLB with hip IR/ER and on foam
  • Half-kneeling balance with eyes closed and chops on foam
  • SLB on foam with dynamic extension, swinging through with abduction into flexion
  • Return-to-running program
  • Y balance exercise
Day 5
  • Running on treadmill
  • Standing hip abduction-extension eyes closed on foam
  • SLB with hip IR/ER and eyes closed on foam
  • Half-inline lunge with eyes closed on foam, progress to chops  
  • SLB on foam with dynamic extension, swinging through with abduction into flexion and eyes closed
  • Lunges
  • Plyometric single-limb hop, triple crossover hop
  • Return-to-running program

Personal Commentary:

This article was particularly interesting due to the controversy behind the “gold standard” for treatment of acetabular labral tears. “Gold standard” can be defined as an intervention, procedure, treatment, or method utilized and known as the best available. The authors collected data and information on a very misunderstood topic. Research on acetabular labral tears has been limited due to the different mechanisms of injury, wide array of symptoms and anatomical disruptions, and causes of hip pain. Many treatment interventions have been studied without success in finding a “gold standard.”

In the article described above, the authors indicated conservative treatment was effective in pain reduction and improvement in functional activities for this patient. However, the authors also recognized, this was a case study with one female patient, who was very compliant and motivated to improve. Other articles regarding conservative treatment have stated that patients with acetabular labral tears have not shown any signs of improvement. It is clear that, the “gold standard” for treatment of acetabular labral tears is still unknown to this day.

Currently, research supports the treatment intervention for acetabular labral tears is widely unknown. The study mentioned above is refuted through certain education and clinical experiences as well. Quality of life improvement through a variety treatment interventions is what physical therapists strive for daily. Regarding acetabular labral tears, conservative treatment is recommended first, in attempt to reduce costs and avoid surgical repair if possible. Thus, maintaining a level of diligence in monitoring patients’ progress from treatment session to treatment session is the key to success. It is suspected that labral tears can also increase a patient’s risk for developing hip osteoarthritis if not treated properly. Without irrefutable evidence of progress with conservative treatment, and attempting to reduce the risk of further injury, referral to an orthopedic physician to discuss surgical repair and facilitate quality of life improvement may benefit the patient long term.

References:

  • Gold standard. (n.d.). Retrieved October 04, 2017, from http://medical-dictionary.thefreedictionary.com/gold standard
  • Khoo-Summers, L., & Bloom, N. J. (2015). Examination and treatment of a professional ballet dancer with a suspected acetabular labral tear: A case report. Manual Therapy,20(4), 623-629.
  • Mccarthy, J., Noble, P., Aluisio, F. V., Schuck, M., Wright, J., & Lee, J. (2003). Anatomy, pathologic features, and treatment of acetabular labral tears. Clinical Orthopaedics and Related Research,406, 38-47.
  • Narveson, J. R., Haberl, M. D., & Grabowski, P. J. (2016). Management of a patient with acute acetabular labral tear and femoral acetabular impingement with intra-articular steroid injection and a neuromotor training program. Journal of Orthopaedic & Sports Physical Therapy,46(11), 965-975. doi:10.2519/jospt.2016.6573
  • Orbell, S., & Smith, T. O. (2011). The physiotherapeutic treatment of acetabular labral tears. A systematic review. Advances in Physiotherapy,13(4), 153-161.

Ligamentum teres tears and femoroacetabular impingement: prevalence and preoperative findings

Chahla J, Soares EA, Devitt BM, Peixoto LP, Goljan P, Briggs KK, Philippon MJ. (2016). Ligamentum teres tears and femoroacetabular impingement: prevalence and preoperative findings. Arthroscopy: The Journal of Arthroscopic and Related Surgery, 32(7): 1293-1297

Abstracted by: Dale Gerke, PT, ScD, COMT, Mequon, Wisconsin — Fellowship Candidate, IAOM-US Fellowship Program & Jean-Michel Brismée, PT, ScD, Fellowship Director, IAOM-US Fellowship program.

While the hip is generally considered a very stable joint because of the deep seated congruency of the acetabulum, there is growing evidence that hip microinstability does exist. The purpose of the article by the authors was to identify the prevalence of Ligamentum Teres (LT) injuries and identify clinical examination findings that fit the diagnosis.

The research was a retrospective analysis of arthroscopic findings for patients with hip pain. The authors completed a prospective examination of the hip to establish a pre-operative diagnosis on patients over the age of 18. The examination was completed less than one month before the hip arthroscopy and included Passive Range of Motion (PROM), Apprehension Test (See Figure 1) Impingement Test, FABER, and Dial Tests for each patient. Radiographs of the hip were also analyzed and measured for each patient. The results of the arthroscopic findings were assessed retrospectively by one orthopedic surgeon. The LT was inspected arthroscopically and the findings were recorded.  The arthroscopic evaluation allowed the surgeon to classify the LT as normal, partially torn, or completely torn. A total of 3,158 hip arthroscopies were performed by the Physician over the 10-year period.  

A total of 2,213 patients met the inclusion criteria for undergoing primary hip arthroscopies on skeletally mature adults being treated surgically for chondrolabral dysfunction associated with Femoroacetabular Impingement (FAI). The results demonstrated 88% of the patients had fraying or tearing of the LT and were classified as partially torn. Eleven percent of the subjects had a normal LT and 1.5% of the patients were identified as having a completely torn LT.

Odds ratios were performed using SPSS. Gender, size, hip morphology, PROM and impingement tests were related to LT tears.  Additional arthroscopic findings also demonstrated chondral tears and coxafemoral joint capsular laxity. The authors found women were more than 3x likely to experience a tear in the LT than men. Radiographic analysis demonstrated a center edge angle (CEA) less than 25 was also associated with LT injury.

 

IAOM Comment:

Previous authors have identified LT injuries during arthroscopy. However, this is the first study to quantify the severity of an LT injury. The authors should be applauded for their work in identifying the very elusive hip instability with clinical examination.

The clinical examination is one of the underpinnings of the IAOM. Identifying the 5 questions of who, what, when, where, why, and to what extent helps shape the clinical hypothesis and subsequent interventions. The article helps us identify that adult women with low BMI are more likely to experience hip instability with LT injury. It should also be considered that women may be more likely to experience generalized laxity more often than men. Radiographic imaging for a small CEA can be helpful, but it is imperative that these findings are also considered in the context of the clinical examination. According to Byrd et al. (2004) 44% of all athletes with LT lesions had an atraumatic etiology preventing the diagnosis from being detected prior to arthroscopy. Similarly, individuals who experienced a traumatic injury did not receive surgery until an average of 28 months following the trauma.1 Delayed identification of the ligament laxity further indicates the need for greater suspicion during the clinical examination. A history of trauma can be helpful to consider an underlying instability, but the repetitive microtraumatic tears of LT are even more challenging to uncover in the clinical examination if there is an absence of pain. Injury to the LT should be considered for post-operative hip surgery as iatrogenic interference has also been suggested as a mechanism of injury to the LT.3

Numerous authors have identified that hip flexion can be limited as a result of the FAI, but hip IR was suggested to be increased by these authors. Assessing hip rotation may be one of the findings to help differentiate hip instability. The authors did not describe the patient position where hip IR was assessed. Alternatively, the IAOM advocates assessing hip IR in both the supine and prone positions. It would be interesting to compare hip IR in each of these positions to determine if motion loss would be different. Similarly, previous authors have used the Dial Test to differentiate instability.11, 12

The authors of the current study found the frequently used Dial Test was not as helpful to detect instability. (See Figure 2) This is understandable because the LT may not be fully elongated in this neutral hip position. Placing the hip in a flexion position brings the attachment of LT posterior to the axis of rotation adding length to the LT. The authors also noted that hip IR was greater in patients with partially torn or completely torn LT, but motion changes were considered controversial and not statistically significant in this article. Nonetheless, hip IR or ER with a soft end feel could increase clinical suspicion for instability. Moreover, a positive impingement test was frequently encountered with hip instability in this article. Several authors have suggested that a position of hip flexion, hip adduction and internal rotation can strain the LT, while others have advocated the hip flexion, adduction and external rotation elongate the LT. Therefore, identifying symptom location and carefully evaluating the end feel during the impingement test can be useful. Furthermore, patients experiencing laxity from a partially torn LT may have a softer end feel that could be limited by diffuse pain. Additionally, patients were recognized as having an isolated cam or pincer impingement more frequently when a partially torn or completely torn LT was identified. It is important to consider the morphology of the cam or pincer lesions because the bone lesions could have been present for many years. Traumatic hip instability certainly is a realistic concern, but many patients could be experiencing repetitive microtraumatic events leading to the subtle instability.

A thorough understanding of hip instability will be helpful for all clinicians. O’Donnell et al. (2013) suggested a novel test for LT insufficiency whereby the examiner places the hip in submaximal flexion.9 In this position, the examiner assesses hip IR and hip ER for total motion and end feel. A painful rotation with soft end feel that is consistently relieved with rotation in the opposite direction can be indicative of LT insufficiency. (Sn: 90, Sp: 85, (+) LR: 6.5, (-) LR 0.11) 9. (See Figure 3) The current authors also suggested using the previously described Dial Test FABER Test. It is believed that the LT has free nerve endings and is capable of having a nociceptive role.10

The authors suggest that early symptom identification can be helpful for surgical considerations. This is understandable considering the morphological differences, labral tears, capsuloligamentous laxity and chondral defects identified via arthroscopy.  A recent study by Devitt et al (2017) suggested that LT involvement was more common in individuals with arthroscopically evaluated capsular slimness.5  They also found that a Beighton Test Score (BTS) ≥ 4 was more predictive of a hypermobility and LT pathology. Devitt also found the average BTS for men and women was 1 and 4 respectively. Identifying more joint hypermobility and LT involvement in women was similar to the current research findings.

No statistical information is available to identify the accuracy of detecting a partial or full tear of LT. Therefore, interpreting results of the entire clinical exam will be meaningful. Considerations for younger women with a BTS > 4/9 experiencing diffuse hip pain with soft end feels into Hip IR or ER warrant judicious investigation for LT pathology.  Limited passive motion has been suggested with LT tears and should continue to be investigated2. Adding atypical findings from the LT Test according to O’Donnell, Impingement, Apprehension, Dial, and FABER Tests can be used cautiously. Identification of chondrolabral pathology through imaging or arthroscopic evaluation should also encourage investigation of ligamentous instability. Furthermore, association of abnormalities in bone morphology such as hip dysplasia or a pincer lesion were also associated with the presence of an LT tear.9

Having a better understanding of clinical hip instability can be beneficial for the manual physical therapist. Early identification of hip instability can lead us to implement appropriate somatosensory motor control exercises that incorporate the deeper stabilizing muscles of the hip to prevent the premature microtraumatic tissue damage in the coxafemoral joint. Hodges et al (2014) identified the role of obturator Internus (OI), piriformis and Quadratus Femoris (QF) with early active hip External Rotation and Abduction.8 To encourage activation of the deep rotators, the load should be low and slow to prevent over activation of the gluteal musculature. The therapist can assist light eccentric activation of the deep external rotators in prone (See Figure 4) while palpating the gluteus maximus (GM) to ensure GM inactivation during the exercise. The clinician may progress to a sidelying position (See Figure 5) after appropriate motor control has been successful in the prone position.

Distal motion deficits such as a lack of ankle dorsiflexion or knee flexion8,9 would also encourage hip adduction and internal rotation during functional activity. These hip positions create a position where the LT can be elongated with repetitive motions or one large traumatic event. Therefore, the clinician needs to look distal to the hip for secondary motion limitations and restore the motion when retraining functional movements such as squatting, jumping or landing.  A lack of improvement despite conservative care may warrant surgical intervention. Surgery could involve the repair of the LT in combination with labral repairs, capsular plication or capsulorrhaphy.

A limitation of the study was the authors failed to distinguish the difference between tears of traumatic and microtraumatic origin. While the authors acknowledged both trauma and microtrauma play a role in LT involvement, it is difficult to ascertain which is more common in this study. However, an individual will frequently remember a traumatic event in the history. Imaging results were also not reported by the authors. Previous investigators have suggested Magnetic Resonance (MR) Imaging to have poorer diagnostic utility (Sn: 41, Sp: 75, PPV: 32) while MR Arthrography would have greater diagnostic power (Sn: 83, Sp: 93, PPV: 76) if there is suspicion for partial LT pathology failing conservative management.4    There is no significant difference between MR Imaging and MR Arthrography when complete tears are identified.

References:

  1. Byrd JW, Jones KS. Traumatic rupture of the ligamentum teres as a source ofhip pain. Arthroscopy; 2004;20:385–91.
  2. Cerezal L, Kassarjian A, Canga A, Dobado MC, Montero JA, Llopis E, Rolon A, Perez-Carro L. (2010) Anatomy, biomechanics and management of ligamentum teres injuries. Musculoskel Imaging; 30(6): 1638-1651.
  3. Cerezal L, Arnaiz J, Canga A, Piedra T, Altonaga JR, Munafo R, Perez-Carro L. (2012). Emerging topics on the hip: ligamentum teres and hip microinstability. Eur J Radiolog; 81:3745-3754.
  4. Datir A, Xing M, Kang J, Harkey P, Kakarala A, Carpenter WA, Terk MR. (2014). Diagnostic utility of MRI and MR arthrography for detection of ligamentum teres tears: a retrospective analysis of 187 patients with hip pain. Am J Roentgenol; 203(2):418-423.
  5. Devitt BM, Smith BN, Stapf R, Tacey M, O’Donnell JM. (2017). Generalized joint hypermobility is predictive of hip capsular thickness. Orthop J Sports Med; 5(4):1-7.
  6. Fong CM, Blackburn JT, Norcross MF, McGrath M, Padua DA. (2011). Ankle-dorsiflexion range of motion and landing biomechanics. J Athl Train; 46(1):5–10
  7. Hagins M., Pappas E., Kremenic I., Orishimo K. F., Rundle A. (2007). The effect of an inclined landing surface on biomechanical variables during a jumping task. Clin Biomech;22(9):1030–1036.
  8. Hodges PW, McLean L, Hodder J. (2014). Insight into the function of the obturator internus muscle in humans: observations with development and validation of an electromyography recording technique. J Electromyog Kinesiol; 24(4):489-496.
  9. O’Donnell J, Economopoulos K, Singh P, Bates D, Pritchard M. (2014). The ligamentum teres test: a novel and effective test in diagnosing tears of the ligamentum teres. Am J Sports Med; 42(1): 138-43.
  10. O’Donnell J, Pritchard M, Salas AP, Singh PJ. (2014). The ligamentum teres – its increasing importance. J Hip Preservation Surg; 1(1):3-11.
  11. Philippon MJ, Zehms CT, Briggs KK, Manchester DJ, Kuppersmith DA. Oper Tech Sports Med; 2007;15:189-94.
  12. Phillipon MC, Briggs KK, Goljian P, Peixoto LP. (2013). The hip dial test to diagnose symptomatic hip instability. Arthroscopy; 29(10):e123.
  13. Shu B &  Safran M. Hip instability: anatomic and clinical considerations of traumatic and atraumatic instability. Clin Sports Med. 2011; 30: 349–67.
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