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Comparison Between Effectiveness of Mechanical and Manual Traction Combined with Mobilization and Exercise Therapy in Patients with Cervical Radiculopathy.

Bukhari, Shakil-ur-Rehamn, Ahmad & Naeem. Pakistan Journal Of Medical Sciences, 32(1), 31-34.

Article summary by Sierra Wooley, SPT from Missouri State University, Springfield, MO

Impingement of a cervical nerve root that causes radiating neurological symptoms is referred as radiculopathy. This condition is generally managed conservatively by physical therapy treatment, which often incorporates manual or mechanical cervical traction. Thirty-six participants with radiculopathy were randomly placed into either a manual traction group or mechanical traction group. Mechanical traction was applied for 10 minutes at 10-15% patient body weight with a 10 second pull and 5 second rest. Manual traction was applied for 10 minutes with 25 degrees of neck flexion a 10 second pull and 5 seconds rest. Both treatments included segmental mobilization of C3-C7 along with stretching and isometric exercises, following traction. Treatments were completed 3 times a week for 6 weeks.

The outcomes were measured using the neck disability index (NDI) and the numeric pain rating scale (NPRS). Statistically both groups were significant for decreasing pain and disability. However, clinically, the group treated with mechanical traction revealed a greater improvement in pain and function. Mechanical traction group had an average pre pain score of 6.26 and an average post pain score of 1.43, while the manual traction group had a mean pre pain score of 6.80 and a post pain score of 3.85. Disability scores for the mechanical traction group decreased from a mean pre score of 24.42 to a mean post score of 7.26, however the manual traction group only decreased from a mean pre score of 21.92 to a mean post score of 12.19. The study concluded that mechanical traction is clinically more affective at decreasing both pain and disability in patients with cervical radiculopathy.

Personal Commentary:

There are many patients who prefer the inclusion of traction in their treatment plan. However, are there significant differences in patient outcomes between the uses of manual versus mechanical traction? The goal of both traction methods is to take pressure off the spine by stretching muscles and ligaments in order to distract the articular surface (Moeti and Marchetti, 2001). In this study, mechanical traction force was set at 10-15% of the subject’s body weight. Like Bukhari et al. mentioned, it is difficult to gauge exactly how much pull the therapist is using during manual traction and therapist fatigue can be a limiting factor. Therefore, mechanical traction seems to be the more consistent treatment option.

Additionally, considerations need to be made for patients who may favor the idea of manual traction directly from a physical therapist. We have been taught that if a patient believes a treatment is going to work, positive results are much more likely. Therefore, patient preference is also a great indicator of which treatment will ultimately provide better results.  The use of traction is speculated to limit adhesions in the dura, as well as, relieve compression of the nerves (Moeti and Marchetti, 2001). This is the anticipated purpose of mechanical and manual traction, which if achieved can led to successfully decreasing pain and disability regardless of the method chosen. Either choice appears to be beneficial for patients experiencing cervical radiculopathy, however, according to Bukhari et al., mechanical traction may be the more reliable choice.


  • Bukhari, S. I., Shakil-ur-Rehamn, S., Ahmad, S., & Naeem, A. (2016). Comparison between effectiveness of mechanical and manual traction combined with mobilization and exercise therapy in patients with Cervical Radiculopathy. Pakistan Journal Of Medical Sciences, 32(1), 31-34.
  • Moeti, P., & Marchetti, G. (2001). Clinical outcome from mechanical intermittent cervical traction fro the treatment of cervical radiculopathy: a case series. Journal of Orthopedic & Sports Physical Therapy, 31(4), 207-213.

What Every Patient Needs – Part 1

The chronic pain client can be a challenge to treat even for the most knowledgeable clinician.

To this day, not only the patient, but also the providers are asking the questions 1) which is the best approach to treating the chronic pain patient: physical therapy or interventional management? 2) what is the best conservative management strategy for treating the chronic pain sufferer? and 3) what does the evidence say?

Numerous studies have shown that the optimal outcomes can be achieved with a multidisciplinary approach to management (1,2). It generally takes a ‘perfect storm’ to place an individual in their current chronic pain condition, meaning that biological/mechanical, social/relational, and psychological/emotional factors all play a role in the initiation or perpetuation of the painful condition(s). Offering treatment that is sequential (first physical therapy, then acupuncture, then interventional management, for instance) rarely, if ever, effectively addresses this very complicated challenge. Rather, simultaneous treatments and attending to what is known to enhance a treatment outcome will offer the greatest opportunity for success.

Such an approach can involve various professional disciplines, such as pain physicians, physical therapists, massage therapists and acupuncturists (to name a few). Each health care provider has the ability to not only employ tools specific to their profession, but additionally to make use of several facets important to the healing process that can be optimized in the local treatment environment (3)(4)(5). In the attainment of functional goals, three important strategies should be applied in the management of clients with chronic pain: (a) reduction of peripheral nociceptive input; (6–11), (b) improvement of central sensitization; and (c) treatment of negative affect, particularly depression (12).

For decades, patients – and clinicians – have searched for the ‘silver bullet,’ or a management approach that would finally and comprehensively ensure patient recovery. For example, clinicians first leaned on traditional physical therapy and then gravitated to rehabilitation based on a sports medicine model; with either, patients’ symptoms often worsened (13–17). Moreover, physical therapy has evolved from the utilization of only exercise, to the addition of application of modalities, to hands-on treatment, to a purely verbal ‘Explain Pain’, to a generalized biopsychosocial treatment paradigm individualized to the client (3,18). Each of these tools are valuable, but insufficient when used in isolation in the management of clients with chronic pain. Not only the plan of care but also the environment in which those treatments are carried out (from clinical setting to the type of music (19)(20)) play an important role in optimizing improvement.

As Bonakdar stated “When assessing pain, it is important to understand the physical and functional limitations that may be imposed. Equally paramount is appreciating and approaching the profound social, psychological, neurologic, and metabolic shifts that occur. This understanding as well as incorporating proper diet, activity, behavioral support, and patient activation as key components of treatment is essential in improving quality of life in those with pain.”(21)

Have you ever asked your client: ‘what does your client feel is wrong and what do they feel that they need to get better?’ How do you decide what or how much to provide? It is all part of being comprehensive and complete as a clinician. What is your art behind the science and clinical reasoning in patient care… Are you offering complete care in your clinical practice?


  1. Akyüz G, Özkök Ö. Evidence based rehabilitation in chronic pain syndromes. Aǧrı  Ağrı Derneği’nin Yayın organıdır = J Turkish Soc Algol [Internet]. 2012;24(3):97–103. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22865515
  2. Guzman J, Esmail R. Multidisciplinary bio-psycho-social rehabilitation for chronic low-back pain. Cochrane Database Syst Rev [Internet]. 2002;(1). Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000963/full
  3. Scott JG, Scott RG, Miller WL, Stange KC, Crabtree BF. Healing relationships and the existential philosophy of Martin Buber. Philos ethics, Humanit Med [Internet]. 2009;4(1):11. Available from: http://peh-med.biomedcentral.com/articles/10.1186/1747-5341-4-11
  4. Iyendo TO, Uwajeh PC, Ikenna ES. The therapeutic impacts of environmental design interventions on wellness in clinical settings: A narrative review. Complement Ther Clin Pract [Internet]. 2016;24:174–88. Available from: http://dx.doi.org/10.1016/j.ctcp.2016.06.008
  5. Karnik M, Printz B, Finkel J. A Hospital ’ s Contemporary Art Collection : 2014;7(3):60–77.
  6. Schaible HG, Grubb BD. Afferent and spinal mechanisms of joint pain. Pain. 1993;55(1):5–54.
  7. Loeser JD, Melzack R. Pain : an overview. 1999;353:1607–9.
  8. Wright  a. Recent concepts in the neurophysiology of pain. Man Ther. 1999;4(4):196–202.
  9. Baker K. Recent advances in the neurophysiology of chronic pain. Emerg Med Australas [Internet]. 2005;17(1):65–72. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15675907
  10. Nie H, Graven-Nielsen T, Arendt-Nielsen L. Spatial and temporal summation of pain evoked by mechanical pressure stimulation. Eur J Pain. 2009;13(6):592–9.
  11. (Karin) Swart C.M.A. CMA, Stins JF, Beek PJ. Cortical changes in complex regional pain syndrome (CRPS). Eur J Pain [Internet]. 2009;13(9):902–7. Available from: http://dx.doi.org/10.1016/j.ejpain.2008.11.010
  12. Staud R. Future perspectives: pathogenesis of chronic muscle pain. Best Pract Res Clin Rheumatol. 2007;21(3):581–96.
  13. Järvholm U, Styf J, Suurkula M, Herberts P. Intramuscular pressure and muscle blood flow in supraspinatus. Eur J Appl Physiol Occup Physiol. 1988;58(3):219–24.
  14. Strobel ES, Krapf M, Suckfill M, Bruckle W, Fleckenstein W, Muller W. Tissue oxygen measurement and31P magnetic resonance spectroscopy in patients with muscle tension and fibromyalgia. Rheumatol Int. 1997;16(5):175–80.
  15. Maekawa K, Clark GT, Kuboki T. Intramuscular hypoperfusion, adrenergic receptors, and chronic muscle pain. J Pain [Internet]. 2002;3(4):251–60. Available from: http://linkinghub.elsevier.com/retrieve/pii/S152659000200010X
  16. Gallagher AM, Coldrick AR, Hedge B, Weir WRC, White PD. Is the chronic fatigue syndrome an exercise phobia? A case control study. J Psychosom Res. 2005;58(4):367–73.
  17. Wasenius N, Karapalo T, Sjögren T, Pekkonen M, Mälkiä E. Physical dose of therapeutic exercises in institutional neck rehabilitation. J Rehabil Med. 2013;45(3):300–7.
  18. Brunner E, De Herdt A, Minguet P, Baldew S-S, Probst M. Can cognitive behavioural therapy based strategies be integrated into physiotherapy for the prevention of chronic low back pain? A systematic review. Disabil Rehabil [Internet]. 2013;35(1):1–10. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22607157
  19. Blödt S, Pach D, Roll S, Witt CM. Effectiveness of app-based relaxation for patients with chronic low back pain (Relaxback) and chronic neck pain (Relaxneck): study protocol for two randomized pragmatic trials. Trials [Internet]. 2014;15(1):490. Available from: http://trialsjournal.biomedcentral.com/articles/10.1186/1745-6215-15-490
  20. Kwekkeboom KL, Gretarsdottir E. Systematic review of relaxation interventions for pain. J Nurs Scholarsh. 2006;38(3):269–77.

21. Bonakdar RA. Integrative Pain Management. Med Clin North Am. 2017;101(5):987–1004.

Abstract: Clustered clinical findings for diagnosis of cervical spine myelopathy

Cook C, Brown C, Isaacs R, Roman M, Davis S, Richardson W. J Man Manip Ther. 2010;18(4):175-80.

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

Cervical spine myelopathy (CSM) is a disorder that involves progressive compression of the spinal cord in the cervical area.  This compression can be caused by degenerative changes due to intervertebral disc disease, spondylosis, or other pathologies that cause degeneration.1  It has been referred to as one of the most common spinal cord disorders in the older populations.1  Many patients complain of stiffness in the neck, radiculopathy, and sometimes shoulder pain.2  According to Northover et al,  C5 and C6 are the most common levels for cord compression.3  With progression of cervical degenerative changes, one often begin experiencing  a loss of strength in the upper extremities and atrophy of the hand intrinsic musculature.4   CSM can best be identified through magnetic resonance imaging (MRI).  It is the best tool for definition of CSM as it demonstrates high sensitivity and specificity for cord compression.5   

No cluster of tests has proven to be more beneficial than any singular test for identifying cervical spine myelopathy.  This study attempted to find a cluster of predictive clinical findings using imaging confirmation after making a clinical diagnosis in hopes of developing a reference standard for CSM.  Many tests have been studied that have a high degree of specificity and can rule in the diagnosis of CSM; however, not many have a high sensitivity, which would help rule this diagnosis out.  The tests with a high specificity are clonus,6 Hoffman sign,7-9 hyper-reflexic deep tendon responses,7,8,10 inverted supinator signs,7,11 and Babinski sign.12  When these tests are used alone, they may lead to false negatives and occasionally false positives.7  When tests are clustered together, they can help overcome the weakness of stand-alone tests.  

Data was taken from 249 patients with cervical spine dysfunction from multiple conditions seen at Duke University from 2006 to 2009.  All participants were diagnosed with CSM by an orthopedic surgeon dependent on a patient’s history and physical examination.  The patient’s history consisted of deep aching pain in the neck, arm or shoulder joint that can be unilateral or bilateral, gait dysfunction resulting in clumsiness or stiffness, loss of dexterity in the hands and stiffness in the neck.  The patients also presented with “multisegmental weakness, losses during coordination testing, and variable losses of sensation and proprioception.”  When a clinical diagnosis was suspected, an MRI was done to confirm or deny the diagnosis of cervical spine myelopathy.  Each participant in this study had positive MRI findings to confirm diagnosis of CSM.  According to many studies, the diagnosis of CSM by MRI is confirmed with a reduction in the anterior-posterior width, signal changes noted in the cord, complete obstruction of the subarachnoid space, and cord compression noted with cross-sectional views on imaging.13-17  Patient’s demographic information, pain scale, neck disability index (NDI) and SF12, which is an outcome measure used to determine a person’s quality of life, were recorded and utilized as descriptive variable.  The predictive variables for the study included gait disturbances (abnormally wide-based gait, spastic gait, or ataxic gait), increased reflexes at the C5-6 level, abnormal brachio-radialis reflex (an inverted supinator sign), increased lower extremity reflexes, Hoffman, Spurling’s test or Babinski, the distraction test, clonus, and pain scores.  

Results and Conclusions:

Thirteen clinical findings were studied including:  pain score, pain consistency, age > 45 years old, hyper-reflexia of the lower extremity reflexes (quadriceps and achilles) as well as C5,6 reflexes in the upper extremity (biceps and inverted supinator sign of brachioradialis), Spurling’s test, Hoffman’s test, clonus, Babinski, distraction test, and gait deviation.   Five clinical findings were identified in the study (gait deviation, Hoffman’s test, inverted supinator sign, Babinski test and age > 45 years old) to be good predictors of CSM.  The patients in this study displayed high specificity for ruling in CSM when 3-4 of these 5 identifiers were present.  Also, there was high sensitivity for ruling out CSM when only 1 of the 5 clinical findings was present.  These clusters may be useful in helping a clinician identify patients with CSM.

IAOM-US commentary:

Many patients present to physical therapy for gait disturbances, which can be one of the initial complaints with a patient with cervical spine myelopathy.  Clinicians should to be aware of certain questions and objective measures to clear patients with this diagnosis.  The consistency of the IAOM-US evaluations, based on Cyriax’s teachings, is to perform a systematic evaluation every time while performing the least amount of testing for the most amount of information.  In doing the same evaluations each time, it is much easier to quickly identify discrepancies with these patients.  When performing a cervical evaluation, it is already recommended to perform upper extremity and lower extremity reflex testing as well as a Babinski as a quick screen.  Adding the performance of the Hoffman’s test can help rule in CSM.  In addition to the objective findings, the patient can quickly be assessed for gait deviations as he/she walks into your clinic for the initial examination.  Very easily and quickly, these 5 clinical findings that form a cluster with high specificity for a diagnosis of cervical spine myelopathy can be identified and the patient can be referred back to the physician for appropriate treatment.    

Hoffman’s Test

  • Grasp the patient’s middle phalanx of the 3rd digit then flick the patient’s distal phalanx into flexion.
  • A positive test is flexion of the interphalangeal joints of the thumb and index finger.

Inverted Supinator Sign

  • The arm is placed in a neutral position, allowing the natural ulnar deviation to occur.  Strike the brachioradialis tendon near the radial styloid process.
  • A positive test is flexion of the fingers.


  • Use the pointed end of the reflex hammer along the plantar surface of the foot then swipe lateral to medial across the ball of the foot.
  • A positive test is great toe extension and splaying of the other digits.


  1. Kalsi-Ryan S, Karadimas SK, Fehlings MG. Cervical spondylotic myelopathy: the clinical phenomenon and the current pathobiology of an increasingly prevalent and devastating disorder. Neuroscientist. 2013;19(4):409-421.
  2. Bednarik J, Kadanak Z, Dusek L, Novotny O, Surelova D, Urbanek I. Presymptomatic spondylotic cervical cord compression. Spine 2004;29:2260–9.
  3. Northover JR, Wild JB, Braybrooke J, Blanco J. 2012. The epidemiology of cervical spondylotic myelopathy. Skeletal Radiol 41:1543–6.
  4. Harrop JS, Hanna A, Silva MT, Sharan A.  Neurological manifestations of cervical spondylosis: an overview of signs, symptoms and pathophysiology.  Neurosurgery 2007;60(1 Supp1.1):S14-20.
  5. Fukushima T, Ikata T, Taoka Y, Takata S. Magnetic resonance imaging study on spinal cord plasticity in patients with cervical compression myelopathy. Spine 1991;16(10 Suppl.):S534–8.
  6. Young WF. Cervical spondylotic myelopathy: a common cause of spinal cord dysfunction in older persons. Am Fam Phys 2000;62:1064–70,1073.
  7. Cook C, Hegedus E, Pietrobon R, Goode A. A pragmatic neurological screen for patients with suspected cord compressive myelopathy. Phys Ther 2007;87:1233–42.
  8. Cook C, Roman M, Stewart KM, Leithe LG, Isaacs R. Reliability and diagnostic accuracy of clinical special tests for myelopathy in patients seen for cervical dysfunction. J Orthop Sports Phys Ther 2009;39:172–8.
  9. Emery SE, Bohlman HH, Bolesta MJ. Anterior cervical decompression and arthrodesis for the treatment of cervical spondylotic myelopathy: two to seventeen-year follow-up. J Bone Joint Surg (AM) 1998;80A:941–51.
  10. Denno JJ, Meadows GR. Early diagnosis of cervical spondylotic myelopathy: a useful clinical sign. Spine 1991;16:1353–5.
  11. Estanol BV, Marin OS. Mechanism of the inverted supinator reflex: a clinical and neurophysiological study. J Neuro Neurosurg Psych 1976;39:905–8.
  12. Ghosh D, Pradhan S. ‘‘Extensor toe sign’’ by various methods in spastic children with cerebral palsy. J Child Neurol 1998;13:216–20.
  13. Matsuda Y, Miyazaki K, Tada K, Yasuda A, Nakayama T, Murakami H, et al. Increased MR signal intensity due to cervical myelopathy — analysis of 29 surgical cases. J Neurosurg 1991;74:887–92.
  14. Matsumoto M, Toyama Y, Ishikawa M, Chiba K, Suzuki N, Fujimura Y. Increased signal intensity of the spinal cord on magnetic resonance images in cervical compressive myelopathy —Does it predict the outcome of conservative treatment? Spine 2000;25:677–82.
  15. McCormick WE, Steinmetz MP, Benzel EC. Cervical spondy- lotic myelopathy: make the difficult diagnosis, then refer for surgery. Cleve Clin J Med 2003;70:899–904.
  16. Al-Mefty O, Harkey LH, Middleton TH, Smith RR, Fox JL. Myelopathic cervical spondylotic lesions demonstrated by magnetic resonance imaging. J Neurosurg 1988;68:217–22.
  17. Wainner RS, Fritz JM, Irrgang JJ, Boninger ML, Delitto A, Allison S. Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy. Spine (Phila Pa 1976) 2003;28:52–62.

SPT Abstract: Effects of Low‐Intensity Walk Training With Restricted Leg Blood Flow on Muscle Strength and Aerobic Capacity in Older Adults

Abe, T., PhD, Sakmaki, M., PhD, Fujita, S., PhD, Ozaki, H., Sugaya, M., Sato, Y., MD, PhD, & Nakajima, T., MD, PhD. Journal of Geriatric Physical Therapy, 33(1), 34-40. January, 2010.

Article summary by Al Tentler, SPT from Missouri State University, Springfield, MO

The purpose of this parallel group, single-blinded, randomized controlled study was to investigate the effects of walk training combined with restricted blood flow to leg musculature, known as KAATSU training, on muscular size and strength, functional ability, and aerobic capacity in older participants. Nineteen men and women, aged 60 to 78 years, volunteered to participate in the study. Participants were randomized into either a KAATSU-walk training group (2 men and 9 women; n = 11) or a non-exercising control group (2 men and 6 women; n = 8). All participants in this study were physically active and most of them walked daily for exercise. Participants in the control group continued their daily physical activity, but no additional exercise routine was imposed by the investigators. The KAATSU-walk group performed 20-minute treadmill walking (67 m/min), 5 days/wk for 6 weeks.

The authors of this study required participants to fill out a medical history questionnaire and participate in a health interview conducted by a physician before being accepted into the study to ensure that there were no existing health risks. Exclusion criteria for this study included history of any cardiovascular disease, diabetes, cancer, orthopedic disorders, deep vein thrombosis, or peripheral vascular disease. None of the participants in this study had participated in strengthen or resistance-type training for a minimum of 2 years prior to the start of the study.

In order to measure and record skeletal muscle mass (SMM), the authors of this study used the combination of derived equations to account for the muscle-bone cross-sectional area and the use of an ultrasound to measure muscle thickness for the mid thigh and 30% of the proximal lower leg. The muscle thickness was converted into kilograms by the use of the derived equations, which were then used to calculate the segmental skeletal mass of the lower extremities. Strong correlations, ranging from r = 0.83 to r = 0.96, were observed between the measured and the predicted SMM for total and all regional segments of the SMM. The standard error of estimates for the various predicted SMMs ranged from 0.6 kg to 1.8 kg. This measurement was completed at baseline and 3 days after the final training.

Maximum voluntary isometric and isokinetic knee flexion and extension contractions were used as the measure of muscular strength. These measurements were determined by using a Biodex System-3 dynamometer. The study participants were able to familiarize themselves with the Biodex and the testing 1 week before the testing. Several warm-up contractions were performed before testing. Participants were then instructed to perform maximal isometric knee extension at a fixed knee joint angle of 75°, followed by maximal isokinetic knee extensions and flexions between 0° and 90° at 3 different testing speeds (30°/s, 90°/s, and 180°/s). A knee joint angle of 0° corresponded to full extension of the knee. The test was assessed at baseline and 3 days after the final walk-training session.

In order to measure aerobic capacity, oxygen uptake was measured before and after the training program by using an automated breath-by-breath mass spectrometry system. Participants warmed up at 60 m/min on a 0% grade for 3 minutes. Then, the treadmill speed was held constant while the grade was increased by 1.8% every 2 minutes until participants reached approximately 80% of their age-predicted maximum HR (220 − age). Each participant’s electrocardiogram was monitored constantly during the exercise session, and was used to measure HR at intervals of 60 seconds. Ratings of perceived exertion were also recorded every 2 minutes during exercise. V̇O2peak was estimated by fitting the age-predicted maximum HR value into the linear regression equation computed from the individual V̇O2 and HR values during graded exercise.

The Timed Up and Go and the Sit to Stand tests (participants stand up for seated position as many times as possible in 30 seconds) were used to asses the participants functional abilities. Scores were recorded before and after training program.

At the baseline measurements, there was no significant differences in any categories. The results of the study showed improvements in the experimental group for isometric (11%) and isokinetic (7%-16%) knee extension and flexion torques, muscle-bone cross-sectional area (5.8% and 5.1% for thigh and lower leg, respectively), and ultrasound-estimated skeletal muscle mass (6.0% and 10.7% for total and thigh, respectively) increased (P < .05) in the K-walk group but not in the control group. Functional ability also increased significantly only in the K-walk group (P < .05); however, there was no change in the estimated peak oxygen uptake (absolute and relative to body mass) for either group.

Personal Commentary:

Blood flow restriction training, known as KAATSU training, is a relatively new concept that is being pushed in the fitness industry. Studies have shown this new training method has shown to significantly increase the size and strength of skeletal muscle using low intensity training (Abe et al., 2005 & Takarada et. al., 2002). If this low-intensity training could be utilized with the elderly population, it may be able to increase function and decrease the risk for future falls, which is the leading cause of fatal injuries among older adults (Fall Prevention Facts, 2016). This training could also be utilized in a patient’s rehabilitation program for more efficient results.

This study assessed if walk exercise with KAATSU would improve muscular fitness and functional ability in aging adults, as it previously had not been studied. However, I do not believe the results of this study are completely valid due to the study design. First off, there is too small of a sample size to consider this study statically significant for the general population. Second, the control group may not be a good representation of the general population, as the majority of the general population may not be walking daily to get physical activity. The control group did not perform the same walk training program as the experimental group. The control group was simply told to continue the active lifestyle they were currently living. Being active can constitute a variety of different things and, therefore, it is unknown what members of the control group where participating in during the study. Therefore, it cannot be determined whether the individuals in the experimental group saw increases in muscular size and strength, along with improved functional ability, as a result of the KAATSU training or from a walking program. The idea of this study was commendable as it appears that KAATSU training can be very beneficial based off of initial findings. If this study was conducted again, in which there was a control group performing the same walking program as the experimental group using KAATSU training, the results would be more valid. During this period of constant change in the health care field, insurance is paying for less visits for patients and it is the job of a physical therapists to become more efficient with his/her treatment. The KAATSU training could be a valuable step to increasing treatment efficiency, however, more valid research needs to be conducted prior to implementation with patients.


  1. Abe, T., PhD, Sakmaki, M., PhD, Fujita, S., PhD, Ozaki, H., Sugaya, M., Sato, Y., MD, PhD, & Nakajima, T., MD, PhD. (2010, January). Effects of Low‐Intensity Walk Training With Restricted Leg Blood Flow on Muscle Strength and Aerobic Capacity in Older Adults. Journal of Geriatric Physical Therapy, 33(1), 34-40. doi:10.1097/JPT.0b013e3181d07a73
  2. Abe T, Yasuda T, Midorikawa T, et al. Skeletal muscle size and circulating IGF-1 are increased after two weeks of twice daily “KAATSU” resistance training. Int J KAATSU Train Res. 2005;1:6–12.
  3. Abe T, Kearns CF, Sato Y. Muscle size and strength are increased following walk training with restricted venous blood flow from the leg muscle, Kaatsu-walk training. J Appl Physiol. 2006;100:1460–1466.
  4. Falls Prevention Facts. (2016). Retrieved September 25, 2016, from https://www.ncoa.org/news/resources-for-reporters/get-the-facts/falls-prevention-facts/
  5. Takarada Y, Sato Y, Ishii N. Effects of resistance exercise combined with vascular occlusion on muscle function in athletes. Eur J Appl Physiol. 2002;86:308–314.

Study: Non-steroidal anti-inflammatory drugs for spinal pain: a systematic review and meta-analysis

Here is another interesting study related to prescribing NSAIDs for spinal pain despite there being no practical evidence that they work.


Background While it is now clear that paracetamol is ineffective for spinal pain, there is not consensus on the efficacy of non-steroidal anti-inflammatory drugs (NSAIDs) for this condition. We performed a systematic review with meta-analysis to determine the efficacy and safety of NSAIDs for spinal pain.

Methods We searched MEDLINE, EMBASE, CINAHL, CENTRAL and LILACS for randomised controlled trials comparing the efficacy and safety of NSAIDs with placebo for spinal pain. Reviewers extracted data, assessed risk of bias and evaluated the quality of evidence using the Grade of Recommendations Assessment, Development and Evaluation approach. A between-group difference of 10 points (on a 0–100 scale) was used for pain and disability as the smallest worthwhile effect, as well as to calculate numbers needed to treat. Random-effects models were used to calculate mean differences or risk ratios with 95% CIs.

Results We included 35 randomised placebo-controlled trials. NSAIDs reduced pain and disability, but provided clinically unimportant effects over placebo. Six participants (95% CI 4 to 10) needed to be treated with NSAIDs, rather than placebo, for one additional participant to achieve clinically important pain reduction. When looking at different types of spinal pain, outcomes or time points, in only 3 of the 14 analyses were the pooled treatment effects marginally above our threshold for clinical importance. NSAIDs increased the risk of gastrointestinal reactions by 2.5 times (95% CI 1.2 to 5.2), although the median duration of included trials was 7 days.

Conclusions NSAIDs are effective for spinal pain, but the magnitude of the difference in outcomes between the intervention and placebo groups is not clinically important. At present, there are no simple analgesics that provide clinically important effects for spinal pain over placebo. There is an urgent need to develop new drug therapies for this condition.

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Natour, J., de Araujo Cazotti, L., Ribeiro, L. H., Baptista, A. S., & Jones, A. (2015). Clinical rehabilitation,29(1), 59-68.

Abstracted by: Rachel Swortwood, SPT, Springfield, Missouri

Article Summary

This randomized, controlled clinical trial with a blinded evaluator, evaluated the effects of pilates as a treatment method on patients with chronic non-specific low back pain (LBP). Sixty patients were selected from a physical therapy waiting list that met the inclusion criteria, and randomly assigned to one of two groups.

The experimental group (n=30) was instructed to maintain medication treatment with the use of non-steroidal anti-inflammatory drug (NSAID), and underwent treatment in a pilates studio from a certified, physical educator with 10 years of experience. Pilates classes lasted 50 minutes, followed a pre-established pilates protocol, and consisted of three to four patients. They took place twice a week for a total of 90 days. The control group (n=30) was instructed to continue medication treatment with the use of NSAID, and did not undergo any other intervention. An examiner blinded to the assignment performed all evaluations at baseline, at 45 days, at 90 days, and at 180 days after the conclusion of the exercise program. Parameters that were assessed included: pain (Visual analog scale), function (Roland-Morris questionnaire), quality of life (SF-36), satisfaction with treatment (Likert scale), flexibility (sit-and-reach), and NSAID intake. Significant differences were found favoring the experimental group regarding pain, function, quality of life domains, and amount of NSAIDs taken.

Personal Commentary

Pilates uses a combination of repetitive exercises that can be adapted to provide either gentle strength training for rehabilitation or a strenuous workout. The exercises are designed to increase muscle strength, endurance, and flexibility, as well as improve balance and posture (Kloubec 2011). As Kloubec stated the focus is on effective muscle recruitment which places the emphasis on energy efficiency and quality of performance. Pilates focuses on breathing and concentration during the execution of each exercise, and prior to each exercise the goal is to properly initiate the transversus abdominis muscle to improve the control of the movement. It is widely known and studied that exercise is better than no exercise on the effects of chronic low-back pain. However, some previous research has not shown significant differences in chronic low-back pain when implementing pilates. A systematic review by Miyamoto and colleagues concluded that “pilates was no better than other types of exercises for reducing pain intensity.” Another systematic review with meta-analysis however, found that pilates-based exercises were superior to minimal intervention for pain relief, and that articles stating otherwise were of low quality and should be interpreted with caution due to the heterogeneity of pooled studies (Lim 2011).
Regardless of the research found, pilates incorporates several components of stabilization that should be included with regular treatment of patients with chronic low back pain, especially if they are experiencing instability. With a good pilates instructor and a patient with an open mind to the concept, the use of pilates may be a unique treatment option that can be used in addition to other skilled physical therapy interventions


Kloubec, J. (2011). Pilates: how does it work and who needs it? MLTJ Muscles, Ligaments and Tendons Journal, 1(2), 61-66.

Lim EC, Poh RL, Low AY, et al. Effects of pilates based exercises on pain and disability in individuals with persistent nonspecific low back pain: a systematic review with meta-analysis. J Orthop Sports Phys Ther 2011; 41:70-80

Miyamoto, G. C., Costa, L. O. P., & Cabral, C. M. N. (2013). Efficacy of the Pilates method for pain and disability in patients with chronic nonspecific low back pain: a systematic review with meta-analysis. Brazilian Journal of Physical Therapy, 17(6), 517–532.


Mintken, PE; McDevitt, AW; Cleland, J; Boyles, RE; Beardslee, AR; Burns, SA; Haberl, MD; Hinrichs, LA; Michener, LA. Journal of Orthopaedic & Sports Physical Therapy. 46(8): 617-628, A1-A8.

Abstracted by: John Chatwell, SPT at Missouri State University, Springfield, Missouri

This multicenter, randomized controlled trial objective was to compare the effects of cervicothoracic manual therapy techniques paired with exercise therapy versus exercise therapy, alone, in the treatment of shoulder patient using two groups, respectively. One-hundred forty participants met the following inclusion criteria: were 18-65 years of age with primary complaint of shoulder pain, and scored greater than a 20% on the Shoulder Pain and Disability Index (SPADI). Exclusion criteria included present contraindications for manipulation techniques or demonstrated severe pathology.

Participant preliminary assessments and outcomes were assessed using the SPADI, the Disabilities of the Arm, Shoulder, and Hand score (QuickDASH), and a numeric pain scale rating (NPSR) (0-10 rating scale), to determine pain, disability, and limitations of function of their upper extremities. Secondary outcomes, the global rating of change (GROC) scale and Patient Acceptable Symptom State (PASS), were conducted to determine “patient perceived recovery” following treatment.

Each group was treated twice a week for four weeks. The “exercise only” group was treated with cervicothoracic range of motion exercises for the first two sessions and received strengthening exercises the following six.  The “manual therapy and exercise” group was treated with “high dose” cervicothoracic manual therapy techniques for the first two treatment sessions and received the same exercise therapies prescribed to the “exercise only” group. The cervicothoracic manual therapy techniques included a gamut of high and low velocity thrust and traction techniques at mid- to end-ranges, developed per Mintken.

Diagnosis and Management Info for Cervical Spine Pain

Baseline outcomes at weeks one and four and six months between the primary outcomes (SPADI, QuickDASH, and NPSR) demonstrated no significant difference between the two treatment groups, remarking that manual therapy techniques did not add any additional benefits to shoulder pain and dysfunction. However, the PASS demonstrated significantly increased values at four weeks and the GROC demonstrated significant improvement at four weeks and six months, demonstrating increased “patient perceived improvement” and “patient-perceived acceptability of symptoms and improvement”, respectively.

In summation the authors acknowledged that manual therapy may improve “patient-perceived acceptability of symptoms and improvement”, without adding any measurable difference to pain and dysfunction, as demonstrated by the primary outcomes. It’s proposed that centralization of chronic pain and disallowing clinical reasoning to adjust techniques and therapy regimens specifically to patient needs could have restricted pain and function improvement due to therapy.

Commentary Notes:

Manual therapy manipulation and soft tissue techniques have been widely utilized and studied with development of various models of treatment since the 1950’s (Pettman, 2007 ) Manual therapy manipulation, has been shown to demonstrate improved pain within 48 hours of treatment of the thoracic spine (Boyles, et al., 2009) and the use of manual therapy may improve recovery speed in shoulder pain patients and improve pain and function compared to that of usual care (Peek, Miller, & Heneghan, 2015). .  Sobel et al. reported that 40% of patients with chronic shoulder pain demonstrated cervicothoracic and adjacent ribs impairments with their pain.  The study implies that manipulative manual therapy, in a fixed standard presentation, provided significantly increased “perceived patient recovery”, implying increased patient comfort and satisfaction with treatment and recovery.  This could imply greater positive outlook of the patient on therapy services and return to activities of daily living with increased comfort regarding the treated upper extremity.

  • Boyles, R., Ritland, B., Miracle, B., Barclay, D., Faul, M., Moore, J., & Koppenhaver, S. W. (2009). The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement syndrome. Manual Therapy, 14(4): 375-380.
  • Peek, A., Miller, C., & Heneghan, N. (2015). Thoracic Manual Therapy in the management of non-specific shoulder pain: a systematic review . Journal of Manual and Manipulative Therapy , 23(4): 176-187.
  • Pettman, E. (2007 ). A History of Manipulative Therapy. Journal of Manual and Manipulative Therapy , (15)3: 165-174.
  • Sobel, J., Kremer, I., Winters, J., Arendzen, J., & de Jong, B. (1996). The influence of the mobility in the cervicothoracic spine and the upper ribs (shoulder girdle) on the mobility of the scapulohumeral joint. Journal of Manipulative and Physiological Therapeutics , 19(7): 469-474.


Martins, W. R., Blasczyk, J. C., Oliveira, M. A., Gonçalves, K. F., Bonini-Rocha, A. C., Dugailly, P., & Oliveira, R. J. (2016). Efficacy of musculoskeletal manual approach in the treatment of temporomandibular joint disorder: A systematic review with meta-analysis. Manual Therapy, 21, 10-17. doi:10.1016/j.math.2015.06.009

Abstracted by: Douglas Cordel, SPT, ACSM EP-C from Missouri State University, Springfield, MO

This systematic review with meta-analysis evaluated the efficacy of the musculoskeletal manual approach (MMA) in the treatment of temporomandibular joint disorder (TMD). From an initial search of “temporomandibular joint disorder” and similar keywords on four databases (PubMed, The Cochrane Library, PEDro and ISI Web of Knowledge), 308 studies were identified to be potentially used in the analysis. Only randomized controlled trials published in English were included in this search. Ultimately, eight randomized controlled trials were included in the analysis, with the following exclusion criteria: subjects with surgical history on the temporomandibular joint, and interventions which the MMA was combined with other therapeutic resources with inadequate control comparisons. The methodological quality of the studies was assessed using the PEDro scale, revealing five of the eight as having high quality, and three having low quality, with a global “high quality” average. The outcome measures were range of motion (ROM) and pain. These were analyzed using standard mean difference pooled with 95% confidence interval and mean difference pooled with 95% confidence interval, respectively.

In the analyzed randomized controlled trials, there were a total of 375 total individuals with ages ranging from 12 to 44.5 years old, both males and females. The individual study size ranged from 26 to 122 individuals, with the comparison group size ranging from 13 to 41 individuals. The majority of studies employed combined articular (mandibular distraction and translation mobilizations, mandibular accessory movements, cervical mobilizations and craniocervical thrust) and extra-articular (myofascial release, muscle energy, cranial-sacral, muscle stretching, and tender trigger point) techniques.

The analysis showed significant results for increased active ROM, and decreased pain with active ROM. It did show improvement, albeit insignificantly, for increased passive ROM and decreased pain at rest. The authors caution the direct interpretation of the insignificant data, however. They cited that every study had considerably favorable data for MMA, and that this outcome could have been attributed to the large variability of confidence intervals between the individual studies. The authors mention that the results were shown to be effective in short term (</= 3-6 months), but that the goals of managing TMD are best achieved when a multi-disciplinary approach is employed, with respect to decreasing pain, and increasing muscular control and strength. The authors concluded that the effects of MMA for short-term treatment of TMD is superior to other conservative treatments for the same.

Other than the apparent biomechanical effects on active ROM, the analgesic effects of MMA as being neurophysiological in nature was discussed, based on recent and growing evidence. This model suggests that the decrease in pain is a result of several neurophysiological processes: actions mediated by the periaqueductal grey; lessening of temporal summation; reduction of blood and serum levels of cytokines and substance P levels; changes in muscle activity and motor neuron pool activity.

Personal Commentary

Manual therapy is a common practice among several clinical practitioners, including physical therapists. As an adjunct or as a primary treatment method for the management of many musculoskeletal conditions, manual therapy is an effective tool. The author mentioned the neurophysiological effects of manual therapy, and this was outlined by Bailosky et al (2009). In a separate systematic review and meta-analysis asking a similar question to this publication, Armijo-Olivo et al (2016) reported that there were no clear advantages to TMD exercises over other forms of conservative management, but that manual techniques alone or combined with exercise showed promise.

It is reasonable to suggest that these short term effects on pain reduction can offer a greater efficacy in the overall treatment of the underlying TMD issues the patient may be facing. Effective pain control will allow clinicians to progress patients through the continuum of musculoskeletal management, from pain reduction, to motor control, to strength and function, to wellness.


Armijo-Olivo, S., Pitance, L., Singh, V., Neto, F., Thie, N., & Michelotti, A. (2015). Effectiveness of Manual Therapy and Therapeutic Exercise for Temporomandibular Disorders: Systematic Review and Meta-Analysis. Physical Therapy, 96(1), 9-25. doi:10.2522/ptj.20140548

Bialosky, J. E., Bishop, M. D., Price, D. D., Robinson, M. E., & George, S. Z. (2009). The mechanisms of manual therapy in the treatment of musculoskeletal pain: A comprehensive model. Manual Therapy, 14(5), 531-538. doi:10.1016/j.math.2008.09.001


Hildago B, Detrembleur C, Hall T, Mahaudens P, Nielens H. Journal of Manual and Manipulative Therapy. 2014;22:59-74  

Abstracted by: Chris Frye, SPT from Missouri State University, Springfield, MO

This systematic review was performed to further understand and update common knowledge of the efficacy of different manual therapy techniques of non-specific low back pain during different stages of the healing process. Therefore, the review was split into two groups; Acute and subacute in one category indicating onset of symptoms less than or equal to twelve weeks and chronic indicating symptom onset longer than twelve weeks. Because the aim of the review was to update common knowledge, the inclusion time frame of each randomized controlled trial used was between January 2000 and April 2013. The process of obtaining articles of review was conducted by two reviewers within MEDLINE, Chochrane-Register-of-Controlled-Trials, PEDro, and EMBASE with inclusion of ages eighteen to sixty years old, single or double blind study design, and low back pain treatment intervention compared to no, placebo, or alternate effective treatment. Low back pain quality inclusion was determined by the Quebec-Task-force categories one through three; Low back pain alone, low back pain radiating to the thigh but not extending below the knee, and low back pain with nerve root pain lacking neurologic deficit respectively. Three hundred and six studies were reviewed and narrowed by inclusion criteria to fifty-six, then further reduced to twenty-three which were determined to be at a low risk for bias with high to moderate quality, and finally reduced to eleven which presented new or updated evidence. The manual therapy treatments observed were in subgroups of lumbo-pelvic manipulation with high velocity low amplitude thrust, non-thrust lumbo-pelvic mobilization and soft-tissue technique, a combination of the two mentioned, a combination of the first two mentioned with general or specific exercise, and usual medical care involving education, activity, and medication.

The consensus of five of the eleven studies suggested that for the acute and sub-acute category manipulation compared to sham/placebo manual therapy had a clinically relevant reduction of pain. Mobilization and manipulation with universal medical care compared to universal medical care alone had clinically relevant reduction of pain.

The consensus of the six of the eleven studies suggested that for the chronic category manipulation compared to sham/placebo manual therapy had clinically relevant reduction of pain. Mobilization/soft tissue therapy with universal medical care including back-school compared to universal medical care including back-school alone had clinically relevant reduction of pain. Manipulation, mobilization/soft tissue therapy, and exercise compared to exercise alone had clinically relevant reduction in pain for both groups, however, functional improvements and return to work rate at two months were in favor of the combined approach. Manipulation with extension exercises once per hour compared to the same extension exercises had clinically relevant reduction in pain with no difference between groups.

Within both categories of low back pain, it cannot be assumed these reductions of pain will be clinically relevant during long term intervention greater than one year. It can also not be assumed that the reduction in pain will cause overall psychosocial and overall health improvements.

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Personal Commentary

As stated in the review, back pain will effect an estimated 80% of the population during their lifetime. This percentage, review, and mission of the authors are relevant to my future career as a licensed physical therapist. Of my own generally narrowed perspective of clinical experience, I have had the opportunity to learn from equally qualified instructors within an outpatient setting of which low back pain was a largely portioned diagnosis. My observation and reflection regarding my experiences was that when manual therapy was utilized as a treatment tool, there appeared to be superior pain and functional outcomes as well as patient perception that therapy was worth their time and resources. This review supports my observation and will directly influence my future clinical judgment and management of low back pain. I will have greater confidence that I am truly practicing a skilled intervention that will provide relief from this debilitating condition as opposed to mere perception that what I am doing is making a difference giving relevance to my career and decision making process. Having said this, It is my belief that the entire continuum of patient centered care should never be viewed as a single dimension/variable and instead viewed as a holistic and multidisciplinary approach. In an article titled Its time for change with the management of non-specific chronic low back pain Peter O’ Sullivan expands on this ideation supporting more aggressive intervention of understanding the patient’s social risk factors and states firm support of the biopsychosocial model compared to the patho-anatomical approach during treatment of non-specific low back pain. Perhaps greater pursuit of emotional factors will provide/attribute to long term success not suggested by the systematic review in question.


  1. Hildago B, Detrembleur C, Hall T, Mahaudens P, Nielens H. (2014) . The efficacy of manual therapy and exercise for different stages of non-specific low back pain: an update of systematic reviews. Journal of manual and manipulative therapy, 22, 59-74. Doi:10.1179/2042618613Y.0000000041
  2. Sullivan, P. (2011) . It’s time for change with management of non-specific chronic low back pain. British journal of sports medicine, 1-4. Retrieved from: https://www.researchgate.net/profile/Peter_OSullivan2/publication/51552098_It’s_time_for_change_with_the_management_of_non-specific_chronic_low_back_pain/links/0046351c1a53137c8b000000.pdf

A Physical Therapist Explains Why It’s Important to Choose the Right Con-Ed Path

Kasey Miller DPT, COMT shares why IAOM-US is the best choice for your continuing education
I’d like to share with you my story and how much the IAOM-US has helped. I am a recent graduate from Kansas University Medical School and have only been out for 1 year (graduated in 2016). Prior to getting exposed to the IAOM systematic approach, I felt that I was lost. I felt that I learned a ton of information in school but did not know exactly how to use it.
I have always known that I wanted to be an outpatient physical therapy but was just so overwhelmed by the lack of structure to the approach that school took which had me questioning whether to complete physical therapy school or shift careers all together.
I got exposed to the IAOM through Esteban, as he and a few of his colleagues came to our school and did a 45 minute lecture on the cervical spine. It was during this lecture, that I realized I learned more in 45 minutes about the cervical spine than I did during my semester long spine course. Once I saw that there was a more thorough approach to treating patients, I was hooked on the IAOM. 
I then signed up to do one of my last internships at Modern Physical Therapy in Kansas City, Missouri, which is an IAOM based clinic. During these 9 weeks, I learned more than I did throughout my whole educational experience at school.
Not only does the IAOM-US approach teach you manual techniques, but it also teaches you when to use them and which patients would benefit from them. One aspect of the IAOM that you will continue to see/hear if you decide to pursue the COMT through us, is that we teach how to diagnose specific pain generators. Too often you see therapist in the clinic treat based off dysfunctions. And as Esteban eluded to in his email, that works great for acute patients but what about those patients who have recurring problems?
It is vital to the patients success that you can figure out what specifically is causing the pain in order to further understand how you can get that pain to go away. Along with the specific pain generators, the IAOM teaches you a systematic algorithm to help you approach every evaluation that you do in the clinic. I found this algorithm to be extremely helpful and truly helps dictate how you create your plan of care. By doing every examination the same, it teaches you the different patterns that every pain generator has, and if you know the patterns, then this allows you to know how to treat your patients more effectively and more efficiently. 
Prior to pursuing the COMT through the IAOM, I took several other classes with different CE groups and can say that I truly feel that IAOM has the most complete package. 
Feel free to ask me any other questions as I would love to help because I was recently in the same spot as you… trying to further my education but did not know which direction to go.
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