This document summarizes and discusses several research studies related to manual therapy and musculoskeletal conditions: - One study found no additional benefit of adding neck manual therapy to treatment for shoulder impingement syndrome. Reasons may include a lack of sufficient dosage or benefits for patients without neck problems. - Another study compared the effects of active craniocervical flexion exercise versus passive mobilization on cervical range of motion and pain in patients with chronic neck pain, finding greater short-term pain relief from exercise. - A third study classified low back pain patients according to an existing system and found most classifications remained stable over 10 days, though differences between subgroups were small. Classification may need to consider psychological factors to be useful.

1. Manuelle Medizin 2014 · 52:349–351
DOI 10.1007/s00337-014-1122-4
Published online: 23. Juli 2014
© Springer-Verlag Berlin Heidelberg 2014
K. Ammer
Wien
Abstracts from the
international literature
Shoulder impingement syndrome (SIS) is
a complex, multifactorial problem that is
treated with a variety of different conser-
vative options. One conservative option
that has shown effectiveness is manual
therapy to the thoracic spine. Another op-
tion, manual therapy to the cervical spine,
has been studied only once with good re-
sults, evaluating short-term outcomes, in
a small sample size. The purpose of this
study was to investigate the benefit of neck
manual therapy for patients with SIS. The
study was a randomised, single blinded,
clinical trial where both groups received
pragmatic, evidence-based treatment to
the shoulder and one group received neck
manual therapy. Subjects with neck pain
were excluded from the study. Compara-
tive pain, disability, rate of recovery and
patient acceptable symptom state (PASS)
measures were analyzed on the 68 subjects
seen over an average of 56.1 days (stan-
dard deviation (SD) =55.4). In all, 86% of
the sample reported an acceptable change
on the PASS at discharge. There were no
between-groups differences in those who
did or did not receive neck manual ther-
apy; however, both groups demonstrated
significant within-group improvements.
On average both groups improved 59.7%
(SD =25.1) for pain and 53.5% (SD =40.2)
for the Quick Disabilities of the Shoulder
and Hand Questionnaire (QuickDASH)
from baseline. This study found no val-
ue when neck manual therapy was added
to the treatment of SIS. Reasons may in-
clude the lack of therapeutic dosage pro-
vided for the manual therapy approach or
the lack of benefit to treating the neck in
subjects with SIS who do not have con-
comitant neck problems.
This study compared the immediate ef-
fects of an assisted plus active cranio-
cervical flexion exercise (exercise group)
versus a passive mobilisation plus assist-
ed cranio-cervical flexion (mobilisation
group) on performance of the cranio-cer-
vical flexion test (CCFT), cervical range of
motion (ROM) and pain in patients with
chronic neck pain. Eighteen volunteers
with chronic idiopathic neck pain partic-
ipated in the study and were randomised
to one of the two intervention groups.
Current level of pain, cervical ROM and
pain perceived during movement, pres-
sure pain threshold (PPT) and surface
electromyography (EMG) during perfor-
mance of the CCFT were measured before
and immediately after the intervention. A
significant reduction in resting pain and
PPT measured over cervical sites was ob-
served immediately following both in-
terventions, although a greater change
was observed for the exercise group. No
change in cervical ROM was observed af-
ter either intervention. Reduced sterno-
cleidomastoid and anterior scalene EMG
amplitude were observed during stages of
the CCFT but only for the participants in
the active exercise group. Although both
active and passive interventions offered
pain relief, only the exercise group im-
proved on a task of motor function high-
lighting the importance of specific active
treatment for improved motor control of
the cervical spine.
Subgrouping of low back pain (LBP) is
believed to improve prediction of prog-
nosis and treatment effects. The ob-
jectives of this study were (1) to exam-
ine whether chiropractic patients could
be subgrouped according to an exist-
ing patho-anatomically-based classifica-
tion system, (2) to describe patient char-
acteristics within each subgroup, and (3)
to determine the proportion of patients
in whom clinicians considered the clas-
sification to be unchanged after approx-
imately 10 days. A cohort of 923 LBP pa-
tients was included during their first con-
sultation. Patients completed an exten-
sive questionnaire and were examined ac-
cording to a standardised protocol. Based
on the clinical examination, patients were
classified into diagnostic subgroups. Af-
ter approximately 10 days, chiropractors
reported whether they considered the
subgroup had changed. The most fre-
quent subgroups were reducible and part-
ly reducible disc syndromes followed by
facet joint pain, dysfunction and sacroil-
iac (SI) joint pain. Classification was in-
Original publication
Cook C, Learman K, Houghton S et al (2014)
The addition of cervical unilateral posterior–
anterior mobilisation in the treatment of pa-
tients with shoulder impingement syndrome:
a randomised clinical trial. ManTher 19:18–24
Original publication
Lluch E, Schomacher J, Gizzi L et al (2014)
Immediate effects of active cranio-cervical
flexion exercise versus passive mobilisation
of the upper cervical spine on pain and per-
formance on the cranio-cervical flexion test.
ManTher 19:25–31
Original publication
Eirikstoft H, Kongsted A (2014) Patient char-
acteristics in low back pain subgroups based
on an existing classification system. A de-
scriptive cohort study in chiropractic practice.
ManTher 19:65–71
349Manuelle Medizin 4 · 2014 |
Literatur im Fokus

2. conclusive in 5% of the patients. Differ-
ences in pain, activity limitation, and psy-
chological factors were small across sub-
groups. Within 10 days, 82% were report-
ed to belong to the same subgroup as at
the first visit. In conclusion, LBP patients
could be classified according to a stan-
dardised protocol, and chiropractors con-
sidered most patient classifications to be
unchanged within 10 days. Differences in
patient characteristics between subgroups
were very small, and the clinical relevance
of the classification system should be in-
vestigated by testing its value as a prog-
nostic factor or a treatment effect modifi-
er. It is recommended that this classifica-
tion system be combined with psycholog-
ical and social factors if it is to be useful.
The aim of this reliability study was to
identify the clinimetric properties, specif-
ically intra- and inter-rater reliability, for
measuring the functionally and clinically
important hand behind back (combined
shoulder internal rotation/adduction and
elbow flexion) range of motion using a
modified technique. Sixty asymptomat-
ic participants (20 male, 40 female) aged
45.4±11.7 years (mean ±SD). Hand be-
hind back was measured as the distance
from the mid-line between the posterior
superior iliac spines (PSIS) to the tip of the
thumb and recorded in centimetres above
the PSIS (a positive measure) or below the
PSIS (a negative measure). The intra- and
inter-rater reliability for the measurement
were excellent, with ICC (2,1) of 0.95 for
intra-rater and ICC (2,2) of 0.96 for inter-
rater reliability. The standard error of the
measurement (SEM) and smallest real dif-
ference (SRD) values showed acceptable
levels of measurement error, SEM 4.3 mm
and SRD 12.8 mm for intra-rater reliabili-
ty and SEM 2.6 mm and SRD 7.7 mm for
inter-rater reliability. The assessment of
hand-behind-back motion from a point
equidistant between the PSISs to the tip
of the thumb is more reliable than tradi-
tional methods and a useful clinical tool.
Objective
The objective of the study was to inves-
tigate the cerebrovascular hemodynam-
ic response of cervical spine positions in-
cluding rotation and cervical spine ma-
nipulation in vivo using magnetic reso-
nance imaging technology on the verte-
bral artery (VA).
Methods
This pilot study was conducted as a blind-
ed examiner cohort with 4 randomized
clinical tasks. Ten healthy male partici-
pants aged 24–30 years (mean 26.8 years)
volunteered to participate in the study.
None of the participants had a histo-
ry of disabling neck, arm, or headache
pain within the last 6 months. They did
not have any current or history of neuro-
logic symptoms. In a neutral head posi-
tion, physiologic measures of VA blood
flow and velocity at the C1–2 spinal level
were obtained using phase-contrast mag-
netic resonance imaging after 3 differ-
ent head positions and a chiropractic up-
per cervical spinal manipulation. A total
of 30 flow-encoded phase-contrast imag-
es were collected over the cardiac cycle, in
each of the 4 conditions, and were used to
provide a blood flow profile for one com-
plete cardiac cycle. Differences between
flow (in milliliters per second) and veloc-
ity (in centimeters per second) variables
were evaluated using repeated-measures
analysis of variance.
Results
The side-to-side difference between ip-
silateral and contralateral VA veloci-
ties was not significant for either veloci-
ties (P=0.14) or flows (P=0.19) through-
out the conditions. There were no other
interactions or trends toward a difference
for any of the other blood flow or veloci-
ty variables.
Conclusion
There were no significant changes in
blood flow or velocity in the vertebral ar-
teries of healthy young male adults after
various head positions and cervical spine
manipulations.
Objective
The purpose of this study was to devel-
op and test a clinically relevant method to
mechanically stimulate lumbar function-
al spinal units while recording brain activ-
ity by means of functional magnetic reso-
nance imaging (MRI).
Methods
Subjects were investigated in the prone
position with their face lying on a mod-
ified stabilization pillow. To minimize
head motion, the pillow was fixed to the
MRI headrest, and supporting straps were
attached around the shoulders. An expe-
rienced manual therapist applied con-
trolled, nonpainful pressure stimuli to
10 healthy subjects at 3 different lumbar
vertebrae (L1, L3, and L5). Pressure ap-
plied to the thumb was used as a con-
trol. The stimulation consisted of pos-
terior to anterior (PA) pressure move-
ment. The therapist followed a random-
ized stimulation protocol projected onto
a screen in the MRI room. Blood oxygen-
ation level-dependent responses were an-
alyzed in relation to the lumbar and the
thumb stimulations. The study was con-
ducted by the Chiropractic Department,
Faculty of Medicine, University of Zürich,
Switzerland.
Results
No participant reported any discomfort
due to the prone-lying position or use of
the pillow. Importantly, PA-induced pres-
Original publication
Dolder PA van den, Ferreira PH, Refshauge
K (2014) Intra- and inter-rater reliability of a
modified measure of hand behind back range
of motion. ManTher 19:72–76
Original publication
Quesnele JJ,Triano JJ, Noseworthy MD,Wells
GD (2014) Changes in vertebral artery blood
flow following various head positions and
cervical spine manipulation. J Manipulative
PhysiolTher 37:22–31
Original publication
Meier ML, Hotz-Boendermaker S, Boender-
maker B et al (2014) Neural responses of
posterior to anterior movement on lumbar
vertebrae: a functional magnetic resonance
imaging study. J Manipulative PhysiolTher
37:32–41
350 | Manuelle Medizin 4 · 2014
Literatur im Fokus

3. sure produced only minimal head move-
ments. Stimulation of the lumbar spi-
nous processes revealed bilateral neu-
ral responses in medial parts of the post-
central gyrus (S1). Additional activity was
observed in the secondary somatosenso-
ry cortex (S2), posterior parts of the insu-
lar cortex, different parts of the cingulate
cortex, and the cerebellum. Thumb stim-
ulations revealed activation only in lateral
parts of the contralateral S1.
Conclusion
The current study demonstrates the feasi-
bility of the application of PA pressure on
lumbar spinous processes in an MRI en-
vironment. This approach may serve as a
promising tool for further investigations
regarding neuroplastic changes in chron-
ic low back pain subjects.
Objective
The purpose of this study was to deter-
mine how the preload that precedes a
high-velocity, low-amplitude spinal ma-
nipulation (HVLA-SM) affects muscle
spindle input from lumbar paraspinal
muscles both during and after the HV-
LA-SM.
Methods
Primary afferent activity from muscle
spindles in lumbar paraspinal muscles
were recorded from the L6 dorsal root in
anesthetized cats. High-velocity, low-am-
plitude spinal manipulation of the L6 ver-
tebra was preceded either by no preload
or systematic changes in the preload mag-
nitude, duration, and the presence or ab-
sence of a downward incisural point. Im-
mediate effects of preload on muscle spin-
dle responses to the HVLA-SM were de-
termined by comparing mean instanta-
neous discharge frequencies (MIF) during
the HVLA-SM’s thrust phase with base-
line. Longer lasting effects of preload on
spindle responses to the HVLA-SM were
determined by comparing MIF during
slow ramp and hold movement of the L6
vertebra before and after the HVLA-SM.
Results
The smaller compared with the larger pre-
load magnitude and the longer compared
with the shorter preload duration signifi-
cantly increased (p=0.02 and p=0.04, re-
spectively) muscle spindle responses dur-
ing the HVLA-SM thrust. The absence
of preload had the greatest effect on the
change in MIF. Interactions between pre-
load magnitude, duration, and downward
incisural point often produced statistical-
ly significant but arguably physiological-
ly modest changes in the passive signal-
ing properties of the muscle spindle after
the manipulation.
Conclusion
Because preload parameters in this an-
imal model were shown to affect neural
responses to an HVLA-SM, preload char-
acteristics should be taken into consid-
eration when judging this intervention’s
therapeutic benefit in both clinical effica-
cy studies and in clinical practice.
Corresponding address
Prof. Dr. K. Ammer
Andergasse 83, 1170 Wien
Österreich
KAmmer1950@aol.com
Compliance with ethical
guidelines
Conflict of interest. K. Ammer states that there are
no conflicts of interest.
Original publication
ReedWR, Long CR, Kawchuk GN, Pickar JG
(2014) Neural responses to the mechanical
parameters of a high-velocity, low-amplitude
spinal manipulation: effect of preload param-
eters. J Manipulative PhysiolTher 37:68–78
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