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ArchivesofPhysiotherapy2016,6(Suppl1):11 DOI10.1186/s40945-016-0022-4 MEETING ABSTRACTS Open Access 5th National Congress of the Italian Society of Physiotherapy Milan,Italy.3–4October2015 Published:14October2016 S1 S2 Criteriaforexercisesselectioninsubjectswithlowbackpain Recentadvancesinpathophysiologyandtreatmentofmyofascial AlessandroAina([email protected]) triggerpoints Physiotherapist,Dip.MDT,privatepractice,Milan,Italy MarcoBarbero([email protected]) ArchivesofPhysiotherapy2016,6(Suppl1):S1 RehabilitationResearchLaboratory,DepartmentofBusinessEconomics, HealthandSocialCare,UniversityofAppliedSciencesandArtsof Fromthe'70suntilthe'90s,inclinicaltrialsaimedatstudyingtheef- SouthernSwitzerland,SUPSI,Manno,Switzerland fectsofconservativeinterventionsinpeoplewithlowbackpain,par- ArchivesofPhysiotherapy2016,6(Suppl1):S2 ticipants were randomly allocated to different treatment groups without a preliminary assessment that went beyond symptoms Theoriginalandthemostcommonlyaccepteddefinitionofmyofas- localization.Theinitialassumptionwasthatpatientsexhibitingsimi- cial pain syndrome has been formulated by Simons and Travell in lar symptoms localization should be considered as a unique group. the first volume of The Trigger point Manual edited in 1983 [1]. The Consequently, theeffectsof differentinterventions weresimilarand authors defined the myofascial pain syndromes as a regional pain guidelinesmerelysuggested“Stayactive”. characterized by the presence of one or more myofascial trigger Sincethe'80ssomephysiotherapistsbegantodevelopanumberof points (MTrP). A MTrP is a distinctive clinical characteristic of this evaluationtestsinordertoidentifyspecificsubgroupsamongpeople painfulsyndromeand it is defined asa hyperirritable palpablenod- with low back pain and develop targeted treatments for each sub- ule contained in the skeletal muscle fibers. It can produce referred group.However,intheearly2000s,theAssessmentDiagnosisTreat- pain, either on digital compression or spontaneously. If stimulated mentOutcome(ASTO)model,developedbyK.Spratt[1],statedthat with dry needling or snapping palpation it may exhibit a typical eachstepmustbevalidatedbeforeproceedingtothenext. musclefasciculationorjumpsign. Thistalkwill: The literature suggests that MTrPs are extremely common and can be considered both a primary cause of a MPS or a secondary pain generatorinpatientsaffectedbyaprincipalmusculoskeletaldisorder 1. Illustratethefollowingassessmentandclassification [2]. Before the mid-1990s, key elements regarding the pathophysi- approaches:A)Mechanicaldiagnosisandtherapy[2],B) ologywereunrecognized.Subsequentlyresearchstudieshavemade Treatmentbasedclassification[3],C)Movementsystem the pathophysiology of myofascial pain syndrome much better impairment[4],D)Cognitivefunctionaltherapy[5],E)Patho- understood.Threemainhypotheseshavebeenprovided:energycri- anatomicbasedclassification[6]. sis theory, muscle spindle concept and the motor endplate hypoth- 2. Providecriteriafortheselectionoftherapeuticexercises. esis [3]. Additionally, recently Mense et al. presented an integrated 3. Highlightthepossibleoverlapsandsynergiesamongdifferent hypothesiswhichisaworkinprogressandupdatedasnewevidence approaches[7]. emerges [4]. This combines recent electrophysiological and histo- pathologicalresearchfindings. References Various methods of MTrP treatment are available but currently no 1. SprattK,Statisticalrelevance,inOrthopaedicKnowledgeUpdate:Spine2, clinicalguidelinesareavailableandcliniciansarerequiredtobalance e.a.D.F.Fardon,Editors,Editor.2002,TheAmericanAcademyof the available evidence, their clinical experience and the patient’s OrthopaedicSurgeons:Rosemont,Illinois,p.497–505;inDonelsonR. preferences. Treatment approaches can be considered as invasive Rapidlyreversablelowbackpain.SelfCareFirst,LLC,Hanover,New andnon-invasive.Dryneedlingorintramuscularstimulation,isanin- Hampshire,Firstedition,2007. vasivetechniqueinwhichathinneedleisusedtopenetratetheskin 2. McKenzie RA, May S. The lumbar spine: mechanical diagnosis and andstimulatetheMTrP. therapy.2ndedition.Waikanae,NewZealand:SpinalPublications,2003. The expected therapeutic effect is to release the taut band and re- 3. Delitto A, et al. A treatment-based classification approach to low back duce the irritability of the spot tenderness. Together with injections syndrome:identifyingandstagingpatientsforconservativetreatment. (localanaesthetics,steroids,BotulinumtoxinA)theseareamongthe PhysTher.1995;75(6):470–489. mostcommontreatmentsformyofascialpainsyndrome. 4. Sahrmann S. Diagnosis and treatment of movement impairment Recentlydryneedlinggainedpopularityamongphysiotherapistsand syndromes.St.Luis,MO:Mosby,Inc.,2002. threesystematicreviewsontheefficacyhavebeencompleted[5–7]. 5. O'Sullivan P. Diagnosis and classification of chronic low back pain Accordingtotheavailablesystematicreviewsdryneedlingshouldbe disorders:maladaptivemovementandmotorcontrolimpairmentas consideredthefirstchoicetreatmentbutduetothesmallnumberof underlyingmechanism.ManTher.2005;10(4):242–255. high quality trials additional research requires to be undertaken. 6. PetersenT,etal.Diagnosticclassificationofnon-specificlowbackpain.A Non-invasive treatments include various manual techniques such as newsystemintegratingpatho-anatomicandclinicalcategories.Physi- ischemiccompressionormanualstretching,andmodalitieslikeultra- otherTheoryPract.2003;19:213–37. sound and low-level laser therapy. No systematic reviews are avail- 7. Karayannis NV et al., Movement-based subgrouping in low back pain: able for these treatments. However, some trials indicated that synergyanddivergenceinapproaches.Physiotherapy.2015Jul3[Epub manualtreatmentofMTrPsmightreducethepressurepainthreshold aheadofprint]. ofspottendernessandtheVASscore[8,9]. ©2016TheAuthor(s).OpenAccessThisarticleisdistributedunderthetermsoftheCreativeCommonsAttribution4.0 InternationalLicense(http://creativecommons.org/licenses/by/4.0/),whichpermitsunrestricteduse,distribution,and reproductioninanymedium,providedyougiveappropriatecredittotheoriginalauthor(s)andthesource,providealinkto theCreativeCommonslicense,andindicateifchangesweremade.TheCreativeCommonsPublicDomainDedicationwaiver (http://creativecommons.org/publicdomain/zero/1.0/)appliestothedatamadeavailableinthisarticle,unlessotherwisestated. ArchivesofPhysiotherapy2016,6(Suppl1):11 Page2of42 References these results may be justified by their poor methodological quality 1. Travell JG and Simons DG. Myofascial pain and dysfunction: the trigger assessedbyusingtheCochraneScale. pointmanual.Baltimore;London:Williams&Wilkins,1983. Despitetheabovebackground,theaimofourstudyistoanalyzeifa 2. FrictonJR.Clinicalcareformyofascialpain.DentClinNorthAm.1991;35:1–28. manual therapy approach is effective for improving the respiratory 3. Simons DG. Clinical and etiological update of myofascial pain from mechanicsofpatientswithdiagnosisofamyotrophiclateralsclerosis triggerpoints.JMusculoskelPain.1996;4:97–125. (ALS). Respiratory issues are a common cause of comorbidities and 4. MenseS,SimonsDGandRussellIJ.Musclepain:understandingitsnature, mortality in patients affected by this disease [4]. The decreased pa- diagnosis,andtreatment.Philadelphia:LippincottWilliams&Wilkins,2001. tient’sbreathingcapacityis,inpart,duetotheprogressivemotoneu- 5. CotchettMP,LandorfKBandMunteanuSE.Effectivenessofdryneedling rons degeneration. The increase of the chest stiffness, because of andinjectionsofmyofascialtriggerpointsassociatedwithplantarheel adaptation of bone and ligamenttissues to a prolongedhypomobi- pain:asystematicreview.JFootAnkleRes.2010;3:18. lity, further worsens this clinical presentation of restrictive nature 6. KietrysDM,PalombaroKM,AzzarettoE,HublerR,SchallerB,SchlusselJM [5,6]. Strongly supported clinical procedures are the non-invasive andTuckerM.EffectivenessofDryNeedlingforUpperQuarter ventilation(NIV),themechanicinspiration-expirationtechniques,the MyofascialPain:ASystematicReviewandMeta-analysis.JOrthopSports coughassistedtechniquesandclearanceoftherespiratorysecretions PhysTher.2013Sep;43(9):620–34. [7]. Based on our knowledge no articles so far investigated the effi- 7. Tough EA, White AR, Cummings TM, Richards SH and Campbell JL. cacyofmanualtechniquesappliedonthespinalthoracicjointswith Acupunctureanddryneedlinginthemanagementofmyofascialtrigger theaimtoreducethestiffnessaroundthisanatomicalareawiththe pointpain:asystematicreviewandmeta-analysisofrandomisedcontrolled final goal to improve the breathing capacity. This modality of treat- trials.EurJPain.2009;13(1):3–10. ment has already been studied in patients affected by chronic ob- 8. Llamas-Ramos R, Pecos-Martin D, Gallego-Izquierdo T, Llamas-Ramos I, structivepulmonarydisease[5]. Plaza-ManzanoG,Ortega-SantiagoR,ClelandJandFernandez-de-Las- Some preliminary results of a single-center randomized controlled PenasC.Comparisonoftheshort-termoutcomesbetweentriggerpoint pilotstudyarepresented.Atpresent18subjectshavebeenrecruited dryneedlingandtriggerpointmanualtherapyforthemanagementof and randomized either in the experimental group or control group. chronicmechanicalneckpain:arandomizedclinicaltrial.JOrthopSports All subjectsreceived2 daily sessionsof conventional physiotherapy; PhysTher.2014;44(11):852–61. eachsessionlastedfor1hour.Inaddition,thesubjectsoftheexperi- 9. Cagnie B, Dewitte V, Coppieters I, Van Oosterwijck J, Cools A and mentalgroupweretreatedwithmanualtechniquesfor30minutesdaily DanneelsL.Effectofischemiccompressionontriggerpointsintheneck for 10 days. Dataof breathing capacity, functional vital capacity(FVC) andshouldermusclesinofficeworkers:acohortstudy.JManipulative and peak-cough expiratory flow (PCF) were recorded before the first PhysiolTher.2013;36(8):482–9. treatmentandimmediatelyafterthelastone.Differencespre-postinter- ventionwereanalyzedwithinthesamegroupandbetweengroups. S3 The two groups were homogeneous at baseline. The statistical ana- Rehabilitationofscapulardyskinesia lysis conducted showed a statistically significant change in FVC in BarbaraCagnie([email protected]) the experimental group after the first treatment of thoracic DepartmentofRehabilitationSciencesandPhysiotherapy,Ghent mobilization(p=0,012).Moreover,changesintheexperimentalgroup University,Ghent,Belgium weresignificantlyhigher(p=0.01)thaninthecontrols.Ifthesedata ArchivesofPhysiotherapy2016,6(Suppl1):S3 willbeconfirmed,additionaltreatmentbasedonmobilizationofthe thoracic spine maybe useful in the management of respiratory im- In this lecture, based on her previous work,1,2 Dr. Cagnie highlights pairmentsinthispopulationofpatients. thecriticalroleofthescapulainprovidingbothmobilityandstability of the neck/shoulder region and illustrates a science based clinical References reasoningalgorithmwithpracticalguidelinesfortherehabilitationof 1. Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ. The scapulardyskinesis. MechanismsofManualTherapyintheTreatmentofMusculoskeletal Pain:AComprehensiveModel.ManTher.200914(5):531–8. 2. PöllmannW,FenebergW.Currentmanagementofpainassociatedwith References 1. Cagnie B, Struyf F, Castelein B, Cools A, Danneels L, O’leary S. The multiplesclerosis.CNSDrugs.2008;22(4):291–324. 3. PaciM,NannettiL,RinaldiL.Glenohumeralsubluxationinhemiplegic:an relevanceofscapulardysfunctioninneckpain:abriefcommentary.J OrthopSportsPhysTher.2014;44(6):435–9. overview.JRehabilResDev.2005Jul-Aug;42(4):557–6. 4. KurianKM,ForbesRB,ColvilleS,SwinglerRJ.Causeofdeathandclinical 2. Cools AM, Struyf F, De Mey K, Maenhout A, Castelein B, Cagnie B. Rehabilitationofscapulardyskinesis:fromtheofficeworkertotheelite gradingcriteriainacohortofamyotrophiclateralsclerosiscases overheadathlete.BrJSportsMed.2014Apr;48(8):692–7. undergoingautopsyfromtheScottishMotorNeuroneDiseaseRegister.J NeurolNeurosurgPsychiatry2009;80(1):84–7. 5. Heneghan NR, Adab P, Balanos GM, Jordan RE. Manual therapy for S4 chronicobstructiveairwaysdisease:asystematicreviewofcurrent Musculoskeletalrehabilitationinsubjectsaffectedbyneurological evidence.ManTher.2012;17(6):507–18. disorders 6. MaclayJD,McAllisterDA,RabinovichR,HaqI,MaxwellS,HartlandS,ConnellM, ElenaCastelli([email protected]) MurchisonJT,vanBeekEJ,GrayRD,MillsNL,MacneeW.Systemicelastin SanRaffaeleScientificInstituteandVitaSaluteUniversity,Milan,Italy degradationinchronicobstructivepulmonarydisease.Thorax.2012;67(7):606–12. ArchivesofPhysiotherapy2016,6(Suppl1):S4 7. Kirsten L. G, Noah L. Respiratory therapies for amyotrophic lateral sclerosis:aprimer.Muscle&Nerve2012;46(3):313–331. Few studies considered the manual therapy techniques applied to patientsaffectedbyneurologicaldisorders.Itiscommonlyaccepted thatmanualtherapytreatmentscanaddressandresolvemanymuscle- S5 skeletalpathologies[1]anditisalsowellknowhowtheseconditions Whichexaminationtestssuggestthebestcandidatesformanual maybeaggravatedbythepresenceofimpairmentsofneurologicalna- therapy ture(patella-femoraljointpainorlowbackpaininpatientswithdiag- ChadCook([email protected]) nosis of multiple sclerosis [2], shoulder sub-luxation in patients after DivisionofPhysicalTherapy,DukeUniversity,NCUSA stroke[3]etc.)buttheirtreatmentmodalityisstilluncharted. ArchivesofPhysiotherapy2016,6(Suppl1):S5 Afterascientificliteraturereview,29articlesincluding11RCTabout theuseofmanualtechniques,suchasspinalandjointmanipulation, Ithasbeenassumedthatonedeterminesapatientisacandidatefor soft tissue techniques and osteopathic approaches, in patients af- manual therapy during a clinical examination, and that the findings fected by neurological diseases, have been selected. Overall, the are specificfor the demandof a manual therapyintervention. Trad- mentionedstudiesshowapoorclinicalefficacyofthesetreatments; itionally, this process (determining candidacy for manual therapy) ArchivesofPhysiotherapy2016,6(Suppl1):11 Page3of42 hasbeenassociatedwithconclusionsfromthephysicalexamination. PSE is considered a relevant mediator in the relationship between Forexample,findingssuchaspositionalfaults,abnormalmovement pain and disability in chronic lower back pain (LBP) [2]. The various patterns, and range of motion loss during movement, all identified outcomes employed were questionnaires and physical clinical tests. during the physical examination are suggested triggers for manual ThequestionnairesusedweretheOswestryDisabilityIndex(ODI-I)to therapyuse.In reality,this concept hasbeenwoefully understudied measuredisability[3],the0/10NumericalRatingScale(NRS)tomeas- and may or may not yield value when determining manual therapy ure pain [4] and the Pain Self Efficacy Questionnaire (PSEQ-I) to candidacy. Threegeneralphilosophieshave beenadvocated:1) Bio- measure personal belief about how successfully one can cope with mechanical assumptions (coupling, stiffness, restrictions, patterns of difficultpainfulsituations[5].Thechoiceoftheseoutcomeshasbeen pain, etc.), 2) Regression based assumptions (modeling and use of achieved with the knowledge of their psychometric properties (in- clinicalpredictionrules),and3)Withinandbetween-sessionchanges ternalconsistency,reproducibility,validityandsensibilityindetecting (from patient response). Of the three concepts, identifying change clinical changes after conservative treatment for subacute and (within but mostly, between session) during the clinical physical chronicLBP)andvalidityinItalianlanguage. examinationhasprovidedthegreatestamountofevidenceinsupport Thephysicalclinicaltestsusedtodetectsegmentallumbarinstability butfailstotrulydetermineifsomeonecouldalsobenefitfromanalter- were the Aberrant Movements test (AMs) (Fig. 1) and the Passive nativeintervention.Thisplatformdiscussesthepresentstateoflitera- Lumbar Extension test (PLE) (Fig. 2). The Active Straight Leg Raise ture associating physical examination testing and manual therapy (ASLR)wasperformedtoassesslumbo-pelvicmotorcontrol,andthe outcomesanddiscussesthefutureneedsforimprovedevidence. Supine Bridge Test (SBT) (Fig. 3) was performed to measure lumbar muscles endurance. The choice of these outcomes has been made References becausetheseclinicaltestshavebeenusedandtheirvalidityinvesti- 1. Thiel HW, Bolton JE. Predictors for immediate and global responses to gatedinpreviousstudiesinSLPpatients[6–7]. chiropracticmanipulationofthecervicalspine.JManipulativePhysiol Cognitiveandbehaviouralprincipleswereintegratedineachindivid- Ther.2008;31(3):172–83. ual program and a functional and graded approach was performed 2. Garrison JC,ShanleyE,ThigpenC,HegedusE,CookC.Between-session toincreasetheactivitylevelandimprovestrength,endurance,range changespredictoverallperceptionofimprovementbutnotfunctional ofmotion,balance,coordinationandself-efficacy. improvementinpatientswithshoulderimpingementsyndromeseenfor Todeterminewhetherthemaingoalswereachieved,weconsidered physicaltherapy:anobservationalstudy.PhysiotherTheoryPract. as Minimal Clinically Important Difference (MCID) results at least 2 2011;27(2):137–45. points score reduction for NRS, 10 points score reduction for ODI-I 3. HahneAJ,KeatingJL,WilsonSC.Dowithin-sessionchangesinpainintensity [8]andascoreimprovementofatleast11forPSEQ-I[9].Weconsid- andrangeofmotionpredictbetween-sessionchangesinpatientswithlow eredapatientdefinitelyimprovedwhenallMCIDwereattained,par- backpain?AustJPhysiother.2004;50(1):17–23. tially improved when at least two MCID were attained, and not- 4. TuttleN.Dochangeswithinamanualtherapytreatmentsessionpredict improved when only one or no MCID was attained. Concerning in- between-sessionchangesforpatientswithcervicalspinepain?AustJ stability and endurance clinical tests (secondary goals), we consid- Physiother2005;51(1):43–8. ered a patient definitely improved when all instability tests were 5. TuttleN,LaaskoL,BarrettR.Changeinimpairmentsinthefirsttwotreatments negative and SBT reached a score higher than 170 seconds (mean predictsoutcomeinimpairments,butnotinactivitylimitations,insubacute durationinasymptomaticpeople)[10]. neckpain:anobservationalstudy.AustJPhysiother2006;52(4):281–5. At the end of the treatment, 7 out of 10 patients were considered 6. Tuttle N. Is it reasonable to use an individual patient's progress after definitelyorpartiallyimproved,accordingtopain,disabilityandself- treatmentasaguidetoongoingclinicalreasoning?JManipulative efficacy.Inanycase,PSEwasthemostimproveddomainandalways PhysiolTher.2009;32(5):396–403. related to significant disability reduction. Clinical improvement ap- 7. WrightAA,AbbottJH,BaxterD,CookC.Theabilityofasustainedwithin- peared coherent with instability and endurance test changes (9 out sessionfindingofpainreductionduringtractiontodictateimproved of10patientsimproved). outcomesfromamanualtherapyapproachonpatientswithosteoarthritis Takehomesuggestions:thevalidityandresponsivenessoftheout- ofthehip.JManManipTher2010;18(3):166–72. comes must be known. To have objective data reflecting changes 8. Saavedra-Hernandez M, Castro-Sánchez AM, Fernández-de-Las-Peñas C, thataremeaningfulforthepatientafteraclinicalintervention,itis ClelandJA,Ortega-SantiagoR,Arroyo-MoralesM.Predictorsforidentify- basicforphysiotherapistswhendeterminingthepatient’sresponse ingpatientswithmechanicalneckpainwhoarelikelytoachieveshort- to treatment and to guide clinical decision-making during the termsuccesswithmanipulativeinterventionsdirectedatthecervicaland courseoftreatment. thoracicspine.JManipulativePhysiolTher.2011;34(3):144–52. Consentforpublication 9. CookC,LawrenceJ,MichalakK,DhiraprasiddhiS,DonaldsonM,Petersen TheauthorshavewritteninformedconsentfromthepeopleinFigs.1,2 S,LearmanK.Istherepreliminaryvaluetoawithin-and/orbetween- and3,andconsenttopublishthephotographs.Therelevantdocuments sessionchangefordeterminingshort-termoutcomesofmanualtherapy canbeprovidedonrequest. onmechanicalneckpain?JManManipTher.2014;22(4):173–80. 10. Cook C, Showalter C, Kabbaz V, O’Halloron B. Can a within/between- References sessionchangeinpainduringreassessmentpredictoutcomeusinga 1. FerrariS,VantiC,CostaF,FornariM.CanPhysicalTherapyimprovePain manualtherapyinterventioninpatientswithmechanicallowbackpain? Self-Efficacyinsymptomaticlumbaristhmicspondylolisthesis?Acase ManTher.2012;17(4):325–9. series.DisabilRehabil.(submitted). 2. Foster NE, Thomas E, Bishop A, Dunn KM, Main CJ. Distinctiveness of psychologicalobstaclestorecoveryinlowbackpainpatientsinprimary S6 care.Pain.2010;148(3):398–406. Casestudy:theroleofthemeasurementsfortheidentificationof 3. MonticoneM, BaiardiP,FerrariS,FotiC,MugnaiR,Pillastrini P,Vanti C, targetsandguidanceofthetreatment ZanoliG.DevelopmentoftheItalianversionoftheOswestryDisability SilvanoFerrari([email protected]) Index(ODI-I):Across-culturaladaptation,reliability,andvaliditystudy. MasterofManualTherapyandMusculoskeletalRehabilitation,Molecular Spine.2009;34(19):2090–5. Medicine,DepartmentofHumanAnatomy,UniversityofPadova,Padova,Italy 4. Hjermstad MJ, Fayers PM, Haugen DF, Caraceni A, Hanks GW, Loge JH, ArchivesofPhysiotherapy2016,6(Suppl1):S6 FainsingerR,AassN,KaasaS.StudiescomparingNumericalRatingScales, VerbalRatingScales,andVisualAnalogueScalesforassessmentofpain Inthisreportwillbediscussedtheoutcomeusedinthetreatmentof intensityinadults:asystematicliteraturereview.JPainSymptom patients with symptomatic lumbar isthmic spondylolisthesis (SPL) in a Manage.2011;41(6):1073–93. caseseriessubmittedtobepublished[1].Theaimofthiscaseserieswas 5. Chiarotto A, Vanti C, Ostelo RW, Ferrari S, Tedesco G, Pillastrini P, toshowamodelofphysicaltherapytreatmenttargetedtoimproving MonticoneM.ThePainSelf-EfficacyQuestionnaire:Cross-CulturalAdapta- painself-efficacy(PSE)intenchronicSPLpatientsanddisplaypossible tionintoItalianandAssessmentofItsMeasurementProperties.Pain relationshipsbetweenclinicalchanges,painanddisability. Pract.2015Nov;15(8):738–47. ArchivesofPhysiotherapy2016,6(Suppl1):11 Page4of42 6. Ferrari S, Vanti C, O'Reilly C. Clinical Presentation and Physiotherapy TreatmentinpatientswithIsthmicSpondylolisthesis.Reportonfour cases.JChiroprMed.2012;11(2)94-103. 7. FerrariS,VantiC,PicarretaR,MonticoneM.Pain,Disabilityanddiagnostic accuracyofclinicalinstabilityandendurancetestsinsubjectswith lumbarspondylolisthesis.JManipulativePhysiolTher.2014;37(9):647–659. 8. OsteloR,DeyoR,StratfordP,WaddellG,CroftP,VonKorffM,BouterLM, deVetHC.Interpretingchangescoresforpainandfunctionalstatusin lowbackpain.Spine.2008;33:90–94. 9. MaughanEF,LewisJS.Outcomemeasuresinchroniclowbackpain.Eur SpineJ.201019:1484–1494. 10. SchellenbergKL,LangJM,ChanKM,BurnhamRS.Aclinicaltoolforoffice assessmentoflumbarspinestabilizationendurance:proneandsupine bridgemaneuvers.AmJPhysMedRehabil.2007;86:380–6. Fig.3(abstractS6)SupineBridgetest S7 Assessmentofjointmobility:stateoftheart AndreaFoglia,PaoloBizzarri Physiotherapists,OrthopaedicManualTherapists(OMT),Private practitioners,CivitanovaMarche Correspondence:AndreaFoglia([email protected])– Physiotherapists,OrthopaedicManualTherapists(OMT),Private practitioners,CivitanovaMarche ArchivesofPhysiotherapy2016,6(Suppl1):S7 More than 90% of the general population will experience at least a musculoskeletal disorder during their lifetime. These types of joint disordersareoftencharacterizedbymultipleclinicalfindings,inpar- ticularpainandreductionofjointrangeofmotion(ROM).Insucha physical therapy setting where the sole radiological investigations Fig.1(abstractS6)AberrantMovements and the medical diagnosis are often not enough to assess the pa- tient’s health status, the need to develop new procedures aimed at defining and documenting the patient’s health status and his/her clinicalcoursehasbroughtaboutanincreasinginterestinthisissue. Overthelastyearsthemainfocushasbeenonestablishingandonval- idating new tools to assess the joint mobility. Although some of the procedures have had a positive effect on the clinical setting,thepro- posedassessment tools wereoften correctfroma biomechanicaland methodologicalstandpoint,butpoorlyapplicableintheclinicalpractice. Moreover,suchmeasurementshaveoftenprovedpartialaccordingto anideabasedonthebiopsycosocialmodel(InternationalClassification of Functioning, Disability and Health - ICF), where the clinical signifi- cance of joint mobility data directly depends on its relation with the person’sreducedactivityandparticipation.Therefore,inthissettingitis possibletospeakoffunctionalrangeofmotion(functionalROM). Thispresentationaimsatdescribingourapproachtotheassessment of the functional ROM, applicable to the clinical setting. This ap- proach is based on the best evidence available in the literature anditisalsobasedonfourcrucialsteps:medicalcasehistory,vis- ual inspection/observation, manual mobility testing, self-reported Fig.2(abstractS6)PassiveLumbarExtensiontest measures. ArchivesofPhysiotherapy2016,6(Suppl1):11 Page5of42 References muscleisgreaterifthespineisextended,whiletheroleoftheexter- 1. 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Contribution and timing of transmitted and examinationresultsinindividualswithfunctionalankleinstabilityand generatedpressurecomponentsinthefemaleurethra.In:‘Female ankle-spraincopers.JAthlTrain.2013Sep-Oct;48(5):581–9. Incontinence’,1981,AllanR.LissInc.,NewYork. 7. WyldeV,LenguerrandE,BruntonL,DieppeP,Gooberman-HillR,MannC, 4. Neumann P, Gill V. Pelvic floor and abdominal muscle interaction: EMG BlomAW.Doesmeasuringtherangeofmotionofthehipandkneeadd activityandintra-abdominalpressure.IntUrogynecolPelvicFloorDys- totheassessmentofdisabilityinpeopleundergoingjointreplacement? funct.2002;13:125–32. OrthopTraumatolSurgRes.2014Apr;100(2):183–6. 5. Sapsford R, Hodges P. Contraction of the pelvic floor muscles during 8. Ruiz FK, Bohl DD, Webb ML, Russo GS, Grauer JN. Oswestry Disability abdominalmaneuvers.ArchPhysMedRehabil.2001;82(8):1081–8. IndexisabetterindicatoroflumbarmotionthantheVisualAnalogue 6. JungingerB,BaesslerL,SapsfordR.Effectofabdominalandpelvicfloor Scale.SpineJ.2014Sep1;14(9):1860–5. tasksonmuscleactivity,abdominalpressureandbladderneck.Int 9. DixonD,JohnstonM,McQueenM,Court-BrownC.TheDisabilitiesofthe UrogynecolJ.2010;21(1):69–77. Arm,ShoulderandHandQuestionnaire(DASH)canmeasuretheimpair- 7. SmithM,RussellA,HodgesP.Doincontinence,breathingdifficulties,and ment,activitylimitationsandparticipationrestrictionconstructsfromthe gastrointestinalsymptomsincreasetheriskoffuturebackpain?JPain. InternationalClassificationofFunctioning,DisabilityandHealth(ICF). 2009;10(8):876–86. BMCMusculoskeletDisord.2008Aug20;9:114. 8. HodgesP,RichardsonC.Inefficientmuscularstabilizationofthelumbarspine 10. RoeY,LundegaardSobergH,Bautz-HolterE,OstensjoS.Asystematicre- associatedwithlowbackpain.Spine(PhilaPa1976).1996;21:2640–50. viewofmeasuresofshoulderpainandfunctioningusingtheInter- 9. Eisenstein S, Engelbrecht D, El Masry W. Low back pain and urinary nationalclassificationoffunctioning,disabilityandhealth(ICF).BMC incontinence.Spine(PhilaPa1976).1994;19:1148–52. MusculoskeletDisor.2013,14:73. 10. O’SullivanP,BealesD,AveryA.Normalisationofaberrantmotorpatterns insubjectswithsacroiliacjointpainfollowingamotorrelearning intervention:amultiplesubjectcasestudyinvestigatingtheASLRtest. S8 FourthInterdisciplinaryWorldCongressonLowBackandPelvicPain, Corestabilizationexercisesinthetreatmentofurinary Montreal,2001. incontinence DonatellaGiraudo([email protected]) SanRaffaeleTurroHospital,Milan,Italy ArchivesofPhysiotherapy2016,6(Suppl1):S8 The functional relationship between the respiratory diaphragm, the abdominalmusclesandthepelvicflooriswell-established:thelatter represents the connective element between the abdominal cavity and the lower limbs, and a correct postural relationship between these two - the abdominal cavity and the thoracic cavity - ensures optimum volume of the "core", optimizing abdominal-pelvic function. Controlofthecontractionofthepelvicfloor,whichifattainedauto- matically on the increaseof intraabdominal pressureoccurs prior to thecontractionoftheabdominalwallmuscles,isamechanismpre- venting the onset of stress urinary incontinence and prolapse. To- gether with the stabilizing action provided by the transverse abdominalmuscle,thepelvicfloorandthediaphragm,theposterior Fig.4(abstractS8)Relationshipbetweenrespiratorydiaphragm, muscles of the spine also contribute to stabilization of the "core", abdominalwall,pelvicfloormusclesandrachisinincorrect thuscounteractingpossibledestabilizationcausedbydysfunction. expiratorypatternwithincompetenceofabdominalwall Many actions which involve the pelvic floor (defecation, urination, pregnancy and childbirth) pose a hazard due to the increase in intraabdominalpressure,whichmustbecounteredwithanappropri- S9 atebreathingpatternandrhythm;simultaneously,themoderatecon- Preventingsurgicalsubacromialdecompressionthroughrotator traction of the abdominal wall directs expiratory pressure towards cuffrehabilitation the glottis and not towards the pelvic floor. On the increase of ChrisLittlewood([email protected]) intraabdominal pressure, contraction of the pelvic floor allows the UniversityofSheffield,Sheffield,UK correctpositionoftheureterovesicaljunctiontobemaintainedand, ArchivesofPhysiotherapy2016,6(Suppl1):S9 togetherwiththecounterthrustprovidedbytheintactfascialsystem, thedevelopmentofforceswhichcontributetotheincreaseinureth- Shoulder pain is one of the most common musculoskeletal symp- ralpressure. tomsandsubacromialimpingementsyndromeanditsvarioussyno- Thecontractionofthepelvicfloor,inturn,affectsthecontractionof nyms including rotator cuff tendinopathy, subacromial pain etc. are theabdominalmuscles.Theroleplayedbythetransverseabdominal widelyregardedasthemostcommoncause. ArchivesofPhysiotherapy2016,6(Suppl1):11 Page6of42 There are a range of treatment options available, both conservative which repetitive movements in a specific direction have the ef- andsurgical.Inrecentyearsthenumberofsubacromialdecompres- fect of reducing pain and symptoms. The most important symp- sions, a widely used surgical treatment approach for this condition, tom is considered the centralization of pain. The group is made hasrisenexponentially.Butwhyisthis? up of specific exercises: Group Extension (symptoms more distal Conservative treatment approaches, particularly exercise, are widely buttock; symptoms that centralize extension lumbar; symptoms regardedaseffectiveinterventionsforthistypeofmechanicalshoul- periferalization during lumbar bending; directional preference: der pain. Recent studies have shown that such conservative ap- extension); Group Flexion [age not younger (>50 years); direc- proaches are comparable to surgical interventions. Also, patients on tional preference: bending; positive imaging for lumbar stenosis]; a surgical waiting list who undertake a structured exercise Group Lateral Shift (visible deviation of the shoulders than the programmemightrespondsufficientlytoelectnottohavetheoper- pelvis in the frontal plane; directional preference: shifting motions ation.So,itseemsthatifallpatientsareexposedtoastructuredex- of the pelvis in the frontal plane). erciseprogrammepriortobeingconsideredforsurgerythenagood CPR4–GroupTraction-Signsandsymptomsofcompressiontothe proportionwillnotrequiresuchinvasiveintervention.But,ifconser- nerveroot;nomovementwhichcentralizesthesymptoms. vativetreatmentisatleastasgoodasoperativetreatmentthenwhy Based on all the above considerations, it can be helpful to develop areweevenbotheringtoconsidersurgeryatallconsideringthatitis an algorithm with some therapeutic indications to help guide the a more invasive, risky and expensive procedure than conservative clinicianintheprocessofdecision-makinginLBP. care? Suchaquestioncanonlybeaddressedbyposinganotherquestion; References ifconservativetreatment‘fails’,whatthen? 1. CurrierLL,FroehlichPJ,CarowSD,McAndrewRK,CliborneAV,BoylesRE, Thistalkwillcovertheresearchinrelationtotheeffectivenessofdif- MansfieldLT,WainnerRS.Developmentofaclinicalpredictionruleto ferenttreatmentapproachesforsubacromialimpingementsyndrome identifypatientswithkneepainandclinicalevidenceofknee (mechanical shoulder pain without movement restriction) before osteoarthritiswhodemonstrateafavorableshort-termresponsetohip considering the principles that physiotherapists should follow when mobilization.PhysTher.2007Sep;87(9):1106–19. designing rehabilitation programmes for their patients with the aim 2. Delitto A, Erhard RE, Bowling RW. A treatment-based classification ap- ofmaximisingclinicaloutcomeandreducingtheneedforsurgery. proachtolowbacksyndrome:identifyingandstagingpatientsforcon- servativetreatment.PhysTher.1995Jun;75(6):470–85. 3. FritzJM,ClelandJA,ChildsJD.Subgroupingpatientswithlowbackpain: S10 evolutionofaclassificationapproachtophysicaltherapy.JOrthop MethodologicalaspectsofClinicalPredictionRulesinthe SportsPhysTher.2007Jun;37(6):290–302.Review.Erratumin:JOrthop rehabilitationofLowBackPain SportsPhysTher.2007Dec;37(12):769. PaoloPillastrini([email protected]) 4. HaskinsR,Osmotherly PG,Rivett DA.Diagnostic clinicalprediction rules DepartmentofBiomedicalandNeuromotorSciences,Universityof forspecificsubtypesoflowbackpain:asystematicreview.JOrthop Bologna,Bologna,Italy SportsPhysTher.2015Feb;45(2):61–76,A1-4. ArchivesofPhysiotherapy2016,6(Suppl1):S10 5. McGinn TG, Guyatt GH, Wyer PC, Naylor CD, Stiell IG, Richardson WS. Users'guidestothemedicalliterature:XXII:howtousearticlesabout ClinicalPredictionRule(CPR)isatooltoassisttheprocessofclassifi- clinicaldecisionrules.Evidence-BasedMedicineWorkingGroupJAMA. cation and improve clinical decision making, using the evidence to 2000Jul5;284(1):79–84. determine which patients will more easily benefit from a specific 6. Sutlive TG, Lopez HP, Schnitker DE, Yawn SE, Halle RJ, Mansfield LT, treatment strategy. Depending on the model proposed by McGinn, BoylesRE,ChildsJD.Developmentofaclinicalpredictionrulefor development and evaluation of CPR is done through a process di- diagnosinghiposteoarthritisinindividualswithunilateralhippain.J videdintothreephases:DerivationofCPR,ValidationofCPR,CPRIm- OrthopSportsPhysTher.2008Sep;38(9):542–50. pactAssessmentontheclinicalbehavior. 7. Vicenzino B, Smith D, Cleland J, Bisset L. Development of a clinical TherearediagnosticandtherapeuticCPR. predictionruletoidentifyinitialresponderstomobilisationwith DiagnosticCPRS movementandexerciseforlateralepicondylalgia.ManTher.2009 RobinHaskins,inhisscientificresearchtitled"Diagnosticclinicalpre- Oct;14(5):550–4. dictionrulesforspecificsubtypesoflowbackpain:Asystematicre- 8. Wainner RS, Fritz JM, Irrgang JJ, Delitto A, Allison S, Boninger ML. view",presentedareviewofthemaindiagnosticCPRpublished.The Developmentofaclinicalpredictionruleforthediagnosisofcarpal search found that 13 diagnostic CPRS for LBP have been derived. tunnelsyndrome.ArchPhysMedRehabil.2005Apr;86(4):609–18. Onethatassistsintheidentificationoflumbarspinalstenosis,and2 whichassistinthescreeningofinflammatorybackpainhaveunder- gone validation. No impact analysis studies were identified. Most S11 diagnostic CPRS for LBP are in their initial development phase and Interpretabilityofoutcomemeasuresinmusculoskeletal cannotberecommendedforuseinclinicalpracticeatthistime. rehabilitation TherapeuticCPRS DanielePiscitelli([email protected]) ThetherapeuticCPRSinLBPhavebeendefinedforthefirst timein Ph.D.CandidateinNeuroscience,DepartmentofTranslationalMedicine 2007 by Julie Fritz, when she presented a Clinical Commentary in andSurgery,UniversityofMilano-Bicocca,Milano,Italy which,fromtheclassificationofCrimeof2005,shesoughttobetter ArchivesofPhysiotherapy2016,6(Suppl1):S11 definethe4subgroups,describingforeachofthemthestateofthe art with respect to the effectiveness of the therapeutic procedures A health outcome measure has been described as a measure of adopted. health change, at a defined time, as a result of one or more health CPR1-GroupManipulation-Nosymptomsbelowtheknee;onsetof care processes [1]. In order to identify relevant problems directly recent (<16 days); low score to FABQ-W (Fear-Avoidance Beliefs frompatients,rehabilitationcliniciansandresearchersneedtoassess Questionnaire-Work Subscale) (<19); hypomobility lumbar spine patient-reported outcomes that may not be directly measurable; for (evaluated withtheSpringtest);ROMofinternalrotationofthe hip example, disability, quality of life, satisfaction, or pain intensity. The greaterthan35°inatleastonehipjoint. InternationalClassificationof Functioning, Disabilityand Health(ICF) CPR2-Groupstabilization-Themostimportantvariableswere:age, framework catalogues these features, consequently the assessment straight-legraise,proneinstabilitytest,aberrantmotions,lumbarhy- can be performed at different levels including body functions and permobility, and fear-avoidance beliefs. Basically, they found: age structures, activities and participation. The majority of outcome re- younger than 40; average SLR> 91°; aberrant trunk movement lated to activity limitations and participation restrictions are often present;proneinstabilitytestpositive. measured indirectly by their manifestations and are referred to as CPR3-Groupspecificexercises-TheywereratedaccordingtoMcKen- “latent variables”, “latent traits” or “constructs” [2]. Therefore, we zie’sapproach,whoidentifiedasmoreappropriateinterventiononein needtotransformthemanifestationsofthese“latent”variablesinto ArchivesofPhysiotherapy2016,6(Suppl1):11 Page7of42 numbers using questionnaire or scale. Such patient-reported out- problem, which remains unknown. Eachtype of surgical, orthoticor comes(PRO)canbetakenasmeasurements,andtheassessmentof exercise-based treatment must act exclusively upon the effects of thepsychometricpropertiesoftheseinstrumentsiscrucial. thediseaseandthusminimizethem. Clinicians need to be aware of the characteristics of outcome mea- Focusing the reasoning on the conservative treatment approaches, surestoselecttheappropriateoneandinterpretcorrectlytheresults. thefirstconcepttoconveyisthat,untiltoday,theonlyreliablestrat- Inthepsychometricfieldhasbeenproposedtwomaintesttheories egiesarethebraceandthespecificexercises.Theuseofalternative [1]: the classical test theory (CTT) and item response theory (IRT). treatmentapproachessuchasdentalbite,heellift,electricalstimula- Recently, an international Delphi study has proposed a Consensus‐ tion,manualapproach[1]orfoodtipshaveneverbeenshownable based Standards for the selection of health Measurement Instru- tomodifythenaturalhistoryofthedisease. ments(COSMIN)[3]aimedatprovidingataxonomyofpsychometric Typically, all over the world, excluding Europe, the most accepted properties, pointing out the measurement properties of PRO instru- therapeutic approach for the treatment of a vertebral misalignment ments assessed by CTT and IRT methods. COSMIN distinguished was the surgery and the conservative treatment has almost always threedomains:reliability,validity,andresponsiveness.Reliabilityhad been considered if not harmful, at least useless. This is due to the three measurement properties: internal consistency, reliability, and scarcityofexperimentaltrialsthathadbeenpublisheduntilthen.In measurementerror.Validityhadthreemeasurementproperties:con- therecentyearsthesituationchangedallowingthedevelopmentof tentvalidity,criterionvalidityandconstructvalidity.Thelastdomain two Cochrane Reviews: one consacreted on Scoliosis and Brace [2] includedonlyoneproperty,theresponsiveness. andthesecondoneonScoliosisandSpecificExercises[3].Ithasjust The interpretability was not taken into account as a measurement beenreleasedanupdateofTheCochraneReviewonbraceswiththe property, but it was considered an important characteristic of a conclusionsabsolutelyinfavouroftheeffectivenessofthistool,con- measurement instrument. It was defined as “the degree to which trary to what is always said by the SRS (Scoliosis Research Society), one can assign qualitative meaning to an instrument’s quantitative theAmericanassociation ofspinesurgeonsspecializedinspinesur- scoresor changeinscores”[4].Themeaningoftheresultsmustbe geryforscoliosisdisease.Adecisiveblowtotheabsoluteconviction interpreted carefully. Indeed, the predominant types of outcomes ofthesurgeonshadalreadybeeninflictedbythepublicationofthe measure are ordinal scale. In PRO tools, by definition, the intervals article"EffectsofBracingwithIdiopathicScoliosisinAdolescents",[4] between categories are separated by unknown quantities, and con- a RCT of 2013, led by the SRS that compared the results of two clusions may, therefore, be misleading; e.g., the calculation of min- groupsofpatients:onegrouptreatedwithbraceandcontrolgroup, imal (clinically) importantdifferencesis compromisedby the lack of totesttheeffectivenessofthebracetolowertheriskofsurgery.The interval scaling [5]. IRT models such Rasch analysis (RA) [6] allow a firstfollowup,absolutelyinfavourofthebrace,haspromptedtheeth- transformation of the ordinal score into a linear, interval scores be- icscommitteetomodifythe research,stoppingthe randomization of causewithRaschtransformationthelocationofitems,aswellaspa- patientsbasedontheeffectivenessofonecomparativeprotocol. tients,arepresentedonthesamescale[7]. Another review on Scoliosis and Specific Exercises has been pub- Aproperknowledgeoftheabove-citiedmeasurementpropertiesisa lished.Theconclusionwasthattheevidencefortheeffectivenessof prerequisite for use toolin clinicalpractice and researchin order to the exercises as a treatment are too weak. As for the Cochrane Re- prevent inappropriate conclusion and to improve clinical decision view concerning the brace, it is also expected an update of this makingprocess[8]. paper.Consideringtheitemsthatwillbeintroducedinthenewver- sion,theconclusionswilldefinitelyincreasethedemonstrableeffect- References iveness of this approach for the treatment of scoliosis. Worldwide, 1. Streiner DL, Norman GR. Health measurement scales : a practical guide the methodsfor scoliosis treatment basedon specificexercisesthat totheirdevelopmentanduse(4thed.).Oxford;NewYork:Oxford have proven effectiveness, with the publication of some articles are UniversityPress,2008. veryfewandarelittleknowninItaly,withtheexceptionoftheSEAS. 2. TesioL.Measuringbehavioursandperceptions:Raschanalysisasatool Oneofthe mostinterestingtreatmentstrategiesfor thefuturecon- forrehabilitationresearch.JRehabilMed.2003;35(3):105–115. sistsintheintegrationofself-correctionintheactivitiesofdailylife, 3. MokkinkLB,TerweeCB,PatrickDL,AlonsoJ,StratfordPW,KnolDL,etal. totrainaneffectivecontrasttotheviciouscircleofStokes[5],repre- TheCOSMINstudyreachedinternationalconsensusontaxonomy, sentingthelinkedcorrelationbetweentheprogressiveworseningof terminology,anddefinitionsofmeasurementpropertiesforhealth- thecurvesandthevertebraedeformation. relatedpatient-reportedoutcomes.JClinEpidemiol.2010;63(7):737–745. 4. Terwee CB, Bot SD, de Boer MR, van der Windt DA, Knol DL, Dekker J, References etal.Qualitycriteriawereproposedformeasurementpropertiesof 1. Romano M, Negrini S. Manual therapy as a conservative treatment for healthstatusquestionnaires.JClinEpidemiol.2007;60(1):34–42. adolescentidiopathicscoliosis:asystematicreview.Scoliosis.2008Jan 5. Doganay Erdogan B, Leung YY, Pohl C, Tennant A, Conaghan PG. 22;3:2. MinimalClinicallyImportantDifferenceasAppliedinRheumatology:An 2. Negrini S, Minozzi S, Bettany-Saltikov J, Chockalingam N, Grivas TB, OMERACTRaschWorkingGroupSystematicReviewandCritique.J Kotwicki T, Maruyama T, Romano M, Zaina F. Braces for idiopathic Rheumatol.2016Jan;43(1):194–202. scoliosis in adolescents. Cochrane Database Syst Rev. 2015 Jun 18; 6. 6. TennantA,ConaghanPG.TheRaschmeasurementmodelinrheumatology: 3. RomanoM,MinozziS,Bettany-SaltikovJ,ZainaF,ChockalingamN,Kotwicki whatisitandwhyuseit?Whenshoulditbeapplied,andwhatshouldone T,Maier-HennesA,NegriniSExercisesforadolescentidiopathicscoliosis. lookforinaRaschpaper?ArthritisRheum.2007;57(8):1358–1362. CochraneDatabaseSystRev.2012Aug15;8. 7. MeroniR,PiscitelliD,BonettiF,ZambaldiM,CerriCG,GuccioneAA.etal. 4. DolanLA,WrightJG,WeinsteinSL.Effectsofbracinginadolescentswith RaschAnalysisoftheItalianversionofPainCatastrophizingScale(PCS-I). idiopathicscoliosis.EnglJMed.2014Feb13;370(7):681. JBackMusculoskeletRehabil.2015Dec2;28(4):661–73. 5. Stokes IA. Mechanical modulation of spinal growth and progression of 8. Black N. Patient reported outcome measures could help transform adolescentscoliosis.StudHealthTechnolInform.2008;135:75–83. healthcare.BMJ.2013Jan28;346,f167. S13 S12 Balancetraininginsubjectswithmusculoskeletaldisorders Conservativetreatmentofthemisalignmentofthespine:stateof AndreaTettamanti([email protected]) theartandperspectives LaboratoryofAnalysisandRehabilitationofMotorFunction, MicheleRomano([email protected]) NeuroscienceDivision,SanRaffaeleHospital,Milan,Italy ISICO,IstitutoScientificoItalianoColonnaVertebrale,Milan,Italy ArchivesofPhysiotherapy2016,6(Suppl1):S13 ArchivesofPhysiotherapy2016,6(Suppl1):S12 Balance and proprioceptive deficits are present in most of the sub- The biggest problem in the treatment of a patient with idiopathic jectswithneurologicaldiseasesandinmanyolderpeople.Theeffect scoliosis is the impossibility of working directly on the cause of the of balance training in these subjects is quite well established [1–3]. ArchivesofPhysiotherapy2016,6(Suppl1):11 Page8of42 Although they are few considered, balance deficits are present also 7. Smith BE, Littlewood C, May S. An update of stabilisation exercises for inmanysubjectswithmusculoskeletaldiseases.Alesionoftheknee lowbackpain:asystematicreviewwithmeta-analysis.BMCMusculoskelet or ankle could lead to a balance deficit, and the effects of balance Disord.2014Dec9;15:416. training is a reduction in the recurrence of ankle sprains in chronic 8. Jull G, Falla D, Treleaven J, Hodges P, Vicenzino B. Retraining cervical ankle instability, a reduction in giving way episodes in ACL injured jointpositionsense:theeffectoftwoexerciseregimes.JOrthopRes. people,areductionofriskoffallinginelderlypeople,andareduced 2007Mar;25(3):404–12. incidence of knee and ankle injuries [4]. Less evident is that also in subjects with low back pain (LBP) or neck pain balance deficit is S14 present. Dosageofmanualtherapy:principlesforclinicalpractice In recent years it has been documented that individuals with acute CarlaVanti([email protected]) andchronicLBPshowchangesintrunkmusclesactivity(transversus DepartmentofBiomedicalandNeuromotorSciences,Universityof abdominis and multifidus particularly). A consistent finding is a de- Bologna,Bologna,Italy layedactivationoftrunkmusclesduringbothunpredictableandpre- ArchivesofPhysiotherapy2016,6(Suppl1):S14 dictable trunk perturbations. Trunk balance deficits and muscle activationimpairmentscouldalsooriginatefrompoorpositionsense, The dosage of manual therapy techniques refers to the optimal whichhasbeenreportedtobepresentinindividualswithCLBP[5]. therapeutic dose(e.g. the amountof treatment thatmayproducea Alsoinpeoplewithneckpainthecoordinationofheadmovements, therapeutic effect) and the optimal interval betweendoses (e.g. the the coordination of the movement of the vertebrae of the cervical sessions’ scheduling). About each session, the main parameters in- spine,andposturalbalancewereshowntobeimpaired[6].Consider- volved in the dosage are: the starting position, the force/pressure ing the prevalence of these two conditions, the number of people exerted,therhythmandspeed,thetypeoftechnique,theRangeof suffering of balance deficits secondary to musculoskeletal disorder Motion (ROM), the stadium of healing, the number of repetitions, couldberelevant. andthetotaldurationofthesession. Despitethedocumentedbalancedeficits,rehabilitativeprotocolsfor Anon-specific/neutral/painlesspositionisacommonchoicetoapply improving muscle activation in subjects with LBP are primarily fo- antalgic techniques, whereas a specific/end of range position is ap- cused on feedforward mechanisms, using exercises that emphasize plied to perform the techniques aiming to improve the ROM. The the maintaining of static postures (i.e. squat exercises, curl up, side amountofforce/pressureexerteddependsonthetypeoftechnique, and front support). These kinds of exercises, including trunk muscle the treated area, the type of pathology/dysfunction, and the mor- strengtheningexercises,areincludedinprotocolsusingtheconcept phologicaltypeofpatientandtherapist.However,theforceusedby ofcorestabilizationtraining.Nevertheless,arecentsystematicreview physical therapists relates not only to patient, but also to physical statedthattheyarenotsuperiortootheractiveexercisesinthelong therapist characteristics (academic qualification, sex, weight and term[7].Insubjectswithneckpainexercisesforimprovingposition height). Nevertheless, it was demonstrated that clinicians can suc- sense and muscle activations rely principally on neck coordination cessfullydeliverprescribedtractionforceswhiletreatingpatients. andrepositioningexercises[8]. Concerning the rhythm/speed, a high rhythm is used to stimulate Onlyfewstudiesinvestigatetheroleofbalanceexercisesinrestoring the β-receptors and improve the movement of fluids, whilst a slow sensorimotorfunctionandalleviatesymptomsinsubjectswithback rhythm is preferred to provoke a tissue deformation. It was shown orneckpain.TheefficacyofbalancetraininginindividualswithCLBP that HVLA manipulation induces an initial mechanical, non-opioid andneckpainwasstudiedintworecenttrials[4,5].Thesekindsof hypoalgesia(superiortoplaceboandcontrol)andthatpassivepain- exercisesaredifferentfromtheclassicalexercisesofcorestabilityfor less techniques induce the H-reflex inhibition. The sympathetic ner- low back pain or exercises of neck coordination. Balance exercises vous system activation is also related to the type of technique (e.g. are focused on the improvement of feedback mechanics of motor HVLAvsmobilization). control, while classical core training or neck coordination exercises ConcerningtheGradesofMovement,manualtherapyliteraturesug- aremainlyfocusedonfeedforwardmuscularactivations.Thesestud- geststo use intermittentGradeI and II to managepainand induce ieson balance trainingsupport the idea thatthiskind of trainingis relaxation, and Grade III, IV and V to treat hypomobility. However, effective and can be practiced easily. In subjects with neck pain it thefrequencyandamplitudeoftheoscillationforcesingradesIand can effectively improvecervical sensorimotor function and decrease IV are poorly reproducible. Moreover, the higher the grade of neckpainintensityandinsubjectswithLBPitreducesdisabilityand mobilization,thegreatertheforceappliedbyphysicaltherapists. improvesqualityoflife. About the total number of sessions, data from clinical trials are ex- tremelyvariable.Whenapatientisinacutephase,normallyatreat- References ment from daily to three times a week is suggested; in subacute 1. Gunn H,Markevics S,HaasB,Marsden J,Freeman J.Systematic Review: phasefromtwicetothreetimesaweek,andinchronicphasefrom TheEffectivenessofInterventionstoReduceFallsandImproveBalance oncetotwiceaweek.Thesessionsschedulingalsodependsonthe inAdultsWithMultipleSclerosis.ArchPhysMedRehabil.2015 Oct;96(10):1898–912. amountofhomeexercisesprescribedandthecomplianceofthepa- tient. Home exercises are commonly indicated from one to five-six 2. VeerbeekJM,vanWegenE,vanPeppenR,vanderWeesPJ,HendriksE, timesaday. RietbergM,KwakkelG.WhatIstheEvidenceforPhysicalTherapy Psychosocial factors should also be considered in the choice of the Poststroke?ASystematicReviewandMeta-Analysis.QuinnTJ,ed.PLoS amountof manualtherapy delivered. Physical therapistscan experi- One.2014;9(2):e87987. encefeelingsoftensionbetweentheadviceandtreatmenttheyfeel 3. MansfieldA,WongJS,BryceJ,KnorrS,PattersonKK.Doesperturbation- is best for their patient and the patient's own beliefs and attitudes. basedbalancetrainingpreventfalls?Systematicreviewandmeta-analysisof preliminaryrandomizedcontrolledtrials.PhysTher.2015May;95(5):700–9. Improving communication skills may help decrease feelings of con- 4. Beinert K, Taube W. The effect of balance training on cervical flict, enhance working relationships, and encourage a more consist- sensorimotorfunctionandneckpain.JMotBehav.2013;45(3):271–8. entapproach. 5. Gatti R, Faccendini S, Tettamanti A, Barbero M, Balestri A, Calori G. According to a shared decision-making approach, clinicians and pa- Efficacyoftrunkbalanceexercisesforindividualswithchroniclowback tientscommunicatewitheachotherwiththebestavailableevidence pain:arandomizedclinicaltrial.JOrthopSportsPhysTher.2011 whenthey have to make decisions. Then,patients are supported to Aug;41(8):542–52. decide on the characteristics and consequences of the various 6. Childs JD, Cleland JA, Elliott JM, Teyhen DS, Wainner RS, Whitman JM, options. SopkyBJ,GodgesJJ,FlynnTW;AmericanPhysicalTherapyAssociation. Neckpain:ClinicalpracticeguidelineslinkedtotheInternational References ClassificationofFunctioning,Disability,andHealthfromtheOrthopedic 1. Chiradejnant A, Latimer J, Maher CG. Forces applied during manual SectionoftheAmericanPhysicalTherapyAssociation.JOrthopSports therapytopatientswithlowbackpain.JManipulativePhysiolTher. PhysTher.2008Sep;38(9):A1-A34. 2002;25(6):362–9. ArchivesofPhysiotherapy2016,6(Suppl1):11 Page9of42 2. Gudavalli MR, Vining RD, Salsbury SA, Corber LG, Long CR, Patwardhan strongly questioned [6,7], and the strongest predictors of persistent AG,GoertzCM.Clinicianproficiencyindeliveringmanualtreatmentfor painafterTKAaremorerelatedtocatastrophizing,mentalhealth,or neckpainwithinspecifiedforceranges.SpineJ.2015;15(4):570–6. preoperativekneepainthanexerciseintensity.Third,theingredients 3. Haas M, Vavrek D, Peterson D, Polissar N, Neradilek MB.Dose–response should not be too many, preferringthe few exercisesthat will have andefficacyofspinalmanipulationforcareofchroniclowbackpain:a thegreatestchanceoftransferfromstrengthgaintoimprovedfunc- randomizedcontrolledtrial.SpineJ.2014Jul1;14(7):1106–16. tional performance. Fourth, the exercises should be well described, 4. Jeffrey JE, Foster NE. A qualitative investigation of physical therapists' including - whenever it is possible - the indication of the relative experiencesandfeelingsofmanagingpatientswithnonspecificlow load/repetitionmaximum. backpain.PhysTher.2012;92(2):266–78. Arewereadytotrythisathome? 5. Jull G, Moore A. What is a Suitable Dosage of Physical Therapy Treatment?ManTher.2002;7(4):181–2. References 6. LeeM,MoseleyA,RefshaugeK.Effectoffeedbackonlearningavertebral 1. Wilk KE. Are there speed limits in rehabilitation? J Orthop Sports Phys jointmobilizationskill.PhysTher.1990;70(2):97–102. Ther.2005;35:50–51. 7. Pentelka L, Hebron C, Shapleski R, Goldshtein I.The effect of increasing 2. RoiGS,CretaD,NanniG,MarcacciM,ZaffagniniS,Snyder-MacklerL.Return sets(withinonetreatmentsession)anddifferentsetdurations(between to official italian first division soccer games within 90 days after treatmentsessions)oflumbarspineposteroanteriormobilisationson anterior cruciate reconstruction:a case report. J Orthop Sports Phys pressurepainthresholds.ManTher.2012;17(6):526–30. Ther. 2005;35:52–61. 8. SandmanL.etal.Adherence,shareddecision-makingandpatientauton- 3. Shelbourne D. Invited commentary. J Orthop Sports Phys Ther. omy.MedHealthCarePhilos.2012;15(2):115–27. 2005;35:61–62. 9. Threlkeld AJ. The effects of manual therapy on connective tissue. 4. Internetsite:www.choosingwisely.org[accessedSeptember15,2015]. Physiotherapy.1992;72(12):893–902. 5. Bandholm T, Kehlet H. Physiotherapy exercise after fast-track total hip 10. WilliamsJM,Cuesta-VargasA.Quantificationofpronethoracicmanipula- andkneearthroplasty:timeforreconsideration?ArchPhysMedRehabil. tionusinginertialsensor-derivedaccelerations.JManipulativePhysiol 2012;93:1292–1294. Ther.2014;37(4):230–5. 6. Jacobsen TL, Husted H, Kehlet H, Bandholm T. Progressive strength training(10RM)commencedimmediatelyafterfast-tracktotalknee arthroplasty:isitfeasible?DisabilRehabil.2012;34:1034–1040. S15 7. van der Weegen W, Kornuijt A, Das D. Do lifestyle restriction and Aretherespeedlimitsinpost-surgerylowerlimbrehabilitation? precautionspreventdislocationaftertotalhiparthroplasty?Asystematic StefanoVercelli([email protected]) reviewandmeta-analysisoftheliterature.ClinRehabil.2015,Mar31 UnitofOccupationalRehabilitationandErgonomics,SalvatoreMaugeri [Epubaheadofprint]. Foundation,IRCCS,Veruno(NO),Italy ArchivesofPhysiotherapy2016,6(Suppl1):S15 S16 Exactlytenyearsago,KevinWilkwroteaneditorial,whereinheques- Classificationofpredominantneuropathic,nociceptiveorcentral tionedthe possibility of identifyingspeedlimitsin rehabilitation [1]. sensationpain In that issue of JOSPT, the accelerated philosophy was applied to a LennardVoogt([email protected]) famous Italian soccer player, who returned to official first division RotterdamUniversityofAppliedSciences,Rotterdam,TheNetherlands soccer games within (only) 90 days after anterior cruciate ligament ArchivesofPhysiotherapy2016,6(Suppl1):S16 reconstruction [2]. Donald Shelbourne commented this exceptional success by encouraging all surgeons and physical therapists to find Over the last decade we have witnessedimpressive progress in the their surgical procedure and rehabilitation protocol limits [3]. How- understanding of neurophysiologic mechanisms underlying chronic ever,thisencouragementdoesnotseemtohavebeenputintoprac- musculoskeletal pain. What we have learned from this scientific re- ticebymostphysicaltherapistsyet.Therefore,in2015,theAPTAfelt searchis thatpainshould beseen asthe outcomeof verycomplex theneedtolaunchacampaignagainstthebadpracticeofprescrib- interactions between biological, psychological and sociological pro- ing under dosed strength training programs. In essence, it was ad- cessesandthatthebrainplaysa centralroleintheintegrationand vised against the use of physical agents except when necessary, as processingofavarietyofinputsintothecreationofaconcretecon- wellastheuseofcontinuouspassivemotionmachinesforthepost- sciousexperienceofpain.Onecharacteristicofthisprocessingisthat operative management of patients following uncomplicated total inputsintothebraincanbemodulatedinseveralways,whichmeans kneereplacement[4]. that the relation between tissue damage and pain experience is Thetypeofphysiotherapyexerciseinterventionsaftermajorsurgery certainlynotlinearperse.Besidesthis,wehavelearnedthatitisof of lower limb (such as total hip or knee arthroplasty, THA and TKA) primary importance that caregivers in the field of chronic musculo- has often been based on treatment tradition or time-progression, skeletalpainhaveathoroughunderstandingoftheneurophysiology andnotonfirmscientificevidence,basicexercisephysiologyprinci- ofpainandthattheytaketheseinsightsintoaccountwhiletheyin- ples, or both [5]. Patients are not all equal, so it is imperative the form, advice and treat their patients. This is even more important needtoshiftthefocusfromthetime-basedprotocolstowardanin- whenweconsiderthefactthatabout20%ofthehumanpopulation dividualized and evaluation-based approach. Recent meta-analyses is now suffering from some form of chronic pain and that our on the effectiveness of physiotherapy exercise after THA and TKA treatment-effectsaremoderateatbest. generallyconcludethatphysiotherapyexerciseeitherdoesnotwork or is it very effective.5 In line with the recent claims from APTA [4], Some scholars in the field of musculoskeletal pain point to the im- portance of a connection between pain-mechanisms and interven- thereasonforthismaybethattherehabilitationwasoftoolittlein- tions in order to improve treatment effects in the near future. tensityorofferedatthewrongtime,toolateaftersurgery[5]. Current research shows that we can distinguish between different Recently, Bandholmand Kehlet[5]set foursimplerulestofollowin clinical practice and in future studies within physiotherapy exercise pain mechanisms and that it is valid to make distinctions between afterTHAandTKA.First,thetimingshouldberight.Thismeansthat nociceptive,neuropathicand‘centralised’pain.Knowledgeofthedif- interventionshouldstartbeforethedeficitsareatthegreatest,ifthe ferent physiological mechanisms underlying these three different goal is a fast recovery. Second, the ingredients should be right and forms of pain is important from a clinical perspective because it basedondocumenteddeficits.Functionalrehabilitationmustbesup- makes it possible to think more effectively about the relation be- plementedbymusclestrengthening(withtherightdose)andrange tween pain-physiology and our (physical therapy) interventions. It of motion recovery. Tradition and fear of symptoms exacerbation seems logical to suppose that nociceptive pain-forms require differ- have typically precluded progressive strength training early after enttreatmentstrategiesthanneuropathicor‘centralised’pain-forms. surgery, and lifestyle restriction are commonly applied after THA to Todosoitisimportantforclinicianstomakevalidinterpretationsre- prevent dislocation. However, both these precautions have been gardingthepain-mechanismsdrivingthepainoftheirpatients. ArchivesofPhysiotherapy2016,6(Suppl1):11 Page10of42 Although the pain laboratory is not the same as the clinical en- Balance Scale score (+6%, p<0.01) and Fatigue Severity Scale score counter, we think that it is indeed possible to translate physio- (−14%,p<0.03)atT1.Placebogroupshowedonlyanincreaseofthe logical knowledge of pain-mechanisms to the clinical encounter time of right double support at T1 (+46%, p=0.05), while no signifi- andthatproperinterpretationsofsignsandsymptomsofpatients cantresultswerefoundforalltheothermeasures. with chronic musculoskeletal pain can be made. For this purpose Conclusions we proposed a clinical algorithm with which clinicians can make This study showed that people with MS treated with Equistasi®, substantiated distinctions between predominant nociceptive, achieved improvements in balance disorders, especially when neuropathicor‘centralised’painintheirpatients.Thealgorithmis assessedthroughGaitAnalysis, comparedtoplacebo.Thispilottrial based on both scientific research and the clinical experience of shows that a physiotherapy program for training balance in associ- specialistsinthefieldof(chronic)musculoskeletalpain.Duringthe ationwithfocalmechanicalvibrationmightbeanhelpfulrehabilita- lecture the algorithm will be presented and discussed in light of tivesupportinimprovingpatients’balance. patientswithlowbackpain.Thewayinwhichthealgorithmshould beusedanddecisionsshouldbemadeisthemainobjectiveofthe References lecture. 1. Volpe D, Giantin MG, Fasano A. A Wearable Proprioceptive Stabilizer (Equistasi)forRehabilitationofPosturalInstabilityinParkinson’sDisease: References APhaseIIRandomizedDouble-Blind,Double-Dummy,ControlledStudy. 1. NijsJ,ApeldoornA,HallegraefH,ClarkJ,SmeetsR,MalflietA,GirbésEL, PlosOne.2014Nov17;9(11):e112065. DeKooningM,IckmansK.Lowbackpain:guidelinesfortheclinical 2. Brunetti O, Botti FM, Roscini M et al. Focal vibration of quadriceps classificationofpredominantneuropathic,nociceptive,orcentral muscle enhances leg power and decreases knee joint laxity in sensitisationpain.PainPhysician.2015;18:E333-E346. female volleyball players. J Sports Med Phys Fitness. 2012 2. NijsJ,Torres-CuecoR,VanWilgenCP,GirbésEL,StruyfF,RousselN,Van Dec;52(6):596–605. OosterwijckJ,DaenenL,KuppensK,VanderweeënL,HermansL,Beckwée 3. MartinCL,PhillipsBA,KilpatrickTJ,etal.Gaitandbalanceimpairmentin D,VoogtL,ClarkJ,MoloneyN,MeeuwsM.Applyingmodernpainneurosci- earlymultiplesclerosisintheabsenceofclinicaldisability.MultScler. enceinclinicalpractice:criteriafortheclassificationofcentralsensitization 2006Oct;12(5):620–8. pain.PainPhysician.2014;18:447–457. 4. Pearson OR, Busse ME, Van Deursen RWM, Wiles CM. Quantification of walking mobility in neurological disorders. QJM. 2004 Aug;97(8):463–475. P1 5. Katusic A, Alimovic S, Mejaski-Bosnjak V. The effect of vibration therapy Awearableproprioceptivestabilizer(Equistasi®)forrehabilitation onspasticityandmotorfunctioninchildrenwithcerebralpalsy:aran- ofbalancedisordersinmultiplesclerosispatients:preliminary domizedcontrolledtrial.NeuroRehabilitation.2013;32(1):1–8. resultsofarandomized,double-blind,versusplacebocontrolled study AcetoMaria1,SpinaEmanuele1,PaonePaolo2,SilvestreFrancesco1, P2 CarotenutoAntonio1,CerilloIlaria1,OreficeGiuseppe1 Effectofrepeatedneckretractionmovementsonstrengthand 1DepartmentofNeuroscience,ReproductiveSciencesandDentistry, EMGactivityoftheupperlimbs,rangeofmotionandcervical FedericoIIUniversity,Napoli,Italy;2Statistician,PacalConsultingSas, posture Milan,Italy BassiRaffaele1,FioritoSerena2,AinaAlessandro3 Correspondence:AcetoMaria([email protected])–Departmentof 1Vita-SaluteSanRaffaeleUniversity,Milan,Italy;2NEMOClinicalCentre, Neuroscience,ReproductiveSciencesandDentistry,FedericoII NiguardaHospital,Milan,Italy;3Physiotherapist,Dip.MDT,private University,Napoli,Italy practice,Milan,Italy ArchivesofPhysiotherapy2016,6(Suppl1):P1 Correspondence:BassiRaffaele([email protected])–Vita- SaluteSanRaffaeleUniversity,Milan,Italy Background ArchivesofPhysiotherapy2016,6(Suppl1):P2 Recentstudieshave stated thatfocal mechanicalvibrationcouldbe aneffectivetoolinthetreatmentofsomeneurologicaldisorders.We Backgroundandaim performed a pilot study to test the feasibility and effectiveness of a Neck pain is a common clinical condition in result of different balancetrainingprograminassociationwithawearablepropriocep- factors including changes in cervical posture [1] and mobility [2]. tive stabilizer (Equistasi®) that emits focal mechanical vibrations in The McKenzie method of Mechanical Diagnosis and Therapy patientswithmultiplesclerosis(MS). (MDT) deals also with neck disorders. Repeated cervical move- Methods ments are the main diagnostic and therapeutic strategy used in Twentypatientswithbalanceandgaitdisordersaffectedbyclinically MDT [3]. The most used is the neck retraction movement, which defined MS were randomly divided into two groups wearing an ac- involves pulling the head and neck posteriorly into a position in tive or inactive device. All patients received a 3 weeks program of which the head is aligned on the thorax, while maintaining the balance training. Assessments were performed at baseline, after the look ahead [4] (Fig. 5). In scientific literature, neck retraction is rehabilitation period (T1), and 3 weeks after (T2) using posturo- poorly investigated even if it has been described as an effective graphicmeasures,dynamicgaitindex,clinicalscalesforbalanceand method to treat symptoms, achieve pain centralization [5], im- fatigue. prove ROM and correct head posture. To date, no articles have Results analyzed the effect of repeated retraction on strength perform- Bothgroupswerematchedforage,sex, EDSSanddiseaseduration. ance and few have dealt with related EMG activity of the upper Therewerenosignificantdifferencesbetween-groupsintheareaof limbs muscles. The aim of this study is to investigate the effect the center of pressure with both opened or closed eyes. Equistasi of 30 repeated neck retractions on upper limbs strength perform- group showed an increased first right step length at T1 (+18%, ance, posture and cervical spine mobility in healthy subjects. p<0.02)andT2(p<0.04)andanincreasedfirstleftsteplenghtatT1 Materialsandmethods (+17%.p=0.05)comparedtoT0withanincreasedaveragestepatT1 50 healthy subjects were recruited and randomly assigned to two (+9%,p<0.03)andT2. groups: CTRL (control), INT (intervention). 25 subjects (CTRL) per- Wealsofoundadecreaseintimeofbothrightandleftdoublesup- formed in sitting position 3 series of 10 flexion-extension cervical port at T1 (−27%, p<0.03; −36%, p<0.01, respectively) and an im- movements, while 25 subjects (INT), in the same position, com- provement in the Functional Reach Test (+19%. p<0.02), Berg pleted 3 series of 10 neck retractions. Each subject was assessed

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that manual therapy treatments can address and resolve many muscle- skeletal pathologies Heneghan NR, Adab P, Balanos GM, Jordan RE. Manual Dosage of manual therapy: principles for clinical practice. Carla Vanti therapist characteristics (academic qualification, sex, weight and height).
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