JENNIFER CHU, MS-DPTC, CPI

UCSF/SFSU GRADUATE PROGRAM IN PHYSICAL THERAPY

 P1
Dull ache in the neck
and upper T/S

P2
Radiating sharp pain
down the arms

P3
Numbness in the
fingertips
 Sitting tolerance < 30min

Using a computer < 20min

Difficulty finding a comfortable

sleeping position
Negative for special questions

Normal neuro exam

Hypomobile cervical and

thoracic spine
  Manual Therapy

  Therapeutic exercise

  Patient education

  Mechanical traction

  Ultrasound
WHY?
  Spinal manual therapy (SMT)

•  Mobilization = low velocity, low or high amplitude thrust prior to

end-range (AAOMPT)

•  Manipulation = high velocity, low amplitude thrust within or at end-

range (AAOMPT)

(Flynn, 2006)
 BIOMECHANICAL N E U R O P H YS I O LO G I C A L
(Cleland 2012)
 ?
BIOMECHANICAL
BIOMECHANICAL N E U R O P H YS I O LO G I C A L
  Neck pain commonly produces distal symptoms

•  14.2% - 71% lifetime prevalence (Wright, 1999)

•  58% of health care visits (BMUS, 2011)

•  $7 billion in annual costs (Fejer, 2006)

  Possible sources:

•  Upper limb nerve entrapment

•  Cervical radiculopathy

•  Cervical stenosis

•  T4 Syndrome
  Patients commonly present with neck and varying UE
symptoms

  There is strong evidence to show the benefits of SMT

  Specific mechanisms are unknown

 Biomechanical

Neurophysiological

Spinal Cord Supraspinal

(Bialosky 2009)
 Decrease Joint
Stiffness

Neurophysiological

Gate Control Stimulate

Theory SNS

(Bialosky 2009)
 Stimulation of the dPAG

Excitation of the SNS

&
MIDBRAIN Affects descending
pain pathways

(Wright 1999 )
 Vasoconstriction =
Skin Temperature
ARTERY

Sweat gland activation =

Skin Conductance
SWEAT GLAND
 Skin Conductance

Skin Temperature
SNS Excitation
Pain

Mechanosensitivity
 Hand Electrodes
Skin
Conductance

Skin Hand Thermistor

Temperature
SNS
Excitation
Hypoalgesia Pain Scale (VAS)

Mechanosensitivity UE ROM
during ULNT
 To determine if SMT to the cervical
or thoracic spine produces a sympathoexcitatory
response in the upper extremity.

To determine if SMT to the cervical

or thoracic spine decreases pain and decreases
mechanosensitivity in the upper extremity.
 I F SMT induces SNS excitation

A N D SNS excitation contributes to hypoalgesia and

decreased mechanosensitivity

T H E N SMT should result in hypoalgesia and

decreased mechanosensitivity in patients with neck
and UE symptoms
  Limited number of studies that observe the
neurophysiologic effects of SMT
•  Small sample sizes with asymptomatic populations
•  Varying thrust vs non-thrust techniques

  Inconclusive results on SMT mechanisms

•  Based on theoretical models
 In patients who have N E C K A N D C O N C U R R E N T
U E S Y M P T O M S, does S P I N A L M A N U A L T H E R A P Y
to the cervical or thoracic spine affect
U E N E U R O P H Y S I O LO G I C M E A S U R E S, as compared
to a C O N T R O L group?

FOREGROUND QUESTION
HO: SMT W I L L N O T P R O D U C E significant changes in:
•  sympathoexcitatory responses: SC and ST
•  clinically relevant outcomes: pain and UE ROM during ULNT

in the upper extremity, P O S T S M T A P P L I C AT I O N

HA: SMT W I L L P R O D U C E significant changes in:

•  sympathoexcitatory responses: SC and ST

•  clinically relevant outcomes: pain and UE ROM during ULNT

in the upper extremity, P O S T S M T A P P L I C AT I O N
HO: SMT W I L L N O T P R O D U C E significant changes in:
•  sympathoexcitatory responses: SC and ST
•  clinically relevant outcomes: pain and UE ROM during ULNT

in the upper extremity, C O M PA R E D T O C O N T R O L S

HA: SMT W I L L P R O D U C E significant changes in:

•  sympathoexcitatory responses: SC and ST

•  clinically relevant outcomes: pain and UE ROM during ULNT

in the upper extremity, C O M PA R E D T O C O N T R O L S
  Reject both null hypotheses

  Post application, SMT will produce:

•  Sympathoexcitatory changes in the upper extremities
•  Decreased pain and improved UE ROM during ULNT

  Compared to controls, SMT will produce:

•  Sympathoexcitatory changes in the upper extremities
•  Decreased pain and improved UE ROM during ULNT
Inclusion Criteria: Exclusion Criteria:

•  English •  Manual therapy performed

•  Human studies at areas other than the
cervical or thoracic spine
•  Measure outcomes in the
upper limb
•  SMT to cervical or thoracic
spine
Databases: Search Terms

•  PubMed In Combination:
•  Google Scholar •  Sympathetic nervous system
•  CINAHL •  Manual therapy
•  PEDro •  Spinal manual therapy
•  Hooked on Evidence •  Hypoalgesia
•  Cochrane •  Neurophysiological
•  Autonomic nervous system
  Single group effect size and 95% CI
•  Change from pre to post intervention

  Two group effect size and 95% CI

•  Post treatment difference between intervention and control groups

  Q statistics for heterogeneity

  Weighting – inverse variance

116 ARTICLES RETRIEVED
FROM INITIAL SEARCH

61 EXCLUDED DUE
TO IRRELEVANCE

55 ARTICLES SCREENED
FOR RELEVANCE
45 EXLUDED DUE
TO NOT MEETING
INCLUSION CRITERIA

1 0 A RT I C L E S I N C LU D E D
2 Parallel 16-36 participants
RCTs
- chronic lateral epicondylalgia
1B - nonacute cervicobrachial pain
- asymptomatic participants
8 Crossover
RCTs
9 STUDIES
Cervical Spine:
Central PA C5-C7
Unilateral PA
Lateral glide
Right rotary SNAG T4

1 S T U DY
Thoracic Spine:
Rotary PA
  Change from pre-treatment to post-treatment

  Does SMT produce sympathoexcitation?

•  Increase in SC
•  Decrease in ST

  Does SMT decrease pain and mechanosensitivity?

•  Decrease in pain on VAS
•  Increase in UE ROM during ULNT
SNS

SNS

PA I N

ROM

ROM
  Compare SMT post-treatment to control post-treatment

  Does SMT produce greater sympathoexcitation than a

control treatment?
•  Increase in SC
•  Decrease in ST

  Does SMT produce a greater decrease in pain and

mechanosensitivity than a control?
•  Decrease in pain on VAS
•  Increase in UE ROM during ULNT
SNS

SNS

PA I N

ROM

ROM
  Single group grand effect sizes
•  SMT has a significant effect on sympathoexcitation, pain, and
mechanosensivitity

  Two group grand effect sizes

•  SMT has a greater effect on sympathoexcitation, pain, and
mechanosensitivity compared to a control

  All individual effect sizes trended in the same

direction

  Homogeneity across studies

 R E J E C T B OT H N U L L H Y P OT H E S E S

  SMT W I L L P R O D U C E significant sympathoexcitatory

changes and clinically relevant outcomes, in the upper
extremity, P O S T S M T A P P L I C AT I O N

  SMT W I L L P R O D U C E significant sympathoexcitatory

changes and clinically relevant outcomes, in the upper
extremity C O M PA R E D T O C O N T R O L S
   Pain on VAS
•  Range of 0.6 – 2.1 points
MCID: 2 points

  Elbow extension during ULNT 1

•  Range of 10.3 – 22.6 degrees
MCID: 10 degrees

C O R R E L AT E D T O I N C R E A S E D
CLINICAL CHANGES
  Harm
•  No adverse effects reported
•  Potential aggravation of patient symptoms

  Cost
•  Not addressed
•  SMT requires competence with manual techniques
  SMT produces a neurophysiologic response

  In patients with neck and UE symptoms

•  SMT to the cervical and/or thoracic spine can produce
sympathoexcitation

•  SMT can result in immediate decreases in pain and

mechanosensitivity
 BIOMECHANICAL N E U R O P H YS I O LO G I C A L
(Bialosky 2009)
  The use of SMT should be strongly considered in the
clinical decision making process

  SMT can be used as an initial intervention

  SMT may increase the effectiveness of other

interventions
  Unknown duration of SMT effects

  SMT in asymptomatic vs symptomatic participants

  Application of SMT is variable

  Studies applying SMT to symptomatic patients

  Long term treatment effects of SMT

  Comparing GPM V to non-thrust techniques

  Assess additional clinically important outcome

measures
  SMT produces a neurophysiologic response

  SMT is effective at reducing pain and decreasing

mechanosensitivity in patients with neck and UE
symptoms
  Betty Smoot, PT, DPTSc

  Sarah Pawlowsky, DPT, OCS

  Willie Graham, DPTc

  Lindsay Loskutoff, DPTc

  UCSF/SFSU Class of 2012

  Family and Friends

1.  Schmid A, Brunner F, Wright A, Bachmann L. Paradigm shift in manual therapy? Evidence for a central nervous system
component in the response to passive cervical joint mobilisation. Manual Therapy. 2008;13:387-396.
2.  Bialosky J, Bishop M, Price D, Robinson M, George S. The mechanisms of manual therapy in the treatment of musculoskeletal
pain: A comprehensive model. Manual Therapy. 2009;14:531-538.
3.  Wright A. Hypoalgesia post-manipulative therapy: a review of a potential neurophysiologic mechanism. Manual Therapy.
1995;1:11-16.
4.  Wright A. Recent concepts in the neurophysiology of pain. Manual Therapy. 1999;4(4):196-202.
5.  Pickar J. Neurophysiological effects of spinal manipulation. The Spine Journal. 2002;2:357-371.
6.  Vernon H. Qualitative review of studies of manupulation-induced hypoalgesia." Journal of Manipulative and Physiologic
Therapeutics. 2000:23(2);134-138.
7.  Evans D. Mechanisms and effects of spinal high-velocity low-amplitude thrust manipulation: Previous theories. Journal of
Manipulative Phyiolosiologic Therapeutics. 2002;25(4):2510262.
8.  Maigne J, et al. Mechanism of action of spinal manipulative therapy. Joint Bone Spine. 2003;70:336-341.
9.  Zusman M. Spinal manipulative Therapy: Review of some proposed mechanisms, and a new hypothesis. The Australian Journal
of Physiotherapy. 1986;32(2):89-99.
10.  Chiu T, Wright A. To compare the effects of different rates of application of a cervical mobilisation technique on sympathetic
outflow to the upper limb in normal subjects. Manual Therapy. 1996;1(4):198-203.
11.  Coppieters M, Stappaerts K, Wouters L, Janssens K. Aberrant protective force generation during neural provocation testing
and the effect of treatment in patients with neurogenic cervicobrachial pain. Journal of Manipulative and Physiological
Therapeutics. 2003;26(2):99-106.
12.  Jowsey P, Perry J. Sympathetic nervous system effects in the hands following a grade III rotary posterior-anterior mobilisation
technique applied to T4: a randomized, placebo-controlled trial. Manual Therapy. 2010;15:248-253.
14.  Moulson A, Watson T. A preliminary investigation into the relationship between cervical snags and sympathetic nervous
system activity in the upper limbs of an asymptomatic population. Manual Therapy. 2006;11:214-224. Peterson N, Vicenzino
B, Wright A. The effects of a cervical mobilisation technique on sympathetic outflow to the upper limb in normal subjects.
Physiotherapy Theory and Practice. 1993;9:149-156.
15.  Saranga J, Green, A, Lewis J, et al. The immediate effects of a cervical lateral glide treatment technique in patients with
cervicobrachial pain. Physiotherapy. 2003;89(11):678-684.
16.  Sterling M, Jull G, Wright A. Cervical mobilisation: concurrent effects on pain, sympathetic nervous system activity, and
motor activity. Manual Therapy. 2001;6(2):72-81.
17.  Vicenzino B, Collins D, Wright A. Sudomotor changes induced by neural mobilization techniques in asymptomatic subjects.
The Journal of Manual & Manipualtive Therapy. 1994;2(2):66-74.
18.  Vicenzino B, Collins D, Wright A. The initial effects of a cervical spine manipulative physiotherapy treatment on the pain
and dysfunction of lateral epicondylagia. Pain. 1996;68:69-74.
19.  Vicenzino B, Collins D, Wright A, et al. An investigation of the interrelationship between manipulative therapy-induced
hypoalgesia and sympathoexcitation. Journal of Manipulative & Physiological Therapeutics. 1998;21(7):448-453.
20.  McLean S, Moffett J, Sharp D, Gardiner E. An investigation to determine the association between neck pain and upper limb
disability for patients with non-specific neck pain: A secondary analysis. Manual Therapy. 2011;16:434-439.
21.  Fejer R, Kyvik KO, Hartvigsen J. The prevalence of neck pain in the world population: a systematic critical review of the
literature. Spine Journal. 2006;15:834-848. 
22.  Wright A, Mayer TG, Gatchel RJ. Outcomes of disabling cervical spine disorders in compensation injuries. Spine.
1999;24:178-183.
23.  American Association of Orthopaedic Surgeons. The burden of musculoskeletal diseases in the United States; 2011.
24.  Butler D. The sensitive nervous system. Adelaide, Australia. Noigroup Publications; 2000. Jewell D. Guide to evidence-
based physical therapy practice. Sudbury, MA. Jones and Bartlett Publishers; 2008.
25.  Jewell D. Guide to evidence-based physical therapy practice. Sudbury, MA. Jones and Bartlett Publishers; 2008.
26.  Cromie J, Robertson V, Best M. Work-related musculoskeletal disorders in physical therapists: Prevalence, severity, risks,
and responses. Physical Therapy. 2000;80:336-351.
27.  Holder N, Clark H, DiBlasio J, et al. Cause, prevalence, and response to occupational musculoskeletal injuries reported by
physical therapists and physical therapist assistants. Physical Therapy. 1999;79:642-652.
28.  Bork B, Cook T, Rosecrance J, et al. Work-related musculoskeletal disoders among physical therapists. Physical Therapy.
1996;76:827-835.
29.  Cleland J, Glynn P, Whitman J, et al. Short-term effects of thrust vesus nonthrust mobilization/manipulation directed at
the thoracic spine in patients with neck pain: A randomized clinical trial. Physical Therapy. 2007;87:431-440.
30.  Boyles R, Ritland B, Miracle B, et al. The short-term effects of thoracic spine thrust manipulation on patients with should
impingement syndrome. Manual Therapy. 2009;14:375-380.
QUESTIONS?