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Objective To assess the influence of clinical, psychological, and psychophysical variables on treatment outcomes after application of exercise combined with education with/without manual therapy in people with tinnitus associated with temporomandibular disorder (TMD). Methods A secondary analysis of a clinical trial was performed investigating the effectiveness of including cervico-mandibular manual therapy into an exercise combined with education program in 61 subjects with TMD-related tinnitus. Clinical outcomes including tinnitus severity and tinnitus-related handicap were assessed at 3 and 6 months post-intervention. Patients were assessed at baseline for clinical (tinnitus severity, tinnitus-related handicap, quality of life), physical (range of motion), psychological (depression), and psychophysical (pressure pain thresholds [PPTs]) variables that were included as predictors. Results The regression models indicated that higher scores of tinnitus severity at baseline predicted better outcomes 3 and 6 months post-intervention (explaining 13% to 41% of the variance) in both groups. Higher scores of tinnitus-related handicap at baseline predicted better outcome of tinnitus-related handicap (45% variance) in the manual therapy with exercise/education group. Lower PPTs over the temporalis muscle at baseline predicted poorer clinical outcomes (10.5% to 41% of the variance) in both groups. Other predictors were sex and quality of life (6.7% variance) in the manual therapy group and PPTs over the masseter muscle (5.8% variance) in the exercise/education group. Conclusion This study found that baseline tinnitus severity and localized PPT over the temporalis muscle were predictive of clinical outcomes in individuals with TMD-related tinnitus following physical therapy. Other predictors (eg, sex, quality of life) were less influential.

Objective The purpose of this study was to determine the relative and absolute reliability of the pressure pain threshold (PPT) in the shoulder muscles of participants with and without unilateral subacromial impingement syndrome. Methods Study of intraday intra- and interrater and interday intrarater reliability. Fifty-two participants symptomatic for unilateral subacromial impingement syndrome were divided into 2 groups (SG1 and SG2) of 26 participants each, and 26 participants asymptomatic for shoulder pain took part in the study. Two raters assessed the PPT in 4 shoulder muscles. Each rater assessed symptomatic (SG1) and asymptomatic participants twice on the same day, and one of the raters on 2 different days (SG2). The intraclass correlation coefficient, standard error of measurement (SEM95% and SEM%), and minimum detectable change (MDC95% and MDC%) were calculated. Results Relative reliability was good or excellent for all assessments, as well as for both groups and raters (intraclass correlation coefficient: 0.87-0.98). The SEM95% values for intra- and interday intrarater measures were between 0.43 and 1.50 kgf/cm2 and SEM% between 6.76 and 12.86%, whereas MDC95% values ranged from 0.60 to 2.12 kgf/cm2 and MDC% from 9.56 to 18.18%. In interrater measures, SEM95% was between 0.58 and 0.77 kgf/cm2 and SEM% between 10.10% and 13.71%, whereas MDC95% varied from 0.82 to 1.08 kgf/cm2 and MDC% from 14.29% to 19.39%. Conclusion Relative reliability was good or excellent. This study presents absolute reliability values that could be used as a reference in the clinical use of PPT.

BACKGROUND Abdominal diastasis (AD) is highly prevalent at post-partum. Although several conservative approaches have been proposed, an effective and protocolized treatment is lacking for this condition. OBJECTIVE To identify modifications of inter-rectus abdominis distance (IRAD), trunk circumferences and mechanical properties of the AD, transversus abdominis and the pelvic floor (PF) muscles, after the application of hypopressive exercises (HE) and at a two-month follow-up in postpartum AD. METHODS Twelve volunteers with post-partum AD followed a four-week (three times a week) tailored program of HE. The main outcome was the IRAD, assessed at four specific supraumbilical points (3, 6, 9, and 12 cm). Abdominal circumference and respiratory expansion were measured at three different locations (axillar, xiphoid, and umbilical), and the mechanical properties of abdomino-pelvic tissues were also assessed using tonometry (MyotonPRO). Four evaluations were performed for all outcomes: at baseline, post-intervention, at a 1-month follow-up, and at a 2-month follow-up. RESULTS The IRAD of participants was reduced (p

Different musculoskeletal disorders are a source of pain in the spinal region, most of them can be divided into mechanical, such as low back pain (LBP), or inflammatory origins, as is the case of axial spondyloarthritis (axSpA). Nevertheless, insufficient information is available about the muscle negative consequences of these conditions. Thus, the objective of this study was to identify whether mechanical muscle properties (MMPs) of cervical and lumbar muscles are different between patients with axSpA, subacute LBP (sLBP), and healthy controls. Furthermore, we aimed identify whether MMPs were related to sociodemographic and clinical variables in various study groups. The MMPs, sociodemographic, and clinical variables were obtained in 43 patients with axSpA, 43 subjects with sLBP, and 43 healthy controls. One-way ANOVAs and ROC curves were applied to identify whether the MMPs could differentiate between the study groups. Intra-group Pearson r coefficients to test the associations between MMPs and the rest of the variables were calculated. The results showed that axSpA subjects have a higher tone and stiffness and a lower relaxation and creep than sLBP and healthy ones (p &lt, 0.05). All lumbar and cervical MMPs, except for decrement, could correctly classify axSpA and healthy subjects and axSpA and sLBP patients (in both cases, Area Under the Curve &gt, 0.8). However, no MMP could differentiate between sLBP and healthy subjects. Each group had a different pattern of bivariate correlations between MMPs and sociodemographic and clinical data, with a worse state and progression of the axSpA group associated with a higher tone and stiffness in both spinal regions. This study supports that MMPs are different and show different patterns of correlations depending on the type of spinal pain.

Background: Studies exploring interventions targeting the cervical spine to improve symptoms in patients with temporomandibular disorders (TMD) are limited. Objectives: To determine whether mobilisation of the upper cervical region and craniocervical flexor training decreased orofacial pain, increased mandibular function and pressure pain thresholds (PPTs) of the masticatory muscles and decreased headache impact in women with TMD when compared to no intervention. Methods: In a single‐blind randomised controlled trial, 61 women with TMD were randomised into an intervention group (IG) and a control group (CG). The IG received upper cervical mobilisations and neck motor control and stabilisation exercises for 5 weeks. The CG received no treatment. Outcomes were collected by a blind rater at baseline and 5‐week follow‐up. Orofacial pain intensity was collected once a week. A mixed ANOVA and Cohen's d were used to determine differences within/between groups and effect sizes. Results: Pain intensity showed significant time‐by‐group interaction (P < 0.05), with significant between‐group differences at four and five weeks (P < 0.05), with large effect sizes (d > 0.8). The decrease in orofacial pain over time was clinically relevant only in the IG. Change in headache impact was significantly different between groups, and the IG showed a clinically relevant decrease after the treatment. No effects were found for PPT or mandibular function. Conclusion: Women with TMD reported a significant decrease in orofacial pain and headache impact after 5 weeks of treatment aimed at the upper cervical spine compared to a CG.

Evidence supports the presence of comorbid conditions, e.g., irritable bowel syndrome (IBS), in individuals with fibromyalgia (FM). Physical therapy plays an essential role in the treatment of FM; however, it is not currently known whether the IBS comorbidity is considered in the selection criteria for clinical trials evaluating physiotherapy in FM. Thus, the aim of the review was to identify whether the presence of IBS was considered in the selection criteria for study subjects for those clinical trials that have been highly cited or published in the high-impact journals investigating the effects of physical therapy in FM. A literature search in the Web of Science database for clinical trials that were highly cited or published in high-impact journals, i.e., first second quartile (Q1) of any category of the Journal Citation Report (JCR), investigating the effects of physical therapy in FM was conducted. The methodological quality of the selected trials was assessed with the Physiotherapy Evidence Database (PEDro) scale. Authors, affiliations, number of citations, objectives, sex/gender, age, and eligibility criteria of each article were extracted and analyzed independently by two authors. From a total of the 412 identified articles, 20 and 61 clinical trials were included according to the citation criterion or JCR criterion, respectively. The PEDro score ranged from 2 to 8 (mean: 5.9, SD: 0.1). The comorbidity between FM and IBS was not considered within the eligibility criteria of the participants in any of the clinical trials. The improvement of the eligibility criteria is required in clinical trials on physical therapy that include FM patients to avoid selection bias.

Our aims were to identify potential differences in muscle mechanical properties (MMPs) of cervical and lumbar tissues and in spinal range of motion (ROM) between patients with acute low back pain (LBP) or acute neck pain (NP) and healthy controls, and to identify if ROMs and MMPs are able to identify subjects among the three groups. Clinical variables (pain, disability, fear of movement, kinesiophobia, quality of life), MMPs and ROMs were obtained in 33 subjects with acute LBP, 33 with acute NP, and 33 healthy control subjects. Between-groups differences and explanatory models to discriminate groups depending on MMPs and ROMs were calculated. The results showed that cervical tone was higher in patients with acute NP than in controls, while cervical decrement was higher in both spinal pain groups. Patients with acute NP showed reduced cervical flexion when compared to acute LBP and control groups, and also cervical rotation, but just against controls. Furthermore, lumbar flexion was reduced in patients with acute LBP when compared to those with acute NP. Cervical decrement was able to discriminate spinal pain individuals from controls in a multinominal regression (R2: Cox–Snell estimation = 0.533, Nagelkerke estimation = 0.600). Lumbar flexion differentiated patients with acute LBP and controls, whereas cervical flexion differentiated patients with acute NP and controls. This study supports a tendency of the affectation of other spinal regions when only one is affected.

The aim of the current scoping review was to identify if the presence of irritable bowel syndrome was included as eligibility criteria of participants included in clinical trials investigating the effects of physical therapy in individuals with temporomandibular pain disorders (TMDs). A systematic electronic literature search in the Web of Science database was conducted. Scientifically relevant, randomized clinical trials (those cited in other studies at least 5 times, or clinical trials published in high-impact journals, i.e., first and second quartiles (Q1-Q2) of any category of the Journal Citation Report (JCR)) evaluating the effects of any physical therapy intervention in patients with TMDs were included. The Physiotherapy Evidence Database (PEDro) scale was used to evaluate the methodological quality of the selected trials. Authors affiliated to a clinical or non-clinical institution, total number of citations, objective, sex/gender, age, and eligibility criteria in each article were extracted and analyzed independently by two authors. From a total of 98 identified articles, 12 and 19 clinical trials were included according to the journal citation criterion or JCR criterion, respectively. After removing duplicates, a total of 23 trials were included. The PEDro score ranged from 4 to 8 (mean: 6.26, SD: 1.48). Based on the eligibility criteria of the trials systematically reviewed, none considered the presence of comorbid irritable bowel syndrome in patients with TMDs. The comorbidity between TMDs and irritable bowel syndrome is not considered within the eligibility criteria of participants in highly cited clinical trials, or published in a high-impact journal, investigating the effects of physical therapy in TMDs.

Biopsychosocial aspects seem to influence the clinical condition of rotator cuff related shoulder pain (RCRSP). However, traditional bivariate and linear analyses may not be sufficiently robust to capture the complex relationships among these aspects. This study determined which biopsychosocial aspects would better classify individuals with acute and chronic RCRSP and described how these aspects interact to create biopsychosocial phenotypes in individuals with acute and chronic RCRSP. Individuals with acute (&lt, six months of pain, n = 15) and chronic (&ge, six months of pain, n = 38) RCRSP were included. Sociodemographic data, biological data related to general clinical health status, to shoulder clinical condition and to sensory function, and psychosocial data were collected. Outcomes were compared between groups and a decision tree was used to classify the individuals with acute and chronic RCRSP into different phenotypes hierarchically organized in nodes. Only conditioned pain modulation was different between the groups. However, the tree combined six biopsychosocial aspects to identify seven distinct phenotypes in individuals with RCRSP: three phenotypes of individuals with acute, and four with chronic RCRSP. While the majority of the individuals with chronic RCRSP have no other previous painful complaint besides the shoulder pain and low efficiency of endogenous pain modulation with no signs of biomechanical related pain, individuals with acute RCRSP are more likely to have preserved endogenous pain modulation and unilateral pain with signs of kinesiophobia.

BackgroundPhysical exercise, a cornerstone of the conservative management of knee osteoarthritis (KOA), is exhaustively recommended by important clinical guidelines. A strength therapeutic exercise program (STEP) relieves pain, improves physical function and ultimately ameliorates quality of life (QoL). Furthermore, photobiomodulation (PBM) has been used as an adjunct treatment for people with KOA; however, there are still controversial recommendations regarding its use on this population. Thus, we hypothesised that PBM, when associated with a STEP protocol on patients with KOA, could induce better clinical outcomes than a STEP protocol alone.Methods and analysisThe study is a 6-month triple-blind placebo-controlled randomised clinical trial with intention-to-treat analysis. The trial will include 120 people with clinic and radiographic signs of KOA. The intervention consists of a supervised STEP and PBM protocols conducted over an 8-week intervention period. Assessments are performed at baseline, right after treatment, and 3-month and 6-month follow-up periods. The primary clinical outcome is pain intensity according to a 10 cm Visual Analogue Scale. Secondary outcomes are the global Western Ontario & McMaster Universities Osteoarthritis Index; QoL assessed by the 36-item Short-Form health survey questionnaire; and performance-based physical parameters assessed by the 30 s chair stand test; the stair climb test; and the 40 m fast-paced walk test.Ethics and disseminationThe trial was approved by the Human Research Ethics Committee of the Federal University of São Carlos, São Paulo, Brazil (REC no 2.016.122). Results will be published in peer-reviewed journals.Trial registration numberBrazilian Clinical Trials Registry (U1111-1215-6510).

Objective To determine inter- and intraexaminer reliability of examiners without clinical experience in identifying and classifying myofascial trigger points (MTPs) in the shoulder muscles of subjects asymptomatic and symptomatic for unilateral subacromial impact syndrome (SIS). Design Within-day inter- and intraexaminer reliability study. Setting Physical therapy department of a university. Participants Fifty-two subjects participated in the study, 26 symptomatic and 26 asymptomatic for unilateral SIS. Interventions Two examiners, without experience for assessing MTPs, independent and blind to the clinical conditions of the subjects, assessed bilaterally the presence of MTPs (present or absent) in 6 shoulder muscles and classified them (latent or active) on the affected side of the symptomatic group. Each examiner performed the same assessment twice in the same day. Main Outcome Measures Reliability was calculated through percentage agreement, prevalence- and bias-adjusted kappa (PABAK) statistics, and weighted kappa. Results Intraexaminer reliability in identifying MTPs for the symptomatic and asymptomatic groups was moderate to perfect (PABAK, .46–1 and .60–1, respectively). Interexaminer reliability was between moderate and almost perfect in the 2 groups (PABAK, .46–.92), except for the muscles of the symptomatic group, which were below these values. With respect to MTP classification, intraexaminer reliability was moderate to high for most muscles, but interexaminer reliability was moderate for only 1 muscle (weighted κ=.45), and between weak and reasonable for the rest (weighted κ=.06–.31). Conclusions Intraexaminer reliability is acceptable in clinical practice to identify and classify MTPs. However, interexaminer reliability proved to be reliable only to identify MTPs, with the symptomatic side exhibiting lower values of reliability.

Mechanical hyperalgesia defined as decreased pressure pain thresholds (PPTs) is commonly associated with pain. In this narrative review, we report the current state of the art within topographical pressure sensitivity maps. Such maps are based on multiple PPT assessments. The PPTs are assessed by an a priori defined grid with special focus on both spatial and temporal summation issues. The grid covers the muscle or the body region of interest using absolute or relative values determined from anatomical landmarks or anthropometric values. The collected PPTs are interpolated by Shepard or Franke and Nielson interpolation methods to create topographical pressure sensitivity maps. This new imaging technique has proven to be valuable in various disciplines including exercise physiology, neurology, physical therapy, occupational medicine, oncology, orthopedics, and sport sciences. The reviewed papers have targeted different body regions like the scalp, low back, neck-shoulder, and upper and lower extremities. The maps have delineated spatial heterogeneity in the pressure pain sensitivity underlining the different extents of pressure pain hyperalgesia in both experimentally induced and disease-associated pain conditions. Furthermore, various intervention studies have proven the utility of topographical pressure pain sensitivity maps. Topographical pressure pain sensitivity maps have contributed to revealing the efficacy of therapeutic, ergonomic, or training interventions that aim at reducing pain.

Objective: The aim of this scoping review was to identify if the phase of the menstrual cycle was considered in observational studies comparing pressure pain sensitivity between women with migraine or tension-type headache (TTH) and headache-free women. Methods: A systematic electronic literature search in PubMed, Medline, Web of Science, Scopus, and CINAHL databases was conducted. Observational studies including one or more groups with TTH and/or migraine comparing pressure pain thresholds (PPTs) were included. The methodological quality (risk of bias) was assessed with the Newcastle-Ottawa Scale. Authors, objectives, inclusion/exclusion criteria, size sample, female sample, tool to assess PPTs, mean age, and the use of any medication were extracted and analyzed independently by two authors. Results: From a total of 1404 and 1832 identified articles for TTH and migraine, 30 and 18 studies satisfied the criteria and were included. Nineteen (63.4%) studies assessing TTH patients and eleven (61.1%) assessing migraine patients showed a high risk of bias. The most common flaws were attributed to improper selection of control and control over other additional factors. Based on the systematic review, just one study including TTH and one including migraine patients considered the menstrual cycle. Conclusion: The results of this scoping review identified that the phase of the menstrual cycle has been rarely considered in studies investigating sensitivity to pressure pain in primary headaches, such as TTH or migraine, although there is evidence showing the relevance of the phase of the menstrual cycle in pain perception.

We aimed to evaluate gender differences in the relationships between headache features, sleep quality, anxiety, depressive symptoms, and burden of headache in 193 patients (73 percent women) with chronic tension type headache (CTTH). Sleep quality was assessed with the Pittsburgh Sleep Quality Index. Headache features were collected with a four-week diary. The Hospital Anxiety and Depression Scale was used to assess anxiety/depressive symptoms. Headache Disability Inventory was used to evaluate the burden of headache. In men with CTTH, sleep quality was positive correlated with headache frequency (r = 0.310; p = .018), emotional (r = 0.518; p < .001) and physical (r = 0.468; p < .001) burden of headache, and depressive symptoms (r = 0.564; p < .001). In women, positive correlations were observed between sleep quality and headache intensity (r = 0.282; p < .001), headache frequency (r = 0.195; p = .021), emotional burden (r = 0.249; p = .004), and depressive symptoms (r = 0.382; p < .001). The results of stepwise regression analyses revealed that depressive symptoms and emotional burden of headache explained 37.2 percent of the variance in sleep quality in men (p < .001), whereas depressive symptoms and headache intensity explained 17.4 percent of the variance in sleep quality in women (p < .001) with CTTH. Gender differences associated with poor sleep should be considered for proper management of individuals with CTTH.

Although hydrotherapy is widely used to treat women with fibromyalgia, no studies have investigated the effects of this intervention on scapular kinematics in this population. This study verified the effectiveness of a hydrotherapy program on scapular kinematics, pain and quality of life in women with fibromyalgia.Twenty women completed the study and performed three evaluations before treatment (to establish a baseline), and two other evaluations (after 8 and 16weeks of hydrotherapy) at the end of treatment. Three-dimensional kinematics of the scapula was evaluated during arm elevation in two different planes with the Flock of Birds® system. Patients also answered quality of life and Fibromyalgia Impact Questionnaires and had pain assessed with a digital algometer. Treatment consisted of 2 weekly hydrotherapy sessions, lasting 45min each, for 16weeks. Data were analyzed with a two-way ANOVA (for kinematics results) and one-way ANOVA (for the other variables). Effect size was assessed with Cohen's d coefficient for all quantitative variables.Although an important improvement was achieved in terms of pain and quality of life (P0.05, effect sizes varied from -1.93 to 1.61 depending on the variable), scapular kinematics did not change after treatment (P0.05, effect sizes from -0.40 to 0.46 for all kinematic variables).The proposed program of hydrotherapy was effective to improve quality of life, pain intensity and fibromyalgia impact in women with fibromyalgia. However, scapular kinematics did not change after the period of treatment. Although symptoms improved after the treatment, the lack of changes in scapular kinematics may indicate these women have an adaptive movement pattern due to their chronic painful condition.

Objective To investigate the short-term effects of thoracic spine manipulation (TSM) on pain, function, scapular kinematics, and scapular muscle activity in individuals with shoulder impingement syndrome. Design Randomized controlled trial with blinded assessor and patient. Setting Laboratory. Participants Patients with shoulder impingement syndrome (N=61). Interventions Participants were randomly allocated to TSM group (n=30) or sham-TSM group (n=31) and attended 2 intervention sessions over a 1-week period. Main Outcome Measures Scapular kinematics and muscle activity were measured at day 1 (baseline, before the first intervention), day 2 preintervention (before second intervention), day 2 postintervention (after the second intervention), and day 3 (follow-up). Shoulder pain and function were assessed by the Disability of the Arm, Shoulder and Hand questionnaire and Western Ontario Rotator Cuff Index at baseline, day 2 preintervention, and follow-up. An assessor blinded to group assignment measured all outcomes. Results Pain decreased by 0.7 points (95% confidence interval, 1.3–0.1 points) at day 2 preintervention and 0.9 points (95% confidence interval, 1.5–0.3 points) at day 2 postintervention in the TSM group. The Disability of the Arm, Shoulder and Hand questionnaire ( P =.01) and Western Ontario Rotator Cuff Index ( P =.02) scores improved in both groups. Scapular upward rotation increased during arm lowering ( P P Conclusions TSM may increase scapular upward rotation during arm lowering. TSM does not seem to influence activity of the scapular muscles. The results concerning shoulder pain, function, scapular tilt, and internal rotation are not conclusive.

Background People with carpal tunnel syndrome (CTS) exhibit widespread pressure pain and thermal pain hypersensitivity as a manifestation of central sensitization. The aim of our study was to compare the effectiveness of manual therapy versus surgery for improving pain and nociceptive gain processing in people with CTS. Methods The trial was conducted at a local regional Hospital in Madrid, Spain from August 2014 to February 2015. In this randomized parallel-group, blinded, clinical trial, 100 women with CTS were randomly allocated to either manual therapy (n = 50), who received three sessions (once/week) of manual therapies including desensitization manoeuvres of the central nervous system, or surgical intervention (n = 50) group. Outcomes including pressure pain thresholds (PPT), thermal pain thresholds (HPT or CPT), and pain intensity which were assessed at baseline, and 3, 6, 9 and 12 months after the intervention by an assessor unaware of group assignment. Analysis was by intention to treat with mixed ANCOVAs adjusted for baseline scores. Results At 12 months, 95 women completed the follow-up. Patients receiving manual therapy exhibited higher increases in PPT over the carpal tunnel at 3, 6 and 9 months (all, p

Objective:The objective was to evaluate the effectiveness of early rehabilitation on arm range of motion (ROM), strength and function after breast cancer surgery (BCS). Data sources: PubMed, MEDLINE, Bireme, Embase, LILACS and CINAHL databases were searched.Methods:Two independent reviewers selected randomized controlled trials evaluating women who underwent early rehabilitation to restore arm ROM, strength or function after BCS. Cochrane Collaboration recommendations and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Methodological quality was assessed by the PEDro scale. The International Classification of Functioning, Disability and Health was considered to analyze results. Effect size (ES) was calculated for clinical relevance interpretation of the outcomes of interest, and the evidence was summarized through the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.Results:Up to June 2019, a total of 1658 references were identified and 15 studies were included. Twelve of them presented adequate methodological quality. A total of 1710 patients were evaluated. Few studies performed the simultaneous assessment of variables related to body structure and function and patient-reported outcomes. A moderate level of evidence was synthesized regarding the effectiveness of ROM exercises for improving arm flexion, abduction and external rotation (ES: 0.45–2.5). A low level of evidence was synthesized regarding the effectiveness of isolated strengthening exercises for patient-reported arm function. ROM exercises associated with muscle strengthening exhibited a moderate level of evidence for improving shoulder flexion (ES: 1.4–2.4).Conclusion:Both ROM and strengthening exercises associated with ROM exercises improved shoulder flexion, abduction and external rotation ROM after BCS. Shoulder abduction and external rotation showed less recovery, irrespective of the intervention applied.

Background Lumbar back pain reduces spinal mobility in patients. Although there are some symptoms that characterise ‘inflammatory back pain’, these are non-specific and the diagnosis is often delayed. It is not clear if there are kinematic differences between axial Spondyloarthritis (axSpA) and other types of back pain. Inertial motion sensors are now available that can accurately and reliably measure spinal mobility. The ViMove system uses two inertial sensors located at L1 and S1 allowing spinal flexion to be separated into its lumbar and pelvic components. The relation between different parts of the spine during a full flexion movement is known as lumbopelvic rhythm. The trunk sensor measures the total flexion, whilst the contribution of hip is measured by the pelvis sensor leaving lumbar flexion as the difference between the two angles. Objectives To analyse relation of lumbopelvic angles in axSpA patients, LBP patients and healthy controls. Methods 92 subjects were included in our study: 56 axSpA (from the COSPAR cohort of the Reina Sofia University Hospital), 14 LBP and 22 healthy controls. Inertial based system, the ViMove, was used to measure mobility. axSpA patients were stratified in three groups according their overall mobility using the BASMI: axSpA Low ( 4) Results Table shows the results of spinal mobility tests in each group. The trunk, pelvis and lumbar angles are expressed in degrees (Mean and SD). cPelvis is the contribution of pelvis to the overall movement as percentage. Three of the five measurements in BASMI are outside the lower back so unlikely to be affected in LBP patients. There were significantly differences in the trunk, lumbar and pelvis angles between control and axSpA groups (p The left part of the figure shows a reconstruction of the mean flexion angles for each group: these are also represented in the bar graph on the right. The trunk angle is higher in the healthy control group, is similar to the less affected axSpA patients (No significant differences between two groups). The most severely affected axSpA patients show reduced lumbar movement, and the pelvic contribution of the pelvis is also higher than the other two axSpA groups (p Conclusion A reduction in spinal flexion was found in all patient groups, but there are interesting differences in the pattern of movement. LBP patients were characterised by a greater reduction in pelvis movement compared to the axSpA patients, although the final trunk flexion angle is actually lower in axSpA. When we compared more and less affected axSpA patients (according to BASMI), the most severely affected had severe restriction in lumbar movement whilst pelvic movement was increased. Lumbo-pelvic rhythm can also be analysed throughout early, middle and the end of the movement. Investigating spinal kinematics could help us to understand better axSpA and how it affects spinal mobility. Acknowledgement This study was funded by FOREUM (www.foreum.org), Junta de Andalucia (PIN-0079-2016) and XXI Research Promotion Program of the University of Cordoba (Spain). Disclosure of Interests None declared

Objective: To investigate the effectiveness of cryotherapy on pain and physical function in knee osteoarthritis. Data sources: An electronic search was performed up to February 2019 on PubMed/MEDLINE, EMBASE, CINAHL, Lilacs, Cochrane, Web of Science, Ibecs, and Scielo databases with keywords knee osteoarthritis and cryotherapy. Methods: Two authors independently performed the study selection. All languages and publication dates were considered. The PEDro scale was used to assess the methodological quality of the studies, and the body of evidence was analyzed and synthesized using the Grading of Recommendations, Assessment, Development, and Evaluation approach. The clinical relevance of the included studies was evaluated using the criteria proposed in the Cochrane Handbook for Systematic Reviews of Interventions. Results: Of the five studies, 202 subjects were included. All studies included participants with established knee osteoarthritis. The mean PEDro score was 4.20/10, and meta-analysis was not possible due to heterogeneity among the studies. The mean clinical relevance was 3/5. Only two studies were considered for analysis based on the GRADE approach, and low level of evidence was synthesized regarding the effectiveness of cryotherapy for pain management, knee stiffness, knee range of motion, and physical function. Application techniques, frequency, and duration did not affect outcomes. Conclusions: There were insufficient primary studies to draw any conclusions about the effectiveness of cryotherapy on pain and physical function on individuals with knee osteoarthritis.

Aim To establish whether there are differences in pain sensitivity between hypertensive and normotensive older adults. Methods A cross-sectional case control study was carried out. A total of 72 older adults, 36 normotensive and 36 hypertensive, participated in the study. The pressure pain threshold (PPT) was assessed on seven points bilaterally in both groups by means of pressure algometry. Two-factor analysis of variance (anova) – group and sex – was carried out, and the magnitude of the differences was calculated using Cohen's index. Results The PPT values were higher in the group of hypertensive older adults compared with the normotensive older adults; that difference was significant (P

Aim To summarise the current evidence regarding the effectiveness of physical therapy on pain, function and range of motion in individuals with subacromial pain syndrome (SAPS). Design Systematic review. Data sources PubMed, Web of Science, CINAHL, Cochrane, Embase, Lilacs, Ibecs and Scielo databases. Eligibility criteria for selecting studies Randomised controlled trials (RCTs) investigating physical therapy modalities for SAPS on pain, function/disability or range of motion were included. Results 64 high-quality RCTs were included. Exercise therapy provided high evidence of being as effective as surgery intervention and better than no treatment or placebo treatment to improve pain, function and range of motion in the short, mid and long terms. The combination of mobilisation and exercises provided high evidence to decrease pain and improve function in the short term. There is limited evidence for improvements on the outcomes with the isolated application of manual therapy. High level of evidence was synthesised regarding the lack of beneficial effects of physical resources such as low-level laser, ultrasound and pulsed electromagnetic field (PEMF) on pain, function or range of motion in the treatment of SAPS. There is limited evidence for microwave diathermy and transcutaneous electrical nerve stimulation. There is moderate evidence to no benefits with taping in the short term. Effects of diacutaneous fibrolysis and acupuncture are not well established yet. Conclusions Exercise therapy should be the first-line treatment to improve pain, function and range of motion. The addition of mobilisations to exercises may accelerate reduction of pain in the short term. Low-level laser therapy, PEMF and taping should not be recommended.

Objetivo: Primeiramente, avaliar o efeito imediato da terapia de compressão isquêmica (TCI) na dor, mobilidade e força dos músculos do ombro em indivíduos com Síndrome do Impacto Subacromial (SIS). Em segundo lugar, verificar se o protocolo de avaliação de força e mobilidade influencia a quantidade de pontos-gatilho miofasciais (PGMs). Métodos: Estudo de braço único com um total de 15 indivíduos (6 mulheres e 9 homens, 34,4±10,43 anos; 24,20±2,18 kg/m2) com sintomas clínicos de SIS unilateral. Todos os indivíduos foram avaliados quanto à quantidade de PGMs nos músculos trapézio superior, trapézio inferior, supraespinhal, infraespinal, peitoral menor e deltóide médio; limiar de dor à pressão (LDP) nos músculos trapézio superior, trapézio inferior, infraespinhal e deltóide médio; amplitude de movimento (ADM) do ombro; e força isométrica dos músculos do ombro. Resultados: Houve redução da quantidade total de PMGs (p0,05) e medidas de força (p>0,24); entretanto, a dor foi menor durante a ADM de elevação sagital (p0,06). Conclusão: A TCI reduziu imediatamente a quantidade de PGMs e a dor durante a mobilidade e força, mas não alterou as variáveis ​​LDP, ADM ou força. A avaliação da mobilidade e força não interferiu negativamente nas variáveis ​​avaliadas.

Background There are insufficient studies providing Minimal Clinically Important Difference (MCID) for outcomes related to temporomandibular disorders (TMD). Objectives (1) To provide the MCID of outcomes related to TMD using the Global Rating of Change Scale (GRCS) as an anchor. (2) To verify which outcomes can predict a moderate or large response to the treatment. Study design Secondary analysis of a randomized controlled trial in subjects with TMD. Methods Sixty-one women with TMD were divided into intervention and control groups. Visual Analogue Scale (VAS), Headache Impact Test (HIT-6), pressure pain thresholds (PPTs) of masticatory muscles, Mandibular Function Impairment Questionnaire (MFIQ), and Craniocervical Flexion Test (CCFT) were collected at baseline and 5-weeks follow-up. Results Participants were divided based on their response to the treatment, according to the GRCS. MCID values were provided for subjects that moderately or largely improved to the treatment. MCID was between 0 and 1.90 for orofacial pain, around 2 points for the MFIQ, between 3 and 6.26 points for the HIT-6, around 0.2 kg/cm2 for the PPTs on masticatory muscles, around 2.5 mm for MMO and between 60 and 68 points for CCFT. Orofacial pain and HIT-6 were the most discriminative variables at determining whether patients would largely/moderately improve or would not improve after treatment. Conclusions The values of MCID could be used as guidance for both clinical practice and research. Pain intensity and headache impact were the most predictive outcomes for improvement of the general health status of women with TMD.

There are no conclusive results concerning changes in scapular kinematics associated with upper limb dysfunctions after breast cancer surgery.To compare the three-dimensional (3-D) scapular kinematics during elevation of the arm between women after breast cancer surgery and controls. Shoulder range of motion (ROM), muscle strength, pain intensity, upper limb function, and quality of life were also assessed.Forty-two women were assigned to two groups (surgery group, n = 21; control group, n = 21). 3-D scapular kinematics was collected during elevation of the arm in the scapular plane. ROM was assessed using a digital inclinometer, muscle strength using a manual dynamometer, pain with the Visual Analogue Scale (VAS), upper limb function with the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and quality of life with the 36-item Short-Form Health Survey (SF36).The surgery group presented decreased scapular upward rotation at 120° of arm elevation in the scapular plane (p .05; d = -0.88), decreased shoulder external rotation ROM and strength of shoulder abduction and external rotation when the affected side was compared to the non-affected side and control group. Moreover, the surgery group also reported higher pain, increased upper limb disability and poorer quality of life compared with healthy controls.Scapular upward rotation seems to be decreased at 120° of arm elevation in women following breast cancer surgery. In addition, shoulder external rotation ROM, abduction strength, external rotation strength, function, and quality of life are also impaired in these women. They also experienced pain during the studied movements.

Randomized controlled trial.To evaluate the effects of an exercise protocol, with and without manual therapy, on scapular kinematics, function, pain, and mechanical sensitivity in individuals with shoulder impingement syndrome.Stretching and strengthening exercises have been shown to effectively decrease pain and disability in individuals with shoulder impingement syndrome. There is still conflicting evidence regarding the efficacy of adding manual therapy to an exercise therapy regimen.Forty-six patients were assigned to 1 of 2 groups, one of which received a 4-week intervention of stretching and strengthening exercises (exercise alone) and the other the same intervention, supplemented by manual therapy targeting the shoulder and cervical spine (exercise plus manual therapy). All outcomes were measured preintervention and postintervention at 4 weeks. Outcome measures were scapular kinematics in the scapular and sagittal planes during arm elevation, function as determined through the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, pain as assessed with a visual analog scale, and mechanical sensitivity as assessed with pressure pain threshold.Independent of the intervention group, small, clinically irrelevant changes in scapular kinematics were observed postintervention. A significant group-by-time interaction effect (P = .001) was found for scapular anterior tilt during elevation in the sagittal plane, with a 3.0° increase (95% confidence interval [CI]: -1.5°, 7.5°) relative to baseline in the exercise-plus-manual therapy group compared to a decrease of 0.3° (95% CI: -4.2°, 4.8°) in the exercise-alone group. Pain, mechanical sensitivity, and the DASH score improved similarly for both groups by the end of the intervention period.Adding manual therapy to an exercise protocol did not enhance improvements in scapular kinematics, function, and pain in individuals with shoulder impingement syndrome. The noted improvements in pain and function are not likely explained by changes in scapular kinematics.

The scope of this paper was to study the relationship between pain intensity, health-related quality of life, disability, sleep quality and demographic data in elderly people with total knee arthroplasty (TKA). 24 subjects who had been subjected to TKA the previous month (4 females; 66 ± 9years) and 21 comparable controls (8 male; 70 ± 9years) participated in the study. Intensity of pain, and highest and lowest pain intensity experienced in the preceding week were collected. The Western Ontario and McMaster Universities index function, quality of life (Medical Outcomes Study Short Form 36), and Pittsburgh Sleep Quality Index were assessed. Age, gender, weight, height, body mass index were also collected. Individuals with TKA presented worse physical function (P < 0.01), social role (P = 0.01), physical performance (P < 0.01), pain (P = 0.04), disability (P = 0.04) and sleep quality (P = 0.03) than the controls. Higher intensity of pain was associated with lower physical function, social role, mental health, vitality and general health, and with higher disability and sleep quality. Disability and sleep quality were negatively associated with several quality of life domains. The associations between the intensity of pain, disability, quality of life and sleep reveal the multidimensional experience of TKA. Objetivo: Identificar as relações entre intensidade da dor, qualidade de vida relacionada à saúde, incapacidade, qualidade do sono e dados demográficos em idosos com artroplastia total de joelho (ATJ). Métodos: Participaram vinte e quatro pacientes que receberam ATJ no mês anterior (4 mulheres; 66 ± 9 anos) e 21 controles comparáveis (8 homens; 70 ± 9 anos). Foram coletadas a intensidade da dor no momento da avaliação, a maior e a menor intensidade de dor sentida na semana anterior. A função (Western Ontario and McMaster Universities index), a qualidade de vida (Medical Outcomes Study Short Form 36), e a qualidade do sono (Pittsburgh Sleep Quality Index) foram avaliadas. Idade, sexo, peso, altura, índice de massa corporal também foram coletados. Resultados: Indivíduos com ATJ mostraram pior função física (P < 0,01), papel social (P = 0,01), desempenho físico (P < 0,01), dor (P = 0,04), incapacidade (P = 0,04) e qualidade do sono (P = 0,03) do que os controles. Maior intensidade da dor foi associada com menor função física, papel social, saúde mental, vitalidade e saúde geral, e com maior incapacidade e qualidade do sono. Incapacidade e qualidade do sono estiveram associa das negativamente com vários domínios de qualidade de vida. As associações entre a intensidade da dor, incapacidade, qualidade de vida e do sono mostram a experiência multidimensional da ATJ.

Background. Hamstring injuries continue to affect active individuals and although inadequate muscle extensibility remains a commonly accepted factor, little is known about the most effective method to improve flexibility.Purpose. To determine if an isolated neurodynamic sciatic sliding technique would improve hamstring flexibility to a greater degree than stretching or a placebo intervention in asymptomatic subjects with short hamstring syndrome (SHS).Study Design. Randomized double-blinded controlled trial.Methods. One hundred and twenty subjects with SHS were randomized to 1 of 3 groups: neurodynamic sliding, hamstring stretching, and placebo control. Each subject’s dominant leg was measured for straight leg raise (SLR) range of motion (ROM) before and after interventions. Data were analyzed with a3×2mixed model ANOVA followed by simple main effects analyses.Results. At the end of the study, more ROM was observed in the Neurodynamic and Stretching groups compared to the Control group and more ROM in the Neurodynamic group compared to Stretching group.Conclusion. Findings suggest that a neurodynamic sliding technique will increase hamstring flexibility to a greater degree than static hamstring stretching in healthy subjects with SHS.Clinical Relevance. The use of neurodynamic sliding techniques to improve hamstring flexibility in sports may lead to a decreased incidence in injuries; however, this needs to be formally tested.

Objective The purpose of this study was to evaluate the immediate effects of seated thoracic manipulation on scapulothoracic kinematics and scapulohumeral rhythm during arm flexion in young asymptomatic participants. Methods A convenience sample of 42 young asymptomatic participants was randomly divided in 2 groups: manipulation and sham group. Measurements were taken before and after the intervention. All participants completed the Disabilities of the Arm, Shoulder, and Hand questionnaire to assess pain and physical function. The manipulation group received the manipulation (high velocity, low amplitude), which was performed by a physical therapist with the patient in the seated position and with the arms crossed over the chest and hands passed over the shoulders. For the sham group, the same procedure was performed, with the exception that the high-velocity thrust was not applied. Three-dimensional (3D) kinematic data were collected with the participants in a relaxed standing position using a 3D electromagnetic tracking system. All participants performed 3 repetitions of arm flexion before and after manipulation. Results There were no differences ( P = .79) in Disabilities of the Arm, Shoulder, and Hand scores when the manipulation (3.37 ± 3.72) was compared with the sham group (3.68 ± 4.27). The 3-way analysis of variance showed no significant interaction among group, angle, and time differences for the outcomes (scapulothoracic internal/external rotation [ F = 0.43; P = .82], upward/downward rotation [ F = 0.08; P = .99], tilt [ F = 0.23; P = .94], and scapulohumeral rhythm [ F = 4; P = .86]). The intragroup effect was small for the outcomes measured in both groups. Conclusions Thoracic manipulation in the seated position did not affect scapulohumeral rhythm and 3D scapular kinematics during arm flexion in young asymptomatic participants.

Background Cultural and social factors play an important role in the development and persistence of Low Back Pain (LBP). Nevertheless, there are few studies investigating differences in LBP features between countries. Objective To determine differences in pain perception between individuals with LBP living in Brazil and Spain. Method Thirty Spanish individuals and 30 age- and sex-comparable Brazilian individuals with LBP were recruited from the Public Health Services of both countries. The Numerical Pain Rating Scale and the pain rating index (PRI), the number of words chosen (NWC), and the present pain index (PPI) extracted from the McGill Pain Questionnaire were used to assess pain. The Oswestry Disability Index, the Short Form-36, Beck Depression Inventory-II, and Pittsburgh Sleep Quality Index were also applied. Differences between countries and the correlation between demographic and clinical variables in each country were assessed with parametric and the nonparametric tests. Results A significant Country by Gender interaction was found for the PRI total score (P=0.038), but not for intensity of pain, disability, PPI, or NWC, in which Spanish women exhibited greater pain ratio than Spanish men (P=0.014), and no gender differences were identified in Brazilians. The Spanish group showed a consistent pattern of correlations for clinical data. Within Brazilian patients, fewer correlations were found and all of the coefficients were lower than those in the Spanish group. Conclusion The pain perception in patients with LBP is different depending on the country. Within Spanish patients, LBP is considered a more global entity affecting multidimensional contexts.

Objective To investigate the effect of a rehabilitation program based on cervical mobilization and exercise on clinical signs and mandibular function in subjects with temporomandibular disorder (TMD). Material and Methods: Single-group pre-post test, with baseline comparison. Subjects Twelve women (22.08±2.23 years) with myofascial pain and mixed TMD according to the Research Diagnostic Criteria for Temporomandibular Disorders. Outcome measures Subjects were evaluated three times: twice before (baseline phase) and once after intervention. Self-reported pain, jaw function [according to the Mandibular Functional Impairment Questionnaire (MFIQ)], pain-free maximum mouth opening (MMO), and pressure pain thresholds (PPTs) of both masseter and temporalis muscles were obtained. Baseline and post-intervention differences were investigated, and effect size was estimated through Cohen’s d coefficient. Results Jaw function improved 7 points on the scale after the intervention (P=0.019), and self-reported pain was significantly reduced (P=0.009). Pain-free MMO varied from 32.3±8.8 mm to 38±8.8 mm and showed significant improvement (P=0.017) with moderate effect size when compared to the baseline phase. PPT also increased with moderate effect size, and subjects had the baseline values changed from 1.23±0.2 kg/cm2 to 1.4±0.2 kg/cm2 in the left masseter (P=0.03), from 1.31±0.28 kg/cm2 to 1.51±0.2 kg/cm2 in the right masseter (P>0.05), from 1.32±0.2 kg/cm2 to 1.46±0.2 kg/cm2 in the left temporalis (P=0.047), and from 1.4±0.2 kg/cm2 to 1.67±0.3 kg/cm2 in the right temporalis (P=0.06). Conclusions The protocol caused significant changes in pain-free MMO, self-reported pain, and functionality of the stomatognathic system in subjects with myofascial TMD, regardless of joint involvement. Even though these differences are statistically significant, their clinical relevance is still questionable.

Knee Osteoarthritis seems to negatively impact ankle biomechanics. However, the effect of knee osteoarthritis on ankle muscle strength has not been clearly established. This study aimed to evaluate the ankle strength of the plantar flexors and dorsiflexors of patients with knee osteoarthritis in different degrees of severity.Thirty-seven patients with knee osteoarthritis and 15 controls, subjected to clinical and radiographic analysis, were divided into three groups: control, mild, and moderate knee osteoarthritis. Participants answered a self-reported questionnaire and accomplished a muscle torque assessment of the ankle using the Biodex dynamometer in isometric, concentric and eccentric modes.The mild osteoarthritis group (peak torque=26.85(SD 3.58)) was significantly weaker than the control (peak torque=41.75(SD 4.42)) in concentric plantar flexion (P0.05). The control and mild osteoarthritis groups were not significantly different from the moderate osteoarthritis group (peak torque=36.12(SD 4.61)) in concentric plantar flexion. There were no significant differences for dorsiflexion among the groups; however the control and moderate osteoarthritis groups presented large and medium standardized mean differences. The mild osteoarthritis group was significantly lower than the control and moderate osteoarthritis groups in the concentric plantar flexion by concentric dorsiflexion torque ratio.Ankle function exhibited impairments in patients with knee osteoarthritis, especially in the plantar flexion torque, in which the mild osteoarthritis group was weaker than the control. Interestingly, patients with moderate knee osteoarthritis showed results similar to the control group in plantar flexion torque. The results raise the possibility of a compensatory mechanism of the plantar flexors developed by patients in more advanced degrees to balance other muscle failures.

The primary objective of this study was to compare the number of myofascial trigger points (MTPs) and the pressure pain thresholds (PPTs) in the shoulder girdle, on the dominant and nondominant sides, between healthy children and adults. The secondary aim was to assess the correlations between the number of MTPs and the PPTs in these populations.A cross-sectional study was performed. Thirty-five children (aged 9.1 ± 1.7 years) and 35 adults (aged 23.4 ± 3.4 years) with no history of shoulder or cervical pathology were included. All participants were examined for MTPs in the shoulder muscles and assessed for PPTs in the neck, shoulder, and tibialis anterior. Parametric and nonparametric tests, effect sizes, and odds ratios were used to determine the differences between groups and sides. Spearman's σ test was used to assess correlations between latent MTPs (LTPs) and PPTs in each group.Children had fewer LTPs than adults did (P = .03). The upper trapezius was the muscle with the largest number of LTPs, affecting 13 adults on the dominant side. Children had lower PPTs compared with adults (P.05). Correlations between the number of LTPs (on both sides and in total) and PPTs were observed only in adults.Healthy children have fewer LTPs and lower PPTs in the shoulder girdle than healthy adults. A relationship was observed between sensitivity to pressure and the presence of LTPs in adults, in whom lower PPT was associated with more LTPs. This relationship was not detected in children.

The purpose of this study was to compare the immediate effects of mobilization with movement (MWM) with sham technique on range of motion (ROM), muscle strength, and function in patients with shoulder impingement syndrome.A randomized clinical study was performed. Participants (mean age ± standard deviation, 31 ± 8 years; 56% women) were divided into 2 groups: group 1 (n = 14), which received the MWM technique in the first 4 sessions and the sham technique in the last 4 sessions; and group 2 (n = 13), which was treated with the opposite order of treatment conditions described for group 1. Shoulder ROM, isometric peak force assessed with a handheld dynamometer, and function as determined through the Disabilities of the Arm, Shoulder and Hand and Shoulder Pain and Disability Index (SPADI) questionnaires were collected at preintervention, interchange, and postintervention moments.Two-way analysis of variance revealed no significant group-by-time interaction for any outcome but did reveal a main time effect for shoulder external rotation (P = .04) and abduction (P = .01) ROM, Disabilities of the Arm, Shoulder and Hand (P.01), SPADI Pain (P.01), SPADI Function (P.01), and SPADI Total (P.01). Only abduction movement and SPADI Pain overcame the clinical relevance threshold. The isometric peak force tests revealed no effects.The MWM technique was no more effective than a sham intervention in improving shoulder ROM during external rotation and abduction, pain, and function in patients with shoulder impingement syndrome.

[En] Background Low back pain (LBP) could be influenced by socio-cultural factors. Pain narratives are important to understand the influence of environment on patients with chronic LBP. There are few studies that have explored the experience of patients with chronic LBP in different socio-cultural environments. The aim of this study was to describe the experience of patients with chronic LBP in Spain and Brazil. Methods A qualitative phenomenology approach was implemented. Chronic LBP patients from the University Hospital of Salamanca (Spain), and/or Federal University of Sao Carlos (Brazil) were included, using purposeful sampling. Data were collected from 22 Spanish and 26 Brazilian patients during in-depth interviews and using researchers' field notes and patients' personal diaries and letters. A thematic analysis was performed and the guidelines for reporting qualitative research were applied. Results Forty-eight patients with a mean age of 50.7 years (SD: +/- 13.1 years) were included in the study. The themes identified included: a) ways of perceiving and expressing pain-the participants focused constantly on their pain and anything outside it was considered secondary; b) the socio-familial environment as a modulator of pain-most participants stated that no one was able to understand the pain they were experiencing; c) religion as a modulator of pain-all Brazilian patients stated that religious belief affected the experience of pain; and d) socio-economic and educational status as a modulator of pain-the study reported that economic factors influenced the experience of pain. Conclusions The influences of LBP can be determined based on the how a patient defines pain. Religion can be considered as a possible mechanism for patients to manage pain and as a form of solace.

Objective The purpose of this study was to investigate the presence of active myofascial trigger points (MTrPs) in a greater number of muscles than previous studies and the relation between the presence of MTrPs, the intensity of pain, disability, and sleep quality in mechanical neck pain. Methods Fifteen patients with mechanical neck pain (80% women) and 12 comparable controls participated. Myofascial trigger points were bilaterally explored in the upper trapezius, splenius capitis, semispinalis capitis, sternocleidomastoid, levator scapulae, and scalene muscles in a blinded design. Myofascial trigger points were considered active if the subject recognized the elicited referred pain as a familiar symptom. Myofascial trigger points were considered latent if the elicited referred pain was not recognized as a symptom. Pain was collected with a numerical pain rate scale (0-10); disability was assessed with Neck Disability Index; and sleep quality, with the Pittsburgh Sleep Quality Index. Results Patients exhibited a greater disability and worse sleep quality than controls (P < .001). The Pittsburgh Sleep Quality Index score was associated with the worst intensity of pain (r = 0.589; P = .021) and disability (r = 0.552; P = .033). Patients showed a greater (P = .002) number of active MTrPs (mean, 2 ± 2) and similar number (P = .505) of latent MTrPs (1.6 ± 1.4) than controls (latent MTrPs, 1.3 ± 1.4). No significant association between the number of latent or active MTrPs and pain, disability, or sleep quality was found. Conclusions The referred pain elicited by active MTrPs in the neck and shoulder muscles contributed to symptoms in mechanical neck pain. Patients exhibited higher disability and worse sleep quality than controls. Sleep quality was associated with pain intensity and disability. No association between active MTrPs and the intensity of pain, disability, or sleep quality was found.

This study evaluated joint position sense (JPS) during medial and lateral rotations of the shoulder in female workers with and without shoulder impingement syndrome (SIS). Three groups were assessed. The case group consisted of 15 female assembly line workers (35.5, SD 5.8 years) with unilateral SIS. Control group 1 consisted of 15 female assembly line workers asymptomatic for SIS (34.4, SD 5.5 years) and control group 2 consisted of 15 female subjects (33.1, SD 6.2 years) asymptomatic for SIS and with no exposure to activities with the upper limbs. The JPS was evaluated bilaterally during passive (2°/sec) and active (5°/sec) repositioning tests using an isokinetic dynamometer. The target angles were 45° of lateral rotation (achieved by medially rotating the shoulder from 90° of lateral rotation) and 75° of lateral rotation (achieved by laterally rotating the shoulder from neutral rotation). There were no differences between sides for all groups (p 0.05). There were no differences in any of the variables between the case group and the control groups (p 0.05). The results of this study suggest that JPS during medial and lateral rotations of the shoulder is not altered in female assembly line workers with SIS.

O objetivo desse estudo foi identificar as correlações existentes entre o número de óbitos de indivíduos idosos e as alterações climáticas no município de São Carlos (SP) em um período de 10 anos (1997-2006). Foram colhidas informações do registro de óbitos por meio do DATASUS, de pessoas com 60 anos ou mais, falecidas entre 1997 e 2006 no município. Os dados mensais da média das Temperaturas Máxima, Média e Mínima e da Umidade Relativa do Ar no município de São Carlos foram fornecidos pelo Instituto Nacional de Meteorologia. Calcularam-se os coeficientes de mortalidade do município, por sexo e faixa etária e os dados foram analisados com teste t, ANOVA de fator único, teste de Bonferroni e teste de Pearson. Ocorreram 8.304 óbitos, com predominância de indivíduos na faixa dos 80 anos ou mais, do sexo masculino. As doenças do aparelho circulatório foram as principais causas de óbito. Houve correlação positiva entre mortalidade por doenças infecciosas e Umidade Mínima e correlação negativa entre mortalidade por doenças infecciosas e Temperatura Mínima Mínima, entre mortalidade por doenças respiratórias e Umidade Mínima, entre mortalidade por doenças endócrinas e Temperatura Mínima Mínima e Temperatura Máxima Máxima. Dessa forma, foi possível concluir que houve relação entre o clima e a mortalidade de idosos em São Carlos.

A randomized controlled clinical trial.To investigate the effects of trigger point (TrP) manual therapy combined with a self-stretching program for the management of patients with plantar heel pain.Previous studies have reported that stretching of the calf musculature and the plantar fascia are effective management strategies for plantar heel pain. However, it is not known if the inclusion of soft tissue therapy can further improve the outcomes in this population.Sixty patients, 15 men and 45 women (mean ± SD age, 44 ± 10 years) with a clinical diagnosis of plantar heel pain were randomly divided into 2 groups: a self-stretching (Str) group who received a stretching protocol, and a self-stretching and soft tissue TrP manual therapy (Str-ST) group who received TrP manual interventions (TrP pressure release and neuromuscular approach) in addition to the same self-stretching protocol. The primary outcomes were physical function and bodily pain domains of the quality of life SF-36 questionnaire. Additionally, pressure pain thresholds (PPT) were assessed over the affected gastrocnemii and soleus muscles, and over the calcaneus, by an assessor blinded to the treatment allocation. Outcomes of interest were captured at baseline and at a 1-month follow-up (end of treatment period). Mixed-model ANOVAs were used to examine the effects of the interventions on each outcome, with group as the between-subjects variable and time as the within-subjects variable. The primary analysis was the group-by-time interaction.The 2 × 2 mixed-model analysis of variance (ANOVA) revealed a significant group-by-time interaction for the main outcomes of the study: physical function (P = .001) and bodily pain (P = .005); patients receiving a combination of self-stretching and TrP tissue intervention experienced a greater improvement in physical function and a greater reduction in pain, as compared to those receiving the self-stretching protocol. The mixed ANOVA also revealed significant group-by-time interactions for changes in PPT over the gastrocnemii and soleus muscles, and the calcaneus (all P.001). Patients receiving a combination of self-stretching and TrP tissue intervention showed a greater improvement in PPT, as compared to those who received only the self-stretching protocol.This study provides evidence that the addition of TrP manual therapies to a self-stretching protocol resulted in superior short-term outcomes as compared to a self-stretching program alone in the treatment of patients with plantar heel pain.Therapy, level 1b.

The objective of this study was to assess the immediate effect of a sciatic nerve slider technique added to sustained hamstring stretching on lumbar and lower quadrant flexibility.This was a randomized controlled pilot study.Eight (8) healthy male soccer players (21 +/- 3 years) were randomly assigned to 2 groups.Group A received 5 minutes of bilateral sustained hamstring stretching. Group B additionally received 60 seconds of a sciatic nerve slider technique for each leg.Pre- and postintervention outcomes taken by an assessor blinded to the treatment allocation of the participants included metric distance on finger-to-floor, sit and reach, and the modified Schöber tests and goniometric range of each hip for the straight-leg raise and each knee for seated slump test. Baseline between-group differences were examined with an independent t test and a two-way repeated-measures analysis of variance with p0.05 and p0.025 analyzed effects of the interventions.There were no significant between-group baseline differences (p0.2). There was a significant effect for time on all outcomes (p0.01) other than the sit and reach test (p = 0.8). A significant interaction between group . time with greater improvements in group B was found for the modified Schöber test (F = 5.5; p0.05), left straight-leg raise (F = 6.1; p0.05) and slump test in either leg (left F = 28.7; p = 0.002; right F = 4.9; p0.05).Adding a sciatic nerve slider technique to sustained hamstring stretching led to greater immediate increases in both lumbar and lower quadrant flexibility in young healthy soccer players as measured by four of the seven outcomes used. Study limitations and suggestions for future studies are discussed.

This study analyzed the immediate effect of hamstring muscle stretching on pressure pain sensitivity over the masseter and the upper trapezius muscles and maximum active mouth opening in healthy subjects.One hundred twenty volunteers, 70 males and 50 females, between the ages of 22 and 47, were randomly divided into 3 groups: group 1 (control group) that did not receive any intervention, group 2 where a unilateral hamstring muscle stretching was applied, and group 3 where a bilateral stretching was applied. Pressure pain thresholds (PPTs) were bilaterally assessed over the masseter and upper trapezius muscles pre- and 5 minutes posttreatment by an assessor blinded to group assignment. Maximum mouth opening was also assessed pre- and 5 minutes posttreatment. Mixed-model analyses of variance (ANOVAs) were used to examine the effects of the intervention. The primary analysis was the group x time interaction.The ANOVA revealed significant group x time interaction for changes in PPTs over the upper trapezius (F = 4.5; P = .01) and masseter (F = 6.3; P = .002) muscles. Pre-post effect sizes were moderate (0.5d0.7) for both stretching groups and negative (d-0.2) for the control group. A significant group x time interaction (F = 8.15; P.001) for maximum mouth opening was also found; both experimental groups showed greater improvement when compared to the control group (P.001). Pre-post effect sizes were large (d0.7) for both stretching groups and negative (d-0.2) for the control group.The application of a stretching of the hamstring musculature produced an immediate increase in PPTs over both masseter and upper trapezius muscles in healthy subjects.

Our aim was to examine the effects of a seated thoracic spine distraction thrust manipulation included in an electrotherapy/thermal program on pain, disability, and cervical range of motion in patients with acute neck pain. This randomized controlled trial included 45 patients (20 males, 25 females) between 23 and 44 years of age presenting with acute neck pain. Patients were randomly divided into 2 groups: an experimental group which received a thoracic manipulation, and a control group which did not receive the manipulative procedure. Both groups received an electrotherapy program consisting of 6 sessions of TENS (frequency 100Hz; 20min), superficial thermo-therapy (15min) and soft tissue massage. The experimental group also received a thoracic manipulation once a week for 3 consecutive weeks. Outcome measures included neck pain (numerical pain rate scale; NPRS), level of disability (Northwick Park Neck Pain Questionnaire; NPQ) and neck mobility. These outcomes were assessed at baseline and 1 week after discharge. A 2-way repeated-measures ANOVA with group as between-subject variable and time as within-subject variable was used. Patients receiving thoracic manipulation experienced greater reductions in both neck pain, with between-group difference of 2.3 (95% CI 2-2.7) points on a 11-NPRS, and perceived disability with between-group differences 8.5 (95% CI 7.2-9.8) points. Further, patients receiving thoracic manipulation experienced greater increases in all cervical motions with between-group differences of 10.6 degrees (95% CI 8.8-12.5 degrees) for flexion; 9.9 degrees (95% CI 8.1-11.7 degrees) for extension; 9.5 degrees (95% CI 7.6-11.4 degrees) for right lateral-flexion; 8 degrees (95% CI 6.2-9.8 degrees) for left lateral-flexion; 9.6 degrees (95% CI 7.7-11.6 degrees) for right rotation; and 8.4 degrees (95% CI 6.5-10.3 degrees) for left rotation. We found that the inclusion of a thoracic manipulation into an electrotherapy/thermal program was effective in reducing neck pain and disability, and in increasing active cervical mobility in patients with acute neck pain.

The purpose of this study is to identify the effects of the suboccipital muscle inhibition technique in patients with short hamstring syndrome by means of tests designed to evaluate the elasticity of the hamstring muscles and pressure algometry of myofascial trigger points.Randomized clinical trial (pre and postintervention). The study population comprised young adult students following their studies at the Physiotherapy School at the University of Extremadura (Spain) and footballers from an Extremadura Football Club with short hamstring syndrome. The sample (70 subjects = 47 male and 23 female) was randomly divided into a control group (n = 34) and an intervention group (n = 36). Mean sample age was 23.40 +/- 3.82 years. The control group was subjected to a placebo technique, whereas the intervention group was subjected to the suboccipital muscle inhibition technique. Pre and postintervention evaluation was used for the assessment of hamstring elasticity, and pressure algometry was also used (myofascial trigger points). Statistical analyses were performed using the SPSS 14.5 package (SPSS Inc, Chicago, Ill), comparing the sample between groups (Kolmorogov-Smirnov test, Student t test, 2-way analysis of variance [ANOVA], the chi(2) test).The distribution of the quantitative variables was normal, and the mean time doing physical activity per week was 2.82 +/- 4.03 hours. Two-way ANOVA afforded statistically significant results for the finger-floor test, straight leg raise test-left, straight leg raise test-right, left popliteal angle test (P values.001), and right popliteal angle test (P = .005). For pressure algometry, only the right semimembranosus muscle afforded statistically significant differences (P = .021).According to the finger-floor distance test, the straight leg raise test, and the popliteal angle test, the suboccipital muscle inhibition technique modified the elasticity of the hamstring muscles for this group of subjects. The suboccipital muscle inhibition technique modifies the pressure algometry of the semimembranosus muscle but does not modify that of the semitendinosus muscle or biceps femoris.

The purpose of this study was to investigate the immediate effects of bilateral talocrural joint manipulation on standing stability in healthy subjects. Sixty-two healthy subjects, 16 males and 46 females, aged from 18 to 32 years old (mean: 21+/-3 years old) participated in the study. Subjects were randomly divided into two groups: an intervention group (n=32), who received manipulation of bilateral talocrural joints and a control group (n=30) which did not receive any intervention. Baropodometric and stabilometric evaluations were assessed pre- and 5 min post-intervention by an assessor blinded to the treatment allocation. Intra-group and inter-group comparisons were analysed using appropriate parametric tests. The results indicated that changes on the X coordinate range, length of motion, and mean speed approximated to statistical significance (P=0.06), and changes on the Y coordinate range reached statistical significance (P=0.02). Average X and Y motions, and anterior-posterior or lateral velocities did not show significant differences. Our results showed that bilateral thrust manipulation of the talocrural joint did not modify standing stability, that is, the behavioural pattern of the projection of the centre of pressure, in healthy subjects.

BACKGROUND: Topographical pain maps (TPM) are useful tools to assess deep tissue sensitivity in musculoskeletal pain conditions. There is evidence suggesting bilateral sensitivity in subacromial pain syndrome (SAPS), although it is not widely accepted. No previous study has investigated TPM of the shoulder in SAPS.OBJECTIVE: To investigate whether differences for TPM of the shoulder are evident among patients with unilateral SAPS and controls.METHODS: Pressure pain thresholds (PPTs) were assessed 3 times at each point and there was a 20 s rest period between each one. The TPM were calculated using 29 pre-determined points on both shoulders in all groups by inverse distance weighted interpolation of PPT data. Multivariate Analysis of Covariance was applied to detect differences in PPTs between groups, sides, points (gender as covariate).RESULTS: The results revealed significant differences between points and genders (both, P < 0.001), but not between groups (P = 0.243) and sides (P = 0.812). Heterogeneous distribution of mechanical pain sensitivity was found in both groups as the PPTs were lower on the root spine of the scapula and the posterior border of the acromion (points 5-8, P < 0.05), glenohumeral joint (points 17-20, P < 0.01) and the anterior deltoid muscle (points 21-25, P < 0.001) compared to the average of the other sites on the shoulder. Women exhibited bilateral lower PPTs in all points than men in both groups (all, P < 0.01).CONCLUSIONS: This study revealed no differences for mechanical pain sensitivity in patients with SAPS experiencing lower levels of pain compared with matched controls, but showed heterogeneous distribution of PPTs in the shoulder.

There is a lack of knowledge about the effectiveness of manual therapy (MT) on subjects with temporomandibular disorders (TMD). The aim of this systematic review is to synthetise evidence regarding the isolated effect of MT in improving maximum mouth opening (MMO) and pain in subjects with signs and symptoms of TMD. MEDLINE(®) , Cochrane, Web of Science, SciELO and EMBASE(™) electronic databases were consulted, searching for randomised controlled trials applying MT for TMD compared to other intervention, no intervention or placebo. Two authors independently extracted data, PEDro scale was used to assess risk of bias, and GRADE (Grading of Recommendations Assessment, Development and Evaluation) was applied to synthetise overall quality of the body of evidence. Treatment effect size was calculated for pain, MMO and pressure pain threshold (PPT). Eight trials were included, seven of high methodological quality. Myofascial release and massage techniques applied on the masticatory muscles are more effective than control (low to moderate evidence) but as effective as toxin botulinum injections (moderate evidence). Upper cervical spine thrust manipulation or mobilisation techniques are more effective than control (low to high evidence), while thoracic manipulations are not. There is moderate-to-high evidence that MT techniques protocols are effective. The methodological heterogeneity across trials protocols frequently contributed to decrease quality of evidence. In conclusion, there is widely varying evidence that MT improves pain, MMO and PPT in subjects with TMD signs and symptoms, depending on the technique. Further studies should consider using standardised evaluations and better study designs to strengthen clinical relevance.

Objective.To compare the effects of combined trigger point dry needling (TrP-DN) and proprioceptive/strengthening exercises to proprioceptive/strengthening exercises on pain and function in ankle instability.Methods.Twenty-seven (44% female, mean age:33±3years) individuals with unilateral ankle instability were randomly assigned to an experimental group who received proprioceptive/strengthening exercises combined with TrP-DN into the lateral peroneus muscle and a comparison group receiving the same proprioceptive/strengthening exercise program alone. Outcome included function assessed with the Foot and Ankle Ability Measure (FAAM) and ankle pain intensity assessed with a numerical pain rate scale (NPRS). They were captured at baseline and 1-month follow-up after the intervention.Results.The ANOVAs found significant Group∗Time Interactions for both subscales of the FAAM (ADL:F=8.211;P=0.008; SPORTS:F=13.943;P<0.001) and for pain (F=44.420;P<0.001): patients receiving TrP-DN plus proprioceptive/strengthening exercises experienced greater improvements in function and pain than those receiving the exercise program alone. Between-groups effect sizes were large in all outcomes (SMD > 2.1) in favor of the TrP-DN group.Conclusions.This study provides evidence that the inclusion of TrP-DN within the lateral peroneus muscle into a proprioceptive/strengthening exercise program resulted in better outcomes in pain and function 1 month after the therapy in ankle instability.

The purpose of this study was to compare the immediate effects of mobilization with movement (MWM) to a sham technique in patients with shoulder impingement syndrome.A randomized controlled trial was performed. Forty-two patients (mean ± SD age, 55 ± 9 years; 81% female) satisfied eligibility criteria, agreed to participate, and were randomized into an MWM group (n = 21) or sham manual contact (n = 21). The primary outcome measures including pain intensity, pain during active range of motion, and maximal active range of motion were assessed by a clinician blinded to group allocation. Outcomes were captured at baseline and after 2 weeks of MWM treatment or sham intervention. The primary analysis was the group × time interaction.The 2×2 analysis of variance revealed a significant group × time interaction for pain intensity during shoulder flexion (F = 7.054; P = .011), pain-free shoulder flexion (F = 32.853; P.001), maximum shoulder flexion (F = 18.791; P.01), and shoulder external rotation (F = 7.950; P.01) in favor of the MWM group. No other significant differences were found.Patients with shoulder impingement syndrome who received 4 sessions of MWM exhibited significantly better outcomes for pain during shoulder flexion, pain-free range of shoulder flexion, maximal shoulder flexion, and maximal external rotation than those patients who were in the sham group.

Clinical measurement.To establish trial-to-trial within-day and between-day reliability, standard error of measurement, and minimal detectable change of scapular orientation during elevation and lowering of the arm, and with the arm relaxed at the side, in individuals with and without shoulder impingement.Electromagnetic devices are commonly used to measure 3-D scapular kinematics during arm elevation in different conditions and for intervention studies. However, there is a lack of studies that evaluate within- and between-day reliability of these measurements.The subjects were allocated to either a control group or an impingement group. Kinematic data were collected using the Flock of Birds electromagnetic device during elevation and lowering of the arm in the sagittal plane on 2 different occasions, separated by 3 to 5 days. Forty-nine subjects were tested for within-day reliability. Forty-three subjects were reassessed for between-day reliability.Intraclass correlation coefficients for within- and between-day assessment of scapular orientation during elevation and lowering of the arm in both groups ranged from 0.92 to 0.99 and from 0.54 to 0.88, respectively. Intraclass correlation coefficients for assessment of scapular orientation with the arms relaxed at the side in both groups ranged from 0.66 to 0.95. The standard error of measurement for between-day measurements ranged from 3.37° to 7.44° for both groups. The minimal detectable change for between-day measurements increased from 7.81° at the lower to 17.27° at the higher humerothoracic elevation angles.These results support the use of Flock of Birds to measure scapular orientations in subjects with and without impingement symptoms. The measurements showed excellent within-day reliability but were not highly reliable over time.

The objectives of this study were to investigate if referred pain elicited by active trigger points (TrPs) reproduced the symptoms in individuals with painful knee osteoarthritis (OA) and to determine the relationship between the presence of active TrPs, intensity of ongoing pain, function, quality of life, and sleep quality in individuals with painful knee OA.Eighteen women with bilateral painful knee OA, aged 79 to 90 years, and 18 matched controls participated. Muscle TrPs were bilaterally explored in several muscles of the lower extremity. Trigger points were considered active if the elicited referred pain reproduced knee symptoms, and TrPs were considered latent if the elicited pain did not reproduce symptoms. Pain was collected with a numerical pain rate scale (0-10), function was assessed with Western Ontario and McMaster Universities, quality of life was assessed with the Medical Outcomes Study Short Form 36 questionnaire, and sleep quality was determined with the Pittsburgh Sleep Quality Index.Women with knee OA exhibited a greater number of active TrPs (mean, 1 ± 1; P.001) but similar number of latent TrPs (mean, 4 ± 2) than healthy women (mean, 4 ± 3; P = .613). A greater number of active TrPs were associated with higher intensity of ongoing pain (r = 0.605; P = .007). Higher intensity of ongoing knee pain was associated with lower physical function (P.05).The referred pain elicited by active TrPs in the lower extremity muscles contributed to pain symptoms in painful knee OA. A higher number of active TrPs was associated with higher intensity of ongoing knee pain.