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The use of quantitative sensory testing (QST) has become more widespread, with increasing focus on describing somatosensory profiles and pain mechanisms. However, the reliability of thermal QST has yet to be established. We systematically searched the literature using key medical databases. Independent reviewers evaluated reliability data using the Quality Appraisal for Reliability Studies checklist. Of the 21 studies we included in this review, we deemed 5 to have high methodological quality. Narrative analysis revealed that estimates of reliability varied considerably, but overall, the reliability of cold and warm detection thresholds ranged from poor to excellent, while heat and cold pain thresholds ranged from fair to excellent. The methodological quality of research investigating the reliability of thermal QST warrants improvement, particularly in terms of appropriate blinding. The results from this review showed considerable variability in the reliability of each thermal QST parameter.

Exercise-related lower limb pain represents one of the most common presentations in sports medicine practice. This is usually caused by musculoskeletal overuse injuries but not uncommonly, a neuropathic cause may be suspected. A review of the literature revealed that peripheral neuropathic pain has never been documented in a child. It is possible that peripheral neuropathic pain of spinal origin may be more prevalent in children than previously recognized. This case report describes the presentation of a 12 year old tennis player with bilateral dorsal foot pain, who presented with positive findings of peripheral nerve sensitization which was successfully managed using neurodynamic treatment techniques. Differential diagnoses are considered and treatment and management described. A discussion of the clinical reasoning which led to the patient's diagnosis is included. This case report suggests the effectiveness of neurodynamic treatment in a child with bilateral foot pain who fulfilled published criteria for peripheral nerve sensitization. However, the single case methodology employed in this study limits generalization of its findings. Further studies are warranted to investigate the role of neurodynamics in musculoskeletal pain disorders in children., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Introduction: The reliability of thermal quantitative sensory testing (QST) has yet to be fully established. In this study we investigated intra- and interrater reliability of thermal QST in a blinded manner., Methods: Two investigators recorded thermal detection and pain thresholds on the hand of 22 volunteers, twice on two occasions. Results were analyzed using descriptive statistics, intraclass correlation coefficients (ICCs), and coefficients of variation (CVs)., Results: Mean intraindividual differences were small for all measures except cold pain thresholds. ICC values for intra- and interrater reliability were: cold detection, 0.27-0.55; warm detection, 0.33-0.69; and heat pain, 0.39-0.86. Cold pain yielded high ICC values (0.87-0.94), but also high CV (84.9-90.2%)., Conclusions: In young, healthy adults, thermal detection and heat pain thresholds of the hand demonstrated good reliability for group comparisons and individual analyses. Cold pain threshold measures may be suitable for group comparisons, but a large variance in the data limits individual analyses., (Copyright © 2011 Wiley Periodicals, Inc.)

The Flexion-Rotation Test (FRT) is proposed to assess mobility primarily at C1-C2. However, there is no in vivo measurement investigating the validity of the FRT. The purpose of this study was 1) to examine measurement reliability of segmental upper cervical movements using magnetic resonance imaging and 2) to investigate the content validity of the FRT. Nineteen asymptomatic female subjects (mean age: 22.2 years) were evaluated with a 0.2-T horizontally open MRI unit. The segmental rotation angles from Occiput-C1 to C3-C4 and the C4 vertebra were assessed with the head maximally rotated to both the right and the left in two conditions - neck in neutral and in flexion. Good reliability of the method of measurement was suggested by error considerations. A repeated measure ANOVA revealed an interaction between the two different neck starting positions and segment levels (P < 0.0001). Post-hoc analysis revealed that there were significant reductions in the flexed position (P < 0.0001) except for at Occiput-C1. While there was only a 16.3% reduction in rotation range at C1-C2, the reduction was 68.1% at C2-C3, 61.4% at C3-C4, and 76.9% at segments below C4, respectively, supporting the content validity of the FRT as a clinical measure of atlanto-axial mobility., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

The objective is to determine if pain and disability outcomes of patients treated with neural mobilisation differ for sub-classifications of low back and leg pain (LB&LP). Radiating leg pain is a poor prognostic factor for recovery in patients with LBP. To improve outcome, a new pathomechanism-based classification system was proposed: neuropathic sensitization (NS), denervation (D), peripheral nerve sensitization (PNS) and musculoskeletal (M). Seventy-seven patients with unilateral LB&LP were recruited. Following classification, all subjects were treated seven times with neural mobilisation techniques. A successful outcome was defined as achieving a minimal clinically important change in pain intensity (11-point numerical rating scale), physical function (Roland Morris disability questionnaire) and global perceived change (7-point Likert scale: from 1 = "completely recovered" to 7 = "worse than ever"). The proportion of responders was significantly greater in PNS (55.6%) than the other three groups (NS 10%; D 14.3% and M10%). After adjusting for baseline differences, mean magnitude of improvement of the outcome measures were significantly greater in PNS compared to the other groups. Patients classified as PNS have a more favourable prognosis following neural mobilisation compared to the other groups.

In the management of neck pain disorders, McKenzie recommends performing neck extension exercises from a fully neck retracted position in order to achieve a maximum range of lower cervical extension. However, no study has investigated the impact of pre-positioning the neck prior to the extension exercise. This study compared end-range sagittal cervical segmental rotation and translation from three starting positions: the neck in neutral (Ex), retraction (Ret-Ex) and protraction (Pro-Ex). Twenty asymptomatic healthy volunteers were recruited. Lateral radiographs were taken in neutral and at each of the three end-range extension positions and differences in sagittal rotation angles and translation from the neck neutral posture were calculated at each segment. The results indicated that there was a significant difference in the pattern of the sagittal segmental rotation (P < 0.001) but no difference in summed rotations (total extension) between the three conditions (P > 0.05). Pro-Ex generated significantly (P < 0.05) greater extension range at C1-2 and Ret-Ex produced significantly (P < 0.05) greater extension range at C6-7 than alternate conditions. In contrast, there was no significant difference in segmental translation values between the three conditions (P > 0.05). These results indicate initial neck positions can influence cervical segmental extension range at C1-2 and C6-7., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

This study investigated the reliability of manual examination procedures and the frequency that each or multiple segments in the upper cervical spine above the C4 vertebra were the dominant source of pain in subjects with cervicogenic headache (CGH). Eighty subjects were evaluated, 60 with CGH (39 females, mean age 33 years) and arbitrarily a further 20 asymptomatic subjects (13 females, mean age 34 years) included to reduce examiner bias, but subsequently omitted from data analysis. Two experienced physiotherapists examined on the same day each subject with standard manual examination procedures, independently rating each segment in the upper cervical spine above the C4 vertebra for involvement. Examiners were blind to each other's findings and the subject's clinical status. Standard and adjusted Kappa coefficients were calculated for each segment in symptomatic subjects only. Chi-squared analysis for goodness of fit was used to identify the segment that was most frequently determined the predominant symptomatic segment. Manual examination above the C4 vertebra showed good reliability. The C1/2 segment was most commonly symptomatic, with a positive finding at this segment in 63% of cases. The high frequency of C1/2 involvement in CGH highlights the importance of examination and treatment procedures for this motion segment., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Objective: This study evaluates the association between probable cervicogenic headache (CGH) and associated headache symptoms and cervical spine impairment identified by the flexion-rotation test (FRT)., Methods: This was an observational study. Ninety-two subjects were evaluated, 72 with probable CGH and 20 who were asymptomatic. Headache symptoms were evaluated by questionnaire. A single blind examiner conducted the FRT, reporting the test state (positive or negative) before measuring range of motion (ROM). Fifteen subjects reported headache during testing and were subsequently retested when pain-free. A paired t test was used to determine whether FRT mobility to the most restricted side differed when the subject was experiencing headache. Univariate linear regression analysis and multiple regression analysis were used to examine the relationship between subject and headache characteristics, and range of motion during the FRT. Logistic regression analysis was used to examine relationships between subject and headache characteristics and whether the FRT was positive or negative., Results: Mean ROM was significantly reduced (P < .01) by 6° in the presence of headache, but this did not influence test interpretation. Regression analysis revealed that half the variance in FRT ROM was explained by an index of headache severity or component parts but not by other headache characteristics., Conclusions: These findings indicate a relationship between cervical movement impairment and the presence and severity of CGH., (Copyright © 2010 National University of Health Sciences. Published by Mosby, Inc. All rights reserved.)

The aim of this study was to compare the findings of the cervical flexion-rotation test (FRT) between subjects with probable cervicogenic headache (CGH), migraine without aura (Migraine), and multiple headache forms (MHF). An additional aim was to identify the diagnostic accuracy of the FRT in CGH evaluation. Sixty subjects were evaluated: 20 with CGH, 20 with Migraine, and 20 with MHF. Subject and headache symptoms were evaluated by questionnaire. A single-blind examiner conducted the FRT, reporting the test state (positive or negative) before measuring range of motion using a goniometer. The average range of unilateral rotation to the most restricted side was 25°, 42° and 35° for groups CGH, Migraine and MHF, respectively. The difference between groups was significant (P < 0.001). Range of rotation was significantly reduced in the CGH group when compared to groups Migraine (P < 0.001) and MHF (P = 0.001), with an additional smaller significant difference between groups Migraine and MHF (P = 0.039). A receiver operating curve revealed that an experienced examiner using the FRT was able to make the correct diagnosis 85% of the time (P < 0.001), with a positive cut-off value of 30°. Multivariate regression analysis revealed that 44% of the variance in FRT range of motion was explained by the presence of two variables: neck movement or positions provoke headache, and neck symptoms precede headache, but not by other factors associated with migraine. These findings provide further evidence supporting the clinical utility of the FRT in CGH evaluation.

Objective: The purpose of this study was to investigate the impact of lower cervical facet joint pain (CFP) on the flexion-rotation test (FRT)., Methods: A single blind, comparative group design was used to investigate whether lower CFP influences FRT mobility and examiner interpretation. Twenty-four subjects were evaluated, 12 with cervicogenic headache (age 26-63 years) and 12 with lower CFP (age 44-62 years), confirmed by therapeutic cervical facet joint intervention. A single blinded examiner conducted the FRT, reporting the test state (positive or negative) before measuring range of motion using a goniometer. Subjects with lower CFP were evaluated by the FRT prior to therapeutic intervention and were excluded from analysis if they did not gain complete symptomatic relief following the procedure. Only subjects with immediate complete relief were included., Results: The average range of unilateral rotation to the limited side during the FRT was 26 and 37.5° for the cervicogenic headache and lower CFP groups respectively. The difference between groups was significant (P<0.01). Sensitivity and specificity for cervicogenic headache diagnosis was 75 and 92% respectively. A receiver operating curve revealed that an experienced examiner using the FRT was able to make the correct diagnosis 90% of the time (P<0.01), with a positive cut-off value of 32°., Discussion: These findings provide further evidence for the clinical utility of the FRT in cervical examination and cervicogenic headache diagnosis.

Background: The McKenzie management strategy of mechanical diagnosis and therapy (MDT) is commonly used for the assessment and management of spinal problems. Within this system, 'derangement syndrome' is the most common classification, for which the conceptual model is an intra-discal displacement. However, the reduction of an intra-discal displacement by MDT has never been documented. The purpose of this study was to compare, using magnetic resonance imaging (MRI), the nucleus pulposus (NP) profiles before and after the use of this approach., Patient Characteristics: The patient was a 34-year-old female with a long history of right sided low back and buttock pain classified with 'derangement syndrome'., Examination: T2-weighted images of the L4-5 disc at initial assessment were compared with that at final assessment 1 month later. Initially, the MRI showed a portion of the NP displaced right and posteriorly towards the side of pain, and an overall NP position in the coronal plane shifted to the left., Intervention: The patient was managed with a 1-month course of the McKenzie management strategy treatment., Outcomes: One month later, the displaced portion of the NP was no longer present and the left-shifted NP was centrally located., Discussion: These intervertebral disc changes coincided with centralization and abolition of symptoms. This case may support the conceptual model of MDT.

It is very common in mathematics to construct surfaces by identifying the sides of a polygon together in pairs: For example, identifying opposite sides of a square yields a torus. In this article the construction is considered in the case where infinitely many pairs of segments around the boundary of the polygon are identified. The topological, metric, and complex structures of the resulting surfaces are discussed: In particular, a condition is given under which the surface has a global complex structure (i.e., is a Riemann surface). In this case, a modulus of continuity for a uniformizing map is given. The motivation for considering this construction comes from dynamical systems theory: If the modulus of continuity is uniform across a family of such constructions, each with an iteration defined on it, then it is possible to take limits in the family and hence to complete it. Such an application is briefly discussed.

Study Design: Reliability of clinical measurements over time., Objectives: To determine the long-term stability and minimal detectable change (MDC) of the flexion-rotation test (FRT) measurements over days in subjects with cervicogenic headache (CGH)., Background: The FRT is used by physical therapists to assist in identifying upper cervical movement impairment, as well as to gauge treatment effectiveness. Test-retest reliability for the FRT has been reported, but the stability of range-of-motion measures taken during the FRT over time and the MDC have not been investigated., Methods: Fifteen subjects with CGH were evaluated on headache-free days using the FRT by a blinded examiner at baseline, 2, 4, and 14 days later. An additional 10 asymptomatic subjects were included for blinding purposes. On each occasion, the examiner measured range of motion and determined whether the FRT was positive or negative., Results: For subjects with CGH, there was no significant change in FRT range of motion over days (P>.05). Intraclass correlation coefficients for intratester reliability were 0.95 (95% CI: 0.90 to 0.98) and 0.97 (95% CI: 0.94 to 0.99) for right and left rotation, respectively. MDC90 was 4.7 degrees for right rotation and 7 degrees for left rotation. Examiner interpretation of the FRT was consistent over time, with kappa = 0.92., Conclusions: This study provides evidence that FRT measurements are stable over time, and the MDC90 indicates that a change in FRT range of motion of at least 7 degrees is required to be confident that a change has occurred due to an intervention rather than measurement error.

Background: Work related upper limb disorders constitute 45% of all occupational diseases and are a significant public health problem. A subgroup, non specific arm pain (NSAP), remains elusive in terms of understanding its pathophysiological mechanisms with its diagnosis based on the absence of specific clinical findings. One commonly proposed theory is that a neural tissue disorder is the primary dysfunction in NSAP and findings from previous studies lend some support to this theory. However, it is not clear if changes identified are simply a consequence of ongoing pain rather than due to specific neural changes. The presence of neuropathic pain has been investigated in several other musculoskeletal conditions but currently, there is no specific diagnostic tool or gold standard which permits an unequivocal diagnosis of neuropathic pain. The purpose of this study is to further describe the somatosensory profiles in patients with NSAP and to compare these profiles to a group of patients with MRI confirmed cervical radiculopathy who have been previously classified as having neuropathic pain., Methods/design: Three groups of participants will be investigated: Groups 1 and 2 will be office workers with either NSAP or cervical radiculopathy and Group 3 will be a control group of non office workers without upper limb pain. Participants will undergo a clinical assessment, pain questionnaires (LANSS, Short Form McGill, DASH and TSK) and quantitative sensory testing comprising thermal detection and pain thresholds, vibration thresholds and pressure pain thresholds., Discussion: The spectrum of clinically suspected neuropathic pain ranges from more obvious conditions such as trigeminal neuralgia to those with vague signs of nerve disorder such as NSAP. A thorough description of the somatosensory profiles of NSAP patients and a comparison with a more defined group of patients with evidence of neuropathic pain will help in the understanding of underlying neurophysiology in NSAP and may influence future classification and intervention studies relating to this condition.

This study investigated the reliability, validity and diagnostic accuracy of manual palpation of the sciatic, tibial and common peroneal nerves in the examination of 45 subjects with low-back related leg pain. The nerves were palpated manually and with an algometer, to determine pressure pain thresholds (PPTs). A second examiner performed the straight leg raise (SLR) and slump tests to determine nerve trunk mechanosensitivity. The procedure was repeated by another examiner to determine inter-rater reliability (n = 20). Kappa scores for agreement between raters for manual palpation were 0.80, 0.70 and 0.79 for the sciatic, tibial and common peroneal nerves respectively, demonstrating excellent reliability. PPTs were significantly lower on the symptomatic side, for each of the three nerves, in subjects who were positive on manual palpation. In subjects who were negative on manual palpation, PPTs were not significantly different between sides, demonstrating criterion-based validity, using PPT as the criterion. Highest scores of diagnostic accuracy were obtained when two or more of the three nerves were positive on palpation (sensitivity = 0.83; specificity = 0.73).

Objective: To determine whether Mulligan ankle tape influenced the performance in subjects with unilateral chronic ankle instability (CAI) during static balance; postural sway recovery patterns after hopping and dynamic tracking balance tasks., Design: A cross-sectional, within-subjects experimental study design between 4 ankle conditions (taped; untaped: injured and uninjured)., Participants: 20 volunteer recreational athletes with unilateral CAI were recruited. Means and standard deviations highlighted the athletes' characteristics: age =23+/-1 years; height=173.1+/-2.4 cm; weight=69.3+/-3 kg; Functional Ankle Disability Index (FADI)=93.5+/-5.1% and FADI Sport=84.2+/-9.4%., Interventions: Mulligan ankle taping., Main Outcome Measurements: Static balance (10s); postural sway recovery patterns after a 30s functional hop test (immediately, 30 and 60s); dynamic tracking balance tasks (wandering, target overshoot and reaction-time)., Results: Between the four conditions, static balance showed no significant differences (p=0.792); significant changes occurred in postural sway over time (p<0.001); no significant changes were reported for the dynamic tracking tasks. Wandering was highly correlated with reaction-time and overshooting (p<0.01)., Conclusion: Under resting and fatigued conditions, Mulligan ankle taping did not impact on the neuromuscular control during static and dynamic balance in subjects with healthy and unstable ankles.

The prone hip extension (PHE) test is commonly used in the evaluation of lumbo-pelvic dysfunction. It has been suggested that altered motor control identified by the PHE test can be improved with the application of compression force across the pelvis, to increase force closure on the sacroiliac joint (SIJ). This repeated measure study design investigated the effect of three levels of pelvis compression (0N, 50N, 100N) on the muscle firing pattern during the PHE test in 20 asymptomatic male subjects tested on two occasions 4-weeks apart. The right gluteus maximus, right semitendinosus and bilateral lumbar erector spinae were analyzed using surface electromyography (EMG). Subjects were instructed to perform right hip extension in prone position while maintaining knee-extension in each measurement condition. Compared with the onset of the semitendinosus muscle, gluteus maximus became active 263.3+/-99.5 ms later with no pelvic compression, 183.5+/-77.9 ms later with 50N compression, 91.5+/-49.7 ms later with 100N compression. While significant differences (alpha=0.05) were found in EMG onset for gluteus maximus under different levels of pelvis compression, this was not the case for the erector spinae, which had an inconsistent pattern of temporal onset and was not influenced by the level of pelvis compression force.

Study Design: A comparative measurement design investigating the C4-Th1 intervertebral foramen under simulated clinical tests for cervical radiculopathy using magnetic resonance imaging., Objective: The purpose of this study was to evaluate functional changes in the cervical intervertebral foramen during the axial compression test (ACT), axial distraction test (DT), and Spurling test (SST)., Summary of Background Data: Although alterations of the cross-sectional area of the cervical intervertebral foramen during flexion/extension and rotation have been reported, there are no studies that have measured functional changes in foramen cross-sectional area (FCSA) or shape during the simulation of clinical tests for cervical radiculopathy., Methods: 23 participants (12 men, age: 24.52 years) without history of significant spinal disorders were studied. The 3-dimensional sequence of the magnetic resonance imaging of the foramen was performed with a 0.2-T horizontally open unit. Measurements were taken of FCSA and foramen shape (ratio of foramen height to FCSA). These measurements were conducted under 4 different conditions; control-resting in supine, DT-neck in neutral with a 12 kg distraction force, ACT-neck in neutral with a 7 kg axial compression force, SST-the cervical spine was extended (12.79 degrees ), rotated (63.36 degrees ), and laterally flexed (28.49 degrees ), in a standardized manner., Results: At all levels except for C7-Th1, the FCSA significantly increased (P < 0.05) during the DT to around 120% of control. In contrast, FCSA significantly decreased to approximately 70% of control (P < 0.05) at all levels during the SST. In addition, there were significant differences (P > 0.05) in foramen shape between the ACT and SST condition, but only at the C4-C5 and C5-C6 levels., Conclusion: During 3 clinical tests for cervical radiculopathy functional, relevant, and changes in the cervical intervertebral foramen were evident particularly in the middle cervical spine.

Leg pain is a frequent accompaniment to low back pain, arising from disorders of neural or musculoskeletal structures of the lumbar spine. Differentiating between different sources of radiating leg pain is important to make an appropriate diagnosis and identify the underlying pathology. It is proposed that low back-related leg pain be divided into four subgroups according to the predominating pathomechanisms involved. The first subgroup features central sensitization with mainly positive symptoms such as hyperalgesia, the second subgroup involves denervation with significant axonal damage showing predominantly negative sensory symptoms and possibly motor loss and the third subgroup involves peripheral nerve sensitization with enhanced nerve trunk mechanosensitization. The fourth subgroup features somatic referred pain from musculoskeletal structures, such as the intervertebral disc or facet joints. Accordingly, four groups of patients with leg pain associated with structures in the lower back can be identified: Each group presents with a distinct pattern of symptoms and signs. Although there may be considerable overlap between the classifications, the authors propose the existence of an overriding mechanism. The importance of distinguishing low back-related leg pain into these four groups is to facilitate diagnosis and provide a more effective, appropriate treatment.

Objective: The straight leg raise (SLR) and slump tests have traditionally been used to identify nerve root compression arising from disk herniation. However, they may be more appropriate as tests of lumbosacral neural tissue mechanosensitivity. The aim of this study was to determine agreement and correlation between the SLR and slump tests in a population presenting with back and leg pain., Methods: This was an observational, cross-sectional study design. Forty-five subjects with unilateral leg pain were recruited from an outpatient Back Pain Screening Clinic at a large teaching hospital in Ireland. The SLR and slump tests were performed on each side. In the event of symptom reproduction, the ankle was dorsiflexed. Reproduction of presenting symptoms, which were intensified by ankle dorsiflexion, was interpreted as a positive test. An inclinometer was used to measure range of motion (ROM)., Results: There was substantial agreement between SLR and slump test interpretation (kappa = 0.69) with good correlation in ROM between the 2 tests (r = 0.64) on the symptomatic side. In subjects who had positive results, ROM for both tests was significantly reduced compared to ROM on the contralateral side and ROM in subjects who had negative results., Conclusions: When the SLR and slump tests are interpreted as positive in the event of reproduction of presenting leg pain that are intensified by ankle dorsiflexion, these tests show substantial agreement and good correlation in the leg pain population. When interpreted in this way, these tests may be appropriate tests of neural tissue mechanosensitivity, but further criteria must be met before a definitive conclusion in relation to neural tissue mechanosensitivity may be drawn.

Study Design: A comparative measurement study of in vivo cervical rotation, induced by shoulder abduction, measured using magnetic resonance imaging., Objective: The purpose of this study was to clarify the kinematics between cervical rotation and shoulder abduction., Summary of Background Data: Although it is believed that abduction of the shoulder induces rotational movement of the cervical spine, there have been no in vivo studies to measure the influence of shoulder movement on the cervical spine at a segmental level., Methods: Twenty-two participants [12 men, age 24.2 years (range, 20-32 years)] without history of significant cervical spine disorders were studied. Kinematic magnetic resonance imaging of the cervical spine was performed with a 0.2-T horizontally open unit. Cervical rotation was assessed with the shoulder in 0, 30, 60, 90, and 120 degrees abduction. In each position, 2 conditions were applied. Firstly no muscle contraction with the arm relaxed and supported and secondly isometric contraction of the shoulder abductors. Isometric contraction was standardized by a 2-kg adduction force applied at the wrist, perpendicular to the arm., Results: No statistically significant differences were found in cervical segmental rotation between each shoulder position under passive conditions (P > 0.05). When the right shoulder was abducted, with isometric contraction, at each shoulder position up to 90 degrees abduction, each cervical vertebra tended to rotate to the left and the largest vertebral movement was seen at C6, being 5.20 degrees (SD = 3.66) at 0 degrees abduction. The pattern of movement changed at 120 degrees abduction, with C1 and C2 rotating to the right., Conclusion: Shoulder abduction up to 90 degrees induced left rotation throughout the cervical spine only in the presence of muscle contraction, with the largest movement occurring at C6. A contrasting pattern of upper and lower cervical rotation occurred when the arm was positioned in 120 degrees abduction.

The aim of this study was to investigate the reliability of a new classification system for low back-related leg pain arising from neural tissue dysfunction. Leg pain is a frequent accompaniment to back pain and is an indicator of the severity and prognosis of the disorder. For optimal patient care, treatment should be directed according to the identified pathophysiological mechanisms. The authors have proposed a sub-classification of neural low back-related leg pain into four categories, each requiring a different management strategy: Central Sensitization (CS), comprising major features of sensitization of the somatosensory system; Denervation (D), arising from significant axonal compromise without evidence of major central nervous system changes; Peripheral Nerve Sensitization (PNS), arising from nerve trunk inflammation without clinical evidence of significant denervation; and Musculoskeletal pain (M), referred from non-neural structures such as the disc or facet joints. The purpose of this study was to investigate the interrater reliability of this classification system. Forty consecutive patients with unilateral low back-related leg pain were independently assessed by five pairs of examiners using a physical examination protocol, screening for central sensitization of the somatosensory system, neurological deficit, and nerve tissue mechano-sensitization. Subjects were classified as follows: CS 30%, D 27.5%, PNS 10%, and M 32.5%. Interrater reliability was good with 80% agreement and a k of 0.72 (95% Confidence Interval (CI) .57-.86). The findings of the study demonstrate that patients with low back-related leg pain can be reliably classified to one of the four proposed groups.

It has been proposed that patients with low back-related leg pain can be classified according to pain mechanisms into four distinct subgroups: Central Sensitization (CS), Denervation (D), Peripheral Nerve Sensitization (PNS), and Musculoskeletal (M). The purpose of this study was to determine whether there were any differences in terms of disability and psychosocial factors between these four subgroups. Forty-five subjects with low back-related leg pain completed the Oswestry Disability Index, the hospital Anxiety and Depression Scale, and the Fear Avoidance Beliefs Questionnaire. Subsequently, an examiner blinded to the questionnaire results classified the subjects into one of the four subgroups, according to the findings of the self-administered Leeds Assessment of Neuropathic Signs and Symptoms questionnaire and a physical examination. It was found that the PNS subgroup had significantly greater disability compared to all other subgroups and significantly greater fear avoidance beliefs about physical activity compared to the CS and D subgroups. This highlights the importance of sub-classification but also the need to take into account disability and psychosocial factors in the management of low back-related leg pain.

The flexion-rotation test (FRT) is commonly used when assessing cervicogenic headache. Additionally, active range of motion (AROM) is frequently used to evaluate impairment in neck pain. No studies have investigated the interaction of the FRT and AROM with age, gender, pain and lifestyle factors. The purpose of this study was to determine the influence of these factors on the FRT and cervical AROM. A group of 66 participants (aged 20-78) were studied, 28 experienced sub-clinical neck pain (recurrent neck pain or discomfort which has not received treatment from a healthcare professional) while 38 did not. Age, gender, lifestyle factors and sub-clinical neck pain were assessed using a questionnaire. Measurement of AROM was performed by two examiners blind to the results of the questionnaire. Multiple linear regression analysis found that 59% of the variance in the FRT was explained by the presence of sub-clinical pain and cervical lateral flexion measures. Secondly, 58-72% of the variance in active cervical ROM measures was influenced by factors including the FRT, gender and movements of the neck in other planes. This study found that lifestyle factors do not influence the cervical FRT and AROM.

A stirring device consisting of a periodic motion of rods induces a mapping of the fluid domain to itself, which can be regarded as a homeomorphism of a punctured surface. Having the rods undergo a topologically complex motion guarantees at least a minimal amount of stretching of material lines, which is important for chaotic mixing. We use topological considerations to describe the nature of the injection of unmixed material into a central mixing region, which takes place at injection cusps. A topological index formula allow us to predict the possible types of unstable foliations that can arise for a fixed number of rods., ((c) 2008 American Institute of Physics.)

Objective: This article evaluates reliability and diagnostic validity of the cervical flexion-rotation test (FRT) to discriminate subjects with headache because of C1/2 dysfunction. In addition, this study evaluates agreement between experienced and inexperienced examiners., Methods: These were 2 single blind comparative measurement study designs. In study 1, 2 experienced blinded examiners evaluated the FRT in 10 asymptomatic controls, 20 subjects with cervicogenic headache (CeH) where C1/2 was the primary dysfunctional level, and 10 subjects with CeH but without C1/2 as the primary dysfunctional level. In study 2, 2 inexperienced and 1 experienced blinded examiners evaluated the FRT in 12 subjects with CeH and 12 asymptomatic controls. Examiners were required to state whether the FRT was positive and also to determine range of rotation using a goniometer. An analysis of variance with planned orthogonal comparison, single measure intraclass correlation coefficient (2,1), and Bland-Altman plot were used to analyze FRT range of rotation between the examiners. Sensitivity, specificity, and examiner agreement for test interpretation were analyzed using cross tabulation and kappa., Results: In study 1, sensitivity and specificity of the FRT was 90% and 88% with 92% agreement for experienced examiners (P < .001). Overall diagnostic accuracy was 89% (P < .001) and kappa = 0.85. In study 2, for inexperienced examiners, FRT mobility was significantly greater than for experienced examiners, but sensitivity, specificity, agreement, and kappa values were all within clinically acceptable levels., Conclusions: The FRT can be used accurately and reliably by inexperienced examiners and may be a useful aid in CeH evaluation.

Headache is a common complaint that affects the majority of the population at some point in their lives. The underlying pathological bases for headache symptoms are many, diverse, and often difficult to distinguish. Classification of headache is principally based on the evaluation of headache symptoms as well as clinical testing. Although manual therapy has been advocated to treat a variety of different forms of headache, the current evidence only supports treatment for cervicogenic headache (CGH). This form of headache can be identified from migraine and other headache forms by a comprehensive musculoskeletal examination. Examination and subsequent diagnosis is essential not only to identify patients with headache where manual therapy is appropriate but also to form a basis for selection of the most appropriate treatment for the identified condition. The purpose of this paper is to outline, in clinical terms, the classification of headache, so that the clinician can readily identify those patients with headache suited to manual therapy.

This single-blind comparative group design aimed to investigate the sensitivity and specificity of the cervical flexion-rotation test in the diagnosis of C1/2-related cervicogenic headache. This study tested 23 cervicogenic headache, 23 asymptomatic controls and 12 migraine with aura subjects, all aged 18-66 years. In stage 1, an experienced manipulative physiotherapist who did not partake in the flexion-rotation test procedure identified C1/2 dysfunction using passive segmental mobility tests in the cervicogenic headache group. Those with C1/2 dysfunction participated in stage 2. In stage 2, using the flexion-rotation test, subjects were tested by two experienced manipulative physiotherapists blinded to the subjects' group allocation. Each therapist stated whether the test was positive or not based on the therapist's interpretation of range of motion. The sensitivity and specificity of the flexion-rotation test was 91% and 90%, respectively (P<.001), with an overall diagnostic accuracy of 91% (P<.001). The cervical flexion-rotation test significantly assists in the differential diagnosis of cervicogenic headache and in the identification of movement impairment at the C1/2 segment in patients with cervicogenic headache.

Study Design: Randomized, double-blind, placebo controlled trial., Objectives: To determine the effect of a C1-C2 self-sustained natural apophyseal glide (SNAG) on cervicogenic headache., Background: Cervicogenic headache is a common condition causing significant disability. Recent studies have shown a high incidence of C1-C2 dysfunction, evaluated by the flexion-rotation test (FRT), in subjects with cervicogenic headache. To manage this dysfunction, Mulligan has described a C1-C2 self-SNAG, though no studies have investigated the efficacy of this intervention approach., Methods: A sample of 32 subjects (mean &#95; SD age, 36 +/- 3 years) with cervicogenic headache and FRT limitation were randomized into a C1-C2 self-SNAG or placebo group. After an initial instruction and practice visit in the clinic, interventions consisted of exercises applied independently by the subject twice daily at home on a continual basis. FRT range was measured twice, before and immediately after the instruction and practice visit. Headache symptoms were determined by a headache index over time, assessed by questionnaire preintervention, at 4 weeks postintervention, and at 12 months postintervention., Results: No differences were found in baseline measures between groups. Immediately after the initial instruction and practice visit performed with the supervision of the therapist, FRT range increased by 15 degrees (SD, 9) for the C1-C2 self-SNAG group (P < .001), which was significantly more than 5 degrees (SD, 5) for the placebo intervention (P < .001). There was also a significant interaction for the variable headache index between group and time (P < .001), indicating that group difference was dependent on time. There was no difference in headache index scores at baseline between groups. Headache index scores were substantially less in the C1-C2 self-SNAG group (mean +/- SD points at 4 weeks, 31 +/- 9; mean +/- SD points at 12 months, 24 +/- 9) compared to the placebo group (mean +/- SD points at 4 weeks, 51 +/- 15; mean +/- SD points at 12 months, 44 +/- 13) at 4 weeks (P < .001) and 12 months (P < .001), with an overall (+/-SD) reduction of 54% (+/-17%) for the individuals in the C1-C2 self-SNAG group., Conclusions: These results provide evidence for the efficacy of the C1-C2 self-SNAG technique in the management of individuals with cervicogenic headache.

Study Design: Prospective nonrandomized controlled trial., Objectives: To determine the effect of fibular repositioning tape (FRT) on incidence and severity of ankle injury., Background: Pain and functional disability is common following ankle sprain and a major problem in sport. A novel method of taping, FRT, which has been described to prevent ankle sprain, requires less tape than traditional methods and is easier to apply. The objective of this study was to determine the effect of FRT on the incidence and severity of ankle injury in basketball., Methods and Measures: One hundred twenty-five male basketball players were assigned at time of play to either the control (209 exposures) or FRT (224 exposures) condition in a manner of convenience. Control participants had the choice on the use and type of prophylaxis, excluding FRT. FRT participants were taped using the method described by Mulligan. Ankle injury data were collected after each exposure. Injury severity was determined by functional limitation, pain levels, and days to return to play., Results: Four hundred forty-three measured basketball exposures resulted in 11 ankle injuries. All injuries occurred in subjects with a history of previous ankle sprain. Significantly less ankle injuries were sustained by members of the FRT condition (n = 2), compared to members of the control condition (n = 9) (Fisher exact test, P = .03). The odds ratio of sustaining an ankle injury was 0.20 (P = .04; 95% confidence interval [CI]: 0.04, 0.93) when taped with FRT and the number needed to treat was 22 (95% CI, 12-312)., Conclusions: This study provides preliminary data regarding the prophylactic effects of FRT on ankle injury in male basketball players.

The aim of this study was to investigate the effects over 24h, on range of motion and pain, of a single intervention of Mulligan's bent leg raise (BLR) technique in subjects with limited straight leg raise (SLR) and low back pain (LBP). Mulligan techniques are frequently used in practice but their effectiveness has not been adequately researched. Ninety-four subjects were contacted by telephone and 46 volunteered for assessment. Of these, 24 fulfilled inclusion criteria of unilateral SLR limitation and LBP. All subjects were naïve to physiotherapy, blinded, and randomly allocated to either a BLR (n=12) or placebo group (n=12). Range of SLR was measured by an assessor blind to group allocation, prior to, immediately following, and 24h after the intervention. Similarly pain was assessed prior to, and 24h after the intervention. After adjusting for differences in baseline values of SLR range, there was no difference between the two groups immediately after the intervention. However, 24h later, there was a significant increase in the range by 7 degrees in the BLR group, which may be clinically important. In addition there was a one-point reduction in pain, but no difference between groups. This preliminary study provides limited support for the use of the BLR technique; however, further research is required.

Some patients who have sustained whiplash injuries present with chronic widespread pain and mechanical allodynia. This single-blind, case control matched study of 43 chronic whiplash patients sought to examine psychophysical responses to non-noxious stimuli and their relationship to psychological profiles. Symptom Check List 90-R (SCL-90-R), Neck Disability Index and Shortform McGill Questionnaire were completed prior to testing. Qualitative stimuli comprised light touch, punctate pressure, moderate heat and cold. Additionally, sustained vibration was administered using a vibrameter which allowed ramping of either frequency or amplitude. Twenty-eight patients reported vibration-induced pain. No control subject experienced pain in response to vibration. No significant differences in perception threshold to vibration were noted between patients and control group. Twenty-three patients and ten control subjects reported painful responses to cold. Eleven patients and nine control subjects experienced pain in response to moderate heat. Four patients rated punctate pressure and one patient rated light touch as painful. SCL-90-R profiles revealed an overall elevated level of distress in the whiplash group. No significant difference was found between patients with and without vibration-induced pain for any dimension of the SCL-90-R. Pain in response to non-noxious stimulation over presumably healthy tissues suggests that central mechanisms are responsible for ongoing pain in at least some whiplash patients. The additional findings of pain on punctate pressure and hyperalgesic responses to heat and cold stimuli are consistent with enhanced central responsiveness to nociceptor input. These results have important therapeutic and prognostic implications., (Copyright 2002 European Federation of Chapters of the International Association for the Study of Pain. Published by Elsevier Science Ltd.)

Clinical and electromyographic (EMG) responses to non-noxious mechanical stimuli were studied in four patients with painful cervical radiculopathy, and in two control subjects. In the symptomatic arm(s), palpation over one or more nerve trunks was painful and accompanied by EMG activity, whereas palpation of adjacent soft tissues was painless and unaccompanied by EMG activity. Electromyographic activity was widespread in three patients when myotatic reflexes were elicited in the symptomatic arm(s). In asymptomatic arms of patients and controls, EMG responses to the myotatic reflexes were more localised. Allodynic nerve trunks in cervical radiculopathy appear to be afferent correlates of central sensitisation; the accompanying EMG activity may represent a motor correlate of this same process.