NEUROPHYSIO LOGICAL EFFECTS OF SPINAL MANUALTHERAPY IN THE UPPER EXTREMITYAN EVIDENCE BASED REVIEWUQJFUniversity of California San FrancisconSan FranciscoState UniversityJennifer Chu, MS-DPTc, CPI ucsf/sfsu graduate program in physical therapy

INTROpiDull ache in the neck and upper T/Sp2Radiating sharp pain down the armsp3Numbness in the fingertipsDUCTION

INTRODUCTION

INTRODUCTIONFIRST TREATMENT CHOICE Manual Therapy Therapeutic exercise Patient education Mechanical traction Ultrasound

CLINICALPROBLEMWHY?

SPINAL MANUAL THERAPY Spinal manual therapy (SMT) Mobilization = low velocity, low or high amplitude thrust prior to end-range (aaompt) Manipulation = high velocity, low amplitude thrust within or at end-range (AAOMPT)(Flynn, 2006)

SPINAL MANUAL THERAPYBIOMECHANICAL(Cleland 2012)NEUROPHYSIOLOGICAL

CLINICAL PROBLEM44BIOMECHANICAL

CLINICALBIOMECHANICALPROBLEM4NEUROPHYSIOLOGICAL

SIGNIFICANCE Neck pain commonly produces distal symptoms 14.2% - 71% lifetime prevalence (Wnght. 1999) 58% of health care visits (bmus, 2011) $7 billion in annual costs (Fejer. 2006)

NECK UPPER EXTRPossible sources:Upper limb nerve entrapment Cervical radiculopathy Cervical stenosis T4 SyndromeANDEMITY PAINnerve discnerve rootdiscspinal cordpinchedherniatedRELEVANCE Patients commonly present with neck and varying UE symptoms There is strong evidence to show the benefits of SMT Specific mechanisms are unknownM T MECHANISMBiomechanicalNeurophysiologicalSpinal CordSupraspinal

M T MECHANISMNeurophysiologicalGate Control TheoryStimulate SNS

PROPOSED ONMIDBRAIN(Wright 1999 )RESPONSEStimulation of the dPAGOExcitation of the SNS&Affects descending pain pathways

SYMPATHOEXCITATIONVasoconstriction =Skin TemperatureSweat gland activation = U Skin ConductanceSWEAT GLAND

P RO POD ONSNS ExcitationRESPON

PROPOSED ONHand ElectrodesHand ThermistorUE ROM during ULNTPURPOSETo determine if SMT to the cervicalor thoracic spine produces a sympathoexcitatory response in the upper extremity.To determine if SMT to the cervicalor thoracic spine decreases pain and decreases mechanosensitivity in the upper extremity.THEORETICAL CONSTRUCTIF SMT induces SNS excitationOAND SNS excitation contributes to hypoalgesia anddecreased mechanosensitivityOTHEN SMT should result in hypoalgesia and decreased mechanosensitivity in patients with neckand UE symptomsGAP Limited number of studies that observe the neurophysiologic effects of SMT Small sample sizes with asymptomatic populations Varying thrust vs non-thrust techniques Inconclusive results on SMT mechanisms Based on theoretical modelsPRIMARY QUESTIONIn patients who have neck and concurrentUE SYMPTOMS, does SPINAL MANUAL THERAPYto the cervical or thoracic spine affect UE NEUROPHYSIOLOGIC MEASURES, as comparedto a CONTROL group?FOREGROUND QUESTIONPRIMARY HYPOTHESEH0:SMTWILL NOT PRODUCE significant changes in: sympathoexcitatory responses: SC and ^ STclinically relevant outcomes: pain and '(y UE ROM during ULNT in the upper extremity, P0ST SMT APPLICATIONHa:SMTWILL PRODUCE significant changes in: sympathoexcitatory responses: ^ SC and ^ STclinically relevant outcomes: pain and '(y UE ROM during ULNT in the upper extremity, P0ST SMT APPLICATIONECONDARY HYPOTHESEH0:SMTWILL NOT PRODUCE significant changes in: sympathoexcitatory responses: SC and ^ STclinically relevant outcomes: pain and UE ROM during ULNT in the upper extremity, CO M PA R E D TO CONTROLSHa:SMTWILL PRODUCE significant changes in: sympathoexcitatory responses: SC and STclinically relevant outcomes: pain and UE ROM during ULNTin the upper extremity, CO M PA R E D TO CONTROLSEXPECTED FINDINGReject both null hypotheses Post application, SMT will produce:Sympathoexcitatory changes in the upper extremities Decreased pain and improved UE ROM during ULNTCompared to controls, SMT will produce:Sympathoexcitatory changes in the upper extremities Decreased pain and improved UE ROM during ULNTMETHODInclusion Criteria: English Human studies Measure outcomes in the upper limb SMT to cervical or thoracic spineExclusion Criteria:Manual therapy performed at areas other than the cervical or thoracic spineMETHODDatabases: PubMed Google Scholar CINAHL PEDro Hooked on Evidence CochraneSearch TermsIn Combination: Sympathetic nervous system Manual therapy Spinal manual therapy Hypoalgesia Neurophysiological Autonomic nervous systemTATISTICAL ANALYSISingle group effect size and 95% CIChange from pre to post interventionTwo group effect size and 95% CIPost treatment difference between intervention and control grouQ statistics for heterogeneityWeighting - inverse varianceSEARCH RESU LTS1 16 ARTICLES RETRIEVEDFROM INITIAL SEARCHo61 EXCLUDED DUE TO IRRELEVANCE55 ARTICLES SCREENEDFOR RELEVANCEo45 EXLUDED DUE TO NOT MEETING INCLUSION CRITERIA10 ARTICLES INCLUDEDSTUDY SUMMARYSTUDYDESIGNLEVELPARTICIPANTSTREATMENT PROTOCOLChiu and Wright..........Crossover RCT.........IB.............16...........C5 Central PA. Gr IIICoppietersetal...........Parallel RCT...........IB.............20...........Lateral Glide at 1 or moresegments (C5-T1), Gr IIIJowseyand Perry.........Parallel RCT...........IB.............36...........T4 Right Rotary PA, Gr IIIMoulson etal..............Crossover RCT.........IB.............16...........C5/C6 Right Rotary SNAG, GrPeterson etal.............Crossover RCT..........IB.............16...........C5 Central PA, Gr IIISarangaetal..............Crossover RCT.........IB.............20...........C5/C6 Lateral Glide, Gr IIISterlingetal...............Crossover RCT.........IB.............30...........C5/C6 Unilateral PA, Gr IIIVicenzinoetal 1994..... Crossover RCT.........IB.............34...........C5/C6 Lateral glide, Gr IIIVicenzinoetal 1996 .....Crossover RCT....... IB........ 15...........C5/C6 Lateral glide, Gr IIIVicenzinoetal 1998..... Crossover RCT.........IB.............24...........C5/C6 Lateral glide, Gr IIITUDY SUMMARYSTUDYDESIGNLEVELPARTICIPANTSChiu and Wright........Coppieters etal.........Jowsey and Perry.......2 Parallel16-36 participantsMoulson et al............RCTsIB- chronic lateral epicondylalgiaPeterson etal...........- nonacute cervicobrachial painSaranga etal............8 Crossover- asymptomatic participantsSterling et al.............RCTsVicenzinoetal 1994Vicenzinoetal 1996Vicenzinoetal 1998TUDY SUMMARYSTUDYTREATMENT PROTOCOLChiu and Wright........Coppieters etal.........Jowsey and Perry.......Moulson et al............Peterson etal...........Saranga etal............Sterling etal.............Vicenzinoetal 1994 Vicenzinoetal 1996 Vicenzinoetal 19989 STUDIESCervical Spine: Central PA Unilateral PA Lateral glide Right rotary SNAG1STUDY ~~ Thoracic Spine:Rotary PArl|E C5-C7r T4faggl-JSrfkINGLE GROUP EFFECT SIZE Change from pre-treatment to post-treatment Does SMT produce sympathoexcitation? Increase in SC Decrease in ST Does SMT decrease pain and mechanosensitivity? Decrease in pain on VAS Increase in UE ROM during ULNTSINGLE GROUP GRAND EFFECT SIZESskin conductanceskin temperaturepainelbow extension during ulnt 1shoulder abduction during ulnt 2b-oOF Cb---1 i-1-1-1-20TWO GROUP EFFECT Compare SMT post-treatment to control post-treatment Does SMT produce greater sympathoexcitation than a control treatment? Increase in SC Decrease in ST Does SMT produce a greater decrease in pain and mechanosensitivity than a control? Decrease in pain on VAS Increase in UE ROM during ULNTTWO GROUP GRAND EFFECT SIZEskin conductance^SNSskin temperature-j^SNSpain^jzpal nelbow extension during ulnt 1^j"ROMshoulder abduction during ulnt 2bH-1-h{}romH-1-1-1-1-2 -1.5 -1 -0.5 0 0.5 1 1.5 2 2.5STATISTICAL ANALYSISSUMMARY Single group grand effect sizes SMT has a significant effect on sympathoexcitation, pain, and mechanosensivitity Two group grand effect sizes SMT has a greater effect on sympathoexcitation, pain, and mechanosensitivity compared to a control All individual effect sizes trended in the same direction Homogeneity across studiesD I S C UI 0 NREJECT BOTH NULL HYPOTHESES SMT WILL PRODUCE significant sympathoexcitatory changes and clinically relevant outcomes, in the upper extremity, POST SMT APPLICATION SMT WILL PRODUCE significant sympathoexcitatory changes and clinically relevant outcomes, in the upper extremity COMPARED TO CONTROLSCLINICAL MEASURES Pain on VAS Range of 0.6 - 2.1 points MCID: 2 points Elbow extension during ULNT 1 Range of 10.3 - 22.6 degrees MCID: 10 degreesCORRELATED TO INCREASED CLINICAL CHANGESHARM AND COST Harm No adverse effects reported Potential aggravation of patient symptoms Cost Not addressed SMT requires competence with manual techniquesCLINICAL IMPLICATIONS SMT produces a neurophysiologic response In patients with neck and UE symptoms SMT to the cervical and/or thoracic spine can produce sympathoexcitation SMT can result in immediate decreases in pain and mechanosensitivity

CLINICAL IMPLICATIONSBIOMECHANICAL(Bialosky 2009)NEUROPHYSIOLOGICALCLINICAL IMPLICATIONSThe use of SMT should be strongly considered in clinical decision making processSMT can be used as an initial interventionSMT may increase the effectiveness of other interventionsLIMI TAT I 0 N Unknown duration of SMT effects SMT in asymptomatic vs symptomatic participants Application of SMT is variableFUTURE RESEARCH Studies applying SMT to symptomatic patients Long term treatment effects of SMT Comparing GPM V to non-thrust techniques Assess additional clinically important outcome measures

CONCLUSION SMT produces a neurophysiologic response SMT is effective at reducing pain and decreasing mechanosensitivity in patients with neck and UE symptomsI

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