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Manual Therapy Research Review November 2017


Welcome
Welcome to the 14th edition of Research Review. I have been on
sabbatical leave from the University for the last three months. A great
time to recharge the batteries but I also caught up with some of my
IFOMPT friends in Italy (Davide Albertoni) and Greece (Kostas Sakellariou
and Alexandros Sideris). Great hospitality from these folks. I
have also been teaching in Sweden and Korea. Quite a different experience but great
to be with enthusiastic manual therapists. In this edition, I have provided a range of
papers from anatomical studies (e.g. Kennedy et al, 2017) to systematic reviews (e.g.
Smith et al, 2017) to a great editorial in the BJSM (Hegedus et al, 2017). I hope you
enjoy these.
Wishing you all a Merry Christmas and prosperous New Year. Duncan

Paper One
Kennedy, E Albert, M, Nicholson, H. Do longus capitis and colli really stabilise the cervical
spine? A study of their fascicular anatomy and peak force capabilities. Musculoskeletal
Science and Practice 32 (2017) 104–113
Background: Longus capitis and colli are proposed to play a role in stabilising the cervical spine,
targeted in clinical and research practice with cranio-cervical flexion. However, it is not clear if
these muscles are anatomically or biomechanically suited to a stabilising role.
Objectives: To describe the fascicular morphology of the longus capitis and colli, and estimate
their peak force generating capabilities across the individual cervical motion segments.
Study design: Biomechanical force modelling based on anatomical data.
Methods: Three-part design including cadaveric dissection (n = 7), in vivo MRI muscle volume
calculation from serial slices in young healthy volunteers (n = 6), and biomechanical modelling of
the peak force generating capacities based on computed tomography scans of the head and
neck.
Results: Longus capitis and colli are small muscles spanning multiple cervical motion segments.
Bilateral peak flexion torque estimates were higher in the upper cervical spine (0.5 Nm), and unlikely
to affect motion below the level of C5 (< 0.2 Nm). Peak shear estimates were negligible
(< 20 N), while peak compression estimates were small (< 80 N).
Conclusions: These data highlight the complex anatomy and small force capacity of longus
capitis and colli, and have implications for their function. In particular, the small peak compression
forces indicate that these muscles have a limited capacity to contribute to cervical stability
via traditional mechanisms. This implies that the mechanism(s) by which cranio-cervical flexion
exercises produce clinical benefits is worth exploring further.
Commentary:
It is great to see well-constructed anatomical studies that challenge clinical thinking and
assumptions. While there are a large number of studies that have used the deep cervical
flexor group of muscles as both tests and treatments, this study questions the capacity of
these muscles to provide sufficient force generation to improve cervical stability, that has
previously been suggested. However, it is also important not to throw away current concepts
but perhaps to consider the complex functions of how muscles provide both stability and
mobility. Normal function requires an orchestra of muscles to work. It is good to challenge
the assumptions around how we think exercises work and this study will provide a stimulus
for other researchers to look at the muscle actions in non-cadaveric studies.


Paper Two
Hutting, N., Kerry, R., Coppieters,M., Scholten-Peeters, G. Considerations to
improve the safety of cervical spine manual therapy. Musculoskeletal Science
and Practice 33 (2018) 41–45
PURPOSE: Manipulation and mobilisation of the cervical spine are well established interventions
in the management of patients with headache and/or neck pain. However, their benefits
are accompanied by potential, yet rare risks in terms of serious adverse events, including
neurovascular insult to the brain. A recent international framework for risk assessment and
management offers directions in the mitigation of this risk by facilitating sound clinical
reasoning.
The aim of this article is to critically reflect on and summarize the current knowledge about
cervical spine manual therapy and to provide guidance for clinical reasoning for cervical spine
manual therapy.
Commentary:
This paper written by one of the IFOMPT MO Delegates (Nathan Hutting) provides a good
overview of the considerations required to provide safe therapy for patients presenting with
cervical spine pain. This is a useful extension of the IFOMPT Cervical Screening documents
available on the website: http://www.ifompt.org/ReportsDocuments/Cervical+Framework+Document.html
These types of papers and documents need to be standard teaching and clinical resources for
all manual therapists dealing with neck pain


Paper Three
Smith BE, Hendrick P, Smith T, et al. Should exercises be painful in the management
of chronic musculoskeletal pain? A systematic review and meta-analysis.
Br J Sports Med 2017;51:1679–1687
Background: Chronic musculoskeletal disorders are a prevalent and costly global health issue.
A new form of exercise therapy focused on loading and resistance programmes that
temporarily aggravates a patient’s pain has been proposed. The object of this review was to
compare the effect of exercises where pain is allowed/encouraged compared with non-painful
exercises on pain, function or disability in patients with chronic musculoskeletal pain within
randomised controlled trials.
Methods: Two authors independently selected studies and appraised risk of bias. Methodological
quality was evaluated using the Cochrane risk of bias tool, and the Grading of Recommendations
Assessment system was used to evaluate the quality of evidence.
Results: The literature search identified 9081 potentially eligible studies. Nine papers (from
seven trials) with 385 participants met the inclusion criteria. There was short-term significant
difference in pain, with moderate quality evidence for a small effect size of −0.27 (−0.54 to
−0.05) in favour of painful exercises. For pain in the medium and long term, and function
and disability in the short, medium and long term, there was no significant difference.
Conclusion: Protocols using painful exercises offer a small but significant benefit over painfree
exercises in the short term, with moderate quality of evidence. In the medium and long
term there is no clear superiority of one treatment over another. Pain during therapeutic exercise
for chronic musculoskeletal pain need not be a barrier to successful outcomes. Further
research is warranted to fully evaluate the effectiveness of loading and resistance programmes
into pain for chronic musculoskeletal disorders.
Commentary:
Both patients and clinicians are often challenged by how hard to push into pain when someone
has a chronic pain condition. This well constructed systematic review offers a good
answer. Moving into pain on the short term offers significant benefit over not moving into
pain. Not surprisingly there appears to be less obvious benefit in the medium to long term.
But as we all know, showing these patients that pain does not equal harm is an important
first step in them taking control of the pain and their lives.
assumptions. While there are a large number of studies that have used the deep cervical
flexor group of muscles as both tests and treatments, this study questions the capacity of
these muscles to provide sufficient force generation to improve cervical stability, that has
previously been suggested. However, it is also important not to throw away current concepts
but perhaps to consider the complex functions of how muscles provide both stability and
mobility. Normal function requires an orchestra of muscles to work. It is good to challenge
the assumptions around how we think exercises work and this study will provide a stimulus
for other researchers to look at the muscle actions in non-cadaveric studies.

Commentary:
Finally, in this version of the Research Review I would like to draw your attention to this
eloquent editorial written by three people who really know their stuff when it comes to
diagnostics!! I really like the following comments from these authors:
“Clinicians should quit looking for overly simplistic answers. Clinical diagnosis, like producing
a great wine, is complex and requires an appreciation of the data that can be gathered within
the nuances of patient interaction. Like a good wine connoisseur who understands what varietal
matches each selected food, the clinician can refine his or her examination by using
meaningful tests and measures that may serve a variety of purposes”
Life is too short to drink bad wine so let’s get better with our tests!

Paper Four
Eric J Hegedus, Alexis A Wright, & Chad Cook. Orthopaedic special tests and diagnostic
accuracy studies: house wine served in very cheap containers. British Journal
Sports Medicine Volume 51, Issue 22 2017 page 1578
Reciprocal Recognition
IFOMPT is working towards reciprocal recognition of members of IFOMPT Member Organisations.
All IFOMPT Member Organisation’s educational
programmes are required to meet IFOMPT educational
standards in advanced orthopaedic manual physical
therapy in order to obtain membership in IFOMPT.
Member Organisations of each country are encouraged
to accept individuals who have trained in other Member
Organisation countries as full, voting members in
their countries’ OMPT organisation.
What is reciprocal recognition?
Reciprocal recognition is when OMPT organisations of
two countries agree that a member of one Member
Organisation is able to become a member of another
Member Organisation without added requirements such as further examination, portfolio review,
or additional education. Reciprocal recognition is linked to allowing the OMPT trained
physical therapist to have the same rights and privileges within the Member Organisation as
others within the organisation who have successfully completed an IFOMPT approved OMPT
educational programme.
Which countries have reciprocal recognition?
The Member Organisations from Australia, Canada, New Zealand, the UK, USA, Germany,
Denmark, Sweden, and Finland accept all graduates of IFOMPT approved OMPT programmes
as OMPT specialists within their organisations. This is essentially expands the concept of
“Reciprocal Recognition” to “Universal Recognition” of the expertise of physical therapists
trained in IFOMPT approval programmes for all the Member Organisations that represent
these countries.
Registration and license to practice
Reciprocal recognition is not linked to registration or licensure to practice in a Member
Organisation country. The physical therapist must still meet the country’s registration or
licensure requirements to work and practice physical therapy
*****

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