The effect of increasing sets and different set durations of lumbar PA mob on PPT

(Pentelka, Hebron, Shapleski, & Goldshtein, 2012)

Aims: To investigate the effect of the number of sets (up to 5) and different durations (30 vs. 60 s) of PA mobilisations on pressure pain thresholds (PPTs) at different sites.

Method: Single blinded, randomized, repeated measures crossover study. ≠ Days and randomized order. 19 Healthy physio students. 5 sets of large amplitude oscillatory mobilisation L4 1 Hz 242N measured by metronome & force plates. Duration was either 30 or 60 sec. 6 measures of PPT, before and after each set (3 times at 4 sites).

Results: No significant effect of duration on PPT across all sites combined (but insignificant trend towards longer duration locally). Significantly higher effect at local than remote location. Maximal increase with significant ≠ with 1st set at the 4th set. Smaller increase until last 5th set (for 30sec) or slightly down (for 60sec).

Limitations: Underpowered, healthy participants, no control group and sample biased towards physiotherapy so blinding may be compromised.

In Practice: 4 sets of mobilisations may provide the higher hypoalgesic effect. We cannot conclude on duration as underpowered: so insignificant but with trend towards longer duration. Local effect superior to remote.

Pentelka, L., Hebron, C., Shapleski, R., & Goldshtein, I. (2012). The effect of increasing sets (within one treatment session) and different set durations (between treatment sessions) of lumbar spine posteroanterior mobilisations on pressure pain thresholds. Manual Therapy, 17(6), 526–530.

Making the most of physiotherapy

First, I would like to recommend you to read the CSP article on what is physiotherapy if you are not familiar with physiotherapy.

Then, you will find in this post a wonderful Blog made by Tina, a person who experienced back pain, persistent pain and physiotherapy. She decided to share her experience through a blog, to inform people that may go through the same journey.

Here is her Blog:

Here is the link of her leaflet:

Mechanotherapy: how physical therapists’ prescription of exercise promotes tissue repair.

(Khan & Scott, 2009)

Aims: To present the current scientific knowledge underpinning how load may be used therapeutically to stimulate tissue repair and remodelling in tendon, muscle, cartilage and bone.

Method: Review, not systematic

Results: Use of the term “mechano-transduction”. mechanical stimuli (general movement, exercise) are converted into biochemical responses. 1. Load/stimuli applied to tissue 2. Tissue communicate / distribute load message 3. Response to the load/stimuli.

Tissue (tendon, muscle, cartilage, bone) respond favourably to stimuli, increasing in strength / healing.

Limitations: Not a systematic review, more like an overview. No critical appraisal of included literature. Doesn’t say anything about optimal dosage, just general assumptions.

In practice: Load applied to tissues is transmitted and cells respond to stimuli increasing strength / healing processes.

Khan, K. M., & Scott, A. (2009). Mechanotherapy: How physical therapists’ prescription of exercise promotes tissue repair. British Journal of Sports Medicine, 43(4), 247–252.

Reliability and MIDC of WBLT: A SR

(Powden, Hoch, & Hoch, 2015)

Aims: To collect, critically appraise, and synthesize the published evidence describing the inter-clinician reliability, intra-clinician reliability, and responsiveness of the WBLT to measure dorsiflexion ROM

Methods: SR, 2 databases, 2 researchers, Inclusion primary aim to examine reliability, no restrictions on population or measurement method. English only. QUAREL for quality.

Results: Strong evidence of good inter and intra-tester reliability of WBLT for all measurements with bests results for tape distance measurement. MIDC = 1,6cm inter clinician or 1,9cm for intra clinician.

Limitations: English only, differences in quality. 9-12 studies included.

In Practice: MIDC values from the included studies inter-clinician changes of 4.6° or 1.6 cm and intra-clinician changes of 4.7° or 1.9 cm should be used.

Powden, C. J., Hoch, J. M., & Hoch, M. C. (2015). Reliability and minimal detectable change of the weight-bearing lunge test: A systematic review. Manual Therapy, 20(4), 524–532.

Normative range of WBLT performance asymmetry in healthy adults

(Hoch & McKeon, 2011)

Aims: To examine the bilateral symmetry of the WBLT in healthy adults and elucidate the individual influences of age, height, mass, leg length, foot length, and posterior displacement of the ankle subtalar-joint complex on WBLT performance.

Methods: 35 healthy adults. 6 trials on each limb, 3 last analysed. Progress every cm until lifting of heel, then smaller increments. Measurement of post displacement of subtalar joint and other individual variations.

Results: Strong intra tester-reliability of the WBLT. No significant relationships between WBLT performance and age, height, mass, left leg length, left foot length, or left posterior talar displacement. Majority of healthy adults exhibited lunge distance asymmetries on the WBLT of 1.5 cm or less (68% of the distribution); however, some individuals demonstrated up to approximately 3 cm bilateral differences. Norm is = 12cm +/- 2,8cm.

Limitations: Healthy adults only. Only intra-tester reliability. Small sample.

In practice: Norm for WBLT is 12cm +/-2,8cm. Normal ≠ between legs 1,5cm. Good intra-tester reliability.

Hoch, M. C., & McKeon, P. O. (2011). Normative range of weight-bearing lunge test performance asymmetry in healthy adults. Manual Therapy, 16(5), 516–519.

Neuropathic pain: Grading system.

(Finnerup et al., 2016)

Aims: Evaluate and update grading system for labelling of nociceptive pain.

Methods: Expert meeting consensus after SR.



a) History, including pain descriptors, the presence of nonpainful sensory symptoms, and aggravating and alleviating factors, suggestive of pain being related to a neurological lesion and not other causes such as inflammation or non-neural tissue damage. The suspected lesion or disease is reported to be associated with neuropathic pain, including a temporal and spatial relationship representative of the condition; includes paroxysmal pain in trigeminal neuralgia.

b) The pain distribution reported by the patient is consistent with the suspected lesion or disease.

c) The area of sensory changes may extend beyond, be within, or overlap with the area of pain. Sensory loss is generally required but touch-evoked or thermal allodynia may be the only finding at bedside examination. Trigger phenomena in trigeminal neuralgia may be counted as sensory signs. In some cases, sensory signs may be difficult to demonstrate although the nature of the lesion or disease is confirmed; for these cases the level “probable” continues to be appropriate, if a diagnostic test confirms the lesion or disease of the somatosensory nervous system.

d) The term “definite” in this context means “probable neuropathic pain with confirmatory tests” because the location and nature of the lesion or disease have been confirmed to be able to explain the pain. “Definite” neuropathic pain is a pain that is fully compatible with neuropathic pain, but it does not necessarily establish causality

Limitations: Expert consensus.

In practice: Follow flowchart to know the level of confidence regarding neuropathic pain. Definite neuropathic pain requires imaging, biopsy or other medical test.

Finnerup, N. B., Haroutounian, S., Kamerman, P., Baron, R., Bennett, D. L. H., Bouhassira, D., … Jensen, T. S. (2016). Neuropathic pain: An updated grading system for research and clinical practice. Pain, 157(8), 1.

Neural mobilization promotes nerve regeneration by nerve growth factor and myelin protein zero increase after sciatic nerve injury.

(Da Silva et al., 2015)

Aim: To analyse if neural mobilisation can change the expression of myelin protein zero (MPZ) and Nerve growth factor (NGF) in the sciatic nerve of adult rats after chronic constrictive nerve injury Reminder: (MPZ is important for myelin formation and may play role in adult axon regeneration and NGF has been found to stimulate nerve regeneration)

Method: Male rats, and 4 groups: 1) Chronic constrictive nerve injury with neural mobilisation group (CCI-NM) 2) Chronic constrictive nerve injury without neural mobilisation (CCI) 3) Sham surgery group 4) Control group The chronic constrictive nerve injury was applied by dissecting to expose the sciatic nerve and 4 ligatures were used to constrict the nerve before the incision was closed. The NM technique in slumped position with ankle flex/ex was applied after 14 days. The technique was applied for 2 mins, with 25 sec pause, for 10 mins and performed on alternate days for a total of 10 sessions. The sciatic nerves were then dissected and analysed by transmission electron microscopy and western blot.

Results: Significant increase in MPZ and NGF found in CCI-NM group suggesting that neural mobilisation may improve axonal regeneration after chronic constrictive nerve injury.

Limitations: Rat study. The artificial application of nerve injury (by application of ligatures) may not represent the type of nerve injury see in human subjects. Dosage between rats / humans for same effect is unknown.

Practice: Tensioners with oscillations may help nerve regeneration by promoting NGF MPZ transcription.

Da Silva, J. T., Dos Santos, F. M., Giardini, A. C., De Oliveira Martins, D., De Oliveira, M. E., Ciena, A. P., … Chacur, M. (2015). Neural mobilization promotes nerve regeneration by nerve growth factor and myelin protein zero increased after sciatic nerve injury. Growth Factors, 33(1), 8–13.

Do sliders slide and tensioners tension?

(Coppieters & Butler, 2008)

Aims: The aim of this cadaveric biomechanical study was to measure longitudinal excursion and strain in the median and ulnar nerve at the wrist and proximal to the elbow during different types of nerve gliding exercises.

Methods: The study consisted in measures with digital devices, of longitudinal nerves’ (ulnar and median) excursion and strain in two embalmed cadavers during sliders, tensioners and isolated movements of the wrist and elbow at ulnar and median nerves.

Results: They found that more strain were measured with tensioning techniques and more excursion was measured during sliding techniques.

Limitations: Only two embalmed and aged cadavers. It worth remembering that it does not provide any information relating to pain, or symptoms during sliding and tensioning techniques. It is just about the mechanical effects on the nerves of the upper arm.

In practice: if we want to strain = tensioners if we want to create excursion and less strain = sliders.

Coppieters, M. W., & Butler, D. S. (2008). Do “sliders” slide and “tensioners” tension? An analysis of neurodynamic techniques and considerations regarding their application. Manual Therapy, 13(3), 213–221.

Shades of grey, the challenge of grumbling CES in older adults with lumbar stenosis.

(Comer, Finucane, Mercer, & Greenhalgh, 2019)

Aims: This paper explores the challenges and evidence gaps relating to CES in older adults with LSS.

Methods: Professional issue : author’s point of view.

Results: Lumbar Spinal Stenosis (LSS) can evolve into CES with degenerative changes increasing the compression phenomenon. The symptoms can be “grumbling” and fluctuate according to position and movements. Symptoms can be under-reported as considered “a normal consequence of ageing” Differential diagnosis should be based on careful questioning, consideration of timeframes, and correlation between onset of signs and symptoms that might indicate early or impending CES.

If new or progressing CSE symptoms over few hours or days or weeks refer for urgent MRI.

If gradual progression over months request routing imaging unless other cause explains symptoms if so, provide “safety net” card and advices.

Limitations: author’s opinion.

In Practice: Differential diagnosis should be based on careful questioning, consideration of timeframes, and correlation between onset of signs and symptoms that might indicate early or impending CES. Give card, explain to patients that are at risk of CES the monitoring.

Comer, C., Finucane, L., Mercer, C., & Greenhalgh, S. (2019). SHADES of grey – The challenge of ‘grumbling’ cauda equina symptoms in older adults with lumbar spinal stenosis. Musculoskeletal Science and Practice, (August), 102049.

Opening clinical encounters in an adult MSK setting.

(Chester, Robinson, & Roberts, 2014)

Aim: This study aims to identify the phrasing preferred by physiotherapists when opening clinical encounters in an adult musculoskeletal outpatient setting.

Methods: Cross-sectional observational study (Audio record of 15 clinicians’ interaction with 42 LBP patients in first and follow up appointments) + an electronic survey with ranking top five and or add their favourite.

Results: Clinicians seems to favour open questions. In the present study, physiotherapists favoured the question: “Do you just want to tell me a little bit about [your problem presentation] first of all?” which is a problem-focused symptom query and is both a question and an invitation.

Limitations: Small & selected sample, low response-rate, verbal communication only.

In practice: Use an open question to give opportunity to express what is important for themselves. Use “first of all” to express that discussion can go further. Mention a topic to gather information with a focus whilst allowing expression.

Think about pré-Key-Question too: Greetings, introduction of name and role, ask for preferred name, explain what will come, and general (social) questions : finding office, weather etc …

Chester, E. C., Robinson, N. C., & Roberts, L. C. (2014). Opening clinical encounters in an adult musculoskeletal setting. Manual Therapy, 19(4), 306–310.