A New Quantitative Tool for the Ultrasonographic Assessment of Tendons: A Reliability and Validity Study on the Patellar Tendon.

Ultrasound is widely used for tendon assessment due to its safety, affordability, and portability, but its subjective nature poses challenges. This study aimed to develop a new quantitative analysis tool based on artificial intelligence to identify statistical patterns of healthy and pathological tendons. Furthermore, we aimed to validate this new tool by comparing it to experts' subjective assessments. A pilot database including healthy controls and patients with patellar tendinopathy was constructed, involving 14 participants with asymptomatic (n = 7) and symptomatic (n = 7) patellar tendons. Ultrasonographic images were assessed twice, utilizing both the new quantitative tool and the subjective scoring method applied by an expert across five regions of interest. The database contained 61 variables per image. The robustness of the clinical and quantitative assessments was tested via reliability analyses. Lastly, the prediction accuracy of the quantitative features was tested via cross-validated generalized linear mixed-effects logistic regressions. These analyses showed high reliability for quantitative variables related to "Bone" and "Quality", with ICCs above 0.75. The ICCs for "Edges" and "Thickness" varied but mostly exceeded 0.75. The results of this study show that certain quantitative variables are capable of predicting an expert's subjective assessment with generally high cross-validated AUC scores. A new quantitative tool for the ultrasonographic assessment of the tendon was designed. This system is shown to be a reliable and valid method for evaluating the patellar tendon structure.

Importance of heat therapy in the treatment of pain in the daily clinical practice.

BACKGROUND: Musculoskeletal (MSK) pain includes a wide variety of causes and conditions. Despite the heterogeneity of MSK pain, it is possible to identify some common clinical features and treatments. Heat therapy (HT) is one of the most common and could be a suitable non-pharmacological approach. OBJECTIVE: To obtain a European overview on the use of non-pharmacological approaches and the role of heat therapy in the treatment of MSK pain. METHODS: Through a two-cycle Delphi-like method, an international board of experts reached a consensus on 13 questions for a survey to healthcare professionals who provide direct patient care. Between November 2021 and January 2022, the resulting web survey was distributed to professionals with the collaboration of ten European scientific societies and associations. Univariate and bivariate analyses were performed on collected data. RESULTS: Two hundred eighty-two answers were validated. Most of the respondents had extensive professional experience. Participants were widely distributed throughout Europe. HT is administered to about 50% of patients, with a higher percentage administered to those affected by low back pain (92%) and neck pain (84%). The choice of exogenous HT is based on both personal clinical experience and scientific evidence. HT is primarily chosen due to its relaxation effect, high safety profile and enhancement of tissue perfusion. The use of HT is recommended by 86.5% of respondents. CONCLUSION: Experts indicate that exogenous HT represents a valid therapeutic choice and is widely used in Europe. Patients should be informed about the use of heat therapy as a valuable self-management therapy option.

The Precision and Safety of Ultrasound-Guided versus Palpation-Guided Needle Placement on the Plantar Fascia and Flexor Digitorum Brevis Interface: An Anatomical Study.

BACKGROUND: Evidence suggests the plantar fascia and its interphase with the flexor digitorum brevis muscle can play a relevant role in plantar heel pain. Needling interventions could offer an appropriate treatment strategy to addressing this interface. OBJECTIVE: We compared the accuracy and safety of ultrasound-guided versus palpation-guided procedures for the proper targeting of the interface between the plantar fascia and the flexor digitorum brevis with a solid needle. METHODS: A crossover cadaveric study was conducted. Five experienced therapists performed a series of 20 needle insertions each (n = 100 in total, 10 landmark-guided and 10 ultrasound-guided) on 10 anatomical samples. The therapists were instructed to accurately place the needle on the interface between the plantar fascia and the flexor digitorum brevis muscle. The distance of the tip of the needle to the identified target (accuracy), the surrounding sensitive structures targeted (safety), the time needed for the procedure, the number of needle passes, and the needle length outside the skin were assessed. RESULTS: The ultrasound-guided technique was associated with a significantly higher accuracy (p < 0.001) but without differences in safety (p = 0.249) as compared to the palpation-guided procedure. CONCLUSION: Our results suggest that ultrasound-guided insertion exhibits greater accuracy but not greater safety than palpation-guided insertion when targeting the interface between the plantar fascia and the flexor digitorum brevis.

In Vivo Effects of Joint Movement on Nerve Mechanical Properties Assessed with Shear-Wave Elastography: A Systematic Review and Meta-Analysis.

Peripheral nerves are subjected to mechanical tension during limb movements and body postures. Nerve response to tensile stress can be assessed in vivo with shear-wave elastography (SWE). Greater tensile loads can lead to greater stiffness, which can be quantified using SWE. Therefore, this study aimed to conduct a systematic review and meta-analysis to perform an overview of the effect of joint movements on nerve mechanical properties in healthy nerves. The initial search (July 2023) yielded 501 records from six databases (PubMed, Embase, Scopus, Web of Science, Cochrane, and Science Direct). A total of 16 studies were included and assessed with a modified version of the Downs and Black checklist. Our results suggest an overall tendency for stiffness increase according to a pattern of neural tensioning. The main findings from the meta-analysis showed a significant increase in nerve stiffness for the median nerve with wrist extension (SMD [95%CI]: 3.16 [1.20, 5.12]), the ulnar nerve with elbow flexion (SMD [95%CI]: 2.91 [1.88, 3.95]), the sciatic nerve with ankle dorsiflexion (SMD [95%CI]: 1.13 [0.79, 1.47]), and the tibial nerve with both hip flexion (SMD [95%CI]: 2.14 [1.76, 2.51]) and ankle dorsiflexion (SMD [95%CI]: 1.52 [1.02, 2.02]). The effect of joint movement on nerve stiffness also depends on the nerve segment, the amount of movement of the joint mobilized, and the position of other joints comprised in the entirety of the nerve length. However, due to the limited number of studies, many aspects of nerve behavior together with the effect of using different ultrasound equipment or transducers for nerve stiffness evaluation still need to be fully investigated.

Diagnostic accuracy of the upper limb neurodynamic test 1 using neurodynamic sequencing in diagnosis of carpal tunnel syndrome.

BACKGROUND: The upper limb neurodynamic test 1 is used in the diagnosis of median nerve neuropathies such as carpal tunnel syndrome but its diagnostic validity remains limited. Neurodynamic sequencing has been suggested to increase the specificity of the neurodynamic tests, however, to date, information on the diagnostic accuracy of this variation in neurodynamic testing is required. OBJECTIVES: The aim of this study was to analyze the diagnostic validity of the local sequence of ULNT1 (LS-ULNT1) (i.e. a sequence that begins at the joint where the problem is (wrist) and progressively moves joints further away from it), in the diagnosis of CTS. A secondary aim was to describe the location of sensory responses to this modified neurodynamic test sequence. DESIGN: A prospective diagnostic accuracy study was designed. METHOD: Nerve conduction studies were used as the gold standard. The LS-ULNT1 was performed in 58 consecutive patients (17 men, 44 women) with suspected CTS. RESULTS: Sensitivity of the LS-ULNT1 was 65.7% (CI 48.0-80.9%) and the specificity was 95.7% (CI 78.1-99.9%). The positive and negative likelihood ratios were >5 and < 0.5, respectively, indicating the ability of the test to generate small but sometimes important changes in post-test probability. CONCLUSIONS: The overall results of this study showed that the LS-ULNT1 could be useful in confirming the diagnosis of CTS. The test demonstrated high specificity and the +LR indicated the ability of the test to generate changes in posttest probability, especially with a positive LS-ULNT1 result.

Is the Straight Leg Raise Suitable for the Diagnosis of Radiculopathy? Analysis of Diagnostic Accuracy in a Phase III Study.

The straight leg raise test (SLR) has been proposed to detect increased nerve mechanosensitivity of the lower limbs in individuals with low back pain. However, its validity in the diagnosis of lumbosacral radiculopathy shows very variable results. The aim of this study was to analyse the diagnostic validity of the SLR including well-defined diagnostic criteria (a change in symptoms with the structural differentiation manoeuvre and the reproduction of the patient's symptoms during the test or the asymmetries in the range of motion or symptoms location between limbs) in a sample of participants in phase III with suspicion of lumbar radiculopathy using the electrodiagnostic studies (EDX) as the reference standard. A phase III diagnostic accuracy study was designed. In total, 142 individuals with suspected lumbosacral radiculopathy referred for EDX participated in the study. Each participant was tested with EDX and SLR. SLR was considered positive using three diagnostic criteria. The sensitivity of the SLR for Criterion 3 was 89.02% (CI 81.65-96.40), the specificity was 25.00% (CI 13.21-36.79), and the positive and negative likelihood ratios were 1.19 (CI 1.01-1.40) and 0.44 (0.21-0.94), respectively. SLR showed limited validity in the diagnosis of lumbosacral radiculopathy. The incorporation of more objective diagnostic criteria (asymmetry in range of motion or localisation of symptoms) improved the diagnostic validity but the imprecision of the confidence intervals limited the interpretation of the results.

Precision and Safety of Ultrasound-Guided versus Palpation-Guided Needle Placement on the Patellar Tendon: A Cadaveric Study.

For decades, needling interventions have been performed based on manual palpation and anatomic knowledge. The increasing use of real-time ultrasonography in clinical practice has improved the accuracy and safety of needling techniques. Although currently ultrasound-guided procedures are routinely used for patellar tendon pathology, e.g., during percutaneous electrolysis, the accuracy of these procedures is still unknown. This study used a cadaveric model to compare and evaluate both the accuracy and safety of ultrasound-guided and palpation-guided needling techniques for the patellar tendon. A total of five physical therapists performed a series of 20 needle insertion task each (n = 100), 10 insertions based on manual palpation (n = 50) and 10 insertions guided with ultrasound (n = 50) to place a needle along the interface between the patellar tendon and Hoffa's fat pad. All procedures were performed on cryopreserved knee specimens. Distance to the targeted tissue, time of the procedure, accurate rate of insertions, number of passes, and unintentional punctured structures between both applications (with and without ultrasound guiding) were compared. The results revealed higher accuracy (100% vs. 80%), a lower distance from needle to the targeted tissue (0.25 ± 0.65 vs. 2.5 ± 1.9 mm), longer surface of contact with the needle (15.5 ± 6.65 vs. 4.7 ± 7.5 mm), and a lower frequency of patellar tendon puncture (16% vs. 52%, p < 0.001) with the ultrasound-guided procedure as opposed to palpation-guided one. Nevertheless, the ultrasound-guided procedure took longer (54.8 ± 26.8 vs. 23.75 ± 15.4 s) and required more passes (2.55 ± 1.9 vs. 1.5 ± 0.95) to be conducted than the palpation-guided procedure (all, p < 0.001). According to these findings, the accuracy of invasive procedures applied on the patellar tendon is higher when conducted with ultrasound guidance than when conducted just on manual palpation or anatomical landmark. These results suggest that ultrasound could improve the clinical application of invasive procedures at the fat-patellar tendon interface. Due to the anatomical features of the targeted tissue, some procedures require this precision, so the use of ultrasound is recommended.

Precision of Ultrasound-Guided versus Anatomical Palpation-Guided Needle Placement of the Ulnar Nerve at the Cubital Tunnel: A Cadaveric Study.

Percutaneous electrical stimulation has been performed for years with only the assistance of anatomical landmarks. The development of real-time ultrasonography guidance has improved the precision and safety of these percutaneous interventions. Despite ultrasound-guided and palpation-guided procedures being performed routinely for targeting nerve tissues in the upper extremity, the precision and safety of these techniques are unknown. The aim of this cadaveric study was to determine and compare the precision and safety of ultrasound-guided versus palpation-guided needling procedure with and without the handpiece of the ulnar nerve on a cadaveric model. Five physical therapists performed a series of 20 needle insertion tasks each (n = 100), 10 palpation-guided (n = 50) and 10 ultrasound-guided (n = 50) on cryopreserved specimens. The purpose of the procedure was to place the needle in proximity to the ulnar nerve at the cubital tunnel. The distance to target, time performance, accurate rate, number of passes, and unintentional puncture of surrounding structures were compared. The ultrasound-guided procedure was associated with higher accuracy (66% vs. 96%), lower distance from needle to the target (0.48 ± 1.37 vs. 2.01 ± 2.41 mm), and a lower frequency of perineurium puncture (0% vs. 20%) when compared with the palpation-guided procedure. However, the ultrasound-guided procedure required more time (38.33 ± 23.19 vs. 24.57 ± 17.84 s) than the palpation-guided procedure (all, p < 0.001). Our results support the assumption that ultrasound guidance improves the accuracy of needling procedures on the ulnar nerve at the cubital tunnel when compared with palpation guidance.

Accuracy of Ultrasound-Guided Needle Placement on the L5 Lumbar Nerve Root: A Cadaveric Study.

OBJECTIVES: The aims of the study are to analyze and describe the accuracy of an ultrasound-guided approach to target the L5 root in cadaveric specimens and evaluate whether gender differences exist. DESIGN: A cross-anatomical study on 40 cadaver L5 nerve roots was performed. A needle was introduced until contacting the L5 nerve root using ultrasound guidance. After that, specimens were frozen and studied by a cross-anatomical view to see the needle's path. The angulation, length, distance from the vertebral spine, the relevant ultrasound anatomical references, and the accuracy of the procedure were evaluated. RESULTS: The needle tip reached the L5 root at a 72.5% rate. The mean angulation degrees of the needle relative to the skin surface were 75.53 ± 10.17 degrees, the length of the needle inserted was 5.83 ± 0.82 cm, and the distance from the vertebral spine to the point of entry of the needle was 5.39 ± 1.44 cm. CONCLUSIONS: An ultrasound-guided technique can potentially be an accurate technique to perform invasive procedures on the L5 root. There were statistically significant differences between males and females in the length of the needle introduced. If the L5 root is not clearly visualized, ultrasound will not be the technique of choice.

Application of Percutaneous Needle Electrolysis Does Not Elicit Temperature Changes: An In Vitro Cadaveric Study.

Percutaneous needle electrolysis (PNE) consists of the ultrasound-guided application of a galvanic electrical current through a solid filament needle. One proposed therapeutic mechanism for this intervention is a potential thermal effect. The aim of this study was to investigate if the application of PNE induces changes in temperature in different cadaveric musculoskeletal tissues. A repeated measure experimental cadaveric study was designed with 10 cryopreserved knees (5 men, 5 women). Sterile stainless-steel needles of 40 mm length and 0.30 mm caliber were used in this study. An ultrasound-guided needling puncture was performed in the targeted tissue (patellar tendon, infra-patellar fat, and vastus medialis muscle). Additionally, the tip of the needle was placed next to the thermometer sensor at the minimum possible distance without direct contact with it. The temperature differences before and after different applications were measured. The applications were: three applications for 3 s of 3 mA of intensity (3:3:3) when the tendon was the targeted tissue, three applications for 3 s of 1.5 mA of intensity (1.5:3:3) when the fat or muscle was the targeted tissue, and 24 s of 1 mA of intensity (1:24:1) in all tissues. No statistically significant Group*Time interactions were found in any tissue (tendon: F = 0.571, p = 0.459, ŋ2 = 0.03; fat pad: F = 0.093; p = 0.764, ŋ2 = 0.01; muscle: F = 0.681; p = 0.420, ŋ2 = 0.04). Overall, no changes in temperature were observed between both applications in the tendon (3:3:3 vs. 1:24:1) and fat/muscle (1.5:3:3 vs. 1:24:1) tissues. The application of two different percutaneous needle electrolysis protocols did not produce appreciable thermal changes in the tendon, fat, and muscle tissues of human cadavers. The results from the current cadaver study support that a thermal effect should not be considered as a mechanism of clinical action regardless of the targeted human tissue when applying percutaneous needle electrolysis since no changes in temperature after its application were observed.

Is Cervical Stabilization Exercise Immediately Effective in Patients with Chronic Neck Pain and Upper Cervical Spine Dysfunction? Randomized Controlled Trial.

Purpose: To compare the effectiveness of a single exercise session with manual therapy techniques in the segments of the upper cervical spine (C0−1, C1−2 and C2−3), against a single exercise session in patients with chronic neck pain and mobility deficits in the upper cervical spine. Methods: A single-blind randomized controlled trial was performed. Fifty-eight patients were recruited (29 for the manual therapy and exercise group and 29 for the exercise group) who presented chronic neck pain and upper cervical spine dysfunction. The exercise focused on the deep muscles. The manual therapy combined manipulations and mobilizations with these exercises. Cervical range of motion, flexion-rotation test, pressure pain threshold and pain intensity were measured by a blind evaluator before and after the intervention. Results: Compared to pre-intervention, after intervention, the exercise group was significantly lower in terms of the range of motion, flexion-rotation test, and pressure pain threshold (p < 0.05). The manual therapy and exercise group improved in upper cervical flexion, the flexion-rotation test and intensity of pain (p < 0.05). Conclusions: It may be necessary to normalize the mobility of the upper cervical spine before cervical stabilization training, in patients with chronic neck pain and mobility deficits in the upper cervical spine.

Comparison of an exercise program with and without manual therapy for patients with chronic neck pain and upper cervical rotation restriction. Randomized controlled trial.

BACKGROUND: Cervical exercise has been shown to be an effective treatment for neck pain, but there is still a need for more clinical trials evaluating the effectiveness of adding manual therapy to the exercise approach. There is a lack of evidence on the effect of these techniques in patients with neck pain and upper cervical rotation restriction. PURPOSE: To compare the effectiveness of adding manual therapy to a cervical exercise protocol for the treatment of patients with chronic neck pain and upper cervical rotation restriction. METHODS: Single-blind randomized clinical trial. Fifty-eight subjects: 29 for the Manual Therapy+Exercise (MT+Exercise) Group and 29 for the Exercise group. Neck disability index, pain intensity (0-10), pressure pain threshold (kPa), flexion-rotation test (°), and cervical range of motion (°) were measured at the beginning and at the end of the intervention, and at 3-and 6-month follow-ups. The MT+Exercise Group received one 20-min session of manual therapy and exercise once a week for 4 weeks and home exercise. The Exercise Group received one 20-min session of exercise once a week for 4 weeks and home exercise. RESULTS: The MT+Exercise Group showed significant better values post-intervention in all variables: neck disability index: 0% patient with moderate, severe, or complete disability compared to 31% in the Exercise Group (p = 0.000) at 6-months; flexion-rotation test (p = 0.000) and pain intensity (p = 0.000) from the first follow-up to the end of the study; cervical flexion (p = 0.002), extension (p = 0.002), right lateral-flexion (p = 0.000), left lateral-flexion (p = 0.001), right rotation (p = 0.000) and left rotation (p = 0.005) at 6-months of the study, except for flexion, with significative changes from 3-months of follow up; pressure pain threshold from the first follow-up to the end of the study (p values range: 0.003-0.000). CONCLUSION: Four 20-min sessions of manual therapy and exercise, along with a home-exercise program, was found to be more effective than an exercise protocol and a home-exercise program in improving the neck disability index, flexion-rotation test, pain intensity, and pressure pain threshold, in the short, medium, and medium-long term in patients with chronic neck pain and upper rotation restriction. Cervical range of motion improved with the addition of manual therapy in the medium and medium-long term. The high dropout rate may have compromised the external validity of the study.

Mouth opening, jaw disability, neck disability, pressure pain thresholds, and myofascial trigger points in patients with disc displacement with reduction: A descriptive and comparative study.

OBJECTIVE: To assess jaw and neck function, pressure pain threshold (PPT), and the presence of trigger points (TrPs) in disc displacement with reduction (DDWR) subjects compared to healthy subjects. METHODS: One hundred DDWR subjects and 100 matched controls were studied. Clinical evaluations included demographic data, range of motion, jaw and neck disability, PPT, and muscle TrPs. RESULTS: DDWR subjects have limited pain-free opening limitation (p < 0.001), jaw and neck disability limitation (p < 0.001), and higher presence of active and latent TrPs limitation (p < 0.001) compared to healthy subjects. CONCLUSION: DDWR subjects present a limited pain-free mouth opening, higher jaw and neck disability, lower PPT, and major presence of active and latent TrPs compared to healthy subjects. Cervical spine and TMJ evaluation and treatment should be considered in DDWR patients.

Effects of occipital-atlas stabilization in the upper cervical spine kinematics: an in vitro study.

This study compares upper cervical spine range of motion (ROM) in the three cardinal planes before and after occiput-atlas (C0-C1) stabilization. After the dissection of the superficial structures to the alar ligament and the fixation of C2, ten cryopreserved upper cervical columns were manually mobilized in the three cardinal planes of movement without and with a screw stabilization of C0-C1. Upper cervical ROM and mobilization force were measured using the Vicon motion capture system and a load cell respectively. The ROM without C0-C1 stabilization was 19.8° ± 5.2° in flexion and 14.3° ± 7.7° in extension. With stabilization, the ROM was 11.5° ± 4.3° and 6.6° ± 3.5°, respectively. The ROM without C0-C1 stabilization was 4.7° ± 2.3° in right lateral flexion and 5.6° ± 3.2° in left lateral flexion. With stabilization, the ROM was 2.3° ± 1.4° and 2.3° ± 1.2°, respectively. The ROM without C0-C1 stabilization was 33.9° ± 6.7° in right rotation and 28.0° ± 6.9° in left rotation. With stabilization, the ROM was 28.5° ± 7.0° and 23.7° ± 8.5° respectively. Stabilization of C0-C1 reduced the upper cervical ROM by 46.9% in the sagittal plane, 55.3% in the frontal plane, and 15.6% in the transverse plane. Also, the resistance to movement during upper cervical mobilization increased following C0-C1 stabilization.

Effects of the Manual Therapy Approach of Segments C0-1 and C2-3 in the Flexion-Rotation Test in Patients with Chronic Neck Pain: A Randomized Controlled Trial.

Background: Flexion-rotation test predominantly measures rotation in C1-2 segment. Restriction in flexion-rotation may be due to direct limitation in C1-2, but also to a premature tightening of the alar ligament as a result of lack of movement in C0-1 or C2-3. The aim of this study was to compare the effect of a 20-min single cervical exercise session, with or without manual therapy of C0-1 and C2-3 segment in flexion-rotation test, in patients with chronic neck pain and positive flexion-rotation test. Methods: Randomized controlled clinical trial in 48 subjects (24 manual therapy+exercise/24 exercise). Range of motion and pain during flexion-rotation test, neck pain intensity and active cervical range of motion were measured before and after the intervention. Results: Significant differences were found in favour of the manual therapy group in the flexion-rotation test: right (p < 0.001) and left rotation (p < 0.001); pain during the flexion-rotation test: right (p < 0.001) and left rotation (p < 0.001); neck pain intensity: (p < 0.001); cervical flexion (p < 0.038), extension (p < 0.010), right side-bending (p < 0.035), left side-bending (p < 0.002), right rotation (p < 0.001), and left rotation (p < 0.006). Conclusions: Addition of one C0-C1 and C2-C3 manual therapy session to cervical exercise can immediately improve flexion-rotation test and cervical range of motion and reduce pain intensity.

Normal response to tibial neurodynamic test in asymptomatic subjects.

BACKGROUND: The straight leg raise test (SLR) is one of the most performed physical tests for mechanosensitivity and impairment of the nervous system. According to the anatomy of the tibial nerve, ankle dorsiflexion and eversion movements could be used to perform the tibial neurodynamic test (TNT). To date, no study has documented the normal responses of the TNT. OBJECTIVE: To document normal responses of the TNT in asymptomatic individuals and to investigate influences from sex and leg dominance. METHODS: A cross-sectional study with 44 asymptomatic volunteer subjects, a total of 88 lower limbs, was carried out. The range of motion (ROM), quality, and distribution of sensory responses were recorded. The hip flexion ROM was measured when subjects reported an intensity of their symptoms of 2/10 (P1) and 8/10 (P2). RESULTS: The mean ROM for hip flexion at P1 was 44.22 ± 13.13∘ and 66.73 ± 14.30∘ at P2. Hip flexion was significantly greater at P2 than P1 (p< 0.001). However, it was not different between sex or limbs (p> 0.05). The descriptor of the quality of sensory responses most often used by participants was stretching (88.6% and 87.5% for P1 and P2, respectively) in the popliteal fossa and posterior calf. CONCLUSIONS: This study describes the sensory responses of asymptomatic subjects resulting from the TNT. Our findings indicate that TNT responses are independent of the influence of sex or leg dominance.

The effect of alar ligament transection on the rotation stress test: A cadaveric study.

BACKGROUND: The rotation stress test is a pre-manipulative screening test used to examine upper cervical instability. This in vitro study simulates the clinical application of the rotation stress test before and after alar ligament transection. METHODS: After the dissection of the superficial structures to the alar ligament and the fixation of C2, ten cryopreserved upper cervical columns were manually mobilized in right and left rotation without and with right alar ligament transection. Upper cervical rotation range of motion (RoM) and mobilization torque were recorded using the Vicon motion capture system and a load cell. FINDINGS: Ligament transection resulted in a larger rotation range of motion in all specimens (contralateral rotation (3.6°, 12.9%) and ipsilateral rotation (4.6°, 13.7%)). The mobilization torque recorded during rotation varied among the different specimens, with a trend towards reduced torque throughout the test in contralateral rotation. INTERPRETATION: This study simulated the rotation stress test before and after alar ligament transection. Unilateral transection of the alar ligament revealed a bilateral increase of the upper cervical rotation. Additional in vivo studies are necessary to validate the results of this study in patients with suspicion of upper cervical instability.

Does the Addition of Manual Therapy Approach to a Cervical Exercise Program Improve Clinical Outcomes for Patients with Chronic Neck Pain in Short- and Mid-Term? A Randomized Controlled Trial.

Chronic neck pain is one of today's most prevalent pathologies. The International Classification of Diseases categorizes four subgroups based on patients' associated symptoms. However, this classification does not encompass upper cervical spine dysfunction. The aim is to compare the short- and mid-term effectiveness of adding a manual therapy approach to a cervical exercise protocol in patients with chronic neck pain and upper cervical spine dysfunction. Fifty-eight subjects with chronic neck pain and upper cervical spine dysfunction were recruited (29 = Manual therapy + Exercise; 29 = Exercise). Each group received four 20-min sessions, one per week during four consecutive weeks, and a home exercise regime. Upper flexion and flexion-rotation test range of motion, neck disability index, craniocervical flexion test, visual analogue scale, pressure pain threshold, global rating of change scale, and adherence to self-treatment were assessed at the beginning, end of the intervention and at 3- and 6-month follow-ups. The Manual therapy + Exercise group statistically improved short- and medium-term in all variables compared to the Exercise group. Four 20-min sessions of Manual therapy + Exercise along with a home-exercise program is more effective in the short- to mid-term than an exercise protocol and a home-exercise program for patients with chronic neck pain and upper cervical dysfunction.

Normal response to sural neurodynamic test in asymptomatic participants. A cross-sectional study.

BACKGROUND: Neurodynamic tests (NDTs) consist of a combination of movements aimed to stress different parts of the nervous system and are considered to be able to detect increased nerve mechanosensitivity. Currently, there are no studies in healthy subjects that define the normal response to sural neurodynamic test (NDTSUR). OBJECTIVES: The main aim of this study was to document normal responses of the NDTSUR in asymptomatic participants. The secondary aim was to investigate potential gender and leg dominance influences. DESIGN: A cross-sectional study was designed. METHODS: NDTSUR was performed on 44 asymptomatic participants with a total of 88 lower limbs. The range of motion at the point of first appearance of symptoms (S1) and the point of pain tolerance (S2), quality and distribution of sensory responses were recorded. RESULTS: Hip flexion was significantly greater (p < 0.001) at S2 (63.6 ± 13.1°) than S1 (42.5 ± 12°) and the mean difference was 21.8° (95% CI: 21.8; 22.8) (p < 0.001). However, hip flexion was not different between gender nor dominance (p > 0.05). The descriptor of the quality of the sensory responses more often used by participants was stretching (87% and 76% for S1 and S2, respectively) in the posterior knee and lateral leg. CONCLUSIONS: This study describes the sensory responses of asymptomatic participants resulting from the NDTSUR. The findings indicate that NDTSUR responses are independent of the influence of gender or leg dominance.

Sensory function in headache: a comparative study among patients with cluster headache, migraine, tension-type headache, and asymptomatic subjects.

AIMS: Studies evaluating sensory function of the entire trigeminocervical region in patients with cluster headache (CH), migraine (MH), and tension-type headache (TH) are required. The purpose of the present study was to evaluate and compare sensory function in the trigeminocervical region in patients with CH, MH, and TH and healthy controls (HC). METHODS: Quantitative sensory testing (QST), including pressure pain threshold (PPT), tactile detection threshold (TDT), prick detection threshold (PDT), and two-point detection threshold (2PDT), was evaluated in 139 patients with headache (CH = 16, MH = 52, TH = 71) and 30 HC. Test sites included bilaterally the first, second, and third divisions of trigeminal nerve (V1, V2, and V3), cervical spine, and thenar eminence. RESULTS: TH presented significantly lower PPT values compared with CH (p < 0.015), MH (p < 0.048), and HC (p < 0.009), while MH demonstrated significantly lower values than HC (p = 0.001-0.023). When analyzing TDT, CH in the symptomatic side presented significantly higher values in V1 compared with MH (p = 0.001), TH (p < 0.001), and HC (p < 0.001) and in V2 compared with TH (p = 0.035). No statistically significant differences were found for PDT (p > 0.005). With regard to 2PDT, CH-s presented significantly higher values in V1 with respect to HC (p = 0.016) but lower values in V2 compared with MH (p < 0.001) and TH (p = 0.003). CONCLUSION: The results of the present study indicate specific and different altered mechanical sensory thresholds in CH, MH, and TH patients compared with HC subjects.