The Somatic Connection  |   July 2011
The Somatic Connection
Article Information
The Somatic Connection   |   July 2011
The Somatic Connection
The Journal of the American Osteopathic Association, July 2011, Vol. 111, 428-430. doi:
The Journal of the American Osteopathic Association, July 2011, Vol. 111, 428-430. doi:
Cervical HVLA vs Thoracic HVLA for Patients With Neck Pain
Puentedura EJ, Landers MR, Cleland JA, Mintken P, Huijbregts P, Fernandez-De-Las-Peñas C. Thoracic spine thrust manipulation versus cervical spine thrust manipulation in patients with acute neck pain: a randomized clinical trial [published online ahead of print February 18, 2011]. J Orthop Sports Phys Ther. 2011;41(4):208-220.  
The safety of cervical spinal manipulation using a thrust maneuver, such as the high-velocity, low-amplitude (HVLA) osteopathic manipulative treatment technique, has been debated for many decades. For this reason, clinical researchers have investigated alternative manipulative approaches for the treatment of patients with cervical pain syndromes that are commonly managed with manual therapy. 
One line of study has focused on manual therapy of the thoracic spine for the management of neck pain. To determine which patients respond favorably to this type of manual therapy, Celand et al developed a clinical prediction rule (CPR) using logistic regression statistical analysis (Phys Ther. 2007;87[1]:9-23). According to this rule, patients most likely to benefit from thoracic thrust joint manipulation for the management of neck pain have symptoms that have lasted less than 30 days, are not distal to the shoulder, and are not aggravated when the patient looks up. The CRF also includes a subscale score of less than 12 on the fear-avoidance beliefs questionnaire about physical activity, a decreased upper thoracic spine kyphosis (T3-T5), and a cervical extension range of motion less than 30 degrees. 
This CPR was used in a randomized clinical trial by Puentedura and colleagues. In the trial, the authors compared the effectiveness of thrust joint manipulation (HVLA) directed to the thoracic spine compared with HVLA applied to the cervical spine in patients with neck pain who met at least 4 of the 6 criteria for Cleland et al's CPR. 
Among the exclusion criteria were serious pathology (eg, neoplasm), cervical spinal stenosis, evidence of central nervous system involvement, 2 or more positive neurologic signs consistent with nerve root compression, pending legal action regarding the neck pain, whiplash injury (<6 weeks before examination), or history of cervical spine surgery, rheumatoid arthritis, osteoporosis, osteopenia, or ankylosing spondylitis. 
Of 96 patients screened, researchers recruited 24 patients (16 women; mean [SD] age, 33.7 [6.4] years; range, 26-48 years) from a physical therapy practice in Las Vegas, Nevada. All participants had a primary report of neck pain with or without unilateral upper extremity symptoms and had a baseline Neck Disability Index score of 10 or more points out of 50. 
All participants underwent physical examination, which included a neurologic examination and a segmental passive motion and tissue sensitivity assessment of the cervical and thoracic spinal vertebrae. After examination, participants were randomly assigned to 1 of 2 treatment groups, both of which consisted of 5 sessions over a 2-week span. For the first 2 sessions, participants received either rotation-focused cervical HVLA (cervical group [n=14]) or thoracic HVLA (thoracic group [n=10]) and a cervical range-of-motion exercise. At the discretion of the manipulating clinician (who had over 30 years experience in HVLA manual therapy), HVLA manipulation was applied to the vertebral segments with hypomobility and tenderness compared with other vertebrae in the region. During the final 3 sessions, participants from both groups completed a standardized upper back, neck, and shoulder exercise regimen. Four participants in the cervical group did not complete the protocol, leaving 10 participants in each group who completed the study. 
Outcome measures collected at 1 week, 4 weeks, and 6 months from the start of treatment included the Neck Disability Index, an 11-point numeric pain rating scale, and a Fear-Avoidance Beliefs Questionnaire. 
Using a per protocol analysis, the authors found statistically significant improvements in Neck Disability Index scores (P<.001), numeric pain rating scale scores (P<.003), and Fear-Avoidance Beliefs Questionnaire physical activity subscale scores (P<.004) at all follow-up times for patients who received cervical HVLA. The number needed to treat to avoid an unsuccessful overall outcome (defined as requiring additional therapy for persistent symptoms) was 1.8 at 1 week, 1.6 at 4 weeks, and 1.6 at 6 months. 
Patients with neck pain who met 4 of 6 of the CPR criteria for successful treatment of neck pain with thoracic spine HVLA manipulation demonstrated a more favorable response when the HVLA was directed to the cervical spine rather than the thoracic spine. Patients receiving cervical HVLA also demonstrated fewer transient adverse effects. Further research along these lines would entail enrolling more patients and adding more groups, such as an exercise-only intervention group and a group that receives both thoracic and cervical HVLA treatments to see if the combination produces better outcomes than a treatment that isolates 1 region. —M.A.S. 
Which Is Better: Conservative or Surgical Intervention of Carpal Tunnel Syndrome?
Shi Q, MacDermid JC. Is surgical intervention more effective than non-surgical treatment for carpal tunnel syndrome? A systematic review. J Orthop Surg Res. 2011;6(1):17 .  
Carpal tunnel syndrome (CTS) is the most common type of entrapment neuropathy in the United States. It is a common condition that can affect adult patients of all ages, but it has the highest incidence rate in patients who are in their late 50s. Surgical and conservative interventions are used to help relieve symptoms of CTS. Surgery is used after conservative measures fail, but it is unclear who will benefit from surgery and when surgery should be performed. In a recent systematic review, Shi and MacDermid compared the efficacy of surgical treatment of CTS with conservative treatment. 
Researchers searched the scientific literature for controlled trials published in English after 1970 that compared surgical intervention (eg, endoscopic or open carpal tunnel release) with conservative therapy (eg, pharmaceuticals, wrist splint, physical therapy, laser therapy) in the management of CTS. Two reviewers selected studies, assessed the studies' methodologic quality, and extracted data from the studies independently of each other. Included in the calculations were weighted mean differences and 95% confidence intervals (CIs) for patient self-reported functional status and symptom questionnaires. In addition, relative risk (RR) and 95% CIs were calculated for complications and electrophysiologic findings. 
Seven studies met the inclusion criteria: 5 randomized clinical trials and 2 controlled trials. No studies assessing the effect of osteopathic manipulative treatment compared with surgical intervention were found in the literature search. The methodological quality of the trials ranged from moderate to high. The most common shortcoming of the articles was lack of blinding and inadequate randomization. 
The weighted mean difference demonstrated a larger treatment benefit for surgical intervention compared with nonsurgical intervention at 6 months for functional status (0.35; 95% CI, 0.22-0.47) and symptom severity (0.43; 95% CI, 0.29-0.57). Differences between intervention options at 3 months were not statistically significant (0.35; 95% CI, 0.15-0.55), but differences at 12 months favored surgery in terms of function and symptom relief (0.37; 95% CI, 0.19-0.56). The RR for normal nerve conduction findings after treatment was 2.3 (95% CI, 1.2-4.4); RR for complication was 2.03 (95% CI, 1.28-3.22). Nerve conduction findings favored surgery but fewer complications were reported for conservative interventions. 
The authors concluded that both surgical and conservative interventions are beneficial in the treatment of patients with CTS. Compared with patients who underwent conservative intervention, patients who underwent surgical release were 2 times more likely to have normal nerve conduction findings but also had more complications and adverse effects (eg, skin irritation, hematoma). Results of this systematic review support the current practice of conservative management of CTS with surgical release for severe or persistent symptoms. —M.A.S. 
Validation of Viscerosomatic Palpatory Findings During Coronary Ischemia
Gwirtz PA, Dickey J, Vick D, Williams MA, Foresman B. Viscerosomatic interaction induced by myocardial ischemia in conscious dogs. J Appl Physiol. 2007;103(2):511-517.  
Osteopathic researchers have long demonstrated that visceral pathology manifests in the paraspinal soft tissues amenable to palpatory diagnostic procedures taught in osteopathic medical schools.1-7 Louisa Burns, DO, established more than a century ago that palpable paraspinal changes occurred in animals in which the organs were ligated or manipulated.8 A more recent animal model lab inquiry into the relationships between coronary artery disease and thoracic somatic dysfunction was reported by Gwirtz et al, who sought to determine whether myocardial ischemia induces increased paraspinal muscular tone at spinal segments T2-T5 that can be detected by palpation. In addition, they tested the theory that the sympathetic innervations carrying afferent stimuli from the heart to the spinal cord are involved in this viscerosomatic reflex. 
Researchers examined chronically instrumented healthy dogs—12 that were neurally intact and 3 that underwent selective left ventricular sympathectomy—before, during, and after experimentally induced myocardial ischemia and sham stenosis. Internal measurements consisted of circumflex arterial blood flow and left ventricular contractile function; external measurements included results of electromyographic (EMG) analysis of paraspinal soft tissues and blinded osteopathic palpatory diagnostic procedures of paraspinal tissues over the transverse processes at spinal segments T2-T5. Measurements were also taken for segments T11-T12 for use as controls. The osteopathic palpatory diagnostic procedure consisted of soft tissue palpation, compression, springing, and rocking of vertebrae to assess for structural asymmetry, motion restriction, and tissue changes. 
Decreased myocardial contractile function and increased heart rate occurred during myocardial ischemia (P<.05). The addition of an α1-adrenergic receptor antagonist, prazosin hydrochloride, increased blood flow distal to the stenosis, but not in the cases of sham stenosis. This effect indicated a viscero-visceral vasoconstriction induced by the experimentally induced coronary artery occlusion. 
Osteopathic palpation revealed markedly increased muscle tension and firmness during ischemia bilaterally at the T2-T5 spinal segments and moderate tension on the left side at T11-T12 spinal segments (P<.05). Findings from EMG testing demonstrated increased amplitude for the T2-T5 segments but not the T11-T12 segments (P<.05). After left ventricular sympathectomy, osteopathic palpation and EMG evidence of increased muscle tone were absent. 
The authors concluded that, in neurally intact dogs, myocardial ischemia is associated with statistically significant increased paraspinal muscle tone in left-sided T4-T5 myotomes. The absence of somatic response after left ventricular sympathectomy suggests that sympathetic neural traffic between the heart and somatic musculature may function as the mechanism for cardio-somatic interactions. This study adds validity to the clinical studies1-6 that identified palpable paraspinal evidence of somatic dysfunction in patients with coronary artery disease. Of interest is that this research path is also being explored by Chinese researchers, who recently reported on the effectiveness of thoracic spinal manipulation for symptoms of chest pain related to coronary artery disease.9 It is still unknown whether osteopathic manipulative treatment alters the pathophysiology or improves symptoms of coronary artery disease, but osteopathic research in this area spanning more than 100 years continues to serve as a foundation for future studies.—M.A.S.  
 “The Somatic Connection” highlights and summarizes important contributions to the growing body of literature on the musculoskeletal system's role in health and disease. This section of JAOA—The Journal of the American Osteopathic Association strives to chronicle the significant increase in published research on manipulative methods and treatments in the United States and the renewed interest in manual medicine internationally, especially in Europe.
 To submit scientific reports for possible inclusion in “The Somatic Connection,” readers are encouraged to contact JAOA Editorial Advisory Board Member Michael A. Seffinger, DO (, or Editorial Board Member Hollis H. King, DO, PhD (
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