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Question: Is massage therapy effective in reducing symptoms of cervicogenic headache in adults?

History of the Case: “DJ” is a 47 year old female with a medical diagnosis of cervicogenic headache post-whiplash injury to her neck, sustained in a MVA on 3/1/07. In the accident, DJ was driving her car at 65mph in highway traffic when she reportedly stopped suddenly to avoid the car ahead, spun and struck a cement wall on the driver’s side of her car. She struck the left side of her head on the window, but did not lose consciousness. Since the accident, she has suffered from neck pain, limited cervical range of motion and intermittent headaches, which become disabling about once per week. She is taking naprosyn 500mg 2x/day and flexiril prn at night, to control her headache. She has no other medical problems. She has had prior whiplash type injuries over the years, but none which caused persistent headaches. JD works full-time as a science teacher. She is married with no children. She has not been able to participate in her usual recreational activities tennis, running, and aerobic dance since the accident. She has tried the usual course of physical therapy with hot packs, electrotherapy, and stretching exercise with minimal temporary relief of the neck pain and headaches. Symptoms return when she is physically active, lifting over 5 pounds, pushing or pulling over 25 pounds, and after attempting to run, dance, or play tennis for over 15 minutes. She has missed several days from work due to the severity of her headaches. She said that massage therapy provides the greatest relief, to allow her to work, but the symptoms return if she exerts herself by lifting over 50 pounds, or if she inverts her head for greater than a minute or two. She had x-rays, neck and brain MRI, which showed DJD of the cervical spine. No further medical testing was performed. She reports her general health is excellent.

To determine if the evidence I found is applicable to this patient, I reviewed studies about manual treatments for headache relief. Some of the evidence indicates that manual therapy or massage may be beneficial for patients with headache. Most articles do not specify what type of headache they review, some group different headache types into a single study. Some studies incorporate several interventions to note the effect on headache, which does not allow us to isolate the effect of a particular intervention. Studies use a variety of different treatment frequencies, durations, and follow-up times. It is difficult to compare evidence when a variety of factors are not homogenous. I recommend future studies review the effect of a single or selected group of interventions on a specific type of headache: migraine, tension, or cluster headache. Future studies must look at the differences between varying frequencies, durations and long term effects of the interventions in homogenous subject groups. My impression of the available full text studies, which are systematic reviews, follows.

A systematic review was conducted by Bronfort, et al, entitled “Noninvasive Physical Treatments for Chronic/Recurrent Headache” in Cochrane Database of Systematic Reviews (1). The authors reviewed 21 randomized and one quasi-randomized controlled trials of 2628 patients with headaches, to quantify and compare the effects of the physical treatments on headaches. The trials were scored for methodological quality, with 100 being the highest score. Ten studies scored at least 50. The review indicated variable results for different types of headaches. One study reported that a combination of auto-massage, stretching, and electrotherapy showed weaker evidence than spinal manipulation for tension headache relief (2). Manipulation was more effective as prophylaxis than massage for short-term relief of cervicogenic headache. Few adverse effects were reported for physical treatments for headaches. The reviewers determined that additional studies of a more homogenous nature are needed to determine which types of physical treatments are effective for reducing headaches. The studies considered several types of headaches including cervicogenic, migraine, cluster, tension and, posttraumatic, and mixed headaches. The authors determined that none of the evidence was conclusive due to the heterogeneity of the samples reviewed.

The treatments reviewed compared the physical treatment to placebo or another intervention or no intervention. Outcome measures included pain level, patient satisfaction, activities of daily living/functional level, medication use, duration and frequency of headache, and level of improvement. Bronfort’s review included a description of the methods of review. Studies were analyzed by two separate reviewers who extracted specific data from each article using a checklist. The reviewers were not blinded, they standardized the effect size scores and outcomes data using percentage points. The quality of individual studies was reported on a scale of zero to 100; studies scored at least a 50 or more were considered to be of high quality. Reviewers classified twenty methodological items as “informativeness” items or “internal validity” items. Some of the items were: randomization, inclusion/exclusion criteria, comparability of variables for groups studied, reliability/validity, blinding, bias, post intervention follow-up periods, description of interventions, comparison to other interventions, study objective or hypothesis, analysis consistency with the design of the study, statistical power, confidence intervals, dropout impact, random data allocation, intention to treat analysis, adjustments made to the number statistical tests, and validity of main conclusions (3).

Researchers classified the quality levels for each study into five levels from strong, moderate, limited, preliminary, or conflicting evidence, based on validity scores. Trial results were pooled if the interventions, outcomes or patient population were homogenous. One primary outcome measure was headache index or pain intensity. Based on the exhaustive nature of the quantitative analysis of trial results and the level of evidence used to evaluate the reviewed studies, it appears that the conclusions generated were substantive.

The valid results of this review are important for many reasons. Physical therapists often use a range of individual physical treatments or a combination of interventions to manage headaches. The reviews included comparing a wide range of individual interventions to combination package interventions and also to controls or placebos. Several of the studies assessed massage as one of the interventions. It appears that the heterogeneity of the interventions used make it difficult to draw conclusions. Of the 22 trials reviewed, only one directly addressed the effect of massage on cervicogenic headache (4). The studies were very different in the number of interventions performed (1-12 over 1-6 weeks). More research is needed to determine the optimal number of interventions and duration of treatment to perform to achieve the desired outcome of headache reduction.

In studies that included massage in combination with other physical treatments such as heat, ultrasound or acupuncture, one cannot decide whether any individual intervention or the combination most influenced the outcome measures. Since massage was not tested as the only variable, no direct conclusion can be drawn about the benefit of massage alone.

The Bronfort review discussed limitations of the study, including publication bias. The authors noted that three of the studies reviewed were ones in which at least one of the authors participated(5). The review included only published research, which is more likely to have positive outcomes than unpublished research (6). The authors also mentioned that clinical trials done in languages other than English may have been missed. The authors used two methodological scoring systems in order to minimize bias. Overall, the review was very comprehensive, with few limitations. The authors made an excellent summary point, stating, “Authors too often draw inappropriate conclusions when they declare treatment effectiveness based solely on presence or absence of statistical differences between a test treatment and a control. To inform decisions about management of individual patients, it may be much more appropriate to think in terms of available treatment options which have shown a meaningful clinical effect, rather than choosing or discarding specific therapies based on mean group differences of undefined clinical importance(7).”

The authors concluded that, “No single approach to interpreting findings from RCTs and systematic reviews is perfect. To inform decisions about the management of individual patients, it may be more appropriate to think in terms of available treatment options that have shown a meaningful clinical effect, rather than choosing or discarding specific therapies solely based on mean group differences of undefined clinical importance (8).” Their conclusion is reasonable in consideration of the fact that therapists select from a wide variety of interventions to treat headaches, and the outcome of primary importance is the response of the individual patient to a given intervention. This systematic review provided some evidence to indicate that manual therapies, including massage and spinal manipulation, may help to reduce headaches, with little adverse effects. More studies must be done using specific headache classifications, subject homogeneity, and specific outcome criteria, in order to identify the types of therapies effective in reducing headache pain. The results of this review are applicable to my case study. In treating my case study patient’s headache, I utilized a combination of massage therapy, joint mobilization, (manipulation) therapeutic exercise, and relaxation training. The evidence from the review provides moderate support for the use of the manipulation, and minimal support for the use of massage, exercise and relaxation training. Overall, there are few side effects of these interventions, and if my patient shows improvement with any of them, I will choose to continue the treatment. Based on the outcomes of the review, I may focus more time on manipulation to reduce headaches, and measure the outcome for my individual patient. If the outcome is favorable, I will continue the treatment.

Another systematic review of the effect of manual therapies on headache reduction was undertaken by Fernandez de las Penas, et al. (9) The authors reviewed the computerized databases Medline, Pubmed, Ovid, Cochrane, AMED, MANTIS, CINAHL, EMBASE, and PEDro. They selected controlled clinical trials and reviews to determine the effect of manual therapy on tension type headaches. The authors reviewed publications based on specific inclusion criteria using a standardized format for data extraction. The authors stated that they agreed on the items in the form, and verified “observer reliability” using coefficient (K= 0.79) (10). Studies selected included open uncontrolled studies and randomized controlled trials, which included manual therapy treatment for tension headaches. The studies were limited to English language publications post-1994. The PEDro quality scoring method was used to determine methodological quality on a scale of 0 to 10, with a score greater than five considered high quality and a score less than five to be low quality. Authors used either effect size (ES) or an outcome quality score of P<0.05 to determine the level of scientific evidence for the trials, ranging from strong, moderate, limited, or inconclusive evidence. The primary outcome measure included headache frequency, intensity, or duration. Fifty-five articles were found, however, only six total articles met their eligibility criteria for final selection (11). The total number of subjects across all studies was 405.

The manual therapies evaluated in the studies included “spinal manipulation, classic massage, connective tissue manipulation, soft tissue massage, Dr. Cyriax’s vertebral mobilization, manual traction, and CV-4 craniosacral technique (12). The studies varied widely in the duration of intervention, from a single session to 6 weeks of therapy. “(mean=3.6+/- 1.9 weeks)…sessions ranged from 1 to 20 (mean = 11.6+/- 7.3) (13). Four of the six studies assessed a single intervention, the others used a combination of techniques. As a result of the mix of interventions, a meta-analysis could not be done. Different controls were used in each study, with variable follow-up periods ranging from immediately post-treatment to 6 months post- treatment. Some used medication groups as controls, others compared manipulation alone to a combination of manipulation with traction or massage or placebo laser, to neck exercises or to no treatment at all. Because so many types of treatments were considered, it is difficult to draw conclusions about any one type of intervention. The interventions are too heterogenous to draw a final conclusion about any one intervention.

The methodological quality of the studies reviewed was determined by use of PEDro scores, which ranged from 2-8 points (mean=5.8+/-2.1) (14). Four of the six trials reviewed scored from 6-8 points, and were therefore considered to be of high quality. The effect size (ES) could only be calculated in two trials. Effect sizes were reported as (0.3) on headache frequency and intensity values (0.49) on pressure pain threshold, and (0.1) on range of cervical motion for the Cyriax mobilization group (15). The craniosacral group has the largest ES (0.84) on pain outcomes relative to the control and exercise groups (16). The authors determined that the level of evidence for the value of spinal manipulation was inconclusive, based on the outcome of two high quality studies and one poor quality study, which had differing results. They found limited evidence for connective tissue massage and craniosacral therapy, since each had only one trial study performed. The authors concluded that due to the limited number of high quality studies on manual therapies, (RCTs) and the heterogeneity of the samples and techniques used, there is little evidence to support the use of manual therapy for tension headaches.

The authors determined that the reviewed studies were nonconclusive in regard to the efficacy of manual therapies on headache for several reasons. The studies used different outcome measures, different manual techniques, and inconsistency in the design of the clinical trails. (Some assessors were not blinded, or did not use an intention-to-treat analysis) They suggest using other standard outcome measures such as the Pressure Pain Threshold, McGill Pain Questionnaire, or Neck Disability Index, to make the outcomes measures more homogenous (17).

Publication bias may be evident in this review, since only published English studies were considered, and mostly positive outcomes may be represented. The authors recommended that future studies of higher quality design with more homogenous subjects and interventions would better represent the outcomes of manual therapies for tension headaches.

One could use the results of Fernandez de las Penas’ review to consider the type of manual therapy to use with this case study patient. They did remark that there if limited evidence for effectiveness of soft tissue manipulation for reducing headaches, and inconclusive findings for the use of manipulation. I utilize both treatments in my plan for headache reduction for my patient, with good results in pain reduction and lower duration of pain, and in the improved scores on the Neck Disability Index. Since the soft tissue intervention has low risk of side effects, (compared to medication or vertebral manipulation) I will continue to use it. I always use outcome measures in my practice, including those recommended by the authors, such as range of motion, Neck Disability Index, and the SF-36 questionnaires. When I note positive outcomes based on these objective measures, I continue to apply the manual therapy to get favorable results. Simply finding a lack of evidence in the literature to support manual therapy does not preclude its use in my practice. I find that using objective measures such as the Neck Disability Index and other standard outcome measures to assess the results of my interventions is superior to using literature review, because I can see the immediate and long term results with my patients on a one-to-one basis. I will use the literature as a guide to determine which interventions may be efficacious for a given problem, such as headaches (18-20). If I do not generate positive results within two to three visits, I will return to the literature to find alternative interventions. Since the research is constantly updated, I obtain the latest information directly in my e-mail from Medline. It is critical to know how to perform a literature review to locate recent studies which may prove beneficial to patients and to practice as a manual therapist. With practice, one can find more high-quality evidence to use in a reasonable period of time. As noted in each study reviewed, more research is needed with better methodology to determine the optimal interventions for a given problem.

REFERENCES
1. Bronfort, G, Nilsson, N, Haas, M, Evans, R, Goldsmith, CH, Assendelft, WJJ, and Bouter, LM. Noninvasive Physical Treatments for Chronic/Recurrent Headache. [Reviews]. Cochrane Database of Systematic Reviews, 2007;3: 1-47. Available at http://0-gateway.tx.ovid.com.lilac.une.edu/gwl/ovidweb.cgi, Accessed November 2, 2007.
Footnote 1-16
2. Bronfort, p. 2. (pp. 11-12)
3. Bronfort, p. 11-12
4. Bronfort, p.15.
5. Bronfort, p.33.
6. Bronfort, p.30
7. Bronfort, p. 31.
8. Bronfort, p. 33.
9. Fernandez de las Penas, C, Alonso-Blanco, C, Luz Cuadrado, M, Miangolarra, JC, Barriga, FJ, and Pareja, JA, Are Manual Therapies Effective in Reducing Pain from Tension Type Headache? A Systematic Review. Clinical Journal of Pain March/April 2006; 22:(3): 278-285.
(Footnote 9-17)
10. Fernandez de las Penas, p. 279.
11. Fernandez de las Penas, p. 280.
12. Fernandez de las Penas, p. 280.
13. Fernandez de las Penas, p. 282.
14. Fernandez de las Penas, p. 282.
15. Fernandez de las Penas, p. 283.
16. Fernandez de las Penas, p. 283.
17. Fernandez de las Penas, p. 284.
18. Haraldsson, BG, Gross, AR, Myers, CD, Ezzo, JM, Morien, a, Goldsmith, C, Peloso, PM, Bronfort, G. Massage for Mechanical Neck Disorders. Cochrane Database of Systematic Reviews. 3:2007.
19. Tsao, JC, Effectiveness of Massage Therapy for Chronic Nonmalignant Pain: a Review. Evidence-based Complementary and Alternative Medicine. 2007 June; 4(2): 165-179. Epub 2007 Feb 5. Available at:http://www.ncbi. nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=show… Accessed November 2, 2007.
20. Biondi, DM. Physical Treatment for Headache: a Structured Review. Headache. 2005 June; 45, (6):738-746.

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Bibliographic Citation: McClure, PW, Flowers, KR. Treatment of Limited Shoulder Motion: A Case Study Based on Biomechanical Considerations. Physical Therapy. 1992(72):929-936

McClure and Flowers presented a case study of a 57 year old woman who sustained a fracture-dislocation of the humeral head (1) They described the patient’s examination, PT interventions used and outcomes to restore range of motion (ROM) in her stiff shoulder. The authors suggested that the standard rationale for manual therapy interventions, known as the concave-convex rule of mobilization, is erroneous. They utilized a variety of clinical reasoning (CR) strategies to explain their findings within this case study.

The authors used two different styles of diagnostic reasoning: hypothetical-deductive and pattern recognition (2). The authors reasoned that according to a biomechanical perspective, treatment must follow one of two types of problems: a structural or nonstructural model of limitation (one must treat the cause of the limitation) (3). They used a disablement model to explain their approach to treating the limited ROM from a hypothetical-deductive view using data gathered from exam findings to generalize about a specific conclusion (4). They cited references for the concave-convex rule which used mechanical models instead of actual measurements on patients (5). They articulated that: “the distinction between the two types of problems with PROM is important because they involve different treatment strategies” (6). Using the disablement model, the authors collected ROM data from the patient and deduced that there must be a motion restriction in a predictable pattern (capsular pattern). They then tested the hypotheses that a restricted joint will be limited in a certain predictable pattern based on the biomechanical rules known as the concave-convex rule (7). They found that in actual subjects, the concave-convex rule was nullified (8). Most joint mobilizations were based on this rule which did not even apply to actual human subjects (9). “To summarize, we believe treatment decisions should be based on consideration of the structures limiting motion and how to best put tensile stress on these structures rather than restoring a translatory motion that does not really occur during physiologic movement” (10).

The authors appeared to use the Hypothesis Oriented Algorithm for Clinicians (HOAC) model of clinical reasoning (CR) to organize the patient data, and test their hypotheses prior to developing a plan of care (11). They used research evidence to question their hypotheses and to alter their approach to treatment. They used task analysis evidence from the literature to show that the concept of component motion is mistaken. They then altered their treatment decisions based on the new evidence. It does not appear they used an enablement model, since they did not present much information from the personal perspective of the patient. They only mentioned she was the wife of a physician, who wanted to restore mobility for ADL, and not for any athletic activities. They could have included more info on the patient’s perceived needs, her resources and abilities (12). The authors analyzed the patient’s performance of specific tasks using her stiff shoulder (13). Although they reported the patient’s complaint, they did not reveal anything much to contribute to understanding the patient’s view of the problem, other than limited motion resulting in limited ADL (14).

McClure and Flowers discussed how pattern recognition did not make sense in light of the standard knowledge of the biomechanical rules of joint motion. It was previously thought that joints possess component motions known as roll, spin, and glide. These component motions were said to occur in predictable patterns in normal joints. In people with motion restrictions, the lack of these component motions was deemed responsible for the impairment. The rationale was therefore that treatment using the component motion will remedy the limitation. When researched on human subjects, this was not the case (15). Pattern recognition would have lead the clinicians to reason “from a set of specific observations toward a generalization, and is known as forward reasoning. Forward reasoning contrasts with hypothetical deductive reasoning where a person moves from a generalization (multiple hypotheses) toward a specific conclusion” (16). Although the pattern recognition is a more efficient mode of CR, in the case of the concave-convex rule, the rationale was based on erroneous research. The authors were astute to reconsider their approach using new research performed on human subjects, instead of mechanical models (17). The authors concluded that “Many of our treatment decisions were based primarily on clinical experience rather than direct scientific data” (18). They came to a generalization about therapy interventions based on actual objective measurements of motion rather than questionable theories and limited evidence. McClure used forward reasoning to come to the specific conclusion that “treatment decisions should be based on consideration of the structures limiting motion and how to best put tensile stress on theses structures rather than restoring translatory motion that does not really occur during physiologic movement” (19).

Other strategies that could have been used to analyze the case from a different viewpoint are the HOAC and the dialectical models of CR. The authors then tested their hypothesis that other structures could be implicated other than the joint capsules stretched during joint mobilization. In the HOAC model, hypotheses are tested repeatedly, allowing the PT to reassess patient management and make changes where needed. Using the HOAC, the authors could have included information about the patient’s resources, environment and abilities to contribute to the resolution of her problem. It appeared this was not a consideration in the deductive model they used. The dialectical model encompasses the most comprehensive aspects of CR, including “those cognitive decision-making processes required to optimally diagnose and manage patient presentations of physical disability and pain (hypothetical-deductive or instrumental reasoning and action) and those required to understand and engage with patients’ (or caregivers’) experience of that disability and pain (narrative or communicative reasoning and action) (20). The dialectical model emcompasses both aspects of the traditional medical model with hypotheses testing and the patient-oriented model of communicative reasoning (21). It is a more comprehensive approach to examination and management.

It appears that the traditional biomechanical models we based most of our manual therapy decisions on are questionable at best. Clinicians must not simply accept what the literature says about why manual therapy interventions work. Often, these conclusions are based on limited or faulty data or statistical methods. We relied on studies that were not done on real people, but rather on models (22). For clinical research to assist us in development of appropriate treatment interventions, we must reflect upon studies which most closely approximate real life situations, not simply models. For a comprehensive approach, we must consider both the deductive and communicative reasoning methods to develop a Wholistic view of a patient’s problem. Patients’ perspectives must be included in the planning and development of their program to generate successful outcomes. It is critical to utilize a variety of CR strategies to achieve maximum benefit to our patients and to our profession.

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Trendsetters: Chat with PT Leaders in the Field

Physical Therapists are exploring unique opportunities in the field both within and outside of traditional clinical practice. In this interview series, we will meet with leaders in PT who are making a difference. We will explore what they do to create that satisfying, successful and prosperous career many therapists dream of. Let’s learn what they do to create an extraordinary quality of life and professional career, and how we too can gain that level of achievement that makes us proud of our profession.

In today’s interview, we meet a PT who developed a unique company devoted to expanding the availability of quality educational programs online and in live conferences. Let’s meet Brandon Osborn, MPT, owner of HomeCEUConnection.com, based in Plano, Texas.

Schmidt: Hello Brandon, thank you for taking the time to share your experience in the field, and for blazing a trail in a new arena of online training and education for healthcare professionals.-How did you become interested in the field of physical therapy initially, and what made you change gears and get involved in the business side of the field?

Osborn: Well, to be perfectly honest I’ve got a bit of a competitive streak. I was originally attracted by the challenge of gaining acceptance to a physical therapy program. Learning to deliver quality care in a phase of the healing process was a bonus.
I discovered my entrepreneurial spirit through several life experiences and side ventures while I was practicing as a therapist. Those life experiences and side ventures led me to focus my energy on an under-served niche: Online continuing education for healthcare providers otherwise known as HomeCEUConnection.com.

What made you choose to develop an online continuing education company? 

The recognition of that niche in the market combined with my love of a challenge made me determined to bring a user friendly, seamless, high quality, reliable, approved learning experience directly to every therapist across the country. Over time HomeCEUConnection.com has become much more than just another continuing education company: It’s about commitment to our core values, outstanding customer service, developing our own unique, positive, fun loving culture. We are raising the bar by embracing advances in technology taking online education, training, compliance and e-learning management to a whole new level for the ultimate customer experience.

Where is the real value for therapists pursuing online education as compared to live seminars? How can therapists benefit from your experience?

The benefits of e-learning are endless: Better accessibility, lower cost, convenience, instant replay and immediate acknowledgment of completion. We know that access to a variety of high quality continuing education, training and compliance can be a real challenge. Thanks to advances in technology, now instead of flying half way around the country and spending buckets of money and time on a live seminar, you can attend quality educational courses without having to leave home or disrupt your schedule.

Speaking of live seminars, what prompted you to create the Rehab Rally conference? 

Rehab Rally serves a few purposes; In addition to providing high quality, high impact therapy continuing education, it gives us a venue to showcase our company culture and core values. This allows us to build long lasting relationships with the therapists we serve every day and with business leaders in our industry. Most importantly we use the feedback we gather from our students and business leaders at Rehab Rally to better serve them in the future.

What is the next step in bringing live programs directly to therapists across the country? Tell us a little bit about the new technology you use.

We’re using cutting edge technology to push the envelope on the customer’s experience and we’re deeply committed to continuing to push that envelope as new technology is developed. Most recently we’ve been able to recreate the live classroom environment in a media rich online product. Seminar-On-Demand courses stream a media rich video and power point presentation seamlessly directly to the student’s computer. In addition we are working tirelessly on a very exciting and significant upgrade of our website and e-learning management system. The new website and e-learning management system will significantly streamline the user experience and lay the foundation for future improvements.

It appears you are now expanding your educational offerings to other healthcare professionals. Tell us about the challenge of meeting the Provider approval across the country?

It’s definitely been a challenge to comply with the rules and standards of each individual state and profession. In order to hold true to Core Value #1 (Delivering a SMILE through service) we created an entire department that’s responsible for maintaining Quality and Accreditation. HomeCEUConnection.com adheres to a strict triple verification process, and our entire team is trained on the rules and regulations to ensure we’re giving our customers top quality, reliable service and information.

How do you feel about the requirement for the DPT as the required entry-level degree in physical therapy?
I think it’s fantastic! I love the fact that the bar is being continuously raised for our profession. It helps attract and retain the best talent available. A close friend of mine has a saying: “If you’re not growing, you’re dying”.

Do you believe this translates into making a difference in how therapists actually practice?

Absolutely I do. For a lot of people, perception is reality. DPT is a huge credibility builder for our profession amongst not only patients, but peers and payors as well. And with more credibility comes more opportunity and with more opportunity comes more responsibility.

What changes do you envision for the field?

Another one of HomeCEUConnection.com’s core values is “Relentless Forward Motion”. It’s imperative that our new DPTs are business savvy so that they can drive the profession forward. I know it’s not generally a popular topic amongst therapists, but in order for our profession to survive and thrive, business skills are absolutely critical.

It appears you have successfully embraced the business side of physical therapy. Do you have any advice for therapists in the field regarding how they too can be successful not only in clinical outcomes, but achieving the level of financial success that we see so much more frequently in business-oriented practices such as chiropractic and medicine?

First and foremost I believe that a business education and/or extensive experience under the guidance of a mentor are vital to financial success in our profession. As therapists we’re trained with a singular vision: Deliver the highest quality care to our patients. This, in itself, is fantastic, but we need to remove the blinders. We have to be able to stick to that vision with sustainability and profitability or we run the risk of being limited to working for someone that does understand how to run a business-oriented practice.

What can our educational programs do to bring us to that next level?

In the near term our schools and clinics need to integrate business classes and or training into the core curriculum emphasizing the utilization of sound business practices in the delivery of quality care. As we move forward with the APTA’s 2020 vision our schools need to begin the process of integrating an MBA program into the core physical therapy curriculum. We need to prepare our next generation of therapists to handle the future challenges of quality, efficient healthcare delivery and the growth of the profession.

Have you any advice for new graduates? Is there a protocol for success? Tell us your strategy!

I call my protocol to success “P2”. Success is a by-product of “Purpose” and “Perseverance”. Purpose can vary from individual to individual but perseverance by its very definition is unchanging. HomeCEUConnection.com’s Core Value #10 exemplifies our commitment to perseverance: “Know No Limits”.

What is your next step?

Our whole organization is deeply committed to Core Value, “Embrace and Drive Change”, with the common goal of exceeding our customer’s expectations and improving their experience. TheHomeCEUConnection.com team is working on some new and exciting things that will allow us to hold true to this core value. Keep up with these developments and all the other exciting things going on at HomeCEUConnection.com on our Facebook page, our Twitter feed and on our blog at www.HomeCEUConnection.com/blog.

Thank you Brandon, for taking the time out of your incredibly busy schedule to speak with us about the opportunities therapists have in our field, and how they too can enrich their lives and the lives of others by becoming successful both professionally and personally. We wish you much success in meeting your goals!

Future interviews will be with leaders in PT entry-level education, geriatric PT clinicians, manual therapy specialists, pediatric experts and more.

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Manual therapists frequently employ soft tissue mobilization interventions such as massage or myofascial release to reduce symptoms of pain, muscle spasm and trigger points in their clients. There is substantial evidence to support the use of such interventions. In this age of rapidly changing health care policies and managed care limitations on therapy reimbursement, it is critical to provide supportive documentation for the use of therapeutic interventions. Using a case study format, I will discuss the research which provides support for manual therapy as an effective intervention for headaches.

History of the Case: “Melinda Jones” is a 47 year old female with a medical diagnosis of cervicogenic headache post-whiplash injury to her neck, sustained in a MVA on 3/1/09. In the accident, Melinda was driving her car at 65mph in highway traffic when she reportedly stopped suddenly to avoid the car ahead, spun and struck a cement wall on the driver’s side of her car. She struck the left side of her head on the window, but did not lose consciousness. Since the accident, she has suffered from neck pain, limited cervical range of motion and intermittent headaches, which become disabling about once per week. She is taking Naprosyn 500mg 2x/day and Flexiril prn at night, to control her headache. She has no other medical problems. She has had prior whiplash type injuries over the years, but none which caused persistent headaches. Melinda works full-time as a science teacher. She has not been able to participate in her usual recreational activities tennis, running, and aerobic dance since the accident. She has tried the usual course of physical therapy with hot packs, electrotherapy, and stretching exercise with minimal temporary relief of the neck pain and headaches. Symptoms return when she is physically active, lifting over 5 pounds, pushing or pulling over 25 pounds, and after attempting to run, dance, or play tennis for over 15 mins. She has missed several days from work due to the severity of her headaches. She said that massage therapy provides the greatest relief, to allow her to work, but the symptoms return if she exerts herself by lifting over 50 pounds, or if she inverts her head for greater than a minute or two. She had x-rays, neck and brain MRI, which showed DJD of the cervical spine. No further medical testing was performed. She reports her general health is excellent.

To determine if the research evidence is applicable to this patient, I reviewed studies about manual treatments for headache relief. Some of the evidence indicates that manual therapy or massage may be beneficial for patients with headache. Most articles do not specify what type of headache they review, some group different headache types into a single study. Some studies incorporate several interventions to note the effect on headache, which does not allow us to isolate the effect of a particular intervention. Studies use a variety of different treatment frequencies, durations, and follow-up times. It is difficult to compare evidence when a variety of factors are not homogenous. I recommend future studies review the effect of a single or selected group of interventions on a specific type of headache: migraine, tension, or cluster headache. Future studies must look at the differences between varying frequencies, durations and long term effects of the interventions in homogenous subject groups. The original studies I located could not be found in full text articles. The library provided only two full text articles from a loan request. My impression of the available full text studies, which are systematic reviews, follows.

A systematic review was conducted by Bronfort, et al, entitled “Noninvasive Physical Treatments for Chronic/Recurrent Headache” in Cochrane Database of Systematic Reviews (1). The authors reviewed 21 randomized and one quasi-randomized controlled trials of 2628 patients with headaches, to quantify and compare the effects of the physical treatments on headaches. The trials were scored for methodological quality, with 100 being the highest score. Ten studies scored at least 50. The review indicated variable results for different types of headaches. One study reported that a combination of auto-massage, stretching, and electrotherapy showed weaker evidence than spinal manipulation for tension headache relief (2). Manipulation was more effective as prophylaxis than massage for short-term relief of cervicogenic headache. Few adverse effects were reported for physical treatments for headaches. The reviewers determined that additional studies of a more homogenous nature are needed to determine which types of physical treatments are effective for reducing headaches. The studies considered several types of headaches including cervicogenic, migraine, cluster, tension and, posttraumatic, and mixed headaches. The authors determined that none of the evidence was conclusive due to the heterogeneity of the samples reviewed.

The treatments reviewed compared the physical treatment to placebo or another intervention or no intervention. Outcome measures included pain level, patient satisfaction, activities of daily living/functional level, medication use, duration and frequency of headache, and level of improvement. Bronfort’s review included a descriptions of the methods of review. Studies were analyzed by two separate reviewers who extracted specific data from each article using a checklist. The reviewers were not blinded, they standardized the effect size scores and outcomes data using percentage points. The quality of individual studies was reported on a scale of zero to 100; studies scored at least a 50 or more were considered to be of high quality. Reviewers classified twenty methodological items as “informativeness” items or “internal validity” items. Some of the items were: randomization, inclusion/exclusion criteria, comparability of variables for groups studied, reliability/validity, blinding, bias, post intervention follow-up periods, description of interventions, comparison to other interventions, study objective or hypothesis, analysis consistency with the design of the study, statistical power, confidence intervals, dropout impact, random data allocation, intention to treat analysis, adjustments made to the number statistical tests, and validity of main conclusions (3).

Researchers classified the quality levels for each study into five levels from strong, moderate, limited, preliminary, or conflicting evidence, based on validity scores. Trial results were pooled if the interventions, outcomes or patient population were homogenous. One primary outcome measure was headache index or pain intensity. Based on the exhaustive nature of the quantitative analysis of trial results and the level of evidence used to evaluate the reviewed studies, it appears that the conclusions generated were substantive.

The valid results of this review are important for many reasons. Manual therapy practitioners often use a range of individual physical treatments or a combination of interventions to manage headaches. The reviews included comparing a wide range of individual interventions to combination package interventions and also to controls or placebos. Several of the studies assessed massage as one of the interventions. It appears that the heterogeneity of the interventions used make it difficult to draw conclusions. Of the 22 trials reviewed, only one directly addressed the effect of massage on cervicogenic headache (4). The studies were very different in the number of interventions performed (1-12 over 1-6 weeks). More research is needed to determine the optimal number of interventions and duration of treatment to perform to achieve the desired outcome of headache reduction.

In studies that included massage in combination with other physical treatments such as heat, ultrasound or acupuncture, one cannot decide whether any individual intervention or the combination most influenced the outcome measures. Since massage was not tested as the only variable, no direct conclusion can be drawn about the benefit of massage alone.

The Bronfort review discussed limitations of the study, including publication bias. The authors noted that three of the studies reviewed were ones in which at least one of the authors participated (5). The review included only published research, which is more likely to have positive outcomes than unpublished research (6). The authors also mentioned that clinical trials done in languages other than English may have been missed. The authors used two methodological scoring systems in order to minimize bias. Overall, the review was very comprehensive, with few limitations. The authors made an excellent summary point, stating, “Authors too often draw inappropriate conclusions when they declare treatment effectiveness based solely on presence or absence of statistical differences between a test treatment and a control. To inform decisions about management of individual patients, it may be much more appropriate to think in terms of available treatment options which have shown a meaningful clinical effect, rather than choosing or discarding specific therapies based on mean group differences of undefined clinical importance (7).”

The authors concluded that, “No single approach to interpreting findings from RCTs and systematic reviews is perfect. To inform decisions about the management of individual patients, it may be more appropriate to think in terms of available treatment options that have shown a meaningful clinical effect, rather than choosing or discarding specific therapies solely based on mean group differences of undefined clinical importance (8).” Their conclusion is reasonable in consideration of the fact that therapists select from a wide variety of interventions to treat headaches, and the outcome of primary importance is the response of the individual patient to a given intervention. This systematic review provided some evidence to indicate that manual therapies, including massage and spinal manipulation, may help to reduce headaches, with little adverse effects. More studies must be done using specific headache classifications, subject homogeneity, and specific outcome criteria, in order to identify the types of therapies effective in reducing headache pain. The results of this review are applicable to this case study. In treating this patient’s headache, I utilized a combination of massage therapy, joint mobilization, (manipulation) therapeutic exercise, and relaxation training. The evidence from the review provides moderate support for the use of the manipulation, and minimal support for the use of massage, exercise and relaxation training. Overall, there are few side effects of these interventions, and if the patient shows improvement with any of them, I will choose to continue the treatment. Based on the outcomes of the review, I may focus more time on manipulation to reduce headaches, and measure the outcome for my individual patient. If the outcome is favorable, I will continue the treatment.

Another systematic review of the effect of manual therapies on headache reduction was undertaken by Fernandez de las Penas, et al. (9). The authors reviewed the computerized databases Medline, Pubmed, Ovid, Cochrane, AMED, MANTIS, CINAHL, EMBASE, and PEDro. They selected controlled clinical trials and reviews to determine the effect of manual therapy on tension type headaches. To authors reviewed publications based on specific inclusion criteria using a standardized format for data extraction. The author stated that they agreed on the items in the form, and verified “observer reliability” using coefficient (K= 0.79) (10). Studies selected included open uncontrolled studies and randomized controlled trials, which included manual therapy treatment for tension headaches. The studies were limited to English language publications post-1994. The PEDro quality scoring method was used to determine methodological quality on a scale of 0 to 10, with a score greater than five considered high quality and a score less than five low quality. Authors used either effect size (ES) or an outcome quality score of P<0.05 to determine the level of scientific evidence for the trials, ranging from strong, moderate, limited, or inconclusive evidence. The primary outcome measure included headache frequency, intensity, or duration. Fifty-five articles were cited, however, only six total articles met their eligibility criteria for final selection (11). The total number of subjects across all studies was 405.

The manual therapies evaluated in the studies included “spinal manipulation, classic massage, connective tissue manipulation, soft tissue massage, Dr. Cyriax’s vertebral mobilization, manual traction, and CV-4 craniosacral technique (12). The studies varied widely in the duration of intervention, from a single session to 6 weeks of therapy. “(mean=3.6+/- 1.9 weeks)…sessions ranged from 1 to 20 (mean = 11.6+/- 7.3) (13). Four of the six studies assessed a single intervention, the others used a combination of techniques. As a result of the mix of interventions, a meta-analysis could not be done. Different controls were used in each study, with variable follow-up periods ranging from immediately post-treatment to 6 months post- treatment. Some used medication groups as controls, others compared manipulation alone to a combination of manipulation with traction or massage or placebo laser, to neck exercises or to no treatment at all. Because so many types of treatments were considered, it is difficult to draw conclusions about any one type of intervention. The interventions are too heterogenous to draw a final conclusion about any one intervention.

The methodological quality of the studies reviewed was determined by use of PEDro scores, which ranged from 2-8 points (mean=5.8+/-2.1) (14). Four of the six trials reviewed scored from 6-8 points, and were therefore considered to be of high quality. The effect size (ES) could only be calculated in two trials. Effect sizes were reported as (0.3) on headache frequency and intensity values (0.49) on pressure pain threshold, and (0.1) on range of cervical motion for the Cyriax mobilization group (15). The craniosacral group has the largest ES (0.84) on pain outcomes relative to the control and exercise groups (16). The authors determined that the level of evidence for the value of spinal manipulation was inconclusive, based on the outcome of two high quality studies and one poor quality study, which had differing results. They found limited evidence for connective tissue massage and craniosacral therapy, since each had only one trial study performed. The authors concluded that due to the limited number of high quality studies on manual therapies, (RCTs) and the heterogeneity of the samples and techniques used, there is little evidence to support the use of manual therapy for tension headaches.

The authors determined that the reviewed studies were inconclusive in regard to the efficacy of manual therapies on headache for several reasons. The studies used different outcome measures, different manual techniques, and inconsistency in the design of the clinical trails. (Some assessors were not blinded, or did not use an intention-to-treat analysis) They suggest using other standard outcome measures such as the Pressure Pain Threshold, McGill Pain Questionnaire, or Neck Disability Index, to make the outcomes measures more homogenous (17).

Publication bias may be evident in this review, since only published English studies were considered, and mostly positive outcomes may be represented. The authors recommended that future studies of higher quality design with more homogenous subjects and interventions would better represent the outcomes of manual therapies for tension headaches.

I could use the results of Fernandez de las Penas’ review to consider the type of manual therapy I may use with this case study patient. They did remark that there if limited evidence for effectiveness of soft tissue manipulation for reducing headaches, and inconclusive findings for the use of manipulation. I utilize both treatments in my plan for headache reduction for my patient, with good results in pain reduction and lower duration of pain, and in the improved scores on the Neck Disability Index. Since the soft tissue intervention has low risk of side effects, (compared to medication or vertebral manipulation) I will continue to use it. I always use outcome measures in my practice, including those recommended by the authors, such as range of motion, Neck Disability Index, and the SF-36 questionnaires. When I note positive outcomes based on these objective measures, I continue to apply the manual therapy to get favorable results. Simply finding a lack of evidence in the literature to support manual therapy does not preclude its use in my practice. I find that using objective measures such as the Neck Disability Index and other standard outcome measures to assess the results of my interventions is superior to using literature review, because I can see the immediate and long term results with my patients on a one-to-one basis. I will use the literature as a guide to determine which interventions may be efficacious for a given problem, such as headaches (18-20). When I do not generate positive results within two to three visits, I will return to the literature to find alternative interventions. Since the research is constantly updated, I obtain the latest information directly in my e-mail from Medline. I recommend manual therapists learn know how to perform a literature review to locate recent studies which may prove beneficial in improving practice outcomes. By reviewing the research regularly, practitioners will find more high-quality evidence to use in clinical practice, in a reasonable period of time. Based on the studies reviewed here, more research is needed with better methodology to determine the optimal interventions for a given problem.

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Muscle Energy Makes Stretching Easy

As the population ages, more people present stiffness as a key component of their physical limitations. How do we meet the demand for improved functional mobility with these patients? To accomplish this goal, therapists must enhance their skills for improving mobility using evidence-based techniques. Muscle energy techniques (MET) are advocated as part of a treatment plan to reduce abnormal muscle tension and to improve functional mobility. MET is a versatile intervention that may be employed to treat patients with neuromusculoskeletal conditions accompanied by limited joint range of motion. MET was initially described within the osteopathic profession by Drs. T.J. Ruddy (1), and Fred Mitchell Sr (2). During the same period, Knott and Voss were developing the Proprioceptive Neuromuscular Facilitation (PNF) Technique in physical therapy (3). MET was later refined by Drs. Greenman (4), Lewit (5,6), Yale, Digiovanna (7), Stiles (1), and Goodridge (1). Modern MET has been incorporated into multiple disciplines, including physical and occupational therapy, massage, chiropractic and personal training with the work of McAtee and Charland’s active stretching (8) and Mattes’ Active Isolated Stretching (AIS) (1). Dr. Leon Chaitow presents a contemporary overview of MET in his text,Muscle Energy Techniques(1).

Clients often present with muscle spasm, painful trigger points, and limited range of motion. MET may be used to enhance outcomes of improved mobility and comfort for clients. Evidence based research indicates the value of MET in improving flexibility in clients of all ages, including rehab clients and the fragile elderly. Schiowitz reported that subjects with neck motion restrictions had a significant increase in cervical range of motion after treatment with MET, as compared to a sham control group (10). Wilson, Payton, and Donegan-Shoaf reported a significant improvement in function and decrease in disability in patients with low back pain treated with MET compared to those treated with traditional exercise and neuromuscular re-education alone (11). Contemporary muscle energy techniques are a part of interdisciplinary patient care, usually combined with manual therapy and exercise.

There are various stretching approaches described by MET practitioners. Each approach has its benefits. Most utilize the effect of post-isometric stretching, in which the involved short muscle (the agonist) is isometrically resisted, followed by passive or active stretching of the agonist by activation of the antagonist and/or passive movement by the practitioner. In PNF, this is known as contract-relax and hold-relax (1,3,8). Two types of MET have been described: post-isometric relaxation (PIR) (5,6) and reciprocal inhibition (RI) (1). In PIR, the short agonist muscle is activated with a gentle resisted isometric contraction for 2-10 seconds, followed by relaxation and passive stretching into the motion barrier within the tolerance of the client. The isometric contraction of the short agonist loads the proprioceptive Golgi Tendon Organ (GTO) within the agonist, causing a reflexive relaxation of the muscle. (GTOs inhibit contraction via the 1b afferent fibers to the spinal cord and efferent motor neuron.) After an active contraction, there is a short latency period within which the short agonist is inhibited. (In physiology, this is called the refractory period, which lasts about 15 seconds (1). Activation of the long antagonist also inhibits the short agonist by reciprocal inhibition, i.e.: when the flexors are activated, there is an automatic inhibition of the extensors by reflex action at the spinal cord level. It is useful to activate the antagonist during the stretch to take advantage of the relaxation response of reciprocal inhibition. Exhalation is often used during the stretching period to enhance the relaxation effect. If the client activates the long antagonist, the effect of the short agonist’s stretch reflex will also be reduced. The combination yields a significant increase in length of the agonist (10).

Key features of effective MET stretches are the use of precise control of the joint being moved, specific resistance intensity to avoid damaging the muscle being stretched, and accurate timing of the stretch to begin after the short muscle has relaxed. MET has been shown to be effective in reduction of hypertonicity, increased range of motion, and reduction in disability and pain (1).

The literature reflects that experts use different variations of MET. McAtee and Charland described the use of strong resisted isometric contractions, followed by active stretching by the client, typically in diagonal patterns (8). One must be cautious when using strong contractions to avoid damaging to the muscle, especially after an injury. Gentler contraction forces are considered safer (1). PNF uses varying intensities of contraction followed by passive or assisted stretching, using both diagonal and straight arc patterns of motion (3,8). AIS uses breathing with repeated (1-2 seconds) isotonic contractions of the antagonist followed by patient-assisted stretching, exhaling while moving the joint through the barrier for 1-2 seconds and returning to neutral (1). Caution must be used to avoid stretching too rapidly when using short duration contractions in severely involved individuals. Drs. Goodridge and Kuchera recommend using low intensity isometric contraction followed by passive stretching to minimize muscle guarding and delayed onset muscle soreness (1). Each practitioner must determine the best method for their client based on the clinical presentation, type of restriction, tolerance of the client and desired outcome. With muscle guarding, simple PIR is effective to reduce contractile hypertonicity. With myofascial restrictions, additional passive stretching through the motion barrier is used and held for 90 seconds to allow the fasciae to lengthen. In most cases, forceful or ballistic stretching is avoided to reduce the incidence of microtrauma in the involved muscle.

To summarize, the steps to perform basic post-isometric relaxation MET with reciprocal inhibition are as follows:
1. Position short muscle into a stretch or point of motion barrier
2. Ask client to use 20%-50% intensity isometric contraction of the short muscle against your resistance 
3. Hold isometric contraction 3-10 secs. with a brief rest period of 2-3 secs.
4. Provide passive or active assistive stretch a bit beyond the resistance barrier within the tolerance of the client. 
5. Practitioner may then ask client to activate the antagonist to move beyond the barrier into the greater range of motion.
6. Perform 3-5 repetitions of the activity and reassess the range of motion, pain level, and function.

Case Report: Maggie is a 57 year old female school teacher with a diagnosis of plantar fasciitis and Achilles tendinitis onset 2 weeks ago due to walking in a fundraiser for 5 miles. (She is used to walking up to one mile daily, but does no other exercise.) She complains of pain upon weight-bearing on both feet, especially after prolonged sitting and upon awakening. Pain decreases once she is walking for 20 mins. She has custom orthotics for pronated feet, which she wears regularly. She is taking ibuprofen 400mg. for pain. Palpation reveals trigger points on both gastrocnemius heads bilaterally, calcaneii and plantar fascia, pain scale 8/10. Range of motion (ROM) is limited in ankle dorsiflexion from 0-10 degrees. Muscle strength is 3+/5 is bilateral plantarflexors. Gait is short in step length with early heel rise. Intervention consisted of myofascial release, massage and manual therapy to both feet and lower legs to improve circulation and relax musculature, muscle energy (contract-relax/PIR) to each gastroc/soleus complex 5 reps followed by full passive stretch with and without extended knees to increase ROM. ROM increased by 7 degrees in ankle dorsiflexion, pain reduced to 2/10 post-intervention. Outcomes were favorable on this initial visit. Client was instructed in home stretching and conditioning program and self-massage. Therapy will continue twice weekly for 3 weeks to achieve full ROM, normal strength, equal step length, and painfree feet.

Note: MET may result in some delayed onset muscle soreness (DOMS). Modify the force and position for each client based on their individual response. Clients may be instructed in the use of ice to diminish DOMS. Practitioners may teach clients to perform their own home programs of MET stretches. There are strengthening programs using MET as well as joint mobilization techniques using MET. For more information on MET, review the references and websites provided at the end of this article. Chaitow offers the most comprehensive review of MET, including techniques which one may apply in practice. Review references by Drs. Fred Mitchell, Ed Stiles, Eileen DiGiovanna, and Stanley Schiowitz, and McAtee and Mattes for additional uses of MET. Live seminars and home study programs are also available. The versatility and clinical efficacy of MET makes it a valuable addition to rehabilitation programs for clients with neuromusculoskeletal conditions across the lifespan. Learn to master these skills to make stretching easy and improve outcomes for your practice.

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