Posts tagged physical thearpy
Individualized Physical Therapy Saves Money Compared to Usual Care for Low Back Pain
low-back-pain-cost-PT-savings

As healthcare costs continue to rise, all stakeholders (patients, providers, and payers) are looking for ways to reduce costs associated with common conditions.  In our field, we see patients given generic, one size fits all exercise programs for common conditions including low back pain.  Our previous post highlights the limitations of this approach including providing incorrect, inadequate, and sometimes harmful exercises to patients without a proper Physical Therapy examination first.  In addition, patients provided these incomplete, generic exercise programs will often spend additional healthcare resources in the coming months looking for relief of their symptoms.  

A recent research article in the journal Spine compared the effectiveness of individualized Physical Therapy services to guideline based advice for patients with low back pain. (Hahne et al. 2016).  300 patients were randomized to one of the two groups then were followed for 1 year to determine the effectiveness and cost of each treatment group.  Patients treated with Physical Therapy reported higher levels of health benefits at a lower cost than the guidelines group.  Specifically, patients missed fewer work days at a savings of close to $2,000 per worker.  This study adds to the existing data on the importance of individualized Physical Therapy for patients with low back pain.  

Resolution of Lumbar Disk Herniation Without Surgery

Physical Therapy remains the first line treatment for lumbar disk injuries due to its' non invasive nature and clinical effectiveness.  The natural history of disk injuries is not well established but preliminary data covered in prior blog posts demonstrates regression of these injuries over time.  A recent case study in the New England Journal of Medicine (Hong et al. 2016) described the case of a 29 year old female with pain and pins and needles into her leg.  Her MRI is shown above on the left side of the screen.  The patient did not want surgery and was instead treated with an injection and Physical Therapy.  After 5 months a second MRI was taken, shown on the right, showing resolution of the disk injury. 

This case adds evidence to the regression and resolution of disk injuries over time with conservative care.  Patients are advised to seek care from a local Physical Therapist before attempting more invasive and costly procedures.

What Happens to Athletes after ACL Reconstruction

Up to 250,000 athletes will sustain an ACL injury each year and the majority of these patients will require Physical Therapy before and/or after their ACL reconstruction surgery.  These athletes may be at risk of future lower extremity injuries either on their involved or uninvolved lower extremity because of inadequate physical therapy, poor movement patterns, and psychological factors including fear of re injury or decreased confidence in their knee.  Strength, balance, and movement impairments up to a year after surgery.  We know athletes like Adrian Peterson below can have MVP season after ACL injury but, the literature was thin on long term outcomes following ACL reconstruction.

A recent article in the American Journal of Sports Medicine followed patients status post ACL reconstruction using their own knee tendons, Bone Patellar Bone, as grafts (Thompson et al. 2015).  A total of 90 patients were followed up to 20 years after their initial ACL repair surgery to determine their future injuries, return to play, and overall function.  32/90 patients sustained another ACL injury either on the involved or uninvolved side by the 20 year follow up.  Surprisingly, the vast majority of these occurred in the non involved limb indicating the risk factors for future injury may be related to altered nervous system function including balance and coordination deficits.  The greatest risk of non involved ACL injury occurred in those younger than 18 at the time of their first injury.  

9% of patients sustained a tear of their reconstructed knee.  The greatest predictors of injury to the graft site included smaller graft angle.  Females, at greater risk for an initial ACL injury, had a lower re injury rate, lower subjective confidence and functional scores, and decreased participation in higher level activities compared to males.  This lower rate of participation in strenuous activities may have placed the graft at a lower risk leading to lower rates of injury.  

In those without subsequent knee injuries, their functional outcomes remained relatively high as seen below.  Prior research has demonstrated patients with or without ACL repair after ACL injury will develop osteoarthritic changes in their knee.  In this sample of patients, 61% demonstrated some bone and cartilage changes on x ray but many of these patients denied pain or osteoarthritic symptoms.  Thus, more evidence of positive findings on imaging within an asymptomatic population.   

Boulder physical therapy, ACL injury, recovery

In short, this study is a great long term study on patients status post ACL reconstruction.  The high rates of re injury especially in the non involved leg indicate a need for further training and physical therapy interventions.  This will treat residual impairments including balance, coordination, and agility allowing patients to function at the highest level of sport possible without increased risk of injury.  

How Important is Imaging for Tendon Pain and Injury?

Our prior posts on tendon injuries have described the structural changes that take place with chronic symptomatic tendinopathies.  The disorganization of tendon fibers and the body's attempts to heal the injured tendon are best viewed on ultrasound or MRI imaging.  MRI is a very sensitive tool, but lacks specificity meaning a positive finding may or may not be contributing to a patient's presentation and symptoms.  Further, we often see positive findings in asymptomatic individuals.  Rio et al. described the presence of positive findings (tendinosis) in asymptomatic and active individuals and also the lack of impact of some findings on a patient's presentation (Sports Med. 2014).  The MRI and ultrasound images document both normal and abnormal imaging findings.  Images courtesy of Docking et al. JOSPT. 2015.

achilles tendon, ultrasound, boulder physical therapy
abnormal achilles tendon, MRI, boulder physical therapy

In the pictures above, we can observe healthy tendon alignment primarily in parallel to resist and absorb tensile forces across the ankle joint, as well as, a high water and protein content reducing friction through the tendon.  Conversely, a tendon with features of tendinosis demonstrates a disorganized tendon structure where tendon cells (tenocytes) are in higher numbers and have a more rounded appearance.  This appearance makes the tendon less resisted to traditional tensile forces since the tendon is not arranged in a parallel alignment.  Finally, there is an ingrowth of nerve fibers and blood vessels which likely contribute to the increased pain and symptoms noted in the achilles as well as in other structures within the body (central sensitization).  If a tendinosis progresses in nature, partial tears in the tendon can also be noted on MRI.  The accuracy of these changes on MRI explaining a patient's symptoms is described as diagnostic utility.  

MRI and ultrasounds greatest limitation on accuracy may be the lack of agreed upon gold standard in the literature.  In a review of the literature Docking et al. reports the specificity for diagnosis with MRI (.68-.70) and ultrasound (.63-.83) for tendinopathies.  Up to 59% of asymptomatic individuals will document some change within the tendon on imaging.  These numbers show a degree of false positives making the clinical examination an essential part of any clinical diagnosis.   This is consistent with the majority of musculoskeletal problems.  If we rely solely on the MRI findings we run the risk of being incorrect in both our diagnosis and treatment.  This will lead to higher healthcare costs and a longer duration of care for the patient.

In short, imaging can be a helpful component of our clinical diagnosis but only if we can use our subjective and objective examination to distinguish between asymptomatic tendinosis or symptomatic tendinopathy.  In addition, an image rarely is helpful in determining how to use manual therapy and exercise to appropriately treat the patient.  

 

 

 

 

Knee Pain and Physical Therapy Treatments
knee pain, physical therapy treatments, boulder physical therapy

Knee Pain Background

Anterior knee pain is a term used to encompass many conditions affecting structures of the knee. The majority of these cases can be attributed to patellofemoral pain syndrome (PFPS) or an abnormal tracking of the patella on the femoral groove secondary to changes in lower extremity alignment, muscle imbalance, or training errors (2).

PFPS is the most common LE condition seen in orthopedic practice and the most common overuse injury in the active population24 attributed to 25-40% of all knee problems in sports medicine centers and 25% of all injuries in runners (1).

PFPS is more common in females who are 2.2 times more likely to experience PFPS than males (3).

The diagnosis of PFPS can be elusive, but recent evidence suggests our strongest diagnostic test is resisted MMT of the quad (+ Likelihood ratio (LR) 2.2), but 2 of 3 positive tests within a cluster (pain with quad contraction, pain with squatting, and pain with palpation) demonstrated a (+) LR of 4.0 (7).

In addition, the eccentric step down test (+ LR 2.34, - LR .70) offers value for differential diagnosis and identifying precipitating or perpetuating impairments (20). 

Physical Therapy Treatments 

Conservative treatment remains the standard of care for PFPS with recommendations from the medical literature including relative rest (decrease aggravating activities), activity modification (shoes, terrain, training volume), and control of the inflammatory process (2).  Authors note good, consistent, high-quality evidence supports Physical Therapy interventions for early management of PFPS.  Authors recommend individualized rehabilitation programs aimed at reducing forces crossing the patellofemoral joint (2).  Physical Therapists may implement interventions tailored to a patient’s specific symptoms including manual therapy, therapeutic exercise, proprioception training, taping, and orthoses. 

Conservative treatment remains the standard of care for PFPS with recommendations from the medical literature including relative rest (decrease aggravating activities), activity modification (shoes, terrain, training volume), and control of the inflammatory process (2).

Authors note good, consistent, high-quality evidence supports Physical Therapy interventions for early management of PFPS.

Authors recommend individualized rehabilitation programs aimed at reducing forces crossing the patellofemoral joint (2).

Physical Therapists may implement interventions tailored to a patient’s specific symptoms including manual therapy, therapeutic exercise, proprioception training, taping, and orthoses. 

Medical Evidence Supporting PT Interventions

Manual Therapy: A recent literature review found level B evidence for the utilization of manual therapy on the lower quarter in patients with PFPS (4).

Crossley demonstrated improved stair climbing function following manual therapy to the patellofemoral and tibiofemoral joints (9).

An immediate decrease in quadriceps inhibition following lumbo- pelvic manipulation has been shown in patients with PFPS (25, 26).

Further, Iverson, et al. demonstrated a >50% reduction in pain with functional activities following lumbopelvic manipulation in a subgroup patients with PFPS. One variable associated with success included a side to side difference in hip IR >16 degrees which improves the probability of success from 45% to 80% (+ LR 4.6) (15).

Recently Lowry et al. demonstrated improvements in pain and disability utilizing manual therapy to the lower quarter, exercise, orthotics and taping in a series of patients with PFPS (17).

Exercise: Herrington examined the benefits of open chain compared to closed chain strengthening in patients with PFPS. Both groups improved short term strength and function, but no statistical differences were found between groups (13)

A recent randomized, controlled trial demonstrated improved pain and function in a group of females with PFPS performing knee and hip strengthening compared to a knee strengthening and a control group (11).

Mascal et al. demonstrated improved pain and function in two females with PFPS utilizing a proximal and distal lower quarter strengthening program (18).

Clark et al. examined the efficacy of the individual components of physiotherapy in subjects with anterior knee pain. Patients who were in a group that included exercise were significantly more likely to be discharged at three months than non- exercising patients (5).

Taping: Patellar taping produces a clinically meaningful change in chronic knee pain, but conflicting results indicates a subgroup of patients may be most appropriate for this intervention (29).

Lescher, et al. developed a clinical prediction rule to determine which patients with PFPS would be most likely to benefit frompatellar taping. Two variables, (+) patellar tilt test and >5 degree tibia varum, increased the probability of success from 52 to 83% (16).

Derasari, et al. documented an inferior glide of patella produced through taping increased patellofemoral joint surface contact area and reduced pressure across the joint during functional activities in patients with chronic PFPS (9).

physical therapy exercise, knee pain

Orthoses: PFPS has been associated with altered foot positioning which can alter mechanics at the knee leading to increased pain with activity. Orthotics have been shown to be effective at improving foot positioning and reducing knee pain in the short term (19).

A randomized study evaluating the effects of custom orthotics for knee pain found custom orthotics were effective at decreasing knee pain and improving running tolerance (14). 

Foot orthotics were not superior to physical therapy management, nor was there any additional improvement by adding orthotics to a physical therapy programs (6).

A recent systematic review supported the use of foot orthoses to prevent a first episode of overuse conditions and demonstrated no difference between custom and prefabricated foot orthoses. Evidence was insufficient to recommend foot orthoses for the treatment of lower limb overuse conditions (23).

When To Seek Physical Therapy Care

Patients with anterior knee pain demonstrate improvements in pain and disability when referred to a licensed Physical Therapist with advanced training in manual therapy and exercise prescription.

 References

1. Bizzini, M. et al. A systematic review of the quality of randomized controlled trials for patellofemoral pain syndrome. JOSPT. 2003; 33(1):4-20.

2. Bolgla, L. et al. An update for the conservative management of patellofemoral pain syndrome: A systematic review of the literature. The International Journal of Sports Physical Therapy. 2011; 6(2):112-125.

3. Boling, M. Gender differences in the incidence and prevalence of patellofemoral pain syndrome. Scand J Med Sci Sports. 2010; 20(5):720-725.

4. Brantingham, J. Manipulative therapy for lower extremity conditions. Expansion of literature review. Journal of Manipulative and Physiological Therapeutics. 2009; 32(1):53-71.

5. Clark D, Downing N, Mitchell J, et al. Physiotherapy for anterior knee pain: a randomized controlled trial. Ann Rheum Dis. 2000; 59: 700-704.

6. Collins N, Crossley K, Beller E, Darnell R, McPoil T, Vicenzino B, et al. Foot orthoses and physiotherapy in the treatment of patellofemoral pain syndrome: randomised clinical trial. Br J Sports Med 2009; 43(3):163-168.

7. Cook, C. et al. Best tests/clinical findings for screening and diagnosis of patellofemoral pain syndrome: a systematic review. Physiotherapy. 2011; 1-8.

8. Creighton, D. et al. Use of Anterior Tibial Translation in the Management of Patellofemoral Pain Syndrome in Older Patients: A Case Series. J Man Manip Ther. 2007; 15(4): 216–224

9. Crossley, K. et al. Physical Therapy improves knee flexion during stair ambulation in patellofemoral pain. Med Sci Sp Ex. 2005; 37:176-183.

10. Derasari A, et al. McConnell taping shifts the patella inferiorly in patients with patellofemoral pain: a dynamic magnetic resonance imaging study. Phys Ther. 2010; 90(3):411-419.

11. Fukuda, T. et al. Short-Term Effects of Hip Abductors and Lateral Rotators Strengthening in Females With Patellofemoral Pain Syndrome: A Randomized Controlled Clinical Trial. JOSPT. 2010; 40(11):736-742

12. Gross MT, Foxworth JL. The role of foot orthoses as an intervention for patellofemoral pain. JOSPT. 2003; 33:661-670.

13. Herrington L, Al-Sherhi A. A controlled trial of weight-bearing versus non-weight-bearing exercises for patellofemoral pain. JOSPT. 2007; 37:155-160.

14. Hirschmuller A, Baur H, Muller S, Helwig P, Dickhuth HH, Mayer F, et al. Clinical effectiveness of customised sport shoe orthoses for overuse injuries in runners: a randomised controlled study. Br J Sports Med 2011; 45(12):959- 965

15. Iverson CA, et al. Lumbopelvic manipulation for the treatment of patients with patellofemoral pain syndrome: development of a clinical prediction rule. JOSPT. 2008; 38:297-309.

16. Lesher J, et al. A clinical prediction rule for classifying patients with patellofemoral pain syndrome who respond to patellar taping. J Orthop Sports Phys Ther. 2006; 36:854-866.

17. Lowry, C. et al. Management of Patients With Patellofemoral Pain Syndrome Using a Multimodal Approach: A Case Series. JOSPT. 2008; 38(11):691-702

18. Mascal CL, Landel R, Powers C. Management of patellofemoral pain targeting hip, pelvis, and trunk muscle function: 2 case reports. JOSPT. 2003; 33:647-660.

19. Munuera PV, Mazoteras-Pardo R. Benefits of custom-made foot orthoses in treating patellofemoral pain. Prosthet Orthot Int 2011; 35(4):342-349.

20. Nijs, J. et al. Diagnostic value of five clinical tests in patellofemoral pain syndrome. Man Ther. 2006; 11:69-77

21. Powers, C. et al. Patellofemoral kinematics during weight-bearing and non-weight- bearing knee extension in persons with lateral subluxation of the patella: a preliminary study. JOSPT. 2003; 33:677-685.

22. Rabin, A. et al. Measures of Range of Motion and Strength Among Healthy Women With Differing Quality of Lower Extremity Movement During the Lateral Step-Down Test. JOSPT. 2010; 40(12):792-800

23. Souza, R. et al. Differences in Hip Kinematics, Muscle Strength, and Muscle Activation Between Subjects With and Without Patellofemoral Pain. JOSPT. 2009; 39(1):12-19.

24. Suter, E. et al. Conservative lower back treatment reduces inhibition in knee extensor muscles: a randomized controlled trial. J Manipulative Physiol Ther. 2000; 23:76-80.

25. Suter, E. et al. Decrease in quadriceps inhibition after sacroiliac joint manipulation in patients with anterior knee pain. J Manipulative Physiol Ther. 1999; 22:149-153.

26. Taunton, J. et al. A retrospective case control analysis of 2002 running injuries. Br J Sports Med 2002; 36:95-101.

27. Tiggelen D.V. et al. Effect of bracing on the prevention of anterior knee pain – a prospective randomized study.

28. Warden S. J. et al. Patellar taping and bracing for the Treatment of Chronic Knee Pain: A Systematic review and Meta-Analysis. Arthritis and Rheumatology(Arthritis Care & Research). Vol. 59, NO.1, January 15, 2008, pp73-83. DOI 10, 1002/art.23242. 2008 American College of Rheumatology.

29. Wilk KE, George JD, Mangine RE and Malone TR. Patellofemoral disorders: A classification system and clinical guidelines for nonoperative rehabilitation. Journal of Ortho and Sports Phys Ther. 1998; 28(5): 307-322.

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Neck Pain and Physical Therapy Treatments
neck pain, physical therapy, treatment

Neck Pain Background Information

Neck pain affects 10-15% of the population at any one time, with a lifetime incidence of 22-70% (1). Only 6% of patients with neck pain report resolution of symptoms at one year (2).

A recent systematic review demonstrated the prognosis from idiopathic neck pain is poor (3) and 50-75% of patients with neck pain will report symptoms at 1 and 5 year follow up (4).

Evidence suggests the utilization of manual therapy and exercise is a more cost effective intervention compared to primary care management alone or standard physical therapy (see graph). (5)

Our effectiveness in treating patients increases as we match interventions to a patient’s signs and symptoms. Evidence suggests outcomes are improved by correctly matching each Physical Therapy intervention to a specific patient category see below.(6)

Patients with mechanical neck pain, cervical radiculopathy, and cervicogenic headaches can benefit from Physical Therapy interventions including manual therapy and exercise to reduce pain and improve disability. 

neck pain costs, manual therapy, boulder physical therapy

Physical Therapy Interventions for Neck Pain

Exercise and Conditioning

Physical Therapy strengthening, neck pain

Patients within this category may display lower pain and disability levels and report a longer duration of symptoms.

Exercises will aim to improve muscle function within the deep cervical flexors and scapular muscles.

A recent systematic review provided Level 1 evidence on the benefits of exercise for patients with mechanical neck pain.(7)

Strong evidence supports the utilization of proprioception and strengthening exercises for patients with recurrent or chronic neck pain.(8)

Headaches

A recent Cochrane review documented the improved effectiveness of manual therapy and exercise over manual therapy alone in patients with neck pain with or without headaches.(10)

Authors report the benefit of cervical manipulation on reducing head- ache intensity and frequency in patients with headache.(9)

The utilization of manual therapy and cervical strengthening has been show to reduce pain, disability, and headaches over both the short and long term (see graph) (11). 

headache, neck pain, boulder physical therapy treatments

Neck and Arm Pain/Cervical Radiculopathy

Centralization

Patients within this category include those who have signs and symptoms of nerve root impingement or radicular symptoms.

Studies demonstrate 26% of patients with cervical radiculopathy who undergo surgery continue to experience high levels of pain at a 1-year follow-up.(12) Studies also suggest that patient outcomes may be superior with conservative management versus surgical interventions.(13, 14)

Physical therapy interventions consisting of manual therapy (17), cervical traction (15, 16), and cervical centralization exercises have been shown to decrease pain and improve function in this population.

Recently authors reported 91% of patients with cervical radiculopathy who underwent treatment of manual physical therapy, cervical traction and strengthening exercises showed significant functional improvement. (17). 

neck and arm pain, boulder physical therapy treatments, centralization

Pain Control

This subgroup comprises patients with acute or traumatic onset of neck pain, including whiplash injury, and those presenting with high levels of pain and disability.

Physical therapy interventions for this category aim to decrease pain and allow transition into other subgroups for treatment to reduce disability.

Evidence suggests utilization of thoracic spine manipulation18, cervical spine mobilizations19, neck active ROM exercises20, gentle soft tissue massage(21), and physical modalities such as TENS (22).

Interventions matched to patient’s signs and symptoms within the category demonstrate greater changes in pain and disability than unmatched interventions (6). 

Mobility

neck pain, mobility, boulder physical therapy treatments

Patients within this group include those with symptoms proximal to the elbow, an acute onset (<30 days), and are younger than 60 years old.(6)

Evidence supports the utilization of both cervical and thoracic mobilization/manipulation, with exercise, to restore mobility, decrease pain, and improve function. (1, 22, 23)

Utilization of manual therapy can reduce long term management costs by as much as 2/3 in comparison with exercises or medical management alone. (24) 

References

Childs, J. Cleland, J. et al. Neck Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health From the Orthopaedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther 2008;38(9):A1-A34.

Picavet HS, Schouten JS. Musculoskeletal pain in the Netherlands: prevalences, consequences and risk groups, the DMC(3)-study. Pain. 2003;102:167-178.

Hush JM, Lin CC, Michaleff ZA, Verhagen A, Refshauge KM. Prognosis of acute idiopathic neck pain is poor: a systematic review and meta-analysis. Arch Phys Med Rehabil 2011;92:824-9

Carroll L. Hogg-Johnson, S. et al. Course and Prognostic Factors for Neck Pain in the General Population. Spine. 2008;33(4):S75–S82.

Korthals-de Bos IB, Hoving JL, van Tulder MW, et al. Cost effectiveness of physiotherapy, manual therapy, and general practitioner care for neck pain: economic evaluation alongside a randomized controlled trial. BMJ. 2003.

Fritz JM, Brennan GP. Preliminary examination of a proposed treatment-based classification system for patients receiving physical therapy interventions for neck pain. Phys Ther. 2007;87:513–524.

Kay, T. Gross, A. et al. Exercises for mechanical neck disorders. Cochrane Database of Systematic Reviews. 2005. CD004250.

Sarig-Bahat, H. Evidence for exercise therapy in mechanical neck disorders. Manual Therapy. 2003;8:10-20.

Nilsson, N. Christensen, J. et al. The effect of cervical manipulation on cervicogenic headache. J Manip Phys Ther. 1997;20:326-330.

10. Gross, A. Hoving, J. et al. A Cochrane Review of Manipulation and Mobilization for Mechanical Neck Pain. Spine 2004;29:1541–1548

11. Jull, G. Trott, P. et al. A Randomized Controlled Trial of Exercise and Manipulative Therapy for Cervicogenic Headache. Spine. 2002;27(17):1835–1843

12. Heckmann JG, Lang CJ, Zobelein I, Laumer R, Druschky A, Neundorfer B. Herniated cervical intervertebral discs with radiculopa- thy: an outcome study of conservatively or surgically treated patients. J Spinal Disord. 1999;12:396-401.

13. Honet JC, Puri K. Cervical radiculitis: treatment and results in 82 patients. Arch Phys Med Rehabil. 1976;57:12-16.

14. Sampath P, Bendebba M, Davis JD, Ducker T. Outcome in patients with cervical radiculopathy. Prospective, multicenter study with independent clinical review. Spine. 1999;24:591-597.

15. Graham N, Gross AR, Goldsmith C. Mechanical traction for mechanical neck disorders: a systematic review. J Rehabil Med. 2006;38:145-152.

16. Moeti P, Marchetti G. Clinical outcome from mechanical intermittent cervical traction for the treatment of cervical radiculopathy: a case series. J Orthop Sports Phys Ther. 2001;31:207-213.

17. Cleland, J; Whitman, J; Fritz, J; Palmer, J. Manual Physical Therapy, Cervical Traction and Strengthening Exercises in Patients with Cervical Radiculopathy: A Case Series. J Orthop Sports Phys Ther. 2005:35(12):802-809.

18. Gonzalez-Iglesias, J., Fernandez-de-las-Penas, C., Cleland, J., & Gutierrez-Vega, M. (2009). Thoracic spine manipulation for the

management of patients with neck pain: a randomized clinical trial. Journal of Orthopaedic & Sports Physical Therapy, 39(1), 20-27.

19. Conlin A, Bhogal S, Sequeira K, Teasell R. Treatment of whiplash- associated disorders, part I: non-invasive interventions. Pain Res Manag. 2005;10:21-32.

20. Rosenfeld M, Gunnarsson R, Borenstein P. Early intervention in whiplash-associated disorders: a comparison of two treatment protocols. Spine. 2000;25:1782-1787.

21. Skyba D, Radhakrishnan R, Rohlwing J. Joint manipulation reduces hyperalgesia by activation of monoamine receptors but not opioid or GABA receptors in the spinal cord. Pain 2003;106:159e68.

22. Cassidy, J.D., Lopes, A.A., Young-Hing, K. The immediate effect of manipulation vs mobilization on pain and range of motion in the cervical spine: a randomized control trial. Journal of Manipulative and Physiological Therapeutics. 1992. 15:9.

23. Cleland, J.A., Mintken, P.E., Carpenter, K., Fritz, J.M., Glynn, P., Whitman, J., Childs, J. Examination of a clinical prediction rule to identify patients with neck pain likely to benefit from thoracic spine thrust manipulation and a generally cervical range of motion exercise: multi-center randomized control trial. Physical Therapy. 2010. 90: 9.

24. Ingeborg, B.C., Korthals-de Bos, Hoving, J.L., Tulder, M.W., Rutten-van Molken, M., Ader, H.J., CW de Vet, H., Koes, B.W., Vondelling, K., Bouter, L.M. Cost effectiveness of physiotherapy, manual therapy, and general practicioner care for neck pain: economic evaluation alongside a randomized control trial. British Medical Journal. 2003. 326:911