1. Muscular ischemic compression vs
Muscular ischemic compression vs. cervical spine manipulation techniques: effects on pressure pain threshold in the trapezius muscle
M. Gazin DO MROF
R. Zegarra-Parodi DO MROF

2. Introduction Myofascial trigger point (MTP): a clinical entity
55% of neck pain and headaches
More frequently women, patients from 30 to 49 years old
Treating MTP
Iatrogenic effects of cervical spine HVLA
Neurovascular accidents (1/200,000 to 1/1 Million)
Side-effets (7%)
Local and distant manual techniques based on different theoretical physiological mechanisms
Simons et al., 1999
Fernández de las Peñas et al, 2005
Gun, 1997 2

3. Purpose
Compare short-term pain effects of two manual techniques, each with differing benefits and risks
C3/C4 HVLA technique vs. ischemic compression technique on the trapezius muscle MTP 3

4. Study design Clinical study, approved by CEESO Ethics Committee
October 2008 to January 2009
81 subjects included
Criteria for inclusion
Criteria for non-inclusion
Criteria for exclusion
Randomisation
HVLA
group
Ischemic group
Placebo group
Number 26 29
Gender (male/female)
14/12
11/18
11/15
Mean age (SD)
21(2)
22(3)
22(4) 4

5. Diagnostic criteria Trapezius muscle MTP, Simons et al, 1999
Palpable taut band
Hypersensitive tender spot
Local twitch response
Referred pain pattern
Somatic dysfunction C3/C4
Restriction of passive mobility
Pain spontaneous or induced by palpation
Bone asymmetry
Soft tissue changes

6. Methods Pressure pain threshold assessment, Fischer, 1990
Definition
Algometer
Two trained students as practitioners
In 5th year of osteopathy
With two years of experience in the clinical department

7. Methods Techniques Statistical analysis HVLA Ischemic compression Sham
Distribution: Agostino and Pearson Test
For each group: ANOVA Test / Bonferroni Post Test
Comparison of groups: Kruskal Wallis Test

8. Results
Pressure pain threshold in the upper trapezius muscle during the study in both groups
HVLA
group (n= 26)
Ischemic group (n= 29)
Sham
group (n=26) t0
1.72 ± 0,46
1.59 ± 0,41
1.44 ± 0,32
t+1
1.94 ± 0,62
1.69 ± 0,50
1.61 ± 0,46
t+5
2.09 ± 0,70
1.71 ± 0,61
1.66 ± 0,52
t+15
2.03 ± 0,60
1.80 ± 0,64
1.66 ± 0,58
ANOVA p= p=
p= 0.003
Post test
t0/t+1 *
t0/t+5 * * *
t0/t+15 * *
t0/t+1 ns
t0/t+5 ns
t0/t+15 *
t0/t+5 * *
Values expressed as mean ± SD (kg/cm²)
ns = not significant, * for p≤0.05, ** for p≤0.001, *** for p≤0.0001

9. Results

10. Results
Average of the variations of the pressure pain threshold before and after technique at different time
HVLA
group
Ischemic group
Sham
Kruskal Wallis test
t0/t+1
 -0.22 (-0.43)
-0.08 (-0.33)
-0.17 (-0.32)
p= 0.59
t0/t+5
-0.36 (-0.5)
-0.1 (-0.41)
-0.22 (-0.34)
p= 0.07
t0/t+15
-0.30 (-0.46)  
-0.21 (-0.47)
-0.22 (-0.4)
p=0.77
Values expressed as mean ± SD (kg/cm²)

11. Discussion First study comparing these two techniques
Influence of techniques on pressure pain threshold
HVLA technique: Ruiz-Sáez et al, 2007
Ischemic compression technique:
Fernández de las Peñas et al, 2006
Dearing et al, 2006
Hodgson et al, 2006
Gemmell et al, 2008
Latency of action:
Ischemic compression vs. HVLA technique

12. Discussion
Distant nervous system disturbance; effects of manual technique on central and peripheral nervous system
McPartland, 2004
Graff, 2004
Butler, 2000
Quintner et al, 1994

13. Discussion
Risk/ benefit ratio for MTP treatment is in favour of ischemic compression
Ethical: contraindication
Legal: France’s case
Practitioner skills

14. Discussion Limitations of this study Future study Source of subjects
Sham group
Future study
Subjects from general public
Symptomatic subjects
Long-term evaluation of pain threshold, Rickards, 2006

15. Conclusion Results of these two techniques vs. sham not significant
Cervical HVLA technique equally effective as ischemic compression for MTP pain threshold, but risk / benefit ratio in favour of ischemic compression technique
Significant pain threshold improvement from manual techniques with differing physiological mechanisms

16. Acknowledgements The CEESO Paris clinic and students
Rafael Zegarra-Parodi and the CEESO Research Department for their support with my current research

17. Thank you for your attention