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

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

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

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

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

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

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

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= 0.0006 p= 0.0353 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

Results

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)

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

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

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

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

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

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

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