Paraspinal cutaneous temperature modification after spinal manipulation at L5. Sympathetic nervous system effects in the hands following a grade III postero-anterior rotatory mobilisation technique applied to T4: a randomised, placebo-controlled trial. How much loss to follow-up is acceptable in long-term randomised trials and prospective studies? A preliminary investigation into the magnitude of effect of lumbar extension exercises and a segmental rotatory manipulation on sympathetic nervous system activity. A preliminary investigation into the relationship between cervical snags and sympathetic nervous system activity in the upper limbs of an asymptomatic population. To compare the effects of different rates of application of a cervical mobilisation technique on sympathetic outflow to the upper limb in normal subjects. Investigation of the effects of a centrally applied lumbar sustained natural apophyseal glide mobilization on lower limb sympathetic nervous system activity in asymptomatic subjects. Hypoalgesic and sympathoexcitatory effects of mobilization with movement for lateral epicondylalgia. The effects of a modified spinal mobilisation with leg movement (SMWLM) technique on sympathetic outflow to the lower limbs. Use of high and low velocity cervical manipulative therapy procedures by Australian manipulative physiotherapists. An investigation into the effects of a unilaterally applied lumbar mobilisation technique on peripheral sympathetic nervous system activity in the lower limbs. Effects of a manually assisted mechanical force on cutaneous temperature. Does Mobilization of the Upper Cervical Spine Affect Pain Sensitivity and Autonomic Nervous System Function in Patients With Cervico-craniofacial Pain?: A Randomized-controlled Trial Changes in biochemical markers of pain perception and stress response after spinal manipulation. Immediate effects of spinal manipulation on nitric oxide, substance P and pain perception. Additional Effect of Static Ultrasound and Diadynamic Currents on Myofascial Trigger Points in a Manual Therapy Program for Patients With Chronic Neck Pain: A Randomized Clinical Trial Cervical mobilisation: concurrent effects on pain, sympathetic nervous system activity and motor activity. Naloxone fails to antagonize initial hypoalgesic effect of a manual therapy treatment for lateral epicondylalgia. An investigation of the interrelationship between manipulative therapy-induced hypoalgesia and sympathoexcitation. A randomised, independent groups study investigating the sympathetic nervous system responses to two manual therapy treatments in patients with LBP. An investigation into the effects of applying a lumbar Maitland mobilisation at different frequencies on sympathetic nervous system activity levels in the lower limb.
OBJECTIVE The purpose of this study was to investigate local paraspinal cutaneous temperature ( CT ) modifications after spinal manipulative therapy at L5 . METHODS Twenty subjects with acute low back symptoms were r and omly assigned to either a treatment or a sham group ( n = 10 per group ) . Subjects underwent an 8-minute acclimatizing period . Temperature was measured bilaterally with infrared cameras at the L5 level . In the treatment group , a traditional chiropractic manipulation ( lumbar roll technique with a pisiform contact on the ipsilateral mamillary of L5 ) was delivered , whereas with the sham group , the same technique was used , but no thrust was applied . Cutaneous temperature control measurements were taken 2 minutes before ( t(-2 ) ) and immediately after the intervention ( t(0 ) ) and at 1 , 3 , 5 , and 10 minutes postintervention ( t(1 ) , t(3 ) , t(5 ) , and t(10 ) , respectively ) . RESULTS At t(0 ) , CT in the treatment group on the treatment side ( ipsilateral side ) warmed up by 0.2 degrees F , whereas in the sham group , there were no significant temperature modifications on either side . At t(3 ) relative to t(0 ) , CT in the treatment group on the treatment side warmed by approximately 0.6 degrees F , whereas the contralateral side ( nontreatment side ) cooled . In the treatment group , significant differences were noted between sides ( F = 13.36 , P = .002 , P = .932 ) and sides x times ( F = 2.97 , P = .016 , P = .838 ) . CONCLUSION The effects of a lumbar spine manipulation appear noticeable by changes in paraspinal CT measurements at the level of L5 . However , the meaning and mechanisms of CT modifications at L5 are still being investigated Joint mobilisation to the T4 vertebra has been advocated as a treatment for T4 syndrome . To date no controlled studies have investigated the effects of thoracic spinal manual therapy ( SMT ) applied to T4 on sympathetic activity in the h and s. This study investigated whether a grade III postero-anterior rotatory joint mobilisation technique applied to the T4 vertebra at a frequency of 0.5 Hz had demonstrably greater effects than a vali date d placebo intervention on skin conductance ( SC ) in the h and s of healthy subjects . A power analysis calculation was performed and using a double blind , placebo-controlled , independent groups design , 36 healthy subjects ( 18 - 35 years ) were r and omly assigned to two groups ( placebo intervention or treatment intervention ) . A BioPac unit recorded continuous SC measures before , during and after each experimental intervention . An exit question naire was used to vali date the expectancy effects of the placebo intervention . Results demonstrated a significant difference between groups in SC in the right h and during the post-treatment rest period ( F = 4.888 , p = 0.034 ) ; with the treatment intervention being sympathoexcitatory in nature . A trend towards a significant difference between groups was also demonstrated in the left h and during the rest period ( F = 4.072 , p = 0.052 ) . This study provides preliminary evidence that joint mobilisation applied to the T4 vertebra at a frequency of 0.5 Hz can produce sympathoexcitatory effects in the h and . Further research is recommended in a patient population to test early  nutritional interventions  and prospect i ve observational cohorts . RCTs are generally accepted as method ologically the best approach for informing health policy . They can equalise unknown as well as known confounding factors and so can demonstrate causation ; they permit estimation of effect size and so can be used to assess likely Two commonly utilised manual therapy techniques ; McKenzie 's lumbar extension exercises ( EE ) ; and segmental rotational grade V manipulation were investigated to determine their magnitude of neurophysiological effect . Proxy measures of sympathetic nervous system ( SNS ) activity ( skin conductance ) were utilised to ascertaining neurophysiological response . This study determined the neurological effects of these two treatment techniques in addition to establishing the Biopac System as a reliable measure of neurophysiological changes . A quasi-experimental , independent group 's design was utilised , with r and om allocation of 50 normal , healthy participants into a manipulation or an EE group .  Neurophysiological measurements of skin conductance were taken in the lower limbs before , during and after the administration of the techniques . Results were converted into percentage change calculations for the intervention and the post-intervention periods . Both treatments increased SNS activity during the intervention period , 63 % for the manipulation group ( p = 0.0005 ) and 42 % for EE group ( p = 0.0005 ) with the manipulative technique having significantly greater effect ( p = 0.012 ) . Further analysis of the manipulation group found no difference between the ' opening ' and the ' closing ' side of the technique ( p = 0.76 ) . Biopac System is a reliable method for measuring SNS activity with minimum measurement variability . Preliminary evidence now exists supporting the neurophysiological effects of two lumbar techniques Spinal manipulative therapy techniques are commonly employed by physiotherapists in the clinical setting for the management of neuromusculoskeletal pain and dysfunction , although their underlying mechanism is not fully understood . Mulligan 's sustained natural apophyseal glides ( SNAGs ) constitute one of these techniques . This preliminary investigation was undertaken to investigate the relationship between the application of cervical SNAGs to the C5/6 intervertebral joint ( with cervical right rotation ) and indirect measures of sympathetic nervous system ( SNS ) activity . Previous investigations have suggested that cervical manipulative therapy techniques , separate to cervical SNAGs , result in a sympatheoexcitatory effect and that this may be instrumental in producing an analgesic response . Sixteen asymptomatic subjects participated in a laboratory-based experiment . A single blind , r and omized , within subject , repeated measures study design which included control , placebo and treatment comparisons was used . Measures of skin conductance ( SC ) and skin temperature ( ST ) in the right and left upper limbs were used as indicators of SNS activity . The cervical SNAG technique produced a sympathoexcitatory response demonstrated by a significant increase in SC during application of the treatment intervention ( P<0.0005 ) and for a 2-min period after the intervention ( P=0.001 ) compared with control . There was also a significant increase in SC for the placebo condition , both during intervention ( P=0.015 ) and after intervention ( P=0.011 ) compared with control . There was a statistically significant difference in SC between placebo and treatment conditions for the 2-min period after the intervention had been applied ( P=0.01 ) . A trend did emerge for ST change , illustrating a decrease in ST for the treatment and placebo conditions compared with control , however this did not reach statistically significant levels . There were no apparent left/right upper limb differences for SC and ST for each condition . The results of this study suggest that cervical SNAG techniques , performed on naïve asymptomatic subjects , have a sympathoexcitatory effect as measured by changes in SC and ST . The importance of this sympathoexcitatory effect in relation to potential mechanisms for manipulation induced analgesia are discussed , and further areas of research proposed SUMMARY . The aim of this study was to compare the effects of different rates of application of a commonly used physiotherapeutic spinal manipulative therapy technique on sympathetic function in normal pain-free volunteers . A r and omized , repeated measures , double blind , controlled study design was used to investigate the effects of two different rates of a C5 grade III central postero-anterior mobilization technique on skin conductance ( SC ) and skin temperature ( ST ) in the distal C6 dermatome of asymptomatic subjects . Sixteen asymptomatic male volunteers participated in the study . Application of a C5 central postero-anterior grade III mobilization at the rate of 2Hz produced significantly greater increases in SC values than that at the rate of 0.5 Hz and control . The results of this study suggest that mobilization with the rate which is commonly used clinical ly causes a greater increase in sympathetic efferent activity in the upper limb of normal pain-free volunteers than a slower rate . These results may also provide a basis for further investigation into the physiological effects of different rates of mobilization and in particular exploration of the relationship between changes in sympathetic function following mobilization and manipulation-induced analgesia . Copyright 1996 Harcourt Publishers OBJECTIVE The purpose of this study was to investigate the effects of a manual mobilization technique on indirect measures of sympathetic nervous system activity . METHODS Forty-five healthy volunteers participated in this r and omized , single-blinded , parallel-group 3-arm design ( experimental , sham [ placebo ] , and control group ) , comprising 15 subjects each . For the experimental group , lumbar mobilization involving an active movement , the Mulligan sustained natural apophyseal glide ( SNAG ) , was applied on L4 spinous process by an experienced manual therapist . Sustained natural apophyseal glides were performed in sitting with active flexion ( 6 times × 3 sets ) . The sham technique simulated the SNAG without applying any force . In the control group , participants were placed in a static sitting position throughout the experiment . Measures of skin conductance in the lower limbs ( L4 dermatome ) were recorded to reflect sympathetic nervous system activity in the preintervention , periintervention , and postintervention periods . Differences in percentage change of skin conductance were analyzed with analysis of variance and post hoc tests . RESULTS Lumbar SNAG produced sympathoexcitation compared with the control group in the intervention period ( P = .04 ) . No significant difference was found between SNAG and sham groups , and no statistically significant difference was found between groups in the final rest period . CONCLUSION The results of this study showed that , in asymptomatic participants , both lumbar SNAG and sham techniques performed on L4/5 intervertebral joint with active flexion induced a sympathoexcitatory response in lower limbs compared with the control group BACKGROUND AND PURPOSE Mulligan has proposed the use of mobilization with movement for lateral epicondylalgia . In this study , mobilization with movement for the elbow was examined to determine whether this intervention was capable of inducing physiological effects similar to those reported for some forms of spinal manipulation . PARTICIPANTS Seven women and 17 men ( mean age=48.5 years , SD=7.2 ) with chronic lateral epicondylalgia participated in the study . METHODS A placebo , control , repeated- measures study was conducted to evaluate whether mobilization with movement at the elbow produced concurrent hypoalgesia and sympathoexcitation . RESULTS The treatment demonstrated an initial hypoalgesic effect and concurrent sympathoexcitation . Improvements in pain result ed in increased pain-free grip force and pressure pain thresholds . Sympathoexcitation was indicated by changes in heart rate , blood pressure , and cutaneous sudomotor and vasomotor function . DISCUSSION AND CONCLUSION This study showed that a mobilization with movement treatment technique exerted a physiological effect similar to that reported for some spinal manipulations Physiotherapy management of lumbar disorders , based on Mulligan 's mobilization techniques , is a treatment of choice by many physiotherapists , however , there is only limited evidence of any neurophysiological effects and much of this has focused on the cervical spine and upper limbs . This study aims to extend the knowledge base underpinning the use of a modified Mulligan 's spinal mobilisation with leg movement technique ( SMWLM ) by exploring its effects on the peripheral sympathetic nervous system ( SNS ) of the lower limbs . Using a single blind , placebo controlled , independent groups study design , 45 normal naive healthy males were r and omly assigned to one of three experimental groups ( control , placebo or treatment ; SMWLM ) . SNS activity was determined by recording skin conductance ( SC ) obtained from lower limb electrodes connected to a BioPac unit . Validation of the placebo technique was performed by post- intervention question naire . Results indicated that there was a significant change in SC from baseline levels ( 30 % ) that was specific to the side treated for the treatment group during the intervention period ( compared to placebo and control conditions ) . This study provides preliminary evidence that a modified SMWLM technique results in side-specific peripheral SNS changes in the lower limbs The use of cervical manipulation presents concerns because of a risk of devastating side effects of trauma to the vertebral artery . Little is known about the frequency of use of cervical manipulation versus passive mobilisation by physiotherapists . A recent national , multi-centre r and omised clinical trial of the physiotherapy management of  cervicogenic headache provided an opportunity to gain an insight into practice s of a sample of manipulative physiotherapists across Australia . The treatment records for the 100 subjects who received only manipulative therapy , or manipulative therapy with exercise as per the trial protocol , were audited . The results revealed that  cervical manipulation  was used in 20.2 % of the 1090 treatments provided to these subjects but  cervical joint mobilisation  only was used in the vast majority of treatments ( 77.6 % ) . Nevertheless , 42 % of subjects were treated with  cervical manipulation  at some time . In most instances , manipulation was accompanied by passive mobilisation in the same treatment session . Patients were manipulated on one to six occasions and this occurred predominantly in the latter half of the 12-treatment program .  Cervical manipulation  was used less frequently in the group who also received exercise . The data suggest that the physiotherapists participating in this study used  cervical manipulation  selectively and relatively conservatively considering the high use of cervical mobilisation techniques . This may reflect their due regard to safety in the treatment of the cervical region Physiotherapeutic management of lumbar disorders often utilises specific segmental joint mobilisation techniques ; however , there is only limited evidence of any neurophysiological effects and much of this has focused on the cervical spine and upper limbs . This study aims to extend the knowledge base underpinning the use of a unilaterally applied lumbar spinal mobilisation technique by exploring its effects on the peripheral sympathetic nervous system ( SNS ) of the lower limbs . Using a double blind , placebo controlled , independent groups study design and based upon power calculations , 45 normal naïve healthy males were r and omly assigned to one of three experimental groups ( control , placebo or treatment ; a unilaterally applied postero-anterior mobilisation to the left L4/5 zygopophyseal joint ) . SNS activity was determined by recording skin conductance ( SC ) obtained from lower limb electrodes connected to a BioPac unit . Validation of the placebo technique was performed by post-intervention question naire . Results indicated that there was a significant change in SC from baseline levels ( 13.5 % ) that was specific to the side treated for the treatment group during the intervention period ( compared to placebo and control conditions ) . This study provides preliminary evidence that a unilaterally applied postero-anterior mobilisation technique performed , at a rate of 2 Hz , to the left L4/5 lumbar zygopophyseal joint results in side-specific peripheral SNS changes in the lower limbs OBJECTIVE Digitized infrared segmental thermometry ( DIST ) is a tool used for measuring cutaneous temperature ( CT ) . This project ascertains the effect of a manually assisted mechanical force producing a chiropractic adjustment in the lumbar spine after the Activator Methods Chiropractic Technique on CT during 2 different time recording periods ( TRPs ) . METHODS Sixty-six healthy subjects ( 36 women and 30 men ) without acute low back conditions or symptoms were recruited . Subjects were r and omly divided into 2 groups based on the length of the acclimatization period ( 8 or 30 minutes ; TRP(8 ) and TRP(30 ) , respectively ) . In turn , each recording period group was divided into 3 subgroups ( n = 11 per subgroup ) : treatment , sham , and control subgroups . Bilateral DIST was conducted at L-4 ( TRP(30 ) ) and L-5 ( TRP(8 ) ) using infrared cameras ( Subluxation Station Insight 7000 ; Chiropractic Leadership Alliance , Mahwah , NJ ) . RESULTS Before treatment ( t(-0.5 ) ) , the TRP(8 ) CT was significantly different between the ipsilateral and the contralateral sides for all subgroups . At 10 minutes ( t(10 ) ) after intervention , CT increased significantly ( P < .05 ) for the treatment group but not for the sham and control groups . In contrast , there were no significant differences in the TRP(30 ) CT before treatment between the ipsilateral and the contralateral sides ; but at t(10 ) , CT was significantly ( P < .05 ) greater for all 3 subgroups compared with preintervention CT . CONCLUSION Contacting the skin with the instrument with ( treatment group TRP(30 ) ) or without ( sham group TRP(30 ) ) a thrust with a sustained pressure stronger than the loading principle taught in the Activator Methods Chiropractic Technique protocol or a thrust respecting the st and ard loading principle ( treatment group TRP(8 ) ) of the instrument produced a CT cooling immediately after the adjustment . Furthermore , we observed that when contacting the skin with the instrument with a thrust respecting the st and ard loading principle ( treatment group TRP(8 ) ) of the instrument , it produced a secondary cooling at t(5 ) followed by a rewarming at t(10 ) . Finally , contacting the skin with the instrument without a thrust and respecting the st and ard loading principle ( sham TRP(8 ) ) of the instrument did not produce a CT change Objectives : The aims were to investigate the effects of anterior-posterior upper cervical mobilization ( APUCM ) on pain modulation in craniofacial and cervical regions and its influence on the sympathetic nervous system . Methods : Thirty-two patients with cervico-craniofacial pain of myofascial origin were r and omly allocated into experimental or placebo groups . Each patient received 3 treatments . Outcome measures included bilateral pressure pain thresholds assessed at craniofacial and cervical points preintervention , after the second intervention and after the final treatment . Pain intensity and sympathetic nervous system variables ( skin conductance , breathing rate , heart rate , and skin temperature ) were assessed before and immediately after each intervention . Results : The pressure pain thresholds in the craniofacial and cervical regions significantly increased ( P<0.001 ) and pain intensity significantly decreased ( P<0.001 ) in the treatment group compared with placebo . APUCM also produced a sympathoexcitatory response demonstrated by a significant increase in skin conductance , breathing rate , and heart rate ( P<0.001 ) , but not in skin temperature ( P=0.071 ) , after application of the technique compared with placebo . Discussion : This study provided preliminary evidence of a short-term hypoalgesic effect of APUCM on craniofacial and cervical regions of patients with cervico-craniofacial pain of myofascial origin , suggesting that APUCM may cause an immediate nociceptive modulation in the trigeminocervical complex . We also observed a sympathoexcitatory response , which could be related to the hypoalgesic effect induced by the technique , but this aspect should be confirmed in future studies STUDY DESIGN Controlled , repeated- measures , single-blind r and omized study . OBJECTIVES To determine the effect of cervical or thoracic manipulation on neurotensin , oxytocin , orexin A , and cortisol levels . BACKGROUND Previous studies have research ed the effect of spinal manipulation on pain modulation and /or range of movement . However , there is little knowledge of the biochemical process that supports the antinociceptive effect of spinal manipulation . METHODS Thirty asymptomatic subjects were r and omly divided into 3 groups : cervical manipulation  ( n = 10 ) ,  thoracic manipulation  ( n = 10 ) , and nonmanipulation ( control ) ( n = 10 ) . Blood sample s were extracted before , immediately after , and 2 hours after each intervention . Neurotensin , oxytocin , and orexin A were determined in plasma using enzyme-linked immuno assay . Cortisol was measured by microparticulate enzyme immuno assay in serum sample s. RESULTS Immediately after the intervention , significantly higher values of neurotensin ( P<.05 ) and oxytocin ( P<.001 ) levels were observed with both cervical and thoracic manipulation , whereas cortisol concentration was increased only in the cervical manipulation group ( P<.05 ) . No changes were detected for orexin A levels . Two hours after the intervention , no significant differences were observed in between-group analysis . CONCLUSION The mechanical stimulus provided by spinal manipulation triggers an increase in neurotensin , oxytocin , and cortisol blood levels . Data suggest that the initial capability of the tissues to tolerate mechanical deformation affects the capacity of these tissues to produce an induction of neuropeptide expression . Previous studies have analyzed the effects of spinal manipulation on pain sensitivity by using several sensory modalities , but to our knowledge , no studies have focused on serum biomarkers involved in the nociceptive pathway after spinal manipulation . Our objectives were to determine the immediate effect of cervical and dorsal manipulation over the production of nitric oxide and substance P , and establishing their relationship with changes in pressure pain thresholds in asymptomatic subjects . In this single-blind r and omized controlled trial , 30 asymptomatic subjects ( 16 men ) were r and omly distributed into 3 groups ( n = 10 per group ) : control , cervical and dorsal manipulation groups . Blood sample s were extracted to obtain serum . ELISA assay for substance P and chemiluminescence analysis for nitric oxide determination were performed . Pressure pain thresholds were measured with a pressure algometer at the C5-C6 joint , the lateral epicondyle and the tibialis anterior muscle . Outcome measures were obtained before intervention , just after intervention and 2 h after intervention . Our results indicated an increase in substance P plasma level in the cervical manipulation group ( 70.55 % ) when compared with other groups ( p < 0.05 ) . This group also showed an elevation in the pressure pain threshold at C5-C6 ( 26.75 % ) and lateral epicondyle level ( 21.63 % ) immediately after the intervention ( p < 0.05 ) . No changes in nitric oxide production were observed . In conclusion , mechanical stimulus provided by cervical manipulation increases substance P levels and pressure pain threshold but does not change nitric oxide concentrations . Part of the hypoalgesic effect of spinal manipulation may be due to the action of substance Objective To assess the additional effect of static ultrasound and diadynamic currents on myofascial trigger points in a manual therapy program to treat individuals with chronic neck pain . Design A single-blind r and omized trial was conducted . Both men and women , between ages 18 and 45 , with chronic neck pain and active myofascial trigger points in the upper trapezius were included in the study . Subjects were assigned to 3 different groups : group 1 ( n = 20 ) was treated with manual therapy ; group 2 ( n = 20 ) was treated with manual therapy and static ultrasound ; group 3 ( n = 20 ) was treated with manual therapy and diadynamic currents . Individuals were assessed before the first treatment session , 48 hours after the first treatment session , 48 hours after the tenth treatment session , and 4 weeks after the last session . Results There was no group-versus-time interaction for Numeric Rating Scale , Neck Disability Index , Pain-Related Self-Statement Scale , pressure pain threshold , cervical range of motion , and skin temperature ( F-value range , 0.089–1.961 ; P-value range , 0.106–0.977 ) . Moreover , we found no differences between groups regarding electromyographic activity ( P > 0.05 ) . Conclusion The use of static ultrasound or diadynamic currents on myofascial trigger points in upper trapezius associated with a manual therapy program did not generate greater benefits than manual therapy alone Recent findings that spinal manual therapy ( SMT ) produces concurrent hypoalgesic and sympathoexcitatory effects have led to the proposal that SMT may exert its initial effects by activating descending inhibitory pathways from the dorsal periaqueductal gray area of the midbrain ( dPAG ) . In addition to hypoalgesic and sympathoexcitatory effects , stimulation of the dPAG in animals has been shown to have a facilitatory effect on motor activity . This study sought to further investigate the proposal regarding SMT and the PAG by including a test of motor function in addition to the variables previously investigated . Using a condition r and omised , placebo-controlled , double blind , repeated measures design , 30 subjects with mid to lower cervical spine pain of insidious onset participated in the study . The results indicated that the cervical mobilisation technique produced a hypoalgesic effect as revealed by increased pressure pain thresholds on the side of treatment ( P=0.0001 ) and decreased resting visual analogue scale scores ( P=0.049 ) . The treatment technique also produced a sympathoexcitatory effect with an increase in skin conductance ( P<0.002 ) and a decrease in skin temperature ( P=<0.02 ) . There was a decrease in superficial neck flexor muscle activity ( P<0.0002 ) at the lower levels of a staged cranio-cervical flexion test . This could imply facilitation of the deep neck flexor muscles with a decreased need for co-activation of the superficial neck flexors . The combination of all findings would support the proposal that SMT may , at least initially , exert part of its influence via activation of the PAG BACKGROUND Recent research has shown that Mulligan 's Mobilization With Movement treatment technique for the elbow ( MWM ) , a peripheral joint mobilization technique , produces a substantial and immediate pain relief in chronic lateral epicondylalgia ( 48 % increase in pain-free grip strength).([1 ] ) This hypoalgesic effect is far greater than that previously reported with spinal manual therapy treatments , prompting speculation that peripheral manual therapy treatments may differ in mechanism of action to spinal manual therapy techniques . Naloxone antagonism and tolerance studies , which employ widely accepted tests for the identification of endogenous opioid-mediated pain control mechanisms , have shown that spinal manual therapy-induced hypoalgesia does not involve an opioid mechanism . OBJECTIVE The aim of this study was to evaluate the effect of naloxone administration on the hypoalgesic effect of  MWM . METHODS A r and omized , controlled trial evaluated the effect of administering naloxone , saline , or no-substance control injection on the MWM-induced hypoalgesia in 18 participants with lateral epicondylalgia .  Pain-free grip strength , pressure pain threshold , thermal pain threshold , and upper limb neural tissue provocation test 2b were the outcome measures . RESULTS The results demonstrated that the initial hypoalgesic effect of the MWM was not antagonized by naloxone , suggesting a nonopioid mechanism of action . CONCLUSIONS The studied peripheral mobilization treatment technique appears to have a similar effect profile to previously studied spinal manual therapy techniques , suggesting a nonopioid-mediated hypoalgesia following manual therapy OBJECTIVE To investigate a proposed model in which manipulative therapy produces a treatment-specific initial hypoalgesic and sympathoexcitatory effect by activating a descending pain inhibitory system . The a priori hypothesis tested was that manipulative therapy produces mechanical hypoalgesia and sympathoexcitation beyond that produced by placebo or control . Furthermore , these effects would be correlated , thus supporting the proposed model . DESIGN A r and omized , double-blind , placebo-controlled , repeated- measures study of the initial effect of treatment . SETTING Clinical neurophysiology laboratory . SUBJECTS Twenty-four subjects ( 13 women and 11 men ; mean age , 49 yr ) with chronic lateral epicondylalgia ( average duration , 6.2 months ) . INTERVENTION Cervical spine lateral glide oscillatory manipulation , placebo and control . OUTCOME MEASURES Pressure pain threshold , thermal pain threshold , pain-free grip strength test , upper limb tension test 2b , skin conductance , pileous and glabrous skin temperature and blood flux . RESULTS Treatment produced hypoalgesic and sympathoexcitatory changes significantly greater than those of placebo and control ( p < .03 ) . Confirmatory factor- analysis modeling , which was performed on the pain-related measures and the indicators of sympathetic nervous system function , demonstrated a significant correlation ( r = .82 ) between the latencies of manipulation-induced hypoalgesia and sympathoexcitation . The Lagrange Multiplier test and Wald test indicated that the two latent factors parsimoniously and appropriately represented their observed variables . CONCLUSION Manual therapy produces a treatment-specific initial hypoalgesic and sympathoexcitatory effect beyond that of placebo or control . The strong correlation between hypoalgesic and sympathoexcitatory effects suggests that a central control mechanism might be activated by manipulative therapy Manual therapy ( MT ) and exercise therapy techniques are commonly utilised , guideline recommended treatment strategies in the management of non-specific low back pain ( LBP ) . Preliminary evidence on asymptomatic participants indicates that two manual therapy techniques ; repeated lumbar extension in lying exercise ( EIL ) ; and segmental rotational grade V manipulation ( manipulation ) , have significant effects on the sympathetic nervous system ( SNS ) as detectable with skin conductance ( SC ) responses . However , it is not known if these responses occur in patients with LBP . A r and omised , independent group 's design was utilised to investigate the immediate SC responses in 50 patients with LBP of less than 12 weeks duration . Patients received either the manipulation technique ( n = 25 ) or the EIL exercise ( n = 25 ) and SC activity was recorded , in a single treatment session , pre- , peri- and post-treatment . Both treatments result ed in a sympatho-excitatory response during the intervention period with the manipulation technique having a 255 % increase ( p < 0.005 ) , and the EIL technique a 94 % increase ( p = 0.019 ) with both treatments having responses that were sustained into the final rest period ( p < 0.005 ) . Between-group comparisons indicate that the manipulation technique had a significantly greater magnitude of effect ( p < 0.001 ) . The results support the sympatho-excitatory responses seen in normative studies but challenge the assumption that normative and patient population s are analogous with respect to the magnitude of effect observed and suggest that SC responses may be a feasible , proxy method of detecting dorsal horn sensitisation and neuro-plastic adaptations occurring in the presence of LBP BACKGROUND Oscillatory Maitl and mobilisations are commonly used in the management of  lower back pain  with research suggesting that mobilisations at 2 Hz may excite the sympathetic nervous system ( SNS ) more than sustained pressure glides or 0.5 Hz oscillatory mobilisations . OBJECTIVES Investigate the effects of increasing the oscillation frequency greater than 2 Hz . DESIGN A double-blind , placebo-controlled , independent group experimental design . METHOD Sixty healthy male volunteers were r and omly allocated to one of four groups ; a control group ( no contact ) , placebo group ( sustained static pressure to L4 vertebra ) , and two intervention groups receiving a central ly applied postero-anterior mobilisation applied at either 2 Hz or 3 Hz for three 1-min periods .  SNS activity was recorded by a blinded data collector by continuous skin conductance ( SC ) activity levels in the feet using a Biopac MP35 electrodermal amplifier . Participants were blinded to their group allocation which was further vali date d by a post-experiment question naire ( p > 0.05 ) . RESULTS The magnitude of sympathoexcitatory response was greatest for the 3 Hz mobilisation ( 20 % ) compared with the 2 Hz mobilisation ( 12 % ) , placebo ( -1 % ) and control conditions ( 3 % ) . Only the 3 Hz group demonstrated statistical significance when compared to placebo intervention ( p = 0.002 ) , and the control group ( p = 0.02 ) . CONCLUSION SC changes reflect those of previous studies using lumbar mobilisations at 2 Hz , however the 3 Hz group was found to have a greater magnitude of effect worthy of consideration within research and clinical setting s. These findings provide preliminary evidence to support the use of 3 Hz oscillatory mobilisations to affect a greater magnitude of SNS activity than those previously reported ( 0.5 , 1.5 and 2 Hz )
BACKGROUND A potential mechanism of action of manual therapy is the activation of a sympathetic-excitatory response .
OBJECTIVE To evaluate the effects of joint mobilisation on changes in clinical manifestations of sympathetic nervous system activity .