Journal of Osteopathic Medicine, 2004; 7(1): 8-14 © 2004 Research Media

Research Report

The effect of manipulation and mobilisation on pressure pain

thresholds in the thoracic spine
G Fryer, J Carub, S Mclver
School of Health Sciences, Victoria University, Melboume, Australia

Abstract
Background and Objectives: High velocity low amplitude thrust manipulation and mobilisation
are commonly used by manual therapists to relieve spinal pain and improve mobility. The aim of
this controlled, single blinded study was to investigate the effect of manipulation and mobilisation
on pressure-pain thresholds in the thoracic spine in an asymptomatic population.
Methods: Subjects (n=96) were screened for tender thoracic segments, and pressure-pain
threshold measurements were made using an electronic pressure algometer immediately before
and after treatment intervention. Subjects were randomly allocated into three intervention groups,
and received either a single high velocity extension thrust, thirty seconds of extension mobilisation,
or thirty seconds of sham treatment (control) consisting of simulated 'laser acupuncture'.
Analysis: Within-group pre- and post-intervention pressure-pain threshold values were analysed
using dependent t-tests, revealing significant changes in the mobilisation (P<0.01) and
manipulation (,°=0.04) groups, but not the sham treatment group (P=0.88). Analysis of mean
group changes using a one-way analysis of variance and post-hoc analysis revealed a significant
difference between the mobilisation and control group (P=0.01), but no significant difference
between the manipulation and control group (P=0.67). Pre-post effect sizes in the mobilisation
group were medium to large (d=0.72), small to medium for manipulation (d=0.32), and small in
the control group (0'=0.02).
Conclusion: Both manipulation and mobilisation produced significantly increased pressure-pain
thresholds (decreased sensitivity to pressure) in the thoracic spine, whereas the sham treatment
did not. Mobilisation appeared to be more effective than manipulation for increasing pressure-
pain thresholds when applied to the thoracic spine in asymptomatic subjects.
Keywords: manipulation, mobilisation, pain, algometry, osteopathy

INTRODUCTION
Manipulation and mobilisation are two manual techniques High velocity, low amplitude (HVLA) thrust manipulation
that are commonly used by osteopaths, chiropractors and (known also as mobilisation with impulse, and grade V
physiotherapists to treat spinal pain and dysfunction. mobilisation) involves a small amplitude thrust to produce
Mobilisation (or 'articulation', as it is known in osteopathy) joint cavitation, and is often accompanied by an audible
involves passive rhythmic and repetitive movements within 'cracking' sound. 1,2,4Brodeur 5 suggested that the audible
a range of motion or against a restrictive barrier. It is an release is produced by the sudden'snap back' of the synovial
extension of passive motion testing and can be applied to a capsule, in association with formation of a gas bubble within
single articulation or a group of spinal segments. It is a the joint.
gentle technique where the force and amplitude can be
controlled depending on the response of the tissues and the Spinal manipulation and mobilisation have been proposed
severity of the condition being treated.l-3 to have a number of therapeutic benefits, including the
stretching of shortened and thickened peri-articular soft
tissues to improve range of motion, improved drainage of
Gary Fryer, BAppSc, ND, Joanne Carub, BSc, MHSc, Steve McIver,
BSe, MHSc, School of Health Sciences, Victoria University, Melbourne fluid within and surrounding the joint, and changes in pain
Australia modulation, motor activity and proprioception.~.6
Address correspondence to: Pain is the perception of an adverse or unpleasant sensation.
Gary Fryer, School of Health Sciences, Victoria University PO Box 14428
A variety of nociceptors may be activated by noxious
MCMC, VIC 8001, Australia.
gary.fryer@vu.edu.au chemical, thermal, or mechanical stimuli, and convey
Received 20/I 0/03, Revised 09/01/04, Accepted 12/01/04 information to the dorsal horn of the spinal cord, which
© 2004 Research Media Fryer G, et al. The effect of manipulation and mobilisation on pressure pain thresholds

after processing may ascend via spinal tracts to higher at two minutes, five minutes and ten minutes post-
centres within the brain. Pain may be generated primarily manipulation. At ten minutes post manipulation, the
by activation of these peripheral tissue receptors, or from manipulated group showed a statistically significant
the central nervous system (central sensitisation) as appears elevation of pain tolerance (140%) when compared with
to occur in many chronic pain sufferers. 7,8 the control group. 2° Schiller reported a lasting increase in
pain threshold after a six-week treatment period of
The exact mechanism of pain relief from manipulation is manipulation or non-functioning ultrasound. There was no
unclear, but it has been suggested that pain is modulated at significant improvement in objective pain measurements in
either the spinal cord or in the higher centers of the central those receiving placebo treatment, whereas subjects
nervous system. 8,9 Manipulation has been suggested to affect receiving the manipulation showed a significant
pain processing at the spinal cord level via a phenomenon improvement between the first and final treatment. This
known as the gate control theory, which was first described improvement was maintained in a one-month follow up. 21
by Melzack and Wall in 1965.1° They proposed that large
diameter myelinated neurons from mechanoreceptors would Similarly, a few researchers have investigated the effects of
modulate and inhibit the incoming nociceptive information. mobilisation on pain levels, 13,22,23although no study has yet
Passive joint mobilisation and manipulation would activate investigated this in the thoracic spine. Clinical trials by
mechanoreceptors and may therefore provide pain relief by Sterling e t al. 23 and Wright and Vicenzino 13have
activating this spinal gate control mechanism.I° demonstrated increases in pain thresholds in symptomatic
and asymptomatic subjects respectively following posterior-
Descending inhibition of pain from higher centres in the anterior mobilisation applied to the cervical spine. Sterling
CNS may also play a role in manipulation-induced hypo- reported an increase in pain measures in the order of 23%
algesia. These descending pain modulatory pathways are while Wright and Vicenzino reported an increase in pain
activated by a number of endogenous opioid peptides, such measures ranging from l 5% to 25%. Vicenzino e t a122 also
as enkephalins, endorphins and dynorphins. 7 In 1986, Vernon discovered increases in pain thresholds occurring at sites
et al. 11found that sertun beta-endorphin levels significantly remote from the application of mobilisation. They found
increased following a single manipulation compared with mobilisation at the level of C5.6 in subjects with lateral
sham treatment and a control group. However, a later and epicondylitis produced a resultant increase in pressure pain
larger study produced conflicting results, finding that thresholds of up 25% at the head of the radius.
manipulation had no effect on beta-endorphin levels in blood
samples taken 5 minutes and 30 minutes post-manipulation. 12 Similar results were found following mobilisation of the
lumbar spine. Goodsel124observed an improvement in pain
The dorsal periaqueductal grey region (dPAG) of the brain levels following posterior-anterior mobilisation applied at
has been suggested to be involved in manipulation-induced a spinal level for three one-minute repetitions on
hypoalgesia. Stimulation of the dPAG produces a profound symptomatic subjects. However, the treatment did fail to
and selective analgesia] and it has been implicated that spinal produce any objective measurable change in the mechanical
manipulative therapy may exert its initial effects by activating behavior of the lumbar spine (posterior-anterior response
this region. 9,I3 and range of movement) and the authors suggested that
improvement in pain levels may have been due to a placebo
The majority of clinical trials that have investigated the
effect.
effects of manipulation on spinal pain have focussed on the
cervical and lumbar spine.14-17 A number of studies have Although the experience of pain is entirely subjective, there
reported cervical manipulation to be effective for pain are a number of methods to measure and monitor it. Self
relief, 14-16with one study finding pain reduction in as many reported pain using visual analogue scales, and pain and
as 85% of subjects. 15 An extensive systematic review of disability questionnaires such as the McGill and Oswestry
randomised clinical trials investigating lumbar manipulation are commonly used research tools that have proven
and pain concluded that manipulation may be effective in reliabilit3zY-27 Another form of pain measurement is pressure
some subgroups of patients with low back pain, and algometry. The algometer is a calibrated pressure gauge
recommended additional research on the topic. 17 that quantifies pain by assessing the pressure-pain threshold
Manipulation of the spine has also compared favourably (PPT) in an individual. PPT can be defined as the minimum
with other interventions. Cassidy et al. 15found manipulation force that induces pain or discomfort in an individual. The
to be more effective than muscle energy technique for pain use and reliability of pressure gauges to determine PPTs on
relief in the cervical spine, while other studies have reported bony and muscle landmarks have been well established. 28-31
between 40-55% improvement in pain following
manipulation when compared with mobilisation.18,19 Algometric measurement has been used to establish normal
PPT values by measuring values in asymptomatic subjects? 1-
In the thoracic spine, both Terret and Vernon 2°and Schiller21 33In the thoracic spine, T 4has been shown to have a normal
recorded manipulation-induced effects on pain. Using an mean PPT 0f324 kPa/cm 2, and T 6 a normal mean PPT of
electrical pain inducer, Terret and Vernon demonstrated an 302 kPaJcm2.32 Although no significant difference was found
immediate increase in pain threshold in myofascial tissue within the thoracic spine (P=0.184), Keating e t al. 32 has
following thoracic manipulation. They found a marked demonstrated a normal regional variance within the spine
increase in pain tolerance in the manipulated group within with PPT increasing in a caudad direction from cervical, to
30 seconds, which was maintained in measurements taken thoracic, to lumbar spinous processes. Fischer 33 and
Journal of Osteopathic Medicine, 2004; 7(1): 8-14 © 2004 Research Media

Hogeweg e t al. 28 have shown that left and right sides of the previously demonstrated that repeated application of the
body have highly correlating PPT values. Hogeweget al. 28 algometer does not result in a change in sensitivity.3°
has suggested that in the case of unilateral pathology,
comparison with the non-affected side can be used to
determine the severity, while Fischer 33also suggested that
normal PPT values could aid with diagnosis.

Few researchers have examined the effect of manipulation

or mobilisation on the thoracic spine or thoracic pain, and
none have compared the two manual techniques in this
region. This study aimed to investigate and compare the
effect of manipulation and mobilisation on PPT in the
Figure 1. The algometer(SomedicAlgometerType 2, Sweden)
thoracic spine in an asymptomatic population

METHODS
Subjects

Ninety-six (96) asymptomatic volunteers (39 male, 57

female, aged 19-34) were recruited for this study from a
student population after completing a consent form and a
questionnaire to exclude thoracic pathology. Testing was
performed in the Victoria University Osteopathy Clinic. The
Victoria University Human Research Ethics Committee
granted ethics approval for the study.

Volunteers were excluded from this study if they were

suffering from a spinal condition or pathology, if they were
a long-term corticosteroid user, or if their spine had been
treated with manipulation or mobilisation in the previous Figure 2. Measurementof pressure painthresholdsusing the algometer
three days.
Procedure
Measurement of pressure pain thresholds
Subjects undressed to expose their thoracic spines, and were
Pressure-pain threshold (PPT) was measured using a hand offered open-backed gowns. Three researchers were
held electronic pressure algometer (Somedic Algometer involved in this study: Researcher 1 identified the most-
Type 2, Sweden) (Figure 1). The electronic algometer used tender thoracic vertebra by twice springing on each thoracic
in the present study has been shown to have excellent vertebra, and marked the spinous process of this level with
reproducibility for recording PPTs over thoracic spinous a skin pencil. Researcher 2 measured the PPT of this level,
processes (ICC=0.93 at T 4 level, ICC=0.90 at T 6 level). 32 and Researcher 3 (a registered osteopath) applied all the
The algometer consisted of a plastic handle with a built-in interventions. Researchers 1 and 2 were blinded to the group
pressure transducer and an LCD display showing pressure allocation of all subjects. Subjects were allocated (by lottery
and slope (the rate of applied pressure). The algometer draw) into three intervention groups: manipulation (n=32),
was calibrated before testing began, and a 2cm rubber tip mobilisation (n=32) or non-operational laser acupuncture
was used because the researcher using the algometer found (n=32), which acted as the control group.
this was easier to stabilise on the thoracic spinous processes,
and was therefore more reliable.

The methodology for the measurement of PPTs was similar

to that used by Keating e t al. 32 With the participant lying
prone on the plinth, the algometer was positioned
perpendicular to the spinous process of the marked
vertebrae. Pressure with the algometer was then applied at
a steady and consistent rate of 30 kPa/second. A visual
indicator on the algometer enabled the force to be applied
at a reasonably accurate rate. Subjects were instructed to
say 'now' as soon as they felt the sensation of pressure
change to one of pain. The downward force was then
immediately ceased, and the maximal pressure applied (ie.
the PPT) was then recorded (Figure 2). Three PPT
measurements were taken, with a break of 20 seconds
between each one, and the average of the three readings Figure 3. ThoracicHVLAmanipulationfor mid and lower levels
was calculated as the PPT for that participant. Studies have
10
© 2004 Research Media Fryer G, et al. The effect of manipulation and mobilisation on pressure pain thresholds

Figure 4. ThoracicHVLA manipulationfor upperlevels Figure 6. Mobilisationof the upperthoracicspine,

Subjects were directed to another room, where they received 'Sham' laser treatment (control)
their intervention treatment from Researcher 3. Immediately
following treatment, subjects returned to the measurement Because participant expectation could potentially influence
room, and were re-measured by Researcher 2, who was pain perception, it was decided that a 'sham' treatment was
blinded to their treatment intervention. preferable to a no-intervention control group, because this
may produce a similar expectation bias as the other treatment
Treatment intervention groups. Sham treatment consisted of 30 seconds of 'laser
acupuncture' to the marked thoracic region using a laser
Manipulation pointer (Laserex LP2000). All subjects in this group were
informed that laser acupuncture is practised widely by
Those in the HVLA manipulation group were instructed to
acupuncturists, and were shown the laser being applied to
sit on the plinth and cross their arms across their chest.
their forearm. Before starting they were told that they should
Standing behind the participant, and using a small towel as
feel no sensation, and if they did they were to inform the
a fulcrum, the researcher delivered an extension thrust to
researcher and the intervention would stop. This was done
the marked thoracic level (Figure 3). If an upper thoracic
to reinforce the impression that laser acupuncture was a
segment (ie. T 1-T4)was marked, the technique was modified
genuine therapeutic technique. The laser was turned off
by using a padded knee contact (see Figure 4). Although
throughout the whole treatment.
the technique was directed at the indicated level, it cannot
be certain whether the joint cavitation occurred at this or Statistical Methods
adjacent levels. These manipulative techniques have been
described in osteopathic technique texts? 34 All data was collated and analysed using the statistical
package SPSS Version 10. To assess the reliability of the
Mobilisation PPT measurement procedure, the Intraclass Correlation
Coefficient (ICC, based on a one-way ANOVA) was
Subjects in the mobilisation group were treated with a seated
calculated for the three PPT recordings taken in all subjects.
extension mobilisation (articulation) technique as described
Pre- and post-intervention PPT measurements were analysed
by Tucker and Deoora? Subjects were positioned seated
for the three intervention groups using paired t-tests, and
on a treatment bench facing the practitioner, who contacted
the pre-post effect sizes (Cohen's d) calculated. A one-way
the marked vertebra and repeatedly applied an extension
ANOVA was then conducted to determine if differences
articulation for thirty seconds (Figure 5). This technique
existed between the changes produced by the three
was modified slightly if the marked level was in the upper
interventions. Statistical significance was set at the alpha
thoracic region (Figure 6).
0.05 level.

RESULTS
Audible joint cavitation was noted for all but one subject
during the administration of HVLA manipulation, although
it cannot be certain at what level the cavitation occurred,
or if only the joints of one level cavitated. The Average
Measure ICC for algometer PPT readings 1, 2 and 3 was
0.93 (95% C.I.: 0.91-0.95;F2,189=14.28,P<0.01), indicating
a high level of reliability for the three readings.

Statistical comparison of pre- and post-intervention PPT

scores using a two-tailed t-test showed there to be a large
Figure 5. Mobilieationof the middleand lowerthoracicspine.
11
Journal of Osteopathic Medicine, 2004; 7(1): 8-14 © 2004 Research Media

improvement in the group receiving mobilisation (28.42 compared to 11.99kPa), a medium to large effect size
kPa), a smaller improvement in the group receiving (d=0.72) compared to a small to medium effect for
manipulation (11.88 kPa), and virtually no difference in the manipulation (d=0.32), and the mean change was
group receiving laser acupuncture (0.94 kPa). The PPT significantly different from the control group (P=0.01),
improvement shown in the mobilisation and manipulation whereas manipulation (P=0.67) was not. Analysis with
groups were both significant (P<0.01 for mobilisation, ANOVA and post-hoc testing, however, failed to show a
P=0.04 for manipulation), whereas the small improvement significant difference between the outcomes in these two
shown in the laser acupuncture group was not significant treatment groups.
(P=0.88). Effect sizes where calculated using Cohen's d
and can be interpreted as small (d=0.2), medium (d=0.5) or A pre-post difference in PPT was not evident in the control
large (d=0.8). 35 Pre-post effect sizes in the mobilisation group, with the sham-laser acupuncture producing a mean
group were medium to large (d=0.72), small to medium for increase of only 0.93 kPa. This lack of treatment effect
manipulation (d=0.32), and small in the control group was expected, as the laser was turned off and there was no
(d=0.02). These results are outlined in Table 1. therapeutic benefit being applied. The very slight increase
in PPT that was seen could possibly be attributed to placebo
A one-way ANOVA found there to be a statistically effect, however it was small and insignificant.
significant difference between the intervention groups (F2.93
= 4.81, P=-0.01). Post-hoc testing (Bonferroni) showed The results of this study support other studies that have
the difference to be between the laser and mobilisation demonstrated an immediate hypoalgesic effect of
groups (P=0.01). No significant difference was seen mobilisation 13,22,23and manipulation1416inthe cervical spine,
between either the laser and manipulation groups (P=0.67), and manipulation in the thoracic spine. 2°'21 The results,
or the manipulation and mobilisation groups (P=-0.20) (Table however, are in contrast with the findings of Cassidy et
2). aL ~5who reported that manipulation was more effective than
mobilisation (which was muscle energy technique) for
Table 1. Within-group differences (pre-post intervention) in PPT (kPa) scores reducing pain in patients with neck pain.
(paired t -test) and effect sizes (Cohen's d)
The pre-intervention mean thoracic PPTs in the sham
LaserAcupuncture Manipulation Mobilisation control, manipulation and mobilisation groups (243.7kPa/
Pre-intervention 243.70 (95.22) 204.64 (85.52) 218.71 (82,91)
cm 2, 204.64kPa/cm2, and 218.71 kPaJcm2respectively) were
Post-intervention 244.64 (91.59) 216,51 (90.50) 247.13 (96.87) lower than the normal values of 324 kPa/cm2 (at T 4 level)
Difference 0.94 (35,07) 11.88 (31.83) 28.42 (39.68) and 302 kPa/cm 2 (at T 6 level) reported by Keating et al. 32
P value 0.88 0.04* 0.00' A plausible explanation for this difference is that although
Effect size (d) 0.03 0,35 0.72
both studies were based on an asymptomatic population,
* indicates statistical significance (P<O.05) (SD) Keating et al. 32examined a pre-determined level, whereas
the most tender thoracic spinal segment was selected and
measured in the present study.
Table 2. One-wayANOVA: Bonferroni Post-hocanalysis
The algometer used in this study was one of the most reliable
Mean difference P of its type: it was electronic, the rate of pressure applied
Mobilisation Manipulation 16.54 0.20 was easy to control, and its reproducibility and reliability
Control 27.48 0.01"
Manipulation Control 10.94 0.67 are well established. 32 The PPT procedure also appeared
highly reliable (ICC=0.93). Despite this, some large
*indicates statistical significance (P<O,05) variations between the three PPT readings were found in
DISCUSSION some subjects in either the pre or post-intervention
measurements, and some subjects experienced large or small
Manipulation and mobilisation are popular manual changes, evidenced by the large standard deviations. The
techniques in osteopathy, physiotherapy and other manual standard deviations, however, were actually lower than
therapy disciplines. Despite their wide use, however, there those found in the repeatability study performed as part of
remains a lack of convincing evidence of their therapeutic the Keating et al. 32study (standard deviation of 141 at T 4
action and efficacy. Previous studies have shown that they level, standard deviation of 147 at Y 6 level), where the
can have a positive effect on pain in the cervical and lumbar algometer readings were still found to be highly reliable.
spine, 13-17.22,23but there is limited evidence in the thoracic Pain is a subjective experience, and the perception of it
region. This study indicated that, in the thoracic spine, differs widely from person to person. It is therefore likely
manipulation and mobilisation do have an effect on perceived that most studies assessing pain with an algometer will
tenderness. Analysis with dependent t-tests demonstrated produce a large amount of variability.
that pre-post changes were significant for both mobilisation
and manipulation (P<0.01 and P=0.04, respectively), but Although the authors felt that most of the subjects believed
not for the sham laser group (P= 0.88). laser acupuncture to be a genuine form of treatment, it
cannot be certain how effective the laser was as a sham.
Mobilisation appeared to be more effective for pain Perception of pain could have been influenced if subjects
threshold reduction, producing greater immediate thought that laser acupuncture was not genuine, and no
improvement in PPT (a mean increase of 28.42 kPa, follow up study was performed to see how many subjects

12
 © 2004 Research Media Fryer G, et al. The effect of manipulation and mobilisation on pressure pain thresholds

were naive to the sham. Subjects in this study were from a 7. Kandel ER, Schwartz JH, Jessell TM. Principles of Neural Science.
student osteopath population, a n d therefore had a certain 4th ed. New York: McGraw-Hill; 2000.
a m o u n t o f m e d i c a l knowledge. It was quite possible that 8. Shac!dock MO. Central pain mechanisms: A new horizon in manual
they would have been less naive than the general population, therapy. Australian Journal of Physiotherapy. 1999;45:83-92.
a n d d e v e l o p i n g an a d e q u a t e s h a m t r e a t m e n t for this 9. Wright A. Hypoalgesia post-manipulative therapy: a review of a
p o p u l a t i o n was a challenge. Despite this, a small m e a n potential neurophysiological mechanism. Manual Therapy.
1995;1(1):11-16.
increase in P P T was f o u n d for the sham control group,
suggesting a modest placebo effect. 10. Melzac R, Wall PD. Pain mechanisms: a new theory. Science.
1965;150:971-979.
The current study o n l y e x a m i n e d the immediate effect o f 11. VernonH, Dhami MSI, Howley TP, Annett R. Spinal manipulation
m a n u a l intervention on P P T levels in the thoracic spine. It and beta-endorphin: a controlled study of the effect of a spinal
w o u l d be o f interest to investigate the lasting effects o f manipulation on plasma beta-endorphin levels in normal males.
m a n i p u l a t i o n and m o b i l i s a t i o n with a longer period o f Journal of Manipulative and Physiological Therapeutics.
1986;9(2):115-123.
follow-up. Future studies could also examine and compare
the effects o f other m a n u a l treatments - such as m u s c l e 12. Christian GF, Stanton GJ, Sissons D, et al. Immunoreactive ACTH,
B-endorphin, and cortisol levels in plasma following spinal
e n e r g y technique, counterstrain, a n d functional technique manipulative therapy. Spine. 1988;13(t2): 1411-1417.
- on P P T levels on the thoracic spine, as well as the cervical
13. Vincenzino B, Collins D, Bensun H, Wright A. An investigation of
and l u m b a r regions.
the interrelationship between manipulative therapy - induced
hypoalgesia and sympathoexcitation. Journal of Manipulative and
It is possible that m a n u a l techniques m a y have a m o r e Physiological Therapeutics. 1998;21(7):448-453.
dramatic and long-lasting effect on a painful j o i n t or spinal
I4. van Schalkwyk R, Parkin-Smith GF. A clinical trial investigating the
region. In the current study, subjects were asymptomatic,
possible effect of the supine cervical rotatory manipulation and the
but a n attempt was m a d e to i d e n t i f y a n d e x a m i n e the supine lateral break manipulation in the treatment of mechanical neck
s e g m e n t that was most tender to palpation. The natural pain: A pilot study. Journal of Manipulative and Physiological
extension o f this research w o u l d be to e x a m i n e the effects Therapeutics. 2000;23(5):324-331.
o f m a n u a l i n t e r v e n t i o n o n P P T levels in s y m p t o m a t i c 15. Cassidy DJ, Lopes AA, Yong-Hing K. The immediate effect of
patients. Different m a n u a l techniques - in isolation or in manipulation versus mobilization on pain and range of motion in the
c o m b i n a t i o n - could be e x a m i n e d to determine the most cervical spine: a randomized controlled trial.Journal of Manipulative
andPhysiological Therapeutics. 1992;15:570-575.
efficacious techniques or approaches for reducing spinal
pain and tenderness. 16. Cassidy DJ, Quon JA, Lafrance LJ, Yong-Hing K. The effect of
manipulation on pain and range of motion in the cervical spine: a
pilot study.Journal ofManipulative and PhysiologicalTherapeutics.
CONCLUSION 1992;15:495-500.
17. KoesBW, AssendelftWJJ,VanderHeijdenGJMG, BouterLM. Spinal
Mobilisation and manipulation both produced a statistically manipulation for low back pain: An updated systematic review of
s i g n i f i c a n t i n c r e a s e in P P T in the t h o r a c i c s p i n e s o f randomized clinical trials. Spine. 1996;21(24):2860-2873.
asymptomatic subjects. This c o m p a r e d with the control
18. Hadler N, Curtis P, Gillings D. A Benefit of spinal manipulation as an
group, w h i c h had almost no change in PPT. M o b i l i s a t i o n adjunctive therapy for acute low back pain: A stratified controlled
appeared to be more effective for pain reduction, producing trial. Spine. 1987;12(7):703-706.
greater i m m e d i a t e i m p r o v e m e n t in P P T levels, a m e d i u m 19. VernonH, Aker P, Bums S, Viljakaanen S, Short L. Pressure pain
to large effect size compared to a small to m e d i u m effect threshold evaluation of the effect of spinal manipulation in the
for manipulation, and a m e a n change which was significantly treatment of chronic neck pain: a pilot study.Journal ofManipulative
and Physiological Therapeutics. 1990;13(1):3-16.
different from the control group, whereas manipulation was
not. Future research is r e c o m m e n d e d to examine the lasting 20. Tenet AC, Vernon H. Manipulation and pain tolerance. A controlled
effect o f m a n u a l techniques o n P P T levels, c o m p a r i n g the study of the effect of spinal manipulation on paraspinal cutaneous
pain tolerance. American Journal of Physical Medicine.
efficacy o f different techniques, and e x a m i n i n g the hypo- 1984;63(5):217-225,
algesic effects o f these techniques in symptomatic patients.
21. SchillerL. Effectivenessof spinalmanipulativetherapy in the treatment
of mechanical thoracic spinal pain: a pilot randomized clinical trial.
REFERENCES Journal of Manipulative and Physiological Therapeutics.
2001 ;24(6):394-401,
1. Greenman PE. Principles of manual medicine. 2nd ed: William &
Wilkins; 1996. 22. Vincenzino B, Collins D, Wright A. The initial effects of a cervical
spine manipulative physiotherapy treatment on the pain and
2. Maitland GD, Hengeveld E, Banks K, English K. Maitland's Vertebral dysfunction of lateral epicondylalgia.Pain. 1996;68:69-74.
Manipulation. 6th ed. Oxford: Butterworth-Heinemarm;2001.
23. Sterling M, Jull GA, Wright A. Cervical mobilisation: concurrent
3. Tucker C, Deoora T. Fundamental Osteopathic Techniques. effects on pain, sympatheticnervous system activityand motor activity.
Melbourne: Research Publications; 1995. Manual Therapy. 2001;6(2):72-81.
4. GibbonsP, Tehan P. Manipulation of the spine, thoraxandpelvis. An 24. Goodsell M, Lee M, Latimer J. Short-term effects of lumbar
osteopathic perspective. London: Churchill Livingstone; 2000. posteroanteriormobilisationin individualswith low back pain.Journal
of Manipulative and Physiological Therapeutics. 2000;23(5):332-
5. Brodeur R. The audible release associated with joint manipulation.
342.
Journal of Manipulative and Physiological Therapeutics.
1995;18:155-164. 25. Triano JJ, McGregor M, Cramer GD, Emde EL. A comparison of
outcome measures for use with back pain patients: results of a
6. Fryer G. Intervertebral dysfunction: a discussion of the manipulable feasibility study. Journal of Manipulative and Physiological
spinal lesion. Journal of Osteopathic Medicine. 2003;6(2):64-73.

13
Journal of Osteopathic Medicine, 2004; 7(1): 8-14 © 2004 Research Media

Therapeutics. 1993; 16(2):67-73. 31. Vanderweeen L, Oostendorp RAB, Vaes P, Duquet W. Pressure
algometry in manual therapy. Manual therapy. 1996;1:258-265.
26. Gloth FM, Scheve AA, Stober CV, Chow S, Prosser J. The Functional
Pain Scale: Reliability, Validity, and Responsiveness in an Elderly 32. Keating L, Lubke C, Powell V, Young TR, Souvlis T, Jull GA. Mid-
Population. JAm Med Dir Assoc. 2001 ;2(3): 110-114. thoracic tenderness: a comparison of pressure pain threshold between
spinal regions, in asymptomatic subjects. Manual therapy. 2001 ;6:34-
27. Davidson M, Keating JL. A comparison of five low back disability 39.
questionnaires: reliability and responsiveness. Physical Therapy.
2002;82(1):8-24. 33. Fischer AA. Pressure algometry over normal muscles. Standard values,
validity and reproducibility of pressure threshold. Pain. 1987;30:115-
28. Hogeweg JA, Langereis MJ, Bemards ATM, Faber JAJ, Helders PJM. 126.
Algometry. Seand J Rehab Med. 1992;24:99-103.
34. Stoddard A. Manual of osteopathic techniques. 3rd ed. London:
29. Hung CZ. Algometry in evaluation of trigger points and referred pain.
Hutchinson & Co.; 1980.
Journal of Musculoskeletal Pain. 1998;6:47-59.
35. Aron A, Aron EN. Statistics for Psychology. 2nd ed. New Jersey:
30. Nussbaum EL, Downes L. Reliability of clinical pressure-pain
Prentice-Hall; 1999.
algometry measurements obtained on consecutive days. Physical
Therapy. 1998;78:160-169.

14