#003- Articles on Tension-Type Headache, CTS, Lumbar Spine Fusion and TKA.


Can you treat tension-type headache with Manual Therapy?

Manual Therapy vs Surgery for Carpal Tunnel Syndrome in Women.

Neural Mobilization+Stabilization exercise vs Myofascial Release+Stabilization Exercise After Lumbar Spine Fusion.

A New Guideline for the management of Total Knee Arthroplasty.**Very long**

Estimated reading time without the last article: 4 minutes, 20 seconds.

Estimated reading time with the last article: 11 minutes, 36 seconds.


Can you treat tension-type headache with Manual Therapy?

Tension Type Headache (TTH): Bilateral pain, pressing or tightening quality (non-pulsating), mild to moderate intensity. The pain is not aggravated by physical activity, (e.g. walking and climbing stairs) and it is not associated with nausea and vomiting.

TTH might be caused by Activation of hyper-excitable peripheral afferent neurons from the muscles of the head and neck, muscle tenderness and muscle tension raised from psychological stress can aggravate TTH.

This systematic review and meta-analysis aimed to investigate the evidence on manual therapy effect on pain intensity, headache frequency, and impact of headache in individuals with TTH.

Data from 15 RCTs, 1131 Participant. Tension-type headache was diagnosed according to the International Classification of Headache Disorders (ICHD).


Manipulation: high velocity and low amplitude were applied on the cervical, thoracic and lumbar spine.

Soft Tissue Techniques: Myofascial release, massage, soft tissue compression, neural mobilization, positional release, CV-4 (craniosacral therapy), and muscle energy. Also, dry needling was used.

Results: (If you read the results, the authors downgraded evidence left and right, not to mention the not superiors ?)

  • Manipulation: Not superior to no treatment on improving of pain intensity (low-quality evidence) and pain frequency (moderate-quality evidence).
  • Soft tissue interventions: Superior to no treatment to reduce pain intensity and frequency (low-quality evidence with large effect sizes). Also, soft tissue interventions were not superior to control group on functional status and well-being.
  • Dry needling: Superior to no treatment for reducing pain intensity and frequency (moderate quality of evidence with large effect sizes).
  • It is worth mentioning that this article investigated manual therapy alone, therefore, combining manual therapy with hands off treatments might result in better outcomes.

Manual Therapy vs Surgery for Carpal Tunnel Syndrome in Women.

Another manual therapy study, this time with 4 YEARS FOLLOW UP RCT on MT vs CTS surgery, this should good.

Objectives: 1- Investigate the 4-year effects of a manual therapy approach for CTS as compared to carpal tunnel release surgery, 2- to determine the recurrence rate of post-treatment carpal tunnel release surgery in the same cohort of women with CTS.

Manual therapy interventions included: Manual compression of the scalene muscles, manual mobilization of the costoclavicular space, manual compression of the pectoralis minor muscle, longitudinal stroke of the biceps muscle, manual mobilization of the bicipital aponeurosis, manual mobilization of the pronator teres muscle, manual mobilization of the transverse carpal ligament, manual stretching of the palmar aponeurosis, manual mobilization of lateral glide of the cervical spine and tendon/nerve gliding exercise targeting the median nerve. Also, guideline for tendon/nerve gliding exercises for home were prescribed. (The article included a very detailed description of all the techniques mentioned above)

Results: (Very interesting results)

Participants: Manual Therapy 60, Surgery 60.

Manual therapies including desensitization maneuvers of the central nervous system are Equal in effectiveness to surgery at 1 year and 4 years follow up in all outcome measures.

Sooo, what now? which should you recommend to your patients? here some factors I think can influence the decision:

1-Cost, it depends on which country/city you are in, for example, where I live CTS surgery is actually cheaper than physiotherapy, that is if the patient is paying not the insurance.

2-Talk to your patient, CTS surgery is quick and safe surgery (of course still a surgery), where physiotherapy might take more effort and time, so present the choices to your patient. It is also worth mentioning that 9 patients in the manual therapy group required surgery after 1 year or 4 years, similarly, 8 surgery patients had a repeat surgery after 1 year and 4 years.

In conclusion Manual therapy for CTS and CTS surgery are weirdly very similar.

Neural Mobilization+Stabilization exercise vs Myofascial Release+Stabilization Exercise After Lumbar Spine Fusion.

After lumbar spine fusion (LSF) 15% of patient show no improvement, 40% unsatisfied with outcomes, 22.1% reoperation rate and 2 year after LSF the rate of other complications was 11.18%.

LSF can affect spine kinematics, load transfer, ROM and strength and endurance of trunk muscles. (So many other negative effects)

Since neural mobilization (NM) and myofascial release (MFR) were shown to improve pain and disability in LBP patients, this RCT investigated the effect of each method + stabilization exercise (SE) after LSF.

Three Groups:

  • SE alone (n= 20) 3 sessions/week for 4 weeks. (Full Program)
  • NM+SE (n= 20) NM 12 to 15 minutes/session 30 second hold and 1-minute rest, NM consisted of straight leg raise (SLR) for longitudinal traction and SLR with hip abduction for sensitization.
  • MFR+SE (n= 20), MFR for thoracolumbar fascia, quadratus lumborum, piriformis, and hamstring muscles, from prone position, counter pressure was applied by one hand while the other hand applied a slow stretch in the opposite direction until a tissue barrier was felt. A sustained pressure was applied to the restricted tissue barrier for approximately 90 to 120 seconds until release was felt, therapist followed the release into a new tissue barrier and holds and so on until the tissue became softer and more pliable.


  • Both NE group and MFR group had improved outcomes in pain and disability.
  • NE group was superior to MFR group (Pain and disability).
  • All groups improved lumbar spine ROM except for left rotation, but no significant difference between groups.

Neural mobilization and stabilization exercise is superior to myofascial release+stabilization exercise or stabilization exercise alone regarding pain measured by Visual analogue scale and disability measured by Oswestry disability index.

A New Guideline for the management of Total Knee Arthroplasty. (!) **Very long**

The guideline first talk about the methods used to assess quality and recommendation strength, also a long list of outcome measures used in the included studies. let’s jump to recommendations.

  1. Preoperative Exercise Program Should include Strengthening and flexibility exercise. ****
    • Benefits: Improved activities, Decreased pain, Improved balance, Improved knee flexion ROM, Improved knee extension ROM, Improved isometric knee and hip strength, improved report of quality of life (eg, as measured by SF-36) and Reduced length of stay of inpatient stay. No reported Harms.
    • Evidence Quality: High; Recommendation Strength: Moderate.
  2. Preoperative Education, includes: Patient expectations during hospitalization and factors influencing discharge planning and disposition, postoperative rehabilitation program, safe transferring techniques, use of assistive devices, and fall prevention.
    • Benefits: Improved patient adherence, decreased post-surgical complication, Shortened inpatient length of stay. No reported Harms.
    • Evidence Quality: Insufficient; Recommendation Strength: Best Practice.
  3. Continuous Passive Movement Device (CPM) Use for Mobilization: Physical therapists should NOT use CPMs for patients who have undergone primary, uncomplicated TKA. (LOL)
    • No benefits.
    • Harms: Bed rest may be prolonged with CPM use and there is an inconvenience of use also might cost more.
    • Evidence Quality: High; Recommendation Strength: Moderate.
  4. Cryotherapy: PT should encourage the use of cryotherapy.
    • Benefits: Improvement in pain management.
    • Harms: There is potential risk of skin irritation, burns, and frostbite; however, risk or harms are not expected when prescribed and monitored appropriately. Appropriately prescribing includes ensuring intact sensation.
    • Evidence Quality: High; Recommendation Strength: Moderate.
  5. Physical Activity: Therapists should develop an early mobility program and progressive physical activity program based on safety, functional tolerance, and physiological response.
    • Benefits: 1-Improved gait function, walking distance, balance, physical function, and health-related quality of life. 2-Improved activities and participation.
    • Harm: No expected risk or harms are expected when progression is monitored and prescribed appropriately. Team members should be aware of potential complications after TKA that may affect exercise including incision healing, thromboembolism, and joint stiffness/arthrofibrosis.
    • Evidence Quality: Insufficient; Recommendation Strength: Best Practice.
  6. Motor Function Training (Balance, Walking, Movement Symmetry): Therapists should include motor function training.
    • Benefits: Improvement in balance, walking function, activities and participation.
    • Harm: Team members should be aware of potential complications after TKA that may affect exercise including incision healing, thromboembolism, and joint stiffness/arthrofibrosis. Some of the more advanced training programs that include weight-bearing biofeedback or robot-assisted gait training may be cost- and resource-prohibitive for most clinical settings.
    • Evidence Quality: High; Recommendation Strength: Strong.
  7. Postoperative Knee ROM Exercise: Therapists should engage and teach patients to implement passive, active assistive, and active ROM exercises.
    • Benefits: Improved ROM of the knee, decreased post surgical complication, Improved functional outcomes.
    • Harm: Team members should be aware of potential complications after TKA that may affect exercise including incision healing, thromboembolism, and joint stiffness/arthrofibrosis.
    • Evidence Quality: Insufficient; Recommendation Strength: Best Practice.
  8. Immediate Postoperative Knee Flexion During Rest for Blood Loss and Swelling: therapists may teach patients to position the operated knee in some degree of flexion (30°–90°) while resting during the first week post-op. ****
    • Benefits: Decrease in blood loss associated with TKA surgery, decrease in swelling in the first 7 days post-surgery and improvement in short term flexion ROM.
    • Harms: There is a potential risk of developing limited extension ROM with this recommendation. Knee extension ROM was not measured in these studies. Limited knee extension could be a risk factor with patients being placed in a knee flexion resting position postoperatively.
    • (Evidence Quality: High; Recommendation Strength: Weak)
  9. Neuromuscular Electrical Stimulation (NMES): therapists should use NMES to improve quadriceps strength, gait performance, performance-based outcomes, and patient-reported outcomes.
    • Benefits: Improvement in quadriceps and hamstrings maximum voluntary isometric contractions from 2 to 52 weeks after TKA and Improvement in walking, stair-climbing performance, and patient-reported outcomes.
    • Harms: The financial cost of using NMES and its availability to patients may be prohibitive for patients, pain/discomfort with use and decreased tolerance.
    • (Evidence Quality: High; Recommendation Strength: Moderate)
  10. Resistance and Intensity of Strengthening Exercise: therapists should design, implement, teach, and progress high-intensity strength training and exercise programs during the early post-acute period (within 7 days after surgery) to improve function, strength, and ROM.
    • Three high-quality studies and 1 moderate-quality study support the benefits of land-based, high-intensity resistance training based on patient tolerance, muscle function, functional performance, and balance. postoperative resistance training (8 weeks) resulted in higher levels of functional mobility and better knee extension ROM.
    • early high-intensity resistance training is as safe as low-intensity resistance training.
    • Effectiveness of high-intensity resistance training may be limited by arthrogenic muscular inhibition of the quadriceps (muscle activation deficits) in the early postoperative period.
    • Benefits: Improvement in muscle strength, balance, knee extension and Improvement in activities related to mobility
    • Harms: Early postoperative high intensity resistance training after TKA, does not have harms or risks when the therapist follows appropriate progression criteria (eg, avoiding excessive swelling, pain, or prolonged soreness following intervention) and educates the patient accordingly. In the absence of appropriate criteria, overly aggressive progression can exacerbate pain and swelling. Team members should be aware of potential complications after TKA that may affect exercise including incision healing, thromboembolism, and joint stiffness/arthrofibrosis.
    • Evidence Quality: High; Recommendation Strength: Moderate.
  11. Prognostic Factors: Body Mass Index (BMI), Depression, Preoperative ROM, Physical Function and Strength, Age, Diabetes, Comorbidities, and Sex:
    • Higher BMI is associated with more postoperative complications and worse postoperative outcomes.
    • Depression is associated with worse postoperative outcomes.
    • Preoperative ROM is positively associated with postoperative ROM but has minimal, if any, effect on physical function and quality of life.
    • Preoperative physical function is positively associated with postoperative physical function.
    • Preoperative strength is positively associated with postoperative physical function.
    • Age is associated with mixed patient-reported, performance-based, and impairment-based outcomes.
    • Diabetes is not associated with worse functional outcomes.
    • A greater degree of comorbidity is associated with worse patient-reported outcomes.
    • Sex is associated with both positive and negative effects on postoperative outcomes.
    • Evidence Quality: High; Recommendation Strength: Moderate.
  12. Prognostic Factors: Tobacco Use and Patient Support:
    • Active tobacco use and lack of patient support should be considered as prognostic/risk factors associated with less than optimal functional outcome.
    • Evidence Quality: Insufficient; Recommendation Strength: Best Practice.
  13. Postoperative Physical Therapy Supervision: Supervised physical therapist management should be provided for TKA, the optimal setting should be determined by patient safety, mobility, environmental, and personal factors.
    • Benefits: Approaches that include supervised physical therapist management may produce better outcomes than approaches with less supervision from a physical therapist. Given that most patients progress after TKA with respect to function, strength, and ROM, supervised physical therapy may allow for more appropriate and safe exercise progression.
    • Evidence Quality: Moderate; Recommendation Strength: Moderate.
  14. Group-Based Versus Individual-Based Therapy: Physical therapists may use group-based or individual-based physical therapy sessions
    • Benefits: Individualized physical therapist management allows for a tailored plan of care for patients based on their physical and psychosocial needs. Group-based therapy may be less costly than individually based therapy.
    • Harms: Group therapy may fail to provide enough progression of therapy for more advanced patients or to provide adequate engagement for patients with lower abilities or significant impairments. Group-based physical therapist management after TKA will require careful selection of patients based on physical therapist examination, and patients’ progress should be monitored throughout their course of care.
    • Evidence Quality: Moderate; Recommendation Strength: Weak.
  15. Physical Therapy Postoperative Timing: Physiotherapy management should start within 24 hours of surgery and prior to discharge.
    • Benefits: Shortened inpatient hospital stay, Reduced pain, Improved physical function.
    • No expected harms are expected with implementing this recommendation. The retrospective study reported no difference in 90-day readmission rate between the early-ambulation group and the later-ambulation group.
    • Evidence Quality; Low, Recommendation Strength: Moderate.
  16. Physical Therapy Discharge Planning: therapists should provide guidance to the care team and patient on safe and objective discharge planning, patient functional status, assistance equipment, and services needed to support a safe discharge from the acute care setting.
    • Benefits: Therapists can provide the care team with valuable information to assure the most appropriate discharge setting, involving physical therapists in discharge planning can prepare the patient for a safe and independent transition to the home environment, health coaching and financial incentives can improve patient functional performance, inpatient rehabilitation may not be more beneficial than discharge directly home
    • Evidence Quality: Low; Recommendation Strength: Moderate.
  17. Outcomes Assessment: Therapists should collect data from the Knee Injury Osteoarthritis Outcomes Survey Joint Replacement (KOOS JR) as a patient-reported outcome measure and from both the 30-Second Sit-to-Stand and TUG tests as performance-based outcomes to demonstrate the effectiveness of care provided. At a minimum, these measures should be collected at the first visit and upon conclusion of care from each setting.
    • Evidence Quality: Insufficient; Recommendation Strength: Best Practice.

?Good Note

  • Manual therapy is as good as surgery for carpal tunnel syndrome. (!cool)
  • For spinal fusion patients I used relay meanly on stabilization exercise, but now, i’ll try to add neural mobilization and maybe myofascial release. ?
  • We got a very beautiful guideline for patients with total knee arthroplasty, it is not like therapists did not do most of things talked about, but it is always nice to have good evidence to support or even change the decisions we make for our patients care.

?Bad Note

  • Neither soft tissue techniques nor manipulation techniques had the evidence to treat headaches. ☹️


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