Massage-Research.com

A relationship between pectoralis minor muscle tightness and rounded shoulder posture (RSP) has been suggested, but evidence demonstrating that treatment aimed at the pectoralis minor affects posture or muscle function such as lower trapezius strength (LTS) remains lacking. In this randomized, blinded, controlled study of the 56 shoulders of 28 healthy participants, the experimental treatment consisting of pectoralis minor soft tissue mobilization (STM) and self-stretching significantly reduced RSP compared to the pre-treatment baseline (Friedman test, < .001) and the control treatment of placebo touch and pectoralis major self-stretching (Mann–Whitney U-test, <.01). RSP remained significantly reduced 2 weeks after the single treatment. Both control and experimental treatments resulted in increased LTS (Friedman test, p< .01) with no significant difference in LTS noted between treatments (p> .05). This study demonstrated that STM and self-stretching of the pectoralis minor can significantly reduce RSP.

The effects of manual treatment on rounded-shoulder posture, and associated muscle strength
Journal of Bodywork and Movement Therapies (In Press, Available online 26 June 2009)
Christopher Kevin Wong, Denise Coleman, Vincent diPersia, Judi Song, Dennis Wright

Effects of abdominal massage in management of constipation—A randomized controlled trial
Kristina Lämås, Lars Lindholm, Hans Stenlund, Birgitta Engström, Catrine Jacobsson
International Journal of Nursing Studies, Volume 46, Issue 6, Pages 759-767 (June 2009)

What is already known about the topic?

• Earlier studies indicate that severity of constipation can be decreased when using abdominal massage.

• The scientific evidence is too weak to make recommendations and more research is needed.

What this paper adds

• This paper demonstrates that abdominal massage decreases severity of gastrointestinal symptoms associated with constipation and abdominal pain syndrome, and increase number of bowel movements.

• The abdominal massage did not lead to a decrease in laxative intake, which indicates that abdominal massage could be seen as a complement to laxative use rather than a replacement.

Background

Associated with decreases in quality of life, constipation is a relatively common problem. Abdominal massage appears to increase bowel function, but unlike laxatives with no negative side effects. Because earlier studies have methodological flaws and cannot provide recommendations, more research is needed.

Objective

This study investigates the effects of abdominal massage on gastrointestinal functions and laxative intake in people who have constipation.

Design

Randomized controlled trial.

Participants and method

A sample of 60 people with constipation was included and randomized in two groups. The intervention group received abdominal massage in addition to an earlier prescribed laxative and the control group received only laxatives according to earlier prescriptions. Gastrointestinal function was assessed with Gastrointestinal Symptoms Rating Scale (GSRS) on three occasions; at baseline, week 4 and week 8. The statistical methods included linear regression, Wilcoxon sign rank test, and Mann–Whitney U-test.

Intervention

The participants in the intervention group had 15 min of massage 5 days per week for 8 weeks. The duration of massage and number of assessments were based on experiences from a pilot study (Lämås et al., 2006) and recommendations from experts with experiences in gastroenterological studies. To create a supportive environment, the massage took place in a secluded room with the participant supine on a bed. Classical music was used to help put the participants at ease, and blankets were available. This study used part of the Tactile Stimulation method.
The massage consisted of very gentle strokes with light pressure. The hands and abdomen were massaged (8 and 7 min respectively) using a systematic movement pattern to stimulate tactile receptors in the skin. The massage started with the participants taking a deep breath to enhance relaxation. Then the back of the hand, fingers, and palm were massaged with strokes and circular movements. The abdomen was massaged with longitudinal and transverse strokes and circular movements in the direction of the colon. The systematic movement pattern is important as the recognition contributes to a feeling of safety that will enhance the relaxation. As the effect of the massage was assumed to be different between participants, participants were instructed to take less laxative when they experienced improved gastrointestinal function.

Result

Abdominal massage significantly decreased severity of gastrointestinal symptoms assessed with GSRS according to total score (p=.003), constipation syndrome (p=.013), and abdominal pain syndrome (p=.019). The intervention group also had significant increase of bowel movements compared to the control group (p=.016). There was no significant difference in the change of the amount of laxative intake after 8 weeks.

Conclusions

Abdominal massage decreased severity of gastrointestinal symptoms, especially constipation and abdominal pain syndrome, and increased bowel movements. The massage did not lead to decrease in laxative intake, a result that indicates that abdominal massage could be a complement to laxatives rather than a substitute.

Abdominal massage was found to decrease severity of gastrointestinal symptoms, especially symptoms associated with constipation and pain syndrome. There was also an increase in bowel movements. The massage, however, did not lead to a decrease in laxative intake, which indicates that massage could be seen as a complement to laxative use rather than a replacement. There was no immediate effect after 15 min of light pressure abdominal massage. The 8-week study period was essential to finding significant differences between the intervention and control group.

Abdominal massage can complement laxative use for people with constipation when laxatives do not have the desired effect. The massage, however, has a delayed effect that may occur first after a number of weeks and is considered to be a long-term treatment. A prerequisite for the massage treatment is that the person feels comfortable with receiving abdominal massage. This requires a sensitive therapist that can develop a trusting relationship.

Slade SC et al. People with non-specific chronic low back pain who have participated in exercise programs have preferences about exercise: a qualitative study. Australian Journal of Physiotherapy 2009;55:115-121

QUESTION: What factors do participants in exercise programs for chronic low back pain perceive to be important for engagement and participation?

DESIGN: Qualitative study of three focus groups. PARTICIPANTS: 18 adults with chronic low back pain who had participated in exercise programs for chronic low back pain.

RESULTS: All focus group results concurred and two significant themes emerged from the focus group data. The first was that the experience of exercise informed participant preferences with respect to exercise environment and type of exercise. Participants described a range of positive and negative experiences, a desire to master exercise techniques, and a preference for exercise that matched their abilities and prior skills. The second significant theme was the helpful and empowering skills of the care-provider, and care-seeker ability to identify and articulate their own needs. Participants regarded carer expertise favourably when positive results were achieved early in the interaction, but were frustrated when they were not listened to and symptoms were aggravated. The relationship was enhanced by effective communication. Participants also recognised they needed to be aware of their own skills and abilities and, and that financial or family support incentives encouraged their adherence to a program.

CONCLUSION: People are likely to prefer and participate in exercise programs that are designed with consideration of their preferences, circumstances, and past exercise experiences. We propose that information about patient exercise preferences should be collected systematically.

Susan Slade and her colleagues in Melbourne looked at the trials that have been done into exercise programs and chronic low back pain and they rarely, if ever, actually asked what we thought was best and what worked for us. You can design the world’s most perfect exercise program but if the customer thinks it’s a crock what’s the point?

Several of the things that people said about the program that it needed to be fun, there needed to be variety, their experience of past exercise needed to be taken into consideration so that might be their level of ability, their experience in the athletic environment in younger days or complete inexperience. The theme that overwhelmingly emerged was one of stigmatisation of people feeling discriminated against and another one was that they wanted to be listened to and have education and have their situation explained to them. And that they wanted to be partners in their care, so they wanted to be part of the decisions that were made about their exercise programs.

They requested that health professionals be receptive and good communicators. That they be non-judgemental, that they explain and provide education about back pain and health care and fitness, direct them to information that is easy for them to understand such as online information through the Cochrane Collaboration which is available to all Australians free of charge or PubMed Clinical Queries where it’s a fairly user friendly website to navigate around rather than the unfiltered general information that comes through on a Google search. They wanted people to supervise their exercise programs and teach them effectively and in saying that I mean a demonstration of an exercise, practice of it under supervision and feedback about their performance so that they felt they had mastery of the exercise,.

So they are not just told ‘here’s what you do and off you go’? They didn’t like that at all and that has been found in the research to be not an effective way of teaching people to give them a leaflet and tell them to go away.

QUESTIONS: How much of an effect do five common physiotherapy interventions need to have for patients with low back pain to perceive they are worth their cost, discomfort, risk, and incovenience? Are there any differences between the interventions? Do specific characteristics of people with low back pain predict the smallest important difference?

DESIGN: Cross-sectional, observational study. PARTICIPANTS: 77 patients with non-specific low back pain who had not yet commenced physiotherapy intervention.

OUTCOME MEASURES: The smallest worthwhile effect was measured in terms of global perceived change (0 to 4) and percentage perceived change.

RESULTS: Participants perceived that intervention would have to make them ‘much better’, which corresponded to 1.7 (SD 0.7) on the 4-point scale, or improve their symptoms by 42% (SD 23), to make it worthwhile. There was little distinction made between interventions, regardless of whether smallest worthwhile effects were quantified as global perceived change (p = 0.09) or percentage perceived change (p = 1.00). Severity of symptoms independently (p = 0.01) predicted percentage perceived change explaining 9% of the variance, so that for each increase in severity of symptoms of 1 point out of 10 there was an increase of 4% in the percentage perceived change that participants considered would make intervention worthwhile.

CONCLUSIONS: Typically people with low back pain feel that physiotherapy intervention must reduce their symptoms by 42%, or make them feel ‘much better’ for intervention to be worthwhile.

Manuela Ferreira is a Research Fellow in the University of Sydney’s Faculty of Health Sciences. The study was the first time in back pain that researchers decided to hear patients on what they considered to be the clinical significance of an intervention. Five different approaches were given to patients with lower back pain: usually used in physiotherapy, massage, heat, ultrasound, exercise and manual therapy.

For measuring the benefit, they used two scales, how much improvement in percentage they would expect to see or they would need to see to consider all that worthwhile.  The patients told the researchers that they needed to be on average 42% better which is a lot more than what previous research had thought.

Now when you look at trials of physiotherapy-type treatments for low back pain compared to placebo or nothing then some of them just scrape into that 42% reduction in symptoms which people needed to have for treatment to be worth the effort. But when you look at research comparing treatments to each other rather than controls then the between treatment of differences in benefit are far lower than the amount wished for by the people in Manuela Ferreira and her colleagues’ study.

It is telling us researchers that we might be measuring the wrong things or we might not be measuring symptom improvement the way we should, the interventions we are using now maybe need to be changed - this is really the consumer’s opinion. They really want to see more improvement than what they are probably seeing right now.

When you are comparing two interventions and you find something that is statistically significant, the clinical significance of that difference is a lot more important.

We know what kind of benefit patients with back pain need, their expectations or perceptions are under-estimated by clinicians and researchers.

The interview from RAdio national

Dr Manuela Ferreira is a Research Fellow in the University of Sydney’s Faculty of Health Sciences.

Manuela Ferreira: It all started when I was doing my PhD and I had to go through a lot of clinical trials and when you read studies of clinical trials you read the results and it’s easy to see whether or not the difference between two groups or if the results of a paper are statistically significant. But I wanted to know if they were clinically significant.

Norman Swan: In other words it mattered to the researchers but did it matter to the consumer?

Manuela Ferreira: Exactly, it does matter to the consumer. There is actually literature and there are studies trying to estimate what we should call the clinical significance of results in clinical trials but it’s usually decided by researchers and clinicians but never by patients. So we thought we should hear patients.

Norman Swan: It’s a bit radical.

Manuela Ferreira: It was actually the first time in back pain that researchers decided to hear patients on what they considered to be the clinical significance of an intervention. So it was a bit radical but I still think it’s the way to go.

Norman Swan: So the questions you asked were geared towards how much of a benefit do you need to get for this to matter, for this to be worth the effort?

Manuela Ferreira: Exactly, we presented scenarios to patients related to low back pain interventions.

Norman Swan: Imaginary or real ones?

Manuela Ferreira: They were evidence based but we told them the risks, the inconvenience and a little bit of the benefits. I say a little bit because they were supposed to say how much benefit they were expecting and costs involved with the interventions and we asked patients how much improvement of their symptoms they needed to see to consider all that worthwhile.

Norman Swan: So you gave them doing nothing, having physiotherapy, having manipulation, maybe even having surgery or something like that.

Manuela Ferreira: Exactly, five different approaches usually used in physiotherapy, massage, heat, ultrasound, exercise and manual therapy.

Norman Swan: What sort of metric did you give them for measuring the benefit? I mean if you asked me I’m not sure I would know how to measure the benefit?

Manuela Ferreira: Yes, we used two scales, we asked them how much improvement in percentage they would expect to see or they would need to see to consider all that worthwhile.

Norman Swan: Just in their own terms accrued percentage?

Manuela Ferreira: Yes, from zero to 100% and the other one we gave them actually termed a little better, a lot better, much better, 100% better.

Norman Swan: Is this just the pain and movement or both?

Manuela Ferreira: It was symptoms. We are now doing a follow-up study and we are asking similar questions but concerning pain and disability and time to recover.

Norman Swan: So what did they tell you?

Manuela Ferreira: They told me that they needed to be on average 42% better which is a lot more than what previous research had thought.

Norman Swan: Now when you look at trials of physiotherapy-type treatments for low back pain compared to placebo or nothing then some of them just scrape into that 42% reduction in symptoms which people needed to have for treatment to be worth the effort. But when you look at research comparing treatments to each other rather than controls then the between treatment of differences in benefit are far lower than the amount wished for by the people in Manuela Ferreira and her colleagues’ study. So where does all that leave those of us who might have a sore back right now and are wondering what we might do about it?

Manuela Ferreira: This survey is just telling us how much they need to see to consider.

Norman Swan: This is placing the bar?

Manuela Ferreira: Exactly, so it’s something that is telling us researchers that we might be measuring the wrong things or we might not be measuring symptom improvement the way we should, the interventions we are using now maybe need to be changed - this is really the consumer’s opinion. They really want to see more improvement than what they are probably seeing right now.

Norman Swan: And we’ve just heard Rob Herbert’s, who is one of your colleagues, trial results using Health Report listeners on stretching where the effect was really tiny of stretching on preventing injury and soreness that when you’re comparing things if the margin is going to be that small it’s not worth it - people are going to say it’s not worth it.

Manuela Ferreira: Exactly, that’s the whole point. When you are comparing two interventions and you find something that is statistically significant, the clinical significance of that difference is a lot more important.

Norman Swan: Did the measure change if it was a cheap intervention for low back pain with no risk? In other words like stretching for example, while if it takes up 10 minutes of my day and I’m happy to do it, why shouldn’t I do it versus something that might actually cost you a fair bit of money and have risk attached to it? Did that change the percentage, I’d accept less benefit for that intervention?

Manuela Ferreira: There’s no difference, we compared five approaches, five interventions and there was no difference in the estimate among the five approaches. The study that we are conducting now we are comparing anti-flammatory pills and physiotherapy so these are very different interventions and they involve different costs and inconvenience and maybe risks, so we might be able to answer that question when we have the results of that one.

Norman Swan: So the bottom line then is that this could help people make decisions about their health care?

Manuela Ferreira: Exactly.

Norman Swan: Because you kind of know what benefit you’re going to get and whether it’s worth it.

Manuela Ferreira: Exactly, and we know what kind of benefit patients with back pain need, their expectations or perceptions are under-estimated by clinicians and researchers.

Norman Swan: So they’ve got to feel much better?

Manuela Ferreira: Yes they need to feel much better.

Norman Swan: Manuela Ferreira is a Research Fellow in the University of Sydney’s Faculty of Health Sciences.

Another new study that examined the effects of stretching has found that stretching does not reduce the overall risk of injury, but does reduce soreness and risk of injury to muscles, tendons and ligaments. The main purpose of ‘The Stretching Study’ was to determine whether stretching reduces the risk of injury and prevents soreness in people who participate recreationally in physical activity. This international study recruits 2,377 adults over the internet who regularly participated in physical activity.  Participants in the stretch group were asked to perform 30-second static stretches of 7 lower limb and trunk muscle groups before and after physical activity for 12 weeks.

The main findings were that:

(a) Stretching does not reduce the overall risk of injury, but it does reduce the risk of specific types of injuries (injuries to muscles, ligaments and tendons).
(b) Stretching produces small reductions in the risk of muscle soreness. People who stretch have about 8% less chance of experiencing soreness in any one week than people who do not stretch. Another way of saying this is that stretching will prevent soreness in any one week in one in every 13 people who stretch.

People who exercise may want to know if these findings mean they should or should not stretch. The researchers summarise the findings in this way: “If you like stretching, the findings of this study support the decision to stretch. However you should not expect large effects of stretching: stretching makes only a small difference to your risk of getting injured or becoming sore. If you do not like stretching you will need to weigh the small potential benefit of stretching (a small reduction in risk of being sore and a small reduction in risk of some injuries) against the effort and time it takes to stretch”.

A quantitative summary of the trial findings can be found in this PDF  The Stretching Study Summary of findings table .

A technical report of the study has been published online in the British Journal of Sports Medicine .
You can download a copy of the report here.

You can hear more about the study on Australia’s ABC Radio National Health Report

A new study by The George Institute for International Health at Sydney University has found Tai Chi to have positive health benefits for musculoskeletal pain. The results of the first comprehensive analysis of Tai Chi suggest that it produces positive effects for improving pain and disability among arthritis sufferers.

The researchers are now embarking on a new trial to establish if similar benefits can be seen among people with chronic low back pain.

“This is the first robust evidence to support the beneficial effects of Tai Chi. Our study proves that Tai Chi relieves pain and disability among people with arthritis and shows a positive trend towards effects for overall physical health. We now want to see if these benefits are the same for people suffering from low back pain”, said author Dr Chris Maher at The George Institute.

Musculoskeletal pain, such as that experienced by people with arthritis, places a severe burden on the patient and community and is recognised as an international health priority. Arthritis is the major cause of disability and chronic pain in Australia, with 3.85million Australians affected. Low back pain is the most prevalent and costly musculoskeletal condition in Australia, estimated to cost up to $1billion per annum with indirect costs exceeding $8billion.

“This research should reassure people with musculoskeletal conditions such as arthritis to seek exercise to relieve the pain. The fact that Tai Chi is inexpensive, convenient, enjoyable and conveys other psychological and social benefits supports the use this type of intervention for pain conditions”, added Ms Amanda Hall, The George Institute.

Tai Chi is a form of exercise that is regularly practiced in China for general health purposes and has gained increasing popularity in North America and Australia and thus a growing body of research aimed at investigating its health benefits has emerged.

Tai Chi is a versatile activity that can be easily incorporated into people’s daily activities. Usually preformed in a group, Tai Chi can also be practiced individually, which differs from traditional exercise therapy approaches in clinic.

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More details can be found at: http://www.biomedcentral.com/1471-2474/10/55/abstract

In the June 2009 issue, Michalsen and co. from Germany report the results of a randomized trial on the clinical effects of traditional cupping therapy in patients with carpal tunnel syndrome are presented. They found that Cupping of segmentally related shoulder zones appears to alleviate the symptoms of carpal tunnel syndrome.

Cupping, a traditional treatment that has been used in several cultures, involves creating a vacuum over certain points on the skin which, in turn, generates a small visible hematoma. Wet cupping also uses laceration of the skin so that blood is extracted from the dermal microcirculation. Cupping is claimed to work via a range of mechanisms from counter-irritation to “detoxification,” but these are mere theories that have not been tested or investigated.

The results of the RCT appear to be encouraging and the authors conclude that “cupping therapy effectively relieves symptoms and pain…”

Michalsen et al recruited their patients through a press release and randomized them into 2 groups. The experimental group received “gentle scarification by means of a microlancet,” followed by wet cupping and subsequent bandaging of the wound. The control group received no scarification, cupping, or bandaging but only a heat pack.
Patients were followed up on day 7 after treatment. The primary outcome, severity of CTS symptoms, was statiscally reduced at day 7 in the cupping group. “The treatment was safe and well tolerated and conclude that cupping therapy may be effective in relieving the pain and other symptoms related to CTS.”

The editor of the journal wrote “Ideally we need a trial where patients are adequately blinded such that any nonspecific effects are neutralized”. Michalsen et al write that “a sham cupping treatment is not available at present.” The editor emphasized it would be possible to create a good sham intervention, and implement it in a truly rigorous RCT of cupping.

1. Michalsen A, Bock S, Lüdtke R, Rampp T, Baecker M, Bachmann J, et al. Effects of traditional cupping therapy in patients with carpal tunnel syndrome. A randomized controlled trial. J Pain. 2009;10:601–608.

Abstract

We investigated the effectiveness of cupping, a traditional method of treating musculoskeletal pain, in patients with carpal tunnel syndrome (CTS) in an open randomized trial. n = 52 outpatients (58.5 ± 8.0 years) with neurologically confirmed CTS were randomly assigned to either a verum (n = 26) or a control group (n = 26). Verum patients were treated with a single application of wet cupping, and control patients with a single local application of heat within the region overlying the trapezius muscle. Patients were followed up on day 7 after treatment. The primary outcome, severity of CTS symptoms (VAS), was reduced from 61.5 ± 20.5 to 24.6 ± 22.7mm at day 7 in the cupping group and from 67.1 ± 20.2 to 51.7 ± 23.9mm in the control group [group difference –24.5mm (95%CI –36.1; –2.9, P < .001)]. Significant treatment effects were also found for the Levine CTS-score (–.6 pts: 95%CI –.9; -.2, P = .002), neck pain (-12.6mm; 95%CI −18.8; −6.4, P < .001), functional disability (DASH-Score) (–11.1 pts; 95%CI –17.1; –5.1, P < .001), and physical quality of life (.3; 95%CI .0; .3, P = .048). The treatment was safe and well tolerated. We conclude that cupping therapy may be effective in relieving the pain and other symptoms related to CTS. The efficacy of cupping in the long-term management of CTS and related mechanisms remains to be clarified.

OBJECTIVES: Low-intensity low-frequency electrostimulation delivered within a myofascial trigger point (MTP) has been used as intervention to deactivate MTPs. The therapeutic effect has been suggested to be due to peripheral mechanisms. However, nonpainful stimuli are also known to reduce simultaneous pain through central effects. The primary objective of the present study was to assess if central pain modulation occurs after intervention with low-intensity electrostimulation within an MTP. We hypothesized that intervention induces pain inhibition via the periaqueductal gray (PAG).

METHODS: Twenty-four patients with myofascial pain syndrome participated in the study. During functional magnetic resonance scanning, painful (high-intensity) intramuscular electrostimulation was delivered at random intervals (mean interstimulus interval=10.2 s) within an MTP of the upper left trapezius muscle. In-between scanning sessions, intervention (intramuscular electrostimulation, low-intensity, interstimulus interval=0.5 s) was applied to the same area. Patients were divided into responders and nonresponders according to their change in pressure pain thresholds relative to intervention. In addition to a whole brain search, a region of interest approach was also implemented to test the effect of intervention on PAG signal change.

RESULTS: The main findings were:
(1) intervention modulated PAG activity to painful stimuli more in responders than in nonresponders,
(2) change in PAG activity from the whole patient population correlated with change in pressure pain threshold, and
(3) a network known to regulate affective qualities of the pain experience was (subsignificantly) engaged more in responders than in nonresponders.

DISCUSSION: The applied intervention most likely involves supraspinal pain control mechanisms related to both antinociception and regulation of pain affect.

The Clinical Journal of Pain: June 2007 - Volume 23 - Issue 5 - pp 440-448
Niddam, David M. PhD; Chan, Rai-Chi MD; Lee, Si-Huei MD; Yeh, Tzu-Chen MD, PhD; Hsieh, Jen-Chuen MD, PhD

Excessive yawning induced by stimulation of myofascial trigger point – case report
C.-C. Chang and S.-T. Chang
Department of Physical Medicine and Rehabilitation, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan

We describe a 44-year-old female patient with unusually severe muscle tightness in upper trapezius, levator scapulae, scalenes and the suboccipital extensors pain, which are ascribable to subcutaneous posterior cervical and thoracic trigger points. She was referred to our department for further rehabilitation therapy because of the muscle pain, which was in accordance with marked hyperesthesia, but without referred (distant) pain. She had no history of hypertension, diabetes mellitus, dyslipidemia or cardiac arrhythmia. There were no specific illnesses in her family background. Results of all laboratory tests were within normal limits. A possible contribution might come from the preexisting degenerative change of cervical spine found on the plain films. Maneuver of self-myofascial release (SMR) together with stretching exercise learned from our therapist was used to improve myofascial restrictions and to restore soft-tissue extensibility. Interestingly, several days later, excessive yawning developed whenever she was performing SMR in our physiotherapy room .

Myofascial pain syndrome (MPS), a kind of non-articular musculoskeletal problem, is a painful condition associated with regional pain and muscle tenderness depicted by the presence of myofascial trigger points (MTPs) with hypersensitive nodules. The signs and symptoms associated with MPS include taut muscular bands, palpable nodules, pain are exacerbated by stress and referred pain patterns [1]. There has been no consensus to diagnose the criteria of MPS, but it is commonly agreed that pain is a significant manifestation arising from MTPs [2]. MTPs are manifested as focal muscle contracture on which pressure induces pain and twitching responses [1].
With regard to the treatment of MTPs, the therapeutic effect on the muscle contractions has been suggested to be due to stretch and relaxation of the involved deep muscle fibers possibly resolving the local ischemia postulated as underlying cause of the pain [3]. Considering another treatment, the SMR is a technique used to mitigate myofascial restrictions and restore the extensible structure of soft-tissue [4]. Niddam et al. have recently provided evidence that the intervention of MTP at least partially involves supraspinal pain control via midbrain periaquaduct gray (PAG) [5]. In addition, van der Plas et al. suggested the PAG involving in the hypotensive pathway can be activated by the electrical stimulation of hypothalamic areas [6].
The above points of view imply that the central modulation of pain evoked from MTP might be connected to excessive yawning via spinothalamic tract, PAG and hypothalamus. Regarding the relationship between excessive yawning and thermoregulation [7], excessive yawning has been noted as a symptom of abnormal thermoregulation influenced by hypothalamus [8]. However, further research should be performed to identify the possible connection between specific thermal responsiveness of ventromedial hypothalamic neurons and yawning induced by the stimulation of MTPs in addition to the nonthermal-related excessive yawning [9].

European Journal of Neurology
Volume 16, Issue 6, Pages e118-e119

A New guideline from NICE, the National Institute for Health and Clinical Excellence, in the UK, say people with low back pain should be offered alternative treatments including manual therapy and acupuncture. It’s the first time that NICE, has recommended alternative treatments.

The guideline covers the early treatment and management of persistent or recurrent low back pain,
defined as non-specific low back pain that has lasted for more than 6 weeks, but for less than
12 months. Non-specific low back pain is tension, soreness and/or stiffness in the lower back region for which it isn’t possible to identify a specific cause of the pain. Several structures in the back, including the joints, discs and connective tissues, may contribute to symptoms.

The new guidelines say people who’ve had lower back pain for more than six weeks should be offered one of the following, according to their own preference:
(1) Structured exercise programme:
– up to 8 sessions over up to 12 weeks
– supervised group exercise programme in a group of up to 10 people, tailored to the person
– one-to-one supervised exercise programme only if a group programme is not suitable
– may include aerobic activity, movement instruction, muscle strengthening, postural control and stretching
(2) Manual therapy:
Manual therapy is a collective term that includes spinal manipulation, spinal mobilisation and massage.
– course of manual therapy, including spinal manipulation
– up to 9 sessions over up to 12 weeks
(3) Acupuncture:
– course of acupuncture needling
– up to 10 sessions over up to 12 weeks

If the chosen treatment doesn’t result in satisfactory improvement, consider offering another of these options