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Neuro Emotional Technique for the treatment of trigger point sensitivity in chronic neck pain sufferers: A controlled clinical trial

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Trigger points have been shown to be active in many myofascial pain syndromes. Treatment of trigger point pain and dysfunction may be explained through the mechanisms of central and peripheral paradigms. This study aimed to investigate whether the mind/body treatment of Neuro Emotional Technique (NET) could significantly relieve pain sensitivity of trigger points presenting in a cohort of chronic neck pain sufferers. Sixty participants presenting to a private chiropractic clinic with chronic cervical pain as their primary complaint were sequentially allocated into treatment and control groups. Participants in the treatment group received a short course of Neuro Emotional Technique that consists of muscle testing, general semantics and Traditional Chinese Medicine. The control group received a sham NET protocol. Outcome measurements included pain assessment utilizing a visual analog scale and a pressure gauge algometer. Pain sensitivity was measured at four trigger point locations: suboccipital region (S); levator scapulae region (LS); sternocleidomastoid region (SCM) and temporomandibular region (TMJ). For each outcome measurement and each trigger point, we calculated the change in measurement between pre- and post- treatment. We then examined the relationships between these measurement changes and six independent variables (i.e. treatment group and the above five additional participant variables) using forward stepwise General Linear Model. The visual analog scale (0 to 10) had an improvement of 7.6 at S, 7.2 at LS, 7.5 at SCM and 7.1 at the TMJ in the treatment group compared with no improvement of at S, and an improvement of 0.04 at LS, 0.1 at SCM and 0.1 at the TMJ point in the control group, (P < 0.001). After a short course of NET treatment, measurements of visual analog scale and pressure algometer recordings of four trigger point locations in a cohort of chronic neck pain sufferers were significantly improved when compared to a control group which received a sham protocol of NET. Chronic neck pain sufferers may benefit from NET treatment in the relief of trigger point sensitivity. Further research including long-term randomised controlled trials for the effect of NET on chronic neck pain, and other chronic pain syndromes are recommended. This trial has been registered and allocated the Australian Clinical Trials Registry (ACTR) number ACTRN012607000358448. The ACTR has met the requirements of the ICMJE's trials registration policy and is an ICMJE acceptable registry.
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BioMed Central
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Chiropractic & Osteopathy
Open Access
Research
Neuro Emotional Technique for the treatment of trigger point
sensitivity in chronic neck pain sufferers: A controlled clinical trial
Peter Bablis
1
, Henry Pollard*
1,2
and Rod Bonello
1
Address:
1
Macquarie Injury Management Group, Macquarie University, Sydney, Australia and
2
Director of Research, ONE Research Foundation,
Encinitas, California, USA
Email: Peter Bablis - pb@universalhealth.com.au; Henry Pollard* - hpollard@optushome.com.au; Rod Bonello - rbonello@els.mq.edu.au
* Corresponding author
Abstract
Background: Trigger points have been shown to be active in many myofascial pain syndromes. Treatment
of trigger point pain and dysfunction may be explained through the mechanisms of central and peripheral
paradigms. This study aimed to investigate whether the mind/body treatment of Neuro Emotional
Technique (NET) could significantly relieve pain sensitivity of trigger points presenting in a cohort of
chronic neck pain sufferers.
Methods: Sixty participants presenting to a private chiropractic clinic with chronic cervical pain as their
primary complaint were sequentially allocated into treatment and control groups. Participants in the
treatment group received a short course of Neuro Emotional Technique that consists of muscle testing,
general semantics and Traditional Chinese Medicine. The control group received a sham NET protocol.
Outcome measurements included pain assessment utilizing a visual analog scale and a pressure gauge
algometer. Pain sensitivity was measured at four trigger point locations: suboccipital region (S); levator
scapulae region (LS); sternocleidomastoid region (SCM) and temporomandibular region (TMJ). For each
outcome measurement and each trigger point, we calculated the change in measurement between pre-
and post- treatment. We then examined the relationships between these measurement changes and six
independent variables (i.e. treatment group and the above five additional participant variables) using
forward stepwise General Linear Model.
Results: The visual analog scale (0 to 10) had an improvement of 7.6 at S, 7.2 at LS, 7.5 at SCM and 7.1
at the TMJ in the treatment group compared with no improvement of at S, and an improvement of 0.04
at LS, 0.1 at SCM and 0.1 at the TMJ point in the control group, (P < 0.001).
Conclusion: After a short course of NET treatment, measurements of visual analog scale and pressure
algometer recordings of four trigger point locations in a cohort of chronic neck pain sufferers were
significantly improved when compared to a control group which received a sham protocol of NET.
Chronic neck pain sufferers may benefit from NET treatment in the relief of trigger point sensitivity.
Further research including long-term randomised controlled trials for the effect of NET on chronic neck
pain, and other chronic pain syndromes are recommended.
Trial Registration: This trial has been registered and allocated the Australian Clinical Trials Registry
(ACTR) number ACTRN012607000358448. The ACTR has met the requirements of the ICMJE's trials
registration policy and is an ICMJE acceptable registry.
Published: 21 May 2008
Chiropractic & Osteopathy 2008, 16:4 doi:10.1186/1746-1340-16-4
Received: 12 May 2007
Accepted: 21 May 2008
This article is available from: http://www.chiroandosteo.com/content/16/1/4
© 2008 Bablis et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0
),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Background
Trigger points have been defined as discrete, hyperirritable
foci usually located within a taut band of skeletal muscle
[1]. The point is a well-circumscribed area in which pres-
sure produces a characteristic referred pain, tenderness
and autonomic phenomena [1]. Trigger points are consid-
ered an essential defining part of the myofascial pain syn-
drome, in which widespread or regional muscular pain is
a cause of musculoskeletal dysfunction [2], as well as
being associated with hyperalgesia, restriction of daily
function or psychological disturbance [3]. Upon clinical
presentation, trigger points are classified depending on
certain characteristics. An active trigger point is defined as
one with spontaneous pain, or pain in response to move-
ment. It is tender on palpation, and may present with a
referral pattern of pain, not at the site of the trigger point
origin. A latent trigger point is a sensitive spot that causes
pain or discomfort only in response to compression. Trig-
ger points are reported to occur more frequently in cases
of mechanical neck pain than in matched controls [4].
Patients may only become aware of pain when pressure is
applied to a muscular point of restriction or weakness.
The pathogenesis of trigger points is not clear, but it is
believed they arise from more than one cause [5]. Fischer
[5] has suggested that trigger points are due to the sensiti-
sation of nerves and the tenderness results from the
decrease in the pain pressure threshold. He further opines
that the tissue damage associated with injury causes the
release of inflammatory products that increase the sensi-
tivity of the nerve to stimulation. These substances
include bradykinins, 5-HT and prostaglandins, though a
recent study found tender points in the trapezius muscle
of patients with tension-type headache were not sites of
ongoing inflammation [6]. Trigger points are also thought
to arise from acute trauma or repetitive microtrauma, such
as lack of exercise, poor nutrition, postural imbalances,
vitamin deficiencies, sleep disturbances and joint prob-
lems [7]. One study suggests overloading of muscle fibres
may lead to involuntary shortening, oxygen and vitamin
deficiencies and increased metabolic demand on local tis-
sues [8], and trigger points have been suggested as
decreasing the extensibility and contractile efficiency of
muscles, and possibly causing muscle fatigue [9]. This is
yet to be confirmed by research.
Trigger points have been shown to be active in fibromyal-
gia [10,11], as well as somatic tenderness secondary to vis-
ceral dysfunction [2], migraine and other forms of non-
pathological headache [12], shoulder [13] neck [14] and
back pain [15]. Specifically, Rosomoff and co-workers
[15] demonstrated that approximately 97% of persons
with chronic intractable pain have trigger points, and of
these, 45% have a non-dermatomal referred pain. Further-
more, Rosomoff's team demonstrated that 100% of neck
pain sufferers possessed the presence of trigger points and
almost 53% of them had non-dermatomal referral [15].
However, it is worthy of note that no evidence describes
the prevalence of trigger points of the neck and face in a
normal population. Indirect evidence presented in the
equine model suggests there to be significant differences
between active trigger points and control points [16].
The diagnosis of a trigger point involves physical exami-
nation by an experienced therapist using a set of cardinal
signs (Table 1) [1]. There have been many studies focused
on the assessment of the reliability of detecting trigger
points. Lew et al. [17] found that both inter and intra-rater
reliability, using two highly trained examiners was poor,
while Gerwin et al [18] found that extensive training of
four clinicians together resulted in improved reliability for
the identification of trigger points. Reeves et al. [19] dem-
onstrated a moderate degree of intra and inter examiner
reliability in determining the location of trigger points. In
older studies values ranged from r = 0.68 to r = 0.86 [19].
In a study by Delaney and McKee [20], interclass correla-
tion co-efficient (ICC) revealed inter-rater reliability to be
high (values ranged from ICC = 0.82 to ICC = 0.92), and
intra-rater reliabilities to be high (values ranged from ICC
= 0.80 to ICC = 0.91) for the use of a pressure threshold
meter in measuring trigger point sensitivity.
In both clinical and experimental practice, a device such
as the pressure algometer would be of great value for reli-
able quantification of trigger point sensitivities, once
manually located. Fischer [5] demonstrated that the use of
algometry in the detection of trigger points was a reliable
procedure. He assessed the pressure threshold of deep ten-
derness in soft tissues, before and after various forms of
treatment such as physiotherapy and drug therapy. In
addition, Reeves et al. [19] reviewed studies that demon-
strated the reliability of the pressure algometer. He found
Table 1: The Cardinal Signs of a Trigger Point (adapted from Simons, Travell and Simons [1]).
Cardinal Signs of a Trigger Point
- Presence of a taut band in the target muscle
- A nodular point of tenderness
- A jump sign: Patient reacts to the application of digital pressure to the taut band or nodular point
- Referral of pain on the application of pressure to the taut band or nodule
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that an experimenter was able to reliably obtain similar
measurements on two occasions, as well as produce simi-
lar scores to independent experimenters. He also noted
that agreement was found between two experimenters
when locating unmarked trigger points and measuring
their sensitivity, but did stress the importance that experi-
menters were experienced and trained. In patients who
present to manual therapists, the use of algometry can be
used to reliably quantify the tenderness associated with a
trigger point and can be used to diagnose their location as
well as to qualify the degree of pressure sensitivity.
Trigger points are potential outcomes of dysfunction in a
region, and conventional treatment is based around the
release of this taut band of skeletal muscle. Manual ther-
apy [21], chiropractic treatment [1,22], electric therapy
[23], local anaesthetic [24] and active therapy [25] have
all been claimed to provide relief of trigger point sensitiv-
ity. Injection therapies involved the use of local anaes-
thetic and saline, while it is postulated that massage and
myofascial release aim to increase local circulation,
improve mobility and relieve subcutaneous tightness. Fur-
thermore, the presence of trigger points has been fre-
quently associated with signs and symptoms in addition
to pain [26], and these syndromes may be in found in dis-
orders associated with chronic psychosocial factors [27].
Whilst it is likely the pathogenesis has at least a partly cen-
tral mechanism, most approaches to the management of
the trigger point phenomenon utilise only peripheral
approaches to the points themselves.
Therapy for trigger points requires an approach that
enhances the central inhibition through pharmacological
or behavioural techniques, and reduces the peripheral
inputs to the maintenance of the reflexes by utilising phys-
ical therapies such as exercise [28], needling and digital
pressure [29]. Offenbacher & Stucki [30] have also sug-
gested that a combined approach to therapy would be
warranted for patients exhibiting myofascial (as well as
other) symptoms in conditions such as fibromyalgia. It
was the specific aim of this research to investigate whether
a new mind body technique called Neuro Emotional
Technique (NET) could significantly relieve pain sensitiv-
ity of trigger points presenting in a cohort of neck pain suf-
ferers.
This study investigated the effects of Neuro Emotional
Technique (NET) on the sensitivity of trigger points pre-
senting in regions of the neck including the suboccipital
region, levator scapulae region, sternocleidomastoid
insertion region and temporomandibular region, in a
cohort of chronic neck pain sufferers. The results of the
study could provide useful information or the treatment
of cervical pain and related psychosocial problems.
Methods
This study received ethics approval from the Macquarie
University Ethics Committee, reference number:
HE24AUG2007-D05403.
Participants
This research was performed in a private practice setting in
Sydney, Australia. A convenience sample of sixty consecu-
tive participants was recruited from new patients present-
ing during the period between February 2005 and June
2005. Every third consecutive chronic neck pain partici-
pant was allocated to a blinded control group to eliminate
selection bias. This protocol resulted in 40 participants
allocated to the treatment group and 20 allocated to the
control group. Sequential allocation was concealed from
the participants. Participants provided informed written
consent prior to participating in the project.
All participants presenting with chronic cervical pain
(greater than 3 months duration) as their primary com-
plaint were invited to participate. Cervical pain was
defined as pain located from a horizontal line drawn at
the level of the 1
st
thoracic vertebrae to a horizontal line
drawn at the level nuchal line of the occiput, and laterally
to the lateral border of the trapezius muscles. Those par-
ticipants who did not have neck pain and headache, or
have acute cervical pain were excluded from the study, as
were participants under 18 years of age, or had undergone
recent surgery or were suffering any concurrent pathology.
Pre-Treatment Protocol
All participants underwent a standard patient evaluation
that included an interview, a questionnaire and a standard
physical examination. This provided information for each
participant in terms of age (years), sex, cause of injury (i.e.
motor vehicle accident), and duration of pain (months).
In addition, participants were evaluated for the presence
of cardinal signs of a trigger point (See Table 1) at four
specific areas. The four areas of trigger points specifically
targeted were the belly of the suboccipital (S) muscle,
levator scapulae (LS) insertion, sternocleidomastoid
(SCM) insertion and the belly of the masseter muscle
(referred to as the temporomandibular (TMJ) region)
(Figures 1, 2, 3).
The patients' perceived pain levels were assessed via a 100
mm visual analog scale (VAS) while the examiner pal-
pated and verified the existence of the trigger point. Partic-
ipants were asked to score the intensity of the pain using
a metal slider with a graduated 10-centimetre rule. Partic-
ipants were asked to rate their pain with zero (0) being no
pain and ten (10) being the worst pain they could imagine
by sliding the ruler to the point that represented their pain
on the scale 0 to 10. Gallagher reports a 13 mm difference
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on the VAS represents the smallest measurable change in
pain severity that is clinically important [31].
Furthermore, a pressure gauge algometer (PGA: Pain
Diagnostics & Thermography Inc, 17 Wooley Lane East,
Great Neck, NY 11021, USA) was used on the location of
the trigger point to assess the amount of pressure the
patient could sustain before the patient registered the
pressure as being painful. These assessments were per-
formed before and after the intervention. The pain thresh-
old meter or PGA consists of a rubber disc with a surface
of exactly 1 cm
2
that is attached to a force (pressure)
gauge. The gauge is calibrated in kilograms and pounds.
According to Smyth [32], the use of the device with a 1
cm
2
disc rather than other larger sizes at its tip has been
called more suitable for the assessment of deep muscle
trigger points.
The participants had the use of the PGA explained to them
using the protocol of Fischer [33], and also the location of
the pain. Following the explanation, the point of maxi-
mum tenderness was determined and marked with indel-
ible ink. Once marked, the pressure threshold was
determined using a control point in a non- painful muscle
in an unrelated area. The control point was taken as the
equivalent point on the opposite side of the body if not
tender; if tender another soft tissue non-tender point was
identified. Once determined, the practitioner guided the
tip of the gauge between the finger and the thumb to
avoid slipping by rounded contours. It was applied per-
pendicular to the long axis of the structure on which it was
placed (Figures 4, 5, 6, 7).
In addition, all participants were asked to rate the inten-
sity of the pain at the trigger point location on the appli-
cation of progressively increasing increments of pressure
(0.45 kg/2.54 cm2 (1 lb/inch 2) at 0.45 kg (1 lb) every one
second [34]). The practitioner used a PGA to score the
pain. The PGA measures the depth of depression of the
muscle during the application of pressure through the
device by the practitioner. Utilising this protocol, the
practitioner was able to determine the gross amount of
depression for a given pain score [34].
Sternocleidomastoid insertion trigger point regionFigure 3
Sternocleidomastoid insertion trigger point region.
Levator scapulae insertion trigger point regionFigure 2
Levator scapulae insertion trigger point region.
Suboccipital and temporomandibular trigger point regionFigure 1
Suboccipital and temporomandibular trigger point region.
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After participants were assessed for the cardinal signs of a
trigger point (Table 1) both groups received their assigned
intervention protocol. The control group received sham
NET protocol, whilst the treatment group received NET
protocol. Participants returned for re-assessment three
days post intervention (See Figure 8).
NET Treatment Protocol
After assessment, participants in the treatment group
underwent the NET protocol as outlined by Walker [35].
The detailed first 12 steps of the NET protocol used in this
study are shown in Additional File 1. Neuro Emotional
Technique, often described as a complementary and alter-
native medicine modality, was administered during the
study as a technique designed to incorporate central and
peripheral components to alleviate the effects of distress-
ing stimuli [36]. Developed by Walker [35], NET has been
described as a 15 step, multi-modal intervention that
incorporates principles of several health disciplines,
including cognitive behavioural psychology, traditional
Chinese medicine pulse assessment, and a feedback tech-
nique called the muscle test [37]. A major goal of NET is
to achieve a reversal (or extinction) of classically condi-
tioned distressing emotional responses to trauma related
stimuli, stimuli that have the characteristic ability to
reproduce or augment pain and other signs of disease
without the original stressor(s) being present. This objec-
tive is similar to treatments of standard cognitive behav-
ioural therapy for traumatic stress, such as exposure
therapy [36]. NET differs from such treatments in that it
supposedly engages the energy system as it is conceived in
the traditional Chinese medical model [38]. This entails
the patients touching the relevant pulse point on the wrist
that is determined to be involved in the body's stress reac-
tion to the given stimuli (Fig 9.) Using principles of tradi-
tional Chinese five-element theory [39], the therapist
helps the patient identify the particular pulse point using
an application of major energy channels, or 'meridians',
that contain specific emotional qualities. In the NET
framework it is thought that the engagement of the body's
energy system in the cognitive-emotional processing of an
event facilitates a resolution to the event [40]. NET aims
to help patients become less physiologically reactive to
distressing stimuli and to become more competent in
choosing alternative responses. NET is intended to be a
Suboccipital region pressure gauge algometer applicationFigure 4
Suboccipital region pressure gauge algometer application.
Levator scapulae insertion region pressure gauge algometer applicationFigure 5
Levator scapulae insertion region pressure gauge algometer
application.
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brief, time-limited intervention. Several recent publica-
tions have discussed the use of NET for conditions such as
hypothyroidism [41] and polycystic ovarian related infer-
tility [42]. In the only clinical trial, investigators demon-
strated a significant decrease in phobic symptoms
following a brief course (2–3 visits) of a variation of NET
[43,44].
Participants were asked to return 3 days later for assess-
ment of the pain level using the VAS and to determine the
status of the four cardinal signs of a trigger point using the
PGA.
Control Treatment Protocol
After the initial assessment, participants in the control
group underwent the sham NET protocol. This included
an information session, painless palpation of trigger
points and administration of a sham NET protocol. Partic-
ipants were asked to return 3 days later for assessment of
the pain level using the VAS and to determine the status of
the four cardinal signs of a trigger point using the PGA.
The assessments were performed by a chiropractor
(number one) and the treatment was provided by another
chiropractor (number two). The results of the study were
tabulated by a third chiropractor. Chiropractor number
one was unaware of the assignment of subjects to groups.
Statistical Analysis
The results were analysed using parametric statistics
because, within each treatment group, each of the
dependant variables exhibited uni-modal frequency dis-
tributions that did not differ significantly from normal
distributions. In all cases the threshold probability for sig-
nificance was 0.05.
Several different statistical methods were adopted. Data
analysis of group participation was performed using anal-
ysis of variance (ANOVA). The experimental design for
this project is split-plot, with patients allocated to treat-
ments and assessments made on each patient pre and post
treatment. As only two assessments were involved, the
split-plot analysis is equivalent to a Students t-test of dif-
ferences (pre-post for VAS scores and post-pre for PGA
measurements. We used GenStat (Payne et al, 2008) for
these analyses, with the package testing for treatment var-
iances automatically before testing for means.
Results
Participants
The average age for participants was 44.1 yrs old (S.D. =
11.7 yrs), with 56% female participants in the treatment
group and 55% in the control group. The average duration
of pain for all participants was 21.0 months (S.D. = 20.5
months). The severity of pain (an average of VAS scores
across trigger points) for patients arriving at the clinic was
8.8 (S.D. = 0.51). There were no significant differences
between the two groups for any of these variables (see
Table 2 for details).
Comparison of control and treatment groups
At all four trigger points, the average change in both VAS
scores and PGA measurements for the treatment group
was strongly significantly different (P < 0.001) from that
for the control group. The mean changes for the two
groups are presented in Table 3. In every case, there was
strong evidence (P < 0.001) of unequal sample variances,
and hence, for the t tests of equal means, variances were
Temporomandibular region pressure gauge algometer appli-cationFigure 7
Temporomandibular region pressure gauge algometer appli-
cation.
Sternocleidomastoid insertion region pressure gauge algom-eter applicationFigure 6
Sternocleidomastoid insertion region pressure gauge algom-
eter application.
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estimated separately for each group. (This form of the t
test is sometimes called the Satterthwaite t test.) Relative
changes to VAS and PGA have been shown in Figures 10
and 11. Scatter plots of raw data is presented for the reader
to visualise the variation between individuals for both the
VAS and PGA outcome measures (Fig 12 and 13).
Control group
For the control group, the change in mean VAS scores was
significantly different from 0 (P = 0.003) at the SCM trig-
ger point. However, the difference, 14 mm, was only just
clinically important; the 95% confidence interval (CI) for
this difference was (5 mm, 22 mm). None of the other
seven mean changes was significantly different from 0.
Treatment group
For the treatment group, all eight individual changes were
strongly significantly different from 0 (P < 0.001). The
mean change in VAS scale for S was 7.6 (95% CI: 7.3, 7.9),
LS was 7.2 (95% CI: 7.0, 7.4), SCM was 7.3 (95% CI: 6.5,
8.1) and TMJ was 6.9 (95% CI: 6.1, 7.7). The mean change
in PGA readings for S was 5.8 (95% CI: 5.6, 6.0), LS was
5.8 (95% CI: 5.7, 6.0), SCM was 5.9 (95% CI: 5.7, 6.1)
and TMJ was 5.8 (95% CI: 5.4, 6.3).
Correlation coefficients
Improvement at one particular trigger point was not asso-
ciated with similar improvements in the same subject for
any other measurement-trigger point combinations.
There were no significant pair-wise correlations amongst
the eight improvements (i.e., both VAS and PGA measure-
Trigger Point study – CONSORT FlowchartFigure 8
Trigger Point study – CONSORT Flowchart.
Trigger Point CONSORT Flowchart
Assessed for eligibility
(n= 60 participants)
Enrollment
Excluded (n= 0)
Randomisation
Allocated to NET protocol (n=40)
Received allocated intervention
(
n=40
)
Allocated to control (n=20)
Received allocated intervention
(
n=20
)
Lost to follow up (n=0)
Lost to follow up (n=0)
Analysed (n= 40) Analysed (n= 20)
Follow Up Period
– 3 days
Analysis
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ments and the four trigger points; P values > 0.05; Pearson
Correlation Test).
Discussion
Recordings of visual analog scale significantly decreased
in sensitivity, and pressure algometer readings signifi-
cantly increased after a single NET treatment. In this
cohort, the use of an NET based cognitive restructuring
and meridian correction protocol, which purports to iden-
tify an initial causative issue of the presenting pain and
dysfunction, had the ability to produce good improve-
ments in simple muscle pain outcomes in the short term,
in a small cohort of chronic neck pain sufferers. As a part
of the NET protocol psychosocial components of the
physical condition are considered. For example, emotion
and memory associated with any relevant traumatic event
is considered important in the recall of the painful experi-
ence, as investigated with the NET process. Participants
are encouraged to reflect with direct referential statements
on the variables whilst also considering the presenting
symptoms. The technique does not incorporate a "talk it
out therapy" or attempt to provide any psychoanalysis
during the process.
Pain is a complicated, individual and variable experience
[41]. Pain can alter in different conditions so it is impor-
tant to assess pain under standardised conditions. Pain
should be assessed: in the same location, on the same type
of tissue (muscle) in a similar area of sensitivity (neck has
a different sensitivity to a back or a knee), by the same
practitioner using the same method of assessment
[4,40,42]. Patient factors such as attitude, sex, cultural role
and age must be recognised in studies such as this, in
which participants record their own levels of pain [44].
Algometry is used to measure the sensitivity of pain or
pressure [4]. Algometer instrumentation can include man-
ual and electric models. The use of any experimental
instrument including the PGA must be tested for validity
and reliability between examiners and between perform-
ances of the same examiner. The PGA used in this study
has been tested against itself, palpation, pressure plates
with reliable results [17,18]. However, the above is based
on the assumption that the tester is trained in the applica-
tion of the PGA otherwise issues associated with the rate
of pressure application [45-47] the determination of an
end point based on a verbal patient response [45,46] and
the possible sensitisation of a selected landmark based on
repeated measures may all alter the accuracy of the out-
come.
This study used the PGA in near optimal conditions. Chi-
ropractor one, who used the PGA in the assessment of the
trigger points had been routinely using the PGA for several
years in a similar fashion to the use described in this study
and was thus highly trained in the operation of the PGA.
The electronic device, not used in this protocol, has been
described as being superior to non-electronic algometric
devices as such devices can control the rate of pressure
application and minimise examiner reaction as well as
calibrate itself [48]. The use of a highly trained individual
minimised the risk of error from these sources but did not
Table 2: Baseline comparisons of control and treated groups of patients
Control (n = 20) Treatment (n = 40)
Mean SEM
1
Mean SEM P for comparison
Age (years) 41.2 2.37 45.6 1.90 0.180
Time with pain (months) 19.5 3.59 21.7 3.57 0.700
Severity of trigger point pain on presentation (VAS) 8.9 0.08 8.8 0.09 0.374
SEM: Standard error of mean
Acupuncture pulse points used at the wristFigure 9
Acupuncture pulse points used at the wrist. From Walker
1996 [34] (Used with permission).
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Page 9 of 12
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eliminate it [49]. Despite early support, the ongoing utili-
sation of pressure algometry in manual therapy warrants
further research into the validity, effectiveness and best-
use principles of such an instrument.
This study represented a first small step into creating a
body of clinical literature on the usefulness of NET treat-
ment in chronic neck pain patients with trigger point
pain. The result of this study is encouraging for the man-
agement of trigger points and suggests psychosocial varia-
bles may have a beneficial effect on the intensity of trigger
points. This view is supported by the work of others [50-
53]. This contrasts with the usually described mechanisms
of trigger points that are more local or spinal in nature
[54,55]. However, if this research is reproducible it is still
unknown which component of NET is useful for painful
trigger points. It maybe that some, or all, components are
useful.
Limitations
No sample size was calculated prior to the commence-
ment of this research project. Whilst the validity and reli-
ability of NET treatments is far from proven, this study
establishes data that may be used in power calculations of
future studies to ensure that the sample sizes are large
enough to detect a worthwhile and statistically significant
effect.
No outcome measures were used to measure patient neck
pain, neck disability or global overall improvement as the
focus of this study was the resolution of the trigger points.
It is recommended that future studies specifically include
neck pain and a co variable and use appropriate outcome
measures such as the Neck Disability Index [56] or the
Patient-Specific Functional Scale [57]. In this trial we used
patient perceived pain levels and the amount of sustaina-
ble pressure via algometer readings at the trigger point site
to denote the level of activity of the trigger points. How-
ever, more extensive and clinically relevant outcome
measures will be required for use in the interpretation of
the effectiveness of this intervention in neck pain in the
clinical setting.
With regard to the ratio of treatment to control partici-
pants, the 2:1 ratio of allocation was chosen for two prag-
matic reasons. The first was to better estimate the effect of
Table 3: Changes to trigger point sensitivity in control and
treatment groups.
CONTROL (n = 20) TREATMENT (n = 40)
Mean SEM Mean SEM
VAS Subocc 0.02 0.05 7.6 0.16
Lev/Scap -0.03 0.06 7.2 0.11
SCM 0.14 0.04 7.6 0.24
TMJ 0.13 0.07 7.3 0.28
PGA Subocc 0.09 0.04 5.8 0.09
Lev/Scap 0.05 0.05 5.8 0.08
SCM 0.06 0.04 5.9 0.11
TMJ 0.08 0.05 5.8 0.23
VAS: visual analog scale; PGA: pressure gauge algometer readings;
Subocc: suboccipital trigger point location; Lev/Scap: levator scapulae
insertion trigger point location; SCM: sternocleidomastoid trigger
point location; TMJ: temporomandibular trigger point location)
Relative changes to visual analog scale scoresFigure 10
Relative changes to visual analog scale scores. (VAS: visual analog scale; PGA: pressure gauge algometer readings; Sub-
occ: suboccipital trigger point location; Lev/Scap: levator scapulae insertion trigger point location; SCM: sternocleidomastoid
trigger point location; TMJ: temporomandibular trigger point location).
Chiropractic & Osteopathy 2008, 16:4 http://www.chiroandosteo.com/content/16/1/4
Page 10 of 12
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this preliminary investigation on the target tissues. The
second and possibly more important factor, was the ethi-
cal requirement to provide patients who presented with
pain the best treatment possible, and not a sham/control
pseudo treatment. Future studies could incorporate a
"waiting list" approach [58] to treatment rendered to the
control group after allocation and completion of "treat-
ment" rendered in the sham/control group and after
appropriate informed consent.
This study was quasi-experimental; participants were
sequentially allocated into treatment and control groups.
Quasi-experiments are potentially prone to selection bias,
that is, unobservable effects that are either unknown to
the researcher or not easily measured which may ulti-
mately affect the study outcome. Randomised controlled
trials are the gold standard in evidence based research for
efficacy and causal relationship, whilst quasi-experimen-
tal studies provide evidence for clinical effectiveness and
Relative changes to pressure gauge algometer readingsFigure 11
Relative changes to pressure gauge algometer readings. (VAS: visual analog scale; PGA: pressure gauge algometer
readings; Subocc: suboccipital trigger point location; Lev/Scap: levator scapulae insertion trigger point location; SCM: sterno-
cleidomastoid trigger point location; TMJ: temporomandibular trigger point location).
Scatter plot of individual changes to visual analog scale scores in both the control and treatment groupsFigure 12
Scatter plot of individual changes to visual analog scale scores
in both the control and treatment groups.
Scatter plot of individual changes to pressure gauge algom-eter readings for both control and treatment groupsFigure 13
Scatter plot of individual changes to pressure gauge algom-
eter readings for both control and treatment groups.
Chiropractic & Osteopathy 2008, 16:4 http://www.chiroandosteo.com/content/16/1/4
Page 11 of 12
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generalisability of results. In contrast to the evidence sup-
porting preferred use of RCT over quasi-experimental trial,
two recent meta-analyses presented evidence that non-
randomised trial data may not be inferior to that obtained
from RCTs [59,60]. They concluded that the value of the
trial rests largely on its real world validity, but this presup-
poses that the trial is till structurally sound as it would be
with an RCT.
Conclusion
Trigger points have been shown to be active in many myo-
fascial pain syndromes, and previous to this study, the
treatment of such trigger points supported the potential
use of central and peripheral approaches to relieve pain
and dysfunction associated with trigger points. Neuro
Emotional Technique was administered to provide partic-
ipants with a mind/body based treatment to relieve the
sensitivity of trigger points associated with their chronic
neck pain. It was found that after a short course of NET
treatment, visual analog scale and pressure algometer
measurements of four trigger point locations were signifi-
cantly reduced compared to pre-treatment. A sham NET
protocol did not produce significant changes in visual
analog scale or pressure algometer measurements. The
successful clinic based outcomes suggest that a mind body
approach to the management of trigger points with NET
should be considered in the management of trigger points
in neck pain sufferers. Further evidence is required for bet-
ter substantiation of the use in conservative management,
with randomised controlled trials for the effect of NET on
chronic neck pain, and other chronic pain syndromes rec-
ommended.
List of abbreviations
NET: Neuro Emotional Technique; ICC: Interclass correla-
tion co-efficient; S: Suboccipital; LS: Levator scapulae;
SCM: Sternocleidomastoid; TMJ: temporomandibular
region; VAS: Visual analog scale; PGA: Pressure gauge
algometer; CAM: complementary and alternative medi-
cine; ANOVA: Analysis of variance; SD: Standard devia-
tion; CI: Confidence Interval.
Competing interests
No funding was received in the preparation of this manu-
script.
PB: Is a research student of Macquarie University.
HP: is a part time employee of 'The ONE (Our Net Effect)
Research Foundation', a non-profit organisation. As an
employee of this organization his interest in this research
would relate to the foundation's mission statement: to
establish natural healing as a standardised care through
Neuro-Emotional Technique (NET) research, education
and public service.
RB: No competing interests.
Authors' contributions
* These authors contributed equally to this work
PB Conceived the idea of the study, wrote and edited the
manuscript
HP Conceived the idea of the study, wrote and edited the
manuscript.
RB Involved in data collection, reviewed and edited the
manuscript
All authors read and approved the final manuscript.
Additional material
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NET Body Entry Protocol. The detailed description provided outlines the
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Click here for file
[http://www.biomedcentral.com/content/supplementary/1746-
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Supplementary resource (1)

... Previous limited investigations have provided evidence supporting the efficacy of NET. One trial was conducted with 60 participants with neck tenderness who received a short single NET treatment, while the control group received a control NET protocol [18]. Other case-based reports have demonstrated some scope of application for NET [19][20][21][22]. ...
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... It is an important first step in evaluating the potential utility of NET in the treatment and management of chiropractic conditions. Whilst previous case based studies have been reported (27)(28)(29)(30)(31), this is the first published randomised controlled trial for this therapy in those with low back pain. ...
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... Pain can be interrupted at 4 levels of ascending nociceptive pathway : Peripheral level, Spinal segmental level, Supraspinal level, Cortical level. According to Melzack & Wall's, gate control theory large diameter mechanoceptor produces inhibition of incoming messages of pain at the dorsal horn of spinal cord 15 Ultrasound is believed to work on painful tissues by improving circulation, has micromassage effect, cause alter viscoelasticity of collagen to become more extensible, thus increasing mobility,relieves subcutaneous tightness and thus pain 16 .Fischer and Solomon suggest that heating of the skin reduces gamma motor neuron excitability. This would decrease the sensitivity of muscle spindles, which may decrease muscle guarding 17 .Ultrasound therapy causes segmental inhibition and physiological blocking by inhibition of activity of small diameter group III & IV fibres before the incoming information ascends and also affects cell permeability and thus reduce the amount of exudates formed in inflammatory process. ...
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... The NET and placebo procedures have been described in depth by several authors [63,64,[78][79][80][81][82][83][84] and it is not within the scope of this article to replicate this discussion. A detailed version of the NET and placebo protocols used in this trial was published in an open-access journal in 2010 [85]. ...
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Hypothyroidism is a common endocrine condition. There is evidence to suggest that, for a proportion of sufferers, the standard medical treatment does not completely reverse the constitutional and neuropsychiatric symptoms brought about by this condition. The management of hypothyroidism follows a biomedical model with little consideration given to alternative management approaches. There exists anecdotal evidence and case reports supporting the use of a biopsychosocial-based intervention called Neuro-Emotional Technique (NET) for this population. The aim of this study was to explore the potential short-medium term clinical efficacy and safety of NET for individuals with primary hypothyroidism.DesignPlacebo-controlled, blinded, parallel groups, randomized trial. Ninety adults with a diagnosis of primary hypothyroidism were recruited from Sydney, Australia. Blinded participants were randomized to either the NET or placebo group and received ten intervention sessions over a six week period. The primary outcome involved the measurement of states of depression using the DASS-42 questionnaire. Secondary outcomes included thyroid function, thyroid autoimmunity testing, SF-36v2 questionnaire, resting heart rate and temperature measurement. Outcomes were obtained at baseline, seven weeks and six months. Questionnaires were completed at the private clinics, and serum measures were obtained and analysed at commercial pathology company locations. Heart rate and temperature were also measured daily by participants. Linear mixed-effects models were used to analyse the continuous outcomes. Unadjusted odds ratios with 95% confidence intervals were calculated for the binary outcomes. Participants were randomly allocated to the NET (n=44) and placebo (n=46) groups. A proportion of the sample displayed neuropsychiatric disturbances and alterations in quality of life measures at baseline. There were no statistically significant or clinically relevant changes in the primary or secondary outcomes between the NET and placebo groups at time seven weeks or six months. There were a few short-lived minor adverse events reported in both the NET and placebo groups that coincided with the application of the intervention. The application of the NET intervention appears to be safe, but did not confer any clinical benefit to the participants in this study and is unlikely to be of therapeutic use in a hypothyroid population. Australian and New Zealand Clinical Trials Registry Number: 12607000040460.
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Objective Given the complex and unclear etiology of neck pain, it is important to understand the differences in central sensitization as well as psychosocial factors in individuals with chronic neck pain and healthy controls. The purpose of this study was to benchmark differences in central sensitization, psychosocial factors, and range of motion between people with nonspecific chronic neck pain and healthy controls and to analyze the correlation between pain intensity, neck disability, and psychosocial factors in people with chronic neck pain. Methods Thirty individuals with chronic neck pain and 30 healthy controls were included in this case–control study. Outcome measures were as follows: central sensitization (pressure pain threshold, temporal summation, and conditioned pain modulation), psychosocial factors (depressive symptoms, pain catastrophizing, and quality of life), and active cervical range of motion. Results People with neck pain had lower local pressure pain threshold, a decrease in conditioned pain modulation, more depressive symptoms, greater pain catastrophizing, lower quality of life, and reduced range of motion for neck rotation when compared with healthy controls. In people with neck pain, moderate correlations were observed between pain intensity and quality of life (ρ = −0.479), disability and pain catastrophizing (ρ = 0.379), and disability and quality of life (ρ = −0.456). Conclusions People with neck pain have local hyperalgesia, impaired conditioning pain modulation, depressive symptoms, pain catastrophizing, low quality of life, and reduced active range of motion during neck rotation, which should be taken into account during assessment and treatment. Impact This study shows that important outcomes, such as central sensitization and psychosocial factors, should be considered during assessment and treatment of individuals with nonspecific chronic neck pain. In addition, pain intensity and neck disability are correlated with psychosocial factors.
Article
Objective: To conduct an updated systematic review of diagnostic criteria for myofascial trigger points (MTrPs) used in clinical trials of physical therapy interventions from 2007 to 2019. Methods: MEDLINE and Physiotherapy Evidence Database (PEDro) were searched using the following MeSH keywords: "trigger points", "trigger point", "myofascial trigger point", "myofascial trigger points", "myofascial pain" and "myofascial pain syndrome". The MeSH keywords were combined by using Boolean operators "OR"/"AND". All physiotherapy clinical trials including patients with musculoskeletal conditions characterized by at least one active MTrP or latent MTrP in any body area were selected. We pooled data from an individual criterion and criteria combinations used to diagnose MTrPs. The protocol was developed in accordance with the PRISMA-P guidelines. Results: Of 478 possibly relevant publications, 198 met our inclusion criteria. Of these 198 studies, 129 studies (65.1%) stated specifically the diagnostic criteria used for MTrPs in the main text, 56 studies (28.3%) failed to report any method whereby MTrP was diagnosed, and 13 studies (6.6%) adopted expert-based definitions for MTrPs without specification. Of 129 studies, the six criteria applied most commonly were: "spot tenderness" (n=125, 96.9%), "referred pain" (95, 73.6%), "local twitch response" (63, 48.8%), pain recognition (59, 45.7%), limited range of motion" (29, 22.5%), and "jump sign" (10, 7.8%). Twenty-three combinations of diagnostic criteria were identified. The most frequently used combination was "spot tenderness", "referred pain" and "local twitch response" (n=28 studies, 22%). Conclusions: A noteworthy number of the included studies failed in properly reporting the MTrP diagnostic criteria. Moreover, high variability in the use of MTrP diagnostic was also observed. Spot tenderness, referred pain and local twitch response were the three most popular criteria (and the most frequently used combination). A lack of transparency in the reporting of MTrP diagnostic criteria is present in the literature. Registry: This systematic review was registered under the Centre for Reviews and Dissemination, PROSPERO number: CRD42018087420.
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Introdução: Síndrome dolorosa miofascial é uma condição dolorosa regional, caracterizada por bandas musculares tensas, havendo áreas hipersensíveis chamadas de pontos gatilho. Objetivo: Revisar a literatura atual para eluci-dar os mecanismos de ação, os parâmetros mais adequados e a efetividade dos tratamentos manuais para síndrome da dor miofascial. Métodos: Realizou-se busca nas bases de dados Sciencidirect, Bireme e Pubmed, publicados entre 1980 a 2011, correlacionando as seguintes palavras-chave: dor miofascial, síndrome dolorosa miofascial, ponto gati-lho miofacial, técnicas manuais e terapia manual, nos idiomas inglês, português e espanhol. Resultados: Dos artigos encontrados as modalidades manuais de tratamento citadas incluem a massoterapia, alongamento, alongamento com spray de gelo, terapia de liberação miofascial, técnica de energia muscular, thrust de alta velocidade e baixa amplitude , compressão isquêmica e terapia de liberação posicional. Conclusão: Esta revisão evidencia que as técnicas ma-nuais podem contribuir para as ações clínicas no tratamento da síndrome dolorosa miofascial, porém há necessidade de novas pesquisas para esclarecimentos sobre a utilização de novos procedimentos, os reais mecanismos de ação, os efeitos terapêuticos e os parâmetros mais adequados de algumas técnicas. Palavras-chave: Síndromes da Dor Miofascial, Modalidade de Fisioterapia, Manipulações Musculosqueléticas. Abstract Introduction: Myofascial pain syndrome is a painful condition of regional bands characterized by muscle tense, with
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Background More than two-thirds of pregnant women experience low-back pain and almost one-fifth experience pelvic pain. The two conditions may occur separately or together (low-back and pelvic pain) and typically increase with advancing pregnancy, interfering with work, daily activities and sleep. Objectives To update the evidence assessing the effects of any intervention used to prevent and treat low-back pain, pelvic pain or both during pregnancy. Search methods We searched the Cochrane Pregnancy and Childbirth (to 19 January 2015), and the Cochrane Back Review Groups' (to 19 January 2015) Trials Registers, identified relevant studies and reviews and checked their reference lists. Selection criteria Randomised controlled trials (RCTs) of any treatment, or combination of treatments, to prevent or reduce the incidence or severity of low-back pain, pelvic pain or both, related functional disability, sick leave and adverse effects during pregnancy. Data collection and analysis Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. Main results We included 34 RCTs examining 5121 pregnant women, aged 16 to 45 years and, when reported, from 12 to 38 weeks’ gestation. Fifteen RCTs examined women with low-back pain (participants = 1847); six examined pelvic pain (participants = 889); and 13 examined women with both low-back and pelvic pain (participants = 2385). Two studies also investigated low-back pain prevention and four, low-back and pelvic pain prevention. Diagnoses ranged from self-reported symptoms to clinicians’ interpretation of specific tests. All interventions were added to usual prenatal care and, unless noted, were compared with usual prenatal care. The quality of the evidence ranged from moderate to low, raising concerns about the confidence we could put in the estimates of effect. For low-back pain Results from meta-analyses provided low-quality evidence (study design limitations, inconsistency) that any land-based exercise significantly reduced pain (standardised mean difference (SMD) -0.64; 95% confidence interval (CI) -1.03 to -0.25; participants = 645; studies = seven) and functional disability (SMD -0.56; 95% CI -0.89 to -0.23; participants = 146; studies = two). Low-quality evidence (study design limitations, imprecision) also suggested no significant differences in the number of women reporting low-back pain between group exercise, added to information about managing pain, versus usual prenatal care (risk ratio (RR) 0.97; 95% CI 0.80 to 1.17; participants = 374; studies = two). For pelvic pain Results from a meta-analysis provided low-quality evidence (study design limitations, imprecision) of no significant difference in the number of women reporting pelvic pain between group exercise, added to information about managing pain, and usual prenatal care (RR 0.97; 95% CI 0.77 to 1.23; participants = 374; studies = two). For low-back and pelvic pain Results from meta-analyses provided moderate-quality evidence (study design limitations) that: an eight- to 12-week exercise program reduced the number of women who reported low-back and pelvic pain (RR 0.66; 95% CI 0.45 to 0.97; participants = 1176; studies = four); land-based exercise, in a variety of formats, significantly reduced low-back and pelvic pain-related sick leave (RR 0.76; 95% CI 0.62 to 0.94; participants = 1062; studies = two). The results from a number of individual studies, incorporating various other interventions, could not be pooled due to clinical heterogeneity. There was moderate-quality evidence (study design limitations or imprecision) from individual studies suggesting that osteomanipulative therapy significantly reduced low-back pain and functional disability, and acupuncture or craniosacral therapy improved pelvic pain more than usual prenatal care. Evidence from individual studies was largely of low quality (study design limitations, imprecision), and suggested that pain and functional disability, but not sick leave, were significantly reduced following a multi-modal intervention (manual therapy, exercise and education) for low-back and pelvic pain. When reported, adverse effects were minor and transient. Authors' conclusions There is low-quality evidence that exercise (any exercise on land or in water), may reduce pregnancy-related low-back pain and moderate- to low-quality evidence suggesting that any exercise improves functional disability and reduces sick leave more than usual prenatal care. Evidence from single studies suggests that acupuncture or craniosacral therapy improves pregnancy-related pelvic pain, and osteomanipulative therapy or a multi-modal intervention (manual therapy, exercise and education) may also be of benefit. Clinical heterogeneity precluded pooling of results in many cases. Statistical heterogeneity was substantial in all but three meta-analyses, which did not improve following sensitivity analyses. Publication bias and selective reporting cannot be ruled out. Further evidence is very likely to have an important impact on our confidence in the estimates of effect and change the estimates. Studies would benefit from the introduction of an agreed classification system that can be used to categorise women according to their presenting symptoms, so that treatment can be tailored accordingly.
Article
Background: Manipulation and mobilisation are commonly used to treat neck pain. This is an update of a Cochrane review first published in 2003, and previously updated in 2010. Objectives: To assess the effects of manipulation or mobilisation alone compared wiith those of an inactive control or another active treatment on pain, function, disability, patient satisfaction, quality of life and global perceived effect in adults experiencing neck pain with or without radicular symptoms and cervicogenic headache (CGH) at immediate- to long-term follow-up. When appropriate, to assess the influence of treatment characteristics (i.e. technique, dosage), methodological quality, symptom duration and subtypes of neck disorder on treatment outcomes. Search methods: Review authors searched the following computerised databases to November 2014 to identify additional studies: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and the Cumulative Index to Nursing and Allied Health Literature (CINAHL). We also searched ClinicalTrials.gov, checked references, searched citations and contacted study authors to find relevant studies. We updated this search in June 2015, but these results have not yet been incorporated. Selection criteria: Randomised controlled trials (RCTs) undertaken to assess whether manipulation or mobilisation improves clinical outcomes for adults with acute/subacute/chronic neck pain. Data collection and analysis: Two review authors independently selected studies, abstracted data, assessed risk of bias and applied Grades of Recommendation, Assessment, Development and Evaluation (GRADE) methods (very low, low, moderate, high quality). We calculated pooled risk ratios (RRs) and standardised mean differences (SMDs). Main results: We included 51 trials (2920 participants, 18 trials of manipulation/mobilisation versus control; 34 trials of manipulation/mobilisation versus another treatment, 1 trial had two comparisons). Cervical manipulation versus inactive control: For subacute and chronic neck pain, a single manipulation (three trials, no meta-analysis, 154 participants, ranged from very low to low quality) relieved pain at immediate- but not short-term follow-up. Cervical manipulation versus another active treatment: For acute and chronic neck pain, multiple sessions of cervical manipulation (two trials, 446 participants, ranged from moderate to high quality) produced similar changes in pain, function, quality of life (QoL), global perceived effect (GPE) and patient satisfaction when compared with multiple sessions of cervical mobilisation at immediate-, short- and intermediate-term follow-up. For acute and subacute neck pain, multiple sessions of cervical manipulation were more effective than certain medications in improving pain and function at immediate- (one trial, 182 participants, moderate quality) and long-term follow-up (one trial, 181 participants, moderate quality). These findings are consistent for function at intermediate-term follow-up (one trial, 182 participants, moderate quality). For chronic CGH, multiple sessions of cervical manipulation (two trials, 125 participants, low quality) may be more effective than massage in improving pain and function at short/intermediate-term follow-up. Multiple sessions of cervical manipulation (one trial, 65 participants, very low quality) may be favoured over transcutaneous electrical nerve stimulation (TENS) for pain reduction at short-term follow-up. For acute neck pain, multiple sessions of cervical manipulation (one trial, 20 participants, very low quality) may be more effective than thoracic manipulation in improving pain and function at short/intermediate-term follow-up. Thoracic manipulation versus inactive control: Three trials (150 participants) using a single session were assessed at immediate-, short- and intermediate-term follow-up. At short-term follow-up, manipulation improved pain in participants with acute and subacute neck pain (five trials, 346 participants, moderate quality, pooled SMD -1.26, 95% confidence interval (CI) -1.86 to -0.66) and improved function (four trials, 258 participants, moderate quality, pooled SMD -1.40, 95% CI -2.24 to -0.55) in participants with acute and chronic neck pain. A funnel plot of these data suggests publication bias. These findings were consistent at intermediate follow-up for pain/function/quality of life (one trial, 111 participants, low quality). Thoracic manipulation versus another active treatment: No studies provided sufficient data for statistical analyses. A single session of thoracic manipulation (one trial, 100 participants, moderate quality) was comparable with thoracic mobilisation for pain relief at immediate-term follow-up for chronic neck pain. Mobilisation versus inactive control: Mobilisation as a stand-alone intervention (two trials, 57 participants, ranged from very low to low quality) may not reduce pain more than an inactive control. Mobilisation versus another active treatment: For acute and subacute neck pain, anterior-posterior mobilisation (one trial, 95 participants, very low quality) may favour pain reduction over rotatory or transverse mobilisations at immediate-term follow-up. For chronic CGH with temporomandibular joint (TMJ) dysfunction, multiple sessions of TMJ manual therapy (one trial, 38 participants, very low quality) may be more effective than cervical mobilisation in improving pain/function at immediate- and intermediate-term follow-up. For subacute and chronic neck pain, cervical mobilisation alone (four trials, 165 participants, ranged from low to very low quality) may not be different from ultrasound, TENS, acupuncture and massage in improving pain, function, QoL and participant satisfaction at immediate- and intermediate-term follow-up. Additionally, combining laser with manipulation may be superior to using manipulation or laser alone (one trial, 56 participants, very low quality). Authors' conclusions: Although support can be found for use of thoracic manipulation versus control for neck pain, function and QoL, results for cervical manipulation and mobilisation versus control are few and diverse. Publication bias cannot be ruled out. Research designed to protect against various biases is needed. Findings suggest that manipulation and mobilisation present similar results for every outcome at immediate/short/intermediate-term follow-up. Multiple cervical manipulation sessions may provide better pain relief and functional improvement than certain medications at immediate/intermediate/long-term follow-up. Since the risk of rare but serious adverse events for manipulation exists, further high-quality research focusing on mobilisation and comparing mobilisation or manipulation versus other treatment options is needed to guide clinicians in their optimal treatment choices.
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Introduction: Recent evidence suggests that chronic low back pain (CLBP) is a complex, multi-factorial phenomenon with physical and biopsychosocial components. The biopsychosocial model of pain acknowledges the biological, psychological and social dimensions of the pain experience. Chiropractors, doctors and other clinicians have begun to embrace the concept of "mind-body" treatments and attempt to integrate the function of the mind in caring for their patients. Despite this development, very few mind-body treatments have been investigated under controlled conditions for their efficacy. Objective: The aim of this research was to explore the value if any, of the Neuro Emotional Technique (NET) approach to the management of CLBP, and to investigate if NET therapy can alter the status of low back pain (LBP) in a group of CLBP patients using a randomised controlled trial design. Methods: An NET protocol for low back pain treatment was standardised for the purpose of this research. Following the conduct of a feasibility study, 112 LBP participants with a pain duration of a minimum three months were randomised into either a treatment (n=58) or control (n=54) group. Participants were allocated to groups by a research assistant and were blinded to their assigned group. The treatment group underwent a course of NET, whilst the control group underwent a sham protocol of NET. Both groups were prescribed intervention at a frequency of two sessions per week for one month. Subjective and objective outcome measures including a numerical pain rating scale (VAS), the Oswestry disability questionnaire (ODQ), General health questionnaires (SF-36) and blood markers were all obtained at baseline, 1 month, 3 months and 6 months. Results: A significant statistical difference between the NET and sham groups was detected in paper based and blood measures assessed in this RCT. The Oswestry, the QVAS and the SF-36 all attained statistical and clinical significance. Two blood inflammatory markers also showed positive changes: C-reactive protein decreased and TNFα decreased. These two measures had participants move from blood concentrations which would be considered abnormal into the normal range. Other blood inflammatory markers- Interleukin-1, Interleukin-6, Interleukin-10 all commenced within normal physiological range for both control and treatment groups. As such even though a positive statistical difference was attained for those markers, the changes are deemed to be of little clinical value. In each of the measures noted above, the changes were most marked in the short term, that is, after one month of intervention. Typically, participants in the experimental cohort retained the changes obtained following the one month intervention period. Conclusion: The findings of this RCT study suggest that NET therapy may be effective in the short term (one month) and medium-long term (six months) for reducing CLBP.
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Objective: The purpose of the study was to evaluate the effectiveness of the stress-reducing technique Neuro Emotional Technique in promoting ovulation by decreasing both apparent and perceived stress. Clinical Features: Two chronic anovulating patients underwent Neuro Emotional Technique. A visual analogue scale was used to evaluate the effectiveness of the intervention. Outcomes: Anovulating patients started to ovulate following a series of treatments. Initial VAS scale on menstrual irregularity was rated 10 out of a possible 10 (anovulation) for both patients. After treatment, both patients rated 0 out of 10 on the VAS scale. A discussion of the potential link between stress and anovulation through decreased insulin sensitivity and how the use of Neuro EmotionalTechnique resolved the anovulation seen in two patients is presented. Conclusion: This study shows the successful management of anovulation by Neuro EmotionalTechnique in an uncontrolled case series.Further study into this through randomised controlled trial is required to inves­tigate this technique as a therapy for anovulation in females.
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Objective: To review the function, anatomy, physiology, development, hormone synthesis and dysfunction of the thyroid gland. Treatment options are discussed, and 2 case studies of a mind-body therapy (Neuro-Emotional Technique-NET) successfully managing hypothyroid dysfunction are presented. Data Sources: MEDLINE search using key words: thyroid, synthesis, development, anatomy, physiology, hyper­thyroidism and hypothyroidism. Data Selection: Eighty-five papers fit the key words and were selected based on relevance to the topic. Papers were selected that contained relevant information on normal and abnormal thyroid function and its management. Data Extraction: Selected papers had to contain information that directly related to the diagnosis, anatomy, physiology and management of hypothyroid conditions. Papers were also selected that described a possible neurophysiological mechanism for the observed treatment effects. Data Synthesis: Objective measures of a new mind-body approach to hypothyroid dysfunction are presented, and its relevance to the biopsychosocial model is discussed. This new treatment is compared to the existing bio­ medical approaches to treatment. Conclusions: Thyroid dysfunction has been effectively treated with medicine for many years. This paper presents a new therapy that produced objective pre-post changes to hypothyroid dysfunction in 2 cases. This therapy may have potential in future circumstances, with further research recommended to confirm its reliability/validity.
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The theory of five elements is extensively used in traditional Chinese medicine. It is proposed that the theory of five elements was developed on the basis of the theory of elements, the law of contagion and the law of similarity which were prevalent in that era. They theory of elements spread in various forms all over the face of the globe. The law of contagion stated that objects, which at one time had been in continuity or juxtaposition, continued to exert an effect one upon the other. The internal organs were coupled probably on the basis of the law of contagion. The law of similarity stated that objects or circumstances which bear apparent similarity in form, shape, color or sequence of events, were considered to be fundamentally related. On the basis of the law of similarity the coupled internal organs were classified into five elements and the theory of five elements was compared with various things like seasons, color, tastes, emotions, etc. The theory of five elements is probably the earliest documented evidence correlating physiology with pathogensis of diseases and a guideline for treatment of diseases.
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Under the division of labor of Western medicine, the medical physician treats the body of patients, the social worker attends to their emotions and social relations, while the pastoral counselor provides spiritual guidance. Body, mind, cognition, emotion and spirituality are seen as discrete entities. In striking contrast, Eastern philosophies of Buddhism, Taoism and traditional Chinese medicine adopt a holistic conceptualization of an individual and his or her environment. In this view, health is perceived as a harmonious equilibrium that exists between the interplay of ‘yin’ and ‘yang’: the five internal elements (metal, wood, water, fire and earth), the six environmental conditions (dry, wet, hot, cold, wind and flame), other external sources of harm (physical injury, insect bites, poison, overeat and overwork), and the seven emotions (joy, sorrow, anger, worry, panic, anxiety and fear). The authors have adopted a body-mind-spirit integrated model of intervention to promote the health of their Chinese clients. Indeed, research results on these body-mind-spirit groups for cancer patients, bereaved wives and divorced women have shown very positive intervention outcomes. There are significant improvements in their physical health, mental health, sense of control and social support.
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Voluntary muscle is the largest human organ system. The musculotendinous contractual unit sustains posture against gravity and actuates movement against inertia. Muscular injury can occur when soft tissues are exposed to single or recurrent episodes of biomechanical overloading. Muscular pain is often attributed to a myofascial pain disorder, a condition originally described by Drs Janet Travell and David Simons. Among patients seeking treatment from a variety of medical specialists, myofascial pain has been reported to vary from 30% to 93% depending on the subspecialty practice and setting. Forty-four million Americans are estimated to have myofascial pain; however, controversy exists between medical specialists regarding the diagnostic criteria for myofascial pain disorders and their existence as a pathological entity. Muscles with activity or injury-related pain are usually abnormally shortened with increased tone and tension. In addition, myofascial pain disorders are characterised by the presence of tender, firm nodules called trigger points. Within each trigger point is a hyperirritable spot, the ‘taut-band’, which is composed of hypercontracted extrafusal muscle fibres. Palpation of this spot within the trigger point provokes radiating, aching-type pain into localised reference zones. Research suggests that myofascial pain and dysfunction with characteristic trigger points and taut-bands are a spinal reflex disorder caused by a reverberating circuit of sustained neural activity in a specific spinal cord segment. The treatment of myofascial pain disorders requires that symptomatic trigger points and muscles are identified as primary or ancillary pain generators. Mechanical, thermal and chemical treatments, which neurophysiologically or physically denervate the neural loop of the trigger point, can result in reduced pain and temporary resolution of muscular overcontraction. Most experts believe that appropriate treatment should be directed at the trigger point to restore normal muscle length and proper biomechanical orientation of myofascial elements, followed by treatment that includes strengthening and stretching of the affected muscle. Chronic myofascial pain is usually a product of both physical and psychosocial influences that complicate convalescence.
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The purpose of this study was to assess a patient specific measure for eliciting and recording patients' problems. While the notion was to develop a measure that would be applicable to a number of conditions or disabilities, this study assessed the measure's performance on 63 out-patients with mechanical low back pain. Patients were asked to identify up to five important activities they were having difficulty with as a result of their back pain. Patients rated difficulty on an 11-point numerical scale. At subsequent reassessments patients were informed of the activities and corresponding difficulty scores identified at the previous assessment and asked to provide a current difficulty score. Concurrent validity of the patient-specific measure was assessed using the Roland-Morris Questionnaire. Sensitivity to valid change over time was determined by comparing the measure's score to the average patient/clinician global rating of change. Moderate to excellent reliability, validity, and sensitivity to change c...
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Kibler (Medicine and Science in Sports and Exercise 30 (1998) 79) suggests that when there is dysfunction in a proximal body segment, distal segments have to change workloads in order to preserve movement outcomes at the most distal body segment. One aspect of function is the timing of muscle activation. As the presence of pain could affect the muscle activation pattern (MAP), the effects of pain-free latent myofascial trigger points (LTrPs) in the scapular rotator muscle group were investigated. Surface electromyography was used to identify the MAP of the upper and lower trapezius, serratus anterior, infraspinatus and middle deltoid during scapular plane elevation. Repeated measures ANOVA was used to compare the control group (n=14) and the LTrP group (n=28). The LTrP group was then randomly assigned to either placebo intervention or true treatment to investigate the effect of removing the LTrPs. The data established that LTrPs in the scapular rotator muscles changes the MAP of this muscle group and of muscles further distal in the shoulder girdle kinetic chain. Treatment to remove LTrPs normalised the MAP.