The differential diagnosis and treatment of headache and craniofacial pain has long been a subject of debate. Historically, much has been written on the topic, extending back into ancient times,1 yet the clinical decision making process with these patients remains challenging.2,3 A 2007 study suggested that the percentage of the global adult population with an active headache disorder was as high as 46%.2 Although reportedly less prevalent, orofacial pain, including tempromandibular joint pain, has a substantial negative impact on patients who suffer with it.3 Accordingly, the International Association for the Study of Pain (IASP) has recently launched the 2013–2014 Global Year Against Orofacial Pain campaign, highlighting the fact that this common form of pain is often poorly recognized and inadequately treated. To launch this special issue on headache and craniofacial pain, we present a two part series by Shaffer and colleagues4,5 which discusses the evaluation and physical therapy management of tempromandibular (TMD) dysfunction. These papers draw from an expanding research literature, and provide an evidence-based review of the biomechanical and clinical features of TMD, as well as valuable guidelines for management. von Piekartz and Mohr6 discuss the unique neurophysiological effects of facial pain. Importantly, this work highlights how facial pain may impede the ability to express emotions, and as a consequence, the ability to perceive emotions in others. This altered affective state, i.e., the inability to express and recognize emotions, painful or otherwise, may predispose the individual to chronic pain.7 This may be a paradigm shift for some clinicians; specifically, that dysfunction in affect may be both a cause and effect of chronic pain. While recent interest has focused on the cognitive sequellae of traumatic brain injury, Defrin8 draws attention to a major adverse outcome that may occur following brain trauma: post-concussive headache. An incredibly high number of individuals experience chronic headache following traumatic head injury.9 Both the contributions by Defrin,8 as well as Fernandez-de-las-Penas and Courtney10 address the complex pathophysiology and the importance of multimodal treatment plans for individuals with headache. This complexity is demonstrated by Stuhr and colleagues,11 who describe a successful outcome in a young patient with both headache and TMD complaints. As guest editors, we postulate that the topic of headache and craniofacial pain is likely under-addressed in many professional and post-graduate education programs. If this is the case, we challenge educators, clinicians, and researchers to turn their attention to this group of chronic pain conditions, which affects such a large proportion of our society.

Background:Neck pain is one of the most common, potentially disabling, and costly musculoskeletal conditions seen in outpatient physical therapy (PT). Clinical decision-making involves referral or the selection of intervention based on the results of the PT examination. Despite evidence that suggests that treatment based classification is most efficacious, it is hypothesized that examination and intervention may be heavily influenced by post-graduate training experiences.Purpose:The purpose of this study was to analyze which tests, measures, and interventions are most commonly selected by physical therapists (PTs) holding a credential from the McKenzie Institute and those holding the McKenzie credential plus the credential of Fellow of the American Academy of Orthopaedic Manual Physical Therapy (FAAOMPT). Their responses were based on a simulated case vignette involving a patient with a presentation of cervical spine disk derangement.Methods:A survey administered through Survey Monkey was sent to 714 members of the McKenzie Institute who are certified or hold a diploma in mechanical diagnosis and therapy (MDT) or these credentials with the addition of Fellowship credentialing (MDT+FAAOMPT). Of the 714 surveyed PTs, 83 completed the survey for a response rate of 11·6%. As the PTs were given further information regarding the patient, they were asked to progress through a clinical decision-making process by indicating their sequence of examination techniques, and then indicating which interventions would be performed based on the results of the examination.Results:A descriptive analysis was conducted to determine the most common sequences chosen by the PTs based on their training. To perform the analysis, only respondents who completed the survey were included: clinicians with MDT credentials, (n = 77), and clinicians with both the MDT and FAAOMPT credentials (MDT+FAAOMPT), (n = 6). Initially, the most common examination chosen regardless of credential was postural analysis. After receiving additional information regarding the patient's posture, the majority of clinicians in each of the three groups then chose active range of motion (AROM). However, after additional information was given, the majority of the MDT group chose repeated end range cervical movements as their next examination measure, and the FAAOMPT group varied. The majority of the FAAOMPT group continued to assess the patient through an entire examination sequence, while the majority of the MDT group discontinued testing. A descriptive analysis of the intervention sequences depicted a trend toward direction of preference (DP) exercises for the MDT group (80·3%), and passive movements or mobilization exercises for the FAAOMPT group.Conclusion:The results of this study suggest that PTs with post-graduate training through the McKenzie Institute or through Orthopaedic Manual Physical Therapy (OMPT) Fellowship training may demonstrate an inherent bias toward their advanced training in the assessment and treatment of acute cervical derangement. Although no significant findings can be reported secondary to sample size limitations, future studies may be performed to further explore this topic.

The butterfly vertebral defect is a rare congenital anomaly of the spine, which is generally considered benign. In this report we present the case of an active young man who presented with recurrent low back pain (LBP), and was found to have a butterfly vertebral defect at the symptomatic L4 lumbar spinal level. We describe the genesis of the butterfly vertebral defect, in the context of normal embryological development of the human vertebra and intervertebral disk. We report the clinical examination findings and therapeutic interventions undertaken prior to the radiographic discovery of the vertebral defect, and discuss the impact that the presence of a butterfly vertebral defect presented to therapeutic decision-making.

Objective and importance:There is a paucity of research that investigates therapeutic interventions of patients with concurrent head and neck lymphedema and temporomandibular dysfunction (TMD). The purpose of this case report is to describe the management and outcomes of a patient with head and neck lymphedema and TMD using a multimodal physical therapy approach.Clinical presentation:A 74-year-old male with a past medical history of head and neck lymphedema and TMD was referred to physical therapy with chief complaints of inability to open his mouth in order to eat solid food, increased neck lymphedema, temporomadibular joint pain, and inability to speak for prolonged periods of time.Interventions:The patient was treated for three visits over 4 weeks. Treatment included complete decongestive therapy (CDT), manual therapy, therapeutic exercise, and a home exercise program. Upon discharge, the patient had improved mandibular depression, decreased head and neck lymphedema, improved deep neck flexor endurance, decreased pain, and improved function on the Patient Specific Functional Scale (PSFS).Conclusion:Utilization of a multimodal physical therapy approach to treat a patient with a complex presentation yielded positive outcomes. Further research on outcomes and treatment approaches in patients with TMD and head and neck lymphedema is warranted.

Reflexive breathing therapy and complementary manual therapy aim to improve breathing by mobilizing the chest, reducing the muscle tone of the breath supporting muscles, and improving secretion and chest wall compliance. We describe an uncommon case of axillary nerve (AN) palsy in association with a treatment session of reflexive breathing therapy combined with manual therapy. After a therapist’s guided intensive movement of crossed arms in front of the body, upward, as high as possible, a sudden ache in the left shoulder that radiated to the lateral upper arm occurred along with loss of elevation and abduction of the shoulder. An electrophysiological examination demonstrated a diminished and delayed compound muscle action potential that indicated AN injury. Following conservative treatment, the nerve dysfunction resolved completely. Stretching of the nerve may have resulted in tearing some nerve fibers and is discussed as a possible pathophysiological mechanism.

The McKenzie method, also known as Mechanical Diagnosis and Therapy (MDT), is primarily recognized as an evaluation and treatment method for the spine. However, McKenzie suggested that this method could also be applied to the extremities. Derangement is an MDT classification defined as an anatomical disturbance in the normal resting position of the joint, and McKenzie proposed that repeated movements could be applied to reduce internal joint displacement and rapidly reduce derangement symptoms. However, the current literature on MDT application to shoulder disorders is limited. Here, we present a case series involving four patients with chronic shoulder pain from a duration of 2–18 months classified as derangement and treated using MDT principles. Each patient underwent mechanical assessment and was treated with repeated movements based on their directional preference. All patients demonstrated rapid and clinically significant improvement in baseline measures and the disabilities of the arm, shoulder, and hand (QuickDASH) scores from an average of 38% at initial evaluation to 5% at discharge within 3–5 visits. Our findings suggest that MDT may be an effective treatment approach for shoulder pain.

Study design:Systematic literature review.Objective:To investigate the various conservative interventions for coccydynia and determine their effectiveness.Background:Coccydynia is the term used to describe pain in the coccygeal region. Pain in this region is typically caused by local trauma. Sitting is typically the most painful position for patients having coccydynia. Various methods of treating coccydynia are found in the literature but to our knowledge no systematic review has been performed that compared the effectiveness of these interventions.Methods:Searches were performed for research studies using electronic databases (Cochrane Library, CINAHL, Medline, PEDro, Scopus, and Sports Discus) from January 2002 through July 2012. The quality of the papers was assessed using the GRADE approach.Results:Seven papers were located that satisfied the inclusion and exclusion criteria (2 RCTs, 5 observational studies). The level of evidence ranged from moderate to very low quality and recommendations for use ranged from weak recommendations for use to weak recommendations against use.Conclusions:Due to the dearth of research available and the low levels of evidence in the published studies that were located we are unable to recommend the most effective conservative intervention for the treatment of coccydynia. Additional research is needed regarding the treatment for this painful condition.

The purpose of this case report is to relate an episode of movement impairment at the cuboid calcaneal articulation leading to symptoms of iliotibial band (ITB) syndrome. An explanation of the etiology and clinical diagnosis in relation to the differential diagnosis, treatment techniques, and patient outcomes are described. The 24-year-old female tri-athlete reported pain at Gerdy’s tubercle and lateral femoral condyle areas occurring within 2 miles of a run. VAS score was 6/10 for the running activity and the lower extremity functional scale (LEFS) score was 93% (74/80). Over the previous 2 years, the ITB symptoms had failed to resolve with extensive conservative treatment at the knee. On weight bearing, the patient demonstrated pain free limitation of active midtarsal pronation more than supination, which correlated with a decrease in passive internal rotation of the cuboid. Symptoms resolved after one cuboid whip manipulation and the patient was able to run pain free. Post-manipulation treatment consisted of two more sessions, which included motor retraining for weight bearing active midtarsal pronation and supination. LEFS was 100% (80/80) and VAS 0/10 with running greater than 10 miles. While causality cannot be inferred from a single case, this report may foster further investigation regarding the differential diagnosis and treatment of a hypomobile cuboid.

The term ‘regional interdependence’ or RI has recently been introduced into the vernacular of physical therapy and rehabilitation literature as a clinical model of musculoskeletal assessment and intervention. The underlying premise of this model is that seemingly unrelated impairments in remote anatomical regions of the body may contribute to and be associated with a patient’s primary report of symptoms. The clinical implication of this premise is that interventions directed at one region of the body will often have effects at remote and seeming unrelated areas. The formalized concept of RI is relatively new and was originally derived in an inductive manner from a variety of earlier publications and clinical observations. However, recent literature has provided additional support to the concept. The primary purpose of this article will be to further refine the operational definition for the concept of RI, examine supporting literature, discuss possible clinically relevant mechanisms, and conclude with a discussion of the implications of these findings on clinical practice and research.

Objectives:Describe short- and long-term outcomes observed in individuals with hip osteoarthritis (OA) treated with a pre-selected, standardized set of best-evidence manual therapy and therapeutic exercise interventions.Methods:Fifteen consecutive subjects (9 males, 6 females; mean age: 52±7·5 years) with unilateral hip OA received an identical protocol of manual therapy and therapeutic exercise interventions. Subjects attended 10 treatment sessions over an 8-week period for manual therapy interventions and performed the therapeutic exercise as a home program.Results:Baseline to 8-week follow-up outcomes were as follows: Harris Hip Scale (HHS) scores improved from 60·3(±10·4) to 80·7(±10·5), Numerical Pain Rating Scale (NPRS) scores improved from 4·3(±1·9) to 2·0(±1·9), hip flexion range of motion (ROM) improved from 99 degrees (±10·6) to 127 degrees (±6·3) and hip internal rotation ROM improved from 19 degrees (±9·1) to 31 degrees (±11·5). Improvements in HHS, NPRS, and hip ROM measures reached statistical significance (P<0·05) at 8-weeks and remained significant at the 29-week follow-up. Mean changes in NPRS and HHS scores exceeded the minimal clinically important difference (MCID) at 8-weeks and for the HHS scores alone at 29 weeks. The 8 and 29 week mean Global Rating of Change scores were 5·1(±1·4) and 2·1(±4·2), respectively.Improved outcomes observed following a pre-selected, standardized treatment protocol were similar to those observed in previous studies involving impairment-based manual therapy and therapeutic exercise for hip OA. Future studies might directly compare the two approaches.Discussion: