ARTICLE IN PRESS

Manual Therapy 11 (2006) 214224 www.elsevier.com/locate/math

Original article

A preliminary investigation into the relationship between cervical snags and sympathetic nervous system activity in the upper limbs of an asymptomatic population
Andrea Moulson, Tim Watson
School of Paramedic Sciences, Physiotherapy & Radiography, Faulty of Health and Human Science, University of Hertfordshire, College Road, Hateld, Hertfordshire AL10 9AB, UK Received 7 November 2005; received in revised form 9 March 2006; accepted 6 April 2006

Abstract Spinal manipulative therapy techniques are commonly employed by physiotherapists in the clinical setting for the management of neuromusculoskeletal pain and dysfunction, although their underlying mechanism is not fully understood. Mulligans sustained natural apophyseal glides (SNAGs) constitute one of these techniques. This preliminary investigation was undertaken to investigate the relationship between the application of cervical SNAGs to the C5/6 intervertebral joint (with cervical right rotation) and indirect measures of sympathetic nervous system (SNS) activity. Previous investigations have suggested that cervical manipulative therapy techniques, separate to cervical SNAGs, result in a sympatheoexcitatory effect and that this may be instrumental in producing an analgesic response. Sixteen asymptomatic subjects participated in a laboratory-based experiment. A single blind, randomized, within subject, repeated measures study design which included control, placebo and treatment comparisons was used. Measures of skin conductance (SC) and skin temperature (ST) in the right and left upper limbs were used as indicators of SNS activity. The cervical SNAG technique produced a sympathoexcitatory response demonstrated by a signicant increase in SC during application of the treatment intervention (Po0:0005) and for a 2-min period after the intervention (P 0:001) compared with control. There was also a signicant increase in SC for the placebo condition, both during intervention (P 0:015) and after intervention (P 0:011) compared with control. There was a statistically signicant difference in SC between placebo and treatment conditions for the 2-min period after the intervention had been applied (P 0:01). A trend did emerge for ST change, illustrating a decrease in ST for the treatment and placebo conditions compared with control, however this did not reach statistically signicant levels. There were no apparent left/right upper limb differences for SC and ST for each condition. The results of this study suggest that cervical SNAG techniques, performed on na ve asymptomatic subjects, have a sympathoexcitatory effect as measured by changes in SC and ST. The importance of this sympathoexcitatory effect in relation to potential mechanisms for manipulation induced analgesia are discussed, and further areas of research proposed. r 2006 Elsevier Ltd. All rights reserved.
Keywords: Sympathoexcitation; Sustained natural apophyseal glides (SNAGs); Manual therapy

1. Introduction The Mulligan concept is integral to the clinical practice of many physiotherapists (Konstantinou et al.,
Corresponding author.

E-mail address: a.moulson@herts.ac.uk (A. Moulson). 1356-689X/$ - see front matter r 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2006.04.003

2002) and includes techniques such as sustained natural apophyseal glides (SNAGs), natural apophyseal glides (NAGs) and mobilization with movements (MWMs). Several clinical studies have suggested that these techniques are an effective physiotherapeutic tool in the treatment of neuromuscular pain and dysfunction (Abbott, 1998, 2001; Folk, 2001; Vicenzino et al., 2001;

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Horton, 2002; Hsieh et al., 2002; Kochar and Dogra, 2002). Recent studies however have questioned Mulligans original belief that biomechanical factors such as the correction of joint maltracking underpin their effect (Hearn and Rivett, 2002; Hseich et al., 2002) and consequently there appears to be a scarcity of quality evidence explaining their underlying mechanism (Wilson, 1995; Exelby, 2002). The limited understanding related to the underlying mechanism of Mulligan techniques is replicated in other commonly used manual therapy treatments such as spinal manipulative therapy (SMT) and it has been suggested that the application of these techniques has been largely based on clinical observations and hypothetical models (McGuiness et al., 1997; Zusman, 2004). A new theory as to the basic science of SMT has recently emerged. Several studies have examined the physiological correlates of manual therapy by investigating the effects of techniques on the nociceptive and sympathetic nervous system (SNS) (Peterson et al., 1993; Slater and Wright, 1995; Vicenzino et al., 1994, 1995; Wright and Vicenzino, 1995; Chiu and Wright, 1996; McGuiness et al., 1997; Vicenzino et al., 1998a b; Willett and Toppenberg, 2001; Perry, 2002). This research suggests a relationship between SMT and changes in SNS activity, specically that SMT induces a pattern of sympathoexcitation which is reected by generalized increases in skin conductance (SC) and concurrent decreases in skin temperature (ST). Furthermore, it has been theorized that patterns of sympathoexcitation may reect primitive defensive ght or ight reactions which are linked to endogenous analgesia (Lovick, 1991; Wright, 1995; Wright and Vicenzino, 1995; Bandler et al., 2000, 2002). The focus of this paper relates to cervical SNAGs. As yet, no study has investigated the relationship between SNAGs and the SNS, although several studies have investigated other cervical SMT, peripheral joint mobilization and SNS activity (Peterson et al., 1993; Vicenzino et al., 1995; Chiu and Wright, 1996; Abbott, 1998; Vincenzino et al., 1998a, b; Abbott, 2001; Sterling et al., 2001; Willet and Toppenberg, 2001; Hseich et al., 2002; Perry, 2002; Paungmali et al., 2003). Peterson et al. (1993) investigated SNS response in asymptomatic subjects to grade three PA mobilizations of C5, as measured by SC and ST changes in the upper limb. Results demonstrated a signicant increase in SC for the treatment condition when compared to placebo and control. There was a corresponding small, but signicant decrease in ST for the treatment condition compared to control, although this was not signicant between treatment and placebo conditions. The studys results indicated that SMT was associated with an increase in SNS activity. Similar results were found in a comparable study by Chiu and Wright (1996) which investigated the effects of different rates of application

of C5 grade three PA mobilizations on SNS correlates in the upper limbs of an asymptomatic population. Chiu and Wright (1996) also speculated that SNS response to SMT may be affected by the duration and frequency of the technique performed. This concept has been supported by other studies investigating the association between dose of treatment and SNS activity over time (Vicenzino et al., 1994; McGuiness et al., 1997; Souvlis et al., 2001). Additional work exploring the relationship between SNS activity and SMT has been completed by Vicenzino et al. (1995) who investigated the effects of C5/6 lateral glide technique on SNS correlates in the upper limb. Results in this study supported previous research and found signicant increases in SC for treatment condition over placebo and control in the asymptomatic population. However, they also found signicant increases in ST for the treatment condition, results which contrasted with previous studies (Peterson et al., 1993; Chiu and Wright, 1996). From these studies it is apparent that there seems to be a consistent sympathoexcitatory relationship between SMT and SC, which appears to be less consistent with regard to ST. In trials which have investigated the SNS response to SMT in the patient population, there does appear to be a correlation between sympathoexcitation and analgesia (Vicenzino et al., 1998a; Sterling et al., 2001). Sterling et al. (2001) investigated the effects of C5, PA, grade three mobilizations on a population of neck pain sufferers with identied dysfunction at this level. Results suggested that the treatment condition stimulated a pattern of sympathoexcitation as measured by SC and ST changes in the upper limb. Sympathoexcitation changes occurred concurrently with signicant reductions in measures of mechanical hyperalgesia, thus lending credence to a possible link between measures of SNS activity and manipulation induced analgesia. Similar conclusions were reached in a study by Vicenzino et al. (1998a) whereby the authors used conrmatory factor analysis to test the correlation between pain perception and parameters related to the SNS function in a population of patients with lateral epicondylalgia. The treatment investigated was a C5/6 lateral glide technique and SNS parameters included measurement of upper limb SC, ST and blood ux. This study found a strong correlation and suggested that those individuals who exhibited the most change in pain perception also were those who exhibited the most change in SNS parameters. The sympathoexcitatory relationship between SC and ST and response to SMT has lead to speculation regarding the nature of manipulation induced analgesia (Wright and Vicenzino, 1995; Wright, 1995, 2002). Patterns of sympathoexcitation have been elicited in animal models with direct stimulation of the dorsolateral periaqueductal grey region of the brain (dlPAG),

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and this has been demonstrated to have an association with the analgesia produced in ght or ight situations (Bandler et al., 1991, 2000; Lovick, 1991). Manual therapists, in conjunction with other researchers, have speculated that manipulation induced analgesia may utilize a similar pathway and hypothesize that manipulative therapy may produce a non-opioid form of analgesia utilizing descending inhibitory pathways involving the PAG (Wright, 1995; Skyba et al., 2003; Zusman, 2004). Recent animal experiments support this concept (Sluka and Wright, 2001; Malisza et al., 2003; Skyba et al., 2003). Consequently, patterns of sympathoexcitation as demonstrated in studies investigating SMT may illustrate a link between manual therapy techniques, the dlPAG and the descending pain inhibitory pathways (Wright and Vicenzino, 1995; Wright, 1995, 2002). The purpose of this research was to investigate the relationship between cervical SNAGs and concurrent effects on SNS activity measured indirectly in the asymptomatic population. The results of this study may contribute to the growing body of information on the neurophysiological effects of manual therapy techniques, and may potentially contribute to a greater understanding of manipulation-induced analgesia.

In overview, 16 subjects attended measurement sessions at the same time, on three different days to receive an intervention of either: treatment, placebo or control. Bilateral upper limb SC and ST were simultaneously recorded before, during and after intervention. Subjects received all three experimental conditions and acted as their own controls. The order of intervention was randomized for each participant to reduce the effect of researcher and order bias (Altman, 1991; Winter et al., 1991; Sims and Wright, 2000).The success of subject blinding to the interventions and purpose of the study was investigated via a post-trial questionnaire to ensure that subjects were na ve to the testing procedure.

2.3. Research method Subjects were positioned in a chair in a standardized position and were instructed to look at a marked spot on the wall. At each recording session, the researcher explained the experimental procedure and whether head rotation to the right ( 3) was required. If it was, subjects were told that they should turn at a speed and distance that was comfortable to them, and that this should be pain free. This procedure was chosen to best reect the clinical environment. Subjects were also informed that whilst turning their heads to the right, the researcher may or may not place their hands their neck. Subjects were advised to inform the researcher if they were uncomfortable at any time. The skin on the palmar surfaces of the subjects rst, second and third digits of the left and right hands were cleaned with an Alcowipe prior to the application of the SC and ST probes (Millington and Wilkinson, 1983; Vicenzino et al., 1994; Chiu and Wright, 1996). The intervertebral joint level of C5/6 was marked on the subjects neck, to ensure rapid location of this level during the experimental procedure. Previous experimental work suggests that experienced manual therapists have acceptable intra tester reliability for the correct location of spinal levels (Jull et al., 1997; McKenzie and Taylor, 1997), suggesting that C5/6 would be consistently located during each experimental procedure. Following this an 8-min period elapsed to allow for stabilization of recording electrodes (Venables and Christie, 1973; Nance and Hoy, 1996; Biopac Systems Inc). After this period, a 2 min baseline measure of SC and ST was made. Following this, the researcher approached the subject from behind and administered one of the three interventions explained below. Once completed the subject then remained in the start position and ST and SC recordings were taken for another 2 min. It was not possible to blind the researcher to the specic intervention applied, although the recording monitor was not visible to the researcher or subject during the application of the intervention in order to minimize potential feedback.

2. Methodology 2.1. Subjects The study included 16 asymptomatic subjects (11 females and 5 males) aged 1837 years (mean 23.06 years; SD 5.35 years). It was envisaged that this preliminary study would provide reliable data for use in future sample size and power calculations for similar studies (Altman, 1991). Exclusion criteria included: previous neuromusculoskeletal dysfunctions affecting the cervical spine and upper quadrant, previous experience of SMT and any subjects with contraindications to manual therapy (Grieve, 1989). Subjects were instructed to refrain from smoking, participating in strenuous exercise and consuming alcohol and caffeine for 1 h prior to the experiment because of their potential inuence on the SNS (Andreassai, 1995; Nance and Hoy, 1996). All volunteers were given written information prior to the experiment and signed a consent form. Ethical approval was gained from the Radiography and Physiotherapy Ethics Committee at the University of Hertfordshire. 2.2. Research design The research design used was a single blind, randomized, within subject, repeated measures design which included control, placebo and treatment comparisons.

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2.3.1. Treatment intervention For the treatment intervention, a cervical SNAG was administered to the subjects C5/6 intervertebral joint whilst the subject simultaneously turned their head to the right from a standardized neutral position (Mulligan, 1999). This procedure was repeated a total of three times in accordance with Mulligans rule of three, which suggests that only three spinal techniques should be used in the rst encounter between therapist and patient (Mulligan, 1999). The researcher maintained contact with the C5/6 intervertebral joint between the application of each SNAG technique to ensure consistency of manual contact. The direction of the SNAG technique was parallel to the plane of the joint (Mulligan, 1999; Exelby, 2002). 2.3.2. Placebo intervention For the placebo intervention, the researcher followed the same procedure as the treatment intervention and applied manual contact to the same points on the cervical spine, but did not apply the accessory glide which would constitute an SNAG technique. The subject was instructed to turn their head to the right from a standardized neutral position whilst the researcher maintained skin contact between her thumbs and the C5/6 intervertebral joint. This procedure was repeated a total of three times. 2.3.3. Control intervention For the control intervention the subject remained seated and looking forward during the whole recording time in a standardized neutral position. The researcher remained behind the subject, as in the placebo and treatment conditions, but made no contact with the subject.

there is increased sweating of the palmar surfaces of the feet and hands in order to facilitate grasping/grip for escape and to play a role in thermoregulation (Darrow, 1933; Edelberg, 1973; Janig, 1990; Andreassai, 1995). As a result of this sympathoexcitatory response, SC and ST are commonly used to measure sudomotor and vasomotor activity, respectively, and are accepted as an indirect measure of SNS activity (Edelberg, 1971; Kornberg and McCarthy, 1992; Andreassai, 1995; Nance and Hoy, 1996; Genno et al., 1997). Continuous recording of subject ST was achieved with the use of non-invasive probes (Biopac TSD102D series temperature transducer) placed on the palmar surface of the distal phalanx of the subjects left and right ring nger (Darrow, 1933; Uematsu et al., 1988; Scerbo et al., 1992; Nance and Hoy, 1996). Continuous SC measurements were also recorded with non-invasive probes (Biopac TSD103A electrodermal activity transducer), placed on the palmar surfaces of the distal phalanx of the left and right rst and second digits (Scerbo et al., 1992; Sterling et al., 2001). A computerized data acquisition system (Acknowledge, version 3.7.1) was employed to sample the analogue data at a rate of 50 Hz. An external foot trigger was used to record the beginning and end of each experimental procedure. All recording units were calibrated prior to experimental use. 3.1. Laboratory Recordings of temperature and humidity were taken before and after each experimental procedure to monitor consistency of these readings. Noise and discussion was kept to a minimum. 3.2. Data analysis All 16 subjects completed the study. Data was divided into three periods for subsequent data analysis: preintervention, during intervention and post-intervention. The mean for each section was determined using data analysis software (Acknowledge version 3.7.1). Data was analysed using the SPSS statistical package (version 11.0). For the experimental study the mean differences of the dependent variables between the intervention period compared with the pre-intervention period (Diff A) and also post-intervention compared with the pre-intervention period (Diff B) were calculated. The data was descriptively explored in order to investigate the assumptions required to use an analysis of variance (ANOVA) statistical test. Normal distribution was conrmed with the use of the ShapiroWilk test. Homogeneity of the data was conrmed with use of the Greenhouse Geisser epsilon and HuynhFeldt epsilon tests of sphericity (Atkinson, 2001). Subsequently a two-way ANOVA with repeated measures and post hoc Bonferroni correction was used to analyse the

3. Instrumentation and measurement It has been suggested that stimulation of the SNS results in vasoconstriction of the artero-venous anastomoses within the skin that, in turn, results in a decrease of cutaneous blood ow, leading to a decrease in ST (Darrow, 1933; Venables and Christie, 1973; Harris and Wagnon, 1987; Uncini et al., 1988; Lovick, 1991; Kornberg and McCarthy, 1992; Chiu and Wright, 1996; Nance and Hoy, 1996). Stimulation of the SNS may also result in an increase in sudomotor activity, via the inuence of cholinergic sympathetic bres, which results in an increase in sweat gland activity and a subsequent decrease in skin resistance and associated increase in SC (Edelberg, 1971; Uncini et al., 1988; Andressai, 1995). This sympathoexcitatory response may be a result of the primitive ght or ight mechanism whereby blood ow is redirected away from the cutaneous surface to aid muscle contraction, and

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statistical signicance of Diff A and Diff B between the independent variables. The factors for the ANOVA were intervention condition (i.e. control, placebo, treatment) and side (left, right). Signicance levels were set at Pp0.05 (Altman, 1991; Polgar and Thomas, 2000).

for all experiments and humidity varied by a maximum of 2%. These levels were consistent with guidelines established in previous trials (Uematsu et al., 1988; Kornberg and McCarthy, 1992; Chiu and Wright, 1996). 4.2. Left and right differences

4. Results The results of the data analysis are discussed in the following paragraphs and presented in Tables 13 and Figs. 14. 4.1. Laboratory conditions 4.3. Skin temperature Measures of laboratory temperature and humidity demonstrated consistent readings throughout all experimental conditions. The temperature remained constant Data analysis indicated a trend suggestive of a decrease in ST for the treatment and placebo conditions There were no statistically signicant differences for the dependant variables (ST and SC) between left and right upper limbs for treatment, placebo or control conditions at any phase of the intervention (see Table 1, Figs. 1 and 2).

Table 1 Analysis of variance for skin temperature and skin conductance for left and right upper limbs for Diff A and Diff B F values Df P value Signicant (S) or nonsignicant (NS)

Skin temperature Diff A (intervention period compared with pre-intervention period) Diff B (post-intervention period compared with pre-intervention period) Skin conductance Diff A (intervention period compared with pre-intervention period) Diff B (post-intervention period compared with pre-intervention period) Signicance set at Pp0.05.

0.217 0.465

1 1

0.648 0.506

NS NS

3.771 0.855

1 1

0.071 0.370

NS NS

Table 2 95% condence intervals (CI) for mean of ST and SC for Diff A and Diff B for each intervention factor Condition Mean SEM 95% CI (lower bound/ upper bound)

Skin temperature Diff A (intervention period compared with pre-intervention period) Diff B (post-intervention period compared with pre-intervention period) Skin conductance Diff A (intervention period compared with pre-intervention period) Diff B (post-intervention period compared with pre-intervention period)

Control Placebo Treatment Control Placebo Treatment Control Placebo Treatment Control Placebo Treatment

0.302 0.147 0.107 0.587 0.145 0.140 0.044 0.080 0.175 0.050 0.032 0.140

0.114 0.071 0.072 0.244 0.086 0.090 0.015 0.052 0.037 0.034 0.011 0.037

0.059/0.545 0.004/0.298 0.048/0.261 0.068/1.107 0.038/0.329 0.053/0.332 0.077/-0.011 0.029/0.190 0.095/0.254 0.123/0.022 0.008/0.056 0.061/0.220

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A. Moulson, T. Watson / Manual Therapy 11 (2006) 214224 Table 3 ANOVA and post hoc data for ST and SC for Diff A and Diff B for each intervention factor F value df P value Signicant (S) or non-signicant (NS) 219

Skin temperature Diff A (intervention period compared with pre-intervention period) Treatment versus control Placebo versus control Treatment versus placebo

2.454 1.261 0.171

1 1 1 1 1 1

0.138 0.279 0.685 0.088 0.118 0.962

NS NS NS NS NS NS

Diff B (post-intervention period compared with pre-intervention period) Treatment versus control 3.333 Placebo versus control 2.751 Treatment versus placebo 0.002 Skin conductance Diff A (intervention period compared with pre-intervention period) Treatment versus control 30.147 Placebo versus control 7.617 Treatment versus placebo 2.017 Diff B (post-intervention period compared with pre-intervention period) Treatment versus control 17.887 Placebo versus control 8.415 Treatment versus placebo 8.543 Signicance set at Pp0.05.

1 1 1 1 1 1

o0.0005 0.015 0.176 0.001 0.011 0.010

S S NS S S S

compared with the control condition (see Table 2 and Figs. 1 and 3). This trend appeared greatest for the treatment condition and was apparent for both Diff A (intervention phase compared to pre-intervention phase), and Diff B (post-intervention phase compared to pre-intervention phase). However, the decreases in ST did not reach statistically signicant levels between independent variables (see Table 3 and Fig. 3). 4.4. Skin conductance Analysis indicated that there was a statistically signicant increase in SC for both treatment and placebo conditions when compared with the control group (see Table 3 and Fig. 4). This was signicant for Diff A (intervention phase compared to pre-intervention), and Diff B (post-intervention phase compared with pre-intervention). There was also a statistically signicant increase in SC for the treatment intervention compared to the placebo condition. However, this was only true for Diff B data, although there also appeared to be a trend suggestive of a greater increase for SC for the treatment condition compared with the placebo condition for Diff A (see Tables 2, 3 and Figs. 2 and 4). 4.5. Post-trial questionnaire Of the 16 subjects surveyed post-experimental procedure, 13 correctly guessed that the SNAG technique was the treatment condition. No subject correctly guessed

the purpose of the study. This corroborated naivety of the subjects to the purpose of the study.

5. Discussion The results of this study appear to have some correlation with similar studies investigating SNS activity and SMT, and appear to have demonstrated that cervical SNAGs performed on the C5/6 intervertebral joint with active right rotation elicited a pattern of generalized sympathoexcitation in the upper limbs which was not specic to side despite the subject rotating their head only to the right. Specically, there was a statistically signicant increase in SC measures for the treatment and placebo conditions when compared to control, both during and after intervention was applied. The treatment condition demonstrated signicantly greater increases in SC compared to the placebo condition once the treatment was nished. There also appeared to be a trend for greater increases in SC for the SNAG technique compared to the placebo whilst the SNAG was performed, although this did not reach statistically signicant levels. The study also demonstrated a trend for a decrease in ST in placebo and treatment conditions when compared to control, which was not side dependant, however, this did not reach statistically signicant levels. In this study, there were no apparent left to right differences. This is consistent with previous research which has, overall, found there to be a generalized

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Skin temperature (degrees Celsius)

32 Skin conductance (mho) 31.5 31 30.5

L R

1 0.8 0.6 0.4 0.2

L R

30 pre during post Time period (control conditions) 32 31.5 31 30.5

L R

(a) Skin temperature (degrees Celsius)

0 cont pre (a) Skin conductance (mho) 1 0.8 0.6 0.4 0.2
L R

cont during

cont post

Time period (control conditions)

30 pre during post Time period (placebo conditions) 32 31.5 31 30.5

L R

(b) Skin temperature (degrees Celsius)

0 plac pre plac during plac post Time period (placebo conditions) 1 0.8 0.6 0.4 0.2
L R

(b) Skin conductance (mho)

30 pre during post Time period (treatment conditions)

(c)

0 treat pre treat during treat post Time period (treatment condition)

Fig. 1. Mean ST for 16 subjects for both left and right upper limbs and for each intervention. Note: The close relationship of left and right sides throughout all time periods for each intervention. Also, note the downward trend for ST in both placebo and treatment conditions compared with control condition: (a) control condition, (b) placebo condition and (c) treatment condition.

(c)

Fig. 2. Mean SC for 16 subjects for both left and right upper limbs and for each treatment condition. Note: The close relationship of left and right sides throughout all time periods for each intervention. Also note the upward trend for SC, during intervention, in both placebo and treatment conditions compared with control conditions: (a) control condition, (b) placebo condition and (c) treatment condition.

sympathoexcitatory response to SMT which is not side specic. It can be speculated that the generalized sympathoexcitatory response to the SNAG technique found in the current study may indicate that SNAGs contribute to manipulation-induced analgesia via a centrally mediated phenomenon, rather than a local mechanism (Vicenzino et al., 1994; Willett and Toppenberg, 2001; Toppenberg and Simpson, 2001; Sterling et al., 2001), although this needs to be considered in light of the asymptomatic population tested. Studies which have found left to right differences have used unilateral techniques such as an AP mobilization on the glenohumeral joint (Simon et al., 1997) and a unilateral PA on the lumbar spine (Perry, 2002). In the current study,

it could be postulated that as the subjects were instructed to rotate their heads to the right a side difference might have occurred. This was not the case. This may be explained by the fact that a central technique was performed. It is possible to speculate that a unilateral SNAG may have yielded different results, and highlights an area for future research. This studys results are consistent with previous research in that there was a greater response of SC to interventions compared with ST. A number of researchers have identied that ST response to SMT is often of a smaller magnitude and demonstrates inconsistency

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2.0

Difference Diff A Diff B

1.0

0.0

-1.0 Control Placebo Condition

Fig. 3. Box plots representing change in skin temperature (1C) for Diff A and Diff B for each intervention.

Treatment

0.4 Change in Skin Conductance (mho)

Difference Diff A Diff B

0.2

0.0

-0.2

-0.4

Control

Placebo Condition

Treatment

Fig. 4. Box plots representing change in skin conductance (mmho) for Diff A and Diff B for each intervention.

compared to SC (Peterson et al., 1993; Vicenzino et al., 1995; Chiu and Wright, 1996; Sterling et al., 2001). At this point, it is relevant to consider the construct validity of using SC and ST as measures of SNS activity in experiments of this nature, and to review this in light

of proposed mechanisms of manipulation-induced analgesia. It would appear from the literature that ST is a more sensitive and reliable measure of SNS activity (Kornberg and McCarthy, 1992; Nance and Hoy, 1996; Watson, 2004), whereas SC is prone to variability as it can be affected by psychological and personality factors (Edelberg, 1973; Millington and Wilkinson, 1983; Barabasz, 1985; Borgeat and Boissonneault, 1989; Uncini et al., 1988; Scerbo et al., 1992). Thacker and Gifford (2002) state that SC, on the palms of the hands, is solely controlled by the psycho-emotional centres and may represent only a measure of psycho-emotional drive. Several authors have cautioned the use of SC as a measure of SNS function as it is inuenced by numerous control centres within the central nervous system (Edelberg, 1973; Janig, 1990; Holstege, 1991; Scerbo et al., 1992; Andreassai, 1995). This suggests a far more complex response than has been proposed by Wright (1995, 2002) whereby SMT stimulate the dlPAG and descending pain inhibitory pathways, and are reected in physiological sympathoexcitatory changes of SC and ST. Additionally, there has also been some dispute over spinal connections with the dlPAG. Bandler et al. (2000) suggest that the dlPAG receives no direct spinal or trigeminocervical nucleus input, implying that the dlPAG may be driven by forces other than physical stressors. The implications of this are that there appears to be no direct pathway linking the physical contact involved in SMT and the dlPAG. It can be speculated that if the dlPAG is involved with response to SMT, it may be as a result of the patient/subjects personal interpretation of the situation and the neurophysiological sequalea this may evoke. In light of the current studys signicant results related to SC it is interesting to speculate that SNAGs may have a profound psychological effect on subjects. This concept is not new and there is much published literature on the relationship between psychological factors and musculoskeletal dysfunction (Hoehler and Tobis, 1983; Flor, 1990; Helliwell et al., 1992; Jensen et al., 1994; Gamsa, 1994; Klaber Moffett and Richardson, 1995; Kendall et al., 1997; Vlaeyen and Crombez, 1999; Turk et al., 2000). In relation to ST, although there have been some questions as to the validity of using ST as a measure of the SNS function (Thacker and Gifford, 2002), it would appear that this is a more reliable and valid measure of vasomotor function (Kornberg and McCarthy, 1992; Nance and Hoy, 1996; Watson, 2004). In view of this it is difcult to explain the lack of signicant ST changes found in this and other similar studies as it would appear that this outcome is a more valid measure of sympathoexcitation. This may potentially compromise proposed theories relating to sympathoexcitation, SMT and manipulation induced analgesia. However, measures of SC and ST should not be considered in isolation and additional studies utilizing

Change in Skin Temperature (degree C)

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measures of mechanical and thermal pain thresholds in addition to SC and ST may reveal more conclusive results. Further to this recent animal studies have begun to shed supplementary light on the complex nature of manipulation induced analgesia and lend support to proposed theories that joint manipulation may produce a non-opioid form of analgesia, mediated by spinal serotonergic and noradrenergic receptors utilizing descending inhibitory pathways, which may involve the PAG and the SNS (Sluka and Wright, 2001; Malisza et al., 2003; Skyba and Wright 2003). The validity of extrapolating this work to human subjects with all their innate complexities is problematic given the sensory and emotional aspects of the pain experience (Merskey et al., 1979; Zusman, 2004). It may be that such a bottom up, positivist approach to research in this area can only provide a limited account of the underlying mechanisms of SMT (Stephenson, 2004). There were some differences between this current study and previous-related research. This study demonstrated no signicant difference between placebo and treatment conditions for SC in Diff A period (intervention compared with pre-intervention phases). However, a signicant difference for Diff B (post-intervention compared with the pre-intervention phase) was demonstrated. This is in contrast to similar studies which have investigated cervical spine SMT and found consistent SC differences between treatment and placebo across all time periods (Peterson et al., 1993; Vicenzino et al., 1995, 1998a; Sterling et al., 2001; Perry, 2002). The contrasting research ndings are interesting to consider in light of a number of factors. In the current study only three SNAGS were performed during the treatment phase for each subject, which is consistent with the standard established by Mulligan for the rst time use of the technique (Mulligan, 1999). This resulted in a mean time for technique performance of 22 s (SD 3.6 s), which was a considerably shorter treatment period than other studies investigating SNS response to cervical SMT (Peterson et al., 1993; Vicenzino et al., 1995, 1998a; Chiu and Wright, 1996; Sterling et al., 2001). Interestingly, several studies have investigated the relationship between dose of SMT treatment and SNS activity over time (Vicenzino et al., 1994; Chiu and Wright, 1996; Souvlis et al., 2001). Results suggest that frequency and duration of treatment time has a signicant impact on the response of SC and ST. It may be that if more SNAGs had been performed a greater difference between placebo and treatment conditions would have been found across the time phases. In support of this it is important to highlight the apparent trend which was demonstrated during the intervention application suggesting a greater increase in SC for the SNAG group when compared to placebo, although this was not at a signicant level (see Fig. 2). This is an area for further research specically in light of

the fact that there is no experimental evidence indicating the optimum number of Mulligan techniques to be performed in treatment sessions. A second factor that potentially explains the apparent similarity between placebo and treatment conditions may be that the statistical analysis used in this study was not directly comparable to analysis completed by other authors. Previous studies have used data analysis using the maximum SC, minimum ST and area under the curve (AUC) values expressed as percentages of baseline means to illustrate results (Vicenzino et al., 1998a, 1995; Peterson et al., 1993; Chiu and Wright, 1996; Sterling et al., 2001). Unfortunately, this process has been methodologically questioned (Vickers, 2001) and so was not used in this instance. The signicant increase in SC over time (i.e. positive for Diff B but not Diff A) for the SNAG intervention, when compared to placebo, suggests that SNAGs may illicit a signicant sympathoexcitatory response after the treatment technique has been completed. This is an unexpected nding when viewed alongside one of the main premises of SNAG techniques in the patient population: that they should be immediately pain relieving. If the underlying mechanism of SNAGs was connected with the dlPAG and descending inhibitory pain pathways it is expected that there would have been an immediate sympathoexcitatory response which was greater than placebo. This was not the case and may indicate that there is a multimodal mechanism underlying the mechanism of SNAGs. It is interesting to speculate that SNAGs may illicit their effects via a mixture of psycho-emotional pathways, such as patient interpretation of the treatment procedure and effect on factors such as fear avoidance as well as physiological pathways such as the primitive ght or ight response. It may be that the laying on of hands (as in the placebo and SNAG intervention) is sufcient to illicit a sympathoexcitatory response greater than control conditions, as this current study demonstrated. However, the movement element of the SNAG technique may be essential to produce a greater increase in this response over time and this may or may not affect the analgesia induced by the technique. However, as the current study was done on asymptomatic subjects the results cannot be extrapolated to the patient population.

6. Conclusion The results of this study add further data to the body of evidence already completed on SMT and their effects on the SNS. The study investigated a technique which has not previously been evaluated and its results suggest that cervical SNAG techniques, performed on na ve asymptomatic subjects, have a sympathoexcitatory effect as measured indirectly by changes in the SC and

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ST. Similar studies suggest that this response is consistent with the ght or ight response and may be linked with midbrain stimulation and endogenous analgesia. The study has highlighted some of the underlying assumptions used in this theory of manipulation-induced analgesia and questions aspects of its validity. From the current study it is difcult to suggest the precise neurophysiological or psycho-emotional pathway by which SNAGs exhibit their clinical effect. However, it has been demonstrated that SNAGs, in an asymptomatic population, do illicit a sympathoexcitatory response and it can be speculated that this may play a role in their underlying pain relieving mechanism. Further research should extend this work by investigating the effect of a longer treatment time, the response of the SNS to unilateral SNAG techniques as well as investigating a patient population.

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