Cervicogenic Dizziness – Should You Treat the Upper Trapezius?

Simons and Travel 1999 describe myofascial pain (MP) as a common symptom usually caused by myofascial trigger points (MTrPs). The MTrPs in the neck muscles have been associated with a possible source of referred facial and cranial pain and could contribute to the nocioceptive activity occurring with Cervicogenic Dizziness.  The muscle most often affected with the presence of MTrPs in the neck region is the trapezius muscle,  specifically the upper fibers, and this is the most hyperalgesic muscle of the neck and shoulder (Sciotti et al 2001Melegar & Krivickas 2007Fischer 1987).  In fact, it is well established that treating soft tissue dysfunction of the upper trapezius is effective in the management of nonspecific cervical pain (Cagnie et al 2015,  Montañez-Aguilera FJ et al 2010Aguilera FJ et al 2009).
The authors of this manuscript consider addressing MTrPs in the descending fibers of the upper trapezius to be an appropriate treatment for individuals suffering from Cervicogenic Dizziness, however, it may be incomplete and suboptimal location to maximize potential outcomes.   It can have an influence on the functional relevance of the neck in its relationship with the cervico-collic reflex and vestibulo-collic reflex, but may not be a significant factor in modulation of its effects on head-in-space and head-on-trunk posture. All things considered, even though it is a popular location to stretch or treat manually, it may not be as much of a contributing factor of nocioceptive input into dysfunction of head on neck proprioception and self-motion perception.
The following two scenarios are the theoretical concepts to this impression:
  1. Relative Abundance of Muscle Spindles
Neck muscles are richly endowed with muscle spindles and contribute greatly to proprioception of the neck (Voss 1958Cooper 1963Kuklarni et al 2001Liu et al 2003).  The high muscle spindle density and the special features of the muscle spindles in the deep neck muscles allow not only great precision of movement but also adequate proprioceptive information needed both for control of head position and movements and for eye/ head movement coordination.
The number of muscle spindles in relation to muscle mass in a recent anatomical study by Banks RW 2006 confirms the greatest abundance is in axial muscles, including those concerned with head position.  The upper trapezius muscle is a high contributor of muscle spindles, but comparably, it is far behind suboccipital musculature, being rated #31 and along the same relative abundance as the adductor pollicis, extensor digitorum brevis, obliquees internus abdominus, omohyoideus, pronator quadratrus and extensor digitorum.  These muscles, due to their location, are of course not primary influence on head-on-neck proprioception.
So, based off of this information and overall thoughts on a patient’s adherence to a home program (keeping 5 exercises or less)— does stretching the upper trapezius, as described in the literature & pictured below, appear to be the most optimal treatment & one we should encourage with patients having cervicogenic dizziness?
Minguez-Zuazo, et al 2016, Malmström et al., 2007; Schenk et al., 2006; Wrisley et al., 2000

2. Influence based off of points of attachment on occiput (from Dvorak J. Manuelle Medizin. 1988)
points of attachment
Based off of the cross section of the occipital anatomy shown above, you can question the influence of the upper trapezius, as compared to suboccipital musculature, on the effect of head on neck posture/proprioception.  The surface area of the upper trapezius is significantly less than other muscles of the cervical spine, especially short dorsal musculature of the upper neck.  Therefore, we must take into account the overall influence of the upper trapezius compared to other musculature to optimize patient outcomes and results to improve pain, joint position error and postural stability.
Thus, the theoretical constructs and literature review for the non-articular management of cervicogenic dizziness is unclear and still under scrutiny.   The application of soft tissue management at one location vs another can be determined through a thorough clinical reasoning process and assessment  The type of soft tissue intervention that is most optimal (i.e. dry needling, ischaemic compression, IASTYM, dry cupping, deep massage, etc.) is still under debate, but the authors of this post do feel the location of your intervention can make a difference.
You can learn more about the screening and treatment process of Cervicogenic Dizzinesss through Integrative Clinical Concepts, where the authors (husband–a manual therapist a wife—a vestibular specialist), teach a very unique course combining both the theory and practice of vestibular and manual principles in their 2-day course.  Pertinent to this blog post, the 2nd day includes the “Physio Blend”, a multi-faceted physiotherapist approach to the management of Cervicogenic Dizziness, which includes treatments of the articular and non-articular system of manual therapy and the most updated sensorimotor exercise regimen.
If you would like to host a course for your staff (either a vestibular, neuro, sports or ortho clinic), please do not hesitate to contact me at harrisonvaughanpt@gmail.com for prices and discounts.
The original article was initially written for In Touch Physical Therapy Blog at:


Harrison N. Vaughan, PT, DPT, OCS, Dip. Osteopracic, FAAOMPT    
Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts
Physical Therapist at In Touch Therapy, South Hill, VA
Danielle N. Vaughan, PT, DPT, Vestibular Specialist  
Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts
Vestibular Physical Therapist at Drayer Neurological Clinic, Raleigh, NC
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Untold Physio Stories S5:E2 – Thorough History and Asking the Right Questions

Download file | Play in new window | Duration: 14:55

2 stories for this episode: First, a patient presents with profound weakness in dorsiflexion (tilting one’s foot towards the head) but no pain. Was it a stroke, painless fracture? Listen in to find out how important a thorough evaluation is.

Second, a patient comes into clinic after falling onto his arm. As Dr. Andrew Somers tells “the patient reports bleeding our of his left ear when sleeping.” Listen in to find out what the final diagnosis was?

Untold Physio Stories is sponsored by the EDGE Mobility System, featuring the EDGE Mobility Tool for IASTM, EDGE Mobility Bands, webinars, ebooks, Pain Science Education products and more! Check it out at edgemobilitysystem.com .  Be sure to also connect with Dr. Erson Religioso at Modern Manual Therapy and Jason Shane at Shane Physiotherapy.
Want an approach that enhances your existing evaluation and treatment? No commercial model gives you THE answer. You need an approach that blends the modern with the old school. Live cases, webinars, lectures, Q&A, hundreds of techniques and more! Check out Modern Manual Therapy!

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Could This be a New Era for Global Health?

For the first time in history an African will be leader of the WHO. Dr Tedros Adhanom Ghebreyesus is an Ethiopian with an impressive CV. The 52 year old used to be Ethiopian minister for foreign affairs as well as chairman of the board of the Global Fund to Fight Aids, TB and Malaria. He also boasts a PhD in community health and is a recognized malaria researcher.

During his address to delegates before voting, Dr Tedros said:

 “Knowing survival to adulthood cannot be taken for granted, and refusing to accept that people should die because they are poor.”

Not only was this the first time an African has had the WHO’s top post, it was the first time a vote for the job has taken place. Previously the WHO board has made the decision. The changes have come as a consequence of the Ebola epidemic and the perceived ‘sluggish response’ to the crisis. This is a step towards transparency and let’s hope Tedros’ leadership is equally honest.

His top five priorities in his new job are:

  • Advancing universal health coverage
  • Ensuring WHO responds rapidly and effectively to disease outbreaks and emergencies
  • Putting the wellbeing of women, children and adolescents at the centre of global health and development
  • Helping nations address the effects of climate change on health
  • Making the agency transparent and accountable

A lot has changed over the past decade, which is the duration of this post, lets hope he achieves his goals and drives improved health for all.

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Which of his five priorities do see see as most important?

OPEN ACCESS: Assessment of reliability of ultrasound scanning to measure the humeral head in a number of GHJ positions

The aim of this study was to assess the intra-rater and inter-rater reliability of real time ultrasound scanning in measuring static humeral head position. Real time ultrasound scanning, an experimental clinical measurement, was used to record measurements of the humeral head position in a sample of (20) healthy volunteers [9 male, 11 female]. While the participant was seated in a standardized chair, Hips and knees were positioned at 90 degrees of flexion. The humeral head position of each subject was imaged at three ultrasound view [anterior, posterior and superior] in a different arm positions; images were repeated three times for each position by the same examiner on the same day to assess Intra-rater reliability. The Images were then analysed by the researcher and a second investigator to assess inter-tester reliability. Intra-rater and inter-rater reliability were quantified by using the intraclass correlation coefficient and standard error of measurement, the smallest detectable difference values were calculated and were used to estimate the magnitude of change that is predictable to exceed measurement error. The intra-rater reliability for all positions was found to be excellent for all tests ranged from 0.83 to 0.99 respectively. Inter-rater reliability between examiners was found to be good to excellent for all test positions ranged from 0.66 to 0.98, and the standard error of measurement for all positions was less than the calculated mean.

This study demonstrates that real time ultrasound scanning is a reliable method of assessing the location of the humeral head in a number of arm positions in healthy subjects when measured by the same examiner and this may suggest that RTUS could be used to assess the impact of rehabilitation programme or surgical interventions for shoulder pathology.

Cervical Radiculopathy or Infected Nerve Root Canal?

The bidirectional relationship of pain between the jaw/face and cervical spine is a clinical challenge for many therapists. It requires a sound understanding of pain mechanisms, behavioral patterns of referred pain and the clinical tools to assess what the primary contributing factors are. This is a case study covers the pain presentation of a patient with concurrent neck pain, arm pain and jaw pain.


Mrs. P presented with excruciating left sided neck pain, left medial scapula pain and pain radiating down her left arm into her 4th and 5th fingers. She was distressed by the severity of her pain and worried that her neck had ‘given way’ because there was no mechanism of injury she could attribute to the onset of her symptoms. I was informed that previous cervical MRI had detected bony spurs around the C5 vertebrae and she was now booked in for a repeat MRI and appointment with a neurosurgeon to discuss further treatment options for her pain. 
Upon further questioning the patient revealed that her primary pain was on the left side of her neck. Constant in nature and fluctuating between a 5-10/10 in severity. This pain was limiting her ability to move her neck and when she did, a second sharp pain came on in the medial border of her scapula. 
There was a third pain which came on her medial scapula pain had been present for 20-30 minutes and it radiated down her arm to the 4th and 5th fingers. 
I thought that this completed the pain presentation and then asked “What about your jaw – do you have any pain there? And are you experiencing any headaches?”
Mrs. P replied “yes and yes”.
The patient had not thought there was a connection between her two weeks of jaw pain, headaches and the symptoms in her neck and arm. Two weeks prior she had developed a terrible pain in her left jaw and the dentist diagnosed this as an infected root canal. She had been to the dentist 8 times in the past two weeks and spent considerable time in a dental chair for treatment prior to coming to Physical Therapy. During her dental visits her neck was rested in right lateral flexion, rotation and extension and the a jaw was sustained in a maximally opened position. 



Before generating a hypothesis list there were a few questions that came to mind about the unusual presentation of this patient’s pain. 
  1. Could the pain be a cervical radiculopathy? It doesn’t follow the pain distribution of a C5 radiculopathy but are there other neural signs? Also, there is no prior history of cervical radiculopathy.
  2. Is the pain originating from the cervical spine, temporomandibular joint or infected root canal. The onset of the pain coincides with the development of tooth pain and during this time the jaw was kept open for prolonged periods and the neck sustained in a position of lateral flexion and extension away from the left side.  
  3. Bony spurs can be a normal part of ageing seen in the cervical spine, so how important is that information to this pain presentation?
  4. Is this scapula pain a cloward sign?
  5. Is this a somatic referral or neuropathic referred pain?
  6. Is the arm pain coming from the thoracic spine or cervical spine?
  7. Are the cervical spine pain and jaw/tooth pain directly linked or concurrent?
  8. Where do I direct my treatment day 1?
Hypothesis list (what’s going to make it into the top 3?):
Systematically I needed to assess the jaw, neck and thoracic spine all together in one day. Try collect enough data to link or unlink pain areas and to find a point to treat. This is definitely a challenge for a patient with severe pain day 1. If you read through the tables (at the bottom) you will notice that while I did assess and treat a lot, I was very careful with the grade of movement and amount of pain reproduction I was hunting for. Keeping severity, irritability and nature in mind the whole time while trying to decipher the clues. 


Day 1, I really wanted to find out if this patient had a cervical radiculopathy, if C5 was the main level contributing to her pain, and if there was any connection between her tooth/jaw symptoms and her neck pain. The treatment was focussed on manual cervical traction, sustained GR IV- PA over T4, sustained trigger point release left masseter and lateral pterygoids and a HEP over cervical retraction in sitting. The tables of treatment for day 1-3 are below the references if you’d like to see the specific details but, the summary is that I treated jaw, neck and thoracic spine all on day 1 and reassessed the asterisks after each treatment to evaluate the effectiveness of each. 
The patient returned 2 days later and she was very happy with the amount of pain relief she had experienced since the treatment and more confident that either the time sitting in the dental chair, or the dental procedures were significantly increasing her pain. Despite her pain continuing, she felt more reassured that her C5 hadn’t ‘given up on her’ and that we were able to address her pain with treatment directed at the thoracic spine, cervical spine and jaw. The treatment for day 2 was a continuation from day 1 with the addition of MWM in sitting. Mrs P responded well to a combination of treatments but the most pain relief was achieve with cervical spine mobilisation. 
Day 3, the following week, was really interesting. At this time the patient had experienced 2 days of complete pain relief and while her tooth continued to be infected and painful, she could tolerate more assessment and load. I was curious to understand if her jaw pain was limiting her neck movement. Using a tongue depressor I asked the patient to bite down on the right side and turn her head to the left. This significantly increased her left neck pain. The bite down on the left (to a comfortable level for the tooth) and turn to the left – no neck pain. 
It the past many teachers have encouraged me to check the TMJ in neck patients but never fully explained what that might involve. Does checking the TMJ involve palpation, assessing active range of movement, doing palpation and movement in combination with neck movements? Usually I assess opening, left and right lateral movements and check for deviations and clicking during range. This was the first time I looked at active bite and it’s impact on movement and both the patient and myself were excited by what we found. 
Day 4, the patient returned 2 weeks later and reports that her pain had completely resolved. Following the previous treatment she used the cervical rotation with tongue depressor as an exercise two times a day for 4 days. Her tooth pain had settled somewhat and she was scheduled for a root canal in 2 weeks but the pain in her neck, shoulder, arm were completely clear. The patient also described that she had been practicing her thoracic mobility exercises daily and replaced her pillow to support her neck while sleeping in side lying. Overall we were both very happy with the improvement and recovery. The patient was relieved that no MRI was needed and now saw the connection between her tooth symptoms and neck symptoms and how both contributed to her overall pain, and how a combination of Physiotherapy and Dentistry would help address these problems. 


This was the first time I have used occlusion to address a cervical mobility problem and have spent considerable time reading literature trying to understand the neurophysiological and biomechanical reason for why it worked. Generally, everything I read about cervical spine disorders and TMD suggests that the muscles of mastication are overactive and need to reduce in work load. For this patient the treatment was the complete opposite. Maybe it comes down to the mechanism of injury? Or maybe it was the unusual high frequency of jaw opening in a patient with pre-existing neck stiffness lead me to think that the jaw needed to be closed back down again? 
A study by Visscher, Slater & Naeije (2000) on the kinematics of the human mandible for different head postures showed that there is movement of the incisal points when the head changes between a forced upright (military), neutral and forward head posture. “According to this study, the opening movement path of the incisal point with the head held in a military posture is shifted anteriorly relative to its path in a natural head posture. In a forward head posture its path is shifted posteriorly. During lateroflexion, the movement path of the incisal point deviates to the side the head is movement to” (2000, p.303). 
With Mrs. P, her head was held in right lateral flexion therefore the incisal points will have moved to the right side. These changes are at maximum 0.19mm, so the clinical relevance of these small changes remains to be determined, however it can be speculated that with a forward head posture and right lateral flexion the intra-articular distance in the TMJ would be increased. 


The link between the tooth pain and limited cervical rotation was an interesting aspect of this case study. You can argue that neurophysiologically these two regions are linked via their afferent input via the trigeminocervical nucleus. While this link existed on day 1 & 2, by day 3 the somatic referral was no longer reproducible. Biomechanically however, the tooth pain was preventing this patient from using their left jaw and this was altering the load of the left cervical spine in movement. Using a tongue depressor was a simple differentiation tool that allowed us to explore if her mouth movements were impacting neck movements, and the pain was rapidly reduced in left cervical rotation when the patient was cued to gently bite down the left teeth onto the piece of wood. Not enough to cause tooth pain but enough to get some muscle activation and see what role inhibition had in this pain presentation. 
Most treatment options discussed in the literature refer to restoring opening and reducing activity in the muscles of mastication. It seems that all evidence points towards occlusion reducing cervical rotation through overactivity of muscles of mastication yet in this case study it did the opposite. Does this mean this is an edge case or does this mean if could be a new approach for treatment?
Another interesting point from this case study was that there were multiple concurrent issues blending into a pain pattern. Sometimes we can find a single root for a pain presentation and addressing that root, addresses all the others. This time it was not the case. I can’t change the fact this patient has an infected nerve in her tooth and that she needs either a root canal or tooth removal. But I can address the biomechanics of her jaw movements and treat the other pain areas resulting from this initial problem to provide pain relief and restoration of function. It wasn’t that simple to find and required a multi-modal approach. 


I wanted to share this case study because it raises many questions:
  1. Is there a causal relationship between occlusion and neck pain?
  2. What is the neurophysiological relationship between occlusion and cervical rotation?
  3. What is the best way to quantify postural abnormalities?
  4. What is the significant of this information regarding balance, occlusion and posture in addressing the patient’s problem of neck pain?
There is a huge amount of interest around the topic of occlusion and posture yet the amount of high quality evidence is lacking. I read articles ranging from neuroscience, physical therapy, dental and osteopathic journals and they all say the same thing – we don’t fully understand this complex system even though intuitively we know how linked the stomagnathic and cervical regions are. Secondly, there is no easy way to explain the complex relationship and interaction between somatosensory, vestibular and visual inputs. 
Posture is a state of biomechanics equilibrium with visual, vestibular and sensory input (Ciancaglini, et al., 2009). After input from these three main system there is complex processing within the central nervous system and multiple parts of the brain. It is difficult to say poor posture is caused by a single factor and delineate such an interdependent system. As such, there is no commonly agreed upon neurophysiological and biomechanics model explaining the connection between the posture of the jaw and cervical spine and how posture alters pain. 
“At the present, there is no scientific evidence to support a correlation between occlusal and postural problems from either a functional or morphological view. Therefore, there is even less evidence for a cause-effect relationship. This does not exclude the opportunity to study with a rigorous and meticulous scientific protocol the problem of the relationship between occlusion and posture, both in healthy subjects and in patients” (Ciancaglini, et al., 2009).


You have to assess the neck.
Don’t confuse pain and posture. We know a lot about the bidirectional relationship of pain through the trigeminocervical nucleus (Walczynska-Dragon, et al., 2014) but we are still learning about wether altered jaw occlusion causes postural problems and vice versa. Make sure you assess the neck in patients with jaw pain. 
Consider posture as a part of the whole picture.
When looking at the jaw during a forward head posture, the incisor point and both temporomandibular condyles move posteriorly. Lateral movement and vertical movement is not effected as much with forward head posture. Ohmure et al (2008, p. 798) found the condyle can move on average 1.1mm posteriorly during a forward head posture. This is thought to add an additional posterior force to muscles and passive structures of the TMJ. Another study found that “prolonged altered head posture due to a cervical dysfunction leads to asymmetric EMG activity in the jaw muscles (particularly masseter)” (Ballenbeger, et al., 2012, p. 315). Therefore, head posture needs to be a consideration in TMJ patients.
It is a valid approach to treat the neck with manual joint mobilisation and deep cervical neck flexor training in patients with TMD (La Touche, et al., 2009). La Touche et al (2009) look at the effect of treatment which is directed at the cervical spine and the impact it has on TMD. Their treatment protocol included only interventions for the cervical spine including: upper cervical flexion mobilisation in supine, central PA mobilisation over C5 in prone, deep cervical neck flexor training with a biofeedback cuff in supine. Following this treatment there was an immediate increase in pain pressure threshold, reduced fascial pain and increased mouth opening by 4.5mm. This study included a small sample size and the “cervical” treatment wasn’t the approach I would have taken but the results did validate that cervical spine directed treatments immediate have a hypoalgesic effect on orofascial pain.  
The presence of limited cervical rotation and pain on palpation of the shoulder and neck muscles is not a differentiating feature between a cervical spine disorder and TMD. In fact, De Laat et al (1998) found in their study that TMD patients were highly likely (between 77-93% of patients) to display limited cervical rotation C0-C4, while these limitations were only found in 20-46% of control subjects. What this means is that neck ROM has to be a consideration in TMD. 
As it currently stands, it is difficult to delineate all of the systems that contribute to posture and balance and clearly identify the amount of contribution each has. “The convergence of all the proprioceptive information on supra spinal motor centres and spinal circuits allows a series of reflex controls on the posture of the entire body, included the stomatognathic system” (Ciancaglini, et al., 2009, p.90). This is a complex system with both medullar and supra spinal control. Understanding what role occlusal information plays in maintaining postural control is hard to delineate from other inputs and processing centres. There is no way to easily separate occlusion and therefore quantify it’s involvement from a neurophysiological perspective. 
Nothing I read talks about using occlusion as a treatment strategy but the mechanism of injury for this patient pointed to that as a treatment direction. The patient demonstrated a 100% recovery in 4 sessions, which we were both very happy about. She also went on to have a root canal after her neck pain resolved. Somethings we do can’t yet be explained by EBP. Just because there isn’t an EBP to prove efficacy doesn’t mean the treatment isn’t effective. Not everything can be tested in a randomised controlled trial. 
I hope this case study helps to explain my clinical reasoning and approach to managing a patient with severe neck pain and jaw pain, discuss the questions and thoughts I had about this pain presentation and enlighten you on the key ideas I found in the research about occlusion, posture and pain.

originally found on Rayner and Smale

Sian Smale is an Australian-trained and APA-titled Musculoskeletal Physiotherapist. Sian has been writing a Physiotherapy evidence-based blog for the past 3 years called Rayner & Smale. Sian is based out of San Francisco and continues to write and teach Clinical Pilates while practicing at TherapydiaSF.  Sian has also created a free, online pregnancy and post-natal home-based workout program Hey Fit Mama.


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Ballenberger, N., von Piekartz, H., Paris-Alemany, A., La Touche, R., & Angulo-Diaz-Parreño, S. (2012). Influence of different upper cervical positions on electromyography activity of the masticatory muscles. Journal of manipulative and physiological therapeutics, 35(4), 308-318.
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Want an approach that enhances your existing evaluation and treatment? No commercial model gives you THE answer. You need an approach that blends the modern with the old school. Live cases, webinars, lectures, Q&A, hundreds of techniques and more! Check out Modern Manual Therapy!

Keeping it Eclectic…

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PEPA Case Studies

Physical Activity, Exercise and Physiotherapy

Over 6 weeks in June 2016, in collaboration with ExerciseWorks, Physiopedia delivered it’s fourth Massive Open Online Course (MOOC) on the topic of physical activity. 8,482 participants formally registered for the Physiotherapy Exercise and Physical Activity course, representing 157 countries and 86% were physiotherapists.

As part of the course there was a final optional case study assignment. These are openly available to use and are an excellent resource for your personal learning or in-service training.

A 10-Week Physical Activity Program for a Hypertensive Obese Adult

Case Study on Aerobic Training in a Subject with Knee Pain

Healthy Mom, Healthy Family (Exercising with Multiple Morbidities

Physical Activity Awareness Campaign in Mbarara Municipality

Let us know how you used to case studies.

Open Access Article: Post-surgical scar assessment in rehabilitation: a systematic review

This is an open access article

Manual therapies are frequently recommended to improve post-surgical scar pliability, e.g., its elasticity and glide capacity with respect to the underlying tissue. A significant percentage of scars are pathological, causing pain, functional/psychological disorders, or cosmetic damage. Hence, early identification of a pathological post-surgical scar is crucial for prompt treatment so as to optimize and evaluate outcome. Scar assessment tools provide data on objective parameters as the basis for planning treatment.

While the published literature contains many reviews on validated tools for post-surgical scar assessment, none specifically analyzes tools for use in the rehabilitative setting. The aim of this focused review was thus to illustrate the tools-instruments, scales and questionnaires-validated to assess post-surgical scar pliability in rehabilitation.

A literature search was conducted on articles published in journals indexed by PubMed before October 15, 2014. The literature search produced 72 papers, 6 of which met our inclusion criteria. These 6 articles deal with the validation of 5 different tools to assess post-surgical scar. Three are devices aimed to assess different pliability characteristics: Adheremeter (degree of scar adherence), Cutometer (elasticity), and Tissue Ultrasound Palpation System (scar thickness). The other two are rating scales developed for general scar assessment (Vancouver Scar Scale, and Patient and Observer Scar Assessment Scale). As the efficacy of manual therapy on post-surgical scar is still debated, it is desirable that in the future increasing use be made of validated tools as outcome measures of the rehabilitation treatment.