Manual Therapy Journal - Volume 10, Issue 1, Pages 1-92 (February 2005)

VOLUME 10 NUMBER 1 PAGES 1–92 FEBRUARY 2005

Editors

International Advisory Board

Ann Moore PhD, GradDipPhys, FCSP, CertEd, FMACP Clinical Research Centre for Healthcare Professions University of Brighton Aldro Building, 49 Darley Road Eastbourne BN20 7UR, UK

K. Bennell (Victoria, Australia) K. Burton (Hudders¢eld, UK) B. Carstensen (Frederiksberg, Denmark) E. Cruz (Setubal Portugal) L. Danneels (Mar|¤ akerke, Belgium) S. Durrell (London, UK) S. Edmondston (Perth, Australia) J. Endresen (Flaktvei, Norway) L. Exelby (Biggleswade, UK) J. Greening (London, UK) C. J. Groen (Utrecht,The Netherlands) A. Gross (Hamilton, Canada) T. Hall (West Leederville, Australia) W. Hing (Auckland, New Zealand) M. Jones (Adelaide, Australia) S. King (Glamorgan, UK) B.W. Koes (Amsterdam,The Netherlands) D. Lawrence (Lombard, IL, USA) D. Lee (Delta, Canada) R. Lee (Hung Hom, Hong Kong) L. Ma¡ey-Ward (Calgary, Canada) J. McConnell (Northbridge, Australia) S. Mercer (Dunedin, New Zealand) E. Maheu (Quebec, Canada) D. Newham (London, UK) J. Ng (Hung Hom, Hong Kong) L. Ombregt (Kanegem-Tielt, Belgium) N. Osbourne (Bournemouth, UK) M. Paatelma (Jyvaskyla, Finland) N. Petty (Eastbourne, UK) A. Pool-Goudzwaard (The Netherlands) M. Pope (Aberdeen, UK) G. Rankin (London, UK) D. Reid (Auckland, New Zealand) M. Rocabado (Santiago, Chile) C. Shacklady (Manchester, UK) M. Shacklock (Adelaide, Australia) D. Shirley (Lidcombe, Australia) V. Smedmark (Stenhamra, Sweden) W. Smeets (Tongeren, Belgium) C. Snijders (Rotterdam,The Netherlands) M. Sterling (St Lucia, Australia) R. Soames (Leeds, UK) P. Spencer (Barnstaple, UK) P. Tehan (Victoria, Australia) M. Testa (Alassio, Italy) M. Uys (Tygerberg, South Africa) P. van Roy (Brussels, Belgium) B.Vicenzino (St Lucia, Australia) H.J.M.Von Piekartz (Wierden,The Netherlands) M.Wallin (Spanga, Sweden) A.Wright (Perth, Australia) M. Zusman (Mount Lawley, Australia)

Gwendolen Jull PhD, MPhty, Grad Dip ManTher, FACP Department of Physiotherapy University of Queensland Brisbane QLD 4072, Australia Editorial Committee Karen Beeton MPhty, BSc(Hons), MCSP (Masterclass Editor) MACP ex o⁄cio member Department of Allied Health Professions—Physiotherapy University of Hertfordshire College Lane Hat¢eld AL10 9AB, UK Je¡rey D. Boyling MSc, BPhty, GradDipAdvManTher, MAPA, MCSP, MErgS (Case reports & Professional Issues Editor) Je¡rey Boyling Associates Broadway Chambers Hammersmith Broadway LondonW6 7AF, UK Tim McClune Spinal Research Unit. University of Hudders¢eld 30 Queen Street Hudders¢eld HD12SP, UK Darren A. Rivett PhD, MAppSc, MPhty, GradDip ManTher, BAppSc (Phty) (Case reports & Professional Issues Editor) Discipline of Physiotherapy Faculty of Health The University of Newcastle Callaghan, NSW 2308, Australia Kevin P. Singer PhD Centre for Musculoskeletal Studies Department of Surgery The University of Western Australia, Royal Perth Hospital Level 2, MRF Building, 50 rear, Murray Street Perth,WA 6000, Australia Raymond Swinkels MSc, PT, MT (Book Review editor and NVMTex o⁄cio member) Ulenpas 80 5655 JD Eindoven The Netherlands

Visit the journal website at http://www.elsevierhealth.com/journals/math doi: 10.1016/S1356-689X(05)00004-4

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Manual Therapy 10 (2005) 1–3 www.elsevier.com/locate/math

Editorial

The use of qualitative research methodologies within musculoskeletal physiotherapy practice 1. Introduction Qualitative research has long been associated with the academic disciplines of anthropology and sociology, and with images of lone researchers travelling to distant and exotic lands to investigate and later write about these cultures. However, the last two decades have witnessed a growing awareness of the relevance of qualitative research for healthcare. The discipline most thoroughly sold on the approach is nursing, since the demonstration of its usefulness in the mid-1980s by a group of American nurse qualitative researchers (Field and Morse, 1985; Leininger, 1985; Chenitz and Swanson, 1986). A decade later, medicine and psychology acknowledged that qualitative methodologies were useful for their respective disciplines (Britten, 1995; Henwood and Nicolson, 1995). More recently, as a result of lobbying by the Mental Health Qualitative Research Network, the British Journal of Psychiatry has this year amended its instructions to authors by including detailed advice on the submission of qualitative research articles (Quirk, 2004).

2. What is qualitative research? Qualitative research is an umbrella term for a collection of methodologies (general approaches) that have in common the desire to uncover and explore how people experience particular events and the meanings they attach to those experiences (Denzin and Lincoln, 2000; Holliday, 2002). Compared with quantitative experimental research, contemporary, sometimes labelled ‘progressive’, qualitative research (Holliday, 2002) proceeds from a different set of assumptions and philosophical beliefs. In healthcare, quantitative researchers seek to test hypotheses to identify cause and effect, while the aim of qualitative researchers is to answer questions, such as ‘how do this group of people experience X’? Quantitative researchers seek to find out about cause and effect 1356-689X/$ - see front matter r 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2004.07.001

through increasingly refined experimental conditions, within which researcher bias is controlled for. In contrast, progressive qualitative researchers argue that such a distanced and controlling approach is inappropriate for the study of human experiences and meanings, asserting that knowledge is inevitably coconstructed between researchers and their participants in qualitative fieldwork. Given this, qualitative researchers are charged with celebrating their inscription within the experiences and meanings of the people, events and issues they investigate, rather than seeing this as troublesome. From this perspective, qualitative researchers have a moral duty to make explicit how they interact with their participants, to explore rather than shy away from issues of power and influence, and to give equal respect in their accounts to their mistakes, as well as moments of epiphany (Denzin and Lincoln 2000; Duncan-Grant, 2001; Sparkes 2002; Holliday 2002). Quantitative researchers seek to increase the accumulated general stock of knowledge in relation to circumscribed causes and effects, independent of time and geographical location. In contrast, qualitative researchers argue that, as far as human experiences and meanings are concerned, knowledge is always provisional, and conceptualized within a particular group of people at a particular time in a particular place. All of the above contrasts can of course be traced to fundamental differences at the level of the philosophy of science. Whereas quantitative experimental researchers rest their case on the positivist/post-positivist paradigm or worldview, within which it makes sense to seek to make robust and global truth claims, progressive qualitative researchers argue than human meaning and experience can only ever at best be interpreted. Because meanings and experiences are socially constructed, an infinite number of stories can be told, so knowledge is never ‘exhausted’. Given this, it is argued that the kinds of ‘grand narratives’ valued by quantitative researches should be treated with a healthy scepticism, at least in the area of human meaning making.

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Editorial / Manual Therapy 10 (2005) 1–3

3. Qualitative research and evidence-based healthcare Recent years have seen turf wars emerging in particular healthcare disciplines over the relative merits of quantitative or qualitative approaches for the development of knowledge. From time to time in nursing, for example, writers from both camps take issue with each other, and the debate often takes a moral ‘one-upmanship’ turn in the direction of which approach supposedly best serves the interests of client groups. Clearly, this kind of ‘either-or’ thinking does little else than further polarize already entrenched positions. A more balanced view is that equal respect should be given to all communities of knowledge production, and that no one paradigm should dominate (Gergen, 1999). Unfortunately, paradigm dominance characterizes the current British healthcare research agenda. The practice of evidence-based health healthcare is promoted on the basis of an established hierarchy of strength of evidence described below, where (1) is assumed to be the source of evidence upon which clinicians can place most confidence (Muir Gray, 1997): (1) Strong evidence from at least one systematic review of multiple and well-designed randomized control trials. (2) Strong evidence from at least one properly designed randomized control trial of appropriate size. (3) Evidence from well-designed research trials that do not contain randomization; single group, pre-post, cohort, time series or matched case-control studies. (4) Evidence from well-designed non-experimental studies from more than one centre or research group. (5) Opinions of respected authorities, based on clinical evidence, descriptive studies, reports or expert committees. Whereas the randomized control trial is lauded as the ‘gold standard’ of healthcare research, ‘non-experimental’ and ‘descriptive’ qualitative research is relegated to the bottom of the confidence hierarchy. Such an arguably unfair over-investment in quantitative approaches can be criticized on inter-related moral and epistemological grounds. From a moral point of view, because quantitative experimental research focuses on clinical outcomes with research done to rather than with patients, the views and experiences of people are accorded insufficient attention. While a randomized control trial can provide valuable health care information, it does not on its own provide a sufficiently rich or holistic picture of the often distressing meanings associated with the experience of ill health. To paraphrase Gergen (1999), we are left with a picture of ‘misery with the tears wiped off’.

Equally, the homogenizing nature of quantitative experimental research means that variations in experiences and meanings are not identified. Writing on the Cochrane consumer website, Hilda Bastion (1994, p. 8) asserted that: People’s views in pluralistic communities cannot, and should not, be squeezed into unidimensional frameworks to meet demands for mathematical order. Values cannot be measured with a ruler, and the pain of people’s struggles with ill-health should not be homogenised till it is no longer recognisable. That something is useful, does not necessarily make it right. It should not be forgotten that utility does not equate with value, and that utilitarian decisions – ‘‘the greatest good for the greatest number’’, by definition discriminate against minorities. Epistemologically, the kinds of evidence-based healthcare assumptions described above clearly influence what is seen to count as quality knowledge in many healthcare disciplines. Such assumptions fuel a form of circular reasoning where clinical outcomes only are seen as worthwhile. Atkinson et al. (2001) described this as ‘paradigm entrapment’, arguing that it contributes to the social construction of patients and the experiences in particular ways. At worst, this can for example lead to clinicians being dismissive of their patients’ experience of ill-health and the distress associated with sometimes painful treatments.

4. How qualitative research might benefit and enrich musculoskeletal physiotherapy practice At a very general level, physiotherapy researchers might use qualitative approaches to explore how patients experience physiotherapy treatments. More specifically, there are lots of exciting research questions that could be asked in relation to the varieties of qualitative research methodologies available. For instance, researchers might want to investigate the lived experience of a patient, or group of patients, with chronic ill-health requiring long-term physiotherapy treatment. A focus on the personal meaning or meanings of the experience of treatment in relation to illhealth would make a phenomenological qualitative approach appropriate. The answers to the research questions posed might well aid in the development and refinement of physiotherapy interventions to the benefit of future patients. A different research focus on the social laws governing the shared and divergent experiences of groups of patients with specific illnesses requiring musculoskeletal physiotherapy interventions might indicate the need for a grounded theory approach. This essentially sociological form of qualitative research seeks to identify patterns in

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the trajectory of patients’ illnesses. An improved knowledge of such patterns might help the profession better understand the value of physiotherapy intervention for specific groups of patients at specific times in the course of their illnesses. A discourse analytic research approach would enable researchers to focus more on the language used by patients in relation to their illnesses. From this perspective, language is not understood as a neutral vehicle to describe experiences but as constitutive of these experiences. Discourse analytic researchers could, for example, use non-participant observational methods to study the verbal interaction between physiotherapists and their patients. This might yield interesting data on what characterizes helpful and unhelpful dialogue, which may in turn inform curriculum development in physiotherapy education. While the above has a focus on, and assumed benefit for, patient treatment, qualitative approaches could equally be used to study the lived experiences of physiotherapy practitioners, and the meanings they attribute to such experiences. A qualitative focus on training and education might lead to an improved curriculum. Equally, studies which addressed questions around particular kinds of post-qualifying experience might uncover important but ‘hidden’ experiences around, for example, bullying, job stress or practitioner burnout. Finally, and perhaps most importantly, the broadening of the research agenda in musculoskeletal physiotherapy in according more respect for, and recognition of, qualitative approaches can only benefit the physiotherapy profession. As Atkinson and his colleagues argued (2001, p. 6), ‘It is singularly unhelpful to all concerned if disciplines become too tightly classified and circumscribed according to styles of research’. As well as the benefits to patients and staff described above, the profession would be following a

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paradigm shift already well established in other healthcare disciplines and would be seen to be responding appropriately to the epistemological and moral difficulties long associated with ‘paradigm entrapment’. References Atkinson PA, Coffey A, Delamont S. A debate about our canon, Qualitative Research 2001;1(1):5–21. Bastion H, Consumer Advocate, December. The power of sharing knowledge: Consumer participation in the Cochrane Collaboration, 1994, www.cochranceconsumer.com. Britten N. Qualitative interviews in medical research. British Medical Journal 1995;311:251–3. Chenitz WC, Swanson JM, editors. From practice to grounded theory: qualitative research in nursing. Menlo-Park, CA: Addison-Wesley; 1986. Denzin NK, Lincoln YS, editors. Handbook of qualitative research. 2nd ed. Thousand Oaks, CA: Sage Publications, Inc; 2000 Duncan-Grant A. Clinical supervision activity among mental health nurses: a critical organizational ethnography. Portsmouth: Nursing Praxis International; 2001. Field PA, Morse JM. Nursing research: the application of qualitative approaches, 2nd ed. London: Chapan & Hall; 1985. Gergen K. An invitation to social construction. London: Sage Publications Ltd; 1999. Henwood K, Nicolson P. Qualitative Research. The Psychologist , 1995;March: 109–110. Holliday A. Doing and writing qualitative research. London: Sage Publications Ltd; 2002. Leininger M, editor. Qualitative research methods in nursing. Orlando, FL: Grune and Stratton; 1985. Muir Gray JA. Evidence-based Healthcare: How to Make Health Policy and Management Decisions. New York: Churchill Livingstone; 1997. Quirk A. Personal communication to Grant, 2 July, 2004. Sparkes AC. Telling tales in sport and physical activity. a qualitative journey. Leeds: Human Kinetics; 2002.

Dr.A.Grant University of Brighton, INAM Aldro building, UK E-mail address: [email protected].

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www.elsevier.com/locate/math

Review article

Manual therapy treatment of cervicogenic dizziness: a systematic review Susan A. Reid*, Darren A. Rivett Discipline of Physiotherapy, Faculty of Health, The University of Newcastle, Callaghan, NSW 2308, Australia Received 23 April 2003; received in revised form 11 March 2004; accepted 14 March 2004

Abstract Dizziness is a common and often disabling disorder. In some people the cause of their dizziness is pathology or dysfunction of upper cervical vertebral segments that can be treated with manual therapy. The aim of the present study was to systematically review the literature on the manual therapy treatment of patients with cervicogenic dizziness, by identifying and evaluating both randomized controlled trials (RCTs) and non-RCTs (controlled clinical trials and non-controlled studies). Seven electronic databases were searched up to July 2003, article reference lists were screened and an expert panel elicited to obtain relevant trials. Nine studies met the inclusion criteria and key data was extracted. Two reviewers assessed the validity of the studies using the Cochrane format and found that all studies had low methodological quality. However, a consistent finding was that all studies had a positive result with significant improvement in symptoms and signs of dizziness after manual therapy treatment. Therefore, Level 3 evidence for manual therapy treatment of cervicogenic dizziness was obtained indicating it should be considered in the management of patients with this disorder provided there is evidence of improvement. This review has identified the need for further RCTs of acceptable methodological quality. r 2004 Published by Elsevier Ltd.

Contents 1. 2.

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4.

Background . . . . . . . . . . . . . . . . . . . . . . Objective . . . . . . . . . . . . . . . . . . . . . . . 2.1. Criteria for considering studies for this review . 2.1.1. Types of studies . . . . . . . . . . . . 2.1.2. Types of participants . . . . . . . . . 2.1.3. Types of intervention . . . . . . . . . 2.1.4. Types of outcome measures . . . . . . Methods . . . . . . . . . . . . . . . . . . . . . . . 3.1. Literature search . . . . . . . . . . . . . . . . 3.2. Study selection . . . . . . . . . . . . . . . . . 3.3. Methodological quality . . . . . . . . . . . . . 3.4. Data extraction . . . . . . . . . . . . . . . . . 3.5. Analysis . . . . . . . . . . . . . . . . . . . . Results . . . . . . . . . . . . . . . . . . . . . . . . 4.1. Selection of studies . . . . . . . . . . . . . . . 4.2. Methodological quality . . . . . . . . . . . . . 4.3. Study characteristics . . . . . . . . . . . . . .

*Corresponding author. Tel.: +61 2 49844480; fax: +61 2 49812111. E-mail address: [email protected] (S.A. Reid). 1356-689X/$ - see front matter r 2004 Published by Elsevier Ltd. doi:10.1016/j.math.2004.03.006

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4.4.

Analysis . . . . . . . . . . . 4.4.1. Quantitative analysis . 4.4.2. Qualitative analysis . 4.4.3. Sensitivity analysis . . 5. Discussion . . . . . . . . . . . . . 6. Conclusions . . . . . . . . . . . . . References . . . . . . . . . . . . . . . .

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1. Background Dizziness is a common complaint in manual therapy and practice. It can be described as light-headedness, imbalance, giddiness or unsteadiness (Oostendorp et al., 1992a). It is a symptom of non-specific pathological importance (Luxon, 1984). A subgroup of those with dizziness complains of vertigo which is an illusion of movement, usually rotation, whirling or spinning of the person or the environment (Froehling et al., 1994; Cronin, 1997; Aalto et al., 1998). Dizziness and vertigo are common presenting symptoms, and were second to low back pain in frequency of occurrence in the adult population at an American Rehabilitation Hospital (Shumway-Cook and Horak, 1989). Dizziness accounts for eight million primary care visits to doctors in the United States each year and is the most common presenting complaint in patients over 75 years (Colledge et al., 1996). It is reported in 30% of people over 65 years and 39% of these people fall because of their dizziness (Colledge et al., 1996). It is particularly relevant to note that out of 18,263 patients presenting to The National Institute of Physical Therapy in the Netherlands for manual therapy from 1972–1992, 18% suffered from vertigo (Oostendorp et al., 1992b). In fact, 40–80% of neck traumatized patients experience vertigo, particularly following whiplash injury (Fitz-Ritson, 1991; Oostendorp et al., 1999; Wrisley et al., 2000). The frequency of dizziness can vary from a rare episode to a constant sensation. There are many symptoms of varying severity reported by patients with dizziness. These symptoms can lead to emotional problems, disorientation, depression, anxiety, a fear of open spaces, an inability to perform activities of daily living, employment difficulties, early retirement and family problems (Yardley et al., 1992). There are a number of different causes of dizziness including those arising from disturbances of the ear, nose and throat (ENT), central nervous system (CNS), cardiovascular system and benign positional paroxysmal vertigo (BPPV). Although diagnosis of the disorder can sometimes be difficult and require specialist facilities, these problems can often be successfully treated. However, in addition to these problems, a group of patients remains and it is suspected that the cause of their problem is a disorder of the cervical spine, known as cervicogenic dizziness.

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Cervicogenic dizziness was first described in 1955 by Ryan and Cope who used the term ‘cervical vertigo’ to refer to a combination of cervical spine problems and dizziness. It is defined as vertigo induced by changes of position of the neck (Luxon, 1984) or vertigo originating from the cervical region (Oostendorp et al., 1992a). Cervicogenic vertigo or dizziness has been a contentious topic since this time. Nevertheless, there is much evidence that cervicogenic dizziness is a distinct disorder. Injections of local anaesthetic into the neck muscles by De Jong et al. (1977) induced ataxia and vertigo in normal volunteers. Wyke (1979) also presented experimental and clinical evidence that altered function of the mechanoreceptors in the cervical joints leads to disequilibrium and ataxia in the older population. In a more recent study of patients with chronic cervicobrachial pain and nerve root compression, 50% were presumed to have cervicogenic dizziness (Persson et al., 1996). It has been suggested that it is a malfunction or disturbance in the afferent flow of impulses from deep cervical tissues and cervical proprioceptors that causes cervicogenic dizziness (De Jong et al., 1977; Luxon, 1984; Persson et al., 1996; Cronin, 1997; Oostendorp et al., 1999; Brandt and Bronstein, 2001). Traumatic, degenerative, inflammatory or mechanical problems in the cervical spine can cause cervicogenic dizziness and unsteadiness. It has been noted that the severity of the dizziness is usually proportional to the severity of more common cervical symptoms such as pain, stiffness and numbness (Wyke, 1979; Froehling et al., 1994; Bracher et al., 2000; Furman and Whitney, 2000). Cervical vertigo is often associated with whiplash injury. Whiplash injuries will be experienced by 0.1% of the population. The incidence of symptoms of dizziness or vertigo in whiplash patients has been reported as 20– 58% by Wrisley (Wrisley et al., 2000) and 80–90% by Hinoki and Heikkila et al. (Hinoki, 1985; Heikkila et al., 2000). Besides whiplash, people with cervical spondylosis and cervical muscle spasms can also have dizziness (Ryan and Cope, 1955). It has been suggested by Hulse that one third of people with cervical disequilibrium have their onset due to trauma such as whiplash, one third have insidious onset and one third have other causes such as manual therapy (Hulse, 1983). It is often assumed that the management of dizziness of cervical origin should be the same as for cervical pain

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(Brandt and Bronstein, 2001). If one is able to reproduce the patient’s dizziness on testing active cervical spine movements, or with passive cervical joint movements, a mechanical disorder is presumed to be indicated (Cronin, 1997). It is clinically expected that manual therapy which increases the range of movement of the neck, reduces muscle spasm, and restores mechanical gliding of the zygapophyseal joints will decrease dizziness and vertigo of suspected cervical origin (Wyke, 1979; Mulligan, 1991; Furman and Cass, 1996; Wilson, 1996). Several case studies have suggested that manual therapy to the upper cervical spine can result in a reduction of dizziness symptoms in patients with cervicogenic dizziness (Ryan and Cope, 1955; Cote et al., 1991; Fitz-Ritson, 1991; Mulligan, 1991; Cronin, 1997; Zhou et al., 1999; Kessinger and Boneva, 2000; Wrisley et al., 2000). Nevertheless, the role of manual therapy in the treatment of cervicogenic dizziness is far from clear and has not been systematically reviewed in the literature.

2. Objective The purpose of this study was to systematically review the literature to evaluate the evidence for the efficacy of manual therapy treatment in the management of cervicogenic dizziness. The review examines the evidence in order to inform practitioners. 2.1. Criteria for considering studies for this review 2.1.1. Types of studies The objective was to include randomized controlled clinical trials (RCTs) and non-RCTs. Non-RCTs (controlled clinical trials and non-controlled studies) were included because there were so few RCTs on this topic. 2.1.2. Types of participants Trials were included that reported on subjects with dizziness or vertigo which was considered to be caused by the cervical spine. These were patients who had dizziness and either simultaneous complaints of pain or stiffness in their cervical spine or dizziness brought on by cervical spine movements or positions. Trials that included subjects with dizziness from ear, nose and throat (ENT), central nervous system (CNS), cardiovascular and benign positional paroxysmal vertigo (BPPV) causes were excluded. 2.1.3. Types of intervention Trials in which at least one of the treatments administered was a type of manual therapy, including manipulation (high-velocity, low-amplitude techniques), mobilization (low-velocity, small or large-amplitude techniques), massage or other manual treatments were

included. Non-touch techniques were excluded. Multimodal interventions were included if they involved a component of manual therapy. 2.1.4. Types of outcome measures Outcome measures had to be for pain (visual analogue scale [VAS], numerical rating scale), dizziness (Dizziness Handicap Inventory [DHI], VAS, numerical rating scale, subjective improvement), postural performance (posturography) or a global measure (overall improvement, per cent of patients better, subjective improvement, functional changes, patient satisfaction, participation in daily activities, global perceived effect).

3. Methods 3.1. Literature search Several bibliographic databases were searched in July 2003. The following electronic databases were searched: MEDLINE using OVID (January 1, 1966 onwards), EMBASE (1988 onwards), Cumulative Index to Nursing and Allied Health Literature (CINAHL) (from 1983 onwards), Physiotherapy Evidence Database (PEDro), the Cochrane Controlled Trials Register in the Cochrane Library (latest edition), Manual Alternative and Natural Therapy Index System (MANTIS) (1880 onwards) and the Allied and Complementary Medicine Database (AMED) (from 1985 onwards). The search strategy recommended by the Cochrane Collaboration (Van Tulder et al., 1997) was used. The search strategies for the databases included terms related to the condition: cervical spine, dizziness, vertigo; terms related to the intervention: manual therapy, chiropractic, physiotherapy, manipulation; and terms related to the method of the studies: randomized controlled trial, placebo, controlled clinical trial, random allocation, double blind method, single blind method, experimental clinical trial, volunteer. These terms were linked with Boolean operators. No language restrictions were applied. 3.2. Study selection One reviewer (SR) performed the database searches and downloaded the authors, title and abstracts. If it was thought that they might meet the inclusion criteria, full text articles were obtained and selection criteria applied. 3.3. Methodological quality The name of the authors, institution and journal were removed from articles before assessment of the methodological quality was performed. Two reviewers (SR

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Table 1 The criteria list from the Cochrane Back Review Group (van Tulder et al., 1997)

contact the authors of the articles by e-mail to obtain more information.

A. Were the eligibility criteria specified? B. 1 Was a method of randomization performed? B. 2 Was the treatment allocation concealed? C. Were the groups similar at baseline? D. Were the experimental and control interventions explicitly described? E. Was the care provider blinded to the intervention? F. Were co-interventions avoided or comparable? G. Was the compliance acceptable in all groups? H. Was the patient blinded to the intervention? I. Was the outcome assessor blinded to the intervention? J. Were outcome measures relevant? K. Were adverse effects described? L. Was the withdrawal/drop-out rate described and acceptable? M. 1 Was a short-term follow-up measurement performed? M. 2 Was a long-term follow-up measurement performed? N. Was the timing of the outcome assessment in both groups comparable? O. Was the sample size for each group described? P. Did the analysis include an intention-to-treat analysis? Q. Were point estimates and measures of variability presented for the primary outcome measures?

3.5. Analysis

and DR) independently assessed the articles using the criteria list and the uniform operationalization of criteria recommended in the method guidelines for the Cochrane Back Review Group (Van Tulder et al., 1997). A consensus method was used to discuss and resolve disagreements between the two reviewers. This criteria list, also known as the MaastrichtAmsterdam criteria list, consists of 19 items that can be rated individually using one of three options: ‘yes/no/ don’t know’ (Table 1). The overall methodological quality score (overall QS) is determined by the traditional vote-counting method of adding up the ‘yes’ ratings and the maximum score is 19. Several items refer to internal validity (criteria B, E, F, G, H, I, J, L, N, P) (Van Tulder et al., 1997). The descriptive criteria (A, C, D, K, M) evaluate external validity. The remaining two items (O,Q) are statistical criteria. Due to different definitions of quality, an internal validity score (IVS) was also given by adding the positive scores for internal validity items (Van Tulder et al., 1997; Peeters et al., 2001; Verhagen et al., 2002). Studies that scored greater than 50% on overall QS or IVS were considered of acceptable validity (Verhagen et al., 2002). 3.4. Data extraction The articles were evaluated and key data were extracted by both reviewers (SR and DR) in the following categories: characteristics of participants (age, gender and diagnosis), treatments given, outcome measures used and results. An attempt was made to

If the studies had been less heterogenous and had valid data of high quality then the results would have been combined in a meta-analysis to provide an overall effect estimate, using a random effects model. If the studies are clinically heterogenous it is not advisable to perform quantitative analysis (Van Tulder et al., 1997). Qualitative analysis was achieved by attributing levels that rate the scientific evidence (Van Tulder et al., 2003a). Level 1: Strong evidence—provided by generally consistent findings in multiple higher quality RCTs. Level 2: Moderate evidence—provided by generally consistent findings in one higher quality RCT and one or more lower quality RCTs. Level 3: Limited evidence—provided by generally consistent findings in one or more lower quality RCTs. Level 4: No evidence—if there were no RCTs or if the results were conflicting. A trial was considered to be of higher quality if it scored 50% or more for the IVS (Van Tulder et al., 1997, 2003a; Verhagen et al., 2002). Generally consistent findings were defined as 75% or more of the studies having statistically significant findings in the same direction (Van Tulder et al., 2003a, b). A sensitivity analysis was conducted looking at different cut-off points for methodological quality. Acceptable (higher) quality was originally defined as 50% or more of the maximum available QS, however an analysis cut-off of 40% was also performed. In addition, a sensitivity analysis was conducted in which all ‘don’t know’ scores on the validity items were assumed to be ‘yes’.

4. Results 4.1. Selection of studies Twenty-six trials were identified using MEDLINE. These were scanned and three trials were identified that met the criteria for inclusion (Karlberg et al., 1996; Bracher et al., 2000; Heikkila et al., 2000). The search of EMBASE identified three German studies (Konrad and Gereneser, 1990; Uhlemann et al., 1993; Biesinger, 1997). The search of AMED identified a further study accepted for the review (Zhou et al., 1999). PEDro, MANTIS, CINAHL and the Cochrane Controlled Trials Register did not identify any further trials. Reference lists of the above English language articles were searched to see if other relevant articles could be identified. Trials by Galm et al. (1998) and Wing and

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by the internal validity criteria, and if these are scored low the study can be considered to have biased findings. The interventions (type, intensity, duration, number and frequency of sessions [D]) were generally not well described for most studies. Initial group characteristics (C) and adverse effects (K) were usually not described and may affect the external validity of the studies. Statistical information was poor. Point estimates and measures of variability (Q) were only described for three trials (Karlberg et al., 1996; Zhou et al., 1999; Heikkila et al., 2000).

Hargrave-Wilson (1974) were found in this manner. Five experts in the field (authors of these articles or other papers on this topic) were contacted by e-mail to see if they knew of any additional relevant sources of information. One unpublished study (Gargano, 2002) was identified but was not able to be accessed and therefore was not included. Thus, nine studies (Wing and Hargrave-Wilson, 1974; Konrad and Gereneser, 1990; Uhlemann et al., 1993; Karlberg et al., 1996; Biesinger, 1997; Galm et al., 1998; Zhou et al., 1999; Bracher et al., 2000; Heikkila et al., 2000) met the inclusion criteria for quality assessment.

4.3. Study characteristics 4.2. Methodological quality See Table 3 for selected characteristics of these studies. Despite the low quality of the selected studies there was a consistent trend in the findings of all the trials. All nine studies found a positive result. There was a significant improvement in symptoms and signs of dizziness after manual therapy treatment of participants with cervicogenic dizziness. See Table 4 for the eight studies that reported the percentage of patients experiencing complete relief or improvement of dizziness. The other trial (Heikkila et al., 2000) reported a reduction in duration of dizziness from 4.5 to 2.2 days in a week and a reduction in maximum intensity of dizziness from 61 to 49 mm on a 100 mm VAS scale. The sole RCT (Karlberg et al., 1996) used passive cervical joint mobilization combined with other interventions including soft tissue treatment, stabilization exercises, relaxation and ergonomic changes to reduce cervical discomfort. Four of the trials used cervical spine manipulation either alone (Zhou et al., 1999; Heikkila et al., 2000) or combined with other interventions, such as electrotherapy, muscle relaxation techniques and collars (Wing and Hargrave-Wilson, 1974; Bracher

Table 2 details the methodological assessment of the nine included studies. The scores from both reviewers for each article were within three points, indicating this to be a reliable process. Any disagreements related to differences in interpretation of the criteria and were resolved with discussion. The methodological quality of the nine trials was poor. None of the studies scored 50% or more on the overall methodological QS or IVS and hence none had acceptable validity (Tulder et al., 1997; Peeters et al., 2001; Verhagen et al., 2002). All studies failed to meet or lacked adequate information on several of the internal validity items (B1, B2, E, F, G, H and I). A common methodological weakness was the failure to have a control group. Following on from this, the method of randomization was not described (B1) and there was no blinding of group allocation (B2, E), blinding of the patient to the intervention (H) or blinding of the outcome assessor to the intervention (I). Insufficient information was given about co-interventions (F) and compliance with interventions (G). Methodological quality is largely defined Table 2 Methodological quality scores in decreasing order of overall quality score A RCT Karlberg et al. (1996) Non-RCTs Zhou et al. (1999) Galm et al. (1998) Bracher et al. (2000) Heikkila et al. (2000) Uhleman et al. (1993) Konrad and Gerencser (1990) Biesinger (1997) Wing and Hargrave-Wilson (1974)

B1

B2

C

D

E

M1

M2

N

O

No D/K D/K D/K No No D/K D/K No D/K Yes Yes Yes

Yes

Yes

Yes

Yes Yes

Yes 9

4

Yes No Yes Yes No No

No Yes Yes Yes Yes Yes

Yes Yes No No No No

No Yes No Yes Yes D/K

Yes Yes Yes Yes Yes Yes

Yes No No Yes No No

No No No No No No

F

D/K D/K D/K D/K D/K D/K

G

D/K D/K No D/K D/K D/K

H

No No No No No No

I

D/K D/K No D/K D/K D/K

J

No No No No No No

L

Yes Yes Yes D/K Yes Yes

P

Yes Yes Yes D/K Yes Yes

Q

QS IVS

No No No No No No

No No No No No No

No D/K No No No No

Yes No Yes Yes No No

8 7 7 7 6 5

3 4 3 2 4 3

No No No No

No No

No No

No No D/K D/K No D/K Yes No Yes Yes No D/K Yes Yes No 5 No No D/K D/K No No Yes No D/K D/K D/K D/K Yes D/K No 2

3 1

Note: D/K=don’t know; QS=overall quality score; IVS=internal validity score.

Yes Yes Yes Yes Yes Yes

K

Table 3 Selected study characteristics Authors RCT Karlberg et al. (1996)

Bracher et al. (2000)

Outcome measures

Results

Comments

17 patients with recent onset of dizziness of suspected cervical origin referred by GPs (range 25– 49 years, mean 37 years). Controls were 17 healthy volunteers (range 25–55 years, mean 36 years)

Patients randomized into 2 groups: treatment (n=9) and delayed treatment (n=8). Physiotherapy treatment included soft tissue treatment, exercises, passive and active cervical spine mobilization, relaxation, home training programs, ergonomic changes. Frequency: median 13 sessions (range 5–23) over 13 weeks (range 5–20). Delayed treatment group waited 8 weeks then had treatment as above

Posturography body sway, 100 mm VAS for pain, 5point scale for frequency and intensity of dizziness

Dizzy patients had impaired postural performance (0.5>P>0.0001) Physiotherapy reduced neck pain intensity (55 to 33 on VAS P=0.004), dizziness frequency (4 to 2, P=0.002), dizziness intensity (3 to 2, P=0.007) and improved postural performance (Po0.05). 12% complete relief of dizziness, 71% improved

RCT with objective outcome measures. No blinding. Multi-modal approach. Small sample size

34 patients with dizziness, nausea and headache (12 males and 22 females, range 29–55 years, mean 39.6 years). Illness for 6 months to 10 years. 45 in control group 50 patients with dizziness and cervical spine disorders (range 19–78 years, mean 43 years)

Traditional Chinese manipulations to the atlantoaxial joint

X-rays to show deviation of dens within the atlas

Excellent results in 73.5% with complete relief of symptoms, partial relief in 17.6%

Group A (n=31)(with upper cervical spine dysfunction) had cervical mobilization and/or manipulation. Group B (n=19)(no dysfunction) had similar manual therapy to Group A. Treatment was for 3 months Group A (n=31)(with upper cervical spine dysfunction) had cervical mobilization and/or manipulation. Group B (n=19)(no dysfunction) had similar manual therapy to Group A. Treatment was for 3 months

Subjective rating: ‘‘free of vertigo, improved or not improved’’

Group A: 77.4% improved, 16% free of vertigo. Group B: none had improvement after 2 weeks, 26.3% improved after 3 months. None free of symptoms

Non-randomized controlled clinical trial. No concealment of group allocation. No short-term follow-up. Insufficient information on blinding of outcome assessor Non-randomized controlled trial. Eligibility criteria not described. No objective outcome measures

Subjective rating: ‘‘free of vertigo, improved or not improved’’

Group A: 77.4% improved, 16% free of vertigo. Group B: none had improvement after 2 weeks, 26.3% improved after 3 months. None free of symptoms

15 patients with cervical vertigo from otolaryngology practices (range 27–82 years, mean 41 years).

Non-randomized controlled trial. Eligibility criteria not described No objective outcome measures

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Galm et al. (1998)

Interventions

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Non-RCTs Zhou et al. (1999)

Participants

9

Table 3 (continued) 10

Interventions

Outcome measures

Results

Comments

Heikkila et al. (2000)

14 patients with dizziness of suspected cervical origin referred by GPs to otorhinolaryngology clinics (range 22–54 years, mean 36 years)

Acupuncture, cervical manipulation, no treatment and NSAIDs. All 4 interventions received in random order

VAS for pain, VAS for dizziness, duration of dizziness, symptom questionnaire, CROM, kinesthetic awareness

Single-subject experimental design. 4 interventions in random order. No longterm follow-up

Uhlemann et al. (1993)

12 patients with dizziness and ‘functional disturbance of the upper cervical spine’

Three treatments of manual therapy over 8 days: mobilization and manipulation (traction manipulation of C7/T1)

Cervical turn test with electronystagmography, subjective reporting of dizziness

Konrad & Gerencser (1990)

54 patients with cervical vertigo (14 males and 40 females, o55 years, mean 34.7 years)

Mobilization and manipulation, 1–3 treatments

Electronystagmography, subjective reporting of dizziness

Biesinger (1997)

52 patients with dizziness and upper cervical spine disturbances, in whom ear and vestibular causes had been eliminated

Electronystagmography, subjective reporting of dizziness

Wing & Hargrave-Wilson (1974)

80 patients with vertigo and cervical pain or occipital headaches (60 females and 20 males, 54% aged 40–60 years, 32% aged 20–40 years)

Manual therapy: manipulation, and/or soft tissue techniques and physiotherapy over a 6 week period. Of those who became complaint-free 47% had 1 treatment, 50% had 2 Cervical spine manipulation, support in a collar, ergonomic changes, anti-inflammatory drugs

Dizziness improved with manipulation (Po0.034), duration reduced from 4.5– 2.2 days/week, maximum intensity 61 to 49 mm (VAS). Pain (39–27 mm) and dizziness (69–59) decreased by acupuncture. Pain intensity decreased by NSAIDs Significantly fewer cervical joint blockages, less dizziness (92% reduced dizziness, 8% no change) and decreased cervical nystagmus Dizziness no longer present in 33%, improved in 41% and unchanged in 26%. Nystagmus and central signs improved 58% were complaint free, 31% had subjective improvement, 11% felt no change

Electronystagmography, subjective reporting of dizziness

73% significantly improved with electronystagmography. 53% reported complete relief and 36% significant relief of symptoms

Non-controlled study. No long-term follow-up. Small sample size. No point estimates or measures of variability Non-controlled study. No long-term follow-up. No point estimates or measures of variability Non-controlled study. No long-term follow-up. Intervention not fully described. No point estimates or measures of variability Non- controlled study. No long-term follow-up. No random allocation to groups or ‘blinded’ research assistant

Note: EMG=electromyogram; GP=general practitioner; NSAID= non-steroidal anti-inflammatory drug; VAS= visual analogue scale; CROM= cervical range of motion instrument; RCT= randomized controlled trial.

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Participants

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Authors

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RCT Karlberg et al. (1996) Non-RCT Zhou et al. (1999) Galm et al. (1998) Bracher et al. (2000) Uhlemann et al. (1993) Konrad and Gerencser (1990) Biesinger (1997) Wing and Hargrave-Wilson (1974)

Complete relief (%)

Improved with treatment (%)

No change (%)

12

71

17

73 16 60 0 33

17.6 77 20 92 41

9.4 7 20 8 26

58 53

31 36

11 11

et al., 2000). The three German trials (Konrad and Gereneser, 1990; Uhlemann et al., 1993; Biesinger, 1997) and Galm et al. (1998) used both cervical spine mobilization and manipulation. It is therefore not clear whether a particular type of manual therapy is superior to other types or whether any benefit can be solely attributed to the manual therapy interventions. The high number of ‘don’t know’ scores was a reflection of the fact that these studies were generally not adequately described.

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4.4.3. Sensitivity analysis If the threshold of acceptability was lowered to 40% of the maximum QS (QS 8/19) then two studies (Karlberg et al., 1996; Zhou et al., 1999) would have achieved ‘acceptable validity’. Therefore, changing the threshold of acceptability would strengthen the conclusions of this review. By changing the threshold to more than 40% for the IVS would not have changed the result as no studies would have achieved ‘acceptable internal validity’. If all ‘don’t know’ scores are assumed to be ‘yes’ instead of ‘no’ the overall QS for each of the studies becomes: Karlberg et al. (1996) 15; Zhou et al. (1999) 11; Galm et al. (1998) 11; Bracher et al. (2000) 8; Heikkila et al. (2000) 12; Uhleman et al. (1993) 9; Konrad and Gerencser (1990) 9; Biesinger (1997) 9; and Wing and Hargrave-Wilson (1974) 9. Four studies would have achieved 50% or more. If all ‘don’t know’ scores are assumed to be ‘yes’ the IVS for each of the studies becomes: Karlberg et al. 8; Zhou et al. 6; Galm et al. 7; Bracher et al. 4; Heikkila et al. 7; Uhleman et al. 7; Konrad and Gerencser, 7; Biesinger, 6 and Wing and Hargrave-Wilson, 6. All of the studies except Bracher et al. would therefore have been rated of acceptable quality by scoring more than 5 out of 10 for internal validity. This would have strengthened the recommendation that manual therapy can be used to treat cervicogenic dizziness.

5. Discussion 4.4. Analysis 4.4.1. Quantitative analysis Since none of the studies had acceptable validity by scoring an overall QS or IVS of 50% or more, and because they were too heterogenous, a meta-analysis was not performed.

4.4.2. Qualitative analysis Level 3 evidence (limited evidence provided by generally consistent findings in one or more lower quality RCTs [Van Tulder et al., 2003a]) was obtained in this systematic review. Although this ‘levels-of-evidence system’ normally applies to RCTs, in this case it was used to describe non-RCTs due to the lack of RCTs on this topic. Based on these results, manual therapy could be considered for the treatment of patients with cervicogenic dizziness provided there was evidence of improvement in reported and measurable outcomes. Nevertheless, the small number of studies available and their poor quality does not permit firm conclusions to be made.

Results from the studies examined in this systematic review showed that there is limited evidence that manual therapy is beneficial in the treatment of cervicogenic dizziness. Due to the lack of RCTs on this topic non-RCTs were included. It has been acknowledged that RCTs are not the only or necessarily the best means of evaluating health care, and the Cochrane Collaboration has considered changing to include other research methodologies (Newman and Jacobsen 1993; Mulrow and Oxman, 1997). However, it is acknowledged that studies which are not RCTs are usually placed low on the ‘hierarchy of evidence’ (McPherson and Lord, 2000). The study by Heikkila et al. (2000) was included for assessment of methodological quality even though it is a single subject experimental design because there were so few clinical trials. It was found to have a control group, random allocation to groups and appropriate outcome measures. Heikkila et al. (2000) was also included in an effort to eliminate inclusion criteria bias. Besides the lack of RCTs and the low-methodological quality of the studies another problem was the poor reporting of the trials which often meant it was not possible to decide if a criterion had been met.

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A qualitative analysis was performed using the levels of evidence approach as recommended by the Cochrane Collaboration Back Review Group (Van Tulder et al., 2003a). However, there are many criteria lists for determining levels of evidence and these have not been standardized. Questions have been raised about the validity of the levels of evidence pooling rules. It is possible that different pooling rules could have resulted in a different level of evidence for this present study (Ferreira et al., 2002). Studies published in languages other than English were included to exclude language bias and increase precision. However, selection bias may be present in the study as only one person (SR) selected the articles. This person conducted both the citation identification and selection phase of the review. Agreement has been found to be fair to good when two people select the studies so it is still recommended. During the assessment of the articles the authors’ names, institution and journal names were removed. Although there was no true blinding as one of the researchers was also involved in article selection, the process followed was recommended by the Cochrane Collaboration Back Review Group (Van Tulder et al., 1997). Interestingly, blinding is a somewhat controversial issue with some researchers finding that blinding resulted in lower and more consistent scores than open assessment, while others did not find this (Van Tulder et al., 1997; Jadad et al., 1998). Due to minimal evidence it is not seen as a mandatory step in performing a systematic review. The findings of this review are consistent with findings from indirect evidence. Mulligan recommends the use of manual therapy in the treatment of vertigo and dizziness (Mulligan, 1991, 1999). The Sustained Natural Apophyseal Glides (SNAGs) technique recommended by Mulligan to treat this condition is now taught and practised by physiotherapists worldwide. Many other authors also suggest using manual therapy on the cervical spine to treat cervicogenic dizziness (Ryan and Cope, 1955; Wyke, 1979; Haldeman, 1980; Grieve, 1981; Odkvist and Odkvist, 1988; Fitz-Ritson, 1991; Wilson, 1996; Kessinger and Boneva, 2000; Wrisley et al., 2000; Brandt and Bronstein, 2001). Borg-Stein et al. (2001) retrospectively reviewed outcomes of 15 patients treated in an outpatient clinic with ‘rehabilitation interventions’ for cervicogenic dizziness and found 27% reported no further dizziness, with 82% of the remaining patients reporting some improvement. Several single case studies have also been reported in which manipulation has been used successfully to treat cervicogenic vertigo (Cote et al., 1991; Cagle, 1995; Cronin, 1997). The findings from this systematic review and from indirect evidence are further supported by the proposed neuroanatomical and neurophysiological basis for cervicogenic dizziness. It has been postulated that cervico-

genic dizziness is caused by cervical spine joint dysfunction and spasm of cervical muscles (Borg-Stein et al., 2001). The cervical zygapophyseal joints are the most densely innervated of all the spinal joints (Wyke, 1979). The upper cervical articular mechanoreceptors and proprioceptors contribute to static postural sensation or the sense of balance (Wyke, 1979; Hulse, 1983). The dorsal roots of the spinal nerves of C2 and C3 synapse with the nucleus abducens in the vestibular nuclei (Borg-Stein et al., 2001). Altered Type 1 cervical articular mechanoreceptors and proprioceptors from dysfunctional joints results in a loss of normal afferent input, which leads to aberrant information being sent to the vestibular nuclei (Wyke, 1979; Cagle, 1995). So even though the vestibular system may be normal, this may result in vertigo, poor balance or unsteadiness (Wyke, 1979). It follows that if one can restore normal gliding movement of the zygapophyseal joints in the upper cervical spine through manual therapy, normal afferent input will also be restored and therefore cervicogenic dizziness reduced.

6. Conclusions This systematic review has found that there is limited evidence at present to support the use of manual therapy in treating cervicogenic dizziness. Insufficient clinical research of satisfactory quality has been performed on this topic. Further RCTs, with high-methodological quality, are needed to clearly determine the role of manual therapy for this disorder. Future research should examine the efficacy of individual types of manual therapy as well as a multimodal approach.

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Review article

Can acute low back pain result from segmental spinal buckling during sub-maximal activities? A review of the current literature Richard Preussa,b, Joyce Funga,b, a

McGill University School of Physical and Occupational Therapy, 3630 Prom. Sir William Osler, Montreal, Canada H3G 1Y5 b Jewish Rehabilitation Hospital Research Centre (site of CRIR), 3205 Place Alton Goldbloom, Laval, Canada H7V 1R2 Received 18 December 2003; received in revised form 16 July 2004; accepted 18 August 2004

Abstract This paper provides a review of the current literature supporting the hypothesis that segmental spine buckling resulting in tissue damage may be a primary cause of sudden onset low back pain, even during activities that are sub-maximal with respect to loading and muscle activation. While a temporal link exists, it is supported primarily by anecdotal and clinical reports. More pertinent to this review is the biological plausibility of segmental spine buckling as a mechanism of acute injury, supported by modelling studies as well as current knowledge of tissue mechanics and neurophysiology. One antithesis, however, is the low incidence of low back injuries reported during sub-maximal tasks. In order to account for this discrepancy, several predisposing factors are addressed, both constant and situation-dependent, which may contribute to the occurrence of segmental spinal buckling during sub-maximal activities. r 2004 Elsevier Ltd. All rights reserved. Keywords: Low back pain; Soft tissue injuries; Joint instability

Contents 1.

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

2.

Spine stability and buckling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

3.

Buckling and tissue injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

4.

Tissue injury and sudden onset LBP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

5.

Predisposing factors to spinal buckling and tissue injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

6.

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Corresponding author. Jewish Rehabilitation Hospital Research Centre, 3205 Place Alton Goldbloom, Laval, Quebec, Canada H7V 1R2. Tel.: +1 450 688 9550; fax: +1 450 688 3673. E-mail address: [email protected] (J. Fung).

1356-689X/$ - see front matter r 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2004.08.006

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1. Introduction While low back injuries often occur during heavy lifting, or in extreme postures, many patients with low back pain (LBP) will describe an initial onset of symptoms during seemingly benign activities, requiring minimal or sub-maximal efforts. This apparent paradox is further perplexed by the fact that these individuals may regularly participate in activities requiring much greater efforts than those encountered at the time of the injury. Physicians, physiotherapists, and other health care professionals involved in the treatment of LBP are then faced with the task of explaining how an injury could occur under these sub-maximal conditions. This review is intended to address the question of whether there exists a credible basis for the hypothesis that episodes of sudden onset LBP can result from tissue damage caused by spinal buckling during activities that are sub-maximal with respect to loading and muscle activation. In short, we will attempt to establish a plausible causative link between segmental spine buckling, tissue damage, and sudden onset LBP under submaximal conditions. It is obviously not feasible to reproduce this type of injury sequence experimentally, due to ethical concerns, as well as a general lack of consistency and ‘‘dose–response’’ relationship (i.e. the incidence of sudden onset LBP during sub-maximal activity is presumably quite low, since nearly all daily activities take place at sub-maximal levels). There are, however, some potential causative links that can be drawn from temporality and biological plausibility, combined with a general coherence of findings from numerous experimental and modelling studies. Addressing the temporal relationship between submaximal activities and sudden onset LBP is particularly difficult, as there may not be a simple cause–effect relationship between these two events, but more likely a chain of events for which each link must be in place before the end effect can occur. As such, we must rely on clinical and anecdotal evidence to establish temporality. McGill (2002), and Cholewicki and McGill (1996), discuss clinical reports of low back injuries related to simple tasks such as picking up a pencil from the floor. Further, these authors hypothesize that injuries occurring during sub-maximal tasks are due to a transient segmental buckling (i.e. the segment will briefly exceed its maximum safe range of motion), similar to a mechanism that has been observed using video fluoroscopy under more strenuous conditions (Cholewicki and McGill, 1996). They suggest that this segmental buckling behaviour may occur as the result of a temporary loss of stability at the segment, possibly resulting from a transient loss of coordination or control of one or more intersegmental muscles. It is important to note, however, that this behaviour was observed under very high loading conditions, and as such remains a hypothetical

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mechanism to explain onset of LBP under sub-maximal conditions. This hypothesis, and the question of how this buckling behaviour might occur during sub-maximal tasks, brings us to the main focus of this review: the issue of biological plausibility. To explore the biological plausibility of this injury sequence, it is important to first address the concept of buckling as it relates to spine stability, and how the segmental buckling phenomenon discussed above might occur, particularly at the relatively low loads that are associated with sub-maximal activities. Secondly, it must be demonstrated that spine buckling under these conditions can be associated with tissue injury. Finally, a link must be drawn between tissue injury and sudden onset LBP. Further, to fully address the question above, we must also address the issue of the general lack of consistency and low ‘‘dose–response’’ relationship for this hypothetical injury sequence. To do this, factors that might predispose an individual to spinal buckling, tissue injury and LBP will be briefly addressed.

2. Spine stability and buckling The concepts of equilibrium and stability are related to the energy of a system (for a review, the reader is referred to McGill and Cholewicki, 2001). Much of the stability of the spine comes from the potential of the periarticular structures to store elastic energy, based on the stiffness of those structures. Each joint possesses some inherent stability due to the stiffness of the ligaments and joint capsule. More importantly, however, the periarticular musculature can impart a large degree of stability on the joint. Muscles can provide stability to a joint through their stiffness, which is related not only to the biomechanical properties of the muscle, but also to the level of muscle activation or force (Bergmark, 1989; Cholewicki and McGill, 1995). As such, co-activation of the periarticular muscles can provide a large increase in stability to the joint, and with the full complement of the stabilizing musculature working coherently, stability can be achieved even under very high loading conditions (Gardner-Morse et al., 1995; Cholewicki and McGill, 1996). In the frontal plane, the spine has been compared to an Euler column with a uniform modulus of elasticity (Crisco and Panjabi, 1992). This system is similar to the mast of a sailboat, whose stays exhibit high stiffness under tension. The stays of the mast are analogous to the global muscle system of the spine: muscles with no direct vertebral attachments, such as Rectus Abdominis. Like the stays of the mast, it is these global muscles that provide the bulk of the stiffness to the spinal column as a whole (Cholewicki and McGill, 1996). Unlike a ship’s mast, however, the spine is made up of several individual

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segments. To maintain a uniform modulus of elasticity for the spine, therefore, muscles with direct attachments to individual vertebrae, such as Multifidus, must provide stiffness to the intervertebral joints. This is referred to as the local muscle system. In order to meet both the equilibrium and stability requirements of the lumbar spine, a balance must be met between the activity of the large, global muscles, and that of the smaller, local muscles (Bergmark, 1989; Cholewicki and McGill, 1996). With regards to transient segmental buckling, however, it is the activity of the local muscles that is of primary interest. Modelling studies have found that inactivity of the local, intersegmental musculature will lead to instability and buckling at the affected segment at loads similar to the critical load of the ligamentous lumbar spine (88 N), regardless of the muscle activity at the other segments, or at the global level (Crisco and Panjabi, 1991; Cholewicki and McGill, 1996). By this reasoning, faulty motor control at the level of the local muscle system may lead to inappropriate levels of muscle force and stiffness at a given spine segment, and may compromise segmental stability at that level (McGill and Cholewicki, 2001). This compromised stability may, in turn, allow for transient intersegmental buckling, as described by McGill (2002). This is characterized by the segment briefly exceeding its safe physiological range of motion, leading to loading of the surrounding soft tissues (ligaments, intervertebral disc, etc.). This phenomenon contrasts with the global buckling behaviour that would occur for an Euler column of uniform stiffness. In the sagittal plane, the normal spinal curvature alters the global buckling behaviour of the spine. Under conditions of uniform stiffness, an excessive vertical load will simply increase the spine’s normal curvature in the sagittal plane, rather than causing a uniform buckling behaviour, as in the frontal plane. Patwardhan et al. (1999) have suggested that the local, intersegmental musculature may act to change the direction of the force vector applied to the spine in the sagittal plane, to produce an internal compressive force tangential to the curve of the spine in this plane. This ‘‘follower load’’ not only prevents excessive change in the spine curvature, but has been shown to enhance the load carrying capacity of the spine, in both the frontal (Patwardhan et al., 2001) and sagittal (Patwardhan et al., 1999) planes, well into the physiological range. If the force vector created by the follower load were to deviate from its ideal path in the sagittal plane, however, a bending moment would result, causing excessive flexion or extension at the affected segment. As such, faulty segmental motor control, at the level of the local muscle system, can once again be seen as a potential cause of excessive intersegmental motion under load: in other words, segmental spine buckling.

While it is clear that the local musculature must play a role in maintaining the stability of the spine, the question remains: how can a loss of stability occur during activities that are sub-maximal with respect to loading and muscle activation, even in individuals capable of performing tasks requiring much higher levels of exertion? The answer to this appears to be related to the observation that the neuromuscular system of the spine does not maintain a constant safety margin for stability during different tasks (Cholewicki and McGill, 1996). Perturbations to the spine may, in fact, be met in two ways (Bergmark, 1989; Stokes et al., 2000; Cholewicki et al., 2000): either through preset levels of stiffness and stability, such as those achieved through preparatory, feedforward muscle contraction (Hodges and Richardson, 1997a,b), or through an active modulation of muscle force and stiffness in response to perturbation, via afferent feedback (Cresswell et al., 1994; Thomas et al., 1998; Brown et al., 2003). By pre-activating the trunk musculature, the stiffness and stability of the spine are increased, decreasing the need for an active response to a transient perturbation (Stokes et al., 2000). Using a detailed model of the spine, and incorporating actual electromyographic (EMG) data, Cholewicki and McGill (1996) found that the stiffness and stability of the spine was increased during more demanding tasks (as defined by joint compression force), but diminished during periods of low muscular activity. In fact, the lowest levels of stability occurred when there was no demand for high muscle forces, such as in upright standing, or prior to a lifting task. Under these conditions, only low levels of trunk muscle co-activation are present (Cholewicki et al., 1997), with preset levels of stability depending predominantly on the passive structures of spine. It has been suggested that this reflects a strategy used by the neuromuscular system to conserve energy, and to maintain muscle contraction below levels likely to cause muscle fatigue or pain (Cholewicki and McGill, 1996; Cholewicki et al., 1997). As a result, the margin of safety for stability in these sub-maximal situations will be narrow, and even small perturbations may require increased and well-coordinated muscle activity to maintain spine stability. Further, the neuromuscular coordination that is required to maintain joint stability appears to be quite complex. Using the elbow to represent an inverted— pendulum—a simple model for joint stability—Stokes and Gardner-Morse (2000) noted that different strategies could be used, under vertical loading conditions, to maintain stable equilibrium. These strategies were based on variations in posture and muscle activation, each with trade-offs between stability and physiological costs. Similarly, different patterns of muscle activation have been noted during slow flexion–extension of the trunk, illustrating not only the potential for more than one

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motor strategy to satisfy equilibrium and stability requirements, but also the potential for error as a result of the system’s complexity (Cholewicki et al., 1997). The relative contribution to spine stability provided by each trunk muscle, in fact, appears to depend not only on the direction and magnitude of trunk loading, but also on the activity of the other trunk muscles (Cholewicki and VanVliet, 2002). One possible exception to this rule is the Transversus Abdominis (TrA), which appears to be controlled independently of the other trunk muscles during the preparatory activation that precedes limb movement, and whose activation does not appear to depend on the direction of that movement (Hodges and Richardson, 1999b). Despite this apparent independent, feedforward control of the TrA, the mechanical effect that this muscle has on the stability of the spine cannot be independent from that provided by the other muscles of the trunk. As a result, faulty activation or insufficient force generation in even one muscle might lead to a transient, segmental insufficiency, potentially resulting in segmental buckling, even under sub-maximal conditions. The potential for neuromuscular error with regards to spine stability may be further increased when preparatory, feedforward muscle activation cannot be used. Following a perturbation, an active response based on afferent feedback may be required from both the global and local musculature in order to maintain upright posture and spine stability. Moseley et al. (2003) have recently demonstrated that the Lumbar Multifidus, an important muscle in the local muscle system of the spine, may respond differently to a perturbation when its timing cannot be anticipated. While this does not necessarily represent an abnormal finding, it may represent a potential disadvantage of the stabilizing system of the spine when feedback control must be relied upon primarily to maintain spine stability. This increased reliance on feedback control may also exist, to a certain degree, even when a perturbation is expected, but when its metrics cannot be predicted, or when its metrics are incorrectly predicted (van Dieen and de Looze, 1999). This situation of external spine loading, with unpredictable timing, magnitude, or direction, is particularly important in light of the potentially high compressive forces that may accompany the global muscle response to external perturbation (Mannion et al., 2000).

3. Buckling and tissue injury From the discussion in the previous section, it seems plausible that segmental instability and buckling of the spine can occur under sub-maximal conditions, likely as a result of faulty motor control. The next issue of

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relevance to this discussion, therefore, is whether this segmental buckling can result in tissue injury. The threshold of clinically relevant mechanical tissue damage is likely to be the elastic limit at which nonreversible deformation first occurs (Adams and Dolan, 1995). This limit can be easily reached when a tissue is loaded rapidly, such as during transient loss of segmental stability resulting in buckling. During activities that are sub-maximal with respect to muscle activation, however, one would also expect the loads on the spine to be fairly small in magnitude, possibly precluding certain forms of injury, and/or allowing some degree of buckling without a resulting injury. This may not, however, be the case. For example, McGill (2002) reports that a man lifting a 27 kg weight held in the hands, using a squat style lift, can experience extensor reaction moments in the low back of 450 Nm, and a compressive load on the lumbar spine of 7000 N. This is particularly important given that the first sign of ligament damage in the spine can occur at bending moments of only 60 Nm, with complete failure occurring at 140–185 Nm (Adams and Dolan, 1995). Based on these values, injury could result if only a fraction of the load experienced during this relatively light lift was transferred to the periarticular ligaments of the spine. Another proposed mechanism of tissue injury resulting from intersegmental buckling is that, in an effort to regain spine stability as segmental buckling is occurring, the neuromuscular system might seek to activate preferentially the small intrinsic muscles spanning the unstable joint, as recruitment of larger ‘‘global’’ muscles would increase the load on the spine, potentially magnifying the effects of the buckling (Cholewicki and McGill, 1996). Conversely, the recruitment of intrinsic muscles may be required as a result of, or in concert with, a reflexive overreaction of the global trunk muscles to unexpected loading (Mannion et al., 2000). There is a limit, however, to the stability that can be achieved by activating the small, intrinsic muscles of the spine, as the load that these muscles are capable of withstanding is low compared to their global counterparts (related to the cross-sectional area of the muscles) (Bergmark, 1989). Consequently, a compensatory or reflexive strategy used by the neuromuscular system to prevent buckling might itself result in muscle injury if the stresses placed on the muscles exceed the limits that these tissues are able to withstand. This type of response would fit into the category of ‘‘bodily response’’, described as one of the top 10 mechanisms of injury in workplace accidents (Liberty Mutual, 2003). Two biologically plausible mechanisms exist, therefore, to link tissue injury to segmental buckling in the spine. The first is injury occurring as a direct result of stresses placed on the periarticular tissues during segmental buckling, which may exceed the elastic limits of these tissues even under relatively low loads. The

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second is a result of the neuromuscular system’s attempt to stabilize a segment by activating the small, intersegmental muscles of the spine, potentially leading to excessive stresses in these muscles. While direct evidence of these injuries may not exist in the literature, possibly due to the fact that a diagnosis of soft tissue injury in the back is rarely confirmed with diagnostic imaging, a clinical diagnosis of muscle strain, or joint sprain, is common in patients presenting with LBP (Micheli and Wood, 1995).

4. Tissue injury and sudden onset LBP The final link in the chain of events described in the hypothesis above is the relationship between tissue injury and the sudden onset of LBP. As this topic has been explored extensively in the literature, it will only be briefly addressed here. For example, Bogduk (1983) provides a brief review of the nerve supply to the lumbar spine, establishing a list of possible sources of primary LBP. Free nerve endings, which act as nociceptors, are found in essentially all of the spine structures that are innervated, including the muscles, the ligaments, the facet joint capsules, and the outer layers of the annulus fibrosis. As such, damage to any of these structures can result in an almost instantaneous onset of pain due to mechanical irritation of these free nerve endings. Further, a more gradual onset of pain, over the course of several hours, can occur as a result of the inflammatory process that accompanies tissue injury (Evans, 1980).

5. Predisposing factors to spinal buckling and tissue injury While anecdotal evidence supports the temporal relationship between sudden onset LBP and submaximal activities, and coherent evidence appears to support the biological plausibility of sudden onset LBP resulting from segmental buckling and tissue injury, the lack of consistency in this injury mechanism can affect the establishment of a causal relationship. Evidently, intersegmental spine buckling does not occur every time an individual engages in activities involving sub-maximal loading and trunk muscle activation. As such, the causal relationship between this type of activity and spine buckling must involve other predisposing factors. As discussed above, intersegmental buckling during sub-maximal activity is likely the result of some error in neuromuscular control, failing either to provide adequate pre-stability to the segment, or to respond appropriately with muscle activation to a perturbation. The first possibility, inadequate pre-stability, would point to an error in the feedforward control of the spine

musculature, while the second would indicate some error in muscle activation modulated by afferent feedback. Cognitive factors, uniformly described by Horak (1996) as ‘‘central set’’, are likely to affect both of these mechanisms for neuromuscular control of spine stability. These may involve issues such as intent, concentration and fatigue, prior experience with a task, or environmental conditions and distractions, each of which has been shown to influence the neuromuscular response to a given task. Errors in feedforward control may also occur at a subconscious level. Abnormalities in the feedforward activation of the TrA, apparently independent of the cognitive factors described above, have been identified in subjects with LBP (Hodges and Richardson, 1996, 1999a). It is unclear, however, if these abnormalities are a cause or consequence of the LBP. What is clear, is that a change in the feedforward activation of the trunk musculature can change the pre-stability of the spine, potentially leading to increased reliance on afferent feedback to maintain spine stability. Given the response time of the trunk muscles to perturbation (Moseley et al., 2003) and the necessary electromechanical delay prior to force generation, it would appear that a certain degree of feedforward control must be necessary to avoid injury above a certain threshold of loading and perturbation velocity. Errors in feedback modulation of spine stability can also occur for a variety of reasons. The ligamentomuscular stabilizing system of the spine (Solomonow et al., 1998, 1999) describes a means by which somatosensory feedback from the spinal ligaments helps to monitor segmental movement and activate the paraspinal musculature to maintain and/or restore stability. It has, in fact, been suggested that this modulation of muscle activity may be the key role of the ligamentous complex of the spine (Solomonow et al., 1998, 1999), which provides little stability in the absence of the musculature (Panjabi et al., 1989; Cholewicki and McGill, 1996). Low threshold mechanoreceptors in the ligaments likely influence muscle activity via the fusimotor system, while high threshold receptors may exert effects directly onto the alpha motorneurons (Dyhre-Poulson and Krogsgaard, 2000). In the spine, such connections exist from mechanoreceptors in the various spinal ligaments, and likely from the discs and facet joint capsules, to the Multifidus, and possibly other muscles (Solomonow et al., 1998, 1999). Solomonow et al. (1999) have demonstrated that laxity in the supraspinal ligament of cats, secondary to cyclic loading, leads to a decrease in the periarticular muscle activation normally associated with the loading of this structure. As such, activities leading to viscoelastic creep in the spinal ligaments, such as prolonged or cyclic loading, may decrease the effectiveness of this neuromuscular stabilizing mechanism, predisposing an individual to

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segmental instability, particularly during activities in which the pre-stability provided by the periarticular musculature is low (i.e. sub-maximal activities such as picking up a pencil from the floor). This becomes all the more important, given that prolonged loading of spinal ligaments decreases their resistance to loading by 42% in just 5 min, and 67% in 1 h (Adams and Dolan, 1995). As a result, intersegmental buckling preceded by a prolonged flexed posture (for example, in subjects who sit all day at work), not only decreases the likelihood of an appropriate, feedback modulated muscle response, but also substantially increases the likelihood of ligament injury. Several other factors can also affect the spine muscles directly. Muscle fatigue, in addition to affecting muscle force and various aspects of the myoelectric signal (e.g. Roy et al., 1989), has also been shown to have a deleterious effect on proprioception (Taimela et al., 1999), likely due to the same factors that affect the ability of the muscle to generate mechanical force and stiffness when fatigued. Vibration (as experienced when operating heavy machinery, driving, etc.), in addition to its mechanical effects on tissue (i.e. cyclic loading), will also affect the function of dynamic muscle spindle la afferents (Cordo et al., 1998), with this effect persisting for some time following prolonged vibration (Rogers et al., 1985; Thompson and Belanger, 2002). A flexed, or horizontal orientation of the trunk, in addition to altering the normal mechanical alignment of the spine, may also decrease spine proprioceptive acuity to some degree (Jakobs et al., 1985; Preuss et al., 2003), possibly as a result of altered feedback from mechanoreceptors in the load-bearing structures of the spine. This is all the more relevant, given that injuries during sub-maximal activities often occur in flexed postures. Finally, it is possible that an individual may possess certain traits that might predispose them to neuromuscular insufficiencies with respect to spine stability. The interdependence of activity between individual trunk muscles (Cholewicki and VanVliet, 2002) leaves open the potential for inefficient coordination patterns of activation due to inappropriate central commands, structural or muscular asymmetries, articular tropisms, etc. These same traits, or sequelae from previous injuries, such as untreated local muscle atrophy (Hides et al., 1994, 1996), may also predispose certain individuals to developing chronic pain following an initial incident of LBP. Such subjects have been observed to have poorer postural control in the lumbar spine (Radebold et al., 2001), and longer trunk muscle reaction times in response to perturbation (Radebold et al., 2000, 2001), both of which are indicative of compromised neuromuscular control. Once again, however, it is unclear whether this compromised control is a cause or a consequence of the LBP.

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6. Conclusion Based on the factors discussed above, it is reasonable to conclude that there exists a strong basis for the hypothesis that episodes of sudden onset LBP can result from tissue damage caused by spinal buckling during sub-maximal activities. While anecdotal evidence supports the existence of a temporal relationship, physiology and modelling studies support its biological plausibility, based on both the mechanics of the system and its neuromuscular behaviour. In order to explain the low consistency and ‘‘dose–response’’ relationship, however, it is necessary to consider several predisposing factors, both constant and situation-dependent, which might contribute to the occurrence of segmental spinal buckling during sub-maximal activities. When designing treatment or preventative programs for LBP, therefore, it is essential to address not only the issue of spine stability and neuromuscular control, but also the possible factors that might predispose the individual to episodes of transient segmental instability.

Acknowledgements R. Preuss receives financial support from the Fonds de la recherche´ en sante´ du Que´bec (FRSQ), the Canadian Institutes of Health Research and from the Richard H. Tomlinson Fellowship Endowment of McGill University. J. Fung is a chercheur-boursier of the FRSQ and a William Dawson Scholar of McGill University. We thank Dr. Ian Stokes for his guidance and valuable feedback.

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Manual Therapy 10 (2005) 21–27 www.elsevier.com/locate/math

Original article

Physiotherapy and osteoporosis: practice behaviors and clinicians’ perceptions—a survey Meena M. Srana,b,d,, Karim M. Khana,c,d a

Osteoporosis Program, Children’s & Women’s Health Centre of British Columbia, Vancouver, Canada b Department of Medicine, University of British Columbia, Vancouver, Canada c Department of Family Practice, University of British Columbia, Vancouver, Canada d Bone Health Research Group, Faculty of Medicine, University of British Columbia, Vancouver, Canada Received 12 November 2003; received in revised form 19 April 2004; accepted 28 June 2004

Abstract Physiotherapists typically use a variety of modes to treat their clients, including manual therapy. The literature cautions against the use of manual therapy in individuals with osteoporosis, (Musculoskeletal Manipulation: Evaluation of the Scientific Evidence, Charles C Thomas Publisher, Springfield, IL; Common Vertebral Joint Problems, 2nd Edition, Churchill Livingstone, New York; Maitland’s Vertebral Manipulation, 6th Edition, Butterworth-Heinemann, Boston; Br. J. Sports Med. 37 (2003) 195–196) yet clinical experience (Br. J. Sports Med. 37 (2003) 195–196) and published cases (J. Manip. Physiol. Ther. 15(7) (1992) 450–454) suggest that these techniques are still being used by at least some clinicians. The purpose of this study was to measure the most common treatment modes used by a random sample of physiotherapists practicing in the province of British Columbia (BC) in the treatment of individuals with osteoporosis. To assess whether physiotherapists in BC have concerns about the use of manual therapy in individuals with osteoporosis, particularly whether physiotherapists have concerns about fracture as a complication of treatment. This cross-sectional study of 171 physiotherapists in BC used a questionnaire developed by the physiotherapist in the Osteoporosis Program at the BC Women’s Health Centre (a part of the Children’s & Women’s Health Centre of BC). The response rate (67/171) was 39%. Ninety-seven per cent of respondents reported using strength exercises and postural reeducation, while 45% reported using manual therapy in this population. Ninety-one per cent of respondents reported having concerns about the use of manual therapy. Vertebral fracture and rib fracture were the most commonly reported concerns. These findings suggest that most physiotherapists practicing in BC, Canada use evidence-based methods (i.e. strength training) when treating individuals with osteoporosis, a large number use manual therapy, and most have concerns about its use. Physiotherapists are most concerned about fractures, in particular vertebral fracture, but injury to other musculoskeletal tissues is also of concern. Studies of safety and effectiveness of manual therapy in this population are needed to guide clinical practice. r 2004 Elsevier Ltd. All rights reserved.

1. Introduction Osteoporosis, characterized by low bone mass and increased fracture risk, is a prevalent condition that affects one in five post-menopausal women (Melton Corresponding author. F2-Women’s Health Centre, 4500 Oak Street, Vancouver, BC, Canada V6H 3N1. Tel.: +1-604-875-2341; fax: +1-604-875-3136. E-mail address: [email protected] (M.M. Sran).

1356-689X/$ - see front matter r 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2004.06.003

et al., 1992; Melton, 1997). Given the population prevalence, and also the various secondary causes of osteoporosis, it is likely that physiotherapists in all areas of practice see patients with compromised bone health (Sran, 2002). Further, an individual may present to physiotherapy for any number of problems, related or unrelated to osteoporosis. For example, back pain is also common in older adults (Badley and Tennant, 1992; Reynolds et al., 1992) and is associated with reduced mobility, independence, and health related quality of life

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(Malmros et al., 1998; Hansson and Hansson, 2000). Back pain is also the most common reason for visiting a physiotherapist (Physiotherapy Association of British Columbia (PABC), October 2001) and there are many individuals with both osteoporosis and back pain (Leidig et al., 1990; Patel et al., 1991; Malmros et al., 1998). Physiotherapists typically use a variety of modes to treat clients with osteoporosis. Pain relief, increased strength, improved posture and improved range of motion are a few common goals of therapy for such individuals (Larsen, 1998; Bennell et al., 2000). Given the effectiveness of manual therapy in various populations (Farrell and Twomey, 1982; Vicenzino et al., 1998; Goodsell et al., 2000; Sterling et al., 2001; Hoving et al., 2002; Niemisto et al., 2003), it seems reasonable that clinicians would consider using such techniques in individuals with osteoporosis. The biological mechanisms underpinning this effectiveness may be related to spinal mobilization stimulating sympathetic nervous system activity (McGuiness et al., 1997; Vicenzino et al., 1998; Sterling et al., 2001) and promoting motor activity (Sterling et al., 2001). For example, emerging evidence suggests that spinal joint mobilization techniques applied to the cervical spine elicit concurrent effects on pain perception, autonomic function, and motor function in patterns that are similar to the patterns of change elicited by stimulation of the periaqueductal grey region of the midbrain (Vicenzino et al., 1998; Sterling et al., 2001; Wright and Sluka, 2001). However, the literature cautions against the use of manual therapy in individuals with osteoporosis (Tobis and Hoehler, 1986; Grieve, 1988; Maitland et al., 2001). There appears to be agreement amongst leading clinicians that spinal manipulation (high velocity thrust) techniques are contraindicated in individuals with osteoporosis, (Tobis and Hoehler, 1986; Grieve, 1988; Maitland et al., 2001; Ernst, 2003) yet clinical experience (Sran, 2003) and published cases (Haldeman and Rubinstein, 1992) suggest that these techniques are still being used by chiropractors. However, there is concern that even spinal mobilization (low velocity techniques) could cause a fracture, (Sran, 2003) especially in individuals with osteoporosis. Clinical experience indicates that while some colleagues have expressed concern about the safety of manual therapy (including low velocity techniques) other clinicians routinely use manual therapy in older people, a proportion of whom will have osteoporosis. There are no previous studies of physiotherapists’ perceptions and current practice patterns with respect to the management of individuals with osteoporosis. Although there is vast literature on the effects of mechanical loading on bone (which physiotherapists can use to prescribe appropriate exercises) there are few data on the safety of manual therapy in this population

(Ernst, 2003; Sran, 2003; Sran et al., 2004). For these reasons the aims of this study were (1) to measure the most common treatment modes used by a random sample of physiotherapists practicing in the province of British Columbia (BC) for treating individuals with osteoporosis and (2) to assess whether physiotherapists in BC have concerns about the use of manual therapy in individuals with osteoporosis, such as fear of fracture as a complication of treatment.

2. Methods 2.1. Design This cross-sectional study was approved by the University of British Columbia Clinical Research Ethics Board and the Research Review Committee at Children’s & Women’s Health Centre of BC. 2.2. Materials The physiotherapist in the Osteoporosis Program at the BC Women’s Health Centre (a part of the Children’s & Women’s Health Centre of BC) developed a brief questionnaire (Appendix A). 2.3. Subjects and procedures The questionnaire and accompanying cover letter were faxed to a random sample of physiotherapists in the province of BC (Canada). The fax was sent to every fifth member with a fax number, from a list of members of the provincial association. The survey was sent to physiotherapists working in all areas of practice. A total of 208 questionnaires were sent but 37 were not transmitted. Thus, a total of 171 questionnaires were both sent and transmitted. Sixty-seven individuals responded by completing the questionnaire and returning it to the BC Women’s Health Centre by fax or mail within 3 weeks (a due date was specified in the cover letter).

3. Data analysis The response rate was calculated by dividing the number of respondents by the number of questionnaires that were both sent and transmitted. The number of respondents who (1) used each treatment mode (Appendix A, Question 1), (2) had concerns about the use of manual therapy, (3) had concerns about injury to each of the tissues/ regions listed (i.e. vertebral fracture, other fracture, disc injury, muscle injury) (Appendix A, Question 3)

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was expressed as a percentage of the total respondents.

Yes No Do not treat OP 3%

6%

4. Results

Other

91%

Fig. 2. Responses to Question ]2: ‘‘Do you have any concerns about the use of manual therapy techniques on individuals with osteoporosis?’’ Three responses given are: (1) yes; (2) no; and (3) do not treat osteoporosis (OP).

3%

muscle

9%

disc

Tissue

The response rate (67/171) was 39%. The percentage of all respondents who selected each treatment mode is presented in Fig. 1. Two respondents (3%) reported that they do not treat individuals with osteoporosis. Thirtynine per cent of respondents reported using treatment modes ‘other’ than those listed. A wide variety of responses were received in the ‘other’ category, including dietary calcium, weight bearing activity, fall prevention education, pain and time management, energy conservation, endurance training, referral to physician for medications, hydrotherapy, support/bracing, and education of personal trainers. Forty-five per cent of respondents reported using manual therapy in this population (Fig. 1). Ninety-one per cent of respondents reported having concerns about the use of manual therapy (Fig. 2). With the exception of one individual, respondents who reported using manual therapy (in Question ]1) also reported concern about its use (in Question ]2). The percentage of respondents concerned about each of the tissues/structures listed is presented in Fig. 3. Vertebral fracture and other fracture were the most commonly reported concerns. Of the respondents who were concerned about ‘other fractures’ (Fig. 3), 13% reported concern about rib fracture. Hip, wrist, and humerus fracture were of concern for a small number of respondents (3%, 1% and 2%, respectively).

6%

tendon

18%

ligt

63%

other #

83%

vert # 0

10

20

30

40

50

60

70

80

90

100

Percentage of Respondents

Fig. 3. Percentage of respondents reporting concerns related to each of the tissues/structures listed in Question ]3. Vert. ]=vertebral fracture; Other ]=other fracture; Ligt.=ligament injury; Tendon=tendon injury; Disc=disc injury; Muscle=muscle injury.

39% 88%

Ergonomics

5. Discussion

Posture

Treatment Mode

97% 18%

Laser

19%

US

46%

Electrother

45%

Man Ther

92%

Flexibility 79%

Balance

97% Strength 0

10

20

30

40

50

60

70

80

90

100

Percentage of Respondents

Fig. 1. Percentage of respondents who chose each of the treatment modes listed in Question ]1: ‘‘Which of the following treatment modes would you likely use with an individual with osteoporosis?’’ Strength=strength exercises; Balance=balance exercises; Flexibility=flexibility exercises; Man. Ther.=manual therapy; Electrother= electrotherapy; US=ultrasound; Laser=laser; Posture=posture reeducation; and Ergonomics=ergonomic advice.

This study presents novel data about current practice behaviors and perceptions of physiotherapists with respect to the management of individuals with osteoporosis in BC, Canada. Most respondents reported concern about the use of manual therapy in this population. Despite this concern, the results suggest that many clinicians (45% of the sample) use manual therapy in this population. Studies suggest that manual therapy can relieve pain (Farrell and Twomey, 1982; Vicenzino et al., 1998; Goodsell et al., 2000; Sterling et al., 2001; Hoving et al., 2002; Niemisto et al., 2003) and improve motor control (Sterling et al., 2001; Jull et al., 2002) so it seems reasonable that physiotherapists would consider the potential benefits of manual therapy for individuals even if they have osteoporosis.

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The questionnaire did not specifically state whether the individual was being treated for osteoporosis or an unrelated injury/condition. However, two respondents reported that they do not treat osteoporosis. One stated that ‘we are a hand-only clinic’. This response is of interest as one would speculate that a hand clinic would see some individuals post-wrist fracture, a common sentinel osteoporotic fracture and a strong predictor of future fracture (Mallmin et al., 1993; Cuddihy et al., 1999). 5.1. Treatment modes As expected, most respondents marked a number of treatment modes. Strength exercises, postural reeducation, flexibility exercises, and ergonomic advice were utilized by a vast majority of respondents (Fig. 1), while balance training was less commonly used yet is also thought to be an important factor in preventing falls and subsequent fractures (Campbell et al., 1997; Malmros et al., 1998; Myers and Briffa, 2003; Liu-Ambrose et al., 2004). Manual therapy was used by almost half the respondents (Fig. 1) yet few data exist with respect to its safety or efficacy in this population. 5.2. Concern of fracture and/or other tissue injury The results suggest that physiotherapists are concerned about fracture as a complication of manual therapy treatment, in particular vertebral fracture and rib fracture. Surprisingly, ligament, tendon, and disc injury were also of concern, albeit for a much smaller number of respondents (Fig. 3). This may reflect a lack of data about secondary tissue changes associated with osteoporosis and/or lack of knowledge on the part of physiotherapists with respect to whether or not they should be concerned about these tissues. 5.3. Response rate The response rate in this study is among the upper range found in surveys of other healthcare professionals (Bhandari et al., 2003; Stone et al., 2003). While some previous studies of physiotherapists report response rates as high as 53% (Robinson et al., 1994) and 65% (Crout et al., 1998), we feel the 39% response rate in our study is acceptable for numerous reasons. First, unlike a previous study (Robinson et al., 1994), we only sent out the questionnaire once (without a follow-up notice) and gave participants only 3 weeks to respond. Of note, some previous studies did not report the length of time allowed for responses (Crout et al., 1998) or did not accurately measure the response rate (Jarski et al., 1990). Next, we only distributed the questionnaire by facsimile, a return-reply envelope was not supplied, and the study included a random sample of all physiothera-

pists who were members of their professional organization in a specific jurisdiction. Research topic has been shown to affect response rates (de Wit et al., 2001) yet few clinicians treat primarily individuals with osteoporosis. Clinicians may be more motivated to respond to a study about direct-access (Crout et al., 1998) (which more obviously affects their caseload and earning potential) or a questionnaire specific to their area of special interest (Mantle and Versi, 1991; Barry et al., 2003). Some previous studies with higher response rates only involved clinicians in a specific area of practice (Barry et al., 2003) or education (Walker, 1998). Incentives have also been shown to affect response rates (Halpern et al., 2002) but we did not offer any in this study. Finally, a study of physicians found differences in response rates are unlikely to significantly impact the quality of data collected unless one achieves a response rate significantly above 65% (Schoenman et al., 2003). 5.4. Further research The brief questionnaire used in this study provides novel information on clinical practice but also has limitations. The frequency of use of manual therapy and clarification of which manual therapy techniques therapists were concerned about are not addressed with this questionnaire. We surveyed physiotherapists working in all areas of practice (public and private workplaces) with or without any specific postgraduate qualifications. A survey of only those with postgraduate qualifications in manual therapy may provide different data and insights. We did not state whether the client was being treated for osteoporosis or an unrelated condition, and whether they were being treated in an area where osteoporotic fractures commonly occur. While this may have been helpful for the participants, we felt that this information would be leading as we were interested in their knowledge of osteoporosis (i.e. it is a systemic condition mainly affecting trabecular bone) and common sites of osteoporotic fracture (Question 3). That we used quantitative research alone limits the type of data we could obtain in this study. We met our objectives but investigation of therapists’ beliefs and concerns using qualitative methodology may provide further insight.

6. Clinical implications These findings suggest that a large percentage of physiotherapists practicing in BC, Canada use evidencebased methods (specifically strength training, Kerr et al.,

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1996; Kohrt et al., 1997; Liu-Ambrose et al., 2004) when treating individuals with osteoporosis. Many also use manual therapy in this population and most have concerns about its use. Given the similarities in physiotherapy training across the various provinces in Canada (CUPAC and The Alliance, 1995; CPA, 2000), it is likely that these BC data would generalize nationwide. Further, manual therapy is an internationally practiced and researched treatment (Tobis and Hoehler, 1986; Vicenzino et al., 1998; Goodsell et al., 2000; Maitland et al., 2001; Sterling et al., 2001; Hoving et al., 2002; Kotoulas, 2002; Niemisto et al., 2003; Sran et al., 2004) so these data may even have international relevance. This suggests a need for appropriately designed studies to provide data to address the safety concerns reported in this study. Physiotherapists are most concerned about fractures, in particular vertebral fracture, but injury to other musculoskeletal tissues is also of concern. Clinical leaders agree that manipulation is contraindicated in this population (Tobis and Hoehler, 1986; Grieve, 1988; Maitland et al., 2001; Ernst, 2003), but consensus on

25

other manual therapy techniques has not been reached. The results of this study suggest that a significant number of physiotherapists use manual therapy in this population. Evidence suggests manual therapy is effective for some conditions, so it seems prudent that physiotherapists would consider using it in this population. However, data are scarce with respect to the safety of manual therapy for individuals with osteoporosis. As clients with osteoporosis could potentially benefit from manual therapy, trials are needed to examine its safety and efficacy in this population.

Acknowledgements M.M. Sran is a Michael Smith Foundation for Health Research and Canadian Institutes of Health Research (Alberta Bone and Joint Health Training Program) Doctoral Scholar. She gratefully acknowledges the Physiotherapy Association of British Columbia for their assistance.

Appendix A

1. Which of the following treatment modes would you likely use with an individual with osteoporosis? (Mark all that apply) & Strength exercises & Balance exercises & Flexibility exercises & Manual therapy & Electrotherapy & Ultrasound & Laser & Postural reeducation & Ergonomic advice & Other (please specify) _____________________________________ 2. Do you have any concerns about using manual therapy techniques on individuals with osteoporosis? & Yes & No 3. If you answered ‘‘Yes’’ to question ]2 then: Are your concerns related to any of the following? (mark all that apply) & Vertebral fracture & Other fracture (please specify) _____________________________________ & Ligament injury & Tendon injury & Disc injury & Muscle injury & Other (please specify) _____________________________________ Thank you for taking the time to fill out this short questionnaire.

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ARTICLE IN PRESS M.M. Sran, K.M. Khan / Manual Therapy 10 (2005) 21–27 Schoenman JA, Berk ML, Feldman JJ, Singer A. Impact of differential response rates on the quality of data collected in the CTS physician survey. Evaluation & the Health Professions 2003;26(1):23–42. Sran MM. Effects of exercise training/mechanical loading on bone— what physiotherapists need to know. Physiotherapy Canada 2002;54(1):S12. Sran MM. Chiropractic spinal manipulation for back pain; commentary. British Journal of Sports Medicine 2003;37:195–6. Sran MM, Khan KM, Zhu Q, McKay HA, Oxland TR. Failure characteristics of the thoracic spine with a posteroanterior load: investigating the safety of spinal mobilization. Spine 2004;29(21). Sterling M, Jull G, Wright A. Cervical mobilisation: concurrent effects on pain, sympathetic nervous system activity and motor activity. Manual Therapy 2001;6(2):72–81. Stone P, Ream E, Richardson A, Thomas H, Andrews P, Campbell P, Dawson T, Edwards J, Goldie T, Hammick M, Kearney N, Lean

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M, Rapley D, Smith AG, Teague C, Young A. Cancer-related fatigue—a difference of opinion? Results of a multicentre survey of healthcare professionals, patients and caregivers. European Journal of Cancer (England) 2003;12(1):20–7. Tobis JS, Hoehler F. Musculoskeletal manipulation: evaluation of the scientific evidence. Springfield, IL: Charles C Thomas Publisher; 1986. Vicenzino B, Collins D, Benson H, Wright A. An investigation of the interrelationship between manipulative therapy-induced hypoalgesia and sympathoexcitation. Journal of Manipulative and Physiological Therapeutics 1998;21(7):448–53. Walker JM. Curricular content on urinary incontinence in entry-level physical therapy programmes in three countries. Physiotherapy Research International 1998;3(2):123–34. Wright A, Sluka KA. Nonpharmacological treatments for musculoskeletal pain. Clinical Journal of Pain 2001;17(1):33–46.

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Manual Therapy 10 (2005) 28–37 www.elsevier.com/locate/math

Original article

Shoulder impingement: the effect of sitting posture on shoulder pain and range of motion Michael P. Bullocka,, Nadine E. Fosterb, Chris C. Wrightc a

Physiotherapy Department, Nottingham City Hospital, Hucknall Road, Nottingham NG5 1PB, UK b School of Health and Rehabilitation, Faculty of Health, Keele University, Staffordshire, UK c School of Health and Social Sciences, Coventry University, Priory Street, Coventry CVI 5FB, UK Received 16 December 2003; received in revised form 20 May 2004; accepted 8 July 2004

Abstract The re-education of spinal posture is an integral part of shoulder impingement management yet supporting evidence is limited. The purpose of this study was to evaluate the effect of slouched versus erect sitting posture on shoulder pain intensity and range of motion (ROM) in subjects with impingement. A same-subject repeated-measures design was utilized. Maximum active shoulder flexion and associated pain intensity were measured in 28 subjects in slouched and erect sitting postures, using video-analysis and visual analogue scales, respectively. An intratester reliability study of the video-analysis system was completed and intra-class correlation coefficients calculated. Shoulder flexion differences between slouched and erect sitting posture were analysed using a repeated-measures analysis of variance (ANOVA). The intra-tester reliability of the video-analysis method was found to be ‘excellent’ (ICC =0.99). Flexion ROM was significantly greater in the erect sitting posture (F=100.3, Po0.0001); the mean ROM difference between postures was 17.671 (79.171). There was no significant difference in pain intensity between postures (F=1.9, P=0.179). An erect sitting posture appeared to increase active shoulder flexion in subjects with shoulder impingement, although there were no differences in reported pain intensity. Further research is required to investigate the long-term effects of postural re-education. r 2004 Elsevier Ltd. All rights reserved. Keywords: Shoulder impingement; Posture; Pain; Range of motion

1. Introduction Epidemiological studies of Western society suggest that the prevalence of shoulder disorders in the general population is high, ranging from 6% (van der Windt et al., 2000), to 14% (Miranda et al., 2001). In 1994, neck and shoulder complaints represented 18% of the total paid sick leave for musculoskeletal disorders in Sweden (Nygren et al., 1995). Studies have encountered methodological difficulties due to the poor agreement in syndrome classification and diagnosis. Arguably, the diagnosis of shoulder dysfunction has been simplified by Corresponding author. Tel.: +44-0115-9691169x45310

E-mail address: [email protected] (M.P. Bullock). 1356-689X/$ - see front matter r 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2004.07.002

the development of recognized clinical syndromes such as adhesive capsulitis, instability and shoulder impingement (Fu et al., 1991; Tibone and Shaffer, 1995). The term ‘shoulder impingement’ was originally introduced by Neer (1972) who described the mechanical wear of the long head of biceps and supraspinatus by the acromion during overhead activities. The understanding of the aetiology and location of shoulder impingement has been substantially improved over the last decade (Lewis et al., 2001), yet the optimal method of management remains unclear. Physiotherapy approaches may include joint mobilization (Conroy and Hayes, 1998), deep friction massage (Cyriax, 1993), taping (Host, 1995), re-education of the rotator cuff (Thein and Greenfield, 1997) and scapular

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stabilizing muscles (Schmitt and Snyder-Mackler, 1999). Postural re-education of the cervical and thoracic spines is a frequently cited treatment recommendation (Keirns, 1994; Turner, 1996; Ayub, 1997). There are many theories underpinning this approach. Solem-Bertoft et al. (1993) suggested that the increased thoracic curvature accompanying a slouched posture may influence scapular kinematics and cause a reduction in the subacromial space. An exaggerated thoracic kyphosis has been suggested to adversely influence length–tension relationships of the shoulder girdle muscles (Grimsby and Gray, 1997) which in turn may cause mal-tracking of the humeral head within the glenoid fossa (Wilk and Arrigo, 1993). Postural correction may restore normal movement patterns and ensure that the dynamic subacromial space is maximized (Solem-Bertoft et al., 1993). However, evidence to support these anecdotal theories is sparse. The correlation between slouched spinal posture and shoulder pain has been explored by comparing the posture of healthy subjects with those who have shoulder pain (Griegel-Morris et al., 1992; Greenfield et al., 1995). Greenfield et al. (1995) compared the posture of 30 subjects with ‘shoulder overuse injuries’ with matched healthy controls. No significant differences were found between groups in relation to thoracic curvature or scapular orientation. The symptomatic group was found to have a significantly greater forward head posture. However, analysis of the data revealed that the mean difference in cervical posture was only 51 whereas the measurement accuracy of photography as a tool for measuring ‘craniovertebral angle’ was found to be between 31 and 6.51 (Braun and Amondsen, 1989). Postural measurement was undertaken with the shoulder in a neutral position. GriegelMorris et al. (1992) concluded that ‘rounded shoulders’, ‘severe kyphosis’ and ‘forward head posture’ correlated with interscapula pain but not shoulder or upper arm pain as that expected of an impingement syndrome (Conray and Hayes, 1998). Conclusions may be limited as all subjects were described as a ‘healthy’ population and the pain report of such subjects may be ambiguous. The influence of spinal posture on shoulder range of motion (ROM) and biomechanics has been evaluated using same-subject designs (Ludewig and Cook, 1996; Kebaetse et al., 1999). Ludewig and Cook (1996) evaluated the effect of cervical position on scapula orientation on 25 healthy subjects. Results suggested that increased cervical flexion prevented upward rotation and posterior tilt. The researchers postulated that cervical flexion generated tension in levator scapulae which impeded optimal scapular kinematics. Impingement subjects have been shown to exhibit reduced scapular posterior tilt during shoulder elevation compared to the normal population (Lukasiewicz et al.,

29

1999). Kebaetse et al. (1999) explored the effects of sitting posture on shoulder elevation in the scapular plane in 34 asymptomatic subjects. Significantly less ROM was noted in a slouched posture as compared to an erect posture. The mean difference was 23.61 and, at 901 and maximum elevation, subjects were found to have significantly less posterior scapular tilt. There appears to be no studies that have evaluated the effect of spinal postural correction on shoulder ROM and pain in a patient population. The current study aimed to compare the effect of slouched versus erect sitting posture on shoulder flexion ROM and pain in a population of subjects with impingement syndrome. It was hypothesized that shoulder flexion ROM would be greater and pain intensity associated with shoulder movement would be less in an erect sitting posture, than in a slouched posture.

2. Methodology 2.1. Subjects Following ethical approval from the Research Ethics Committee at the City Hospital, Nottingham and written informed consent, 28 subjects (14 male and 14 female) with a mean age of 48.2 years (SD=13.9 years) were recruited from the physiotherapy department at the above hospital. Potential subjects who were receiving treatment for shoulder pain were referred to the principal researcher (MB) for screening against inclusion/exclusion criteria. The principal researcher was unaware of the subjects’ response to postural correction prior to the recruitment process. All participants exhibited classic signs and symptoms of shoulder impingement. Diagnosis was determined by the inclusion/exclusion criteria described below which have previously been utilised by Lukasiewic et al. (1999). 2.2. Inclusion criteria The following tests were performed and at least three of the following six criteria had to be satisfied to confirm the diagnosis.









Positive modified Neer sign—shoulder pain was elicited when the shoulder was passively flexed whilst preventing scapula superior translation (Neer, 1983). Positive Hawkins sign—pain was provoked by medial rotation overpressure in 901 flexion (Magee, 2002). Painful arc with active shoulder flexion or abduction (Cyriax, 1993). Pain with palpation of the rotator cuff tendons. Anterior or lateral shoulder pain. Pain with resisted isometric abduction.

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2.3. Exclusion criteria










Cervical referred shoulder pain as indicated by a positive Spurling’s test (Viikari-Juntura, 1989), or cervical flexion quadrant (combined flexion, side flexion and rotation to the contralateral side) (Maitland et al., 2001). Upper limb neurological deficit. Adhesive capsulitis as determined by a classic capsular pattern (Cyriax, 1993). Severe constant pain of an irritable nature which may have introduced bias due to pain or fatigue effects. Past or present upper limb fracture.

2.4. Measurement tool for shoulder flexion range of motion (ROM) A video camera (Panasonic NV-M5OB) was utilized, in combination with the Peak Performance Technologies System (PPTS) which was capable of providing data regarding body location and geometry (Scheirman and Cheetham, 1990). Flexion ROM was calculated by manual acquisition involving the superimposing of cursors over pre-identified landmarks (lateral epicondyle of the humerus, central axis of shoulder rotation, and a plumbline behind the subject). The validity and reliability of this system has previously been found to be ‘excellent’ (Richter and Avena, 1993; Selfe, 1998). Selfe (1998) reported a mean difference of 0.271 (7SD 0.241), whereas Richter and Avena (1993) reported a mean difference of 0.701 (7SD 0.271). However, the above studies involved the filming of static objects (i.e. goniometers) and extrapolation of reliability measures to human subjects is not possible. Therefore, an intratester reliability study was conducted on ten asymptomatic subjects. Four images were collected for each subject in slouched and erect postures and with the shoulder above and below 901. The same video footage was digitized twice by the principle researcher (MB). There was a 1 week interval prior to re-digitisation. Intraclass correlation coefficient (ICC 2,1) values were 0.99 in all posture and angle combinations, indicating that intra-tester reliability was ‘very high’ (Munro, 2001). Bland and Altman plots (Fig. 1) as advocated by Bland and Altman (1986) and Bruton et al. (2000) indicated that there was minimal bias and there was no apparent difference in measurement variance according to posture or angle magnitude. Mean differences ranged from 0.51 to 1.001. 2.5. Additional measurement tools for the main experiment 2.5.1. Pain measurement A 100 mm horizontal visual analogue scale (VAS) was utilised to measure pain intensity experienced during

shoulder flexion. This has established reliability and validity (Huskisson, 1974; Chok, 1998; Melzack and Katz, 1999). A pilot study was undertaken to explore the appropriateness of this method. The main study procedure required the subjects to flex the shoulder three times. It was felt that pain reporting using the VAS after each arm manoeuvre may have caused an alteration in spinal posture as the subject handled the pen and paper when completing the form. The use of a single VAS score, completed after the third shoulder movement, to reflect the average maximal pain intensity, aimed to ensure that spinal position remained static within the slouched and erect postures. The pilot study was undertaken using five symptomatic subjects during which pain intensity was recorded following each shoulder flexion movement (three in total). There was minimal variability in VAS reporting across the three arm movements (average variability=1.75 mm, maximum variability=3 mm), hence the use of average VAS data was justified. 2.5.2. Cervical spine posture The intra-tester reliability of the cranio-vertebral angle, as described by Braun and Amondsen (1989), was considered good (10.5% measurement error). This was measured by digitizing reflective markers placed on C7 and the tragus. An angle was formed by the intersection of a line between these points and the horizontal (calculated via a plumbline). 2.5.3. Thoracic spine posture A flexirule technique devised by Greenfield et al. (1995) was described as being ‘satisfactory’ (ICC=0.84) with a mean measurement error of 71. A flexirule was conformed to the thoracic contour from T2 to T12 in each sitting posture. The contour was transposed to A1 graph paper, where the height and length of the curve were measured. The thoracic angle was then calculated using the formula: 4  [arctan (2  height divided by length)].

3. Main study procedure For the main study, subjects were seated on a plinth of adjustable height, with a spondylometer positioned anteriorly, and a plumbline posteriorly (see Fig. 2). The video camera was positioned lateral and perpendicular to the subject. The camera lens was set 150 cm away and level with a subject’s head. Subjects undertook an arm warm-up comprising three shoulder elevations (without exacerbating pain) and a spinal warm-up which involved the subjects actively moving from a sitting position of end-range cervical protraction/thoracic flexion to a sitting position of end-range cervical retraction/thoracic extension. This sequence was repeated three times. A

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6

Slouched posture > 90 degrees

5 4 3 2 1 0 -1 -2 -3 -4 110

120

130

140

150

160

Difference in shoulder flexion ROM (degrees)

Difference in shoulder flexion ROM (degrees)

M.P. Bullock et al. / Manual Therapy 10 (2005) 28–37

Erect posture > 90 degrees

6 5 4 3 2 1 0 -1 -2 -3 -4 90

Difference in shoulder flexion ROM (degrees)

Slouched posture < 90 degrees 6 5 4 3 2 1 0 -1 -2 -3 -4 40

50

60

70

80

100

110

120

130

140

150

160

Average shoulder flexion ROM (degrees)

90

Average shoulder flexion ROM (degrees)

Difference in shoulder flexion ROM (degrees)

Average shoulder flexion ROM (degrees)

-5 30

31

Erect posture < 90 degrees 6 5 4 3 2 1 0 -1 -2 -3 -4 -5 30

40

50

60

70

80

90

Average shoulder flexion ROM (degrees)

Fig. 1. Bland and Altman plots to illustrate the intra-tester reliability of the PPTS in measuring shoulder flexion above/below 901 in slouched and erect postures. The Bland and Altman plots display levels of mean difference (_ _ _ _), two standard deviations from the mean (- - - -) and the difference between the first and second shoulder flexion measurement (&) A scatterplot is presented for each posture/shoulder angle combination. There was minimal indication of bias with mean differences ranging from 0.471 to 1.011. The highest range of 95% agreement occurred in the slouched o901’ combination where 95% limits of agreement were 3.29 to +5.49.

reflective ball was then applied to C7 and the subject assumed the first posture (slouched or erect as determined by randomization using sealed envelopes). Positioning aimed to achieve end-range cervical protraction and thoracic flexion or neutral erect sitting as described by Kendall and McCreary (1993). Postures were achieved by using standardized verbal commands and manual facilitation by the principal investigator (MB). Two rods of the spondylometer were drawn forwards against the subject’s chin and sternum and taped in position to prevent anterior translation. Subjects maintained contact with the rods during shoulder motion. The pilot study concluded that this was an effective means of stabilizing spinal posture during the arm manoeuvres. Thoracic curvature was then measured using the flexirule. The subject then maximally flexed the shoulder with the elbow extended in the sagittal plane. This was repeated three times ensuring that spinal posture was

static. A 10 s rest interval was incorporated between each movement. ROM data were calculated using the mean of these three arm manoeuvres. Pain data were calculated by measuring VASs that reflected the ‘average maximal pain intensity’ felt during the three arm manoeuvres. Shoulder flexion angles, associated pain intensity scores and thoracic posture measurements were completed in the second posture using the same technique. The video camera recorded the entire procedure allowing digitization of shoulder ROM and cervical posture.

4. Data analysis Analyses were undertaken using the Statistical Package for the Social Sciences (SPSS version 9.0 for Windows) and all statistical tests were performed at the 5% level of significance. Descriptive data including

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Fig. 2. Equipment set up/filming of shoulder flexion in erect and slouched postures. Shoulder flexion was calculated by digitising points on the lateral epicondyle of the humerus, central axis of the gleno-humeral joint and 2 points along the plumbline. Note the rods of the spondylometer which were utilized to ensure thoracic and cervical postures were constant during shoulder motion.

means, standard deviations and ranges of measurement were calculated. Data were depicted using box-plots and t-tests were performed to verify that cervical and thoracic positions varied significantly between the slouched and erect postures. A repeated measures analysis of variance (ANOVA) was utilized to analyse the difference in ROM and pain intensity according to posture and measurement order (Sim and Wright, 2000). All statistical assumptions were satisfied regarding interval data and normal distribution requirements. Retrospective power calculations were conducted and are reported in the discussion.

5. Results 5.1. Main study The demographic details of the 28 subjects are summarized in Table 1. The mean age of the population is of importance (48.2 years). Individuals over the age of 40 have been reported to commonly develop degeneration of the acromioclavicular joint (Bonsell et al., 2000) and stage three impingement (Neer, 1983). The latter involves rotator cuff disruption and osteophyte formation around the acromion and acromioclavicular joint. 5.2. The effect of posture on ROM The mean maximal shoulder ROM was 109.71 in the slouched posture and 127.31 in the erect posture. The

mean difference of 17.71 (SD=9.21) highlighted a tendency for shoulder flexion ROM to be greater in the erect sitting posture (Table 2 and Fig. 3). There was no statistically significant difference between the order of measurement i.e. whether erect or slouched posture was measured first (F=0.1, P=0.81). However, there was a statistically significant mean difference between the two postures regarding ROM (F=100.23, P=0.0001, 95% CI=14.11 to 21.21). 5.3. The effect of posture on pain intensity There was no statistically significant difference with respect to measurement order (F=0.3, P=0.6). The mean pain intensity in the slouched posture was 38.89, and 34.39 mm in the erect posture. There was a mean difference of 4.50 mm (SD=17.93), with mean scores being less in the erect posture (Table 2 and Fig. 3). There was no statistically significant difference (P=0.18) between postural groups with respect to mean level of pain intensity (95% CI of difference in mean VAS between postures=2.09 to 11.09 mm). 5.4. The effect of posture on cranio-vertebral angle/ thoracic angle Mean cranio-vertebral (CV) angles in the erect position were significantly greater than in the slouched position (Po0.001) with a mean difference of 13.51 (SD 8.11) between postures. A greater angle was associated with forward head posture. Mean thoracic angles in the

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Table 1 Summary of subjects’ demographic details (n=28) Age (years) Mean7SD

Gender % No.

Body Mass Index Mean7SD

Duration of symptoms Mean7SD

Activity levels

Previous shoulder injections

ADL limitation

48.2713.9

Male n ¼ 14 Female n ¼ 14

24.172.7

3.6 years

Sedentary 60.7% n ¼ 17

yes 60.7% n ¼ 17 No 39.3% n ¼ 11

mild 46.4% n ¼ 13 mod. 50% n ¼ 14 Severe 3.6% n¼1

74.7 Strenuous 39.3% n ¼ 11

Strenuous activity levels may include manual labour, sports involving the upper extremities, repetitive overhead activity. Activities of Daily Living (ADL) limitation: subjects graded their functional deficit by answering the following question:- My shoulder limits my daily activities: mildly &; moderately &; severely &.

Table 2 Summary of descriptive data for shoulder ROM, pain intensity, cervical and thoracic posture in slouched and erect postures

Shoulder ROM (deg)

Pain intensity (VAS— mm)

Thoracic posture (deg) Cervical posture (deg)

Outcome variable

Mean

Std. deviation

95% confidence Interval

Range Min/Max (deg)

Maximum ROM (Erect) Maximum ROM (Slouched) Difference in mean ROM between postures Maximum VAS (Erect)

127.32 109.65 17.67

25.81 25.53 9.17

117.31, 137.33 99.75, 119.55 14.11, 21.22

83.93–174.50 68.67–155.50 5.47–38.06

34.39

20.93

26.28, 42.51

0.00–81.00

Maximum VAS (Slouched) Difference in mean pain intensity between postures Erect

38.89 4.5

30.00 17.93

31.23, 46.56 2.09, 11.09

3.00–86.00 40 to +45.00

35.61

13.70

30.30, 40.93

12.63–69.79

Slouched Erect Slouched

53.46 47.00 33.53

12.02 7.21 7.66

48.81, 58.13 44.20, 49.79 30.56, 36.50

27.54–88.53 33.27–60.13 17.05–49.36

slouched position were significantly greater than in the erect position (Po0.0001) with a mean difference of 17.91 (7SD 10.11). This confirmed that there was a statistically significant difference between the mean cervical and thoracic positions across the slouched and erect postures, as anticipated (Table 2). In summary, postural positioning which emphasised cervical retraction and thoracic extension in sitting had no significant immediate effect on reported pain intensity associated with shoulder flexion. However, the change in spinal position associated with erect sitting caused an immediate significant increase in shoulder flexion ROM.

6. Discussion This study aimed to investigate the effect of sitting posture on shoulder pain and ROM in subjects with impingement. The results provide strong evidence that a

slouched posture was associated with decreased shoulder ROM. This was the case in 26 of the 28 subjects with a mean difference of 17.71 (SD=9.21). Although results suggested that the effects of posture on shoulder flexion ROM were statistically significant, the clinical importance of the changes seen requires further discussion. Several researchers have evaluated the functional effects of shoulder stiffness and have associated a reduction in ROM with high disability (Roach et al., 1991; Chatravarty and Webley, 1993; Triffit, 1998). Chatravarty and Webley (1993) assessed a sample of 100 healthy, elderly subjects and concluded that 30% actually suffered considerable disability due to shoulder symptoms. Functional limitations (e.g. grooming, bathing and dressing) were significantly correlated with reduced shoulder ROM. The mean difference in shoulder flexion ROM between the disabled group and the healthy group was 311, yet the mean ROM difference between slouched/erect postures in the current study was only 171. It is unclear whether a 171

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Shoulder ROM (degrees)

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Shoulder flexion ROM - slouched versus erect sitting posture 200 150 100 50 0 1

2

3

4

5

6

7

9 10 11 12 13 14 15 16 17 18 19 19 20 21 22 23 24 25 26 27 28

Subject Slouched

Erect

Shoulder flexion pain intensity - slouched versus erect sitting posture 100

VAS (mm)

80 60 40 20 0 1

2

3

4

5

6

7

9 10 11 12 13 14 15 16 17 18 19 19 20 21 22 23 24 25 26 27 28

Subject Slouched

Erect

Fig. 3. Bar graph of individual data for shoulder flexion ROM and reported pain intensity differences between slouched and erect postures It was apparent that only 1 subject had less shoulder flexion ROM in an erect posture; the remaining subjects’ shoulder flexion ROM was greater in an erect posture. Although differences in reported pain intensity were not statistically significant between slouched and erect postures, 19 of the 28 subjects reported less pain during shoulder flexion when in an erect posture. This is a clinically significant result when taking into account the greater shoulder ROM measured in an erect posture.

rather than a 311 reduction in shoulder ROM would still substantially affect disability. However, comparison of the current study’s results with previous work by Triffitt (1998) suggests that a 171 increase in shoulder flexion which may arise from postural correction may cause functional improvements with respect to hair combing, putting on a coat, backwashing, washing the contralateral axilla, sleeping on the affected shoulder, reaching to a high shelf, pulling, and performing work-related activities. The demographics of the samples in both studies are similar in relation to age, mean ROM and diagnosis. Fig. 4 provides a visual example of how a 171 increase in shoulder elevation may ensure combing the hair is ‘somewhat difficult’ rather than ‘very difficult’ and therefore appears to go somewhere towards justifying the role of postural correction in the treatment of impingement syndrome. The limitation in shoulder flexion in a slouched posture may be caused by several factors. An increased

thoracic kyphosis may lead to anteriorly tilted scapulae (Culham and Peat, 1994; Kaebetse et al., 1999) and excessive cervical flexion may exaggerate this due to tension in the levator scapulae (Ludewig and Cook, 1996). The resultant change in scapular position may narrow the subacromial space (Solem-Bertoft et al., 1993), cause impingement of suprahumeral soft tissue and subsequently reduce the overall ROM. Impingement subjects have been shown to display excessive anterior scapular tilt during shoulder motion (Warner et al., 1990; Lukasiewicz et al., 1999). Alternatively, the change in spinal posture may not have influenced scapular kinematics but may have had a direct effect on shoulder flexion due to the thoracic spine’s inherent contribution to upper quadrant elevation (Crawford and Jull, 1993). The mean difference in thoracic angle correlates very closely to the mean difference in shoulder ROM (i.e. thoracic angle difference of 17.91: shoulder ROM mean difference of 17.71). This suggests that ROM loss may be directly attributed

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35

180 160

Erect 127.32o

140 120 100

Slouched 109.65 o

80 Degrees

60 40 0

20 0

0

1

1

2

2

3

Difficulty Combing the Hair 0 = impossible for patient to perform activity 2 = it is somewhat difficult

1 = it is very difficult 3 = it is not difficult at all

Fig. 4. The effect of a 171 increase in shoulder flexion ROM on the ability to comb hair (reproduced with permission of Triffitt and Journal of Bone and Joint Surgery (American) 1998). A 171 increase in shoulder flexion associated with postural correction may immediately improve shoulder function. For example, combing the hair may become ‘somewhat difficult’ rather than ‘very difficult’ by adopting an erect posture during functional activities involving flexion.

to changes in thoracic posture. However, irrespective of the cause of ROM increases, functional activities involving elevation may be facilitated by postural correction. The hypothesis that flexion-related pain intensity would be significantly less in an erect sitting posture was not supported. Results showed a trend for lower reported pain intensity in the erect position (4.5 mm mean difference), and this was evident in 19 of the 28 subjects. An erect posture, in some individuals, may be sufficient to immediately improve abnormal motor control of the scapulo-thoracic and gleno-humeral joints and cause pain reduction with shoulder flexion. In those subjects for whom pain intensity worsened or remained unchanged, the correction of spinal posture may have failed to cause an instantaneous change in shoulder kinematics. For these individuals, more specific, longterm retraining of the serratus anterior and lower fibres of trapezius may be required (Mottram, 1997). Muscle length of the pectoralis minor and levator scapulae may need specific therapy and length changes cannot be expected to occur immediately with a change of spinal posture (Sahrmann, 2002). The researchers believe that the absence of worsening pain in the presence of increasing ROM is potentially clinically important. Secondary observations of the data revealed potentially important clinical findings regarding cervical posture and mobility. In comparison to previous normative studies, the CV angles of impingement subjects during the erect sitting posture (encouraging cervical retraction) were less (average of 46.81) than those measured in natural resting postures of healthy subjects (Goldstein et al., 1984 reported 501; Dalton, 1989 reported 501; Greenfield et al., 1995 reported 521).

The same measuring tool was utilised in all these studies and this may suggest that impingement subjects had stiff cervicothoracic junctions which prevented the restoration of ‘normal’ erect cervical posture. This may have contributed to the lack of significant change in pain intensity reporting. Greenfield et al. (1995) also demonstrated a greater forward head posture in subjects with shoulder ‘overuse’ syndrome. Further research in this area is required. 6.1. Limitations of the study One limitation of the current study is that of a relatively small sample size. However, retrospective power calculations highlight that the magnitude of difference in shoulder ROM associated with slouched and erect posture is sufficient to make firm conclusions. Using the observed standard deviation between positions, a statistical hypothesis test with n=28 has a power of 0.9 of detecting a difference of 5.61 between mean slouched ROM and mean erect ROM at a significance level of 5%. A second limitation relates to diagnostic accuracy. It was felt in hindsight that the addition of a sub-acromial injection of local anaesthetic in conjunction with the Neer’s and Hawkin’s tests may have improved differential diagnosis. However, this was not feasible at the time of the study. The measurement of 3D scapula orientation would also have enhanced knowledge of the cause of effects seen in this study. Results of the current study were limited to postural effects in a sitting position. The interrelationship between spinal posture and shoulder biomechanics, ROM and function merits further study in a more dynamic context.

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7. Conclusion It is evident that the maintenance of an erect sitting posture may significantly increase the range of shoulder motion and consequently, a moderate improvement of upper limb function may result. In addition, improvements in mobility may occur without a significant increase in pain and such benefits may be immediately apparent following postural re-education. A significant reduction in pain intensity was not noted during the adoption of an erect posture, although this study cannot exclude the possibility of this occurrence if such posture was maintained over time. Further studies to address the long-term effects of spinal postural re-education are required.

Acknowledgements The authors wish to thank the following: patients and staff of the physiotherapy department, City Hospital, Nottingham; the Physiotherapy Division at Nottingham University for the use of the Peak Performance equipment; the Shoulder and Elbow Unit and Rheumatology Department at the City Hospital, Nottingham.

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Dalton MB. The effect of age on cervical posture in a normal female population. In: Jones HM, Jones MA, Milde MR editors. Proceedings of the Sixth Biennial Conference of the Manipulative. Adelaide: Therapists Association of Australia; 1989. p. 34–44. Fu FH, Harner CD, Klein AH. Shoulder impingement syndrome. A critical review. Clinical Orthopaedics and Related Research 1991;269:162–73. Goldstein DF, Kraus SL, Williams WB, Clasheen-Wray M. Influence of cervical posture in mandibular movement. Journal of Prosthetic Dentistry 1984;52:421–6. Greenfield B, Catlin PA, Coates PW, Green E, McDonald JJ, North CC. Posture in patients with overuse injuries and healthy individuals. Journal of Orthopaedic Sports Physical Therapy 1995;21:287–95. Griegel-Morris P, Larson K, Mueller-Klaus K, Oatis C. Incidence of common postural abnormalities in the cervical, shoulder and thoracic regions and their association with pain in two age groups of healthy subjects. Physical Therapy 1992;72(6):425–30. Grimsby O, Gray J. Interrelationship of the spine to the shoulder girdle. In: Donatelli R editor. Physical Therapy of the shoulder. 3rd ed. New York: Churchill Livingstone; 1997. p. 95 (Chapter 4). Host HH. Scapula taping in the treatment of anterior shoulder impingement. Physical Therapy 1995;75:803–12. Huskisson EC. Measurement of pain. The Lancet 1974;9:1127–31. Kebaetse M, McClure P, Pratt N. Thoracic positional effect on shoulder range of motion, strength, and 3D scapular mechanics. Archives of Physical Medicine and Rehabilitation 1999;80:950–4. Keirns MA. Conservative management of shoulder impingement. In: Andrews JR, Wilk KE editors. The athlete’s shoulder. New York: Churchill Livingstone; 1994. p. 605 (Chapter 48). Kendall F, McCreary, Muscles, testing and function. 4th ed. London: Williams & Wilkins; 1993. p. 91 (Chapter 4). Lewis JS, Green AS, Dekel S. The aetiology of subacromial impingement syndrome. Physiotherapy 2001;87(9):458–69. Ludewig PM, Cook TM. The effect of head position on scapular orientation and muscle activity during shoulder elevation. Journal of Occupational Rehabilitation 1996;6(3):147–58. Lukasiewicz AC, McClure P, Michener L. Comparison of 3-dimensional scapular position and orientation between subjects with and without shoulder impingement. Journal of Orthopaedic and Sports Physical Therapy 1999;29:574–83. Magee DJ. Orthopedic physical assessment, 4th ed. Philadelphia: Saunders; 2002. p. 263 (Chapter 5). Maitland GD, Banks K, English K, Hengeveld E. Vertebral manipulation, 6th ed. London: Butterworth-Heinemann Publishers; 2001. p. 235. Melzack R, Katz J. Pain measurement in persons in pain. In: Wall PD, Melzack R editors. Textbook of pain. 4th ed. Churchill Livingstone: Edinburgh; 1999. p. 411 (Chapter 17). Miranda H, Viikari-Juntura E, Martikainen R, Takala EP, Riihimaki H. A prospective study of work related factors and physical exercise as predictors of shoulder pain. Occupational & Environmental Medicine 2001;58(8):528–34. Mottram S. Dynamic stability of the scapula. Manual Therapy 1997;2(3):123–31. Munro BH. Statistical methods for health care research, 4th ed. Philadelphia: Lippincott; 2001. p. 234 (Chapter 10). Neer CS. Anterior acromioplasty for the chronic impingement of the shoulder. Journal of Bone and Joint Surgery 1972;54A:41. Neer CS. Impingement lesions. Clinical Orthopaedics 1983;173:70–7. Nygren A, Berglund A, Von Koch M. Neck and shoulder pain, an increasing problem. Strategies for using insurance material to follow trends. Scandinavian Journal of Rehabilitation Medicine 1995;32:107–12 (Supplement).

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Thein LA, Greenfield BH. Impingement syndrome and impingement related instability. In: Donatelli R editor. Physical therapy of the shoulder 3rd ed. New York: Churchill; 1997. p. 229 (Chapter 9). Tibone JE, Shaffer B. Shoulder pain: when is it impingement? The Journal of Musculoskeletal Medicine 1995;4:65–77. Triffitt P. The relationship between motion of the shoulder and the stated ability to perform activities of daily living. The Journal of Bone and Joint Surgery 1998;80-A(1):41–6. Turner HM. Rehabilitation of the sporting shoulder. Physiotherapy in Sport 1996;XIX(1):6–11. Van der Windt DAWM, Thomas E, Pope DP, de Winter, Andrea F, Macfarlane GJ, Bouter LM, Silman AJ. Occupational risk factors for shoulder pain: a systematic review. Occupational and Environmental Medicine 2000;57(7):433–442. Viikari-Juntura E. Interexaminer reliability of observations in physical examination of the neck. Physical Therapy 1989;65:1526–32. Warner JJP, Micheli LJ, Arslanian LE, Kennedy J, Kennedy R. Scapulothoracic motion in normal shoulders and shoulders with glenohumeral instability and impingement syndrome. A study using Moire topographic analysis. Clinical Orthopaedics and Related Research 1990;285:191–8. Wilk KE, Arrigo C. Current concepts in the rehabilitation of the athletic shoulder. Journal of Orthopaedic and Sports Physical Therapy 1993;18(1):365–72.

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Manual Therapy 10 (2005) 38–43 www.elsevier.com/locate/math

Original article

Do Norwegian manual therapists provide management for patients with acute low back pain in accordance with clinical guidelines? Liv Inger Stranda,, Alice Kvalea, Ma˚lfrid Ra˚heima, Anne Elisabeth Ljunggrena a

Department of Public Health and Primary Health Care, Section for Physiotherapy Science, University of Bergen, Kalfarveien 31, 5018 Bergen, Norway Received 8 December 2003; received in revised form 4 May 2004; accepted 8 July 2004

Abstract Manual therapists (MTs) are specialized in examining and treating patients with low back pain (LBP). The aim of the study was to investigate if patients’ consultations with Norwegian MTs are in accordance with clinical guidelines for the management of acute LBP. Semi-structured interviews were conducted based on observation of the first consultation. Twenty-two MT students observed two consultations, and thereafter interviewed MTs (convenience sample) about clinical findings, information, advice and specific therapeutic procedures given. The interviews were tape-recorded, transcribed, and organized. Forty-two reports were derived from 34 MTs (12% of all in Norway). The MTs commonly informed the patients of main clinical findings. The intention to eliminate fear avoidance was specifically mentioned in 43% of the interviews. Advice of being active in daily life activities was given to 50% of the patients, and 43% were advised to avoid particular pain provoking movements. Working ability and sick leave was considered in only 20% of those employed. The most frequent treatment modalities recommended were home-exercises (69%) and a combination of joint mobilization and individually tailored exercises (48%). To some extent the MTs acted according to main points of clinical guidelines. However, functioning at the participation level was little emphasized in the consultations. r 2004 Elsevier Ltd. All rights reserved. Keywords: Clinical guidelines; Acute low back pain; Manual therapists

1. Introduction The prevention of long-term disability in back pain is a major challenge to health personnel. Fear avoidance beliefs and catastrophizing related to the musculoskeletal pain are claimed to play an important role in the process of developing disability (Waddell et al., 1993; Vlaeyen and Linton, 2000; Fritz et al., 2001; Buer and Linton, 2002). Carefully selected and presented information and advice to counteract negative thoughts and beliefs, and educating and empowering patients to treat their own problems, are recommended at an early stage of back pain management (Borkan and Cherkin, 1996; Waddell et al., 1997; Indahl et al., 1998; Burton et al., 1999; Hagen et al., 2000; Linton and Andersson, 2000). Corresponding author. Tel.: +47-55586123, fax: +47-55586139.

E-mail address: [email protected] (L.I. Strand). 1356-689X/$ - see front matter r 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2004.07.003

Since 1993 clinical guidelines for the management of acute low back pain (LBP) have been developed in various countries based on systematic reviews of published evidence (Burton and Waddell, 1998). There has been a progressive recognition that psychosocial factors (yellow flags) are important determinants for risk of chronicity and that such factors need to be addressed clinically. Pincus et al. (2002) question, however, the emphasis on psychological factors in current guidelines, finding that they may go a little beyond the current evidence. According to guidelines from 11 different countries, the identification of potential serious pathology (red flags) is a prime aim of the initial clinical assessment. Consistent features are also the early and gradual activation of patients, and discouragement of prescribed bed rest (Koes et al., 2001). While manipulation is considered a potential good treatment within the first 4–6 weeks according to

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some guidelines (United States, New Zealand, Finland, Switzerland, Sweden), the Dutch guidelines recommend this treatment after 6 weeks within an active approach. Some question, however, the effectiveness of manipulation altogether (Israel, Australia). Exercises are only recommended after 4–6 weeks in most national guidelines (Koes et al., 2001), while specific exercises are not considered useful at all in the New Zealand guidelines. The evidence summarized in a systematic review by van Tulder et al. (2000) indicates that specific exercises are not effective for the treatment of acute LBP (o3 months), but might be helpful for patients with chronic LBP to increase return to normal daily activities and work. Maher et al. (1999) had a similar conclusion from their systematic review. Acute pain was, however, in their study defined as pain that had lasted for o6 weeks. They found strong evidence supporting the use of structured exercise programs in sub-acute (6–12 weeks) and chronic (43 months) nonspecific LBP, and in the prevention of such problems. Some studies have been conducted to examine whether recommendations given in clinical guidelines have been implemented into clinical practice (Schers et al., 2000; Gracey et al., 2002; Werner et al., 2002; Armstrong et al., 2003). Among treatment modalities given by physiotherapists in Northern Ireland to patients with LBP, advice was the most frequent, then McKenzie exercises and Maitland mobilization (Gracey et al., 2002). The nature and content of information and advice was, however, not addressed. As questionnaire surveys of the therapists are most commonly used to examine how back pain is managed, limited insight is given into what is actually communicated to the patients during consultations with health personnel. Manual therapists (MTs) are physiotherapists specialized in examination and treatment of patients with musculoskeletal conditions, particularly in primary health care. They are presumed to be familiar with topical results from clinical research and clinical guidelines regarding treatment for patients with back pain. Patients with acute LBP are commonly referred from general practitioners to MTs for further examination, and eventual treatment. Some MTs in Norway, however, may also be the primary contact for patients in the early stage of back pain, and authorized to prescribe sickness certification (o8 weeks). The aim of the present study was to examine whether MTs acted in accordance with clinical guidelines regarding information, advice and other therapeutic procedures for patients with acute LBP.

39

consultations. The observations and interviews were carried out by 22 MT students (physiotherapists specializing in manual therapy), 14 were men and 8 women, mean age 37 years (SD 5), range 30–46 years. They were instructed during theoretical and practical sessions in techniques of observation and interviewing. As the procedure is quite time-consuming, each MT student was to carry out data collection of only 2 patient consultations with 1 or 2 MTs. The students worked in supervised clinical practice in different parts of Norway. Accordingly, a convenience sample of MTs from the Northern, Middle, SouthEastern and Western parts of the country were asked to be informants (subjects) for the study. Written informed consent was derived from the therapists, as well as from the patients. They were informed that the students were to carry out a systematic study of clinical practice and reasoning in manual therapy. 2.1. Procedure The students were to be present during the patient consultation, but at a discrete distance, and should not interfere. Each student had an instruction sheet containing main points of what to observe (Table 1). They also had an instruction sheet of main themes to be pursued in the following interview, regarding history, clinical examinations, information, advice and plan for treatment. The interviewer should try to repeat things said and done by the MT during the patient consultation, and ask him/her to elaborate on the themes. The interview took place immediately after the consultation. It lasted for about an hour and was tape-recorded. 2.2. Analysis The tape recordings were transcribed by the students, and analysed by the first author. Each interview included extensive data from the consultation, particularly the history and the physical examination. However, only demographic data of the patient, and information restricted to the themes of the research question was used in the present study, such as information given to patients, advice related to exercises, activities and work, plan for treatment, and adjacent clinical reasoning. The next step included organizing information from the reports in separate documents according to the themes. Main information was summarized using descriptive statistics. Clinical reasoning of MTs was reported to give a fuller description of the material.

2. Material and methods

3. Results

Semi-structured interviews were conducted, after structured observation of how MTs acted in patient

A total of 42 reports were derived of patients with acute LBP based on consultations with 34 different MTs

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40 Table 1 Instruction sheet for observation 1. 2. 3. 4. 5.

What does the MT ask the patient about? Which examinations are done? Which findings and information from the examination is communicated to the patient? Which advice and points of view are imparted from the MT to the patient concerning movements, physical activity and work? Which remedial actions does the MT suggest to the patient?

Table 2 Characteristics of demographic variables Patients, n ¼ 42 Age, yrs: mean, SD, range Pain duration, weeks: mean, SD, range Gender, %: men, women Occupation, %: blue, white collar, no work Sick leave of workers, %: yes, no

37, 12, 12–61 6, 4, 1–12 57, 53 45, 42, 13 38, 62

Manual therapists, n ¼ 34 Age, yrs: mean, SD, range Gender, %: men, women Clinical experience, yrs: mean, SD, range

43, 7, 33–58 71, 29 10, 6, 2–26

(12% of all MTs in Norway). LBP had lasted for o6 weeks in half the group of patients. Demographic variables of both patients and MTs are listed in Table 2. The clinical examination resulted in localized patho-anatomical explanation in approximately half of the cases. A bulging disc was suspected in 20% of the patients, spondylolysis or spondylolythesis in 15%, and a neurogenic affliction in 11%. The most frequent functional aberrations reported were diagnoses not endorsed in the clinical guidelines, like spinal hypomobility (39%), and a combination of spinal hypo- and hypermobility (15%), and affliction of facet joints (13%). 3.1. Information of clinical findings Most patients (90%) were informed of important clinical findings during their first consultation. The remaining MTs told some patients that they needed more time or further examination to make a conclusion. Main findings from the examination were presented at the end of the consultation. One patient, for instance, was informed that he had decreased mobility of the lower lumbar spine, another that he possibly had a central disc protrusion, and a third that he had asymmetry of the back muscles and decreased mobility of the spine. When MTs sometimes explained in great detail to the patients during the course of examination what they observed, they reasoned that this was done to make the patients more educated and responsible for their treatment. Patients were commonly informed of anatomical structures and function of the spine and trunk. Different pedagogical aids were used such as

spine models, slide presentations and illustrations from books. Movements were demonstrated to let patients learn about muscle function. The importance of such information could be phrased as follows ‘‘the more the patients understand, the better.’’ 3.2. Fear avoidance In 43% of the cases the MTs mentioned the intention of decreasing fear and fear avoidance, specifically in the interview. The importance of capturing the patients’ thoughts and understanding of their painful condition was sometimes explored by asking open questions, such as ‘‘what is it that concerns you about your back pain?’’ Words like harm, damage and chronic were avoided, and the condition was intentionally characterized as common. As many patients were anxious about having a serious disease, positive information was considered important to decrease fear. One patient, for instance, was reassured that he had no signs of serious pathology, another that she did not have sciatica or pelvic girdle relaxation. It was stressed that defusing of symptoms and reassurance of the patient should be based on evidence from a thorough clinical examination. If a serious medical condition was suspected, the patient was not commonly informed at this first consultation, but was referred for further examination (e.g. CT, X-rays). Sometimes the opposite of reassurance seemed appropriate, as one MT said: ‘‘A reckless patient should be warned about possible consequences of such behavior.’’ 3.3. Advice related to daily activities Advice about being active in daily life activities was given to 50% of the patients. Such advice was most commonly given when patients were found to have spinal hypo-mobility and muscular tension. No patient was advised to stay in bed. One MT clearly stated: ‘‘Advice of being active rather than resting in bed is the most important information that can be given to patients with acute pain to avoid long-term disability’’. A total of 43% of the patients were advised to avoid particular pain provoking movements. Such movements were typically lifting, bending and rotating the trunk, and sitting for a long time. Whenever registering painful movements, patients were shown alternative ways of moving. One patient, who complained of worsened

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symptoms while sitting, was shown an adjusted sitting position, another who got pain during jogging, was advised to avoid that activity for a while. The other patients (57%) were not warned about particular movements or activities. They were advised to be physically active with activities that they liked. One MT phrased it this way ‘‘by being active the patients will experience that it is safe to move’’. Another MT maintained that restrictions should not be given unless there were ‘‘red flags’’. When being afraid that pain means harm, the patients might not only avoid the pain provoking activities, but limit physical activity in general. 3.4. Advice related to work Information about work status of 2 patients was missing. A total of 35 patients (88% of the remaining patients) were employed, and 40% of the employed (14 patients) were partly or on full sick leave. The MTs actively considered working ability and sick leave in 20% of those who were employed, 5 were sick listed by the MTs, while 2 were not. Patients tended to be only partly sick-listed by the MTs, and for a limited time (1–2 weeks). They were advised to gradually increase working hours as symptoms abated. 3.5. Exercise and manual techniques A total of 69% of the patients were shown physical exercises to be practiced at home. The treatment was individually tailored based on findings from the physical examination, often with the aim of improving mobility and muscular control of the lumbar spine. Some patients (14%) were neither given home exercises nor general advice to be physically active. Approximately half of the patients (48%) were to receive a combination of spinal joint mobilization techniques and exercises, while only mobilization techniques were given to 17%. Manipulation was prescribed for six patients (14%) found to have spinal locking, or hypo-mobility. Another six patients (14%) were to have exercises solely, and 20% received only information and advice. Passive techniques like massage and mobilization were sometimes suggested as first treatments, always to be followed by active exercises. Spinal traction was never used. There was no difference in treatment modalities suggested, comparing groups of patients with LBP lasting foro6 weeks, and between 6 weeks and 3 months.

4. Discussion In this study, we have focused on information, advice and other treatment given by MTs to patients with acute LBP at first consultations, and adjacent clinical reason-

41

ing (Table 3). Recently developed clinical guidelines are mainly focusing on these aspects in treating LBP. Accordingly, we have summarized main findings with existing clinical guidelines in mind. However, it is underscored that a more qualitatively based analysis of all aspects of our material would have given us the opportunity to describe and discuss a fuller picture of the consultations. A large and varied group of MTs participated in the present study. However, as the MTs were not randomly selected, we do not know whether the results reflect if and how Norwegian MTs in general are using the clinical guidelines. The reader should further take into consideration that the results are based on the first consultation only. However, instructions about taking care of the back tend to be given at the start of treatment (Kerssens et al., 1999). After the time of data collection, the Norwegian Multidisciplinary Clinical Guidelines for the treatment of acute LBP were published (Nasjonalt ryggnettverk—Formidlingsenheten, 2002). Whether this has altered Norwegian MTs use of clinical guidelines, is not known. The study indicates that MTs usually inform and educate patients, and thus empower them in their rehabilitation process. To avoid unnecessary preoccupation with bodily signs and symptoms, they tend to inform the patients of main findings only. In most cases (90%) the therapists were able to conclude with a possible cause or physical manifestations of the back pain, and were concerned about effectively informing the patients. Such information is in accordance with UK Clinical Guidelines for the Management of Acute LBP, stating that patients should be given accurate information about the structure and function of the back (Royal College of General Practitioners, 1996 and 1999). How much detailed information from the examination that is helpful to the patient may, however, be questioned. The importance of reducing fear and fear avoidance was addressed by the MTs in relation to 43% of the patients. In these cases the MTs sometimes asked openended questions to let patients express worries about their condition. It is recommended that concerns and maladaptive beliefs should be directly addressed at the first visit, as they may act as obstacles to recovery (Klaber Moffett, 2002). Misconceptions should be replaced with an explanation that is credible, providing the patient with confidence to encourage self-management. The patients were often reassured that there were no signs of serious pathology, that back pain is very common and that symptoms tend to abate over some time. Interestingly, the major group of MTs did not address the subject of fear avoidance. This may be due to ignorance of the issue, or reflects the fact that not all patients have fear related to their functional problems. In individual patients the reduction of fear avoidance

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may be irrelevant, and even contra-indicated. According to a recent systematic review by Pengel et al. (2003) there is still limited evidence that fear avoidance is a clinically important prognostic factor of disability in acute LBP. Advice to stay active in daily life is considered important in the management of acute LBP for a faster return to work, and for fewer chronic disabilities and recurrence problems (Waddell et al., 1997; Bekkering et al., 2003). In the present study half the group of patients were given such advice, consistent with the clinical guidelines, but such advice might also be given later in the course of treatment. Some MTs may, however, believe that physical exercise and manual therapy techniques are sufficient interventions to improve daily functioning, and may for that reason simply not advocate the resumption of physical activities. The patients, who reported problems when performing specific movements or activities due to aggravation of pain, were commonly helped to find alternative ways of moving. Such advice is partly in accordance with clinical guidelines. Recommendations are given in the US Guidelines (Bigos et al., 1994) that specific activities like sitting for a long time, heavy lifting, twisting and bending are reduced or avoided in acute pain to decrease excessive loads on the back. In the New Zealand Acute Low Back Pain Guide (ACC, the National Health Committee, 1997) it is acknowledged that activities and postures may need to be modified in the short term. Patients are, however, recommended to increase physical activity progressively according to a timetable rather than to be guided by the pain level. According to Waddell (1998), referring to the UK Clinical Guidelines, the patients should be recommended to continue normal daily activities, and return to work as fast as possible. Depending on how bad the back feels, however, activities are suggested modified and medication recommended to control the pain. There seem to be different opinions regarding advice to modify or avoid painful movements. Vlaeyen and Linton (2000) argue that avoidance learning occurs when the undesirable event has been successfully avoided. Linton et al. (2002) attribute fear-avoidance beliefs to health personnel who give advice that imply restrictions of movements. MTs in our study, however, found patients less afraid of physical activities, after they had experienced control during graded or modified performance. Traditionally, physiotherapists in Norway need a patient referral from a physician. However, all MTs in Norway may, in the near future, become primary contacts for patients with an acute episode of back pain, and given the authority to prescribe sick leave (o8 weeks). At the time of the study, MTs of only three Norwegian counties (two included in the present study) were trying out this new responsibility. When the MTs prescribed sick leave, they seemed to adhere to a time

Table 3 Main themes related to clinical guidelines addressed in MTs’ first consultations with patients who had acute low back pain n ¼ 42 % of all cases (%) Information of main clinical findings Fear avoidance Advice to avoid pain provoking movements Advice to be active in daily life activities Advice related to work Home exercises Exercises and joint mobilization Mobilization techniques, only Manipulation

90 43 43 50 20 69 48 17 14

contingent approach, consistent with evidence-based guidelines (Bekkering et al., 2003). The relationship between back problems and work were rarely addressed during the first consultations. The MTs often recommended exercise therapy in the active phase of back pain, also when back pain had lasted for less than 4 weeks. This is contrary to recommendations in most clinical guidelines of not recommending exercises at all in the acute phase, only in long-lasting back pain. Manipulation, which is recommended in some clinical guidelines, was only used in a minor group (14%) of the patients. The information and advice, as well as specific therapeutic procedures given by the MTs in the first consultations were commonly individually tailored. Reassurance and active coping strategies seemed to be an important focus.

5. Conclusion To some extent the Norwegian MTs did provide management for patients with acute LBP in accordance with clinical guidelines, but little emphasis was placed on functioning on the level of participation, and the use of exercises was not in accordance with the guidelines. To answer the research question of the present study is not straightforward. It should be emphasized that guidelines are not prescriptive. Guidelines are based on generalized knowledge from controlled trials where outcomes of groups receiving different interventions are compared statistically. In the clinic, as in our study, the individual patient stands out as the main focus, not the group, and treatment is adjusted in accordance with the individual patients’ problem. The importance of such individually tailored treatment should, however, be further explored in scientific studies.

Acknowledgement The authors thank the manual therapists who willingly participated as informants in the study. The

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Masters students in manual therapy are thanked for doing the elaborate work of collecting and transcribing the data. Jostein Ellingsen, manual therapist and clinical lecturer, is thanked for being helpful in the planning process of the study. References ACC. The National Health Committee. New Zealand Acute Low Back Pain Guide. Wellington, New Zealand, 1997. Armstrong MP, McDonough S, Baxter GD. Clinical guidelines versus clinical practice in the management of low back pain. International Journal of Clinical Practice 2003;57:9–13. Bekkering GE, Hendriks HJM, Koes BW, Oostendorp RAB, Ostenlo RWJG, Thomassen JMC, van Tulder MW. Duch Physiotherapy Guidelines for Low Back Pain. Physiotherapy 2003;89:82–96. Bigos S, Bowyer O, Braen G, et al. Acute low back problems in adults: Clinical practice guideline no. 14. AHCPR publication no. 95-0642. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, US Department of Health and Human Services. December 1994. Borkan JM, Cherkin DC. An agenda for primary care research on low back pain. Spine 1996;2:2880–4. Buer N, Linton SJ. Fear-avoidance beliefs and catastrophizing: occurrence and risk factor in back pain and ADL in the general population. Pain 2002;99:485–91. Burton AK, Waddell G. Clinical guidelines in the management of low back pain. Baillieres Clinical Rheumatology 1998;12:17–35. Burton AK, Waddell G, Tillotson KM, Summerton N. Information and advice to patients with back pain can have a positive effect. A randomized controlled trial of a novel educational booklet in primary care. Spine 1999;24:2484–91. Fritz JM, George SZ, Delitto A. The role of fear-avoidance beliefs in acute low back pain: relationships with current and future disability and work status. Pain 2001;94:7–15. Gracey JH, McDonough SM, Baxter GD. Physiotherapy management of low back pain: a survey of current practice in Northern Ireland. Spine 2002;27:406–11. Hagen KB, Hilde G, Jamtvedt G, Winnem MF. The Cochrane review of bed rest for acute low back pain and sciatica. Spine 2000;25: 2932–9. Indahl A, Haldorsen EH, Holm S, Reikeras O, Ursin H. Five-year follow-up study of a controlled clinical trial using light mobilization and an informative approach to low back pain. Spine 1998; 23:2625–30. Kerssens JJ, Sluijs EM, Verhaak PF, Knibbe HJ, Hermans IM. Back care instructions in physical therapy: a trend analysis of individualized back care programs. Physical Therapy 1999;79:286–95.

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Klaber Moffett J. Back pain: encouraging a self-management approach. Physiotherapy Theory and Practice 2002;18:205–12. Koes BW, van Tulder MW, Ostelo R, Kim BA, Waddell G. Clinical guidelines for the management of low back pain in primary care: an international comparison. Spine 2001;26:2504–13. Linton SJ, Andersson T. Can chronic disability be prevented? A randomized trial of a cognitive-behavior intervention and two forms of information for patients with spinal pain. Spine 2000;25: 2825–31. Linton SJ, Vlaeyen J, Ostelo R. The back pain beliefs of health care providers: are we fear-avoidant? Journal of Occuptional Rehabilitation 2002;12:223–32. Maher C, Latimer J, Refshauge K. Prescription of activity for low back pain: what works? Australian Journal of Physiotherapy 1999;45:121–32. Norwegian Back Pain Network—The Communication Unit. Acute low back pain. Multidisciplinary clinical guidelines] Oslo, Nasjonalt ryggnettverk, 2002. Pengel LH, Herbert RD, Maher CG, Refshauge KM. Acute low back pain: systematic review of its prognosis. British Medical Journal 2003;327:323–7. Pincus T, Burton AK, Vogel S, Fields AP. A systematic review of psychological factors as predictors of chronicity/disability in prospective cohorts of low back pain. Spine 2002;27:E109–20. Royal College of General Practitioners. Clinical Guidelines for the Management of Acute Low Back Pain. London: Royal College of General Practitioners, 1996 and 1999. Schers H, Braspenning J, Drijver R, Wensing M, Grol R. Low back pain in general practice: reported management and reasons for not adhering to the guidelines in the Netherlands. British Journal of General Practice 2000;50:640–4. van Tulder M, Malmivaara A, Esmail R, Koes B. Exercise therapy for low back pain: a systematic review within the framework of the cochrane collaboration back review group. Spine 2000;25: 2784–96. Vlaeyen JW, Linton SJ. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain 2000;85: 317–32. Waddell G. The back pain revolution. Edinburgh: Churchill Livingstone, 1998, 438p. Waddell G, Newton M, Henderson I, Somerville D, Main CJ. A FearAvoidance Beliefs Questionnaire (FABQ) and the role of fearavoidance beliefs in chronic low back pain and disability. Pain 1993;52:157–68. Waddell G, Feder G, Lewis M. Systematic reviews of bed rest and advice to stay active for acute low back pain. British Journal of General Practice 1997;47:647–52. Werner EL, Laerum E, Ihlebaek C. How is the general practitioner managing the back pain? Tidsskrift for den Norske Laegeforening 2002;122:1800–3.

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Manual Therapy 10 (2005) 44–51 www.elsevier.com/locate/math

Original article

Influence of cranio-cervical posture on three-dimensional motion of the cervical spine Stephen J. Edmondstona,, Svein-Erik Henneb, Winston Lohb, Eirik Østvoldb a

School of Physiotherapy, Curtin University of Technology, P.O. Box U1987, Perth, WA, Australia b Master of Manipulative Therapy Program, Curtin University of Technology, Australia Received 10 December 2003; received in revised form 17 May 2004; accepted 8 July 2004

Abstract Although a consistent pattern of ipsilateral movement coupling between cervical spine rotation and lateral flexion has been widely described, variability in these movement patterns has not been reported. In 30 asymptomatic subjects, the ranges of primary and coupled movements were determined in the neutral posture, and in the extremes of cervical spine protraction and retraction. All measurements were performed using the SpinT three-dimensional goniometer for which excellent intra-tester reliability was demonstrated for both primary (ICC3,1 0.93–0.98) and coupled (ICC3,1 0.76–0.98) movements. The ranges of primary and coupled movements changed significantly when movement was initiated from the end-range postures (Po0:001). In the neutral posture, approximately 70% of subjects demonstrated an ipsilateral pattern of coupled movement. During cervical rotation, the dominant coupling pattern seen in neutral was no longer retained in retraction, while the protracted posture had a greater influence on the coupled movements accompanying primary lateral flexion. The concept of a stereotypical pattern of cervical spine movement coupling is not supported by these results. The posture in which movements are initiated appears to have a significant influence on the three-dimensional kinematics of the cervical spine. r 2004 Elsevier Ltd. All rights reserved.

1. Introduction Neck pain is a common complaint, which although not as costly to society as low back pain, contributes significantly to the cost of healthcare (Korthals-de Bos et al., 2003). With increasing emphasis on evidencebased management of spinal pain, it is important to evaluate methods of physical examination commonly used in this patient population. Since the examination of the range and patterns of movement is a routine part of the evaluation of patients presenting with neck pain, knowledge of normal movement patterns and variability between individuals is fundamental to the interpretation of these observations (Dvorak et al., 1992; McCarthy, 2001). Furthermore, cervical mobility has been recomCorresponding author. Tel.:+61-8-9266-3665; fax: +61-8-92663699 E-mail address: [email protected] (S.J. Edmondston).

1356-689X/$ - see front matter r 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2004.07.004

mended as a primary outcome measure in neck pain research, yet few studies have examined the variability in the three-dimensional kinematics of the cervical spine in the asymptomatic population, or in patients with neck pain (Bronfort et al., 2001; Philadelphia panel, 2001). In the cervical spine, axial rotation and lateral flexion are coupled movements due to the oblique orientation of the zygapophyseal joints, and the presence of the uncinate processes (Milne, 1993). Coupled motion is defined as a consistent association of one motion about an axis with another motion about a second axis (White and Panjabi, 1990). Coupled motion in the cervical spine has been studied in cadaveric specimens (Lysell, 1969; Panjabi et al., 2001), and using radiological imaging techniques (Dvorak et al., 1987; Penning and Wilmink, 1987; Mimura et al., 1989) or motion analysis systems in human subjects (Trott et al., 1996; Feipel et al., 1999). In the disc segments of the spine, and for the cervical spine as a whole, a consistent pattern of coupled ipsilateral

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rotation and lateral flexion has been described (Lysell, 1969; Trott et al., 1996; Panjabi et al., 2001). The conclusion, which must be drawn from these studies, is that there is a stereotypical pattern of cervical spine movement in rotation and lateral flexion which is consistent between all individuals. However, observation of movement patterns in normal subjects, and in patients with neck pain, highlights what appears to be considerable inter-individual variation in habitual patterns of movement. Surprisingly, variability in range and patterns of cervical spine coupled movement between individuals, has not been reported in any of the previously published studies. Methods of measurement of cervical spine coupled movement, which have been used in radiological and laboratory studies, have limited application to clinical practice as they require exposure to ionizing radiation, or use complex motion analysis systems. Goniometerbased systems such as the CROM are reliable for the measurement of uniplanar cervical spine movement, but have design limitations which do not permit the measurement of coupled movements (Performance Attainment Associates, 1986). More recently, Haynes and Edmondston (2002) described the SpinT, a threedimensional goniometer, which has demonstrated accuracy, and a high level of reliability for measurement of cervical spine mobility. This device provides the opportunity to more readily examine cervical spine movement patterns in the normal population, and in patients with neck pain. One commonly described mechanism for the development of neck pain is the adoption of habitual postures, which place the cervical spine away from a neutral spinal alignment (Szeto et al., 2002). This may result in abnormal loading of supporting ligaments, and altered levels of muscle activity. However, postures away from a ‘neutral’ upright position may also result in changes in the ranges of movement, and movement coupling characteristics. The magnitude of the lumbar lordosis has been shown to influence movement coupling between lumbar spine rotation and lateral flexion (Cholewicki et al., 1996). In the cervical spine, the position from which rotation is initiated influences the range of axial rotation, while the posture of the upper cervical spine has a significant influence on coupled movement patterns (Panjabi et al., 1993; Walmsley et al., 1996). Although protracted postures of the head and neck have been linked to the development of neck pain and headache, the reason for this association has not been clearly defined. One possibility is that these habitual postures may result in changes in patterns of spinal movement and joint loading, which may ultimately contribute to the development of neck pain. While clinical texts suggest that motion coupling in the cervical spine is independent of neck position, a quantitative evaluation of the associa-

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tion between cervical spine posture and coupled movement patterns has not been described (Stoddard, 1983; Gibbons and Tehan, 1998). The purpose of this study was to use the SpinT goniometer to examine variability in the ranges and patterns of three-dimensional cervical spine movement in asymptomatic subjects. The second objective was to examine the influence of cranio-cervical posture on the range of cervical spine rotation and lateral flexion, and the associated ranges and patterns of coupled movement.

2. Method 2.1. Subjects A within-subjects, repeated measures study was conducted in which 30 asymptomatic subjects (13 males, 17 females) whose ages ranged from 18 to 35 years (mean 24.6, SD=5 years) were recruited. Subjects with conditions, which may have affected the mobility of the cervical spine, such as a history of trauma or current cervical pain, were excluded from the study. Prior to commencement of the study, subjects received a full explanation of the experimental procedure and signed an informed consent form. This study was approved by the Human Research Ethics Committee of Curtin University of Technology. 2.2. Apparatus and measurements The SpinT goniometer, a new protractor-based device was used to measure cervical range of motion in three planes (Fig. 1), and has been described in detail by Haynes and Edmondston (2002). Briefly, angle meters in

Fig. 1. Measurement of primary right rotation and related coupled movements using the SpinT goniometer. The T-square is held in contact with an adjacent wall, and with the spindle of the angle meter in order to derive the measurements.

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the three cardinal planes on the SpinT goniometer are mounted on a spectacle-type frame, which is worn on the head. The angle meters of the SpinT comprise of a dial marked in 11 intervals and a spindle which pivots around the dial. A T-square was held against a nearby wall and contacted the spindle along its length. By doing this, the T-square sets the spindle at 901 to the wall’s surface while the movement of the head rotates the dial. The way in which the SpinT uses a nearby wall to reference the angle meters permits measurements of the primary and coupled movements which occur around the three axes. The T-square is used to zero each angle meter prior to movement, and the range of movement is determined separately for each plane at the end of the available range. The SpinT has been shown to be highly accurate for the measurement of uniplanar movements and has demonstrated excellent reliability (Haynes and Edmondston, 2002).

order of testing assigned randomly. Horizontal excursion of the head between each of the three postures was recorded by measuring the distance of the tragus of the ear from the wall in front of the patient. Full protraction was attained by instructing the subject to push the chin fully forward, while maintaining the eyes level horizontally (Walmsley et al., 1996). Two repetitions of rotation and lateral flexion were performed and measured as described above. The subject was instructed to maintain the fully protracted position while performing the requested movements, and correction was given if the subject was not observed to do so. Full retraction was attained by instructing the subject to pull the chin in as far as possible, while maintaining the eyes at the same horizontal level. A further two repetitions of rotation and lateral flexion were performed and the ranges of primary and coupled movements were recorded. To minimize error, all measurements were performed by one examiner throughout the study.

2.3. Procedure Subjects were asked to sit in a straight backed chair, with their lumbar spine contacting the back of the chair. Movement of the thoracic spine was constrained at approximately the T4 level using a chest strap, as it has been suggested that T4 represents the lower boundary of the cervicothoracic junction (Boyle et al., 1997). The SpinT goniometer was then secured to the subject’s head using Velcro straps. In order to familiarize subjects with the test procedure and minimize the effects of tissue creep on cervical spine movement, a warm up of three repetitions of full rotation and lateral flexion to both sides was performed. Neutral cranio-cervical posture was attained by instructing the subject to sit in a comfortable upright position such that the sacrum and thoracic spine were in contact with the back of the chair. Subjects were asked to turn their head (rotation) until they felt the onset of a comfortable stretch at the end of range. The ranges of rotation and coupled lateral flexion, and extension or flexion were recorded, and the procedure was repeated for the opposite rotation. This procedure was repeated for left then right lateral flexion. Lateral flexion was attained by asking subjects to tilt their head towards their shoulder until the onset of a comfortable stretch at the end of range. During the movement testing, there was no attempt to guide or modify the subjects’ movement, and subjects were not encouraged to move beyond a comfortable end-range position. The order of testing was randomized for both direction and side. Each movement was measured twice and the mean primary and coupled movement values were used in the data analysis. Following the measurements in the neutral posture, the measurement procedure was repeated with the head and neck in full protraction and retraction, with the

2.4. Reliability In order to test reliability of the apparatus and procedure, repeat measurements of primary and coupled movements were performed on each subject by one examiner, and intra-class correlation coefficients (ICC3,1) were calculated for each movement. The intra-examiner reliability on a given day was excellent with intra-class correlation coefficients (ICC3,1) ranging from 0.93 to 0.98 for primary movements and from 0.76 to 0.98 for the coupled movements. 2.5. Data management Data were analysed using SPSS version 11 (SPSS Inc.). Descriptive statistics were calculated and used to examine the ranges of primary and coupled movements in each posture. Frequency analysis was used to describe the patterns of movement coupling associated with the primary movements of rotation and lateral flexion. Subjects were divided into two groups according to their pattern of movement. The first group consisted of subjects who demonstrated true ipsilateral movement coupling (ipsilateral lateral flexion or rotation, and extension), while the second group consisted of subjects who demonstrated any other pattern. This frequency analysis was repeated for each of the test postures. A one-factor repeated measures analysis of variance (ANOVA) with pre-specified contrasts was performed to test for differences in the ranges of primary and coupled movements between the three postures. The prespecified contrasts involved comparison between each of the three postures in which the movements were performed. The criterion for statistical significance was set at the Po0:05 level.

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3. Results

3.3. Coupled movements

3.1. Cranio-cervical posture

The ranges of coupled movement associated with primary rotation and lateral flexion are shown in Figs. 2 and 3. There were significant differences in the ranges of coupled movement associated with primary rotation and lateral flexion, between the three postures (Po0:01).

The mean range of head excursion measured in the sagittal plane was 9.68 cm (SD=2.55). The mean range of retraction from neutral was 3.45 cm (SD=1.45) and the mean range of protraction was 6.23 cm (SD=2.14) from neutral. Consequently, the neutral posture was on average 36% (SD=15%) forward of the fully retracted position.

3.2. Primary movements The ranges of primary movements in the three postures are presented in Table 1. There was a significant difference in the range of primary rotation between the three postures (Po0:001) with a decrease in range in the end-range postures compared to the neutral posture. A significant difference in the range of primary lateral flexion was also identified between the three postures (Po0:001) and although not as prominent as for rotation, a decrease in range was observed when movement was performed out of the neutral posture.

3.4. Patterns of coupled movement The patterns of coupled movement in the three different starting positions are shown in Fig. 4. For primary rotation, the pattern of movement coupling was similar between the right and left sides in neutral and retraction but was less side-consistent in protraction. The ipsilateral lateral flexion/extension coupling pattern was dominant in neutral (70%) and protraction (58%) but not in retraction (35%). In protraction, there was a difference in the coupling pattern between right and left sides. For primary lateral flexion there was consistency in patterns of movement coupling between sides for all three positions. The ipsilateral rotation/extension pattern of movement coupling was the dominant pattern in neutral (77%) and retraction (62%) but not in protraction (42%).

3.5. Changes in coupling patterns Table 1 Mean (SD) range of motion (in degrees) for primary rotation and lateral flexion measured in three cervical spine postures

Right rotation Left rotation Right lateral flexion Left lateral flexion

Neutral

Retraction

Protraction

68 71 37 36

43 45 30 28

48 52 33 33

(7.6) (7.8) (6.7) (6.7)

(11.0) (11.9) (8.1) (7.6)

(11.2) (10.8) (8.2) (8.9)

Neutral

With neutral as reference posture, the majority of subjects changed their pattern of movement coupling in both primary rotation and lateral flexion when movement was performed in a fully retracted posture (Table 2). Similarly, there was an equal distribution of subjects between those who changed, and those who retained, their neutral posture pattern of movement when they started from a fully protracted posture.

Retraction

30 20

30

**

* **

**

20

0 -10

** NS

**

0 -10 -20

NS

-30

(A)

**

10

Degrees

Degrees

10

-20

Protraction

**

Lateral flexion

Extension/Flexion

* **

-30

(B)

Lateral flexion

Extension/Flexion

Fig. 2. Ranges of coupled movements associated with primary (A) right and (B) left rotation in three cervical spine postures. The positive values represent ipsilateral lateral flexion and extension while negative values represent contralateral lateral flexion and flexion.  Po0:01 and  Po0:05:

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Neutral ** 30

Retraction

Protraction

NS

** 30

**

NS

**

20

10

10

Degrees

Degrees

** 20

0 -10

0 -10

**

**

-20

-20

-30

Rotation

(A)

**

Extension/Flexion

-30

(B)

**

Rotation

**

Extension/Flexion

Fig. 3. Ranges of coupled movements associated with primary (A) right and (B) left lateral flexion in three cervical spine postures. The positive values represent ipsilateral rotation and extension while negative values represent contralateral rotation and flexion.  Po0:01 and  Po0:05:

Fig. 4. Patterns of coupled movement associated with primary (A) right and (B) left rotation, and primary (C) right and (D) left lateral flexion in three postures of the cervical spine. The ipsilateral pattern is the commonly described pattern of ipsilateral lateral flexion or rotation and extension. The ‘other’ group includes subjects who had a movement pattern which was different to the commonly described pattern.

Table 2 Number of subjects who changed (retained) the pattern of coupled movement which was demonstrated in the neutral posture, when moving from the fully retracted and protracted postures Neutral to

Retraction Protraction

Primary movement (R) Rot.

(L) Rot.

(R) Lat. flex.

(L) Lat. flex.

18 (12) 16 (14)

15 (15) 13 (17)

20 (10) 14 (16)

20 (10) 19 (11)

4. Discussion The ranges of cervical spine rotation in the neutral posture determined in this study (Table 1) are consistent with those reported in previous in vivo studies for individuals in a similar age range. The mean bilateral range of rotation in the present study was 1391, which compares favourably with previous studies which have described ranges of rotation of between 1401 and 1491 (Hole et al., 1995; Trott et al., 1996; Feipel et al., 1999).

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The bilateral range of lateral flexion in this study of 731 is lower than those reported in previous studies (mean values: 80–931), including those which have used the same measurement technique (Haynes and Edmondston, 2002). The reason for this difference is likely to be the relatively constrained subject position employed in the present study, and the instruction to the subjects to cease movement when a comfortable end-range position was achieved. The measurement procedure in this study was designed to achieve optimal consistency in the patterns of movement, and in doing so may have constrained coronal plane movement relative to that which has been achieved in previous studies. The clinical observation that the mobility of the spine is influenced by the position from which movement is initiated is supported by the results of this study. When movements of lateral flexion and rotation were performed at the extremes of protraction and retraction, a significant decrease in the range of motion was observed. This finding is consistent with the results of previous studies which have examined cervical spine rotation in the extremes of flexion and extension, as well as protraction and retraction (Dvorak et al., 1992; Walmsley et al., 1996). Cervical spine protraction and retraction increase tensile loading in the posterior ligaments of the upper and lower cervical segments, as well as the anterior annular fibres of the inter-vertebral disc (Panjabi et al., 1993; Putz and Muller-Gerbl, 2000; Mercer and Bogduk, 2001). The combined effects of this ligamentous tension and changes in joint loading would be likely to reduce the mobility of these segments, compared to that which would be achieved in a more unconstrained posture. The dominant pattern of movement coupling associated with primary rotation and lateral flexion in the neutral position observed in this study was extension combined with ipsilateral lateral flexion or rotation (Fig. 3). This pattern is consistent with previous descriptions of cervical spine movement coupling in asymptomatic subjects and cadaveric specimens (Trott et al., 1996; Panjabi et al., 2001). However, for both primary movements, up to 30% of subjects had a pattern of movement coupling which was different to that which is commonly described. This inconsistency in rotation and lateral flexion movement coupling between subjects has not been previously reported in the cervical spine; however, a similar trend has been described in the thoracic spine (Willems et al., 1996). Similarly, variation between individuals in patterns of sagittal plane movement in the cervical and lumbar regions has been reported (Van Mameren et al., 1990; Gatton and Pearcy, 1999). It is evident from the present results that while the majority of individuals have a pattern of movement coupling which is consistent with that which is commonly described, a stereotypical pattern of movement coupling of the cervical spine which is consistent across all individuals appears not to exist.

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Post-mortem studies have repeatedly demonstrated ipsilateral coupling of rotation and lateral flexion in the C2 to T1 motion segments (Lysell, 1969; Panjabi et al., 2001). However, during rotation of the cervical spine, ipsilateral lateral flexion will occur in the disc segments, but the head is kept upright by a compensatory lateral flexion of the upper cervical spine in the opposite direction (Penning, 1998). This complex interaction between the kinematics of the two regions of the cervical spine is likely to explain the variability in global patterns of movement coupling observed in this study, particularly when movements were performed in the protracted and retracted postures. The dominant influence of the disc segments on movement coupling appears to be reduced when movements are performed in end-range postures. The constraint of low cervical rotation in retraction in this study was associated with a decrease in the range of coupled lateral flexion, and movement of the neck into flexion rather than extension. This later movement is likely to occur more in the upper cervical spine, where rotation in flexion (as would occur in retraction) tends to promote greater sub-occipital flexion (Panjabi et al., 1993). In contrast, protraction of the head and neck had a greater influence on the coupled movement pattern associated with primary lateral flexion. The major influence of protraction was a decrease in the range of coupled rotation with a trend towards contralateral rotation. Again, this reflects the dominant influence of the upper cervical spine, where lateral flexion in extension (as would occur in upper cervical protraction) is associated with contralateral rotation (Panjabi et al., 1993). Studies of muscle activity during cervical spine movement describe co-contraction of muscles around the moving segments, and a high level of intra-subject consistency in the patterns of muscle activity (Lu and Bishop, 1996; Choi, 2003). In contrast, the patterns of muscle activity tend to vary between individuals, particularly during dynamic movements (Lu and Bishop, 1996). These differences in patterns of muscle recruitment between individuals could explain the variation in patterns of movement coupling in the neutral posture observed in the present study. In the extreme sagittal postures used in this study, patterns of movement are likely to be influenced predominantly by ligamentous tension and joint morphology. However, in less extreme postures, the neuromuscular influence on movement patterns would be greater, and accordingly, cervical spine posture has been shown to influence the level of activation and efficiency of the muscles of the neck (Schuldt, 1988; Mayoux-Benhamou and Revel, 1993). In the present study, primary rotation performed in neck protraction tended to exaggerate the range of coupled extension. This effect may be due to the increased moment arm of muscles which traverse the cervical spine and generate rotation and extension

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torque, when the upper cervical spine moves from a neutral to an extended posture (Vasavada et al., 1998). Protracted or flexed postures of the cervical spine have been considered a risk factor for the development of neck pain and cervicogenic headache (Watson and Trott, 1993; Ariens et al., 2001). An hypothesis arising from this study is that the postural change may lead to the development of neck pain through the associated change in cervical spine movement patterns. While this concept requires evaluation in a clinical study, the results of this study raise a possible link between changes in cervical spine posture and the development of neck pain. Similarly, rotation movements in endrange retraction postures have been encouraged in the management of some pain disorders of the cervical spine (McKenzie, 1990; Grimmer, 1996). While these exercises may assist in modifying pain location and intensity, caution is required when encouraging patients to move from over-corrected retraction postures due to the potential to introduce movement patterns which are different to those which the individual would achieve in their neutral posture. In the present study, the natural pattern of movement coupling associated with primary rotation was altered when this movement was performed in end-range retraction. This may not be advantageous to patients with neck pain who are seeking to restore normal patterns of pain-free movement. A number of issues need to be considered in the measurement and interpretation of three-dimensional motion of the cervical spine. Previous studies have used either electromagnetic or potentiometer systems, while this is the first study to describe the use of a goniometerbased system for this purpose (Trott et al., 1996; Feipel et al., 1999; Koerhuis et al., 2003). The electromagnetic systems derive measurements using Euler angles or related methods. One of the inherent limitations of these methods is that the three-dimensional description of the head position is dependent upon the rotation sequence used to derive the measurements (Hof et al., 2001). In contrast, a potential advantage of the SpinT system is that measurements can be derived directly from the goniometer using the wall as a fixed reference system. The accuracy of the SpinT has been previously demonstrated, and the validity of the system is further supported by the general agreement between measurements derived in this study, and those reported using electromagnetic systems (Chen et al., 1999; Feipel et al., 1999; Haynes and Edmondston, 2002). While the SpinT may appear somewhat cumbersome, it is easy to use, measurements can be derived immediately, and it can be used in clinical practice. Procedural issues have been suggested to be an important source of variability in measurements reported in cervical spine mobility studies (Chen et al., 1999). Two important influences on the range and pattern of movement identified in the preliminary phase

of this study were the starting position of the subject, and the specific instructions they were given in relation to the movement required. Careful consideration was given to these factors throughout this study in order to minimize these procedural influences on the derived measurements. One potential limitation of the SpinT is the ability to position the T-bar on the dials in subjects who have extreme ranges of motion. This was particularly the case for the measurement of sagittal plane coupled movements in the more extreme ranges of lateral flexion. Despite this difficulty, there was no evidence of greater measurement variability in the subjects who had higher ranges of lateral flexion mobility.

5. Conclusion The results of this study challenge the concept of a stereotypical pattern of coupled movement of the cervical spine during rotation and lateral flexion. In the neutral cervical spine posture, about 30% of subjects demonstrated a pattern of coupled movement which was different to the ipsilateral coupling pattern which is commonly described. When rotation and lateral flexion movements were performed in end-range protraction or retraction postures, changes in the ranges of primary and coupled movements were observed, as well as changes in some of the dominant patterns of movement coupling. These results highlight the need for further evaluation of cervical spine kinematics in normal subjects, and particularly in individuals with neck pain.

Acknowledgements The authors acknowledge with appreciation Dr. Michael Haynes DC, Ph.D. for permission to use the SpinT goniometer, and his technical assistance during the study. The statistical advice of Dr. Ritu Gupta, Department of Mathematics & Statistics, Curtin University of Technology is also acknowledged. References Ariens GA, Bongers PM, Douwes M, Miedema MC, Hoogendoorn WE, van der Wal G, Bouter LM, van Mechelen W. Are neck flexion, neck rotation, and sitting at work risk factors for neck pain? Results of a prospective cohort study. Occupational and Environmental Medicine 2001;58:200–7. Boyle J, Milne N, Singer KP. Clinical anatomy of the cervicothoracic junction. In: Giles LGF, Singer KP editors. Clinical Anatomy and Management of Cervical Spine Pain. Oxford: Butterworth-Heinemann; 1997. p. 40–52 [Chapter 3]. Bronfort G, Evans R, Nelson B, Aker PD, Goldsmith CH, Vernon H. A randomised clinical trial of exercise and spinal manipulation for patients with chronic neck pain. Spine 2001;26:788–99.

ARTICLE IN PRESS S.J. Edmondston et al. / Manual Therapy 10 (2005) 44–51 Chen J, Solinger AB, Poncet JF, Lantz CA. Meta-analysis of normative cervical motion. Spine 1999;24:1571–8. Choi H. Quantitative assessment of co-contraction in cervical musculature. Medical Engineering and Physics 2003;25:133–40. Cholewicki J, Crisco JJI, Oxland TR, Yamamoto I, Panjabi MM. Effects of posture and structure on three-dimensional coupled rotations in the lumbar spine: a biomechanical analysis. Spine 1996;21:2421–8. Dvorak J, Hayek J, Zehnder R. CT-functional diagnostics of the rotary instability of the upper cervical spine. Part 2. An evaluation on healthy adults and patients with suspected instability. Spine 1987;12:726–31. Dvorak J, Antinnes JA, Panjabi M, Loustalot D, Bonomo M. Age and gender related normal motion of the cervical spine. Spine 1992;17:S393–8. Feipel V, Rondelet B, Le Pallec J- P, Rooze M. Normal global motion of the cervical spine: an electrogoniometric study. Clinical Biomechanics 1999;14:462–70. Gatton ML, Pearcy MJ. Kinematics and movement sequencing during flexion of the lumbar spine. Clinical Biomechanics 1999;14:376–83. Gibbons P, Tehan P. Muscle energy concepts and coupled motion of the spine. Manual Therapy 1998;3:95–101. Grimmer K. The relationship between cervical resting posture and neck pain. Physiotherapy 1996;82:45–51. Haynes MJ, Edmondston S. Accuracy and reliability of a new, protractor based neck goniometer. Journal of Manipulative and Physiological Therapeutics 2002;25:579–86. Hof AL, Koerhuis CL, Winters JC. Coupled motions in the cervical spine can be misleading. Clinical Biomechanics 2001;16:455–8 [Letter to the Editor]. Hole DE, Cook JM, Bolton JE. Reliability and concurrent validity of two instruments for measuring cervical range of motion: effects of age and gender. Manual Therapy 1995;1:36–42. Koerhuis CL, Winters JC, van der Helm FC, Hof AL. Neck mobility measurement by means of the ‘Flock of Birds’ electromagnetic tracking system. Clinical Biomechanics 2003;18:14–8. Korthals-de Bos IBC, Hoving JL, van Tulder MW, Rutten-van Molken MPM, Ader HJ, de Vet HCW, et al. Cost effectiveness of physiotherapy, manual therapy and general practitioner care for neck pain: economic evaluation alongside a randomised controlled trial. British Medical Journal 2003;326:911–6. Lu WW, Bishop PJ. Electromyographic activity of the cervical musculature during dynamic lateral bending. Spine 1996;21:2443–9. Lysell E. Motion in the cervical spine. Acta Orthopaedica Scandinavia 1969;123:4–54. Mayoux-Benhamou MA, Revel M. Influence of head position on dorsal neck muscle efficiency. Electromyography and Clinical Neurophysiology 1993;33:161–6. McCarthy CJ. Spinal manipulative thrust technique using combined movement theory. Manual Therapy 2001;6:197–204. McKenzie RA. The cervical and thoracic spine. Mechanical diagnosis and therapy. Waikanae: Spinal Publications Ltd.; 1990. p. 140–41 [Chapter 12]. Mercer SR, Bogduk N. Joints of the cervical vertebral column. Journal of Orthopaedic and Sports Physical Therapy 2001;31:174–82.

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Milne N. Composite motion in the cervical disc segments. Clinical Biomechanics 1993;8:193–202. Mimura M, Moriya H, Watanabe T, Takahashi K, Yamagata M, Tamaki T. Three-dimensional motion analysis of the cervical spine with special reference to the axial rotation. Spine 1989;14:1135–9. Panjabi MM, Oda T, Crisco JJ, Dvorak J, Grob D. Posture affects motion coupling patterns of the upper cervical spine. Journal of Orthopaedic Research 1993;11:525–36. Panjabi MM, Crisco JJ, Vasavada A, Oda T, Cholewicki J, Nibu K, et al. Mechanical properties of the human cervical spine as shown by three-dimensional load-displacement curves. Spine 2001;26: 2692–700. Penning L. Normal kinematics of the cervical spine. In: Giles LGF, Singer KP editors. Clinical Anatomy and Management of Cervical Spine Pain. Oxford: Butterworth-Heinemann; 1998. p. 53–70 [Chapter 4]. Penning L, Wilmink J. Rotation of the cervical spine. Spine 1987;12: 732–8. Performance Attainment Associates. CROM procedure manual: procedure for measuring neck motion with the CROM. St. John: Performance Attainet Associates; 1986. Philadelphia panel. Philadelphia panel evidence-based clinical practice guidelines on selected rehabilitation interventions for neck pain. Physical Therapy 2001;81:1701–17. Putz RV, Muller-Gerbl M. Ligaments of the human vertebral column. In: Giles LGF, Singer KP editors. Clinical Anatomy and Management of Thoracic Spine Pain. Oxford: Butterworth-Heinemann; 2000. p. 35–44 [Chapter 3]. Schuldt K. On neck muscle activity and load reduction in sitting postures. Scandinavian Journal of Rehabilitation 1988;19(Suppl.): 1–49. Stoddard A. Manual of osteopathic practice, 2nd ed. London: Hutchinson; 1983. p. 289. Szeto G, Straker, Raine S. A field comparison of neck and shoulder postures in symptomatic and asymptomatic office workers. Applied Ergonomics 2002;33:75–84. Trott PH, Pearcy MJ, Ruston SA, Fulton I, Brien C. Threedimensional analysis of active cervical motion: the effect of age and gender. Clinical Biomechanics 1996;11:201–6. Van Mameren H, Drukker J, Sanches H, Beursgens J. Cervical spine motion in the saggital plane (I). Range of motion of actually performed movements, and X-ray cinematographic study. European Journal of Morphology 1990;28:47–68. Vasavada A, Li S, Delp S. Influence of muscle morphometry and moment arms on the moment generating capacity of human neck muscles. Spine 1998;23:412–22. Walmsley RP, Kimber P, Culham E. The effect of initial head position on active cervical axial rotation range of motion in two age populations. Spine 1996;21:2435–42. Watson D, Trott P. Cervical headache. An investigation of natural head posture and upper cervical flexor muscle performance. Cephalalgia 1993;13:272–84. White A, Panjabi M. Clinical Biomechanics of the Spine, 2nd ed. Philadelphia: JB Lippincott Co.; 1990. p. 88. [Chapter 2]. Willems JM, Jull GA, Ng JK- F. An in-vivo study of the primary and coupled rotations of the thoracic spine. Clinical Biomechanics 1996;11(6):311–6.

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Manual Therapy 10 (2005) 52–60 www.elsevier.com/locate/math

Original article

The impact of neurodynamic testing on the perception of experimentally induced muscle pain Michel W. Coppieters, Kimberly Kurz, Thor Einar Mortensen, Nicola L. Richards, Ingrid A˚. Skaret, Laurie M. McLaughlin, Paul W. Hodges Division of Physiotherapy, School of Health and Rehabilitation Sciences, The University of Queensland, St. Lucia, QLD 4072, Brisbane, Australia Received 11 March 2004; received in revised form 8 July 2004; accepted 27 July 2004

Abstract Neurodynamic tests such as the straight leg raising (SLR) and slump test are frequently used for assessment of mechanosensitivity of neural tissues. However, there is ongoing debate in the literature regarding the contributions of neural and non-neural tissues to the elicited symptoms because many structures are affected by these tests. Sensitizing manoeuvres are limb or spinal movements added to neurodynamic tests, which aim to identify the origin of the symptoms by preferentially loading or unloading neural structures. A prerequisite for the use of sensitizing manoeuvres to identify neural involvement is that the addition of sensitizing manoeuvres has no impact on pain perception when the origin of the pain is non-neural. In this study, experimental muscle pain was induced by injection of hypertonic saline in tibialis anterior or soleus in 25 asymptomatic, naı¨ ve volunteers. A first experiment investigated the impact of hip adduction, abduction, medial and lateral rotation in the SLR position. In a second experiment, the different stages of the slump test were examined. The intensity and area of experimentally induced muscle pain did not increase when sensitizing manoeuvres were added to the SLR or throughout the successive stages of the slump test. The findings of this study lend support to the validity of the use of sensitizing manoeuvres during neurodynamic testing. r 2004 Elsevier Ltd. All rights reserved.

1. Introduction The ability to identify the tissue origin of symptoms and to recognize the neurophysiological mechanisms involved in a patient’s pain state is often challenging, even for skilled clinicians. The straight leg raising (SLR) is traditionally considered an important diagnostic test for lumbar intervertebral disc herniation and nerve root inflammation (Thelander et al., 1992; Jonsson and Stromqvist, 1995; Rebain et al., 2002). Only recently has this test been used to assist in the identification of more distal nerve entrapments such as entrapment of the common fibular nerve at the head of the fibula or the plantar nerves at the heel (Butler, 1991; Meyer et al., 2002). Corresponding author. Tel: +61-7-3365-4589; fax: +61-7-3365-2775. E-mail address: [email protected] (M.W. Coppieters).

1356-689X/$ - see front matter r 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2004.07.007

Neurodynamic tests, also termed neural provocation tests (Elvey, 1997), are sequences of movements designed to assess the mechanics and physiology of part of the nervous system (Shacklock, 1995; Butler, 2000). The mechanical components include the ability of the nerve to move and strain in relation to surrounding tissues, and the physiological components relate to, for example, inflammation, ischaemia, and altered ion channel activity resulting in sites of abnormal impulse generation. The underlying concept for these tests is that sensitized and painful neural tissues may become noncompliant to an increase in relative length of the nerve bedding to which the nerve must accommodate (Elvey, 1997). A neurodynamic test is considered positive if symptoms can be reproduced, if responses on the involved side differ from the uninvolved side or from known normal responses, and if structural differentiation supports a neurogenic source (Butler, 2000). In this

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study, we focused on the use of sensitizing manoeuvres to structurally differentiate peripheral tissues involved in nociception. Previous studies have demonstrated that neurodynamic tests are able to reproduce the symptoms of patients with peripheral nerve disorders and that differences between the involved and uninvolved side can be objectively measured (Shacklock, 1996; Coppieters et al., 2003a; Coppieters et al., 2003b). The key concept for use of sensitizing manoeuvres (also called qualifying tests (Breig and Troup, 1979)) to identify neurogenic disorders is that the nervous system is continuous and that certain movements load the peripheral nervous system more than the overlying muscles or fascia (Elvey, 1994; Butler, 2000). Hip adduction, for example, is regarded as an effective sensitizing manoeuvre to add to the SLR (Breig and Troup, 1979) because the sciatic nerve runs lateral from the origin of the hamstrings and is loaded by this manoeuvre. Further load can be placed on the sciatic and tibial nerve by adding medial hip rotation or ankle dorsiflexion. In a cadaveric study, Breig and Troup (1979) demonstrated that medial hip rotation resulted in increased tension of the sacral plexus and movement relative to the greater sciatic notch of up to 1 cm. Other examples of sensitizing manoeuvres are the addition of ankle dorsiflexion and eversion to the SLR to assess possible entrapment of the medial calcaneal nerve or lateral plantar nerve in patients with heel pain (Meyer et al., 2002) and the addition of plantar flexion and inversion to assist in the differential diagnosis of fibular nerve problems (Rebain et al., 2002). It has been demonstrated that the available range of movement of a particular joint is dependent on the position of other body segments. For example, the range of SLR decreases when ankle dorsiflexion is added (Gajdosik et al., 1985; Boland and Adams, 2000) and the addition of cervical flexion, ankle dorsiflexion or medial hip rotation reduces knee extension range during the slump test (Fidel et al., 1996; Johnson and Chiarello, 1997). Although it was hypothesized that neuromeningeal structures were the most likely structures to cause the change in range of motion (ROM), decisive conclusions could not be made. Other structures that have been suggested to contribute to a limitation in ROM are subcutaneous connective tissues, skin, blood vessels and fascia (Gajdosik et al., 1985). Continuity of the fascial system may provide an alternative explanation for changes in ROM and pain perception during neurodynamic testing (Gajdosik et al., 1985; Barker and Briggs, 1999). A continuous fascial network has been reported to extend via the thoracolumbar fascia to the gluteal muscles, the sacrotuberous ligament and biceps femoris (Vleeming et al., 1995; 1996). The deep crural fascia of the leg has connections with the iliotibial band, which is connected to the tendinous insertion of the caudal part of the gluteus

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maximus to the gluteal tuberosity (Gerlach and Lierse, 1990). This continuity of the facial system may allow effective load transfer between spine, pelvis and legs (Vleeming et al., 1995). In addition, the posterior layer of the thoracolumbar fascia has attachments to the tendons of splenius capitis and cervicis (Barker and Briggs, 1999). It has been argued that this fascial network may account for positive findings such as pain and limited ROM when cervical flexion is added to the slump test (Barker and Briggs, 1999). There is no doubt that neurodynamic tests not only load the nervous system, but also challenge non-neural structures. This contributes to the controversy regarding the origin of the elicited symptoms and the difficulty with which the tests are interpreted. To validate the use of sensitizing manoeuvres, it would be ideal to compare the impact of sensitizing manoeuvres between patients with isolated peripheral nerve disorders characterized by an increased mechanosensitivity and patients in whom the peripheral nervous system is not the origin of the pain perception. However, nerve disorders rarely occur in isolation, like median nerve entrapment in the carpal tunnel due to inflammation of the flexor tenosynovium (Gerritsen et al., 2002), and the aim of neurodynamic tests is often to determine the relative contribution of the peripheral nervous system in the origin of the symptoms. A prerequisite for use of sensitizing manoeuvres to identify neural involvement is that the addition of sensitizing manoeuvres has no impact on pain perception when the origin of the pain is non-neural and when an upregulated central nervous system or pathological central mechanisms do not play a dominant role in the patient’s symptoms (Shacklock, 1996). This condition was tested by analysis of the impact of the SLR and slump test on the perception of experimentally induced muscle pain elicited by injection of hypertonic saline. Intramuscular injection of hypertonic saline induces isolated sensitization of muscle nociceptors which leads to muscle tenderness and hyperalgesia (Graven-Nielsen and Mense, 2001). We hypothesized that the perception of this pain of non-neural origin would not change when sensitizing manoeuvres were added to the SLR and slump test.

2. Methods Two studies were undertaken to assess whether postures or specific positions of the lower limb influenced the perception of pain in distal body segments when pain is induced by injection of hypertonic saline. In the first experiment we investigated the SLR and the impact of sensitizing manoeuvres on experimentally induced muscle pain in tibialis anterior. In the second experiment, we investigated the effect of the different stages of the slump test on experimental muscle pain in the soleus.

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2.1. Evaluation of pain response A single bolus of 0.5 ml of hypertonic saline (5% NaCl) causes a rapid increase in pain, followed by a rapid decrease (Graven-Nielsen and Mense, 2001). In most subjects, the pain almost completely resolves within 5 min. As this period was too short for our experiments, we conducted a pilot study to analyse the effect of an intramuscular injection of 1.2 ml of hypertonic saline (5% NaCl) in tibialis anterior. Seven asymptomatic volunteers participated (4 males, 3 females; age (mean7SD): 29.474.4 years; height: 177.9710.3 cm; weight: 72.6711.3 kg). In a supine position, subjects were asked to indicate the intensity of the pain on a visual analogue scale (VAS) every 20 s. Recordings started ten seconds after the injection and continued for ten minutes, or longer if the pain had not yet disappeared. No trunk, neck or lower limb movements were performed during the experiment. Fig. 1 shows the course of the intensity of experimentally induced muscle pain over time. A more gradual decrease could be observed and the duration of the pain was substantially longer than has been reported for a single bolus of 0.5 ml with the same concentration. Based on this pilot study, a single bolus of 1.2 ml of hypertonic saline (5% NaCl) was used for the experiments. 2.2. Subjects Fifteen asymptomatic volunteers participated in the first experiment (13 males, 2 females; age (mean7SD): 23.974.6 years; height: 179.979.3 cm; weight: 78.07 15.3 kg) and 10 asymptomatic participants volunteered for the second experiment (9 males, 1 female; age: 24.973.9 years; height: 182.276.3 cm, weight: 81.07 9.3 kg). To be suitable for inclusion, each participant had to be free of back, neck and right leg pain in the last 10

Pain intensity (VAS) Pai

6 5 4 3 2 1 0 0

60

120

180

240

300

360

420

480

540

600

Ti Time (s)

Fig. 1. Time course of experimentally induced pain following injection of hypertonic saline (1.2 ml; 5%NaCl). The solid line represents the mean intensity and the dotted lines represent71 SD. The pain intensity recorded during the first (J) and second (K) series of the SLR experiment have been added to the figure.

year and had to be naı¨ ve to the concept of neurodynamic testing. Subjects with a history of neurogenic disorders or any known contraindication to injections were excluded. Participants were given a full explanation of the procedure, without disclosing information regarding the hypothesis of the study. Consent was ascertained prior to the commencement of the study and all procedures were approved by the Institutional Ethics Committee. 2.3. Experimental muscle pain An experimental pain model was used to ensure that pain was isolated in muscle tissue. Injection of hypertonic saline has been used extensively because the quality of the induced pain is considered comparable to acute clinical muscle pain and shows localized as well as referred pain characteristics (Graven-Nielsen and Mense, 2001). A 1.2 ml bolus of hypertonic saline (5% NaCl) was injected intramuscularly. In the first experiment, hypertonic saline was injected in the tibialis anterior, approximately 2 cm lateral and 7 cm caudal to the tibial tuberosity. Pain is reported to be felt over the anterolateral side of the lower leg and dorsum of the foot (Graven-Nielsen and Mense 2001), which corresponds with the symptomatic area in superficial or common fibular nerve entrapment and with the L5–S1 dermatome. In the second study, soleus was injected at the dorsomedial side of the lower leg, distal to the muscle belly of the gastrocnemius muscle, which is reported to cause pain in the calf (Matre et al., 1999). 2.4. Neurodynamic tests 2.4.1. Straight leg raising According to the recommendations for standardization of the passive SLR (Rebain et al., 2002), subjects were positioned supine on a plinth with the trunk and neck in a neutral position (Fig. 2). For each subject, the submaximal range of SLR was determined for the right leg. The submaximal range was defined as the maximal range of SLR, with medial hip rotation or adduction, without causing any discomfort. The rationale for moving the limb to a position that did not provoke symptoms, such as a pulling sensation at the posterior thigh or calf, was that pilot trials demonstrated that these additional symptoms distracted the subject, reducing their ability to concentrate on the experimental muscle pain. Six tests were performed in random order: (1) SLR to the submaximal range, (2) SLR to half of this range, (3,4) the addition of 301 medial or lateral hip rotation to the SLR and (5,6) the addition of 301 hip adduction or abduction to the SLR (Table 1A). An electronic clinometer (Accustar, Schaevitz Sensors, Virginia, USA) was placed proximal to the lateral

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femoral condyle to measure the angle of hip flexion during the SLR. An ankle splint was used to limit change in muscle length of the tibialis anterior. Twin axis electrogoniometers were attached with double sided adhesive tape to the lateral side of the ankle and knee to monitor possible changes in knee and ankle position (SG65 and SG110, Penny and Giles Biometrics Ltd, Blackwood Gwent, UK). To measure the amount of hip rotation, one endblock of a third electrogoniometer (SG65) was placed on a wedge attached to the heel of the ankle splint and a weight (65 g) was attached to the other freely suspended endblock to create a pendulumtype electrogoniometer. Strips of tape were applied to

Ele Electrogoniometer El Electrogoniometer Elec Electrogoniometer Clinometer Ankl splint Ankle EMG tibialis anterior

Fig. 2. Set-up for Experiment 1 (SLR). A screen was placed across the subject’s abdomen to make the subject visually unaware of the movements of the leg.

Table 1 Different positions for the SLR and slump test A. Experiment 1: Straight leg raising Starting position

End position

SLRZERO SLRZERO SLR

SLR1/2 SLR SLR+301 rotation SLR+301 rotation SLR+301 adduction SLR+301 abduction

SLR SLR SLR

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the plinth to mark the target range of hip abduction and adduction. Electromyographic activity (EMG) was recorded from the tibialis anterior by Ag–AgCl surface electrodes placed 1/3 of the distance between the head of the fibula and the medial malleolus (Hermens et al., 1999). Because muscle activity may impact on pain, EMG recordings were made throughout the experiment to ensure that the participants remained relaxed. 2.4.2. Slump test The slump test (Maitland, 1979, 1985) involves a combination of knee extension, ankle dorsiflexion, slouched sitting and neck flexion. The aim of the test is to assess the peripheral nerves of the lower extremity, the neural structures in the spinal canal and the connective tissues, such as the meninges. Prior to the start of the experiment, the maximal range of knee extension in the slumped position (including cervical flexion) without causing any discomfort was determined and identified as the submaximal ROM. The subject sat on the edge of the plinth while the different stages of the slump test were performed: (1) neutral sitting, (2) stage 1 plus passive knee extension, (3) stage 2 plus thoracolumbar flexion, (4) stage 3 plus cervical flexion, and (5) neutral sitting (Table 1B). An ankle splint was used to prevent changes in muscle length of the soleus (Fig. 3). An electrogoniometer was used to verify the position of the ankle (SG65, Penny and Giles Biometrics Ltd) and to measure the range of knee extension (SG110). EMG electrodes were placed over the soleus at 2/3 of the distance between the medial condyle of the femur and the medial malleolus (Hermens et al., 1999) to verify that the muscle was relaxed throughout the experiment.

Medial hip Lateral hip Hip Hip

B. Experiment 2: Slump test Progressive stages 1. Neutral sitting 2. Neutral sitting, Knee extension 3. Thoracolumbar flexion, Knee extension 4. Thoracolumbar flexion, Knee extension, Cervical flexion 5. Neutral sitting

2.5. Pain measurement Because pain is subjective, self-reports are regarded to provide the most valid measure of the experience (Katz and Melzack, 1999). Participants indicated pain intensity on a 10 cm VAS anchored with ‘‘no pain’’ and ‘‘worst possible pain’’. The VAS was mounted on a 10 cm sliding potentiometer, which was connected to the data acquisition system. To indicate the size of the area of the elicited pain, subjects were shown a diagram depicting a series of 10 circles increasing in size from 1 to 10 cm in diameter. This scale has been used previously (Bennell et al., 2004). 2.6. Procedure

SLRZERO, zero degrees of hip flexion, no rotation and no abduction or adduction; SLR, submaximal straight leg raising (maximal range without causing any discomfort), no rotation and no abduction or adduction; SLR1/2, half of the ROM of the SLR, no rotation and no abduction or adduction.

In both experiments, three series of tests were performed. The first series was performed prior to injection of hypertonic saline, and the subsequent two

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experiment. For the second experiment, a one-way, repeated measures ANOVA was performed (5 levels: ‘Progressive stages’: see Table 1B). Tukey tests were used for the post-hoc analysis. The level of significance was set at Po0.05.

Electrogoniometer

3. Results 3.1. Straight leg raising

Ankle splint EMG soleus (medial side)

Fig. 3. Set-up for Experiment 2 (Slump test).

series were performed with experimental pain. Following injection, participants were asked to describe the quality of the pain, mark the location of the pain on a body chart and indicate the pain intensity and size. Tests with induced muscle pain started once the level of pain had reached a plateau. In the first experiment, the subject was asked to compare the pain intensity and size in the end position with the ratings in the starting position (for starting and end positions: Table 1A). Participants were made aware that the pain could increase, decrease or remain unchanged in one position relative to another. The slider knob on the VAS was returned to zero before each starting position. In the second experiment, pain size and intensity were compared between the four successive stages of the slump test (Table 1B). The VAS was returned to zero when returning to the final test position (neutral sitting). A one-minute pause was provided after the first series with experimental muscle pain. To improve standardization in the first experiment, the examiner who performed movements of the leg observed a monitor, which displayed the target range of SLR and hip rotation. Knee and ankle angles were also shown on the screen to provide feedback of confounding movements. In the second experiment, one examiner sat next to the subject in order to guide the subject through the different stages of the slump test. In the tests with knee extension, the subject’s foot was placed on a height-adjustable surface in order to maintain a constant range of knee extension. 2.7. Statistical analysis A two-way, repeated measures analysis of variance (ANOVA) with two repeated factors (‘Test’ [6 levels: see Table 1A] and ‘Position’ [2 levels: starting and end position]) was performed to analyse the data of the first

3.1.1. Test characteristics The mean range7SD of SLR without causing any discomfort was 52.9711.41 (range: 36.1–72.11). All target positions for the different tests were achieved within a few degrees. The examiner achieved hip rotation within 1.370.81 from the target position and SLR within 2.373.01. The mean changes in ankle and knee position were 0.472.31 and 0.373.01, respectively. These results demonstrate that the tests were performed accurately. The position of the ankle in the splint was 37.178.71 plantar flexion and was held constant. 3.1.2. Pain measures Apart from one position for one participant, all positions without hypertonic saline were reported to be pain-free. Following intramuscular injection of hypertonic saline into tibialis anterior, pain was predominately perceived over the middle shin around the injection site, with a separate area of referred pain over the ankle joint (Fig. 4). The participants described the pain as a throbbing, dull, deep aching and sometimes cramping pain. The pain intensity plateaued approximately one and a half minutes after the injection (92725 s) at 4.971.6 cm on the VAS. The initial series with experimental pain lasted approximately 5 min (268742.1 s) with a mean VAS of 3.071.2 cm. The second series lasted for approximately three and a half minutes (211.3751 s) with a mean VAS of 1.170.7 cm. The pain intensity and size of pain for the different tests in the three series are presented in Figs. 5 and 6. For the experimental pain conditions, the Position x Test interaction was not significant for pain intensity or pain size (F5,84p1.86, PX0.11), demonstrating that the tests, which load the neuromusculoskeletal structures had a similar effect on the pain perception as the tests that unload the structures. For the initial series with experimentally induced pain, the main effect for Position was significant for both pain intensity and pain size (F1,84X8.89, Pp0.004). Pain ratings were significantly lower in the end position than in the starting position. However, the decreases in VAS ( 0.470.4) and pain size ( 0.470.3) were small and the changes were not significant in the second series (VAS: 0.270.2; size

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0.070.1). There was no difference between the tests which intend to load or unload the neural structures. 3.2. Slump test 3.2.1. Test characteristics The maximal angle of knee extension in the slump position without causing any discomfort was 22.677.91 from full knee extension. This position altered only slightly after the addition of thoracolumbar flexion (knee: 1.971.91) or cervical flexion (knee: 0.470.81). The position of the ankle in the splint was 22.977.91, which changed minimally throughout the experiment (0.072.11 during knee extension; 0.270.81 after thoracolumbar flexion; and 0.170.41 after the addition of neck flexion). Fig. 4. Location of the experimentally induced pain following injection of soleus (left panel) and tibialis anterior (right panel). A higher grey scale represents a larger number of subjects reporting pain in that area.

3.2.2. Pain measures Before injection of hypertonic saline in soleus, all stages of the slump test were pain free. The experimentally induced pain was predominantly perceived around SLR Zero

SLR Zero 0.0

+0.2

0.0

–0.2

–0.7

–0.1

SLR 1/2

SLR 1/2

SLR Zero

SLR Zero 0.0

+0.1

–0.6

0.0

–0.1

0.0

+0.1

–0.5

SLR

SLR

SLR

SLR 0.0

+0.3

–0.2

–0.7

SLR + Hip abd

SLR + Hip abd

SLR

SLR 0.0

+0.6

–0.4

0.0

+0.2

–0.3

0.0

–0.1

0.0

0.0

–0.1

–0.1

SLR + Hip add

SLR + Hip add SLR

SLR +0.1

+0.2

+0.2

SLR + Med hip rot

SLR + Med hip rot

SLR

SLR 0.0

+0.1

–0.9

1

3

SLR + Lat hip rot

SLR + Lat hip rot 0

0

2

4

5

10

1

2

3

4

5

6

10

Painful area (size)

Pai intensity (VAS) Pain Fig. 5. Pain intensity (mean and SD) for the different SLR positions. Numbers indicate the mean difference in VAS between the start and end position for each manoeuvre. &=No experimental pain; J=experimental pain (series 1); K=experimental pain (series 2). See Table 1 for description of abbreviated start and end positions.

Fig. 6. Size of painful area (mean and SD) for the different SLR positions. Numbers indicate the mean difference in painful area between the start and end position for each manoeuvre. &=No experimental pain; J=experimental pain (series 1); K=experimental pain (series 2). See Table 1 for description of abbreviated start and end positions.

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the injection site in the lower third of the medial calf (Fig. 4). Pain intensity reached a steady state approximately one and a half minutes after the injection (84.3726.8 s) and equalled a mean VAS score of 4.971.3 cm. The first series with experimental pain lasted approximately one and a half to 2 min (103.0719.0 s) with a mean VAS of 4.170.3 cm. The second series lasted for approximately one and a half minutes (92.7714.0 s) with a mean VAS of 2.670.3 cm. The pain intensity and size of pain for the different stages of the slump test in the three series are presented in Figs. 7 and 8. The ANOVA revealed significant differences for pain intensity and pain size for both series with experimentally induced pain (VAS: 10

Pain intensity (VAS)

7 6 5

–0.6 0.1

0.0

–0.6*

4 –0.2 –0.2

3

–0.1 –0.8*

2 1 0.0

0.0

0.0 0.0

0 Sitting

+ Knee extension

+ Trunk flexion

+ Neck flexion

Sitting

Fig. 7. Pain intensity (mean and SD) for the different stages of the slump test. Numbers indicate the mean difference in VAS between the progressive stages of the slump test. An asterisk indicates a significant difference between the pain intensity in sitting at the start and end of the series. &=No experimental pain; J=experimental pain (series 1); K=experimental pain (series 2).

10 7

Painful area (size)

6

–0.5

–0.2

+0.1

5

–0.7* –0.4

4

–0.2

0.0 –1.0*

3 2 1 0.0

0.0

0.0 0.0

0 Sitting

+ Knee extension

+ Trunk flexion

+ Neck flexion

Sitting

Fig. 8. Size of painful area (mean and SD) for the different stages of the slump test. Numbers indicate the mean difference in painful area between the progressive stages of the slump. An asterisk indicates a significant difference between the size of the painful area in sitting at the start and end of the series. &=No experimental pain; J=experimental pain (series 1); K=experimental pain (series 2).

F4,36X2.52; Pp0.04, size: F4,36X3.71; Pp0.01). The post-hoc analysis revealed no significant differences between two consecutive stages of the slump test, but did reveal a significant decrease for the pain measures for the neutral sitting position at the start and end of each series (VAS: Pp0.048; size: Pp0.002).

4. Discussion The first experiment demonstrated that the SLR did not increase the perception of experimentally induced muscle pain in tibialis anterior. Furthermore, sensitizing manoeuvres that have been demonstrated to further increase tension in the peripheral nervous system, such as medial hip rotation or hip adduction, did not increase the perception of pain. Results from the second experiment revealed similar findings. The addition of knee extension, thoracolumbar flexion, and cervical flexion to the sitting position did not increase the perception of experimental muscle pain in the soleus. These findings support the hypothesis that different stages of the slump test and the SLR have no impact on pain perception when the origin of the pain is not neural in origin and when the pain mechanism is predominantly related to a peripheral sensitization of muscle nociceptors. Although we anticipated no change in pain with the addition of sensitizing manoeuvres, the progressive stages of the slump test and the addition of sensitizing manoeuvres to the SLR showed a trend of decreasing pain perception. This occurred despite the accumulation of load, which the SLR and slump test have been reported to place on the neuromusculoskeletal structures. Several mechanisms may account for this unexpected trend. For instance, spinal and supraspinal analgesic effects have been reported from increased discharge of joint and ligament afferents (Wright, 1995). However, the most likely explanation for the decrease in pain is the dispersion of intramuscular saline over time. Three factors support this hypothesis. First, for the slump test, pain in the neutral sitting position at the end of the series was significantly lower than at the start. Second, pain scores at the intermediate stages of the slump test lay between the ratings at the start and end of the series. Third, the pilot study demonstrated that the rate of decrease of pain over time when the leg was not moved was similar to the reduction in the SLR experiment (Fig. 1). In these experiments, the SLR and the range of knee extension during the slump test were taken to a submaximal range, i.e., the maximal range without causing sensory responses. The rationale for doing so was that testing toward the maximal range elicits additional symptoms which would distract the subject from the experimental muscle pain. Although this

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reduced the ROM, it is likely that neuromusculoskeletal structures were still considerably challenged. For instance, the average range of SLR of 52.9711.41 equalled the ROM when symptoms were elicited in a group of patients reporting unilateral lumbar pain with or without ipsilateral leg symptoms (Boland and Adams, 2000). A knee extension position of 22.677.91 (01 corresponds with full knee extension) in a fully slumped position, including neck flexion, should also load the neuromusculoskeletal structures considerably in most subjects. Furthermore, the addition of medial hip rotation and adduction are regarded as a useful sensitizing manoeuvres when performed near the limit of pain free SLR (Breig and Troup, 1979). The present study was not designed to confirm that all symptoms elicited during neurodynamic testing are of neural origin. However, the concept of using sensitizing manoeuvres to identify neurogenic disorders would have been compromised if the perception of experimentally induced acute muscle pain would have been altered with the addition of sensitizing manoeuvres. From this perspective, the findings of this study contribute to the validity of neurodynamic tests, in particular, to the specificity of the SLR and slump test. Tests with a high specificity have few false positive results. When analysing the slump test in healthy subjects, Lew and Briggs (1997) demonstrated an increase in posterior thigh pain with cervical flexion and a decrease with cervical extension. As measurements of biceps tendon strain revealed no differences in tension, it was hypothesized that a structure with links to the cervical spine, most likely the nervous system, was responsible for the posterior thigh pain rather than changes in hamstring tension. However, more recently, Barker and Briggs (1999) provided an alternative explanation for positive findings during neurodynamic testing by demonstrating continuity of the thoracolumbar fascia with the rhomboids and with the tendons of splenius cervicis and capitis. In addition, although studies vary manifestly regarding the anatomic description of the inferior muscle attachments to the thoracolumbar fascia (Bogduk and Macintosh, 1984; Vleeming et al., 1995), if the deep lamina is continuous with the sacrotuberous ligament, and via it with biceps femoris (Vleeming et al., 1995), there is continuity of the fascial system from the cervical spine well into the lower limb. As these attachments are capable of transmitting tension (Vleeming et al., 1995; Barker and Briggs, 1999), continuity of the fascial system may provide an alternative explanation for changes in symptoms during neurodynamic testing. An increase in tension may result in increased pain perception when the tension is sufficient to stimulate the nociceptors of which the threshold has been reduced due to inflammation. Alternatively, tension may also stimulate the mechanoreceptors from myelinated fibres embedded in the musculoskeletal

59

structures which may result in inhibition of the small diameter nociceptive afferent input at the level of the dorsal horn which may reduce the perception of pain. Although this study demonstrated no increase in pain perception with the addition of sensitizing manoeuvres when pain is of non-neural origin, a change in symptoms with the addition of sensitizing manoeuvres should still be interpreted with care in clinical practice (Zusman, 1992, 1994). While sensitizing manoeuvres may be used to structurally differentiate neurogenic disorders when the processes involved relate predominantly to peripheral sensitization of nerves, the elicited symptoms do not necessarily originate from the peripheral nerve or root. When processes of central sensitization are dominant, the increased pain response following the addition of a sensitizing manoeuvre may be triggered by a barrage of normal input to an already sensitized central nervous system (Gifford and Butler, 1997; Butler, 2000; Coppieters and Butler, 2001). When pathological central mechanisms are involved, signals from receptor types which are normally not associated with pain now acquire the capacity to evoke pain (Raja et al., 1999). This condition arises through augmentation of responsiveness of central pain signalling neurons to input from low-threshold mechanoreceptors. Therefore, the clinician’s impression about the pathobiological pain processes in operation, based on the interview and physical examination, should always be taken into consideration when interpreting the results of neurodynamic tests and many other clinical tests.

5. Conclusion Increasing tension in the neuromusculoskeletal structures with the slump test and with the SLR, including the addition of sensitizing manoeuvres, does not increase the perception of experimentally induced muscle pain in the lower leg. Although care should be taken when interpreting changes in symptoms induced by changes in the loading of neuromeningeal structures, the findings of this study support the validity of the use of sensitizing manoeuvres during neurodynamic testing.

Acknowledgements The authors wish to thank David Butler and Lorimer Moseley for reviewing a previous version of this manuscript. References Barker PJ, Briggs CA. Attachments of the posterior layer of lumbar fascia. Spine 1999;24(17):1757–64.

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Bennell K, Hodges P, Mellor R, Bexander C, Souvlis T. The nature of anterior knee pain following injection of hypertonic saline into the infrapatellar fat pad. Journal of Orthopaedic Research 2004;22(1):116–21. Bogduk N, Macintosh JE. The applied anatomy of the thoracolumbar fascia. Spine 1984;9(2):164–70. Boland RA, Adams RD. Effects of ankle dorsiflexion on range and reliability of straight leg raising. Australian Journal of Physiotherapy 2000;46:191–200. Breig A, Troup JD. Biomechanical considerations in the straight-legraising test. Cadaveric and clinical studies of the effects of medial hip rotation. Spine 1979;4(3):242–50. Butler DS. Mobilisation of the nervous system. Melbourne: Churchill Livingstone; 1991. Butler DS. The sensitive nervous system. Unley, South Australia: Noigroup Publications; 2000. Coppieters MW, Butler DS. In defense of neural mobilization. Journal of Orthopaedic and Sports Physical Therapy 2001;31(9):226–35. Coppieters MW, Stappaerts KH, Wouters LL, Janssens K. Aberrant protective force generation during neural provocation testing and the effect of treatment in patients with neurogenic cervicobrachial pain. Journal of Manipulative and Physiological Therapeutics 2003a;26(2):99–106. Coppieters MW, Stappaerts KH, Wouters LL, Janssens K. The immediate effects of a cervical lateral glide treatment technique in patients with neurogenic cervicobrachial pain. Journal of Orthopaedic and Sports Physical Therapy 2003b;33(7): 369–78. Elvey RL. The investigation of arm pain: signs of adverse responses to the physical examination of the brachial plexus and related neural tissues. In: Boyling J, Palastagna N editors. Grieve’s modern manual therapy. Edinburgh: Churchill Livingstone; 1994. p. 577–85. Elvey RL. Physical evaluation of the peripheral nervous system in disorders of pain and dysfunction. Journal of Hand Therapy 1997;10(2):122–9. Fidel C, Martin E, Dankaerts W, Allison G, Hall T. Cervical spine sensitizing maneuvers during the slump test. Journal of Manual and Manipulative Therapy 1996;4(1):16–21. Gajdosik RL, LeVeau BF, Bohannon RW. Effects of ankle dorsiflexion on active and passive unilateral straight leg raising. Physical Therapy 1985;65(10):1478–82. Gerlach UJ, Lierse W. Functional construction of the superficial and deep fascia system of the lower limb in man. Acta Anatomica 1990;139(1):11–25. Gifford LS, Butler DS. The integration of pain sciences into clinical practice. Journal of Hand Therapy 1997;10(2):86–95. Gerritsen AA, De Krom MC, Struijs MA, Scholten RJ, De Vet HC, Bouter LM. Conservative treatment options for carpal tunnel syndrome: a systematic review of randomised controlled trials. Journal of Neurology 2002;249(3):272–80. Graven-Nielsen T, Mense S. The peripheral apparatus of muscle pain: evidence from animal and human studies. Clinical Journal of Pain 2001;17(1):2–10.

Hermens HJ, Freriks B, Merletti R, Hagg G, Stegeman D, et al. SENIAM 8: European recommendations for surface electromyography. Roessingh Research and Development, 1999. Johnson EK, Chiarello CM. The slump test: the effects of head and lower extremity position on knee extension. Journal of Orthopaedic and Sports Physical Therapy 1997;26(6):310–7. Jonsson B, Stromqvist B. The straight leg raising test and the severity of symptoms in lumbar disc herniation. A preoperative evaluation. Spine 1995;20(1):27–30. Katz J, Melzack R. Measurement of pain. Surgical Clinics of North America 1999;79(2):231–52. Lew PC, Briggs CA. Relationship between the cervical component of the slump test and change in hamstring muscle tension. Manual Therapy 1997;2(2):98–105. Maitland G. Negative disc exploration: positive canal signs. Australian Journal of Physiotherapy 1979;25(3):129–34. Maitland G. The slump test: examination and treatment. The Australian Journal of Physiotherapy 1985;31(6):215. Matre DA, Sinkjaer T, Knardahl S, Andersen JB, Arendt-Nielsen L. The influence of experimental muscle pain on the human soleus stretch reflex during sitting and walking. Clinical Neurophysiology 1999;110(12):2033–43. Meyer J, Kulig K, Landel R. Differential diagnosis and treatment of subcalcaneal heel pain: a case report. Journal of Orthopaedic and Sports Physical Therapy 2002;32(3):114–22. Raja SN, Meyer RA, Ringkamp M, Campbell JN. Peripheral neural mechanisms of nociception. In: Wall PD, Melzack R editors. Textbook of pain. Edinburgh: Churchill Livingstone; 1999. p. 11–57. Rebain R, Baxter GD, McDonough S. A systematic review of the passive straight leg raising test as a diagnostic aid for low back pain (1989 to 2000). Spine 2002;27(17):E388–95. Shacklock M. Neurodynamics. Physiotherapy 1995;81:9–16. Shacklock MO. Positive upper limb tension test in a case of surgically proven neuropathy: analysis and validity. Manual Therapy 1996;1:154–61. Thelander U, Fagerlund M, Friberg S, Larsson S. Straight leg raising test versus radiologic size, shape, and position of lumbar disc hernias. Spine 1992;17(4):395–9. Vleeming A, Pool-Goudzwaard AL, Hammudoghlu D, Stoeckart R, Snijders CJ, et al. The function of the long dorsal sacroiliac ligament: its implication for understanding low back pain. Spine 1996;21(5):556–62. Vleeming A, Pool-Goudzwaard AL, Stoeckart R, van Wingerden JP, Snijders CJ. The posterior layer of the thoracolumbar fascia. Its function in load transfer from spine to legs. Spine 1995;20(7):753–8. Wright A. Hypoalgesia post-manipulative therapy: a review of a potential neurophysiological mechanism. Manual Therapy 1995;1(1):11–6. Zusman M. Central nervous system contribution to mechanically produced motor and sensory responses. Australian Journal of Physiotherapy 1992;38(4):245–55. Zusman M. The meaning of mechanically produced responses. Australian Journal of Physiotherapy 1994;40(1):35–9.

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Manual Therapy 10 (2005) 61–67 www.elsevier.com/locate/math

Original article

A descriptive study of the usage of spinal manipulative therapy techniques within a randomized clinical trial in acute low back pain$ Deirdre A. Hurleya,, Suzanne M. McDonoughb, G. David Baxterb, Martin Dempsterc, Ann P. Moored a School of Physiotherapy, University College Dublin, Republic of Ireland Rehabilitation Sciences Research Group, University of Ulster, Northern Ireland c School of Psychology, Queen’s University, Northern Ireland d Clinical Research Unit for Healthcare Professions, University of Brighton, UK

b

Received 12 February 2004; received in revised form 27 June 2004; accepted 27 July 2004

Abstract The majority of randomized clinical trials (RCTs) of spinal manipulative therapy have not adequately defined the terms ‘mobilization’ and ‘manipulation’, nor distinguished between these terms in reporting the trial interventions. The purpose of this study was to describe the spinal manipulative therapy techniques utilized within a RCT of manipulative therapy (MT; n=80), interferential therapy (IFT; n=80), and a combination of both (CT; n=80) for people with acute low back pain (LBP). Spinal manipulative therapy was defined as any ‘mobilization’ (low velocity manual force without a thrust) or ‘manipulation’ (high velocity thrust) techniques of the spine described by Maitland and Cyriax. The 16 physiotherapists, all members of the Society of Orthopaedic Medicine, utilized three spinal manipulative therapy patterns in the RCT: Maitland Mobilization (40.4%, n=59), Maitland Mobilization/Cyriax Manipulation (40.4%, n=59) and Cyriax Manipulation (19.1%, n=28). There was a significant difference between the MT and CT groups in their usage of spinal manipulative therapy techniques (w2=9.178; df=2; P=0.01); subjects randomized to the CT group received three times more Cyriax Manipulation (29.2%, n=21/72) than those randomized to the MT group (9.5%, n=7/74; df=1; P=0.003). The use of mobilization techniques within the trial was comparable with their usage by the general population of physiotherapists in Britain and Ireland for LBP management. However, the usage of manipulation techniques was considerably higher than reported in physiotherapy surveys and may reflect the postgraduate training of trial therapists. r 2004 Elsevier Ltd. All rights reserved.

1. Introduction Spinal manipulative therapy is commonly used by physical therapists, chiropractors and osteopaths for the management of people with low back pain (LBP), and is advocated by the majority of national clinical guidelines (Koes et al., 2001). Manipulative therapy typically $ This study was presented at the International Forum VI for Primary Care Research on Low Back Pain, Linko¨ping, Sweden 22–24 May 2003. Corresponding author. Tel.: +353-18034310; fax: +353-18303550. E-mail address: [email protected] (D.A. Hurley).

1356-689X/$ - see front matter r 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2004.07.008

incorporates both mobilization (non-forceful, oscillatory techniques of high or low velocity) and manipulation (low amplitude range-expanding thrusts of high velocity) techniques that aim to reduce pain and increase joint range of movement (Kotoulas, 2002). While both forms of passive treatment fall within the remit of manipulative therapy, practitioners view them quite separately and this is reflected in their clinical practice. Large scale surveys have reported that mobilization is used by up to 59% of physiotherapists in the UK health service for the treatment of back pain, in contrast to a 9% uptake of manipulation techniques (Foster et al., 1999; Gracey et al., 2002).

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A recent review found that the majority (14/15) of randomized clinical trials (RCTs) of lumbar spine disorders failed to provide adequate definitions of the terms ‘mobilization’ and ‘manipulation’, and did not distinguish between these terms in reporting the trial interventions (Kotoulas, 2002). Many RCTs also permit therapists to utilize both mobilization and manipulation techniques within the manipulative therapy (MT) arm of a trial (Farrell and Twomey, 1982; Arkuszewski, 1986; Meade et al., 1990; Aure et al., 2003), thus mirroring clinical practice, but then fail to report separately on the usage of these techniques, details that are relevant to the clinician. Such limitations and lack of specificity in clearly defining manipulative therapy may result in misinterpretation of the literature by individuals, systematic reviewers and clinical guideline developers. Clinical trialists have therefore been urged to provide adequate definitions of the manipulative therapy techniques under investigation, as well as detailing the usage of these techniques (Kotoulas, 2002). The authors have completed a three-arm RCT that investigated the difference in effectiveness of manipulative therapy and interferential therapy for patients with acute LBP when used as sole treatments and in combination (Hurley et al., 2004). The trial concluded that for acute LBP there was no difference at discharge, 6 or 12 month follow-up between the effects of a combined manipulative therapy and interferential therapy package and either manipulative therapy or interferential therapy alone. As subjects in two arms of the RCT received manipulative therapy the current study aimed to describe the usage of these techniques within the context of the trial.

postgraduate membership examination (recognized by the Chartered Society of Physiotherapy and the International Federation of Orthopaedic Manipulative Therapists) as well as participating in a revision session lead by one of the senior SOM tutors. None of the participating therapists were members of the MACP. 2.2. Trial procedures Following completion of a range of valid and reliable outcome measure questionnaires consenting subjects received a copy of the evidence-based patient education booklet the Back Book (Anon, 1996), which was designed to complement and support the UK Clinical Guidelines for Acute LBP (Waddell et al., 1996), and were randomized to one of three groups, i.e. manipulative therapy (MT), interferential therapy (IFT), or combined therapy (CT). Subjects in the MT and CT groups received the spinal manipulative therapy protocol detailed below, and those in the CT group also received a standardized IFT treatment that has been previously described (Hurley et al., 2001). 2.3. Spinal manipulative therapy protocol Standardized operational definitions were used for the spinal manipulative therapy techniques within the trial, i.e. any ‘mobilization’ or ‘manipulation’ techniques for the lumbar spine described by Maitland (2000) or Cyriax (1984). The elements of the spinal manipulative therapy package were:



2. Methods 2.1. Spinal manipulative therapy education The UK clinical guidelines for acute back pain state that the risks of MT are low provided patients are selected and treated appropriately by trained therapists (Waddell et al., 1999). The two largest professional bodies involved in postgraduate education in manipulative therapy in the UK are the Manipulation Association of Chartered Physiotherapists (MACP) and the Society of Orthopaedic Medicine (SOM). The MACP traditionally based its curriculum on the techniques described by Mr. Geoffrey Maitland, an Australian physiotherapist, while the SOM approach originated from the work of Dr. James Cyriax, a British orthopaedic physician. In the RCT 240 patients with acute LBP (4–12 weeks duration) were treated by one of 16 therapists who had received training in the Maitland approach at undergraduate level, and had successfully completed the SOM







Maitland Mobilization o Grade I, II, III or IV postero-anterior central, anteroposterior central, postero-anterior unilateral and transverse vertebral pressure glide techniques of the lumbar spine. o Grade I, II, III or IV unilateral rotation, longitudinal, flexion, straight leg raise, slump or manual traction oscillatory movements of the lumbar spine. Maitland Manipulation o Grade V postero-anterior central, postero-anterior unilateral and transverse vertebral pressure glide techniques of the lumbar spine. o Grade V unilateral oscillatory rotation movements of the lumbar spine. Cyriax Mobilization (grade A or B) o Grade A or B distraction technique; short and long lever rotation techniques. o Grade A or B straight extension, unilateral extension and extension with leverage techniques. Cyriax Manipulation o Grade C distraction technique; short and long lever rotation techniques. o Grade C straight extension, unilateral extension, extension with leverage techniques.

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On the basis of the advanced clinical reasoning skills utilized during individual patient examination each physiotherapist determined the type(s) of mobilization and manipulation techniques to use and when, and the spinal levels to which they were applied at each intervention session. Therapists completed a proforma of the treatment provided after each session to verify adherence to the protocol; this included the spinal levels, manipulative therapy techniques and grades administered at each treatment session. Other than the designated protocol, therapists were not permitted to administer any other forms of spinal manipulative therapy, electrotherapy or other techniques (spinal traction, heel raises, corsets, acupuncture, injection therapy or taping) during the intervention period of the trial. 2.4. Data analysis All data were analysed using the Statistical Package for the Social Sciences (Windows 11.0) according to the ‘intention-to-treat’ principle. The type of spinal manipulative therapy treatment provided to patients in the MT and CT groups was categorized according to the type and grade of movement applied as follows: (i) ‘Maitland Mobilization’: Grades I to IV; (ii) ‘Maitland Manipulation’: Grade V; (iii) ‘Cyriax Mobilization’: Grade A and B; (iv) ‘Cyriax Manipulation’: Grade C and (v) all possible combinations of the above. Differences in patterns of usage of the spinal manipulative therapy techniques were determined using w2 analysis for categorical variables, and ANOVA for continuous variables.

3. Results 3.1. Physiotherapists profile The majority of therapists (81%; n=13/16) treated subjects in both the MT and CT trial groups. Almost all clinicians had a B.Sc. level undergraduate physiotherapy education, were at least 6 years post qualification and held a senior clinical grade of employment (Table 1). All had received undergraduate education in the Maitland approach to mobilization, but not manipulation techniques. At postgraduate level, in addition to 100% membership of the SOM, the vast majority had attended courses in the McKenzie Approach (94.8%, n=15/16), over half had attended Maitland short courses, and 25% mobilization with movement (MWMs) courses. 3.2. Patterns of usage of spinal manipulative therapy 3.2.1. Overview The majority of patients received mobilization, rather than manipulation techniques within the trial. Three

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Table 1 Summary of physiotherapists’ profile Valid percentage

Frequency

Years since qualification 0–2 years 3–5 years 6–10 years Above 10 years

00.0 18.8 50.0 31.3

0 3 8 5

Level of qualification Diploma B.Sc. Degree

6.3 93.8

1 15

Clinical grade Senior II Senior I Superintendent

50.0 43.8 6.3

8 7 1

100.00 6.3 56.3 94.8 25.0 18.8 6.3 6.3

16 1 9 15 4 3 1 1

Postgraduate courses SOM Membership Exam High velocity manipulation Maitland short courses McKenzie Mobilization with movement Acupuncture Muscular system Nervous system

distinct patterns of MT techniques were utilized by the therapists: i.e. (i) ‘Maitland Mobilization’ (40.4%, n=59), (ii) ‘Maitland Mobilization/Cyriax Manipulation’ (40.4%, n=59), and (iii) ‘Cyriax Manipulation’ (19.1%, n=28). There was no evidence of subjects being treated with ‘Cyriax Mobilization’ or ‘Maitland Manipulation’ techniques. 3.2.2. Individual therapists usage of spinal manipulative therapy The patterns of spinal manipulative therapy used by each therapist are detailed in Table 2 and showed no obvious trends. For example, two physiotherapists used the same MT pattern to treat all patients in the trial, nine used two patterns and five used three patterns. Of the 13 therapists who treated patients in both RCT groups, one used the same pattern of MT treatment, four used the same two patterns, and one used the same three patterns. The results of w2 analyses showed no significant difference between groups in the number of MT patterns used and either the clinical grade, number of years’ since qualification or level of postgraduate training of therapists (P40.05). 3.2.3. Comparison of randomized clinical trial groups There was a significant difference between the MT and CT groups in the overall use of spinal manipulative therapy techniques (w2=9.2; df=2; P=0.01). Subjects randomized to the CT group received a significantly higher number of ‘Cyriax Manipulation’ techniques

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Table 2 Patterns of spinal manipulative therapy techniques used in the randomized clinical trial Therapist

MT Group (n=74) MMob

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

CT Group (n=72) MMob/CManip

CManip

MMob

MMob/CManip

2 5 2 2 2 2 9 3 1 1 1 4 2

34

2 5 1

5 1 3 2 2 2

CManip

1 1 1

2 4 1

1 1 1

1 5 3 7

1 1

33

7

4

3 1 1 1

3 1 2

6 2 5

1 3 7 5

4 4 25

1 2 21

26

MT=Manipulative Therapy Group, CT=Combined Therapy Group. MMobs=Maitland Mobilization, CManip=Cyriax Manipulation. The numbers in each box represent the number of patients treated by each therapist with each spinal manipulative therapy technique.

3.3. Frequency of spinal manipulative therapy treatment In the RCT, subjects received an average of five physiotherapy treatments (7SD=2.5), over a period of five weeks (7SD=2.3), and there were no significant differences between intervention groups for the number of treatments (F=0.49; df=2; P=0.61) or the number of weeks of treatment (F=0.18; df=2; P=0.84) received. However, univariate ANOVA showed there was a significant difference in the number of treatments received by patients according to the type of manipulative therapy treatment provided (F=7.92; df=2; P=0.001; Table 3). Those treated with ‘Maitland Mobilization/Cyriax Manipulation’ received significantly more treatment sessions than those treated with ‘Maitland Mobilization’ (Po0.001; mean difference=1.61; 95% CI difference 2.63 to 0.59, Tukey test) or ‘Cyriax Manipulation’ (P=0.019; mean difference=1.47; 95% CI difference 2.74 to 0.20, Tukey test). Similarly, there was a significant difference in the

40 MMob CManip MMob/CManip

30 Number of Subjects

(29.2%, n=21/72) than those randomized to the MT group (9.5%, n=7/74; w2=8.7; df=1; P=0.003), as illustrated in Fig. 1. There was a similar rate of usage of ‘Maitland Mobilization’ (MT: 45.9%, n=34/74; CT: 34.7%, n=25/72; w2=2.0; df=1; P=0.15) and ‘Maitland Mobilization/Cyriax Manipulation’ techniques (MT: 44.6%, n=33/74; CT: 36.1%, n=26/72; w2=1.2; df=1; P=0.28).

20

10

0 MT Group

CT Group

Randomised Clinical Trial Group Fig. 1. Patterns of usage of spinal manipulative therapy.

number of weeks of treatment received by patients for each type of MT treatment (F=3.9; df=2; P=0.023; Table 3). Post hoc analysis showed patients treated with ‘Maitland Mobilization/Cyriax Manipulation’ had a significantly greater number of weeks of treatment than those receiving ‘Cyriax Manipulation’ (P=0.032; mean difference=1.47; 95% CI difference 2.85 to 0.09).

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3.4. Outcome of spinal manipulative therapy treatment Outcome was evaluated in terms of mean change in the primary outcome measure, the Roland Morris Disability Questionnaire (RMDQ). Regardless of the type of SMT treatment, subjects experienced a clinically significant improvement of at least four points on the RMDQ at discharge and 12 months (Stratford et al., 1998; Table 4), with no significant differences detected between SMT groups.

4. Discussion One of the most common barriers to the uptake of evidence is the lack of consistency between research protocols and clinical practice (Hurley, 2000). Exploration of the patterns of usage of spinal manipulative therapy within a RCT, as reported in this study, should allow manual therapists to determine how closely the trial design, practitioners and interventions mirror their practice setting. Consequently, clinicians can interpret and perhaps implement the evidence in a more meaningful way. Furthermore, systematic reviewers and clinical guideline developers are provided with details of the spinal manipulative therapy elements of the trial, which should contribute to the evidence base. The physiotherapists in the trial were an experienced group of clinicians comparable with the general population of physiotherapists treating patients with LBP in the publicly funded health services of Britain and

Table 3 Frequency of each spinal manipulative therapy treatment Type of SMT

N

Number of treatments (mean, SD)

Number of weeks (mean, SD)

MMob MMob/CManip CManip

59 59 28

4.5 (2.4) 6.2 (2.4) 4.7 (2.2)

4.7 (2.3) 5.6 (2.4) 4.1 (1.9)

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Ireland (Foster et al., 1999; Gracey et al., 2002). While the usage of spinal manipulative therapy was analysed within a RCT setting rather than routine clinical practice, this was a pragmatic trial and the treating physiotherapists were free to select any type of MT techniques described by Maitland and Cyriax. The high usage of Maitland Mobilization techniques within the trial was consistent with their previously reported popularity in the physiotherapeutic management of people with LBP in the British Isles generally (Foster et al., 1999; Gracey et al., 2002). In contrast, there was a markedly higher usage of manipulation techniques within this study than previously observed amongst Northern Ireland physiotherapists (Gracey et al., 2002). Furthermore, therapists exhibited a marked preference for Cyriax rather than Maitland Manipulation techniques; due to the study criteria all therapists were members of the SOM, which is higher than the general physiotherapy population of 23% (Foster et al., 1999). Members of the SOM have a reportedly higher usage and somewhat less conservative attitude to manipulation than members of the MACP (Adams and Sim, 1998), which may reflect the view of Cyriax (1984) that manipulation should be used on all patients presenting with recent LBP unless otherwise contraindicated. The higher usage of Cyriax Manipulation techniques in the CT group compared to the MT group was an interesting and unexpected finding. There is no previous evidence that usage of spinal manipulative therapy techniques is related to whether they are delivered as a sole treatment or in combination with other modalities, and thus possible explanations are purely speculative. Perhaps therapists were more likely to use manipulation in combination with IFT confident in the knowledge that they could apply the electrotherapy modality afterwards to minimize treatment soreness. In a preliminary study the therapists stated they would use IFT to ‘calm down inflammation’, ‘relieve treatment soreness’ and ‘reduce muscle spasm’ (Hurley, unpublished data). Additionally, the shorter time for delivery of a manipulation technique may have been preferable to that required for a series of mobilization techniques, in addition to interferential therapy in the CT arm of the trial.

Table 4 Outcome of each type of spinal manipulative therapy treatment Type of SMT

Roland Morris difference score at discharge (n=146) (mean, 95% CI)

Roland Morris difference score at 12 months (n=113) (mean, 95% CI)

MMob MMob/CManip CManip ANOVA results

5.1 (3.8–6.4) 4.4 (3.1–5.6) 5.8 (3.9–7.6) F=0.79; df=2; P=0.45

6.1 (4.5–7.7) 5.9 (4.3–7.5) 6.4 (4.1–8.6) F=0.05; df=2; P=0.95

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The findings also suggested that factors related to the patient rather than therapists’ clinical grade, level of experience and postgraduate training influenced the usage of SMT techniques. It has been previously shown that the selection of treatment techniques for patients with musculoskeletal disorders by expert clinicians is closely linked to specific hypotheses within the hypothetico-deductive clinical reasoning process related to individual patient presentation (Doody and McAteer, 2002). Patients who were treated with both mobilization and manipulation techniques received a higher number of treatments and weeks of treatment (at potentially higher cost) than those who were managed by manipulation or mobilization techniques alone. Perhaps patients in the former group failed to respond to a particular technique, which necessitated a change in SMT approach. Nonetheless, as no differences in the Roland Morris Disability Questionnaire change scores were detected at follow-up, the findings empower therapists to utilize their preferred spinal manipulative therapy approach (with or without interferential therapy) in the management of patients with acute LBP. Given the multitude of variables that could contribute to the selection of spinal manipulative therapy techniques, research should establish the relative effect of the therapist, patient, environment, evidence base, and clinical guidelines.

5. Conclusion A detailed description of the type of spinal manipulative therapy utilized within a RCT of manipulative therapy and interferential therapy for acute LBP has been provided. The findings showed that a group of experienced physiotherapists with postgraduate training in the SOM approach to manipulative therapy employed a range of mobilization techniques that were comparable with the general population of physiotherapists in Britain and Ireland. However, the usage of manipulation was considerably higher than reported in physiotherapy surveys and may reflect the postgraduate training of trial therapists.

Acknowledgements This work was developed from DA Hurley’s PhD work at the University of Ulster Rehabilitation Sciences Research Group. The authors gratefully acknowledge the physiotherapists in the United Hospitals Health and Social Services Trust who took part in this study: Yvonne Kirkpatrick, Maureen Campbell, Stephen Doherty, Joe Fegan, Dot Gaston, Nuala Grant, Mary

Halferty, Aine Hasson, Shona Magill, Florence Mawhinney, Elizabeth McGarry, Mark McGladdery, Sarah McKay, Sean Moran, Debbie Ross, Mary Scullion, Sandra Taggart and Margaret Walls and the general practitioners in the Northern Health and Social Services Board Northern Ireland who referred patients. The authors would also like to acknowledge the Society of Orthopaedic Medicine (UK and Republic of Ireland), and the Manipulation Association of Chartered Physiotherapists for financial assistance and Tenscare Ltd for loan of interferential therapy OmegaTM Inter 4150 portable units.

References Adams G, Sim J. A survey of UK manual therapists’ practice and attitudes towards manipulation and its complications. Physiotherapy Research International 1998;3: 206–27. Anon. The Back Book. London: The Stationery Office; 1996. Arkuszewski Z. The efficacy of manual treatment in low back pain: a clinical trial. Manual Medicine 1986;2:68–71. Aure OF, Nilsen JH, Vasseljen O. Manual therapy and exercise therapy in patients with chronic low back pain: a randomized controlled trial with 1-year follow-up. Spine 2003; 28(6):525–32. Cyriax J. Textbook of Orthopaedic Medicine, 11th ed. London: Balliere Tindall; 1984. Doody C, McAteer M. Clinical reasoning of expert and novice physiotherapists in an outpatient orthopaedic setting. Physiotherapy 2002;88(5):258–68. Farrell JP, Twomey LT. Acute low back pain: comparison of two conservative treatment approaches. Medical Journal of Australia 1982;1:160–4. Foster NE, Thompson KA, Baxter GD, Allen JM. Management of non-specific low back pain by physiotherapists in Britain and Ireland: a descriptive questionnaire of current clinical practice. Spine 1999;24(13):1332–42. Gracey JH, McDonough SM, Baxter GD. Physiotherapy management of low back pain: a survey of current practice in Northern Ireland. Spine 2002;27(4):406–11. Hurley DA, Minder PM, McDonough SM, Walsh DM, Moore AP, Baxter GD. Interferential therapy electrode placement technique in acute low back pain: a preliminary investigation. Archives of Physical Medicine and Rehabilitation 2001; 82:485–93. Hurley DA, McDonough SM, Dempster M, Moore AP, Baxter GD. A randomised clinical trial of manipulative therapy and interferential therapy for acute low back pain. Spine 2004;29(20), In press. Hurley M. Linking research with practice: The missing linkcollaboration. Physiotherapy 2000;86:339–41. Koes BW, vanTulder MW, Ostelo R, Burton AK, Waddell G. Clinical guidelines for the management of low back pain in primary care: an international comparison. Spine 2001;26(22): 2504–14. Kotoulas M. The use and misuse of the terms ‘‘manipulation’’ and ‘‘mobilization’’ in the literature establishing their efficacy in the treatment of lumbar spine disorders. Physiotherapy Canada 2002;4:53–61. Maitland GD. Vertebral manipulation, 6th ed. London: ButterworthHeinemann; 2000.

ARTICLE IN PRESS D.A. Hurley et al. / Manual Therapy 10 (2005) 61–67 Meade TW, Dyer S, Browne W, Townsend J, Frank AO. Low back pain of mechanical origin: randomised comparison of chiropractic and hospital outpatient treatment. British Medical Journal 1990;300:1431–7. Stratford PW, Binkley JM, Riddle DL, Guyatt GH. Sensitivity to change of the Roland-Morris Back Pain Questionnaire Part 1. Physical Therapy 1998;78:1186–96.

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Waddell G, Feder G, McIntosh A, Lewis M, Hutchinson A. Low Back Pain Evidence Review. London: Royal College of General Practitioners; 1996. Waddell G, McIntosh A, Hutchinson A, Feder G, Lewis M. Low Back Pain Evidence Review. Royal London: College of General Practitioners; 1999.

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Technical and measurement report

Measurement of cervical range of motion pattern during cyclic neck movement by an ultrasound-based motion system$ Shwu-Fen Wang, Chin-Chih Teng, Kwan-Hwa Lin Graduate Institute and School of Physical Therapy, College of Medicine, National Taiwan University, No. 1, Jen-Ai Rd, Section 1, Taipei, Taiwan, ROC Received 22 November 2003; received in revised form 27 July 2004; accepted 27 August 2004

Abstract Goniometers and radiographic imaging have been used to measure active or passive cervical range of motion (ROM) in asymptomatic adults. However, the ultrasound-based coordinate measuring system (CMS) can measure continuous neck motion in three dimensions. The aims of this investigation are to evaluate the reliability and validity of ultrasound-based CMS (Zebris, CMS 70P), and to compare the cervical ROM patterns of asymptomatic young and middle-aged adults during continuous neck motions in the three cardinal planes. The ROM reciprocal ratio was defined as the ratio of the ROM from neutral position in one direction versus that in the opposite direction at the same cardinal plane. This study demonstrated the high test–retest reliability and validity of CMS during cervical motion in Chinese participants. Middle-aged adults exhibit reduced ROM ratios in the sagittal and frontal planes. The advantages and limitations of the CMS measurement tool and the potential future applications are documented. The measurement of neck motion pattern by ultrasound-based CMS may provide information on the management of neck dysfunction during functional movements. r 2004 Elsevier Ltd. All rights reserved. Keywords: Cervical range of motion; Ultrasound-based coordinate measuring system; Degenerative joint disease; Aging

1. Introduction The prevalence of cervical pain among adults has progressively increased (Bovim et al., 1994; Giez et al., 2003). The early detection of an abnormal range of motion (ROM) or asymmetrical patterns is important for preventing and interventing in cervical dysfunction. However, the measurements made using various devices yield inconsistent results (Mannion et al., 2000). Plastic goniometers, inclinometers (i.e. gravity-based goniometry) and potentiometers (Youdas et al., 1992; Capuano-Pucci et al., 1991) are used extensively for clinical purposes, but these devices only measure the $ The Human Ethic Committee of College of Medicine, National Taiwan University has approved the protocol of the study. Corresponding author. Tel.: +886 2 23123456 ext 7558; fax: +886 2 23313598. E-mail address: [email protected] (K.-H. Lin).

1356-689X/$ - see front matter r 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2004.08.009

static ranges of joint motion in two dimensions. Although cinematography has been introduced to measure the dynamic ROM in the three cardinal planes since 1950 (Fielding, 1957), its application is limited to laboratory investigations due to its inconvenience and cost. Recently, an ultrasound-based coordinate measuring system (CMS) was developed in Germany for measuring motions of the spines in three dimensions (Castro et al., 2000; Dvir and Prushansky, 2000). CMS has been reported to exhibit good intra-rater and interrater test–retest reliabilities (Castro et al., 2000; Mannion et al., 2000). The ultrasound-based CMS also exhibits good validity while compared to the computerized potentiometer (CA6000 spine motion analyzer) (Mannion et al., 2000). However, these studies were performed in Western countries. The reliability and validity of this device in Asia has not yet been examined. Furthermore, measuring the reciprocal ROM ratio, which is defined as the ratio of ROM in one direction

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to that in the opposite direction (extension vs. flexion, right rotation vs. left rotation or right side-bending vs. left side-bending), might reduce the measurement errors of this device. Therefore, the aims of this report are to describe the reliability and validity of ultrasound-based CMS with Chinese participants, and to apply this CMS to compare the reciprocal ROM ratio in asymptomatic young and middle-aged adults.

2. Three-dimensional coordinate measuring system (CMS) The ultrasound-based three-dimensional system, CMS 70P (Zebris system, Medizintecknik GmbH, Tubingen Germany), is designed to measure the propagation time of the ultrasound pulse (Fig. 1). Two sets of ultrasound triple markers were arranged to detect cervical motion via three miniature ultrasound transmitters (U) with an

Fig. 1. Experimental set-up of the ultrasound-based CMS. The subjects sat on a chair with feet on the floor and the trunk fastened to the back of the chair. The subject wore the head attachment (H) and shoulder cap (S) on the right shoulder. The reference shoulder coordinate was generated from three miniature ultrasound transmitters (U), which were attached to the triple marker on the shoulder cap. Lateral to the right side of the subject was the transducer sensor stand (T) with three microphones of transducer sensor (M) to receive the ultrasound wave (H: head attachment with a triple marker; S: shoulder cap with a reference triple marker; U: miniature ultrasound transmitters; T: transducer sensor stand; M: microphones of the transducer sensor).

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output frequency of 35 kHz. The upper triple marker is on the head (H in Fig. 1), while the lower one is on the shoulder cap (S) and serves as the reference plane. The transducer on the transducer sensor stand (T) consists of three integrated microphones (M) that record the ultrasound waves and relay them to the computer. The sampling frequency of each sound wave during cervical motion is set at 25 Hz. The coordinate information recorded by the sensor is analysed by the Win-data 2.11 software, by applying the principle of coordinate transformation to calculate the desired angle between the local coordinate and reference plane, rather than the Euler angler or the projected angel (see Appendix A).

3. Reliability and validity of CMS Preliminary experiments were performed in our laboratory and some of the results were published (Wang et al., 2002, 2003). The cervical ranges of 20 Chinese adults (average age=39.9720.2 yr, 10 females, 10 males) were measured twice by the same rater in the same day at 10 min intervals, to test the intra-session test–retest reliability in the six directions of the three cardinal planes. The ICC values of the intra-session test–retest reliability of the six principal cervical motions ranged between 0.85 and 0.95. The cervical ROM of another group of 28 healthy adults (average age=21.773.8 yrs, 15 females and 13 males) were repeatedly measured by the same rater within a 2-week interval to determine inter-session reliability. The intersession reliability ranged from 0.58 to 0.88. This result corresponded to the results in the in Western and Middle-Eastern literature (Castro, et al., 2000; Dvir and Prushansky, 2000). Castro et al. (2000) showed that the variation coefficient (standard deviation/mean) for intra-observer retest on three different days was from 3.75 to 6.33, and that the test–retest values did not differ significantly. Moreover, Dvir and Prushansky (2000) reported that the correlation coefficients (g) for test–retest separated by a 1–16 week intervals (mean 3.3 wk) were 0.52–0.82 (Dvir and Prushansky, 2000). The validity of this Zebris device used in the pilot study was obtained by comparing the ROM data with those measured by gravity-based goniometers (cervical ROM device; CROM; Performance Attainment Associates, 958 Lydia Drive, Roseville, MN 55113, USA). The gravity-based goniometers are characterized by two goniometers attached to a head set to measure separately the cervical motion in the sagittal and frontal panes. The validity of these gravity-based goniometers was demonstrated by the high correlation (r=0.97–0.98 for the sagittal plane) of cervical motions with those by the radiographic method, which is considered to be a golden standard in measuring of cervical ROM (Tousignant et al., 2000). The pilot study revealed a

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Table 1 Regression model of cervical range of motion between gravity-based goniometer and ultrasound-based coordinate measuring system (CMS) Motion (deg)

Goniometer mean (SD)

CMS mean (SD)

B

Adjusted R2

Flexion Extension Left side-bending Right side-bending

52.9 (8.1) 79.1(17.0)* 39.4 (7.3) 40.8 (7.6)

52.2 (8.9) 76.5(16.6)* 39.2 (6.7) 40.1(7.1)

0.89 0.92 0.93 0.86

0.66 0.88 0.87 0.86

Significant difference between measured values.

significant difference between the extension angles measured by two devices (Table 1). However, the R2 values of the regression model indicated that the ranges measured by the ultrasound-based coordinate system (ranging from 0.66 to 0.88) and the gravity-based goniometer in 40 healthy adults (range 19–45 years old) were highly correlated (Po0:001; Table 1).

4. Measurement of cervical reciprocal ROM ratio pattern Each subject sat upright on a chair, sitting and looking straight ahead, with feet on the floor and trunk against to the back of the chair at chest level. The subjects wore a head attachment and a shoulder cap, which was placed on the right shoulder (Fig. 1). The transducer sensor stand was placed 0.7–1 m laterally away from the right side of the subject. Demonstration and practice trials were conducted for each direction of neck movement before data were collected. The subjects moved their necks actively from the neutral position to the maximal range, and vice versa, in a series cycle in the three cardinal planes. Each subject moved the neck (flexion and extension, side-bending and rotation) at a self-determined comfortable speed for five repetitions, taking approximately 15 min per session. The angles of primary movement in the three cardinal planes (sagittal, frontal and horizontal planes) were measured during the continuously cyclic movements. The cervical ROM of 40 asymptomatic young adults, ranging from 20 to 30 years old (mean=21.970.6), and 40 asymptomatic middle-aged adults, ranging from 40 to 65 years old (mean=55.871.3) was measured. The young subjects were recruited among medical and law school students, and the middle-aged subjects were recruited via posters that asked for volunteers from the local community. The recruited participants were all right-handed. The Human Ethics Committee at the university approved the recruitment procedure and the protocol for cervical measurement. To eliminate the possibility that less effort was made during the 1st and 5th repetitions than the middle three repetitions, only the middle three repetitions in each direction were analysed and averaged. The ROM reciprocal ratio was defined as the ratio of the ROM

ROM ratio

*

1.8 1.6 1.4 1.2 1.0 0.8 0.6 0.4 0.2 0

young

* *

sagittal

frontal

middle-aged

transverse

Fig. 2. The ROM reciprocal ratios of maximal cervical ROM in sagittal, frontal and transverse planes in asymptomatic young and asymptomatic middle-aged adults.

from the neutral position in one direction versus that in the opposite direction in the same cardinal plane. Therefore, the reciprocal ratio was the ratio of the ROM of the right (R) side-bending to that of the left (L) side-bending (R/L SB) in the frontal plane, or rotation (R/L ROT) in the transverse plane, or of extension (Ext) and flexion (Flex) in the sagittal plane (Ext/Flex). The data were compared using multivariate analysis of variance (MANOVA). The significance level was set at a=0.05. Fig. 2 plots the ROM reciprocal ratios in the three cardinal planes (sagittal, frontal and transverse planes). The ROM data were expressed as mean7standard error. The ROM ratios of Ext/Flex (75.472.61 vs. 53.071.81), R/L SB (39.570.91 vs. 38.470.91) and R/L ROT (63.471.31 vs. 65.171.31) in the young adult group were 1.4770.07, 1.0470.03, and 0.9870.02, respectively. The ROM ratios of Ext/Flex (65.472.11 vs. 53.771.41), R/L SB (34.971.31 vs. 37.471.11), and R/L ROT (64.571.51 vs. 69.071.51) in the middle-aged group were 1.2570.06, 0.9370.02, and 0.9470.02, respectively. Significant differences between the young and middle-aged groups were found in the sagittal (Ext/Flex) and frontal (R/L SB) planes (F(1. 78)=6.16, P ¼ 0:015; and F(1, 78)=9.58, P ¼ 0:003; respectively). The cervical ROM in extension and right side-bending of middle-aged adults were lower than those in the young adult group.

5. Discussion The advantages of using an ultrasound based motion system to record the motion are as follows. (1) The CMS

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system employs built-in markers on the shoulder or head attachment instead of using individual reflective markers, and no individual bony landmarks have to be identified, reducing the preparation time. (2) The system is reliable and valid, as verified by this work as well as in other laboratories (Castro et al., 2000; Dvir and Prushansky, 2000). (3). The CMS equipment used in a clinical setting is more cost-effective than other sophisticated motion analysis systems such as the Vicon system. However, the limitations of the CMS include the following. First, CMS is not able to measure segmental cervical motion. Second, the CMS only measures the motions confined to a relatively small space (within 3 m  3 m  3 m). The ultrasound can record spinal and upper extremity motions, which are confined to a small space. Motion that requires a large space, such as gait analysis, may be difficult to record when the ultrasound transmitter on the limb is out of the recording space. The source of error in the present set-up is the malalignment of shoulder reference and the head position. The shoulder reference used in the present method is more convenient to wear than a sternal reference, and the participants felt more comfortable during testing. However, shoulder and scapular motion during the neck motion had to be eliminated to reduce the measurement error. Furthermore, wearing the head attachment in a consistent manner during test and retest by aligning the horizontal frame of the head attachment to the anatomical landmark of the head (such as: the horizontal plane of the eyes) eliminates the measurement errors during the placement of the markers. This present study revealed that the ROM reciprocal ratios in the sagittal and frontal planes were reduced due to the reduction of ranges of extension and right sidebending in the asymptomatic middle-aged participants. Hagen et al. (1997) mentioned that patients with neck pain exhibited asymmetrical change of cervical ROM. Accordingly, the measurement of the cervical reciprocal ratios in asymptomatic adults may facilitate the early detection of the cervical dysfunction. Furthermore, the measurement of the ROM pattern by ultrasound-based CMS in patients with chronic neck pain may yield valuable information regarding the effective management of cervical dysfunction. The results of the present study demonstrate similar ranges of cervical motion as found in an investigation that used the same instruments to take measurements of a Middle-Eastern population (Dvir and Prushansky, 2000). Dvir and Prushansky (2000) reported that 25 subjects of age 26–48 years old had cervical ranges (mean7standard deviation) of extension, flexion, right side-bending, left side-bending, right rotation and left rotation of 62.4718.8, 59.9713.0, 42.477.9, 41.077.7, 68.3711.3 and 75.079.5, respectively. Hence, the averaged ROM ratios in the study of Dvir and Prushansky (2000) are

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1.04, 1.03 and 0.91 in the sagittal, frontal, and transverse planes, respectively. The ROM ratios were almost identical in the frontal and transverse planes to the ROM ratios in the young adults in the present study, although a greater discrepancy was observed in the sagittal plane. The factors that contributed to the greater reduction of cervical extension range require further investigation to determine whether this difference is related to the age, anatomical structure, or the daily activity of neck motion among other factors. Previous studies have documented several agedrelated changes of cervical spines in asymptomatic adults. For instance, Castro et al. reported that decline in active cervical ROM was greatest at advanced age (over 70 years). However, Dvorak et al. (1992) reported greater decreases of passive motions between the decades of 30–39 and 40–49. The present study revealed that asymptomatic middle-aged adults (40–65 years) exhibited a reduction in the active cervical ROM and reciprocal ratio in the sagittal and frontal planes, but not in the transverse plane. The changes of active cervical ROM patterns with the head moving against the gravitational force might shed light on the mechanism of age-related change of cervical motions.

6. Conclusion This present study established the high test–retest reliability and validity of CMS during cervical motion in Chinese participants. The effect of age on cervical active ROM was identified, because both the ROM angle and the ROM reciprocal ratio in the sagittal and frontal planes were less in the middle-aged adults than that in the young group. The ROM reciprocal ratio was proposed to normalize the data to enable comparison of results obtained using various instruments or in various laboratories. Furthermore, the measurement of neck motion pattern by ultrasound-based CMS may yield information on the management of neck dysfunction during functional motions.

Acknowledgments The authors would like to thank the Department of Health (Contract No. DOH88-HR-823), and the National Health Research Institute (NHRI-GTEX89E823C) of the Republic of China, Taiwan for financially supporting this research.

Appendix A Demonstration of the calculation of triplet angles in Zebris system by Windata First, the rotation angle was

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measured in relation to the movement of the triplet. One of the axes of the triplet was selected as axis of rotation. Do calibration before beginning the measurement. Movements around the axis of the selected triplet’s then were used to calculate the a angle. The procedure is described in detail below and illustrated by the accompanying figures. Assumption: (A0; B0; C0) (A; B; C) r0; r z0; z

calibrated original position of a triplet. current position of a triplet. axis of the rotation selected. any axis perpendicular to r0, r.

Procedure: 1. The origin of (A; B; C) is brought to the origin (A0; B0; C0) mathematically to eliminate the unwanted shift. The resulting triplet is represented as (A0 ; B0 ; C 0 ). 2. (A0 ; B0 ; C 0 ) is rotated mathematically to remove the unwanted rotation, so that r0 goes to r0. The resulting triplet is represented as (A00 ; B00 ; C 00 ). 3. The desired angel (a) in the plane perpendicular to the selected axis is the angle between z0 and z00 .

References Bovim G, Schrader H, Sand T. Neck pain in the general population. Spine 1994;19:1307–9. Capuano-Pucci D, Rheault W, Aukai J, Bracke M, Day R, Pastric M. Intratester and intertest reliability of the cervical range of motion device. Archive Physical Medicine and Rehabilitation 1991;72:338–40. Castro WH, Sautmann A, Schilgen M, Sautmann M. Noninvasive three-dimensional analysis of cervical spine motion in normal subjects in relation to age and sex. An experimental examination. Spine 2000;25:443–9. Dvir Z, Prushansky T. Reproducibility and instrument validity of a new ultrasonography-based system for measuring cervical spine kinematics. Clinical Biomechanics 2000;15:658–64. Dvorak J, Antinnes JA, Panjabi M, Loustalot D, Bonomo M. Age and gender related normal motion of the cervical spine. Spine 1992;17: S393–8. Fielding JW. Cineroeentgenography of the normal cervical spine. Journal of Bone Joint Surgery (Am) 1957;39:1280–8. Giez M, Hildingsson C, Stegmayr B, Toolanen G. Chronic neck pain of traumatic and non-traumatic origin: a population-based study. Acta Orthopaedica Scandinavica 2003;74:576–9. Hagen KB, Harms-Ringdahl K, Enger NO, Hedenstad R, Morten H. Relationship between subjective neck disorders and cervical spine mobility and motion-related pain in male machine operators. Spine 1997;22:1501–7. Mannion AF, Klein GN, Dvorak J, Lanz C. Range of global motion of the cervical spine: intraindividual reliability and the influence of measurement device. European Spine Journal 2000;9:379–85. Tousignant M, de Bellefeuille L, O’Donoughue Grahovac S. Criterion validity of cervical range of motion (CROM) goniometter for cervical flexion and extension. Spine 2000;25:324–30. Wang S-F, Chai H-M, Lu T-W. Comparison of ranges of cervical motion measured by gravity-based goniometry and ultrasoundbased motion analysis system. Formosan Journal of Physical Therapy 2002;27:124–30. Wang S-F, Teng C-C, Chai H-M. Intra-rater reliability of measurement of cervical range of motion using an ultrasound-based motion analysis system. Formosan Journal of Physical Therapy 2003;28:181–8. Youdas JW, Garrett TR, Suman VJ, Bogard CL, Hallman HO, Carey JR. Normal range of motion of the cervical spine: an initial goniometric study. Physical Therapy 1992;72:770–80.

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Case Report

Neck pain and headache as a result of internal carotid artery dissection: implications for manual therapists Alan J. Taylora,, Roger Kerryb a

Nottingham Nuffield Hospital, 748 Mansfield Road, Woodthorpe, Nottingham NG5 3FZ, UK b University of Nottingham, Nottingham, UK Received 4 December 2003; received in revised form 20 May 2004; accepted 11 June 2004

1. Introduction Physical therapy (PT) knowledge and literature relating to vascular issues in the cervical spine has traditionally paid particular attention to vertebrobasilar insufficiency (VBI) related to manipulation. Although internal carotid artery dissection (ICAD) and its sequelae are well reported in medical and chiropractic literature, only a few reports appear in PT texts. Internal carotid artery pathology has been documented as presenting with acute onset headache, facial and neck pain (Sturzenegger, 1995). Indeed, Smith et al. (2003) have suggested quite logically, that patients may seek spinal manipulative therapy (SMT) in the presence of a pre-existing cervical artery dissection which presents as neck and/or head pain. We report a case of ICAD in a 51-year-old male Physiotherapist. The ICAD appears to be the result of sneezing whilst in full cervical rotation, which to the authors’ knowledge has not been previously documented. The case study lends weight to the contention that arterial injury can present as mechanical onset neuromusculoskeletal (NMS) pain. The authors contend that subtle clues obtained during the subjective history taking and clinical reasoning process may alert the aware clinician of a potential vascular hypothesis, thus informing the decision with regard to management and potential SMT. Such case studies illustrate that a knowledge of haemodynamic issues relating to the cervical arteries Corresponding author. Tel.: +44-115-920-9209; fax: +44-115-9673005.

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are an essential prerequisite for all manual therapists using movement techniques including exercise and mobilisation. This case illustrates that certain individuals with no apparent risk factors may be prone to arterial injury as a result of cervical movement and trauma.

2. Case report This case report is compiled with consent from the account and records of the patient. A 51-year-old Chartered Physiotherapist and Manual Therapy tutor attended a pre-Christmas dinner party. Whilst sitting at the table he felt a sudden urge to sneeze. Conscious of the need not to spread his germs over the food, he turned his head fully to the left and sneezed several times. He jarred his neck at the time and gradually became aware of left sided mid-upper cervical pain and ‘‘aching’’ in the region of the left temporomandibular joint and mandible (see Fig. 1). He was able to complete his meal in some discomfort and felt that he had ‘‘strained his neck’’. On waking the next day he was aware of ongoing symptoms, presenting as pain in the left sub-occipital region and he had difficulty turning his head to the left. He was also aware of a general left sided headache affecting the left frontal region and eye. These symptoms remained constant at a pain level estimated at 6/10 and continued throughout the day requiring the use of analgesia/NSAIDS. Unable to contact a Physiotherapist for treatment over the Christmas holiday period, he

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carotid artery based on the clinical picture. He was advised to monitor his symptoms and call back urgently if there was any alteration particularly with regard to any signs of transient ischaemic attack (TIA). Increasingly concerned he presented to the local accident and emergency department. An ultrasound scan and a subsequent CT scan at this stage failed to confirm the clinical diagnosis. However, he was admitted for one night and prescribed Warfarin and Clexane. A diagnosis of ICAD was eventually confirmed by magnetic resonance arteriography (MRA) 2 weeks postinjury (Fig. 2) and a management plan of further anticoagulation (Warfarin combined with Aspirin 300 mg) implemented. He was advised to rest from work (6 weeks) and particularly exertion because of the potential danger of embolisation. One month after the onset of the symptoms the patient was still in considerable discomfort and had developed paraesthesia in the occipital region and a sensation of a ‘‘brittle feeling’’ as if ‘‘something was about to break’’. He still required NSAIDS to manage the symptoms. In addition he had become aware of pulsatile tinnitus, which was ascribed, by the vascular specialist, to the formation of collateral circulation in the external carotid. The patient was monitored with Duplex ultrasound and regular blood tests over a 12-month period. He returned to work 6 weeks after the onset of his symptoms. The pain and Horner’s’ syndrome partially resolved over the next 12 months though the patient still reports mild ptosis and intermittent transient pain in the cervical/carotid and frontal region. The pain appears related to pressure on the supraclavicular region or effort of the upper limb and shoulder girdle (i.e. during his work as a Physiotherapist).

Fig. 1. Pain charts showing symptom distribution immediately after onset.

self-managed his condition with continued analgesia. There was no change in his condition over a 48-h period with the distribution and level of pain remaining constant. Whilst driving to work 48 h later he became aware of ptosis (drooping) of the left eyelid and constriction of the pupil on the left. He realised that he had developed Horner’s Syndrome—defined as injury or interruption to the sympathetic nerves of the face (Thomas and Venes, 1999). The patient consulted his GP, who discussed the case with a Professor of Neurology. It was suggested by the latter that there might be a possible dissection of the

Fig. 2. Magnetic Resonance Arteriogram (MRA) demonstrating the left internal carotid artery (ICA) tapering to an occlusion (arrow A). This classic ‘rat tail’ sign is consistent with the diagnosis of ICAD. The blood flow within this vessel should normally be comparable with the opposite sided ICA (arrow B).

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Fig. 3. Pain chart showing right arm symptoms which existed for some time before the cervical trauma. On examination these symptoms were found to have been of a vascular (arterial) origin.

The patient reported no underlying risk factors for vascular disease. There was no family history of vascular disease and the patient was not taking any medication. The patient could not relate to any past medical history of a single traumatic event. However, he did make the observation that as a postgraduate physiotherapy tutor he had spent a number of years involved in teaching practical cervical treatment techniques involving varying degrees of cervical range of motion to end range. Furthermore, he had for a number of years suffered an undiagnosed problem of right-sided upper limb and hand fatigue and discomfort (Fig. 3) associated with playing a percussion instrument. Later examination of the right side revealed blanching of the hand associated with prolonged effort whilst playing the spoons. A further interesting feature of the case was the development (‘‘some weeks’’ after the initial injury) of symptoms of paraesthesia and discomfort on the right side of the head. These symptoms were investigated and though unexplained by the vascular consultant were thought not to be related to the arterial dissection. They have since been treated successfully with manual therapy and have resolved.

3. Discussion The carotid artery despite its common link to stroke and TIA is seldom considered in PT education as a

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potential source of symptoms related to cervical and head pain syndromes. It has however, been implicated directly in case studies leading to fatal dissection following manipulation (Peters et al., 1995). Its significance in relation to differential diagnosis and treatment is not commonly considered in PT undergraduate or postgraduate training. Whilst it is outside the scope of this paper to detail the precise haemodynamic factors involved, it is well documented that the carotid artery is subject to external and internal stresses linked to compression, kinking and looping (Grego et al., 2003). Rivett (1997) has already detailed a theoretical basis for intimal trauma to the carotid artery due to compressive factors in the upper cervical region. Duplex flow ultrasonography has demonstrated reduced flow in the contralateral internal carotid artery during end range cervical rotation (Refshauge, 1994). The hypothesised mechanism was compression or constriction of the artery between the layers of muscular tissue, which are stretched on full end range rotation. Although the precise pathological mechanism is unknown this case study is important because it provides a salient example of how an arterial lesion can present as a typical musculoskeletal presentation—mechanical onset of neck pain, headache and restriction of range of motion. This patient, a physiotherapist himself, would by his own admission have sought treatment during the first 48 h (i.e. before the onset of neurological symptoms) had it not been for the holiday period. It is not outside the realms off possibility for a patient presenting with those initial symptoms to be treated with postural advice, exercise, spinal mobilisation techniques and/or manipulation. Indeed it is a commonly held view backed up by current research that acute onset ‘‘mechanical’’ pain responds well to early manipulation (Cassidy et al., 1992; Baltaci et al., 2001). Unfortunately clinicians do not have the equivalent of a dermatomal or myotomal map for arteries. However, it is known that arterial pathology can mediate pain at various anatomical sites such as the aorta for the lumbar spine (Yabuki et al., 1999), the external iliac artery for the lower limb (Schep et al., 2002) and the subclavian artery for the shoulder and arm (Yao, 1998). Nicholls et al. (1993) were able to conclusively demonstrate the ability of arteries to produce neck, head and even trapezious pain via the inflation of a angioplasty balloon inside the vertebral and basilar arteries in healthy subjects. Similarly Munari et al. (1994), demonstrated cervical, facial and headache in patients undergoing percutaneous angioplasty of the carotid artery. In this case the patient described unilateral neck/ facial pain and severe headache with a mechanical onset. Sturzenegger (1994) detailed acute onset of neck pain and headache in a series of 14 patients with both vertebral and carotid artery dissection. The paper described headaches ‘‘unlike any other’’ with a

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delay before the onset of obvious frank neurological symptoms. The confounding factor for the therapist is often the co-existence of neck pain and a ‘‘mechanical’’ history, which fits with a conventional NMS pain pattern. Whilst arteries are known to be very tough or resilient on their outer (tunica adventitia) layer; repeated stress to the inner layer (endothelium) has been shown to lead to pathological changes in the arterial wall at various anatomical sites (Ross, 1993; Schep et al., 2002). The patient in this case described one potential source of arterial trauma—his repeated practical teaching sessions involving various cervical manoeuvres and sustained end range positions. The link is purely hypothetical but is worthy of consideration when arterial pathobiomechanics are considered. One further significant finding in the history of this case was the co-existence of another pain/fatigue syndrome affecting the upper limb. This undiagnosed problem had been long standing and preexisted the arterial dissection by ‘‘some years’’. However, the nature of the symptoms purely from the history (exercise/activity induced fatigue/discomfort) was strongly suggestive of a vascular hypothesis. As vascular pathology (atherosclerosis for example) is known to coexist at different, and specific, anatomical sites then this factor adds information to the clinical picture and may inform decision-making. Of particular interest is the fact that contralateral symptoms (thought to be joint related and not of vascular origin) were successfully treated using upper cervical manual therapy techniques. This perhaps adds some credence to the concept that careful and reasoned manual therapy is not totally contraindicated in cases of resolving arterial dissection—a theory put forward by a number of chiropractic texts (e.g. Michaud, 2002). It is important that Manual Therapists incorporate knowledge of haemodynamic principles related to movement and range using the best of the available scientific evidence into their clinical reasoning and decisionmaking matrix. However, the authors’ would like to draw the reader’s attention to the fact that this is a special case of a Manual Therapist treating a colleague. As such both the care provider and more importantly the recipient were both acutely aware of the potential risks and benefits of the treatment techniques. Furthermore treatment was provided with fully informed consent. The fact remains however, that the risk of TIA, stroke or death during or following treatment was, whilst unquantifiable, very real. In the case of the more common therapist to patient relationship, the clinical decision-making process and risk–benefit matrix may well have led to a different outcome. The factual information related to the use of manual therapy following this particular case of ICAD is purely that, and is included for interest and discussion. However, it should not be misconstrued as a green light

for manual therapy in such cases. The fact that a catastrophic event did not occur in this case is of course no guarantee that it may not occur in the future. It is entirely feasible that patients with an acute arterial injury may present themselves for treatment for a perceived ‘‘neck sprain’’ which may or may not actually co-exist. There are two specific considerations for any therapist confronted with that situation: 1. Is the pain mediated from a vascular injury (with or without concomitant NMS injury) such as a dissection or aneurysm? 2. Could treatment techniques in the presence of a NMS lesion alter local haemodynamics and lead to vascular injury? The conundrum then is to establish quickly via sound history taking, clinical reasoning and risk benefit analysis whether and indeed what type of management is appropriate. This of course requires a basic knowledge of haemodynamic principles and mechanisms of injury or compromise of the arterio-venous system. Interestingly Chiropractic and Osteopathic literature is often a revealing source of educational material and knowledge of the vascular system. Chiropractors have been compelled to improve their knowledge in order to provide a creditable defence against detractors of their profession and manipulative techniques in particular. Physical Therapists, who tend to manipulate less commonly but, who frequently use through and end range mobilisation techniques, may have been lulled into a false sense of security by literature, which suggests that non-manipulative techniques are less likely to produce cervical spine injury including arterial dissection (Di Fabio, 1999). This assertion is challenged directly by a number of authors (Terrett, 2000; Michaeli, 1993) who contend that it is not the ‘‘thrust’’ that is dangerous but rather the extremes of movement. This theory is backed up to some extent by the numerous case reports of arterial dissection following visits to the hairdresser, yoga, ceiling painting, stargazing and archery (Zetterling et al., 2000). Interestingly as part of their defence of their own techniques some chiropractic texts directly implicate McKenzie cervical end range techniques as being extremely stressful on the vertebral artery (Michaud, 2002). These debates should be seen as healthy rather than destructive and should encourage further research to establish the real effects of movement and treatment techniques in this most vital of areas.

4. Conclusion It is the authors’ belief that all practitioners who assess and treat the cervical spine with any form of movement technique whether manipulative or not,

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require a robust knowledge of the haemodynamic principles affecting that area. This case is an illustration that cervical rotation combined with the ‘‘trauma’’ of sneezing can result in arterial injury which for 48 h at least, presented as a typical mechanical onset of pain and for which there were no obvious contra indications for SMT. What is clear is that cases like this will present to Manual Therapists and seek treatment. The job of the clinician is then to assess whether the clinical picture fits and then, based on a risk benefit analysis and sound clinical reasoning, decide whether treatment should commence and what format that treatment should take. Acute onset of headache, described as ‘‘unlike any other’’ with or without apparent trauma and unresponsive to manual therapy may be a warning sign of underlying arterial injury. References Baltaci G, Ergun N, Bayrakci V. The short-term effect of manipulation and mobilization on pain and range of motion in patients with mechanical neck pain. The Journal of Orthopaedic Medicine 2001;23(3):93–6. Cassidy JD, Lopes AA, Yong-Hing MB. The immediate effect of manipulation versus mobilisation on pain and range of motion in the cervical spine: a randomised controlled trial. Journal of Manipulative and Physiological Therapeutics 1992;15(9):570–5. Di Fabio RP. Manipulation of the cervical spine: risks and benefits. Physical Therapy 1999;79(1):50–65. Grego F, Lepidi S, Cognolato D, Frigatti P, Morelli I, Deriu GP. Rationale of the surgical treatment of carotid kinking. Journal of Cardiovascular Surgery 2003;44(1):79–85. Michaeli A. Reported occurrence and nature of complications following manipulative physiotherapy in South Africa. Australian Journal of Physiology 1993;39:309–15. Michaud TC. Uneventful upper cervical manipulation in the presence of a damaged vertebral artery. Journal of Manipulative and Physiological Therapeutics Sep 2002;25(7):472–83.

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Munari LM, Belloni G, Moschini L, Mauro A, Pezzuoli G, Porta M. Carotid pain during percutaneous angioplasty (PTA). Pathophysiology and clinical features. Cephalalgia 1994;14(2):127–31. Nicholls FT, Mawad M, Mohr JP, et al. Focal headache during balloon inflation in the vertebral and carotid arteries. Headache 1993;33:87–9. Peters M, Bohl J, Thomke F, Kallen KJ, Mahlzahn K, Wandel E, Meyer zum Buschenfelde KH. Dissection of the internal carotid artery after chiropractic manipulation of the neck. Neurology 1995;45(12):2284–6. Refshauge KM. Rotation: a valid pre manipulative dizziness test? Does it predict safe manipulation?. Journal of Manipulative and Physiological Therapeutics 1994;17:15–9. Rivett DA. Preventing neurovascular complications of cervical spine manipulation. Physical Therapy Reviews 1997;2:29–37. Ross R. Atherosclerosis: current understanding of mechanisms and future strategies in therapy. Transplantation Proceedings 1993; 25(2):2041–3. Schep G, Bender MH, van de Tempel G, Wijn PF, de Vries WR, Eikbloom BC. Detection and treatment of claudication due to functional iliac obstruction in top endurance athletes: a prospective study. Lancet 2002;359(9305):466–73. Smith WS, Johnstone SC, Skalabrin EJ, Weaver M, et al. Spinal manipulative therapy is an independent risk factor for vertebral artery dissection. Neurology 2003;60:1424–8. Sturzenegger M. Headache and neck pain: the warning symptoms of vertebral artery dissection. Headache 1994;34(4):187–93. Sturzenegger M. Spontaneous internal carotid artery dissection: early diagnosis and management in 44 patients. Journal of Neurology 1995;242(4):231–8. Terrett AGJ. Vertebro basilar stroke following spinal manipulation. In: Murphy DReditor. Conservative Management of Cervical Spine Syndromes. New York: McGraw-Hill; 2000. p. 553–77 chapter 22. Thomas CL, Venes D. Tabers Cyclopedic Medical Dictionary, 19th ed. Philadelphia: FA Davis; 1999. p. 914. Yabuki S, Kikuchi S, Midorikawa H, Hoshino S. Vascular backache and consideration of its pathomechanisms: Report of two cases. Journal of Spinal Disorders 1999;12(2):162–7. Yao JST. Upper extremity ischemia in athletes. Seminars in Vascular Surgery 1998;11(2):96–105. Zetterling M, Carlstrom C, Konrad P. Internal carotid artery dissection. Acta Neurological Scandinavia 2000;101:1–7.

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Case Report

A patient with severe right frontal headache Henry Tsao 12 Dandelion Street, Eight Mile Plains, Brisbane, Qld. 4113, Australia Received 11 December 2003; accepted 4 May 2004

1. Introduction As physiotherapists, our primary role in the field of headaches is the management of cervicogenic headaches, that is, headaches arising from musculoskeletal dysfunction in the cervical spine. A recent randomized controlled trial conducted in Australia demonstrated the benefits of specific therapeutic exercise and manipulative therapy for cervicogenic headaches (Jull et al., 2002). The problem with headaches is two-fold: (1) all headaches have commonalities in their anatomy and physiology in that they are mediated by the trigeminocervical nucleus (Bogduk, 1995); (2) there can be symptomatic overlap between many headache types as well as some seemingly common provocative factors (IHS, 1988; Leston, 1996; Hagen et al., 2002). Therefore, the ability of physiotherapists to identify cervicogenic headache, or to exclude it and refer accordingly is important, especially when acting as first contact practioners (Jull, 1994). This case study demonstrates the significance of recognizing headaches of nonmusculoskeletal origin.

upper cervical spine in the form of a dull ache (VAS 7 out of 10), especially after she had been studying for more than 10 min (Fig. 1). There was no radicular pain or peripheral neurological symptoms, but she reported associated dizziness, double vision in the right eye and difficulty concentrating for a prolonged period of time. Apart from studying, lying down and exertion (e.g., walking up and down stairs) increased her headaches and upper cervical pain as well as her associated symptoms. The pain was worse at night and she was more comfortable sleeping in long sitting. She had visited her local GP who sent her for a CT scan of the brain, which was clear. Her general health was good with no relevant history of headaches, neck pain or other medical problems. The GP diagnosed her as having a cervicogenic headache most likely due to the

2. Presentation A 23-year-old nursing student attended the physiotherapy clinic complaining of a constant unremitting right frontal headache above the right eyebrow for the last two weeks. She could not recall any related incidents of trauma and she believed the headaches could be due to her recent increase in studying for the forthcoming exams. The nature of the pain was deep throbbing (VAS 9 out of 10), and it intermittently referred down to the E-mail address: [email protected] (H. Tsao). 1356-689X/$ - see front matter r 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2004.05.001

Fig. 1. Body chart illustrating the pain presentation.

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increase in studying and poor posture, and referred her for physiotherapy.

The oculomotor nerve supplies the levator palpebrae of the eyelid as well as having a parasympathetic supply to the pupil constrictors. Testing is in two parts: *

3. Examination On initial observation, her right eyelid was 1/4 closed, and on encouragement to open the right eyelid, she felt generally unwell and stated that the pain was too severe. Active cervical movements were all full range but increased her discomfort, especially rotation both sides (which enhanced her dizziness). A cautious VBI test was conducted which reproduced the onset of her dizziness and increased her headaches. Palpation of the cervical spine revealed tenderness in the right upper cervical regions, especially in the suboccipital muscles. Careful manual examination of the cervical segments (Maitland, 1986) failed to reveal any evidence of cervical joint dysfunction. Likewise cautious testing of neural tissue movement using passive neck flexion and straight leg raise was also negative.

4. Clinical reasoning Several historic and physical signs indicated possibilities of danger signs or red flags, namely: * *

*

*

* * * * *

Right eyelid ptosis. Presence of associated dizziness and double vision which increased as the headache worsened. Lack of related trauma or other provocative incident of sufficient magnitude to correspond to the severity of the symptoms. End of range rotation during VBI testing reproduced her symptoms. Severity and quality of pain. Age and health of the patient. Lying down and exertion increased her symptoms. Presence of night pain. Lack of cervical joint signs.

The patient was further assessed neurologically due to the presence of red flags, and it was found that her right pupil was dilated and not reacting to light. She was immediately referred back to the GP for further investigations. The GP subsequently referred her to a neurosurgeon. An MRI examination was conducted on the brain revealing a large aneurism at the junction between the basilar and the posterior cerebral artery, compressing and irritating the oculomotor nerve. She was diagnosed with CNIII (Oculomotor) palsy, and underwent emergency surgery.

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*

Ability of the pupil to react to light. Ability of the eye to track a moving object.

Symptoms of oculomotor paresis or paralysis include diplopia, caused by reduced ability to fix the eyes on an object correctly and fuse the two images, and photophobia, caused by the dilated pupil (Meadows, 1999). A CT scan is usually the recommended first line of screening by the GP when suspecting vascular or nervous system lesions such as an aneurism (Goodman and Snyder, 2000). However, as demonstrated in this case study, CT scans may produce false negatives and in the presence of red flags, appropriate referral and further investigations such as an MRI should be carried out immediately.

5. Summary It is commonly stated that 1% of patients with red flags will be missed by the physician (Goodman and Snyder, 2000). This case study accentuates the importance of clinical reasoning and the recognition of red flags that may lead to the identification of nonmusculoskeletal conditions. As highlighted, a failure to refer quickly in the presence of red flags could have had fatal implications.

References Bogduk N. Anatomy and physiology of headache. Biomedicine and Pharmacotherapy 1995;49:435–45. Goodman CG, Snyder TK. Differential diagnosis in physical therapy, 3rd ed.. Pennsylvania: WB Saunders Company; 2000. Hagen K, Einarsen C, Zwart JA, Svebak S, Bovim G. The cooccurrence of headache and musculoskeletal symptoms amongst 51050 adults in Norway. European Journal of Neurology 2002;9(5):527–33. International Headache Classification Committee. Classification, diagnostic criteria for headache disorders, cranial neuralgias, and facial pain. Cephalalgia 1988;8:9–96. Jull G, Trott P, Potter H, Zito G, Niere K, et al. A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine 2002;27(17):1835–43. Jull GA. Cervical headache: a review. In: Grieves Modern Manual Therapy, 2nd ed. Edinburgh: Churchill Livingstone; 1994. [Chapter 23]. Leston JA. Migraine and tension-type headache are not separate disorders. Cephalalgia 1996;16:220–2. Maitland GD. Vertebral manipulation, 5th ed.. London: Butterworth & Co. Ltd; 1986. Meadows JT. Orthopaedic differential diagnosis in physical therapy. New York: McGraw-Hill; 1999.

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Case Report

Manipulation following regional interscalene anesthetic block for shoulder adhesive capsulitis: a case series Robert E. Boylesa,*, Timothy W. Flynnb, Julie M. Whitmanc a

US Army-Baylor University Doctoral Program in Physical Therapy 3151 Scott Rd, Rm 1303, Fort Sam Houston, TX 78234-6138 USA b Regis University, Denver, CO 80221, USA c Kirtland Air Force Base, Albuquerque, NM 87117, USA Received 26 June 2003; received in revised form 16 December 2003; accepted 4 May 2004

1. Background and purpose Adhesive capulitis (AC) of the glenhumeral joint, commonly known as ‘‘frozen shoulder’’, is a prevalent condition that is frequently treated by physical therapists (Dockrell and Wiseman, 1995; Holmes et al., 1997; van der Heijden et al., 1997; Winters et al., 1997; Connolly, 1998; Pearsall and Speer, 1998; Schwitalle et al., 1998; van der Windt et al., 1998; Siegel et al., 1999; Sandor, 2000; Bentley and Tasto, 2001; Green et al., 2001; Vermeulen et al., 2000). AC is more prevalent in women and in middle-aged individuals (Nevaiser, 1983,1987; Siegel et al., 1999), in the diabetic patient population, with a rate of 2–5% in the non-diabetic population and 10–20% patients with non-insulin dependant diabetes mellitus (Siegel et al., 1999; Carette, 2000; Bentley and Tasto, 2001). Patients with glenohumeral AC typically suffer from significant pain and progressively diminishing shoulder function (Nevaiser, 1983,1987; Roubal et al., 1996; Placzek et al., 1998; Sandor, 2000). In a recent review on interventions for shoulder pain by the Cochrane Collaboration, Green et al. (2001), define AC as the presence of shoulder pain with restriction of passive and active glenohumeral motion. However, in their review of the literature, these same researchers found no standardized definitions for AC and reported conflicting criteria defining AC in the clinical trials reviewed. The recommended course of treatment for patients with adhesive capsulitis is highly variable (Thomas et al., 1981; Nevaiser, 1983,1987; Parker et al., 1989; Grubbs, 1993; Dockrell and Wiseman, 1995; Holmes et al., 1997; van der Heijden et al., 1997; Winters et al., 1997; *Corresponding author. Tel.: +1-210-221-7582; fax: +1-210-2217585. E-mail address: timothy.fl[email protected] (R.E. Boyles). 1356-689X/$ - see front matter r 2004 Published by Elsevier Ltd. doi:10.1016/j.math.2004.05.002

Connolly, 1998; Harwood, 1998; Schwitalle et al., 1998; Tukmachi, 1999; Griggs et al., 2000; Hannafin and Chiaia, 2000; Sandor, 2000; Bentley and Tasto, 2001; Green et al., 2001; Jerosch, 2001; Kivimaki and Pohjolainen, 2001; Omari and Bunker, 2001). Dockrell and Wiseman (1995) randomly surveyed 100 patient records from 10 out-patient physical therapy clinics in an effort to determine the ‘‘typical’’ physical therapy (PT) treatment for patients with a primary diagnosis of shoulder AC The majority of patients received 8–18 treatments over a 2-month period of time. The most frequently utilized treatments included exercise (98%), manual glenohumeral mobilization (93%), and thermal modalities (60%). In a retrospective descriptive study evaluating the 10-year outcomes of a cohort of 50 patients, Miller et al. (1996) reported that many patients with AC will regain motion with minimal pain following a treatment programme of home based therapy, moist heat, NSAIDs, and physician directed rehabilitation. Griggs et al. (2000) conducted a trial of clinic and homebased stretching exercises as a treatment for a cohort of 75 consecutive patients with AC. Although 85 percent of the patients reported satisfactory outcomes, significant differences still existed in pain and range of motion when compared to the unaffected shoulder. Variables associated with unfavourable outcomes were a previous unsuccessful trial of PT and the presence of severe pain and functional limitations prior to the initiation of treatment. Two recent, large randomized clinical trials have compared physical therapy (PT) treatments to steroid injection (Winters et al., 1997; van der Windt et al., 1998). Van der Windt et al. (1998) in a study of painful, stiff shoulders noted greater short-term improvements in pain and disability with injections versus a combined programme of mobilization, exercise, and physical agents but no long-term differences (26 and 52 weeks).

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In a similar study, Winters et al. (1997) compared treatments of physiotherapy (without mobilization/ manipulation), injection, and manipulation to the entire upper quarter for 198 patients with shoulder complaints. Of those patients thought to have symptoms primarily of glenohumeral etiology, patients receiving corticosteroid injections showed quicker recovery and higher patient perceived ‘‘cure’’ rates compared to patients receiving the other treatments. However, recurrence of pain by 11 weeks was highest in the injection group (18%), followed by physiotherapy (13%) and manipulation (8%). These trials appear to indicate that steroid injections are more helpful than conventional physical therapy for short-term pain relief and improved disability scores, but this difference in benefit diminishes in the long term. Manipulation under anesthesia (MUA) using long lever arm techniques in physiologic planes of motion, i.e. flexion, abduction and rotations, has been described in the treatment for AC and is considered a last resort procedure for these patients (Neviaser, 1983,1987; Grubbs, 1993; Connolly, 1998; Pearsall and Speer, 1998; Siegel et al., 1999). In this procedure, the clinician moves the patient’s shoulder through physiologic motions while the patient is under general anesthesia. Although positive post-manipulative clinical outcomes have been reported, potential complications associated with this long lever arm technique include rotator cuff tears, humeral fractures, and brachial plexus injuries (Neviaser, 1983,1987; Parker et al., 1989; Roubal et al., 1996; Connolly, 1998; Placzek et al., 1998; Sandor, 2000). In contrast to this technique, Roubal et al. (1996) and Placzek et al. (1998) have reported on a total of 39 patients treated with translational manipulations immediately following a regional interscalene brachial plexus anesthetic block. The technique utilized is purported to be safe and effective because small amplitude, high-velocity, short lever arm manipulations are employed rather than long lever arm techniques (Roubal et al., 1996; Placzek et al., 1998). In both of these studies, marked improvements in shoulder range of motion without complication were reported. Although Roubal et al. (1996) did not report long-term outcomes, favourable outcomes were reported at the 1 year follow-up for the 31 patients in the Placzek et al. (1998) study. Researchers in both studies concluded that manipulation can be an effective intervention for patients with adhesive capsulitis and that this intervention should be considered by those practitioners skilled in joint manipulation. On the whole, it seems that some patients improve after a programme of physical therapy, steroid injections, and/or physician or therapist directed home care. However, some patients fail to respond to these approaches and continue to demonstrate residual PROM and functional losses in the long term (Shaffer

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et al., 1992). Therefore, some patients may elect for a manipulative approach in an attempt to improve the mobility and function of the affected shoulder. In this case series, the use of manipulation to the glenohumeral joint after an interscalene anesthetic block for patients with adhesive capsulitis is described. In addition, the use of video fluoroscopy to assess glenohumeral joint arthrokinematics is presented.

2. Case description 2.1. Patient presentation The following four patients were referred to physical therapy (PT) at Brooke Army Medical Center and Wilford Hall Air Force Medical Center, San Antonio, TX for management of shoulder disorders: Patient 1: A 47 yr/o female nurse practitioner with a 7month history of right shoulder pain, stiffness and inability to perform her normal activities of daily living. Referral diagnosis: adhesive capsulitis. Patient 2: A 45 yr/o female homemaker with an insidious onset, 6-month history of left shoulder pain and stiffness, sleep cycle disturbances, and inability to perform daily activities such as bathing, cleaning the house, and cooking. She particularly reported difficulty with overhead tasks such as washing her hair. This patient had already been treated with steroid injections with no reported improvements in mobility, function, or pain. Referral diagnosis: rotator cuff tear. Patient 3: A 56 yr/o male computer programmer with a 7-month history of right shoulder pain, sleep cycle disturbance, and inability to put on his jacket or shirt without pain, reach across his desk, or use a computer mouse. Referral diagnosis: shoulder pain. Patient 4: A 66 yr/o male retired army officer with a 10-month history of left shoulder pain, stiffness, and sleep cycle disturbance. Symptoms increased with shoulder elevation, reaching behind the back, and reaching across his body (horizontal adduction). This patient had already received steroid injections without relief of symptoms or improved shoulder function. Referral diagnosis: shoulder impingement. All patients had received prior PT interventions (shoulder joint mobilization, active and passive mobility exercise programmes, strengthening exercises, and/or modalities) without satisfactory improvement in function or pain. Two had received prior steroid injections and two declined this treatment option.

3. Baseline examination Passive range of motion (PROM) measurements as well as the Shoulder Pain and Disability Index (SPADI)

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were used as outcome measures. PROM measurements were used because these measurements are important in the diagnosis of AC and are frequently used as an outcome measure in clinical research. All PROM measurements were performed as described by Norkin and White (1999). The SPADI is a 100-point, 13 item self-administered questionnaire designed to quantify shoulder pain and disability. Michener and Leggin (2001) reported a high test–retest reliability and internal consistency for the SPADI, while Williams et al. (1995) have shown that the instrument is responsive to change and accurately discriminates between patients who are improving or worsening. It is reported to have a moderately strong construct validity and more responsive to change than the Sickness Impact Profile (SIP), Heald and Riddle (1997). They also recommend the SPADI over the SIP for measuring the extent of disability in patients with shoulder problems. Additionally, a 10-point change on the SPADI has been identified as the minimally clinically important change needed to be confident that a change has actually occurred (Heald and Riddle, 1997). The MRI reports for three patients (2, 3, 4) demonstrated various degrees of rotator cuff tears. Physical examination findings for all four patients included the following: (1) markedly decreased range of motion (flexion, abduction, and internal/external rotation); (2) essentially equal impairment in both active and passive shoulder motion; (3) pain at the end of each range of motion; (4) capsular end-feels with passive glenohumeral joint mobility assessment. Based on patient history and the four physical examination findings listed above, the diagnostic clinical criteria for AC were standardized by all investigators. As part of the physical examination, Patients 1 and 4 had pre-manipulation video fluoroscopy studies. Anterior to posterior views were recorded on both extremities while the patient actively and repeatedly abducted the shoulder. The pre-manipulation study for both patients demonstrated a loss of normal arthrokinematics of the glenohumeral joint on the involved side. As described by Maitland (1999) and Levangie and Norkin (2001) the humeral head should glide inferiorly as the patient abducts the shoulder. In these two patients, the humeral head on the involved side failed to move caudally during physiological shoulder abduction. In fact, in both cases, the humeral head elevated with abduction. 3.1. Intervention As recommended by Placzek et al. (1998), patients were prescribed a 6-day Medrol Dosepak (Pharmacia and Upjohn Company, Kalamazoo, MI) by their referring physicians and started this medication the day before the manipulation. Patient 3 was not prescribed this medication because he is diabetic, a

contraindication for taking the drug. After the patients signed the standard consent form utilized by the facility for all patients undergoing this procedure, an anesthesiologist performed a regional interscalene block on each patient. The blocks were found to last from 4 to 6 h. This procedure is described elsewhere (Roubal et al., 1996; Placzek et al., 1998). Patients then proceeded immediately to the outpatient physical therapy clinic for treatment. A sling was used in transit to protect the patients’ anesthetized extremities. Immediately prior to the manipulation session, the patient’s shoulder passive range of motion (PROM) was recorded for flexion, abduction, and internal and external rotation. End feels were also assessed to ensure that (1) the restrictions were still present after the extremity was anesthetized to ensure true AC, and (2) to be sure that any increase in motion was a direct result of the manipulation and not the anesthesia. The reports by Placzek et al. (1998) and Roubal et al. (1996) describe manipulations that are performed only in two directions, anterior-to-posterior and superior-toinferior. In this case series, the physical therapists performed these same manipulations. Additionally, the therapists performed mobilization/manipulation in the directions of the remaining perceived joint restriction. To assess glenohumeral joint mobility, the therapists grasped the proximal humerus as close to the glenohumeral joint as possible and then glided the humeral head in anterior, posterior, caudal, and combined directions, in an attempt to detect joint hypomobility. This procedure was performed with the shoulder at various degrees of flexion, abduction, and internal/ external rotation in attempt to detect the position and direction of motion where proximal humeral translation was the most limited (joint hypomobility). Once the therapist identified what he/she perceived to be joint hypomobility when gliding the proximal humerus in a specific direction, two to three 30 s bouts of a low velocity, oscillatory mobilization, or Maitland Grade IV to IV+ (Maitland, 1999) was applied in that direction. If this failed to result in immediate increases in PROM, high-velocity, low-amplitude (HVLA) (Maitland, 1999) manipulations were performed. To ensure the block did not wear off before completion of the intervention, it was not possible due to time constrints to record PROM measurements after the application of each mobilization/manipulation technique. However, in our four cases, the addition of these HVLA thrust techniques appeared to result in additional gains in shoulder PROM beyond those attained after the application of the two techniques previously described by Placzek et al. (1998) and Roubal et al. (1996). All manipulations performed were short-lever-arm, low-amplitude procedures. As advocated by Placzek et al. (1998) and Roubal et al. (1996), several measures were taken in attempt to avoid brachial plexus injury: (1) an assistant stabilized

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the scapula against the trunk and in an elevated position, (2) the cervical spine was positioned in ipsilateral sidebending, and (3) the elbow was never fully flexed or fully extended. Following the manipulation session, PROM measurements were again recorded. Finally, with the patient resting in supine and the patient’s hand placed behind his/her head, the treated shoulder was wrapped in an ice pack for approximately 20 min. Patients were then instructed in active assisted range of motion (AAROM) exercises and instructed to perform these exercises every 2 h at home, when awake, for the next 24 h. The AAROM exercises included: wand exercises for flexion, abduction, internal and external rotations. They were also instructed to apply ice packs to the shoulder for 20 min every 2 h with the ice packs circumferentially around the shoulder while lying supine, hand resting behind their head (the combined position of abduction and external rotation). Patients followed-up with the treating physical therapist (PT) daily for 1 week and received further glenohumeral joint mobilization Grade II to IV+ (Maitland, 1999), ROM exercises, and cryotherapy. Home programmes included active, active assisted and passive shoulder range of motion exercises. After the first week, patients were treated three times per week to address individual impairments in shoulder motion and strength, and typically discharged to a home programme after 3 weeks. See Appendix A for an example of the exercise programme and Appendix B for a sample clinical pathway.

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initial gains in PROM and all improvement in the disability scores were maintained at the patients’ final follow-up visit. Additionally, Patients 1 and 2 had full, pain free AROM that was equal to the opposite, noninvolved shoulder and full pain-free motion with activities. Patient 3 missed several post-manipulation treatment sessions and was unable to reproduce the home exercise programme. Therefore, compliance with the home programme was questionable. Patient 4’s only remaining symptom was occasionally slight pain after rolling onto his affected shoulder at night. Patients 1 and 4 had follow-up video fluoroscopy studies at the six-week follow-up visit and Patient 1 again received a video fluoroscopy study at the 12-week visit. The studies were performed in the same manner as previously described. In contrast to the baseline video fluoroscopy studies, the 6-week, and 12-week follow-up sessions for Patient 1 and the 6-week follow up session for Patient 4, video fluoroscopy demonstrated a smooth, ‘‘normal’’ GH motion. Figs. 2a and b are end range images of Patient 1’s video fluoroscopy study for the involved versus uninvolved side, respectively, prior to the initiation of the manipulative intervention. Fig. 3 shows the same patient’s involved shoulder at the 12week follow-up evaluation and illustrates the appropriate gliding of the humeral head caudally as the patient performs active shoulder abduction.

4. Outcomes Pre- and post-Manipulation and follow-up SPADI and PROM scores at baseline, 3-week, 6-week, and 12week follow-up are reported in Fig. 1 and Table 1, respectively. Throughout the manipulation treatment and the subsequent follow-up periods, no adverse events were reported. All patients demonstrated improvements in both PROM measurements and disability scores immediately after the manipulative intervention. Most

Fig. 1. Shoulder Pain and Disability Index (SPADI) scores for each patient.

Table 1 Passive range of motion measurements in degrees, for patients at baseline, immediately after the manipulative intervention, and at specific follow-up sessions Patient 1

Pre-treatment Immediately Post-Rx 3 Weeks 6 Weeks 12 Weeks

Patient 2

Patient 3

Patient 4

Flex

Abd

IR

ER

Flex

Abd

IR

ER

Flex

Abd

IR

ER

Flex

Abd

IR

ER

120 170 165 160 160

90 155 170 165 165

25 75 70 65 70

40 100 105 90 95

115 135 150 140

50 90 95 130

25 70 70 55

5 35 35 95

110 160

70 160

20 90

25 45

130 125

110 110

40 70

40 50

115 170 135 165 165

85 160 120 120 120

25 70 60 40 40

30 85 65 55 55

Denotes measurement not obtained.

















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Fig. 3. Patient 1’s involved shoulder at the 12-week follow-up evaluation.

Fig. 2. a–b. End range images of patient 1’s video fluoroscopy study for the involved versus uninvolved side, respectively, prior to the initiation of the manipulative intervention.

5. Discussion Although a similar treatment approach as described by Placzek et al. (1998) and Roubal et al. (1996) was utilized in this case series, several aspects of our patients’ care was unique. After using the techniques described by these authors, therapists also performed further mobilization/manipulation in the directions of remaining perceived joint hypomobility. Although not measured, the additional techniques appeared to yield immediate and substantial additional gains in shoulder ROM in every case. These gains were made in light of the study by Gokeler et al. (2003) that reported no significant changes in humeral head distances with traction force applied to the GH joint in the maximally loose pack position when compared to the closed pack position. Perhaps, this is due to the specific direction and grade of the mobilization used by the authors in this study. It should be noted that Hsu et al. (2000a, b) in

two separate cadaver studies reported significant increases in GH abduction immediately following anterior–posterior glides and significant increases in GH abduction immediately following caudal glides. Although outcomes for only four patients are reported, it is our opinion that the additional gains in mobility attained though the utilization of our model of treatment were important enough that researchers should consider this approach in future clinical trials. Placzek et al. (1998) and Roubal et al. (1996) outlined a extensive post-manipulation protocol. These authors used many physical modalities in an attempt to decrease pain and enhance rehabilitation. Patients were also given an extensive exercise regime to perform both in the clinic with supervision and as a home programme. In contrast, our post-manipulation rehabilitation programme was designed to maintain gains in shoulder mobility and specifically address each individual patient’s remaining impairments while minimizing the amount of time that the patient had to come to the facility for his/her rehabilitation. Compared to the protocols used by Placzek et al. (1998) and Roubal et al. (1996), our patients were treated with fewer exercises and the use of physical modalities (except for cryotherapy) was eliminated. Further, our patients required approximately 4–5 fewer post-manipulation physical therapy visits than patients in the previous studies. In our opinion, an extensive post-manipulation rehabilitation programme may not be necessary; a more parsimonious rehabilitation programme may result in favourable gains in mobility and improvements in disability scores, while conserving valuable patient and clinic time and resources. Additionally, although many theorize about the effects that adhesive capsulitis has on normal arthrokinematics (Maitland, 1999) and the effect of an

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intervention on the arthrokinematics, documented cases of patients receiving video fluoroscopy studies to demonstrate a loss of normal joint kinematics before intervention and return of more normal joint kinematics after the application of an intervention have not been found. It is believed that this is the first attempt to demonstrate this. Video fluoroscopy of anterior– posterior views during active shoulder abduction revealed increased caudal translation of the glenohumeral joint following manipulation when compared to the pre-manipulation video fluoroscopy studies. Because video fluoroscopy is a non-invasive, low-risk, and expedient imaging modality it is therefore considered that it may be an ideal tool to monitor the arthrokinematics of the glenohumeral joint. Researchers should consider including the use of video fluoroscopy in future studies when investigating the effects of interventions on the mechanics of the glenohumeral joint. Except for the regional interscalene block performed by the anesthesiologist, all interventions in this study and others (Roubal et al., 1996; Placzek et al., 1998) were performed by physical therapists. The Guide to Physical Therapist Practice (American Physical Therapy Association, 2001) defines mobilization/manipulation as ‘‘a manual therapy technique comprising a continuum of skilled passive movements to the joints and/or related soft tissues that are applied at varying speeds and amplitudes, including a small-amplitude/high-velocity therapeutic movement’’. The Guide lists mobilization/ manipulation as an intervention appropriate for the care of patients with adhesive capsulitis. Since physical therapists possess and already utilize these mobilization/manipulation skills in the care of patients with adhesive capsulitis without anesthetic blocks, it is our belief that physical therapists are ideally suited to be the practitioner of choice to perform this treatment on patients who have received a regional interscalene block.

rotator cuff pathology as demonstrated by MRI. It is our opinion that this intervention should be considered for patients with AC if a trial of more conventional treatment strategies has failed to produce satisfactory results. Additionally, the use of video fluoroscopy may be an ideal imaging modality for further investigation of the biomechanical changes that occur in the glenohumeral joint after the application of an intervention in patients with adhesive capsulitis. However, before this treatment method for shoulder AC is advocated for wide spread use, randomized controlled trials comparing this treatment to competing treatments are warranted.

6. Conclusion

*

The AC patients in this case series, treated with translational manipulation following an interscalene block, showed rapid improvement in PROM and improved levels of disability as measured by the SPADI. The results are consistent with previous reports (Roubal et al., 1996; Placzek et al., 1998) demonstrating that, in patients with adhesive capsulitis, this type of intervention may result in positive outcomes that are considerably quicker than improvements attributed to the natural history of this disorder. It appears that translational manipulation by a physical therapist can be a safe and potentially effective treatment option for these patients, even those presenting with underlying

Appendix A. Post-anesthesia shoulder programme Same day: * *

* *

*

*

Pre anesthesia PROM measurements. Mobilizations/manipulations to address capsular restrictions. Post-anesthesia PROM measurements. Instruct in home exercise programme of AAROM for shoulder flexion. To be performed every 2 h for 5 min to end range with 5 s holds. Ice pack around the shoulder 20–30 min. Patient should be resting supine with hand behind the head to encourage continued stretch in external rotation and abduction. Use of ice at home 20–30 min following exercise. 1–5 days post-manipulation:

*

*

Patient to attend daily physical therapy sessions for shoulder mobilization, exercise and ice. Instruct in AAROM wand exercises for flexion, abduction, internal and external rotation, selfstretches for horizontal flexion. Ice to the shoulder following treatment in supine with hand behind head for 20–30 min. Continue with home exercise programme every 2 h for the first week. Ice 20–30 min after treatments. 2nd and 3rd weeks:

* *

*

* * *

Continue with clinic sessions 3 times per week. Continue with shoulder mobilizations to address tightness/ restrictions. Advance to rotator cuff strengthening as motion and pain allows. Ice following treatment as needed. Continue with home exercise programme. Discharge at the end of third week to home programme.

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Appendix B. Pre-manipulation shoulder patients

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pathway

for

frozen

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List of Reviewers 2004 Jull, Gwendolen; Department of Physiotherapy, University of Queensland, Brisbane, Queensland 4072, Australia; Tel.: +61 7 3365 2008/2019; fax: +61 7 3365 2775; [email protected] Edmondston, Steven J.; School of Physiotherapy, Curtin University of Technology, P.O. Box U1987, Perth, WA 6845, Australia; Tel.:+61 8 9266 3665; fax: +61 8 9266 3699; [email protected] Hurley-Osing, Deirdre; DH, School of Physiotherapy, University College Dublin, Mater Misericordiae Hospital, Eccles Street, Dublin 7, Republic of Ireland; Tel.: +353 1 8034310; fax: +353 1 8303550; [email protected] Swinkels, Raymond; Ulenpas 80, 5655 JD Einhoven, The Netherlands; Tel.: +3140 2853 287; fax: +3140 2528 687; [email protected] Bennell, Kim; Director of Centre for Sports Medicine Research and Education, School of Physiotherapy, University of Melbourne, 2000 Berkeley St., Carlton, Victoria 3053, Australia; Tel.: +61 3 8344 4171; fax: +61 3 8344 4188; [email protected] Rivett, Darren; Head, Physiotherapy, Faculty of Medicine & Health Sciences, The University of Newcastle, University Drive, Callaghan, Newcastle NSW 2308, Australia; Tel.: +61 2 4921 7821; fax: +61 2 4921 7479; [email protected] Boyling, Jeffrey D.; Broadway Chambers, Hammersmith Broadway, London W6 7AF, UK; Tel.: +44 20 8748 6878 (Home tel); fax: +44 208 748 4519 [email protected] Shirley, Debra; School of Physiotherapy, Faculty of Health Sciences, University of Sydney, P.O. Box 170, Lidcombe NSW 1825, Australia; Tel.: +61 2 9351 9177; fax: +61 2 9351 9601; [email protected] Maher, Chris; School of Physiotherapy, Building C42, University of Sydney, P.O. Box 170, Lidcombe NSW 1825, Australia; Tel.: +61 2 9351 9192; fax: +61 2 9351 9601 [email protected] doi:10.1016/j.math.2004.10.002

Singer, Kevin; Director, Centre for Molculoskeletal Studies, Department of Surgery, Royal Perth Hospital, The University of Western Australia, 58 Murrary St., Perth, WA 6000, Australia; Tel.: +61 8 9224 0200; [email protected] Winn, Sandra; School of Applied Social Science, P Block, Falmer Site, University of Brighton, Village Way, Falmer BN1 9PH, UK; Tel.: +44 1273 643488; fax: +44 1273 64 3473; [email protected] Wright, Tony; The Head of School of Physiotherapy, Curtin University of Technology, G.P.O. Box U1978, Perth WA 6845, Australia; Tel.: +61 8 9266 3618; fax: +61 8 9266 3699 [email protected] Beeton, Karen; Senior Lecturer, Department of Physiotherapy, University of Hertfordshire, College Lane, Hatfield, Herts AL10 9AB, UK; Tel.: +44 1707 284 114; fax: +44 1701 284 977; [email protected] Greening, Jane; Research Fellow, School of Physiotherapy, University College London, Gower Street, London WC1E 6BT, UK; Tel.: +44 207 380 3139; fax: +44 207 383 7005; [email protected] McConnell, Jenny; McConnell & Clements Physiotherapy, 4 Bond Street, Mosmann, New South Wales 2088, Australia; Tel.: +61 2 9968 4766; fax: +61 2 9968 4963 [email protected] Vicenzino, Bill; Department of Physiotherapy, The University of Queensland, St. Lucia, Queensland 4072, Australia; Tel.: +61 7 33652781; fax: + 61 7 33652775; [email protected] Rankin, Gabrielle; Research Advisor, Research & Clinical Effectiveness Unit, Chartered Society of Physiotherapy, 14 Bedford Row London WC1R 4ED, UK; Tel.: +44 20 7306 6601; fax: +44 20 7306 6653; [email protected] Cheek, Elizabeth; School of Computing & Mathematical Sciences, Watts Building, University of Brighton, Watts Building, Lewes Road, Brighton BN1 4CJ, UK; Tel.: +44 1273 642527; fax: +44 1273 642405; [email protected]

ARTICLE IN PRESS List of Reviewers / Manual Therapy 10 (2005) 88–90

Hall, Toby; 81 Northwood Street, West Leederville, Western Australia 6007, Australia; Tel.: +61 8 9381 1863; [email protected] Cairns, Mindy C.; Senior Lecturer, Department of Physiotherapy, Faculty of Health and Human Sciences, University of Hertfordshire, College Lane, Hatfield, Herts, AL10 9AB, UK; Tel.: +44 1707 284 127; fax: +44 1707 284 977; [email protected] McCarthy, Chris; The Centre for Rehabilitation Science, University of Manchester, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK; Tel.: +44 161 276 6672; fax: +44 161 276 6672; [email protected] Lee, Raymond; Department of Rehab. Sciences, Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong, Peoples’ Republic of China; Tel.: +852766 4889; fax: +852 2330 8656; [email protected] Redhead, Lucy; School of Healthcare Professions, University of Brighton, Robert Dodd Building, 49 Darley Road, Eastbourne, East Sussex, BN20 7UR, UK; Tel.: +44 1273 643650; fax: +44 1273 643652; [email protected] Gross, Anita; Hamilton Health Sciences, Chedoke Campus, Out-Patient Physiotherapy, Wilcox Building 1st Floor, 565 Sanatorium Road, Hamilton, Ont., CA L8N 3Z5, Canada; Tel.: +1 905 521 7945; fax: +1 905 521 2606; [email protected] Schuit, Dale; Department of Physical Therapy, Rosalind Franklin University of Medicine and Science, 3333 Green Bay road, Chicago, Illinois 60064-3095, USA; Tel.: +1 847 578 8830; fax: +1 847 578 8816; [email protected] Sterling, Michele; Department of Physiotherapy, The University of Queensland, St Lucia 4072, Australia; Tel.: +61 7 3365 4569; fax: +61 7 3365 2775 [email protected] von Piekartz, Harry JM.; NOI-Europe, Stobbenkamp 10, 7631 CP Ootsmarsum, The Netherlands; Tel.: +31 541 294 001; fax: +31 541 294 002 [email protected] Pool-Goudzwaard, Annelies; Medical Centre Impact, Meeuwenveld 1, 2727 AK Foefermeer, The Netherlands; Tel.: +31 79 3313 065; fax: +31 79 3425 765 [email protected] Richardson, Carolyn; Department of Phyiotherapy, The University of Queensland, Brisbane, Queensland 4072, Australia; Tel.: +61 317 3365 2209; fax: +61 317 3 365 2275 [email protected] O’Sullivan, Peter; School of Physiotherapy, Curtin University of Technology, Kent Street, Bentley WA 6845, Australia; Tel.: +61 8 9266 3629; fax: +61 8 9266 3699; [email protected]

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Hides, Julie; Back Stability Clinic, Mater HospitaL, Raymond Tce, South Brisbane Qld 4001, Australia; Tel.: +61 7 3365 2019; fax: +61 7 3365 2775; [email protected] Stokes, Maria; School of Health Professions and Rehabilitation Sciences, University of Southampton, Highfield Campus, Southampton SO17 1BJ, UK; Tel.: +44 23 8059 5306; [email protected] Hough, Alan; Research Fellow, Clinical Research Centre for Health Professionals, Aldro Building, University of Brighton, 49 Darley Road, Eastbourne BN20 7UR, UK; Tel.: +44 1273 643766; fax: +44 1273 643944; [email protected] Vogel, Steven; Stockwell Group Practice, 107 Stockwell Road, London SW9 9TJ, UK; Tel.: +44 20 72743223; fax: +44 207 7385005; [email protected] Danneels, Lieven; Department of Rehabilitation Science & Physical Therapy, University Hospital Gent, De Pinterlaan 185 6K3, 900 Gent, Belgium; Tel.: +32 9 240 26 35; fax: +32 9 240 38 11 [email protected] Rushton, Alison; School of Health Sciences (Physiotherapy), University of Birmingham—Morris House, Edgbaston, Birmingham B15 2TT, UK; Tel.: +44 121 627 2832; fax: +44 121 627 2021 [email protected] Louw, Gail; Senior Lecturer, Postgraduate Medical School, D Block, University of Brighton, Falmer Site, Village Way, Falmer, BN1 9PH, UK; Tel.: +44 1273 644004; fax: +44 1273 644002; [email protected] Cools, Ann; University Hospital, Dept. Of Rehabilitation Sciences and Physiotherapyand Postgraduate Education in Manual Therapy, De Pintelaan 185, 1B3, B9000 Gent, Belgium; Tel.: +32 9 240 26 32; fax: +32 9 240 38 11; [email protected] Foster, Nadine; Department of Physiotherapy Studies, Keele University, Keele, Staffs ST5 5BG, UK; Tel.: +44 1782 584195; fax: +44 1782 584255; [email protected] Adams, Mike; Department of Anatomy, University of Bristol, Southwell Street, Bristol, BS2 8EJ, UK; Fax: +44 117 925 4794; [email protected] Springett, Kate; School of Health Professions, Division of Podatry, Leaf Hospital, University of Brighton, St Annes, Road, Eastbourne, East Sussex, UK; Tel.: +44 1323 636706; [email protected] Latimer, Jane; School of Physiotherapy, University of Sydney, P.O. Box 170, East Street, Lidcombe NSW 2141, Australia; Tel.: +61 2 9351 9191; fax: +61 2 9351 9601; [email protected]

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List of Reviewers / Manual Therapy 10 (2005) 88–90

Lew, Paul; Moonee Pond Physiotherapy Centre, 25 Moore SE, Melbourne, Australia; lew@pacific.net.au Lewis, Jeremy; Physiotherapy Department, Chelsea & Westminster NHS Trust, 369 Fulham Road, London SW12 9NH, UK; Tel.: +44 20 8746 8406; fax: +44 20 8746 8880 [email protected] Burge, Julie; Physiotherapy Department, Maidstone Hospital, Hermitage Lane, Barming, Kent ME16 9QQ, UK; Tel.: +44 1622 224300; [email protected] Refshauge, Kathryn; Room O152, School of Physiotherapy, University of Sydney, P.O. Box 170, East Street, Lidcombe, NSW 2141, Australia; Tel.: +61 2 9351 9180; fax: +61 2 9351 9601 [email protected] Dziedzic, Krysia; Department of Physiotherapy Studies, Keele University, Keele, Saffs ST5 5BG, UK; Tel.: +44 1782 584190; fax: +44 1782 4255; [email protected] Souvlis, Tina; Queensland University, Australia; [email protected] Beith, Iain; Physiotherapy Division, GKT School of Biomedical Sciences, Kings College London, Shepherds House, Guys Campus, London SE1 1UL, UK; [email protected] Snijders, Chris; Department of Biomedical Physics and Technology, Erasmus MC, University Medical Center Rotterdam, P.O. Box 1738, 3000 DR Rotterdam, The Netherlands; Tel.: +31 10 408 7368; fax: +31 10 408 9463; [email protected] Hicks, Carolyn; Health Sciences, University of Birmingham, 52 Pritchatts Road, Birmingham B15; UK; [email protected]

Crowell, Rick; 6189 McQuade Road, Duluth, MN 55804, USA; Tel.: +1 218 525 7103 (Work); Tel.: +1 218 786 5433; [email protected] Wallin, Marina; Treasurer, Swedish Society of Orthopaedic Manipulative Therapies, Intagsgrand 8, S163 41, Sweden; Tel.: +46 8 36 43 61; fax: +46 8 760 1399 [email protected] van der Wurff, Peter; Tel.: +31 343 474507; [email protected] Shacklock, Michael; 6th Floor, 118 King William Street, Adelaide, SA, 5000, Australia; Tel.: +61 8 8212 4886; fax: +61 8 8212 8028; [email protected] Swinkels, Annette; Physiotherapy Section, School of Allied Health Professions, Faculty of Health and Social Care, University of West England, Glenside Campus, Blackberry Hill, Stapleton Bristol BS16 1DD, UK; Tel.: +44 117 9758408; [email protected] Kondracki, Mike; AECC, Chiropractic College Clinic, Bournemouth, Dorset, UK; [email protected] van Dieen, Jaap; Professor of Biomechanics, Faculty of Human Movement Sciences, Van der Boechorststraat 9, NL-1081 BT Amsterdam, The Netherlands; Tel.: +31 20 4448501; fax: 31 20 4448529; [email protected] Miles, Ken; Chair of Medical Imaging, Brighton & Sussex Medical School, Medical School Building, Falmer, Brighton BN1 9PX, UK; Tel.: +44 1273 877754; [email protected] Selfe, James; Reader in Physiotherapy, Allied Health, University of Central Lancashire, UK; [email protected]

Manual Therapy (2005) 10(1), 91–92

Diary of events

Technological Advances in PM&R Meet the Expert Sessions Updates in Evidence-Based Medicine

2–5 March, 2005, Vienna, Austria Physiotherapy and Prevention Physical Activity through Physiotherapy work place: A challenge for Physiotherapists ICF: International Classification of Functioning, Disability and Health Further Information can be obtained from the congress website: www.physioaustria.at/congress2005 or you can contact Physio Austria, Linke Wienzeile 8/28, A-1060 Wien. Tel: 0043/1/578 99 51-19; Fax: 0043/1/587 99 51-30.

EXECUTIVE SECRETARIAT Connect Organizac¸a˜o e Promoc¸a˜o de Eventos Rua Joa˜o Cachoeira, 488-Cj. 806-04535-001 – Sa˜o Paulo - SP – Brazil Phone/Fax: 55 11 3168-1149/55 11 3168-3538 http://www.connecteventos.com.br mailto:[email protected]

11–12 March 2005, Veldhoven, The Netherlands

VENUE Grand Hotel Meli Av. das Nac¸o˜es Unidas, 12559 - Sa˜o Paulo - SP http://www.solmelia.com

24th congress of the Dutch Association for Manual Therapy (NVMT) Congress theme: Evidence Based Practice on the shop floor Venue: The Conference centre of ‘‘Koningshof ’’ in Veldhoven, The Netherlands. Speakers include: Prof. Ann Moore, Ian Edwards, Deborah Falla, Anita Gross, Lorimer Mosely. Information: e-mail to: [email protected] or visit the website: www.nvmt.nl

29, 30, 31 July 2005, Rotorua, New Zealand NZMPA Biennial Scientific Conference Getting Connected – Bone and Tendon Keynote speakers: Jill Cook, Steephen Edmondston, Meena Sran and Bill Vicenzino. Further information is available by contacting Vicki Reid at mailto:[email protected] [email protected] or by visiting our website http://www.nzmpa.org.nz. Phone +64 9 476 5353, Fax +64 9 476 5354

April 8,9–2005 Biological and Applied Aspects of Somato-Autonomic Interactions Kyoyo University, Japan

21–26 August 2005, Sydney, Australia Aim: To critically consider and debate the current scientific research data concerning somato-autonomic interactions from the perspectives of basic physiology and clinical application. Participants: Biomedical and Clinical Scientists in the disciplines of Neuroscience and Health Care. Publication: Monograph Title: Biological and Applied Aspects of Somato-Autonomic Interactions to be published by Elsevier B.V. as a volume in the International Congress Series Dr. Brain Budgell, chair School of Health Sciences, Faculty of Medicine Kyoto University, Kyoto, Japan [email protected]

11th World Congress on Pain, Workshop and Plenary Proposals. Please send proposals to the Chair of the Scientific Program Committee: Herta Flor, PhD, Central Institute of Mental Health, Dept of Clinical and Cognitive Neuroscience, PF 12 21 20, 68072 Mannheim, Germany. Tel: 49-621-170-3922; Fax: 49-621-170-3932; E-mail: fl[email protected] Workshop and plenary suggestions should be submitted by 15 March 2003 at the latest so that they can be considered by the Scientific Program Committee. Note that announcements, deadlines, and other information relating to the 2005 Congress will be routinely updated on the IASP Web page: www.iasp-pain.org

Details can be found at http://www.nuancekk.com/Kyoto2005

23–25 September 2005

Abstracts Deadline: Nov 15th 2004

2nd International Conference on Movement Dysfunction Pain & Performance: Evidence & Effect Location: Edinburgh, UK Website: www.kcmacp-conference2005.com Organizers: Hosted by Kinetic Control and the Manipulation Association of Chartered Physiotherapists Administered and Sponsored by Elsevier/Manual Therapy Call for Papers Abstract Deadlines 15 January 2005 Secretariat: Nina Woods Kinetic control and MACP Conference Secretariat

April, 10th–15th, 2005 Third World Congress of the International Society of Physical and Rehabilitation Medicine Gran Meli WTC – Sa˜o Paulo – Brazil REGISTRATION ON LINE http://www.isprm.org/brazil CONGRESS HIGHLIGHTS Hands-On Workshops Current Mechanism-Based Treatments Multiprofessional Approach 91

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Elsevier, The Boulevard, Langford Lane, Kidlington, Oxford OX5 1GB, UK Tel: +44 (0) 1865 843297 Fax: +44(0) 1865 843958 E-mail: [email protected] 25–27 September, 2005, Albuquerque, NM Highlighting Massage Therapy in CAM Research Conference Venue: Sheraton Old Town, Albuquerque, NM Sponsored by the Massage Therapy Foundation For the latest information, please visit www.massagetherapyfoundation.org or contact (847)869-5019 Abstracts for research presentations and for educational workshops/ training sessions are currently being accepted. Please submit abstracts to [email protected] by February 1, 2005. Thursday, 24th November – Saturday, 26th November 2005 MPA2005–MUSCULOSKELETAL PHYSIOTHERAPY AUSTRALIA 14TH BIENNIAL CONFERENCE Theme: Positive Precise Performance Location: Brisbane Convention and Exhibition Centre, Brisabne, Queensland, Australia Call for Submissions: Musculoskeletal Physiotherapy Australia invites submissions form people interested in presenting papers, posters, workshops or pre or post

conference courses on the major theme of Positive Precise Performance or on the sub-themes of Pain; Lower limb function; Motor control; Musculoskeletal physiotherapy and its relationship to the fitness industry. Submission is online via mpa2005.com.au/submissions.shtml. Closing date for the receipt of submissions is 31 March 2005. Full details www.mpa2005.com.au Email: [email protected] Janet G. Travell, MD Seminar Series, Bethesda, USA For information, contact: Myopain Seminars, 7830 Old Georgetown Road, Suite C-15, Bethesda, MD 20814-2432, USA. Tel.: +1 301 656 0220; Fax: +1 301 654 0333; website: www.painpoints.com/seminars.htm; E-mail: [email protected] Evidence-based manual therapy congress Further information: www.medicongress.com Intensive courses in Manual Therapy Further information: http://allserv.rug.ac.be/bvthillo If you wish to advertise a course/conference, please contact: Karen Beeton, Department of Physiotherapy, University of Hertfordshire, College Lane, Hatfield, Herts AL10 9AB, UK. There is no charge for this service.