Manual Therapy Journal - Volume 10, Issue 3, Pages 175-238 (August 2005)

VOLUME 10 NUMBER 3 PAGES 175– 238 AUGUST 2005 Editors International Advisory Board Ann Moore PhD, GradDipPhys, FCSP, ...

Author: Editors: Ann Moore and Gwen Jull

194 downloads 721 Views 2MB Size Report

This content was uploaded by our users and we assume good faith they have the permission to share this book. If you own the copyright to this book and it is wrongfully on our website, we offer a simple DMCA procedure to remove your content from our site. Start by pressing the button below!

Report copyright / DMCA form

DOWNLOAD PDF

VOLUME 10 NUMBER 3 PAGES 175– 238 AUGUST 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 (Davenport, IA, USA) D. Lee (Delta, Canada) R. Lee (Hung Hom, Hong Kong) C. Liebenson (Los Angeles, CA, USA) 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) M.Wessely(Paris, France) 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 D.O. 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) Ulenpas 80 5655 JD Eindoven The Netherlands

Visit the journal website at http://www.intl.elsevierhealth.com/journals/math doi: 10.1016/S1356-689X(05)00088-3

ARTICLE IN PRESS

Manual Therapy 10 (2005) 175–179 www.elsevier.com/locate/math

Editorial

Improving application of neurodynamic (neural tension) testing and treatments: A message to researchers and clinicians 1. Introduction Compared with other approaches in the treatment of neuromusculoskeletal disorders, neurodynamic or neural tensions tests are relatively new, only entering manual therapy with signiﬁcance from the 1970s onwards (Grieve, 1970; Elvey, 1979; Maitland, 1979; Kenneally et al., 1988; Butler, 1991, 2000; Shacklock, 1995a, b, 2005). As a reﬂection, investigation of this growing area is also relatively new. In its youth, neural research contains problems that should be brought to the attention of the clinician and anyone who intends to conduct research into this subject. Hence, the aim of this editorial is to highlight some key issues that can be improved upon in the future. Much criticism has been directed at the neural approach, some of it being quite fair and well-founded. Nevertheless, we must accept that neural techniques are probably here to stay and it is better to have the subject researched rigorously, showing its strengths, weakness and limitations so that the ﬁeld can grow into a more mature, well balanced and well founded aspect of manual therapy. With that, several key issues related to neurodynamics research that need elucidation are as follows: nomenclature, review of the literature, ethics, scientiﬁc rigor, standardization and safety with performance of neurodynamic techniques.

2. Nomenclature Nomenclature of any specialized ﬁeld reﬂects how we think about, and apply, our knowledge of the area. A key problem with discussions of neural testing and treatment has been use of the words ‘tension’ and ‘stretch’. During the early proliferation of the neural approach, the diagnosis of ‘adverse neural tension’ became enormously popular, in fact ubiquitous, particularly in the 1990s. Whether the diagnosis has any validity is not the subject of this editorial. However, the 1356-689X/$ - see front matter r 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2005.03.001

consequences of these two words being the mainstay of diagnosis and therapy were two-fold. First, patients were treated with neural stretches because the clinician had in mind the neural tissues being too tight, such that they needed lengthening. Neural techniques were performed in a way that operated solely along this paradigm, at the expense of other crucial facets, namely neurophysiology and pain mechanisms. In fact, ‘neural stretching’ had been performed in the 1800s, with occasional disastrous results, including nerve damage (Marshall, 1883). The clinical result of more contemporary treatments has been somewhat less hapless, but still frequently consists of increased symptoms for a period of time. This has driven many therapists away from the approach out of concern for their patients and their own reputation. The term ‘adverse neural tension’ probably came from Dr. Alf Breig’s books of his classic studies on cadavers in which the biomechanics and pathomechanics of the central nervous system were illustrated and described as such (Breig, 1960, 1978). This was perpetuated in the 1990s with the popularity of other publications (Butler and Gifford, 1989; Butler, 1991) where the term was also utilized. Effectively, a neurological problem was treated as an orthopaedic one (this is not a criticism but rather a recount of where knowledge was at that time in order to explain where progress ought to head in the future). An anecdote from the early literature (Marshall, 1883) is useful here to illustrate exactly how nerve stretching started and that techniques today are not entirely different from the earlier approach. The following is an excerpt from an article that describes a lecture given to the Royal College of Surgeons of England in December 1883 by the surgeon, Dr. John Marshall. I believe if stretching with a moderate power, prolonged for a certain time, was really the modus operandi adopted by surgeons, they would have better and safer results than they have now. A sudden pull is not enough, however hard it may be: a series of jerks, also, are inadequate, for each jerk only repeats the mischief of the impression produced by the

ARTICLE IN PRESS 176

Editorial / Manual Therapy 10 (2005) 175–179

previous one; but, if you put a strain upon the nerve, and stretch continuously, say for ﬁve minutes, with a moderate pull, you are producing insensibly those internal changes of which I have spoken as essential to the production of genuine nerve-stretching. Now, with regard to pulling the nerves upwards or downwards, it does not seem, in experiments, to have had much effect. Stintzing says that, on therapeutic grounds, it would be far better to stretch downwards in tabes, and upwards in neuralgia. I should say myself, stretch both ways for neuralgia, and yet as near to the seat of severest pain as possible. It is of less consequence to stretch from the extremities in tabes; it is essential to stretch from the trunk or body. Before concluding, I must ask you to bear in mind that the cutting operation to which I have alluded hitherto is not the only way of stretching nerves; for it has been found, in the case of the sciatic, that if you bend the thigh upon the body so that the knee comes up to the chin, and then straighten the leg upon the thigh, and ﬂex the foot upon the leg, so as to stretch the ankle-joint also, you can produce an extraordinary strain and tension upon the sciatic nerve as it passes out of the pelvis. Trombetta, who is a great advocate for this method—Bilroth has the credit for introducing it, but I believe Trombetta was earlier— found that the sciatic nerve in the dead body could be stretched one inch by this proceeding; but the proceeding must be tolerably ﬁrm and resolute; and I would say, in order that it should succeed, it should be continued for ﬁve minutes. That is the sort of rule I would lay down in all these cases. Mr. Horsley has stretched the sciatic nerve on the dead body in this way, and has found that it does diminish the diameter of the nerve. He intended to have brought the specimen here to compare it with an unstretched nerve. As a matter of fact, the nerve is stretched according to Trombetta, and it is diminished in diameter according to Horsley. In a living person, I have found the exposed sciatic to be very tightly stretched by forced ﬂexion of the lower limb. Here there is an undoubted power of stretching the sciatic without a cutting operation. This description clearly refers to nerves being damaged during stretch procedures and should alert the researcher and clinician to the potential dangers of the approach and problems with the current nomenclature. It can be seen that some of the procedures still performed today host similarities to those that were executed in earlier times. Second, we had great difﬁculty in explaining the neural tension approach to our medical colleagues, and justiﬁably so, because medical practitioners often place greater emphasis on physiological and chemical mechanisms and have more scant a background in the

mechanical aspects of the human body. This is also because not much research into the validity and efﬁcacy of neural techniques had been performed. A key failure of the neural tension approach was its inability to link clinical phenomena solely to neural tension mechanisms. This is because other aspects naturally take part in the production of symptoms and physical signs with neurodynamic testing, namely physiological mechanisms such as intraneural blood ﬂow (Ogata and Naito, 1986), neural inﬂammation (Zochodne and Ho, 1991), mechanosensitivity (Calvin et al., 1982; Nordin et al., 1984) and muscle responses (Hall et al., 1995, 1998; van der Heide et al., 2001). This is why the concept of neurodynamics was proposed and its application presented (Shacklock, 1995a, b). In this proposal, it was stated that therapists ought to bring these other aspects into the analysis (discussed in more detail in Butler, 2000 and Shacklock, 2005). The corollary of integrating neurophysiological mechanisms is that these neural tests should be called ‘neurodynamic tests’, rather than ‘neural tension tests’ or ‘neural provocation tests’. Currently, research still makes use of the terms ‘neural tension’ and ‘neural stretches’ and marks a dated approach to the subject. It is recommended that these terms be replaced with those that relate to ‘neurodynamics’. The key reason for this is that the newer term highlights the fact that physiological and mechanical mechanisms act together to explain many of the clinical phenomena that we encounter and these should be borne in mind when conducting research into this area and performing treatment on patients. Also, an abnormal test has often been considered to reﬂect ‘adverse neural tension’. The problem with this is that, in the patients in whom an abnormal test is manifest, we have no direct measurements of the tension in the nervous system and can only surmise about the diagnosis. Instead, in bringing neurodynamics, i.e. mechanics and physiology, into our conceptualization of the problem, we are in a position to say that the neural tissues may be hypersensitive (a problem of pathophysiology) or have a tension problem (mechanical) or a combination of both. Alternatively, the primary mechanical fault may be one of reduced sliding (neural sliding dysfunction), which is not directly a tension problem. It could also be a compression problem that relates to the tissues that form a mechanical interface to the nervous system. This directs us to the nomenclature of what an abnormal test represents. In the event of a tension-based pattern of symptomatology being present, the problem would be called a ‘neural tension dysfunction’ that might contain pathomechanical and pathophysiological aspects. Hence, the term ‘neural tension dysfunction’ is recommended in preference to the term ‘adverse mechanical tension’. The reader should also bear in mind that this diagnosis does not in isolation offer much about the

ARTICLE IN PRESS Editorial / Manual Therapy 10 (2005) 175–179

causes, because they can be numerous. More detailed discussion on this has been presented by Shacklock (1996, 2005) and Butler (2000). A case in point is the straight leg raise (SLR) test in which the key issue of physiology linking with mechanical function of the nervous system is illustrated. The SLR is commonly impaired in cases of low back pain and sciatica. However, a key question is whether pathophysiological mechanisms can be shown scientiﬁcally to interact directly and simultaneously with mechanical issues in the nervous system in the same human subjects. Kobayashi et al. (2003) showed conclusively that such interactions occur. At surgery, they measured intraneural blood ﬂow and the amount of movement in the nerve roots in patients with sciatica. Impairment in movement of the lumbosacral nerve roots correlated directly with both reduced intraneural blood ﬂow and reduced range of motion of the SLR. Furthermore, the onset of these abnormal changes in physiology occurred at the exact same position in the range of motion of the SLR that had produced symptoms in these patients during clinical examination. Surgical release of the cause (usually disc protrusion and scarring around the nerve root resulting in adherence) produced simultaneous improvements is all these parameters.

3. Review of the literature A problem with the literature quoted in submissions on research into neurodynamic testing and treatments is that it is often second generation. This means that it is taken from books that summarize and hypothesize and does not originate from, or describe, the original scientiﬁc papers whence the neural approach arose. A detailed history of the origins of the approach is not necessary. However, it is important that readers of such research reports are reassured that the literature is reviewed from a position closest to the basic scientiﬁc research as possible, for instance, biomechanical studies of cadavers, invivo measurements of normative responses and neurophysiological and clinical investigations. For instance, in describing the slump test, Butler (1991) is often the only reference quoted. This is certainly a good reference but, in fact, the slump test was described earlier by Maitland (1979) and its modus operandi has been veriﬁed in other neurobiomechanical and clinical literature (Breig and Marions, 1963; Goddard and Reid, 1965; Breig and Troup, 1979; Troup, 1986; Beith et al., 1995). Another case in point is the upper limb ‘tension’ test. In describing the median neurodynamic test 1 (upper limb tension test 1) (Kenneally et al., 1988; Butler, 1991; Shacklock, 2005), the biomechanical literature is frequently omitted (McLellan and Swash, 1976; Selvaratnam et al., 1988;

177

Wright et al., 1996; Lewis et al., 1998; Kleinrensink et al., 2000). Hence, it is vitally important that the review of literature in submissions reﬂect a position of critical appraisal, has as solid a base in science and be taken from as wide a range of sources as possible.

4. Ethical and safety issues Many peer-reviewed journals prefer that submitted research is approved by an institutional ethics committee. What is apparent in some research is that persons on ethics committees that scrutinize submissions for neurodynamics research may not be savvy to the potential negative effects of some neural techniques, to the point that it is surprising that some research is ever approved. Some negative effects consist of pain and other symptoms and the possibility of lasting neurological consequences with strong or sustained neural techniques. Neural tissues are highly sensitive to physical insults that may produce hypoxia through the application of tension and compression (Lundborg and Rydevik, 1973; Gelberman et al., 1983; Wall et al., 1992; Lundborg and Dahlin, 1996). Strong or sustained neurodynamic tests typically constitute highly sensitized techniques and are often contraindicated in some asymptomatic subjects, let alone patients with sensitized or compromised neural tissues. The reason for mentioning this is that neurological consequences may occur with movements that tension the nervous system (Yamada et al., 1981; Pang and Wilberger, 1982; Tani et al., 1987). There is also anecdotal evidence of numbness lasting for several months after neural testing in some asymptomatic subjects. I have on occasions been asked to comment on the value of testing subjects with a sustained ‘neural tension’ test at end range for between 30 s and 3 min at a time. This clearly poses potential hazards for research subjects and our patients. Even though the optimum strength or duration for a neurodynamic test is not known, it is recommended that these facets be kept to a minimum for reasons of safety and the general duration of testing be described in research reports. Where appropriate, the existence of potential contraindications should be established prior to execution of neurodynamic tests. For instance, these can consist of tethered spinal cord for the lower quarter, brachial amyotrophy and polyneuropathy, depending on the nature of the study. Wherever this is not possible, or is impracticable, it will for safety reasons be necessary to modify the neurodynamic technique to prevent the risk of complications. Another problematic aspect of research into neurodynamic testing is neurological examination. This is because, even though neurological examination is frequently performed prior to testing in relation to

ARTICLE IN PRESS 178

Editorial / Manual Therapy 10 (2005) 175–179

inclusion and exclusion of subjects, rarely is it performed afterwards. This provides no reassurance that neurological complications have not occurred as a result of the techniques administered and this is especially relevant in studies in which sustained or forceful techniques are performed as ‘neural stretches’. Hence, a recommendation here is that it is desirable to perform neurological testing as a means of verifying that the applied techniques produced no neurological complications and contributes to the overall issue of safety. Naturally, this ought to be documented as a form of a brief morbidity report with research submissions. The same applies to documentation of any lasting symptoms after neurodynamic tests. This would, over time, contribute to a bank of knowledge on potential complications of neural testing and treatment, which is not currently available.

5. Method of neurodynamic testing 5.1. Structural differentiation Another key issue with procedures involving neurodynamic testing is whether any evidence is provided that the tests used are actually focused speciﬁcally on the nervous system as opposed to musculoskeletal structures. Structural differentiation is a manoeuvre that emphasizes the neural tissues as opposed to musculoskeletal tissues. For instance, in cases of neck investigation, release of wrist extension at the end of the median neurodynamic test 1 would be used to produce changes in neck symptoms. In the event of a change in relevant neck symptoms with wrist movement whilst holding the neck and shoulder tissues stationary, evidence of a neurodynamic mechanism taking part is present. Support for a neurodynamic mechanism also exists when a change in lumbar symptoms occurs with dorsiﬂexion with the SLR or release of neck ﬂexion with the slump test. Conversely, the argument for a neural contribution with a test is weakened considerably without performance of a structural differentiation manoeuvre. Therefore, a recommendation is that structural differentiation be an integral part of diagnosis with neurodynamic tests and some studies do not include this in their protocol. 5.2. Neurodynamic sequencing Another important aspect of neurodynamic testing is the sequence of movements. There is evidence that the application of component movements in a different order may inﬂuence the symptom response (Shacklock, 1989; Zorn et al., 1995), mechanical changes in the neural tissues (Lew et al., 1994; Tsai, 1995) and range of motion of contiguous joints (Coppieters et al., 2001). There is considerable variation in the way in which

neurodynamic tests can be performed which in turn may affect the result of the test. This means that it is important that the sequence of movements be described in detail and is so that standardization of neurodynamic sequences can be achieved and comparisons between research reports easily made. 5.3. Reliability testing Reliability is a key issue for all manual therapy techniques. The evidence in support of neurodynamic tests being reliable is good in many cases (Philip et al., 1989; Coppieters et al., 2002). However, an important error made by researchers is that, rather than verifying that their own examiners performed neurodynamic testing reliably, they merely quote the literature that supports the test they used as being reliable. The problem here is that the test is only reliable when it is performed reliably. Therefore, a recommendation is that, when appropriate, reliability testing is performed on all examiners prior to commencing experimental testing to verify that they can consistently produce a normal response in at least several asymptomatic subjects. This is naturally an important aspect of standardizing research into neurodynamic testing. In presenting shortcomings of research into neurodynamic testing and treatments, the intended message here is not that research is performed poorly. Rather it is to provide a stimulus for improved research and clinical standards in this aspect of manual therapy. This is critical for the maturation of this exciting and promising area whereby robust and ethical research and appropriate clinical application are the outcomes. Research is not a lucrative business and it is clear that those who do research in this area make huge commitments with considerable sacriﬁces in personal gain. In doing so, they make a greatly valued contribution to our patients and profession and they are to be commended highly for their efforts. I hope the research continues and that it bears the fruits it richly deserves.

References Beith I, Robins E, Richards P. An assessment of the adaptive mechanisms within and surrounding the peripheral nervous system, during changes in nerve bed length resulting from underlying joint movement. In: Shacklock M, editor. Moving in on Pain. Sydney: Butterworth-Heinemann; 1995. p. 194–203. Breig A. Biomechanics of the central nervous system. Stockholm: Almqvist and Wiksell; 1960. Breig A. Adverse mechanical tension in the central nervous system. Stockholm: Almqvist and Wiksell; 1978. Breig A, Marions O. Biomechanics of the lumbosacral nerve roots. Acta Radiologica Diagnosis 1963;1:1141–60. Breig A, Troup J. Biomechanical considerations in the straight leg raising test. Cadaveric and clinical studies of medial hip rotation. Spine 1979;4(3):242–50.

ARTICLE IN PRESS Editorial / Manual Therapy 10 (2005) 175–179 Butler D. Mobilisation of the Nervous System. Edinburgh: Churchill Livingstone; 1991. Butler D. The sensitive nervous system. Adelaide: NOI Press; 2000. Butler D, Gifford L. The concept of adverse mechanical tension in the nervous system. Physiotherapy 1989;75(11):622–36. Calvin W, Devor M, Howe J. Can neuralgias arise from minor demyelination? Spontaneous ﬁring, mechanosensitivity, and afterdischarge from conducting axons. Experimental Neurology 1982;75:755–63. Coppieters M, Stappaerts K, Evaert D, Staes P. Addition of test components during neurodynamic testing: effect on range of motion and sensory responses. Journal of Orthopaedic and Sports Physical Therapy 2001;31(5):226–37. Coppieters M, Stappaerts K, Janssens K, Jull G. Reliability of detecting ‘onset of pain’ and ‘submaximal pain’ during neural provocation testing of the upper quadrant. Physiotherapy Research International 2002;7(3):146–56. Elvey. Brachial plexus tension tests and the pathoanatomical origin of arm pain. In: Idczak R, editor. Aspects of manipulative therapy. Melbourne: Lincoln Institute of Health Sciences; 1979. p. 105–10. Gelberman R, Szabo R, Williamson R, Hargens A, Yaru N, MinteerConvery M. Tissue pressure threshold for peripheral nerve viability. Clinical Orthopaedics and Related Research 1983; 187:285–91. Goddard M, Reid J. Movements induced by straight leg raising in the lumbo-sacral roots, nerves and plexus, and in the intrapelvic section of the sciatic nerve. Journal of Neurology, Neurosurgery and Psychiatry 1965;28(12):12–8. Grieve G. Sciatica and the straight-leg raising test in manipulative treatment. Physiotherapy 1970;56:337–46. Hall T, Zusman M, Elvey R. Manually detected impediments in the straight leg raise test. In: Jull G, editor. Clinical Solutions. Ninth Biennial Conference of the Manipulative Physiotherapists’ Association of Australia. Gold Coast, Queensland; 1995. p. 48–53. Hall T, Zusman M, Elvey R. Adverse mechanical tension in the nervous system? Analysis of the straight leg raise. Manual Therapy 1998;3(3):140–6. Kenneally M, Rubenach H, Elvey R. The upper limb tension test: the SLR of the arm. In: Grant R, editor. Physical Therapy of the Cervical and Thoracic Spine. New York: Churchill Livingstone; 1988. p. 167–94 (Chapter 10). Kleinrensink GJ, Stoeckart R, Mulder PG, Hoek G, Broek T, Vleeming A, Snijders C. Upper limb tension tests as tools in the diagnosis of nerve and plexus lesions. Anatomical and biomechanical aspects. Clinical Biomechanics 2000;15(1):9–14. Kobayashi S, Shizu N, Suzuki Y, Asai T, Yoshizawa H. Changes in nerve root motion and intraradicular blood ﬂow during an intraoperative straight-leg-raising test. Spine 2003;28(13):1427–34. Lew P, Morrow C, Lew A. The effect of neck and leg ﬂexion and their sequence on the lumbar spinal cord. Implications in low back pain and sciatica. Spine 1994;19(21):2421–5. Lewis J, Ramot R, Green A. Changes in mechanical tension in the median nerve: possible implications for the upper limb tension test. Physiotherapy 1998;84(6):254–61. Lundborg G, Dahlin L. Anatomy, function and pathophysiology of peripheral nerves and nerve compression. Hand Clinics 1996;12:185–93. Lundborg G, Rydevik B. Effects of stretching the tibial nerve of the rabbit: a preliminary study of the intraneural circulation and barrier function of the perineurium. Journal of Bone and Joint Surgery 1973;55B:390–401. Maitland G. Negative disc exploration: positive canal signs. Australian Journal of Physiotherapy 1979;25(3):129–34.

179

Marshall J. Nerve stretching for the relief or cure of pain. British Medical Journal 1883:1173–9. McLellan D, Swash M. Longitudinal sliding of the median nerve during movements of the upper limb. Journal of Neurology, Neurosurgery and Psychiatry 1976;39:556–70. Nordin M, Nystrom B, Wallin U, Hagbarth K. Ectopic sensory discharges and paresthesiae in patients with disorder of peripheral nerves, dorsal roots and dorsal columns. Pain 1984;20:231–45. Ogata K, Naito M. Blood ﬂow of peripheral nerve effects of dissection, stretching and compression. Journal Hand Surgery 1986; 11B(1):10–4. Pang D, Wilberger J. Tethered cord syndrome in adults. Journal of Neurosurgery 1982;57:32–47. Philip K, Lew P, Matyas T. The intertherapist reliability of the slump test. Australian Journal of Physiotherapy 1989;35:89–94. Selvaratnam P, Glasgow E, Matyas T. Strain effects on the nerve roots of brachial plexus. Journal of Anatomy 1988;161:260–4. Shacklock M. The plantarﬂexion inversion straight leg raise. Master of applied science thesis. Adelaide: University of South Australia; 1989. Shacklock M. Neurodynamics. Physiotherapy 1995a;81:9–16. Shacklock M. Clinical application of neurodynamics. In: Shacklock M, editor. Moving in on Pain. Sydney: Butterworth-Heinemann; 1995b. p. 123–31. Shacklock M. Positive upper limb tension test is a case of surgically proven neuropathy: analysis and validity. Manual Therapy 1996;1:154–61. Shacklock M. Clinical neurodynamics: a new system of musculoskeletal treatment. Oxford: Elsevier; 2005. Tani S, Yamada S, Knighton R. Extensibility of the lumbar and sacral cord. Pathophysiology of the tethered spinal cord in cats. Journal of Neurosurgery 1987;66:116–23. Troup J. Biomechanics of the lumbar spinal canal. Clinical Biomechanics 1986;1:31–43. Tsai Y-Y. Tension change in the ulnar nerve by different order of upper limb tension test. Master of Science Thesis. Chicago: Northwestern University; 1995. Van der Heide B, Allison G, Zusman M. Pain and muscular responses to a neural tissue provocation test in the upper limb. Journal of Manual Therapy 2001;6(3):154–62. Wall E, Massie J, Kwan M, Rydevik B, Myers R, Garﬁn S. Experimental stretch neuropathy: changes in nerve conduction under tension. Journal of Bone and Joint Surgery 1992;74B(1):126–9. Wright T, Glowczewskie F, Wheeler D, Miller G, Cowin D. Excursion and strain of the median nerve. Journal of Bone and Joint Surgery 1996;78A(12):1897–903. Yamada S, Zinke D, Sanders D. Pathophysiology of ‘‘tethered cord syndrome’’. Journal of Neurosurgery 1981;54:494–503. Zochodne D, Ho L. Stimulation-induced peripheral nerve hyperemia: mediation by ﬁbers innervating vasa nervorum? Brain Research 1991;12, 546(1):113–8. Zorn P, Shacklock M, Trott P, Hall R. The effect of sequencing the movements of the upper limb tension test on the area of symptom production. Proceedings of the 9th biennial conference of the Manipulative Physiotherapists’ Association of Australia; 1995. p. 166–7.

Michael Shacklock Neurodynamic Solutions, 6th floor, 118 King William Street, Adelaide 5000, Australia E-mail address: [email protected]

ARTICLE IN PRESS

Manual Therapy 10 (2005) 180–190 www.elsevier.com/locate/math

Masterclass

Hamstring injury management—Part 2: Treatment Wayne Hoskins, Henry Pollard Macquarie Injury Management Group, Macquarie University, Sydney, Australia Received 29 December 2004; accepted 11 May 2005

Abstract The management of hamstring injuries can be described as vexed at best. One reason for this may be because of a lack of highquality research into the methods of treatment, rehabilitation and prevention. As a result, an evidence-based approach to injury management does not exist. Management is based on clinical experience, anecdotal evidence and the knowledge of the biological basis of tissue repair. Previous hamstring injury is the most recognized risk factor for injury, which indicates that treatment approaches may be suboptimal under certain conditions. The identiﬁcation of these risk factors and the methods best designed to manage them should be addressed with future research efforts. Much anecdotal and indirect evidence exists to suggest that several non-local factors contribute to injury. Despite the knowledge that these factors may exist, the literature appears almost devoid of research investigating their possible identiﬁcation and treatment. Treatment has traditionally been in the form of altering the muscle repair process through the application of electrophysical therapy and various soft-tissue-based and exercise-based techniques. Little research has investigated the role of other forms of manual therapy particularly when directed at non-local structures. This paper will explore and speculate on this potential connection and offer some new contributive factors for hamstring injury management. r 2005 Published by Elsevier Ltd. Keywords: Hamstring; Sports injury; Muscle strain; Treatment

1. Introduction The management and treatment of hamstring injuries has evolved through empiricism rather than through objective outcomes-based research. As many aspects of manual therapy are now under the spotlight of evidencebased practice ideals and outcomes, so too will the management of common sporting injuries. This is indicated by the fact that recurrent hamstring injuries commonly occur and anecdotally, tend to be more severe and disabling than the initial injury (Fried and Lloyd, 1992). On average, one in three Australian Rules football players will re-injure their hamstring on return to competition (Orchard and Seward, 2003). Risk of recurrence persists for 3 months after return to play, Corresponding author. Macquarie Injury Management Group, C/o P.O. Box 448, Cronulla, NSW 2230, Australia. Tel.: +612 9523 4600; fax: +612 9527 3856. E-mail address: [email protected] (W. Hoskins).

1356-689X/$ - see front matter r 2005 Published by Elsevier Ltd. doi:10.1016/j.math.2005.05.001

with the cumulative risk for the remainder of the season being 30.6% (Orchard and Best, 2002). In soccer, the reinjury rate is between 12% (Woods et al., 2004) and 14% (Dadebo et al., 2004). A previous or recent hamstring injury is the most recognized risk factor for future injury (Verrall et al., 2001; Orchard and Seward, 2002a). Given the high recurrence rates, hamstring injuries provide a signiﬁcant challenge to the treating clinician. Knowledge surrounding optimal treatment and preventative measures is therefore critical. This article will use the current available evidence to document the methods of hamstring injury treatment, rehabilitation and prevention. It will identify and speculate on potential local and non-local factors, which may be important in hamstring injury risk that may be addressed through the application of manual therapy. In doing so, it will provide a reﬂective essay on the status of hamstring injury management and propose some different directions for the management of hamstring injuries in the future. It will not focus heavily on

ARTICLE IN PRESS W. Hoskins, H. Pollard / Manual Therapy 10 (2005) 180–190

diagnosis, or individual treatment or rehabilitation protocols that have been covered in previous reviews (Agre, 1985; Worrell, 1994; Kujala et al., 1997; Clanton and Coupe, 1998; Croisier, 2004; Hoskins and Pollard, 2005b). In presenting this article the Medline, Mantis, Sports discus, Pedro, Cochrane and Cinahl databases were reviewed (from inception to present) with the following key words: hamstring, injury, treatment, prevention. All papers were considered in the review as due to a lack of quantity of high-level evidence; particular emphasis could not be given to the methodology used.

2. Treatment Little consensus exists as to how hamstring injuries should be effectively treated, although a multidisciplinary approach has been recommended (Croisier, 2004). Treatment should be aimed at both the local hamstring muscle injury and the non-local functional deﬁciency or aetiological factor responsible for the overload causing injury, if they exist (See Table 1) (Hoskins and Pollard, 2005a, b). Only one randomised controlled trial could be found that investigated hamstring treatment (Reynolds et al., 1995). Given the high prevalence and recurrence rates of hamstring injuries, it behoves sports clinicians to prove most favourable treatment approaches through controlled trials. It is agreed that treatment should be tailored to the grade of injury and be conservative, based on the knowledge of the biological background of the healing process, with aggressive rehabilitation (Kujala et al., 1997; Jarvinen et al., 2000). This should curtail the amount of muscle damage and reduce the occurrence of later complications. Surgery has been advocated in cases resistant to conservative therapy where scar and adhesions prevent normal functioning of the hamstrings (Kujala et al., 1997). However, surgery is rare if ever required (Woods et al., 2004). The use of cryotherapy has become the accepted initial treatment for hamstring injuries (Clanton and Coupe, 1998). Measures such as compression, elevation, rest and immobilization should also be carried out in the acute phase (Jarvinen et al., 2000). This should continue for 48–72 h as per guidelines for acute muscle injuries (Kellett, 1986). 2.1. Cryotherapy Cryotherapy has a positive effect on pain reduction, reduced inﬂammation and injury recovery (Swenson et al., 1996). Heat applied initially may affect resolution and prolong rehabilitation (Kalenak et al., 1975). In a systematic review of cryotherapy, it was concluded that few clinicians can give speciﬁc evidence-based guidance on the duration, frequency or length of ice treatment, or

181

on the use of barriers between ice and the skin (MacAuley, 2001). However, no evidence of an optimal mode or duration of treatment exists (Bleakley et al., 2004), and more high-quality, hamstring-speciﬁc trials are needed. 2.2. Immobilization The length of time for immobilization depends on the grade of injury and should not be longer than needed for the scar to bear the pulling forces without re-injury (Jarvinen et al., 2000). A tradeoff exists between strength and maturation of the scar tissue and loading, with the increasing likelihood of decreasing ﬂexibility and atrophy, which will vary according to the grade of injury. Immobilization should not be longer than 1 week, even for the most severe hamstring strain (Clanton and Coupe, 1998), as marked atrophy can occur (Jarvinen and Lehto, 1993). Relative rest should be promoted to avoid atrophy. Mobilization started immediately after injury is followed by dense scar formation in the injury area, prohibiting muscle regeneration (Jarvinen and Lehto, 1993). 2.3. Mobilization After immobilization, controlled and progressive mobilization guided by the pain response should be performed (Kannus et al., 2003). Mobilization should include pain-free strengthening (beginning with isometrics then concentrics and eccentrics last), ﬂexibility and endurance exercise programs (Geffen, 2003). Best practices of early application of loading and motion to facilitate healing have not been deﬁned. Controlled trials need to be conducted to demonstrate best practices. 2.4. Electrophysical therapies Various forms of deep heat modalities and electrical currents have been used to augment the healing process of soft tissue injuries. Evidence to support electrophysical therapies is lacking and no hamstring-speciﬁc research exists, despite their use being well established within physiotherapy practice (Watson, 2000). Ultrasound is the most widely used therapeutic agent to enhance soft tissue healing (Robertson and Baker, 2001). Despite this, meta analyses have found it no more clinically effective than placebo in the treatment of musculoskeletal injury (Gam and Johannsen, 1995; van der Windt et al., 1999; Robertson and Baker, 2001). A review also found insufﬁcient biophysical evidence to provide a scientiﬁc foundation for its clinical use (Baker et al., 2001). Very few clinical trials of interferential have been performed, meaning there is a lack of evidence to support or refute its use. No experimental or controlled clinical results have been

ARTICLE IN PRESS 182

W. Hoskins, H. Pollard / Manual Therapy 10 (2005) 180–190

Table 1 Indirect evidence and speculation for consideration, suggesting non-local factors contributing to hamstring injury which could act as a guide to constructing a complete rehabilitation and prevention program Body region

Indirect evidence and speculation

References

Lumbar–pelvis

Athletic activities can predispose SIJ dysfunction, which decreases hip range of motion and alters gait and bicep femoris activation.

Lumbar–pelvis

Biceps femoris has indirect attachments to the TLF, linking it to the shoulder, upper torso and skull. Contracture of the TLF’s attachments causes TLF displacement and may predispose SIJ dysfunction. Biceps femoris is the most commonly injured hamstring muscle, possible due to its myo-fascial relationships. Transversus abdominus and internal oblique muscles attach to the TLF and lowlevel contraction can tension the TLF. This may stabilize intersegmental lumbar motion. Low-back pain causes increased transversus abdominus activation threshold and delays activation. Earlier biceps activation also occurs which may cause the biceps femoris to compensate and stabilize the TLF.

Herzog and Conway, 1994; Cibulka et al., 1998; Hungerford et al., 2003; Brolinson et al., 2003 Vleeming et al., 1995, 1989a, b; Van Wingerden et al., 2004; Woods et al., 2004

Lumbar–pelvic

Lumbar–pelvis Lumbar–pelvis

Lumbar–pelvis Lumbar–pelvis

Lumbar–pelvis

Lumbar–pelvis

Lumbar–pelvis Lumbar–pelvis

Lumbar–pelvis

Lumbar–pelvis

Lumbar–pelvis

Lumbar–pelvis and lower limb Lower limb

Lower limb Lower limb

Previous groin injuries and osteitis pubis are a risk for hamstring injury, which links pelvic function to injury. Lumbar spine, SIJ or pelvic dysfunction may cause residual hamstring weakness and predispose recurrent injuries. SIJ manipulation increases hamstring strength in hamstring-injured athletes. Restricted movement through the lumbar spine or pelvis and the hamstrings myofascial connections may cause the hamstrings to be overloaded. Neuromuscular rehabilitation decreases re-injury rates more than standard rehabilitation. Decreased proprioception and side to side weight bearing exists in low-back pain populations. Injury may occur through inappropriate neuromuscular control or proprioception levels. Faster gait has less stance phase, requiring more precise lumbar–pelvis neuromuscular control. Faster athletes have a greater risk of injury. Delayed activation, atrophy and decreased endurance of lumbar multiﬁdus occurs following back pain, causing altered lumbar intersegmental stabilization. Low-back pain and injury causes decreased hamstring extensibility and predisposes referred pain. Up to 45% of hamstring injuries have no evidence of muscle damage. The L4/5 and L5/S1 spinal levels degenerate earlier, especially in athletes, and an L5 and S1 injury pattern exists, especially in older athletes. Forward lean gait, which causes a lengthening of the hamstring muscles, is a common cause of injury. Forward lean may result from gluteus maximus weakness and requires increased lumbar erector spinae activity, both of which alter with low-back pain. Excessive lumbar lordosis exists in athletes with hamstring injuries, while lumbar–pelvis postural deformities predispose lower limb injuries anatomically associated with the site of deﬁciency. Gluteus maximus provides powerful hip extension when sprinting. Hamstrings should act as a transducer of power. Chronic low-back pain alters gluteus maximus ﬁring, causing hamstrings to be overactive which may predispose injury. Tight hip ﬂexors and increased thoracic kyphosis with decreased mobility may cause an anterior tilted pelvis, which is a risk factor for hamstring injury. Increased kyphosis will affect hamstrings myo-fascial connections. Fatigue has been linked with injury. Fatigue is known to decrease lower extremity and lumbar–pelvis proprioceptive acuity. Attachment of the biceps femoris to the ﬁbula and peroneus longus links it to the function of the superior tibial–ﬁbular joint, ankle and foot, suggesting they should be assessed with injury. Semimembranosus is anatomically and functionally linked to the knee joint. A past knee injury is a risk factor for injury. The hamstring-ACL arc and afferent input from proprioceptors, mechanoreceptors and cutaneous receptors may be important for the function of hamstrings in gait, especially during the terminal stages of swing phase where injury commonly occurs. Proprioception deﬁciency occurs following knee injury.

Gracovetsky et al., 1981; Bogduk and Macintosh, 1984; Macintosh et al., 1987; McGill and Norman, 1988; Vleeming et al., 1995; Hodges and Richardson, 1997, 1998; Hodges et al., 2003; Hungerford et al., 2003; Barker et al., 2004 Verrall et al., 2001 Cibulka et al., 1986; Jonhagen et al., 1994; Croisier et al., 2002 Sihvonen, 1997 Brumagne et al., 2000; Newcomer et al., 2000; Childs et al., 2003; O’Sullivan et al., 2003; Sherry and Best, 2004 Thorstensson et al., 1982; Biedermann et al., 1991; Hides et al., 1996; Hodges and Richardson, 1998; Watson, 2001; Hodges et al., 2003; Hodges and Moseley, 2003 Verrall et al., 2001; Halbertsma et al., 2001; Woods et al., 2004 Orchard et al., 2002b; Ong et al., 2003; Woods et al., 2004 Carlson et al., 1988; Orchard, 2002; Hodges and Moseley, 2003; Vogt et al., 2003

Hennessey and Watson, 1993; Watson, 1995, 2001 Simonsen et al., 1985; Jacobs et al., 1996; Vogt et al., 2003 Cibulka et al., 1986; Janda, 1996; Barker and Briggs, 1999; Leibenson, 2001 Johnston et al., 1998; Taimela et al., 1999; Miura et al., 2004 Moore and Dalley, 1999; Weinert et al., 1973; Woods et al., 2004 Bejui et al., 1984; Moore and Dalley, 1999; Verrall et al., 2001; Beltran et al., 2003 Osternig et al., 1995; Duysens et al., 1998; Roberts et al., 1999; Christensen et al., 2000; Tsuda et al., 2001

SIJ ¼ sacroiliac joint, TLF ¼ thoracolumbar fascia, ACL ¼ anterior cruciate ligament.

presented to support diadynamic current (Hamalainen and Kemppainen, 1990). The clinical effectiveness of transcutaneous electrical nerve stimulation is controver-

sial, with some studies supporting and others refuting its clinical use (Sluka and Walsh, 2003). The efﬁcacy of laser therapy for musculoskeletal disorders is average

ARTICLE IN PRESS W. Hoskins, H. Pollard / Manual Therapy 10 (2005) 180–190

(Beckerman et al., 1992; Gam et al., 1993). There is no evidence suggesting electrophysical therapies should be used in the management of hamstring injuries. 2.5. Non-steroidal anti-inflammatory medication (NSAIDs) NSAIDs have been described as the keystone for treating hamstring strains (Clanton and Coupe, 1998) and are generally used in a multimodal approach to hamstring management. Despite this, literature reviews conclude that the beneﬁts for managing soft tissue injuries have not been clearly demonstrated in clinical trials (Almekinders and Gilbert, 1986). A double-blind, placebo, controlled trial of NSAIDs in combination with physiotherapy modalities on the rate of healing of acute hamstring muscle tears found no additive effect on the healing rate (Reynolds et al., 1995). For severe injuries, reported pain scores at day 7 were signiﬁcantly lower in the placebo group. Animal studies suggest NSAIDs may be beneﬁcial early on for pain control, however, long term use may delay the repair process and muscle regeneration (Almekinders and Gilbert, 1986; Obremsky et al., 1994). Furthermore, the routine use of NSAIDs in muscle injuries may need to be critically evaluated because low-cost and low-risk analgesics may be just as effective (Rahusen et al., 2004). The use of NSAIDs is not recommended in an evidence-based approach for the management of hamstring injuries.

3. Non-hamstring sources of pain and dysfunction The sacroiliac joint (SIJ) is the link between the lower extremities and spine (Brolinson et al., 2003). It has been suggested that during athletic activities the SIJ sustains higher loads than normal, predisposing dysfunction (Brolinson et al., 2003). Dysfunction is related to reduced or asymmetric range of motion at the hip (Cibulka et al., 1998), altered gait (Herzog and Conway, 1994), earlier activation of biceps femoris during forward ﬂexion and altered lumbopelvic stabilization (Hungerford et al., 2003). This will disrupt load transference through the pelvis and possibly increase injury. A past history of groin injury and osteitis pubis, being signiﬁcant risk factors for hamstring injury, is evidence that altered pelvic mechanics may play a role in injury (Verrall et al., 2001). One clinical trial has looked at the effectiveness of SIJ manipulation in the treatment of hamstring muscle strains (Cibulka et al., 1986). Although small with non-blinded assessors, the manipulation group had signiﬁcantly increased hamstring peak torque compared to the control group. Referred pain from the lumbar spine, sciatic nerve or gluteal and piriformis muscles can mimic grade 1

183

hamstring strains (Verrall et al., 2001). Injury surveillances use an umbrella term for hamstring injuries and fail to differentiate the diagnosis, meaning the true prevalence of ‘back related’ hamstring injuries is unknown. Using MRI to conﬁrm diagnosis, 14–19% of all hamstring injuries are without muscle damage (Verrall et al., 2001; Verrall et al., 2003; Woods et al., 2004), suggesting no local muscle pathology. A recent study found this ﬁgure to be as high as 45% (Gibbs et al., 2004). Back-related hamstring injuries are classiﬁed as having both local hamstring signs and positive lumbar signs (Bennell et al., 1998; Orchard, 2001) and require different treatment methods than simple muscular–tendon strains. The slump test is said to signiﬁcantly differentiate referred posterior thigh pain from that due to hamstring injury (Kornberg and Lew, 1989; Lew and Briggs, 1997) as it is assumed to be a measure of ‘neural tension’ or ‘adverse mechanical tension in the nervous system’, which are postulated to predispose to hamstring injury (Butler and Gifford, 1989; Kornberg and Lew, 1989) (Fig. 1). However, the functional anatomical connections of the hamstrings have implications for orthopaedic tests used to measure neural tension such as the slump test (Barker and Briggs, 1999), as it may be myo-fascial tension, or possibly a combination. In a small controlled study assessing recurrent hamstring strains, signiﬁcant neural tension identiﬁed by the slump test was present, while hamstring ﬂexibility did not vary (Turl and George, 1998). This could indicate that the TLF system is involved with recurrent injuries. When the slump test is positive, using the slump test as a treatment procedure with traditional physiotherapy treatment has been found to be more beneﬁcial in returning athletes to competition than standard physiotherapy treatment alone (Kornberg and Lew, 1989). This provides evidence that the low back and pelvis and the myo-fascial system should be assessed for treatment and prevention of injury. Alternative methods to slump stretching, including spinal manipulative therapy (SMT) and other forms of manual therapy, should be investigated for the treatment of hamstring injuries. Hamstring injuries may occur due to poor functioning of the lumbar spine. In people with low-back pain and injury, restricted range of motion and decreased extensibility of the hamstrings exists (Halbertsma et al., 2001). A past history of back injury correlates with an increased risk of referred pain and back-related hamstring injuries (Verrall et al., 2001). The low back is also related to the hamstrings by the action of the lumbar–pelvic rhythm; the coordinated action of the pelvis, lumbar spine and hips, during trunk ﬂexion (Sihvonen, 1997). If the pelvic or lumbar spine component is limited, it may put extra stress on the hamstrings, particularly when in a lengthened position at the end of the swing phase of gait where injury often occurs.

ARTICLE IN PRESS 184

W. Hoskins, H. Pollard / Manual Therapy 10 (2005) 180–190

Fig. 1. Slump stretching procedure.

A relationship between age and hamstring, calf and Achilles injuries (with a L5/S1 nerve supply) exists in Australian Rules football players, whereas this does not exist for L2-4 innervated muscles (Orchard and Seward, 2002b). Hamstring injuries are also signiﬁcantly more likely in older elite athletes (Woods et al., 2004). The L4/5 and particularly L5/S1 levels are the most common areas for spinal degeneration and athletes are susceptible to degenerative changes at an earlier age than the normal population (Ong et al., 2003). It may be speculated that altered neural input may be contributing to causing or prolonging hamstring injuries; however, this is yet to be scientiﬁcally associated with injury. Proprioceptive defects as determined by lumbar–pelvic position sense are known to exist in low-back pain populations (Brumagne et al., 2000; Newcomer et al., 2000; O’Sullivan et al., 2003), which may contribute to hamstring injury through alterations in neuromuscular motor control or through resultant lumbar–pelvic functional instability. Subjects with low-back pain are also known to demonstrate signiﬁcantly greater side to

side bearing asymmetry than healthy control subjects (Childs et al., 2003), which show immediate improvement following application of high-velocity SMT (Childs et al., 2004). This could imply that methods of improving lumbar–pelvic proprioception may be warranted in the management of hamstring injuries in subjects with a history of low-back pain. 3.1. Spinal manipulative therapy Evidence provided by human and animal studies has established that lumbar zygopophyseal joints (McLain and Pickar, 1998), ligaments (interspinal, supraspinal anterior longitudinal, posterior longitudinal and ligamentum ﬂavae (Gronblad et al., 1991; Jiang et al., 1995; Roberts et al., 1995), intervertebral discs (Roberts et al., 1995) and muscles (Nitz and Peck, 1986) as well as the SIJs (Vilensky et al., 2002) are innervated with mechanoreceptors. Mechanoreceptors transform mechanical force, or displacement into action potentials (Price, 1988). Through afferent input to the central nervous

ARTICLE IN PRESS W. Hoskins, H. Pollard / Manual Therapy 10 (2005) 180–190

system, mechanoreceptors provide complex sensory feedback which is required to update and modify motor functions by the coordination of muscle function and is integral for normal joint motion and protection (Krogsgaard and Solomonow, 2002). For this reason, the identiﬁcation of a reﬂex arc from mechanoreceptors to the multiﬁdus muscles in the lumbo-pelvic spine has been described as an emerging concept important in neurological mechanisms for the protection and stability of the spine (Solomonow et al., 1999). Human (Solomonow et al., 1998) and animal studies (Indahl et al., 1995, 1999) have identiﬁed that lumbo-pelvic mechanoreceptor stimulation can induce reﬂex change in multiﬁdus muscle activation capable of stabilizing and stiffening the spine. The extent of innervation and symmetrical distribution pattern of such receptors has been hypothesized to support this process (Jiang et al., 1995). The small number of receptive nerve endings in lumbar facet capsules also suggests that these receptors may have a relatively large receptive ﬁeld, indicating that small amounts of damage may disproportionately impact on joint function and stability (McLain and Pickar, 1998). Low-back pain subjects are known to display signiﬁcantly lower muscle activity of multiﬁdus muscles during coordination activities (Danneels et al., 2002) and this activity may be a consequence of such hypothesized damage. SMT is commonly used to manage such complaints (Swenson and Haldeman, 2003) (Fig. 2). As the cause of hamstring injury can often be associated with non-local factors including lumbo-pelvic conditions (Hoskins and

185

Pollard, 2005a, b), SMT may be an appropriate intervention for the management of hamstring injury in some circumstances. The mechanisms underlying the beneﬁts of SMT are not well understood. Data from animal studies suggest that a high-velocity, short duration load delivered during the impulse of SMT can stimulate muscle spindles, pacinian corpuscles and golgi tendon organs more than preload or that achieved by mobilizations (Pickar and Wheeler, 2001). SMT has been identiﬁed to produce gapping of the zygopophyseal joint present on MRI greater than just side posture positioning, the effects of which were present 15 min after the procedure (Cramer et al., 2002). It has been hypothesized that there is a possibility that tissues surrounding the facet joint could be stretched for periods of time longer than the duration of SMT itself (Pickar, 2002). It may be hypothesized that a physiological effect of SMT may relate to discharge of proprioception producing multiﬁdus activation and spinal stabilization. To support this view, reﬂex responses from erector spinae muscles have been observed after high-velocity mechanically assisted SMT (Colloca and Keller, 2001), while signiﬁcantly increased sEMG activity of erector spinae isometric muscle output has also been demonstrated (Keller and Colloca, 2000). Other literature has documented that high-velocity SMT was capable of eliciting muscle activation, whereas slow force application did not (Herzog et al., 1995). Further to this hypothesis is the observation that the audible release did not (by itself) evoke muscle activation or a joint proprioceptive reﬂex response as has been

Fig. 2. Short lever, high-velocity thrust manipulation technique for the sacroiliac joint.

ARTICLE IN PRESS 186

W. Hoskins, H. Pollard / Manual Therapy 10 (2005) 180–190

speculated in the literature (Bateman et al., 2004). This is espoused by the fact that most prominent mechanoreceptor types identiﬁed in zygopophyseal joints are type II which are classiﬁed as being dynamic, responding to rapid motion (McLain, 1994; McLain and Pickar, 1998). The unique neurophysiologic effects provide enough theoretical rationale for high-velocity SMT and mobilization to be assessed independently as individual clinical interventions.

4. Rehabilitation No consensus exists for the rehabilitation of hamstring strains. This may be due to the lack of knowledge of the aetiological and predisposing factors for injury. Correct treatment should take steps to address the aetiological factors underlying initial injury to prevent recurrence (Croisier, 2004). Several individual rehabilitation protocols have been published; however, only one small randomly controlled trial (n ¼ 24) has been performed looking at rehabilitation methods (Sherry and Best, 2004). In this study, a program of rehabilitation focusing on static stretching, progressive resistance and icing was compared with a program focusing on progressive agility, trunk neuromuscular stabilization exercises and icing. Whilst there was no difference between the groups in return to play time, there was signiﬁcant less re-injury over the critical 2-week period and over the course of a year for the agility and neuromuscular stabilization group. This suggests that a lack of neuromuscular control of the trunk and pelvis may contribute to and predispose initial injury. Neuromuscular control and proprioceptive defects as determined by lumbar–pelvic position sense are known to exist in low-back pain populations (Brumagne et al., 2000; Newcomer et al., 2000; O’Sullivan et al., 2003), which may contribute to hamstring injury through deﬁciency in neuromuscular motor control of the hamstring muscles or through resultant lumbar–pelvic functional instability. Methods of improving neuromuscular control and lumbar–pelvic proprioception for the rehabilitation and prevention of hamstring injuries need to be identiﬁed. It is agreed that for rehabilitation it is important to restore strength, endurance and ﬂexibility prior to return to competition to help prevent recurrence of injury. Isokinetic normalization by rehabilitation has been shown to signiﬁcantly reduce hamstring muscle re-injury (Croisier et al., 2002). Alternate activities should be provided to improve physiological and psychological outlook (Croce and Gregg, 1991) and so the non-injured muscles remain active and cardiovascular ﬁtness maintained (Croce and Gregg, 1991; Irrgang et al., 1995). Return to jogging and cross training activities is possible as they are unlikely to stress the hamstring muscles.

Functional rehabilitation incorporating coordination, skill patterns, power and agility to progress the athlete to highly complex movement patterns and sport-speciﬁc activities should be incorporated in rehabilitation (Lephart and Henry, 1995), but at what stage is unknown. This is as exercises that isolate muscles will not mimic the way they are actually used (Rutherford, 1988) and gains made in training are usually limited to the positions or ranges of motions used (Sale and MacDougall, 1981). Monitoring and benchmarking progress should occur so adjustments to the rehabilitation program can be made according to progress (Knight, 1985). Goals and objective criteria of function should be established (Lephart and Henry, 1995), which ideally should be met before a return to normal activity (Hawkins et al., 2001). However, no consensus exists as to when an athlete can safely return to competition (Orchard and Best, 2002). It has been suggested that return to full speed running and training should only occur when normal hamstring strength (490% of the uninjured side) and range of motion have returned (Heiser et al., 1984). Research is needed to clarify the efﬁcacy of speciﬁc rehabilitation protocols to develop best practices and establish return to competition protocols. The speciﬁc adaptation to imposed demands (SAID) concept is one of the underlying tenets of the strength and conditioning ﬁeld, as the largest strength gains will be realized if training is performed using the same muscle action required in performance. SAID is known to produce greater improvements in performance (Augustsson et al., 1998). As the hamstring muscle group is commonly injured in an eccentric phase of contraction (Hoskins and Pollard, 2005b), it would seem appropriate that dynamic eccentric exercise could potentially prevent and effectively rehabilitate hamstring injuries. Including eccentric actions in exercise is also known to produce the greatest dynamic strength improvements (Dudley et al., 1991). Despite this, only one controlled study could be found emphasizing eccentric hamstring overload to prevent injury (Askling et al., 2003). In this study, preseason eccentric strength training signiﬁcantly decreased the occurrence of hamstring strain. Increases in strength and speed were also demonstrated. Eccentric training in rats is known to prevent ultra-structural muscle injury (Lynch et al., 1997). Research is needed to determine the best methods of eccentric exercise, such as down hill running (Eston et al., 1995), to prevent injury and for rehabilitation and performance enhancement. 4.1. Psychological rehabilitation Rehabilitation should involve psychological considerations (Crossman, 1997). Anxiety, low self esteem and depression are experienced frequently by injured athletes

ARTICLE IN PRESS W. Hoskins, H. Pollard / Manual Therapy 10 (2005) 180–190

and non-compliance to the rehabilitation program as a result is a signiﬁcant problem (Smith, 1996; Ford and Gordon, 1997). A review of the psychological impact of injuries found that interventions such as positive selftalk, relaxation, goal setting and healing imagery all resulted in faster healing in athletes (Smith, 1996). The role of psychological rehabilitation, particularly in the case of recurrent hamstring strain, requires further research.

5. Conclusions Given the prevalence of hamstring injuries, rates of recurrence and costs involved, future research should investigate treatment efﬁcacy, prevention and return to play outcomes in an evidence-based paradigm. Randomized controlled trials with long-term follow up are encouraged. In addition, less emphasis should be given to unimodal methods of treatment and a greater emphasis on multimodal aspects of care. On the basis of the indirect evidence and speculation, it would appear that several non-local factors potentially contribute to hamstring injury. Despite much anecdotal and indirect evidence, further research should speciﬁcally target this proposed association. Further research should investigate commonly used protocols and therapies currently used to manage hamstring injury, as well as other newer approaches that incorporate spinal manipulation in multimodal management approaches of hamstring injury in selected cases.

Acknowledgements No source of funding was used in the preparation of this manuscript. The authors have no conﬂict of interest that is directly relevant to the content of this manuscript. References Agre JC. Hamstring injuries. Proposed aetiological factors, prevention, and treatment. Sports Medicine 1985;2(1):21–33. Almekinders LC, Gilbert JA. Healing of experimental muscle strains and the effects of nonsteroidal antiinﬂammatory medication. The American Journal of Sports Medicine 1986;14(4):303–8. Askling C, Karlsson J, Thorstensson A. Hamstring injury occurrence in elite soccer players after preseason strength training with eccentric overload. Scandinavian Journal of Medicine & Science in Sports 2003;13(4):244–50. Augustsson J, Esko A, Thomee R, Svantesson U. Weight training of the thigh muscles using closed vs. open kinetic chain exercises: a comparison of performance enhancement. The Journal of Orthopaedic and Sports Physical Therapy 1998;27(1):3–8. Baker KG, Robertson VJ, Duck FA. A review of therapeutic ultrasound: biophysical effects. Physical Therapy 2001;81(7): 1351–8.

187

Barker PJ, Briggs CA. Attachments of the posterior layer of lumbar fascia. Spine 1999;24(17):1757–64. Barker PJ, Briggs CA, Bogeski G. Tensile transmission across the lumbar fasciae in unembalmed cadavers: effects of tension to various muscular attachments. Spine 2004;29(2):129–38. Bateman W, Pollard H, Vemulpad S. Spinal manipulation in Australia: to what extent does Australian legislation protect the public and the professions? Chiropractic Journal of Australia 2004;34(2):129–35. Beckerman H, de Bie RA, Bouter LM, De Cuyper HJ, Oostendorp RA. The efﬁcacy of laser therapy for musculoskeletal and skin disorders: a criteria-based meta-analysis of randomized clinical trials. Physical Therapy 1992;72(7):483–91. Bejui J, Walch G, Gonon GP, Carret JP, Neidhardt JH, Fischer LP. Anatomical and functional study on the musculus semimembranosus. Anatomia Clinica 1984;6(3):215–23. Beltran J, Matityahu A, Hwang K, Jbara M, Maimon R, Padron M, Mota J, Beltran L, Sundaram M. The distal semimembranosus complex: normal MR anatomy, variants, biomechanics and pathology. Skeletal Radiology 2003;32(8):435–45. Bennell K, Wajswelner H, Lew P, Schall-Riaucour A, Leslie S, Plant D, Cirone J. Isokinetic strength testing does not predict hamstring injury in Australian Rules footballers. British Journal of Sports Medicine 1998;32(4):309–14. Biedermann HJ, Shanks GL, Forrest WJ, Inglis J. Power spectrum analyses of electromyographic activity. Discriminators in the differential assessment of patients with chronic low-back pain. Spine 1991;16(10):1179–84. Bleakley C, McDonough S, MacAuley D. The use of ice in the treatment of acute soft-tissue injury: a systematic review of randomized controlled trials. The American Journal of Sports Medicine 2004;32(1):251–61. Bogduk N, Macintosh JE. The applied anatomy of the thoracolumbar fascia. Spine 1984;9(2):164–70. Brolinson PG, Kozar AJ, Cibor G. Sacroiliac joint dysfunction in athletes. Current Sports Medicine Reports 2003;2(1):47–56. Brumagne S, Cordo P, Lysens R, Verschueren S, Swinnen S. The role of paraspinal muscle spindles in lumbosacral position sense in individuals with and without low back pain. Spine 2000;25(8): 989–94. Butler DS, Gifford L. The concept of adverse mechanical tension in the nervous system. Part one: testing for ‘dural tension’. Physiotherapy 1989;75:622–9. Carlson H, Thorstensson A, Nilsson J. Lumbar back muscle activity during locomotion: effects of voluntary modiﬁcations of normal trunk movements. Acta Physiologica Scandinavica 1988;133(3): 343–53. Childs JD, Piva SR, Erhard RE, Hicks G. Side-to-side weight-bearing asymmetry in subjects with low back pain. Manual Therapy 2003;8(3):166–9. Childs JD, Piva SR, Erhard RE. Immediate improvements in side-toside weight bearing and iliac crest symmetry after manipulation in patients with low back pain. Journal of Manipulative and Physiological Therapeutics 2004;27(5):306–13. Christensen LO, Petersen N, Andersen JB, Sinkjaer T, Nielsen JB. Evidence for transcortical reﬂex pathways in the lower limb of man. Progress in Neurobiology 2000;62(3):251–72. Cibulka MT, Rose SJ, Delitto A, Sinacore DR. Hamstring muscle strain treated by mobilizing the sacroiliac joint. Physical Therapy 1986;66(8):1220–3. Cibulka MT, Sinacore DR, Cromer GS, Delitto A. Unilateral hip rotation range of motion asymmetry in patients with sacroiliac joint regional pain. Spine 1998;23(9):1009–15. Clanton TO, Coupe KJ. Hamstring strains in athletes: diagnosis and treatment. The Journal of the American Academy of Orthopaedic Surgeons 1998;6(4):237–48.

ARTICLE IN PRESS 188

W. Hoskins, H. Pollard / Manual Therapy 10 (2005) 180–190

Colloca CJ, Keller TS. Electromyographic reﬂex responses to mechanical force, manually assisted spinal manipulative therapy. Spine 2001;26(10):1117–24. Cramer GD, Gregerson DM, Knudsen JT, Hubbard BB, Ustas LM, Cantu JA. The effects of side-posture positioning and spinal adjusting on the lumbar Z joints: a randomized controlled trial with sixty-four subjects. Spine 2002;27(22):2459–66. Croce P, Gregg JR. Keeping ﬁt when injured. Clinics in Sports Medicine 1991;10(1):181–95. Croisier JL. Factors associated with recurrent hamstring injuries. Sports Medicine 2004;34(10):681–95. Croisier JL, Forthomme B, Namurois MH, Vanderthommen M, Crielaard JM. Hamstring muscle strain recurrence and strength performance disorders. The American Journal of Sports Medicine 2002;30(2):199–203. Crossman J. Psychological rehabilitation from sports injuries. Sports Medicine 1997;23(5):333–9. Dadebo B, White J, George KP. A survey of ﬂexibility training protocols and hamstring strains in professional football clubs in England. British Journal of Sports Medicine 2004;38(4):388–94. Danneels LA, Coorevits PL, Cools AM, Vanderstraeten GG, Cambier DC, Witvrouw EE, De CH. Differences in electromyographic activity in the multiﬁdus muscle and the iliocostalis lumborum between healthy subjects and patients with sub-acute and chronic low back pain. European Spine Journal 2002;11(1):13–9. Dudley GA, Tesch PA, Miller BJ, Buchannan P. Importance of eccentric actions in performance adaptations to resistance training. Aviation, Space and Environmental Medicine 1991;62:543–50. Duysens J, van Wezel BM, van de Crommert HW, Faist M, Kooloos JG. The role of afferent feedback in the control of hamstrings activity during human gait. European Journal of Morphology 1998;36(4-5):293–9. Eston RG, Mickleborough J, Baltzopoulos V. Eccentric activation and muscle damage: biomechanical and physiological considerations during downhill running. British Journal of Sports Medicine 1995;29(2):89–94. Ford IW, Gordon S. Perspectives of sport physiotherapists on the frequency and signiﬁcance of psychological factors in professional practice: implications for curriculum design in professional training. Australian Journal of Science and Medicine in Sport 1997;29(2):34–40. Fried T, Lloyd GJ. An overview of common soccer injuries. Management and prevention. Sports Medicine 1992;14(4):269–75. Gam AN, Johannsen F. Ultrasound therapy in musculoskeletal disorders: a meta-analysis. Pain 1995;63(1):85–91. Gam AN, Thorsen H, Lonnberg F. The effect of low-level laser therapy on musculoskeletal pain: a meta-analysis. Pain 1993;52(1):63–6. Geffen SJ. Rehabilitation principles for treating chronic musculoskeletal injuries. The Medical Journal of Australia 2003;178(5): 238–42. Gibbs NJ, Cross TM, Cameron M, Houang MT. The accuracy of MRI in predicting recovery and recurrence of acute grade one hamstring muscle strains within the same season in Australian Rules football players. Journal of Science and Medicine in Sport 2004;7(2):248–58. Gracovetsky S, Farfan HF, Lamy C. Mechanism of the lumbar spine. Spine 1981;6(1):249–62. Gronblad M, Weinstein JN, Santavirta S. Immunohistochemical observations on spinal tissue innervation. A review of hypothetical mechanisms of back pain. Acta Orthopaedica Scandinavica 1991;62(6):614–22. Halbertsma JP, Goeken LN, Hof AL, Groothoff JW, Eisma WH. Extensibility and stiffness of the hamstrings in patients with nonspeciﬁc low back pain. Archives of Physical Medicine and Rehabilitation 2001;82(2):232–8.

Hamalainen O, Kemppainen P. Experimentally induced ischemic pain and so-called diaphase ﬁx current. Scandinavian Journal of Rehabilitation Medicine 1990;22(1):25–7. Hawkins RD, Hulse MA, Wilkinson C, Hodson A, Gibson M. The association football medical research programme: an audit of injuries in professional football. British Journal of Sports Medicine 2001;35(1):43–7. Heiser TM, Weber J, Sullivan G, Clare P, Jacobs RR. Prophylaxis and management of hamstring muscle injuries in intercollegiate football players. The American Journal of Sports Medicine 1984;12(5): 368–70. Hennessey L, Watson AW. Flexibility and posture assessment in relation to hamstring injury. British Journal of Sports Medicine 1993;27(4):243–6. Herzog W, Conway PJ. Gait analysis of sacroiliac joint patients. Journal of Manipulative Physiological Therapeutics 1994;17(2): 124–7. Herzog W, Conway PJ, Zhang YT, Gal J, Guimaraes AC. Reﬂex responses associated with manipulative treatments on the thoracic spine: a pilot study. Journal of Manipulative & Physiological Therapeutics 1995;18(4):233–6. Hides JA, Richardson CA, Jull GA. Multiﬁdus muscle recovery is not automatic after resolution of acute, ﬁrst-episode low back pain. Spine 1996;21(23):2763–9. Hodges PW, Moseley GL. Pain and motor control of the lumbo-pelvic region: effect and possible mechanisms. Journal of Electromyography and Kinesiology 2003;13(4):361–70. Hodges PW, Richardson CA. Relationship between limb movement speed and associated contraction of the trunk muscles. Ergonomics 1997;40(11):1220–30. Hodges PW, Richardson CA. Delayed postural contraction of transversus abdominis in low back pain associated with movement of the lower limb. Journal of Spinal Disorders 1998;11(1): 46–56. Hodges PW, Moseley GL, Gabrielsson AH, Gandevia SC. Acute experimental pain changes postural recruitment of the trunk muscles in pain free humans. Experimental Brain Research 2003;151:262–71. Hoskins WT, Pollard HP. Successful management of hamstring injuries in Australian Rules footballers: two case reports. Chiropractic and Osteopathy 2005a;13:4. Hoskins WT, Pollard HP. Hamstring injury management: part one: issues in diagnosis. Manual Therapy 2005b;10(2):96–107. Hungerford B, Gilleard W, Hodges P. Evidence of altered lumbopelvic muscle recruitment in the presence of sacroiliac joint pain. Spine 5 2003;28(14):1593–600. Indahl A, Kaigle A, Reikeras O, Holm S. Electromyographic response of the porcine multiﬁdus musculature after nerve stimulation. Spine 1995;20(24):2652–8. Indahl A, Kaigle A, Reikeras O, Holm S. Sacroiliac joint involvement in activation of the porcine spinal and gluteal musculature. Journal of Spinal Disorders 1999;12(4):325–30. Irrgang JJ, Delitto A, Hagen B, Huber F, Pezzullo D. Rehabilitation of the injured athlete. The Orthopedic Clinics of North America 1995;26(3):561–77. Jacobs R, Bobbert MF, van Ingen Schenau GJ. Mechanical output from individual muscles during explosive leg extensions: the role of biarticular muscles. Journal of Biomechanics 1996;29(4):513–23. Janda V. Evaluation of muscular imbalance. In: Liebenson C, editor. Rehabilitation of the spine. Baltimore: Lippincott Williams & Wilkins; 1996. p. 97–112 Chapter 6. Jarvinen MJ, Lehto MU. The effects of early mobilisation and immobilisation on the healing process following muscle injuries. Sports Medicine 1993;15(2):78–89. Jarvinen TA, Kaariainen M, Jarvinen M, Kalimo H. Muscle strain injuries. Current Opinion in Rheumatology 2000;12(2):155–61.

ARTICLE IN PRESS W. Hoskins, H. Pollard / Manual Therapy 10 (2005) 180–190 Jiang H, Russell G, Raso VJ, Moreau MJ, Hill DL, Bagnall KM. The nature and distribution of the innervation of human supraspinal and interspinal ligaments. Spine 1995;20(8):869–76. Johnston 3rd RB, Howard ME, Cawley PW, Losse GM. Effect of lower extremity muscular fatigue on motor control performance. Medicine and Science in Sports and Exercise 1998;30(12):1703–7. Jonhagen S, Nemeth G, Eriksson E. Hamstring injuries in sprinters. The role of concentric and eccentric hamstring muscle strength and ﬂexibility. The American Journal of Sports Medicine 1994;22(2): 262–6. Kalenak A, Medlar CE, Fleagle SB, Hochberg WJ. Athletic injuries: heat vs. cold. American Family Physician 1975;12(5):131–4. Kannus P, Parkkari J, Jarvinen TL, Jarvinen TA, Jarvinen M. Basic science and clinical studies coincide: active treatment approach is needed after a sports injury. Scandinavian Journal of Medicine & Science in Sports 2003;13(3):150–4. Keller TS, Colloca CJ. Mechanical force spinal manipulation increases trunk muscle strength assessed by electromyography: a comparative clinical trial. Journal of Manipulative & Physiological Therapeutics 2000;23(9):585–95. Kellett J. Acute soft tissue injuries—a review of the literature. Medicine and Science in Sports and Exercise 1986;18(5):489–500. Knight KL. Guidelines for rehabilitation of sports injuries. Clinics in Sports Medicine 1985;4(3):405–16. Kornberg C, Lew P. The effect of stretching neural structures on grade one hamstring injuries. The Journal of Orthopaedic and Sports Physical Therapy 1989;10:481–7. Krogsgaard M, Solomonow M. The sensory function of ligaments. Journal of Electromyography and Kinesiology 2002;12(3):165. Kujala UM, Orava S, Jarvinen M. Hamstring injuries. Current trends in treatment and prevention. Sports Medicine 1997;23(6): 397–404. Leibenson C. Self-Treatment of mid-thoracic dysfunction: a key link the body axis. Part 1: overview and assessment. Journal of Bodywork and Movement Therapies 2001;5(2):90–8. Lephart SM, Henry TJ. Functional rehabilitation for the upper and lower extremity. The Orthopedic Clinics of North America 1995;26(3):579–92. 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. Lynch GS, Fary CJ, Williams DA. Quantitative measurement of resting skeletal muscle (Ca2+)i following acute and long-term downhill running exercise in mice. Cell Calcium 1997;22(5):373–83. MacAuley D. Do textbooks agree on their advice on ice? Clinical Journal of Sport Medicine 2001;11(2):67–72. Macintosh JE, Bogduk N, Gracovetsky S. The biomechanics of the thoracolumbar fascia. Clinical Biomechanics 1987;2:78–83. McGill SM, Norman RW. Potential of lumbosacral fascia forces to generate back extension moments during squat lifts. Journal of Biomechanical Engineering 1988;10:312–8. McLain RF. Mechanoreceptor endings in human cervical facet joints. Spine 1994;19:495–501. McLain RF, Pickar JG. Mechanoreceptor endings in human thoracic and lumbar facet joints. Spine 1998;23(2):168–73. Miura K, Ishibashi Y, Tsuda E, Okamura Y, Otsuka H, Toh S. The effect of local and general fatigue on knee proprioception. Arthroscopy 2004;20(4):414–8. Moore KL, Dalley AF. Clinical orientated anatomy, 4th ed. Baltimore: Lippincott Williams & Wilkins; 1999 Chapter 5, p. 563. Newcomer KL, Laskowski ER, Yu B, Johnson JC, An KN. Differences in repositioning error among patients with low back pain compared with control subjects. Spine 2000;25(19):2488–93. Nitz AJ, Peck D. Comparison of muscle spindle concentrations in large and small human epaxial muscles acting in parallel combinations. The American Surgeon 1986;52(5):273–7.

189

Obremsky WT, Seaber AV, Ribbeck BM, Garrett Jr WE. Biomechanical and histological assessment of a controlled muscle strain injury treated with piroxicam. The American Journal of Sports Medicine 1994;22:558–61. Ong A, Anderson J, Roche J. A pilot study of the prevalence of lumbar disc degeneration in elite athletes with lower back pain at the Sydney 2000 Olympic Games. British Journal of Sports Medicine 2003;37(3):263–6. Orchard JW. Intrinsic and extrinsic risk factors for muscle strains in Australian football. The American Journal of Sports Medicine 2001;29(3):300–3. Orchard J. Biomechanics of muscle strain injury. New Zealand Journal of Sports Medicine 2002;30:92–8. Orchard J, Best TM. The management of muscle strain injuries: an early return versus the risk of recurrence. Clinical Journal of Sports Medicine 2002;12(1):3–5. Orchard J, Seward H. Epidemiology of injuries in the Australian Football League, seasons 1997–2000. British Journal of Sports Medicine 2002a;36(1):39–44. Orchard J, Seward H. 2002b. AFLMOA. AFL Injury Report 2002 (online). Available from URL: http://www.ausport.gov.au/fulltext/ 2003/aﬂ/2002_aﬂ_injury_report.pdf Orchard J, Seward H. 2003. AFLMOA AFL Injury Report 2003 (online). Available from URL: http://injuryupdate.com.au/images/ research/AFL2003InjuryReport.pdf Osternig LR, Caster BL, James CR. Contralateral hamstring (biceps femoris) coactivation patterns and anterior cruciate ligament dysfunction. Medicine and Science in Sports and Exercise 1995;27(6):805–8. O’Sullivan PB, Burnett A, Floyd AN, Gadsdon K, Logiudice J, Miller D, Quirke H. Lumbar repositioning deﬁcit in a speciﬁc low back pain population. Spine 2003;28(10):1074–9. Pickar JG. Neurophysiological effects of spinal manipulation. The Spine Journal 2002;2(5):357–71. Pickar JG, Wheeler JD. Response of muscle proprioceptors to spinal manipulative-like loads in the anesthetized cat. Journal of Manipulative & Physiological Therapeutics 2001;24(1):2–11. Price D. Psychological and neural mechanisms of pain. New York: Raven Press; 1988. p. 76–99. Rahusen FT, Weinhold PS, Almekinders LC. Nonsteroidal antiinﬂammatory drugs and acetaminophen in the treatment of an acute muscle injury. The American Journal of Sports Medicine 2004;32(8):1856–9. Reynolds JF, Noakes TD, Schwellnus MP, Windt A, Bowerbank P. Non-steroidal anti-inﬂammatory drugs fail to enhance healing of acute hamstring injuries treated with physiotherapy. South African Medical Journal 1995;85(6):517–22. Roberts S, Eisenstein SM, Menage J, Evans EH, Ashton IK. Mechanoreceptors in intervertebral discs. Morphology, distribution, and neuropeptides. Spine 1995;20(24):2645–51. Roberts D, Friden T, Stomberg A, Lindstrand A, Moritz U. Bilateral proprioceptive defects in patients with a unilateral anterior cruciate ligament reconstruction: a comparison between patients and healthy individuals. Knee Surgery, Sports Traumatology, Arthroscopy 1999;4(4):217–24. Robertson VJ, Baker KG. A review of therapeutic ultrasound: effectiveness studies. Physical Therapy 2001;81(7):1339–50. Rutherford OM. Muscular coordination and strength training, implications for injury rehabilitation. Sports Medicine 1988;5(3): 196–202. Sale D, MacDougall D. Speciﬁcity in strength training: a review for the coach and athlete. Canadian Journal of Sports Science 1981;6:87. Sherry MA, Best TM. A comparison of 2 rehabilitation programs in the treatment of acute hamstring strains. The Journal of Orthopaedic and Sports Physical Therapy 2004;34(3):116–25.

ARTICLE IN PRESS 190

W. Hoskins, H. Pollard / Manual Therapy 10 (2005) 180–190

Sihvonen T. Flexion relaxation of the hamstring muscles during lumbar–pelvic rhythm. Archives of Physical Medicine and Rehabilitation 1997;78(5):486–90. Simonsen EB, Thomsen L, Klausen K. Activity of mono- and biarticular leg muscles during sprint running. European Journal of Applied Physiology and Occupational Physiology 1985;54(5):524–32. Sluka KA, Walsh D. Transcutaneous electrical nerve stimulation: basic science mechanisms and clinical effectiveness. The Journal of Pain 2003;4(3):109–21. Smith AM. Psychological impact of injuries in athletes. Sports Medicine 1996;22(6):391–405. Solomonow M, Zhou BH, Harris M, Lu Y, Baratta RV. The ligamento-muscular stabilizing system of the spine. Spine 1998; 23(23):2552–62. Solomonow M, Zhou BH, Baratta RV, Lu Y, Harris M. Biomechanics of increased exposure to lumbar injury caused by cyclic loading: Part 1. Loss of reﬂexive muscular stabilization. Spine 1999;24(23):2426–34. Swenson R, Haldeman S. Spinal manipulative therapy for low back pain. The Journal of the American Academy of Orthopaedic Surgeons 2003;11(4):228–37. Swenson C, Sward L, Karlsson J. Cryotherapy in sports medicine. Scandinavian Journal of Medicine & Science in Sports 1996;6(4):193–200. Taimela S, Kankaanpaa M, Luoto S. The effect of lumbar fatigue on the ability to sense a change in lumbar position. A controlled study. Spine 1999;24(13):1322–7. Thorstensson A, Carlson H, Zomlefer MR, Nilsson J. Lumbar back muscle activity in relation to trunk movements during locomotion in man. Acta Physiologica Scandinavica 1982;116(1):13–20. Tsuda E, Okamura Y, Otsuka H, Komatsu T, Tokuya S. Direct evidence of the anterior cruciate ligament-hamstring reﬂex arc in humans. The American Journal of Sports Medicine 2001; 29(1):83–7. Turl SE, George KP. Adverse neural tension: a factor in repetitive hamstring strain? The Journal of Orthopaedic and Sports Physical Therapy 1998;27(1):16–21. van der Windt DA, van der Heijden GJ, van den Berg SG, ter Riet G, de Winter AF, Bouter LM. Ultrasound therapy for musculoskeletal disorders: a systematic review. Pain 1999;81(3):257–71. Van Wingerden JP, Vleeming A, Buyruk HM, Raissadat K. Stabilization of the sacroiliac joint in vivo: veriﬁcation of muscular

contribution to force closure of the pelvis. European Spine Journal 2004;13(3):199–205. Verrall GM, Slavotinek JP, Barnes PG, Fon GT, Spriggins AJ. British Journal of Sports Medicine 2001;35(6):435–9. Verrall GM, Slavotinek JP, Barnes PG, Fon GT. Diagnostic and prognostic value of clinical ﬁndings in 83 athletes with posterior thigh injury: comparison of clinical ﬁndings with magnetic resonance imaging documentation of hamstring muscle strain. The American Journal of Sports Medicine 2003;31(6):969–73. Vilensky JA, O’Connor BL, Fortin JD, Merkel GJ, Jimenez AM, Scoﬁeld BA, Kleiner JB. Histologic analysis of neural elements in the human sacroiliac joint. Spine 2002;27(11):1202–7. Vleeming A, Stoeckart R, Sniders VJ. The sacrotuberous ligament: a conceptual approach to its dynamic role in stabilizing the sacroiliac joint. Clinical Biomechanics 1989a;4:201–3. Vleeming A, Van Wingerden JP, Snijders CJ, Stoeckart R, Stijnen T. Load application to the sacrotuberous ligament: inﬂuences on sacroliliac joint mechanics. Clinical Biomechanics 1989b;4: 204–9. 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 1 1995;20(7): 753–8. Vogt L, Pfeifer K, Banzer W. Neuromuscular control of walking with chronic low-back pain. Manual Therapy 2003;8(1):21–8. Watson AW. Sports injuries in footballers related to defects of posture and body mechanics. Journal of Sports Medicine and Physical Fitness 1995;35(4):289–94. Watson AW. Sports injuries related to ﬂexibility, posture, acceleration, clinical defects, and previous injury, in high-level players of body contact sports. International Journal of Sports Medicine 2001;22(3):222–5. Watson T. The role of electrotherapy in contemporary physiotherapy practice. Manual Therapy 2000;5(3):132–41. Weinert Jr CR, McMaster JH, Ferguson RJ. Dynamic function of the human ﬁbula. American Journal of Anatomy 1973;138(2):145–9. Woods C, Hawkins RD, Maltby S, Hulse M, Thomas A, Hodson A. The Football Association Medical Research Programme: an audit of injuries in professional football—analysis of hamstring injuries. British Journal of Sports Medicine 2004;38:36–41. Worrell TW. Factors associated with hamstring injuries. An approach to treatment and preventative measures. Sports Medicine 1994; 17(5):338–45.

ARTICLE IN PRESS

Manual Therapy 10 (2005) 191–197 www.elsevier.com/locate/math

Reliability of palpation of humeral head position in asymptomatic shoulders David Bryde, B. Jane Freure, Leighton Jones, Melanie Werstine, N. Kathryn Briffa School of Physiotherapy, Curtin University of Technology, GPO Box U1987 Perth, Western Australia 6845 Received 9 January 2003; received in revised form 29 June 2004; accepted 27 August 2004

Abstract The purpose of this study was to determine if, within a normal population: (1) palpation of the humeral head, relative to the acromion, in three static positions, was a reliable technique (2) there was a difference in humeral head position between the dominant and non-dominant shoulders in the three positions (3) there was a difference in humeral head position relative to the acromion between the arm at side (AS), the 90 1 abduction/external rotation (AER) and 90 1 abduction/internal rotation (AIR) positions. This test–retest study recorded palpation landmarks using a standardized protocol. Intra-tester reliability was above 0.8 for both AS and AER and all other ICCs were below 0.6. There was no systematic difference between dominant and non-dominant sides in any of the three positions (AS P=0.408, AER P=0.448, AIR P=0.233). There was a signiﬁcant difference in measurements between each position (Po0.001). It can be concluded that, palpation of humeral head position in relation to the acromion is a reliable technique in the AS position. These normative data provide a baseline that can be used for future comparison if differences are found to exist in subgroups with pathological shoulder conditions where larger glenohumeral translations are thought to exist. r 2004 Elsevier Ltd. All rights reserved. Keywords: Reliability; Palpation; Intra-and inter-tester; Shoulder

1. Introduction Clinicians depend upon palpation techniques, which are compared bilaterally, to assist in diagnosis and treatment in a clinical setting. Physiotherapists commonly palpate humeral head position in relation to the acromion as an index of the relative position of the humeral head in the glenoid in resting and functional positions. As the glenoid is not accessible to direct palpation, the most anterior aspect of the acromion is used clinically as a landmark to indicate the relative position of the humeral head. It is thought that altered humeral head position in the glenoid may predispose an individual to shoulder pain (Bak and Fauno, 1997; Corresponding author. Fowler Kennedy Sport Medicine Clinic, 3M Centre, University of Western Ontario, London, Ontario, Canada N6A 1K7. Tel.: +1 519 661 2111; fax: +1 519 661 3379. E-mail address: [email protected] (M. Werstine).

1356-689X/$ - see front matter r 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2004.08.010

Ludewig and Cook, 2002). However, the reliability and validity of assessing humeral head position by palpation has not been established on a normative population in a standardized environment. As well, the difference between altered humeral head position due to pathology and normal variation between sides, as assessed by palpation, has not been deﬁned in the literature. Before the validity of a palpation technique can be determined by comparing landmark measurements to the gold standard of radiographs, the reliability of the technique must be assessed. This paper aimed to establish the reliability of a speciﬁc palpation technique, thus providing normative data from which future studies, using pathological shoulder populations, could be compared. A number of studies have described anterior/posterior translations of the humeral head in relation to the glenoid (Itoi et al., 1994; Karduna et al., 1996; Debski et al., 1999). Controlling mechanisms considered to

ARTICLE IN PRESS 192

D. Bryde et al. / Manual Therapy 10 (2005) 191–197

inﬂuence glenohumeral translations include congruency of the joint surfaces, intra-articular pressure, ligamentous constraints and muscular forces. Joints with less congruent articular surfaces have been shown to exhibit larger net anterior/posterior translations with active shoulder movements than joints with more congruent surfaces (Karduna et al., 1996; Kelkar et al., 2001). Altered intra-articular pressure of the glenohumeral joint has been shown to have effects on humeral head translation. Provided the glenohumeral capsule is a sealed unit, joints with limited volume have greater glenohumeral stability and reduced humeral head translation (Gibb et al., 1991; Moskal et al., 1999; Hurschler et al., 2000). With capsular venting, the amount of force necessary to translate the humeral head was more than halved. Also, it is likely that shoulders with excessively lax capsules may demonstrate increases in translation due to intra-articular pressure changes. Humeral head translation tends to occur at extreme ranges of glenohumeral rotation (Branch et al., 1999; McQuade et al., 1999). At the extremes of rotation, as one part of the capsule tightens, the humeral head is thought to translate away from this portion of the capsule. However, controversy exists in the literature as to whether the humeral head translates towards or away from the tight part of the capsule (Harryman et al., 1990; Kiss et al., 1997). The rotator cuff and other muscles that cross the glenohumeral joint also play a major stabilizing role in the amount of humeral head translation (Karduna et al., 1996; Apreleva et al., 1998; Graichen et al., 2000). With active movements it has been shown that the humeral head remains centrally located during glenohumeral elevation movements whereas during passive movements, the humeral head showed increased translation. When comparing internal and external rotation, the mean anterior/posterior translation of all movements were approximately four times larger with passive versus active movements (Karduna et al., 1996). Overall, these studies indicate that the muscular constraints control humeral head position during normal ranges of motion whereas the capsuloligamentous complex only affects humeral head position at the end of available range. This demonstrates the importance of neuromuscular control in keeping the humeral head centred in the glenoid. The purpose of this study was to determine if, within a normal population: (1) palpation of the humeral head, in three static positions, was a reliable technique in determining the humeral head position relative to the acromion (2) there was a difference in humeral head position between the dominant and non-dominant shoulders in the three positions (3) there was a difference in humeral head position relative to the acromion between the arm at side (AS), the 901 abduction/external rotation (AER) and 901 abduction/internal rotation (AIR) positions.

2. Methods 2.1. Study design This test–retest study of intra- and inter-therapist reliability compared the humeral head position, relative to the acromion, in the dominant and non-dominant arms and in three different arm positions. The independent variables were the three test positions (AS, AER, AIR), the dominant/non-dominant arm, intra-therapist repeated measures and inter-therapist measures. The dependent variable was the perpendicular distance from the anterior surface of the acromion to the marked ﬁnger on the most anterior landmark on the humeral head. 2.2. Subjects Thirty-one healthy volunteers between the ages of 23 and 49 were recruited through verbal contact with people in the community and students at Curtin University. These subjects had a mean (SD) age of 34 (8) years. Each subject was asked to read and sign a consent form and ﬁll out a questionnaire regarding age, level of sports participation and upper extremity pathologies. Height and weight were measured and recorded by one of the investigators. Eligibility requirements for inclusion were: (1) no history of prior shoulder trauma or surgery, (2) no history of neuromuscular dysfunction or inﬂammatory disease, (3) aged between 18 and 50, (4) ability to attain all test positions, and (5) no participation of a single arm sport at an elite level. The study was conducted at the School of Physiotherapy, Curtin University, Perth, Western Australia and approved by the University Human Research Ethics Committee. 2.3. Investigators The investigators were four Master of Manipulative Therapy students enrolled at Curtin University in the 2002 academic year. The two investigators involved in palpation of the humeral head position were experienced therapists who had clinical orthopaedic experience of 7 and 10 years, respectively. 2.4. Procedure Subjects were tested on one occasion for approximately 30 min. Arm dominance was determined by throwing a ball. Group allocation (intra- or inter-tester) was determined by lottery, as was the shoulder for duplicate measurement (left or right). The individual order of position testing (AS, AER, AIR) was one of six patterns where each was correlated with one of the numbers on a die (Table 1). The subject was asked to sit

ARTICLE IN PRESS D. Bryde et al. / Manual Therapy 10 (2005) 191–197

193

Table 1 Randomization

Intra-tester group 14 Subjects Study design (3 males, 11 females)

Inter-tester group 17 Subjects (10 males, 7 females)

Shoulder

Investigator

Measured

1

A A

3 positions 3 positions

2

A

3 positions

1

A B

3 positions 3 positions

2

A

3 positions

Fig. 1. Overhead camera view of the right shoulder. The investigator’s middle ﬁnger is palpating the most anterior landmark on the humerus. The anterior edge of acromion is marked with a straight line.

on a chair, against the backrest with their shoulders exposed. A mark was placed on the lateral side of the investigators distal phalanx of the middle ﬁnger. The marked ﬁnger then palpated the most anterior aspect of the humeral head and applied a ﬁrm downward and inward pressure to minimize the inﬂuence of the soft tissues on the measurement. The investigator then palpated the most anterior border of the acromion with the index ﬁnger of their other hand and marked a line with a water-based marker on the subject’s skin corresponding to this border (Fig. 1). In each of the three positions, a still photograph of the shoulder was then taken with a digital camera (Olympus C-3000) attached to the chair, on a custom made stand, 20 cm vertically above the shoulder (Fig. 2). A ruler marked with 1.0 cm divisions was included in the photograph to allow for scaling correction. A sticker with the subjects testing number, side, position, and test type was placed on the skin and displayed in the photograph. The markings made on the subjects shoulder were removed with an alcohol wipe by a different investigator after each measurement until no visible line could be seen. For the AER and AIR positions, subjects were asked to lift their arm out to the side, supported on a custommade frame so that it was parallel to the ﬂoor. A spirit

Fig. 2. Subject is seated in custom made device with shoulder resting in the abducted/externally rotated position. The camera is positioned over the test shoulder.

level conﬁrmed that the arm was horizontal. The subject was asked to actively rotate their arm as far back (external rotation) or as far forward (internal rotation) as possible without their scapula moving. A mirror was used for visual feedback and the investigator informed the subject when they had attained maximal active external or internal rotation. For intra-tester reliability, investigator A palpated the static humeral head position relative to the acromion in the three positions. The test was repeated by investigator A using the same shoulder and order of positioning. For inter-tester reliability, investigator B independently performed the palpation in the three shoulder positions, on the same shoulder and order as investigator A. In both reliability studies, Investigator A then took three measurements on the opposite shoulder. Therefore, each subject had nine still photographs taken in total. Once the photographs were printed, a different investigator super-imposed a straight line of best ﬁt over the marked anterior acromion and drew a perpendicular line connecting the line to the reference mark on the middle ﬁnger that palpated the most

ARTICLE IN PRESS D. Bryde et al. / Manual Therapy 10 (2005) 191–197

194

anterior aspect of the humeral head. This distance was measured to the nearest millimetre, recorded, and entered into SPSS Version 10.

in measurements between positions on both the dominant and non-dominant sides.

4. Results 3. Data analysis The Intraclass Correlation Coefﬁcient (ICC) was used to calculate the reliability of palpation of the position of the humeral head. The ICC, derived from a two-way mixed effect model, was calculated for the intra-tester reliability, whereas a two-way random effect model was used for inter-tester reliability. Ninety-ﬁve per cent conﬁdence intervals were then constructed around the point estimates to take into account sampling variation. Standard Error of the Measurement (SEM) was calculated from the same ANOVA model using the pﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃ formula: SEM ¼ MSE; where MSE is the mean square error. Further, to determine the magnitude of the difference between serial measurements required to be 95% conﬁdent that the difference was more than simply a manifestation of measurement error, the following formula was used: pﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃ Measurement Errorjx1 x2 j 1:96 2Sw2 where Sw2 ¼

X

d 2 =ð2nÞ,

where d is the difference between the ﬁrst (x1) and second (x2) measures and n = the number of paired observations (Henzell et al., 2000). Two measurements in an individual would need to differ by at least the value of the calculated measurement error to be sure that a real change had occurred. The difference in distance measured between dominant and non-dominant sides was compared using a paired-samples t-test in each of the three positions. A one-sample t-test was used to compare the absolute value of the differences in side-to-side measurements in individual subjects in each position, with a test value set at zero, as it was hypothesized that there would be no difference between sides. A repeated measures ANOVA was then used to determine the signiﬁcance of difference

One photograph was excluded due to light reﬂection from the camera ﬂash masking the drawn line on the acromion. This photograph was from Investigator B and therefore was removed from the inter-tester reliability study for the AS position only. Intra-tester reliability ICC values were above 0.8 for both AS and AER all other ICCs were below 0.6 (Table 2). The lowest measurement error was 6.2 mm for the AS intra-tester measurement and considerably higher for the other two positions and inter-tester measurements. There was no systematic difference between dominant and non-dominant sides in any of the three positions (Table 3). However, there was a signiﬁcant difference in all positions when comparing side-to-side in individual subjects (Po0.001) (Table 4). The results using the ANOVA showed that there was a signiﬁcant difference in measurements between each position (Po0.001) (Fig. 3). The same pattern of change in measured distance was observed in both dominant and non-dominant arms between each of the three positions. There was an increased distance measured in

Table 3 Dominant and non dominant comparison of the average measured distance Position

Mean dom arm (mm)

Mean non-dom arm (mm)

Std. deviation Sig. (2between pairs tailed)

AS AER AIR

19 40 25

18 41 26

4.93 7.95 6.79

0.408 0.448 0.233

AS=Arm at side. AER=Arm in abduction and external rotation. AIR=Arm in abduction and internal rotation. Mean Dom arm=Mean measured distance in the dominant arm from humeral head to acromion. Mean Non-Dom arm=Mean measured distance in the non-dominant arm from humeral head to acromion.

Table 2 Reliability (ICC), standard error of measurement (SEM) and measurement Error (M E) for intra- and inter-tester measurements Position

ICC Intra

95% CI

SEM (mm)

M E (mm)

ICC Inter

95% CI

SEM (mm)

M E (mm)

AS AER AIR

0.86 0.82 0.58

0.62–0.95 0.52–0.94 0.10–0.84

2.3 4.9 4.3

6.2 13.2 11.9

0.48 0.56 0.52

0.00–0.78 0.12–0.81 0.07–0.80

4.1 4.9 5.6

11.0 13.3 16.8

AS=Arm at side. AER=Arm in abduction and external rotation. AIR=Arm in abduction and internal rotation.

ARTICLE IN PRESS D. Bryde et al. / Manual Therapy 10 (2005) 191–197 Table 4 Side to side comparison on individual subjects using the absolute distances between dominant and non-dominant arms Position

Mean difference (mm)

Std. dev.

Sig. (2tailed)

95% conﬁdence

AS AER AIR

3.96 6.06 5.42

2.78 5.12 4.36

o0.001 o0.001 o0.001

2.89–5.04 4.18–7.95 3.86–6.98

AS=Arm at side. AER=Arm in abduction and external rotation. AIR=Arm in abduction and internal rotation. Mean difference=Mean absolute measured distance between dominant and non-dominant sides in individuals.

Fig. 3. Distance measured in three positions for dominant and nondominant arms. AS = Arm at side. AER = Arm in abduction and external rotation. AIR = Arm in abduction and internal rotation. Black bars = dominant shoulder. Striped bars = non-dominant shoulder.

both AER and AIR compared to AS and an increased distance when comparing AER to AIR.

5. Discussion The ICCs for intra-tester reliability for AS and AER were both above 0.8 suggesting that palpation, using the most anterior part of the humerus and the anterior border of the acromion in either the AS or AER positions, may be a reliable technique. However, in the AIR position or when two testers were included ICCs were 0.58 or below. Indeed the lower limits of the 95% conﬁdence interval for the inter-tester ICCs suggest that the true ICC may be very close to zero. The SEM reﬂects the error with which the humeral head position can be measured. Smaller errors indicate more precise and therefore potentially more useful measures. The SEMs observed in this study, particularly where the measurements are made in abduction or by more than one investigator, suggest that measurement error is likely making a considerable contribution to the variability of the data. The implications of this are that

195

samples and/or larger effect sizes will be necessary for biologically relevant differences to be detectable. Should serial measurements within an individual be of interest, measurement error values indicate the magnitude of the difference that would be required before it could conﬁdently be concluded that a real change had occurred. The lowest measurement error value was 6 mm, a considerable difference, particularly when compared with the absolute value of the mean side-toside differences observed (Table 2). In other words, if a clinician was using this technique to evaluate the effects of an intervention in an individual patient, the measured value would need to change by at least 6 mm (in the AS position and more in the other positions) before it could be interpreted that a clinical change had occurred. Side-to-side comparisons (Table 4) revealed that there was no systematic difference between the dominant and non-dominant shoulders. This means that the humeral head in the dominant shoulder, in a normal population, is not consistently more anterior or more posterior relative to the acromion when compared to the nondominant side. The average value of the absolute difference was consistently less than the measurement error, which means that the side-to-side difference may be the result of measurement error. Clinically speaking, this test may be used for bilateral comparison as there is no clinically signiﬁcant difference between sides. Previous in vivo and in vitro studies using more precise measures of glenohumeral translation clearly show that AP translation does vary in response to changes in muscle forces, capsuloligamentous integrity and joint position. The magnitude of such changes in AP translation will dictate the utility of this technique. The largest glenohumeral translations occur in response to applied loads. In these circumstances ‘‘normal’’ amounts of translation can be considerable. For example AP translations of 10 mm in response to manually applied forces were observed in a healthy young woman (Beulieu et al., 1999). In studies of cadavers with mechanically applied loads the observed translation increases and various combinations of simulated muscle activity and instability have been evaluated. In a study of cadavers, simulated type II superior labral lesions increased mean anterior translation in response to anterior load from 18.7 (78.5) mm to 26.2 (76.5) mm (Burkart et al. 2003). The utility of this palpatory techique in the various positions that have been tested needs to be evaluated in the context of the individual clinical or research application and the feasibility of more precise but more expensive and invasive alternatives. As the AS position in the hands of a single clinician had the highest precision we would recommend, if this technique is to be used, that this be the favoured approach unless clinical rational or research question dictates otherwise.

ARTICLE IN PRESS 196

D. Bryde et al. / Manual Therapy 10 (2005) 191–197

The AER and AIR positions both had signiﬁcantly increased distances, relative to the AS position (Po0.001). The consensus of current literature is that with active range of motion, when the neuromuscular system is activated, the humeral head remains relatively centred in the glenoid fossa (Karduna et al., 1996; Graichen et al., 2000; Hodge et al., 2001). Assuming that no translation has taken place, the difference may be due either to a change in the most anterior palpable bony landmark on the humerus associated with internal or external rotation or a change in the depth and tone of the soft tissue overlying the bony landmark anteriorly. Some studies suggest that AP translations of 4–5 mm do occur during active glenohumeral motion and that pathology alters the mechanics of such translation (Howell et al., 1988). The palpatory technique described would not enable differentiation of whether differences in the measurement are due to glenohumeral translation or other changes in the orientation of soft tissue or bony landmarks. Possible sources of error in this study may have included: Biological: Soft tissue and bony morphology are known to vary between individuals (Bigliani et al., 1991; von Schroeder et al., 2001). Degenerative changes of the anterior third of the acromion resembling a traction spur at the anterior edge (Edelson and Taitz, 1992) could make it more difﬁcult to accurately palpate the anterior edge of the acromion and hence affect the accuracy of the measurement. Humeral head morphology can also be extremely variable. A study of 60 cadavers showed a large variability of humeral head retroversion (9.5–311) and a signiﬁcant difference in head inclination angles between left and right sides (Robertson et al., 2000). These variations have been found to produce associated differences with palpation accuracy of humeral bony structures (de Groot, 1997). Instrumentation: In some of the subjects, the shoulder was not situated directly under the camera secondary to differences in body sizes, scapular positions and thoracic kyphosis. In these cases, some inaccuracies of measurement may have been introduced, as digital cameras have distortion towards the periphery of the viewing ﬁeld. However, these inaccuracies could have been minimized if the shoulder landmarks were positioned directly under the camera. This could be achieved by having either a moveable backrest on the seat or the camera frame modiﬁed to allow forward and backward movement of the camera. Investigator variation: The possibility for error exists with the angle of the middle ﬁnger palpating the most anterior bony landmark of the humerus. It is possible that Investigator A and B could be palpating the exact same location but produce a different point of pressure. This difference in pressure could change the angle of the line marked on the middle ﬁnger thereby producing a

Fig. 4. An overhead view of a shoulder demonstrating ﬁnger palpation of the anterior aspect of the humerus. The dotted lines show how the two investigators could identify different parts of the acromion as the most anterior aspect and lead to discrepancies in the measured distances.

discrepancy in the distance measured. Also, there were several occasions when the angle of the line drawn on the most anterior aspect of the acromion was markedly different between testers, resulting in a difference between the two measurements (Fig. 4). This difference in measurement was greatest between testers in the AIR and AS positions, which also had lower inter-tester reliability. The distances that were palpated by Investigator B were consistently larger than those measured by Investigator A in the AIR position (Po0.001). This may represent a systematic error due to differences in palpation technique. Test–retest timing: There was minimal time between test and retest of humeral head position for intra-tester reliability, which may have inﬂuenced landmark selection secondary to recall of a previously palpated position. However, the ability of Investigator A to recall landmarks was minimized by having all markings removed independently and by returning the arm to the resting position after each measurement. As well, two additional positions were tested prior to retest. The actual number from the measurement was not generated by the investigator who was palpating so it was not a matter of recalling a number as may be case for other clinical measurements. The time between tests that was used in this study is similar to the time frame utilized in a clinical setting when therapists re-assess humeral head position following a treatment technique.

6. Conclusion This investigation has established that palpation of humeral head position in relation to the acromion is a

ARTICLE IN PRESS D. Bryde et al. / Manual Therapy 10 (2005) 191–197

reliable technique for a normal population, in a standardized environment, for intra-tester AS. There was not a signiﬁcant difference between the dominant and non-dominant shoulders. However, there was a signiﬁcant difference in the distance measured in all three positions with AER having the largest distance followed by AIR and AS, respectively. Future studies need to determine whether the relative position of the humeral head in relation to the acromion, in particular the AS position, as established by the palpation technique used in this study, correlates to the radiological position of the humeral head in the glenoid fossa. This palpation protocol would further be used in subgroups of pathological shoulder populations where larger glenohumeral translations are thought to exist.

Acknowledgements We would like to thank Satvinder Dhaliwal and Marie Blackmore for statistical advice and Leanda McKenna for providing us with the information about digital measurement that she has developed as part of her Ph.D. studies. References Apreleva M, Hasselman C, Debski R, Woo SY, Warner J. A dynamic analysis of glenohumeral motion after simulated capsulolabral injury. Journal of Bone and Joint Surgery 1998;80A(4):474–80. Bak K, Fauno P. Clinical ﬁndings in competitive swimmers with shoulder pain. The American Journal of Sports Medicine 1997;25(2):254–60. Beulieu C, Hodge D, Bergman A, Butts K, Daniel B, Napper C, Darrow R, Dumoulin C, Herfkens R. Glenohumeral relationships during physiologic shoulder motion and stress testing: initial experience with open MR imaging and active imaging-plane registration. Radiology 1999;212:669–705. Bigliani L, Tucker J, Flatow E, Soslowsky L, Mow V. The relationship of acromial architecture to rotator cuff disease. Clinics in Sports Medicine 1991;10(4):823–39. Branch T, Avilla O, London L, Hutton W. Correlation of medial/ lateral rotation of the humerus with glenohumeral translation. British Journal of Sports Medicine 1999;33:335–47. Burkart A, Debski R, Musahl V, McMahon P. Gleonhumeral translations are only partially restored after repair of a simulated Type II superior labral lesion. American Journal of Sports Medicine 2003;31(1):56–8. de Groot J. The variability of shoulder motions recorded by means of palpation. Clinical Biomechanics 1997;12(7/8):461–72. Debski R, Sakane M, Woo S-Y, Wong E, Fu F, Warner J. Contribution of the passive properties of the rotator cuff to

197

glenohumeral stability during anterior–posterior loading. Journal of Shoulder and Elbow Surgery 1999;8(4):324–9. Edelson J, Taitz C. Anatomy of the coraco-acromial arch. Journal of Bone and Joint Surgery 1992;74-B:589–94. Gibb T, Sidles J, Harryman D, McQuade K, Matsen F. The effect of capsular venting of glenohumeral laxity. Clinical Orthopaedics and Related Research 1991;268(July):120–7. Graichen H, Stammberger T, Bonel H, Englmeier K-H, Reiser M, Eckstein F. Glenohumeral translation during active and passive elevation of the shoulder—a 3D oper-MRI study. Journal of Biomechanics 2000;33:609–13. Harryman D, Sidles J, Matsen F. The humeral head translates on the glenoid with passive motion. In: Hawkins RJ, Morrey BF, Post M, editors. Surgery of the shoulder. St Louis: Mosby Year-Book; 1990. p. 186–90. Henzell S, Dhaliwal S, Pontifex R, Gill F, Price R, Retallack R, Prince R. Precision error of fan-beam dual X-ray absorptiometry scans at the spine, hip and forearm. Journal of Clinical Densiometry 2000;3(4):359–64. Hodge D, Beaulieu C, Thabit G, Gold G, Bergman A, Butts R, Dillingham M, Herfkens R. Dynamic MR imaging and stress testing in glenohumeral instability: comparison with normal shoulders and clinical/surgical ﬁndings. Journal of Magnetic Resonance Imaging 2001;13:748–56. Howell S, Galinat B, Renzi A, Marone P. Normal and abnormal mechanics of the glenohumeral joint in the horizontal plane. Journal of Bone and Joint Surgery 1988;70-A(2):227–32. Hurschler C, Wulker N, Mendila M. The effect of negative intraarticular pressure and rotator cuff force on glenohumeral translation during simulated active elevation. Clinical Biomechanics 2000;15:306–14. Itoi E, Motzkin N, Morrey B, An K. Contribution of axial arm rotation to humeral head translation. The American Journal of Sports Medicine 1994;22(4):499–503. Karduna A, Williams G, Williams J, Iannotti J. Kinematics of the glenohumeral joint: inﬂuences of muscle forces, ligamentous constraints, and articular geometry. Journal of Orthopaedic Research 1996;14(6):986–93. Kelkar R, Wang V, Flatow E, Newton P, Ateshian G, Bigliani L, Pawluk R, Mow V. Glenohumeral mechanics: a study of articular geometry, contact, and kinematics. Journal of Shoulder and Elbow Surgery 2001;10(1):73–84. Kiss J, McNally E, Carr A. Measurement of the anteroposterior translation of the humeral head using MRI. International Orthopaedics 1997;21:77–82. Ludewig P, Cook T. Translations of the humerus in persons with shoulder impingement symptoms. Journal of Orthopedic and Sports Physical Therapy 2002;32:248–59. McQuade K, Shelley I, Cvitkovic J. Patterns of stiffness during clinical examination of the glenohumeral joint. Clinical Biomechanics 1999;14:620–7. Moskal M, Harryman D, Romeo A, Rhee Y-G, Sidles J. Glenohumeral motion after complete capsular release. Journal of Arthroscopic and Related Surgery 1999;15(4):408–16. Robertson D, Yuan J, Bigliani L, Flatow E, Yamaguchi K. Threedimensional analysis of the proximal part of the humerus: relevance to arthroplasty. Journal of Bone and Joint Surgery 2000;82-A(11):1594–602. von Schroeder H, Kuiper S, Botte M. Osseous anatomy of the scapula. Clinical Orthopaedics and Related Research 2001;383(Feb):131–9.

ARTICLE IN PRESS

Manual Therapy 10 (2005) 198–206 www.elsevier.com/locate/math

Original article

A normative database of lumbar spine ranges of motion Michael Trokea,, Ann P Moored, Frederick J Maillardetb, Elizabeth Cheekc a

Head of Research & Enterprise, York St John College, Lord Mayor’s Walk, York, YO31 7EX, UK b Clinical Research Centre for Health Professions, University of Brighton, UK c University of Brighton, UK d Faculty of Management & Information Sciences, University of Brighton, UK Received 4 June 2003; received in revised form 17 September 2004; accepted 25 October 2004

Abstract The overall aim of the work was to develop a comprehensive normative database of indices for ranges of motion in the lumbar spine, in an asymptomatic sample of the general population. This was a repeated measures prospective study utilizing a reliable and valid instrument, the modiﬁed CA6000 Spine Motion Analyzer (Orthopedic Systems Inc. Union City CA & Troke/University of Brighton). The portable equipment was used to collect data in a variety of community settings (e.g. schools, GP surgeries, ofﬁces, leisure centres, emergency services stations). A total of 405 asymptomatic subjects (196 female, 209 male) aged 16–90 yr from sedentary, mixed and physically demanding occupations participated in the study and data were collected in standing, at different times of the day, following a standardized methodology for lumbar spine motion in the sagittal, coronal and horizontal planes. Age-related centile graphs were derived separately for male and female subjects in ﬂexion, extension, left and right lateral ﬂexion and left and right axial rotation. All 12 graphs are presented as an appendix located on the Manual Therapy website (www.elsevierscience.com/journals/math). Overall, ﬂexion (73–401) and lateral ﬂexion (28–141, L&R) declined 45% and 48%, respectively, across the age range. Extension (29–61) declined the greatest at 79%. By contrast, no overall decline in axial rotational RoMs was recorded, and the median RoM remained at 71 each way across the age spectrum examined. A comprehensive database of indices of lumbar spine ranges of motion has thus been developed which is gender speciﬁc, age related, drawn from a wide age range and presents data for all three planes of motion. It is considered that the new database has a number of potential clinical and research applications. r 2004 Elsevier Ltd. All rights reserved. Keywords: Normative; Database; Lumbar; Spine

1. Introduction An introductory paper has been published in Clinical Rehabilitation (Troke et al., 2001b), in which the methodology developed for this work, along with a new approach to the analysis of lumbar spine normative data were discussed. Summary results were also presented along with an example of the database graphs. The principal purpose of this current paper is to publish the new, comprehensive, normative database of lumbar Corresponding author.

E-mail address: [email protected] (M. Troke). 1356-689X/$ - see front matter r 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2004.10.004

spinal motion in full, and make the complete database available to interested clinicians and researchers. The clinical relevance of this work is considered in Section 5. Many papers and publications offering normative data for lumbar spine movement have used different types of equipment, a variety of methodologies and different methods of analysis. Some only offer data across a limited spectrum of age ranges, do not encompass all three planes of movement, or are not gender speciﬁc. This present work is an attempt to address these limitations, following the development of the modiﬁed CA6000 Spine Motion Analyzer (Troke and Moore, 1995).

Table 1 Selected comparative ranges of lumbar spinal motion including this current normative database 1978

1979

1985

1993

1994

1995

1995

2000

2001

2001

Author(s)

Kapandji

Twomey

Pearcy

Russell et al. Dopf et al.

Reliability reported Validity reported Total subjects No. (Female No.) (Male No.) Ages (Yr) Spinal RegionReported Gender speciﬁc Age related Measurement Methods Results Flexion Extension R Lat Flex L Lat Flex R Ax Rotn L Ax Rotn

No

White and Panjabi No

Dvorak et al. Yes

McGregor et al. Yes

Van Herp et al. No

Ng et al.

Troke et al.

Yes

Greene and Heckman No

No

Yes

No

Yes

Yes

No

No

No

Yes

No

No

No

No

No

Yes

No

Yes

Not stated

Composite

144

31

245

120

(a)

104

203

100

35

405

Not stated Not stated Not stated T12-sacrum

Not stated Not stated Not stated T12-sacrum

72 72 20–60+ T12-sacrum

0 31 21–37 L1-sacrum

118 127 20–69 L1-sacrum

60 60 20–35 T12-sacrum

(a) (a) (b) T12/L1-sacrum

42 62 20–70 T12-sacrum

100 103 20–70 T12-sacrum

50 50 20–77 T12-sacrum

0 35 Mean 29 T12-sacrum

196 209 16–90 T12-sacrum

No

No

Yes

Yes

Yes

No

Yes

Yes

Yes

Yes

Yes

Yes

No Not stated

No Not stated

Yes Mechanical with cadavers Note: Where a range of values is reported, 60 115–70 39–24 35 Combined 14–9 20 47–23 20–14 20 Combined 20–13 5 18–17 16–12 5 Combined 16–12

1994

No Yes No No Yes Yes Yes StereoIsotrak CA6000 with Radiographic CA6000 CA6000 Isotrak radiographic straps+others with straps with straps they are shown here in descending order according to ascending age. All values are shown in degrees 51 75–58 81 76–70 75–55 64–45 59–51 16 28–15 35 Combined 31–17 30–13 37–15 17 57–35 45 50–40 36–23 35–25 26–15 18 Combined 46 Combined 35–20 36–25 26–15 4 36–26 42 12 48–32 30–23 19–13 5 Combined 43 Combined 48–33 31–23 19–11

No Yes Inclinometer+ CA6000 rotameter with Pads 52 19 31 30 32 33

72–40 29–6 28–15 29–16 7 7

Key: T12-sacrum: Whole lumbar spine region; L1-sacrum: Excluded T/Lumbar junction. (a) Given in cited studies—Dvorak: 41(23 Male, 18 Female), Pearcy: 11 (all Male). (b) Given in cited studies—Dvorak: 22–50 yr, Pearcy: 25–36 yr.

ARTICLE IN PRESS

1974

M. Troke et al. / Manual Therapy 10 (2005) 198–206

Year

199

ARTICLE IN PRESS 200

M. Troke et al. / Manual Therapy 10 (2005) 198–206

Increasingly more sophisticated methods have been developed including the use of stereo X-ray equipment (Pearcy, 1985) and different electronic methods (Hindle et al., 1990; Gomez et al., 1991; Russell et al., 1993; Dopf et al., 1994; Dvorak et al., 1995; McGregor et al., 1995; Van Herp et al., 2000). Of these, the Dopf, Dvorak and McGregor studies utilized the unmodiﬁed CA6000 Spine Motion Analyzer with strap ﬁxation. A modiﬁed version of that instrument utilising a new skin pad ﬁxation system was used for this current work. Selected publications which offered normative data of lumbar spine motion are summarized in Table 1 and reviewed below. Kapandji (1974) provided maximal ﬁgures for ranges of motion which bear comparison with this current work. It is not clear what methodologies were drawn upon to establish the maximal RoMs quoted, although work by Tanz (1953) is cited, but not speciﬁcally referenced. The data were not gender speciﬁc but age-related segmental ranges by Tanz were reproduced, and these have also been cited by White and Panjabi (1990). Normative data reported by White and Panjabi (1978a) were originally published in a journal paper and also in the ﬁrst edition of their book (White and Panjabi, 1978b). Their ﬁgures for individual segments of the lumbar spine were drawn from comprehensive references and the ‘‘authors’ own best opinion’’, based upon a review of the literature at the time, as well as their own analysis. Neither the number of subjects from which the data were drawn, nor their gender and ages were reported and nor the methods by which the representative values offered by these authors were derived. In 1979, Twomey published a paper on the effects of age on the RoMs of the lumbar spine. Results were reported on 200 cadaveric specimens, secured in a mechanical test vice, of which 144 were in the adult age ranges from 20 years to over 60 years, with an equal number of male and female subjects. Measurements were taken from T12 to S2, as in this current work. The ranges of motion were categorized according to age and gender, ﬂexion, extension, left and right lateral ﬂexion and left and right axial rotation. The work of Pearcy (1985), described extensive studies utilizing stereo radiography. The author reported on work with 31 male subjects who were exposed to stereo-radiographic X-rays in a specially constructed framework. Eleven subjects were measured for ﬂexion/ extension and had a mean age of 29 yrs (SDs not given). A further 10 subjects carried out lateral ﬂexion movements (mean age 28 yrs) and another 10 subjects carried out axial rotation movements (mean age 24 yrs). Measures (in degrees) were reported for each segment from L1 to the sacrum, but excluded the thoraco-lumbar junction (T12/L1). Russell et al. (1993) utilized the Isotrak electromagnetic equipment (Polhemus Navigation, Inc.) to

investigate normal ranges of motion for groups of males and females aged from 20 to 69 years. The authors chose to combine left and right lateral ﬂexion and axial rotation ﬁgures to give total ranges and like Pearcy (1985) this work reports motion of the lumbar spine taken from L1. In 1994, the American Academy of Orthopedic Surgeons (AAOS) published a revised and updated edition of their earlier book (AAOS, 1965) on joint motion (Greene and Heckman, 1994). The latter book drew on two papers (Pearcy et al., 1984; Dvorak et al., 1991) to tabulate radiographic segmental RoMs for the lumbar spine from L1 to S1. Additionally, when discussing clinical measurements of the lumbar spine, the authors compared earlier results using the Schober (1937) method with the later work which utilized inclinometers and goniometers (Loebl, 1967; Fitzgerald et al., 1983). A study by Van Herp et al. (2000) utilized the 3-Space Isotrak electro-magnetic system (as did Russell et al., 1993) to produce a normative database involving 50 male and 50 female subjects aged from 20 to 77 years. The data reported by Van Herp and colleagues involved the whole of the lumbar region (as in this current work), the instrument having been applied from the T12 vertebra to the sacrum. The data were arranged in 10year age bands, were gender speciﬁc and demonstrated changes in RoMs with advancing age. In their reliability and normative study, Ng et al. (2001) utilized double inclinometers and rotameter techniques. Like Pearcy (1985), Ng et al. involved a small sample (31 and 35, respectively) of young male subjects.

1.1. Normative work with the CA6000 Spine Motion Analyzer The ﬁrst study to be published which offered normative values for lumbar spinal motion utilising the unmodiﬁed CA6000 was published by Dopf et al. (1994). In 1995, Dvorak et al. reported on data from a substantial number of subjects across a wide age range (20–70 yr), and the data were age related and gender speciﬁc. McGregor et al. (1995) discussed normative data for RoMs as well as for velocity of movement. Like Dvorak et al.’s (1995) work, McGregor and colleagues’ data were gender speciﬁc and age related in 10-year age bands. The diversity of methods used to establish lumbar spine normative RoMs and summarized in Table 1, illustrate the signiﬁcant lack of agreement and very wide variation in reported RoMs for substantially the same region of the spine. The values reported demonstrate the need for a comprehensive normative database, and the

ARTICLE IN PRESS M. Troke et al. / Manual Therapy 10 (2005) 198–206

work highlighted in Table 1 is considered further in the discussion section of this paper. Developmental work on the CA6000 spinal motion analysis system has been described in a series of conference presentations and journal papers. In the light of difﬁculties encountered with the manufacturers’ strap ﬁxation, and the exaggerated results obtained with the un-modiﬁed instrument, the programme of work began with the development of a new skin ﬁxation system (Troke and Moore, 1995). The system comprises semi-ﬂexible self-adhesive pads with balance weights and squared alloy mounting hooks. The linkage consists of six potentiometers connected by light alloy tubular rods. The instrument is thereby secured directly onto the skin, typically over the spinous processes of T12 and S2 vertebrae. This work was followed by a series of reliability studies (Troke et al., 1996, 1998) and a study of validity (Troke et al., 2001a), all directed towards the development of a credible clinical tool.

2. Aim and objectives for the normative database study The aim of the study was to develop a comprehensive normative database of indices for ranges of lumbar spinal motion in an asymptomatic sample of the general population, utilizing a reliable and valid instrument. The principal objectives were to generate these data utilizing the modiﬁed CA6000 Spine Motion Analyzer (Orthopedic Systems Inc. Union City CA and Troke / University of Brighton), and to analyse and present gender-speciﬁc and age-related results for all planes of movement which clinicians and researchers interested in spinal dysfunction could readily utilize.

201

movements intended to overcome any initial stiffness were carried out. Four successive lumbar spine movements in each plane (sagittal, coronal and horizontal) were then recorded from a standing start position. In order to encompass diurnal variations, two complete data sets of lumbar spine movement data were recorded at different times of the day. Over the course of two separate days, a total of 24 observations were taken with each of the 405 subjects. The methodology used for this study has been described in detail in an introductory paper published in the journal Clinical Rehabilitation (Troke et al., 2001b). The statistical analysis of the data produced agerelated centiles as a continuum across all the subject ages, in each gender, and for each plane of movement. This is in accordance with the epidemiological and statistical advice received, plus reference to Altman (1993), and is thought to be an innovative approach to the presentation of spinal motion data. Prior to the construction of the centile graphs, analyses of variance (2-way) were conducted, leading to the calculation of Type 2,1 Intra-class Correlation Coefﬁcients (Shrout and Fleiss, 1979) in order to test the reliability of the data. Initial trends emerged, some of which appeared to conﬁrm established knowledge about the effect of age on lumbar spine ranges of motion, and some of which appeared to shed new light on this area. Using regression analysis techniques, age-related centiles were constructed from the data collected. The graphs are gender speciﬁc, illustrate the age-related variations in lumbar ranges of motion as a continuum across the age spectrum, and relate to each plane of movement (sagittal ﬂexion–extension, coronal lateral ﬂexion to the right and to the left, and horizontal axial rotation, with the shoulders rotating clockwise towards the right and anti-clockwise to the left).

3. Method Ethical approval for the work was granted by the University of Brighton Research Ethics Committee. Data collection was carried out in a variety of community locations (e.g. schools, GP surgeries, ofﬁces, leisure centres, emergency services stations, etc.). A portable system linked to a laptop computer was utilized with the CA6000 instrument and the skin pad ﬁxation system as described in previous papers (Troke and Moore, 1995; Troke et al., 1996, 1998). Over 400 participants were recruited for the study with ages ranging from 16 to 90 years, 209 of whom were male, and 196 of whom were female. In excess of 20 companies, institutions or groups were involved, from a variety of sedentary, mixed and physically demanding occupations. Data collection was carried out according to the standardized protocol developed during the reliability studies (Troke et al., 1996). The instrument was secured over T12 and S2 vertebrae, and preliminary

4. Results As examples from the complete website database (www.elsevierscience.com/journals/math), graphs for female ﬂexion, extension, lateral ﬂexion and axial rotation are illustrated in Figs. 1–4. The graphs show the centiles as a continuum for all subjects, according to gender, with individual data points shown as a scatter plot. The 50th centile (median), the 97th, 90th, 10th and 3rd centiles are superimposed. The 50th centile represents the values such that half of the subjects will have RoM values greater, and half will have RoM values less than the median. The values found between the 90th and 10th centiles represent RoMs which it might be expected that 80% of the population would achieve. The values beyond these centiles are either in the upper 10% or lower 10% of the general population distribution. The values found below

ARTICLE IN PRESS M. Troke et al. / Manual Therapy 10 (2005) 198–206

Degrees

202

100 90 80 70 60 50 40 30 20 10 0 10

20

30

40

50 60 Age (years)

70

80

90

Fig. 1. Flexion-females 3rd, 10th, 50th, 90th and 97th Centiles. r Copyright M. Troke.

50

Degrees

40 30 20 10 0 10

20

30

40

50 Age (years)

60

70

80

90

Fig. 2. Extension-females 3rd, 10th, 50th, 90th and 97th Centiles. r Copyright M. Troke.

50

Degrees

40 30 20 10 0 10

20

30

40

50 Age (years)

60

70

80

90

Fig. 3. Right lateral ﬂexion-females 3rd, 10th, 50th, 90th and 97th Centiles. r Copyright M. Troke.

the 3rd or above the 97th centiles could be regarded as at the extremes of RoMs to be expected in the general population. The median ﬂexion RoM value for male subjects declined from 731 to 401 across the age spectrum of 16–90 yr. The median value for females was similar, from 681 to 401. In extension, the male median RoM declined with age from 291 to 71 and the female median

RoM similarly declined from 281 to 61. These overall ranges of motion are summarized in Table 2. In lateral ﬂexion both male and female median values were very similar, ranging from 281 to 141, left or right. In axial rotation, the median RoM value, both for male and female subjects, to both the left and the right remained at approximately 71 in each direction, across the whole age spectrum studied.

ARTICLE IN PRESS M. Troke et al. / Manual Therapy 10 (2005) 198–206

203

30

Degrees

25 20 15 10 5 0 10

20

30

40

50 Age (years)

60

70

80

90

Fig. 4. Left axial rotation-females 3rd, 10th, 50th, 90th and 97th Centiles. r Copyright M. Troke.

Table 2 Maximum and minimum median ranges of lumbar spinal motion across all subjects (overall age range of subjects 16–90 yr) Movement

Flexion Extension Right lateral ﬂexion Left lateral ﬂexion Right axial rotation Left axial rotation

Male

Female

Max (median of values) (deg)

Min

Max (median of values) (deg)

Min

73 29 28 28 7 7

40 7 15 16 7 7

68 28 27 28 8 6

40 6 14 18 8 6

Whilst the apparent effect on RoMs of increasing age is self-evident, it will be noted that this change (where it occurs) is generally linear. Nevertheless, it is also noteworthy that extension appears to decline as a slight curve and that all the axial rotation RoMs remain substantially constant across the age spectrum. On comparing Fig. 1 with the male equivalent, there appears to be slightly greater variability in RoMs, and therefore the centiles are more closely spaced with male subjects. Female subjects have lower RoMs at 16 yr, but appear to equal male subjects in the ﬁnal decade. The decline in RoMs is linear, and between ages 16 and 90 yr the reduction is 45%. In extension, the male and female values and centile patterns are almost identical. The slightly curved changes suggest a steeper decline in earlier years, which levels out somewhat in later life. Overall, the reduction across the age ranges is 79%, and is the greatest decline of any of the primary movements. In lateral ﬂexion, the decline in RoMs is linear at 48% overall. There appears to be less variability with male subjects than with females. Overall patterns between movement to the left and right are very similar. In axial rotation, no overall decline is apparent in RoMs across the age spectrum. The 50th centile value is very similar for both men and women, and overall variability is also comparable.

The presentation of the results of this study as centile graphs has been designed to make direct reading of ranges immediately accessible, if comparison needed to be made with other subjects or patients of a given gender and age, in a given plane of motion. It can be seen that the centiles offer a comprehensive reference for ranges of motion of the lumbar spine for each sex and in all three planes of motion, in either a clinical or research arena.

5. Discussion 5.1. Current work with the modified CA6000 There was considerable agreement between the overall maximum and minimum RoMs achieved by the male and female participants in this study. This is in contrast to many previous studies which have found differences between overall mobility in spinal motion between the sexes. Results from this database suggest that there was no discernable difference in RoMs between males and females. A possible exception was that the median value for the youngest of the female subjects was approximately 51 less in ﬂexion than the equivalent male ﬁgure. This difference is less than 10% and may therefore be considered by some clinicians as within the bounds of normal variation.

ARTICLE IN PRESS 204

M. Troke et al. / Manual Therapy 10 (2005) 198–206

The use of centile graphs to present the complete normative data sets is thought to be an innovative way of presenting spinal motion data whilst making the overall results readily accessible and easy to use. The age-related data can be related directly to the individual research subject or clinical patient RoM values achieved, and used as part of a broader clinical assessment of possible spinal pathology or dysfunction. Centiles were also used in order to avoid artiﬁcial age bands and in order to present the individual’s results as a continuous correlation between range of motion and age. The centiles were calculated using regression techniques with the 50th centile (median value) being the line of best ﬁt. The reference intervals are consequential upon this approach. Utilization of age-related centiles also enabled the use of reference intervals (e.g. 80% of the population between the 10th and 90th centiles) to determine the location of an individual’s results as within the reference interval, or not, as the case may be. Use of the term ‘reference interval’ can be as an alternative to describe ‘normal’ or ‘normative’ data in the context of range of motion (Bland and Altman, 1995). In this study, reference interval is deﬁned as a range of values obtained from a majority of normal subjects. Extensive speculation as to the possible reasons for the substantially similar RoMs achieved by male and female subjects in this study, and for the age-related changes, or lack of change, in the lumbar spinal RoMs shown in the new database, is perhaps more suited to a future paper. However, given the availability of the new database, further research may now be able to offer greater insight into lumbar spinal motion, and offer substantiated propositions for these similarities, and for the age-related changes found in this work. 5.2. Earlier work with the unmodified CA6000 Dopf et al. (1994) made comparisons with other methods of measuring spinal motion including the Schober (1937) method for measuring ﬂexion, and inclinometers for measurements in other planes. The RoMs reported for horizontal axial rotation were clearly exaggerated when compared to the Kapandji (1974) data, White and Panjabi (1978a, b), Twomey’s (1979) paper and Pearcy’s (1985) data. It is perhaps unfortunate that Dopf et al. (1994) did not acknowledge the limitations of the early versions of the CA6000 when reporting their ﬁndings. In a subsequent study, Dvorak et al. (1995) used a much more constrictive method when measuring subjects in lateral ﬂexion than this current work or any other studies which utilised the CA6000. Unlike Dopf et al. (1994) however, Dvorak et al. acknowledged that the results obtained for axial rotation were exaggerated and that the strap ﬁxation supplied by the manufacturer was

a likely source of error. Insofar as the paper provided an interesting insight into various aspects of lumbar spinal movement, comparison of results with the new normative database reported here requires caution in the light of Dvorak and colleagues’ own reservations. A similar criticism to that which could be applied to the RoMs reported by Dopf et al. (1994) in axial rotation could also be applied to McGregor et al.’s (1995) results. In comparison to earlier work (e.g. Panjabi et al., 1994) the axial rotation RoMs again appeared exaggerated. 5.3. Clinical applicability of the new database The modiﬁed CA6000 instrument is a safe, noninvasive means of establishing reliable and valid indices of regional lumbar spine motion. The new normative database offers complementary data on lumbar ranges of motion which might be expected amongst an asymptomatic population. It has been established as easy to use in different clinical and community locations, economic of operator’s time and readily portable. The new database is intended to be quick and easy to interpret by clinicians, and where appropriate to be used in explanations to patients as a means of offering feedback following treatment intervention. In considering the possible clinical applicability of the instrument and the new database, it should be acknowledged immediately, that RoM indices and patterns of movement graphs can only be part of the whole clinical picture and the clinical relevance of such data is still a matter for debate. The graphical representations provided by the instrument combined with the new normative database could, however, be seen as useful adjuncts in initial assessment in the context of speciﬁc spinal conditions, monitoring the progress of rehabilitation and the efﬁcacy of treatment regimes. It has been suggested anecdotally that research colleagues investigating low back pain (LBP) syndromes in general, as well as more speciﬁc conditions, have possibly been reluctant to utilize objective measures of lumbar spinal RoMs in their studies. This has been in some measure due to the lack of conﬁdence in the results produced by some instruments purporting to quantify lumbar spine motion. Long-term monitoring of the progress (or otherwise) of rheumatic diseases such as ankylosing spondylitis also suggest themselves as examples where reliable and valid RoMs data on lumbar spinal motion would be advantageous. Additionally, studies are already progressing on assessing risks associated with speciﬁc manual handling tasks, applications in the ﬁeld of occupational health, and post-surgical outcomes—all areas of current research seen as of high priority. It is expected that future use of the data will itself promote further opportunities to evaluate treatment

ARTICLE IN PRESS M. Troke et al. / Manual Therapy 10 (2005) 198–206

efﬁcacy, monitor diseases and quantify outcomes in clinical and research settings—and relate ﬁndings to the age-related data illustrated in the new normative database. 5.4. Further developments with the instrument and the database It might be desirable to replicate this study in a number of diverse locations nationally, with the aim of reﬂecting differing living environments. Statistical (actuarial) advice would, however, be advisable in this respect to avoid expanding the database to an unnecessary extent without the beneﬁt of clear advantages in terms of statistical power and the generalizablity of the results. All the subjects for this study were of caucasian background, although people from other backgrounds were not speciﬁcally excluded from volunteering for the studies. It might therefore be argued that to be truly representative of the overall diversity of cultural and ethnic backgrounds to be found in the UK, people with a variety of ethnic backgrounds should be included in an expanded database. This might appear to be a counsel of perfection, which would be theoretically desirable but logistically impractical. It might therefore be more feasible to carry out small-scale studies involving participants from speciﬁc ethnic backgrounds (e.g. the Indian sub-continent, Africa, the Far East), and compare their results with the existing database to establish if any signiﬁcant difference exists. In considering the possible inﬂuence of coupled motion characteristics on primary movement a detailed analysis of the three-dimensional data collected was beyond the scope of this work. However, the raw data were recorded in three dimensions as part of the normal collection process. Given recent developments in calibration and computer modelling of the instrument’s measures of coupled motion (Higgison, 2004, pers. comm.), subsequent analysis could focus on the coupled motion characteristics displayed by this group of subjects. The coupled RoMs and patterns of movement could be directly related to the individual participants, and also analysed as centile graphs. The results could also be presented as parallel data to the primary movement centiles illustrated in Figs. 1–12 in the website appendix (www.elsevierscience.com/journals/math).

6. Conclusions As has been previously noted, there has been considerable diversity in approach to the collection of normative data for motion of the lumbar spine. Similarly, there has been considerable variation in the

205

analysis or presentation of results, making the comparison of different studies very difﬁcult. The innovative, clear, consistent and uniform presentation of the normative values for spinal motion data in all three planes of movement has been achieved in this work. It is anticipated that the results may be of particular value to clinicians who are involved in research with, or the management of, patients with low back pain syndromes. The database offers comprehensive indices of spinal RoMs, and may also be of interest to clinicians utilizing other forms of spinal measurement equipment. Additionally, the database may be of interest to clinicians and researchers working in occupational health, primary, secondary or intermediate care settings. In due course the database may be used in the monitoring of rehabilitation programmes, the evaluation of treatment regimes and as an outcome measure for interventions.

Acknowledgement The authors gratefully acknowledge the support of South Thames Regional Health Authority for this work.

References AAOS. Joint motion, method of measuring and recording. Chicago: American Academy of Orthopedic Surgeons; 1965. Altman DG. Construction of age-related reference centiles using absolute residuals. Statistics in Medicine 1993;12:917–24. Bland JM, Altman DG. Comparing two methods of clinical measurement: a personal history. International Journal of Epidemiology 1995;24(Suppl. 1):S7–S14. Dopf CA, Schlomo SM, Geiger DF, Mayer PJ. Analysis of spine motion variability using a computerised goniometer compared to physical examination. Spine 1994;19(5):586–95. Dvorak J, Panjabi MM, Chang DG, Theiler R, Grob D. Functional radiographic diagnosis of the lumbar spine. Spine 1991;16(5):562–71. Dvorak J, Vajda EG, Grob D, Panjabi MM. Normal motion of the lumbar spine as related to age and gender. European Spine Journal 1995;4:18–23. Fitzgerald GK, Wynveen KJ, Rhealt W, Rothschild B. Objective measurement with establishment of normal values for lumbar spinal range of motion. Physical Therapy 1983;63(11):1776–81. Gomez T, Beach G, Cooke C, Rudley WH, Goyert P. Normative database for trunk range of motion, strength, velocity and endurance with the Isostation B200 lumbar dynamometer. Spine 1991;16(1):15–21. Greene WB, Heckman JD. The clinical measurement of joint motion. Chicago: American Academy of Orthopedic Surgeons; 1994. Higgison D. Oxford Brookes University; 2004, personal communication. Hindle RJ, Pearcy MJ, Cross AT, Miller DHT. Three dimensional kinematics of the human back. Clinical Biomechanics 1990;5(4):218–28. Kapandji IA. The Physiology of the Joints. 2nd ed. vol. 3. Trunk & Vertebral Column. Edinburgh: Churchill Livingstone; 1974.

ARTICLE IN PRESS 206

M. Troke et al. / Manual Therapy 10 (2005) 198–206

Loebl WY. Measurement of spinal posture and range of spinal movement. Annals of Physical Medicine 1967;IX(3):103–10. McGregor AH, McCarthy ID, Hughes SP. Motion characteristics of the lumbar spine in the normal population. Spine 1995; 20(22):2421–8. Ng JK-F, Kippers V, Richardson CA, Parnianpour M. Range of motion and lordosis of the lumbar spine. Spine 2001;26(1): 53–60. Panjabi MM, Oxland TR, Yamamoto I, Crisco JJ. Mechanical behaviour of the human lumbar and lumbosacral spine as shown by three-dimensional load-displacement curves. Journal of Bone and Joint Surgery 1994;76A(3):413–24. Pearcy MJ, Portek I, Shepherd J. Three-dimensional X-ray analysis of normal movement in the lumbar spine. Spine 1984;9(3): 294–7. Pearcy MJ. Stereo radiography of lumbar spine motion. Acta Orthopaedica 1985;56(212 (Suppl)):1–41. Russell P, Pearcy MJ, Unsworth A. Measurement of the range and coupled movements observed in the lumbar spine. British Journal of Rheumatology 1993;32(6):490–7. Schober P. The lumbar vertebral column and backache. Munich Medical Wschr 1937;84:336. Shrout PE, Fleiss JL. Intra-class correlations: Uses in assessing rater reliability. Psychological Bulletin 1979;86:420–8. Tanz SS. Motion of the lumbar spine: A roentgenologic study. American Journal of Roentgenology 1953;69(3):399–412.

Troke M, Moore AP. The development of a new form of instrument ﬁxation for the OSI CA6000 spine motion analyzer. Manual Therapy 1995;1(1):43–6. Troke M, Moore AP, Cheek E. Intra-operator and inter-operator reliability of the OSI CA6000 Spine Motion Analyzer with a new skin ﬁxation system. Manual Therapy 1996;1(2):92–8. Troke M, Moore AP, Cheek E. Reliability of the OSI CA6000 spine motion analyzer with a new skin ﬁxation system when used on the thoracic spine. Manual Therapy 1998;3(1):27–33. Troke M, Moore AP, Maillardet FJ, Cheek E, Wells NS, Sidhu PS. X-ray validation of measures recorded by the modiﬁed CA6000 spine motion analysis system. Physiotherapy 2001a;87(2):90–1. Troke M, Moore AP, Maillardet FJ, Hough A, Cheek E. A new, comprehensive normative database of lumbar spine ranges of motion. Clinical Rehabilitation 2001b;15(4):371–9. Twomey L. The Effects of age on the ranges of motions of the lumbar region. Australian Journal of Physiotherapy 1979;25(6):257–63. Van Herp G, Rowe PJ, Salter P, Paul JP. Three dimensional kinematics: a study of 100 healthy subjects aged 20–60+yrs. Rheumatology 2000;39:1337–40. White A, Panjabi MM. Basic kinematics of the human spine. Spine 1978a;3(1):12–20. White A, Panjabi MM. Clinical Biomechanics of the Spine. Philadelphia: Williams & Wilkins; 1978b. White A, Panjabi MM. Clinical biomechanics of the spine, second ed. Philadelphia, Lippincott: Williams & Wilkins; 1990.

ARTICLE IN PRESS

Manual Therapy 10 (2005) 207–218 www.elsevier.com/locate/math

Original article

Diagnosis of Sacroiliac Joint Pain: Validity of individual provocation tests and composites of tests Mark Lasletta,, Charles N. Aprillb, Barry McDonaldc, Sharon B. Youngd a

Department of Health and Society, Linko¨pings Universitet, Linko¨ping, Sweden b Magnolia Diagnostics, New Orleans, LA, USA c Massey University, Institute of Information and Mathematical Sciences, Albany, New Zealand d Mobile Spine and Rehabilitation Center, Mobile, AL, USA Received 11 December 2002; received in revised form 1 September 2004; accepted 4 January 2005

Abstract Previous research indicates that physical examination cannot diagnose sacroiliac joint (SIJ) pathology. Earlier studies have not reported sensitivities and speciﬁcities of composites of provocation tests known to have acceptable inter-examiner reliability. This study examined the diagnostic power of pain provocation SIJ tests singly and in various combinations, in relation to an accepted criterion standard. In a blinded criterion-related validity design, 48 patients were examined by physiotherapists using pain provocation SIJ tests and received an injection of local anaesthetic into the SIJ. The tests were evaluated singly and in various combinations (composites) for diagnostic power. All patients with a positive response to diagnostic injection reported pain with at least one SIJ test. Sensitivity and speciﬁcity for three or more of six positive SIJ tests were 94% and 78%, respectively. Receiver operator characteristic curves and areas under the curve were constructed for various composites. The greatest area under the curve for any two of the best four tests was 0.842. In conclusion, composites of provocation SIJ tests are of value in clinical diagnosis of symptomatic SIJ. Three or more out of six tests or any two of four selected tests have the best predictive power in relation to results of intra-articular anaesthetic block injections. When all six provocation tests do not provoke familiar pain, the SIJ can be ruled out as a source of current LBP. r 2005 Elsevier Ltd. All rights reserved. Keywords: Sacroiliac joint; Low back pain; Physical examination; Diagnosis; Validity; Sensitivity; Speciﬁcity

1. Introduction The sacroiliac joint (SIJ) can be a nociceptive source of low back pain (Fortin et al., 1994a, b; Bogduk, 1995). SIJ pain has no special distribution or features and is similar to symptoms arising from other lumbosacral structures. There are no provoking or relieving movements or positions that are unique or especially common to SIJ pain (Dreyfuss et al., 1996; Fortin et al., 1994a, b; Schwarzer et al., 1995; Maigne et al., 1996; Fortin and Falco, 1997). The clinical diagnosis of symptomatic SIJ Corresponding author. Department of Health and Society, Linkopings University, Auckland, New Zealand. Tel.: +64 9 626 0015. E-mail address: [email protected] (M. Laslett).

1356-689X/$ - see front matter r 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2005.01.003

remains problematical, but the ability to make the diagnosis is an important objective. It may be presumed that treatment strategies for SIJ lesions should differ from strategies intended to relieve and treat pathologies of other structures such as disk, nerve root or facet joint pain. Without a readily accessible means of differentiating between these possible sources of pain, treatment strategies are perforce non-speciﬁc, and likely to have at best, modest efﬁcacy. At present, a current acceptable method of conﬁrming or excluding the diagnosis of a symptomatic SIJ is ﬂuoroscopically guided, contrast enhanced intra-articular anaesthetic block (Fortin et al., 1994b; Grieve, 1988; Merskey and Bogduk, 1994; Schwarzer et al., 1995; Sakamoto et al., 2001; Adams et al., 2002). While

ARTICLE IN PRESS 208

M. Laslett et al. / Manual Therapy 10 (2005) 207–218

certain SIJ tests have been shown to have acceptable inter-rater reliability (Laslett and Williams, 1994; Kokmeyer et al., 2002), current evidence suggests that these tests alone cannot predict the results of a criterion standard such as diagnostic injection (Dreyfuss et al., 1996; Maigne et al., 1996; Slipman et al., 1998). These reports have not reported the sensitivity, speciﬁcity or likelihood ratios or provided data on the diagnostic power of individual or composites of provocation SIJ tests (Slipman et al., 1998). However, in a previous publication, the current authors have identiﬁed a composite of three provocation SIJ tests in the absence of centralization during repeated movement testing has clinically useful sensitivity, speciﬁcity and positive likelihood ratio (93%, 89% and 6.97%, respectively) (Laslett et al., 2003). Conceptually, it seems reasonable to propose that stress testing of the SIJ should provoke pain of SIJ origin. However, clinical stress tests are unlikely to load the targeted structure alone. Herein lies the problem. When a test provokes familiar pain, the question arises if this is evidence of pathology within the targeted structure, or evidence of pathology in a different but nearby structure that is also stressed at the same time. However, if different stress tests of a structure provoke pain, greater diagnostic conﬁdence may result. The use of composites of tests is common in musculoskeletal medicine. When a straight leg raise test provokes familiar leg pain, nerve root irritation from a herniated lumbar disc may be suspected. However, pain, paraesthesiae or skin anaesthesiae in a known segmental distribution, weakness of key muscles or reﬂexes must also be present before the diagnosis of a herniated lumbar disc can be made with any degree of conﬁdence. Conﬁrmation with computed tomography or magnetic resonance imaging completes the composite of tests for this diagnosis. The need for diagnostic research to investigate the added value of composites of tests within the diagnostic process has been emphasized (Deville et al., 2000; Grieve, 1988). This current study explored the utility of utilizing composites of SIJ provocation tests to predict the results of ﬂuoroscopically guided, contrast enhanced SIJ blocks (diagnostic injection).

radiology practice in New Orleans specializing in the diagnosis of spinal pain at regular intervals between January 1997 and August 1998 to carry out the clinical evaluations. Patients were not consecutive. Patients deemed likely by clinic staff to have SIJ pain were scheduled to receive the SIJ provocation tests on a day when an examining physiotherapist visited the clinic. The clinical examination and injection procedures were completed the same day. No other treatment was provided by the physiotherapist. The physiotherapists were blinded to the results of previous diagnostic injections and the results of previous imaging studies. Diagnostic injection was conducted blind from the results of SIJ provocation tests and the results of the physiotherapy examination. Results from the clinical and SIJ injection procedures were recorded on separate standardized data collection forms. Informed consent was sought prior to the clinical evaluations. 2.1. Inclusion criteria Patients with buttock pain, with or without lumbar or lower extremity symptoms were invited to participate in the study. Patients were scheduled for the clinical evaluation in an opportunistic fashion with some patients being examined by the physical therapist at their initial visit to the clinic and others scheduled to return on a day when the physical therapist was present. Each patient had undergone imaging studies and had a variety of unsuccessful therapeutic interventions. They were referred for diagnostic evaluation and procedures by a variety of medical and allied health practitioners and a few were self-referred. Patients were drawn from the New Orleans metropolitan area, with some intrastate and interstate referrals. 2.2. Exclusion criteria Patients were excluded from the study if they were unwilling to participate, had only midline or symmetrical pain above the level of L5, had clear signs of nerve root compression (complete motor or sensory deﬁcit), or were referred for speciﬁc procedures excluding SIJ injection. Those deemed too frail to tolerate a full physical examination, were also excluded.

2. Material and methods 2.3. Background data collection The diagnosis of symptomatic SIJ pathology may mean that either SIJ structures contain the pain generating tissues, or that the SIJ functions or malfunctions in such a way as to cause pain. Throughout this report, references to symptomatic SIJ, SIJ pain or pathology are conﬁned to meaning that the pain originates from the SIJ structures. The study design is presented graphically in Fig. 1. Physiotherapists (ML and SBY) visited a private

Patient data recorded included age, gender, occupation, employment status, pending litigation, duration of symptoms, aggravating/relieving factors and cause of current episode. The patient completed detailed pain drawings (Ohnmeiss et al., 1999; Beattie et al., 2000) and pain intensity was measured on a verbal analogue scale (VAS) (0 ¼ ‘‘no pain’’ and 10 ¼ ‘‘worst imaginable pain’’). Disability was estimated with the

ARTICLE IN PRESS M. Laslett et al. / Manual Therapy 10 (2005) 207–218 Forms for demographics, relevant case history, pain drawing / pain VAS, Roland, Dallas Questionnaires completed

Patients with buttock pain with or without LBP referred to clinic

Inclusion criteria met?

209

no

yes

yes

Informed consent?

no

Exclusion criteria criteria met?

yes

Excluded

no

SIJ provocation tests performed and results recorded

yes

Decision re: diagnosis of painful SIJ

pre-diagnostic injection pain drawing / numeric pain score completed

no

Diagnostic SIJ Injection

Clinical Diagnosis of SIJ pain

Clinical Diagnosis of Non-SIJ pain

Criterion Standard Diagnosis of SIJ pain

Criterion Standard Diagnosis Non-SIJ pain

post-diagnostic injection pain drawing / numeric pain score completed

no

yes

Decision re: diagnosis of painful SIJ

Fig. 1. Flow diagram of study protocol.

Roland–Morris questionnaire (Roland and Morris, 1983; Jensen et al., 1992) and the Dallas Pain and Disability questionnaire (Lawlis et al., 1989). 2.4. Operational definitions The familiar symptom: The familiar symptom is the pain or other symptoms (such as aching, burning, paraesthesiae or numbness) identiﬁed on a pain drawing, veriﬁed by the patient as being the complaint that has led the patient to seek diagnosis and treatment. During a diagnostic test the familiar symptoms must be distinguished from other symptoms produced by the test, and may be produced, increased, decreased or abolished. Choice of SIJ tests to evaluate: Tests based on palpation for positional faults or movement dysfunc-

tions were not considered for inclusion in the current study, since adequate inter-examiner reliability has not been demonstrated in earlier studies (Potter and Rothstein, 1985; McCombe et al., 1989; Meijne et al., 1999). However, one study found that a selection of pain provocation tests were found to have acceptable reliability (Cohen’s Kappa 40.04) (Laslett and Williams, 1994) and these were considered as suitable procedures for evaluation of diagnostic validity. Positive provocation SIJ test: A provocation SIJ test that produces or increases familiar symptoms. Negative provocation SIJ test: A provocation SIJ test that does not produce or increase familiar symptoms. Positive SIJ injection: Slow injection of solutions provokes familiar pain, and instillation of a small volume of local anaesthetic (less than 1.5 cc) resulted in 80% or more relief of the pain for duration of effect

ARTICLE IN PRESS 210

M. Laslett et al. / Manual Therapy 10 (2005) 207–218

of the anaesthetic agent. Anaesthetic effect was assessed by change in pre- and post-injection numeric pain rating scales. Patients reporting a concordant pain response and at least 80% relief of their familiar pain were scheduled for a conﬁrmatory block. Lidocaine was used in the initial injection and Bupivicaine was used in the conﬁrmatory block to eliminate the need for a sham injection (Barnsley et al., 1993). Negative SIJ injection: Diagnostic injections were considered indeterminate when there was a concordant pain response but insufﬁcient pain relief, or when substantial pain relief was reported in the absence of provocation of familiar pain. Indeterminate responses were considered negative for statistical analysis. Injections not causing concordant pain provocation or analgesic response were deemed negative. 2.5. Clinical evaluation The clinical evaluation was carried out by physiotherapists with 25 years (ML) and 17 years (SBY) experience in orthopaedic examinations of spinal pain patients and included a standard history and structured physical examination lasting between 30 min and 1 h. The structured physical examination included a McKenzie examination of the lumbar spine (McKenzie, 1981), SIJ provocation tests (Laslett and Williams, 1994), and a hip joint assessment (Cyriax, 1975). The sacroiliac pain provocation tests: The tests employed in this study were: distraction (Fig. 2), right sided thigh thrust (Fig. 3), right sided Gaenslen’s test (Fig. 4), compression (Fig. 5) and sacral thrust (Fig. 6) and have acceptable inter-rater reliability (Kokmeyer et al., 2002) and have been described previously (Cyriax,

1975; Laslett and Williams, 1994; Maigne et al., 1996; Laslett et al., 2003). 2.6. Radiology examination The technique used for ﬂuoroscopically guided contrast enhanced SIJ arthrography has been previously described (Fortin et al., 1994b; Schwarzer et al., 1995). The radiologist examiner (CA) has over 20 years experience in diagnostic spinal injection procedures, including SIJ injection. The SIJ injection was given within 30 min of completion of the physiotherapy clinical examination. Pain drawings and numeric pain rating scales for pain intensity were acquired prior to and 30–60 min following diagnostic injection. During this study, corticosteroid was introduced into the joint as a therapeutic procedure when the initial injection of contrast and Lidocaine provoked familiar symptoms, as was normal practice at the clinic. The radiologist documented the procedure(s) performed, radiographic ﬁndings and conclusions. Pain provocation and analgesic responses to SIJ injection were recorded. 2.7. Data reduction and analysis Statistical calculations were performed using statistical software Minitab (version 13.31 Minitab Inc. r2000), and CIA (version 2.0.4 r Trevor N Bryant, 2000 University of Southhampton) (Bryant, 2000). Two by two contingency tables were constructed and sensitivity, speciﬁcity, positive and negative predictive values, and likelihood ratios with 95% conﬁdence intervals were calculated for each test independently and for composites of SIJ tests. Sensitivity, speciﬁcity,

Fig. 2. Distraction provocation SIJ test.

ARTICLE IN PRESS M. Laslett et al. / Manual Therapy 10 (2005) 207–218

211

Fig. 3. Thigh thrust SIJ provocation test.

Fig. 4. Gaenslen’s provocation SIJ test (right sided test).

positive and negative predictive values have been calculated using the Wilson method (Altman et al., 2000; Bryant, 2000). Likelihood ratios have been calculated using the score method (Altman et al., 2000). Receiver operator characteristic (ROC) curves are an overall measure of diagnostic efﬁcacy (Altman et al., 2000, pp. 111–116). These curves combine sensitivity and speciﬁcity, and the area under the curve (AUC) is a summary measure of achieved discrimination, with perfect discrimination represented by an AUC of 1.0, and scores equal to or less than 0.5 are equivalent to or

worse than can expected by random chance. The closer the AUC approaches 1.0, the better discriminatory power the diagnostic test has in relation to the criterion or reference standard.

3. Results Sixty-two patients agreed to participate and were examined by both radiologist and physical therapist. Of these patients, three were unable to tolerate the physical

ARTICLE IN PRESS 212

M. Laslett et al. / Manual Therapy 10 (2005) 207–218

Fig. 5. Compression provocation SIJ test.

Fig. 6. Sacral thrust provocation SIJ test.

examination, two were pain free on the day of the clinical assessment, seven had no SIJ injection, and two had a bony obstruction causing a technical failure to inject the SIJ. These patients were excluded from the study. Forty-eight patients satisﬁed all inclusion criteria. Twenty-seven patients received the clinical assessment at their ﬁrst clinic visit, 21 patients at the second. There were no signiﬁcant differences between positive and negative responders to diagnostic injection with regards to age, gender, working status, Dallas and Roland questionnaire results or pain intensity prior to

examination. Table 1 presents basic demographic, and disability data for all included patients. Of the 48 patients satisfying inclusion criteria 16 patients had positive SIJ injections. There were no adverse effects reported by patients from either the physical examination or SIJ injection, other than temporary local soreness at the injection site or increase in discomfort from the clinical examination. The provocation SIJ tests provoked familiar pain in those patients conﬁrmed by diagnostic injection as having painful SIJ pathology more commonly than

ARTICLE IN PRESS M. Laslett et al. / Manual Therapy 10 (2005) 207–218

213

Table 1 Patient characteristics (n ¼ 48) Number

%

32 16

66.7 33.3

Mean

Median

SD

Range

Age (years) Symptom duration (months) Off work (months) Questionnaire Roland–Morris (N ¼ 42)

42.1 31.8 17.8 Mean % 75.7

42.0 22 19 Median % 82.5

12.3 38.8 33.4 SD % 21.6

20–79 2–156 2–84 Range % 22–100

Dallas pain and disability (N ¼ 48) Daily activities interference Work leisure interference Anxiety/depression Social interference

61.2 66.2 54.3 48.7

66.0 75.0 55.0 50.0

18.0 22.6 27.2 24.8

23–93 14–95 0–100 0–85

Female Male

Table 2 Prevalence, sensitivity, speciﬁcity and likelihood ratios for individual SIJ provocation tests

Prevalence of positive test Sensitivity 95% CI

Distraction

Compression

Thigh thrust

Gaenslen’s (right)

Gaenslen’s (left)

Sacral thrust

31.9% 0.60 0.36,0.80

43.8% 0.69 0.44, 0.86

50.0 0.88 0.64, 0.97

37.0% 0.53 0.30, 0.75

31.1% 0.50 0.27, 0.73

37.5% 0.63 0.39, 0.82

Speciﬁcity 95% CI

0.81 0.65, 0.91

0.69 0.51

0.69 0.82

0.71 0.53, 0.84

0.77 0.60, 0.89

0.75 0.58, 0.87

PPV 95% CI

0.60 0.36, 0.80

0.52 0.32, 0.72

0.58 0.39, 0.76

0.47 0.26, 0.69

0.50 0.27, 0.73

0.56 0.34, 0.75

NPV 95% CI

0.81 0.65, 0.91

0.82 0.63, 0.92

0.92 0.74, 0.98

0.76 0.58, 0.88

0.77 0.60, 0.89

0.80 0.63, 0.91

+LR 95% CI

3.20 1.42, 7.31

2.20 1.18, 4.09

2.80 1.66, 4.98

1.84 0.87, 3.74

2.21 0.95, 5.00

2.50 1.23, 5.09

LR 95% CI

0.49 0.24, 0.83

0.46 0.20, 0.87

0.18 0.05, 0.55

0.66 0.34, 1.09

0.65 0.34, 1.03

0.50 0.24, 0.87

Notes: PPV ¼ positive predictive value, NPV ¼ negative predictive value, +LR ¼ likelihood ratio for positive test, LR ¼ likelihood ratio for negative test, 95% CI ¼ 95% conﬁdence interval.

those with negative injections. However, false positive tests were common. Prevalence of positive tests in the sample ranged from 29.2% to 50.0%. Sensitivity, speciﬁcity, positive and negative predictive values and likelihood ratios for each individual test are presented in Table 2. One approach to combining tests is simply to count the number of positives. Two by two contingency tables for the results of composites of all six SIJ tests (0, 1 or more, 2 or more and so on) versus the results of diagnostic injection and are presented in Table 3. Sensitivity, speciﬁcity, positive and negative predictive values and likelihood ratios were calculated and are presented in Table 4. The optimum composite rule was to identify the SIJ as the pain generator if there were

three or more positive tests, with estimated sensitivity of 93.8%, speciﬁcity of 78.1%, and AUC of 0.842 (s.e. 0.042). On the other hand, looking at speciﬁc combinations of tests, it was found that the distraction test had the highest single positive predictive value (PPV) and AUC, the thigh thrust, compression and sacral thrust tests improved the overall diagnostic ability (as measured by improvement in AUC). The Gaenslen’s tests did not improve the AUC value. This implies that Gaenslen’s tests did not contribute positively and may be omitted from the diagnostic process without compromising diagnostic conﬁdence. The optimal rule was to perform the distraction, thigh thrust, compression and sacral thrust tests but stopping when there are two positives.

ARTICLE IN PRESS M. Laslett et al. / Manual Therapy 10 (2005) 207–218

214

Table 3 Two by two contingency tables for results of composites of six SIJ tests and diagnostic injection Composite of SIJ provocation tests

Positive SIJ injection

Negative SIJ injection

Totals

1 or more positive tests (+) Zero positive tests () Totals 2 or more positive tests (+) Less than 2 tests () Totals 3 or more positive tests (+) Less than 3 positive tests () Totals 4 or more positive tests (+) Less than 4 positive tests () Totals 5 or more positive tests (+) Less than 5 positive tests () Totals 6 positive tests (+) Less than 6 positive tests () Totals

16 0 16 15 1 16 15 1 16 9 6 15 4 11 15 1 14 15

18 14 32 11 21 32 7 25 32 6 26 32 4 28 32 4 28 32

34 14 48 26 22 48 22 26 48 15 33 47* 8 40 47* 5 43 47*

*

One patient without a distraction test but positive on the other three. Bold numerals indicate the actual data in the 2 2 tables.

Table 4 Sensitivity, speciﬁcity, positive and negative predictive values and likelihood ratios (95% conﬁdence intervals) for composites from one to six SIJ tests Statistic

1 or more positive tests

2 or more positive tests

3 or more positive tests

4 or more positive tests

5 or more positive tests

Sensitivity Speciﬁcity PPV NPV +LR LR

1.00 0.44 0.47 1.00 1.78 0.00

0.93 0.66 0.58 0.96 2.73 0.10

0.94 0.78 0.68 0.96 4.29 0.80

0.60 0.81 0.60 0.81 3.20 0.49

0.27 0.88 0.50 0.72 2.13 0.84

(0.81, (0.28, (0.32, (0.79, (1.41, (0.00,

1.00) 0.61) 0.63) 1.00) 2.54) 0.46)

(0.72, (0.48, (0.39, (0.78, (1.72, (0.02,

0.99) 0.80) 0.75) 0.99) 4.64) 0.45)

(0.72, (0.61, (0.47, (0.81, (2.34, (0.14,

0.99) 0.89) 0.84) 0.99) 8.58) 0.37)

(0.36, (0.65, (0.36, (0.65, (1.42, (0.24,

0.80) 0.91) 0.80) 0.91) 7.31) 0.83)

(0.11, (0.72, (0.22, (0.56, (0.64, (0.54,

0.52) 0.95) 0.79) 0.84) 6.83) 1.11)

Notes: PPV ¼ positive predictive value, NPV ¼ negative predictive value, +LR ¼ likelihood ratio for positive test, LR ¼ likelihood ratio for negative test.

This resulted in an AUC of (0.819, s.e. 0.054) with sensitivity of 0.88 and speciﬁcity of 0.78. Table 5 presents two by two contingency tables for the four tests that positively contribute to making the diagnosis (distraction, thigh thrust, compression and sacral thrust). Table 6 presents sensitivity, speciﬁcity, positive and negative predictive values and likelihood ratios for two positives of these four tests.

4. Discussion All patients with SIJ pathology identiﬁed by injection had at least one positive test. Only one patient out of 16 with SIJ pain had a single positive test with 15 having two or more positive SIJ tests. Consequently, one reasonable clinical rule is that when all provocation SIJ tests are negative, symptomatic SIJ pathology can be ruled out. The thigh thrust test is the most sensitive test and the distraction test is most speciﬁc.

Three or more of the six tests produce the highest likelihood ratio (4.29), but removal of Gaenslen’s test from the examination and application of the rule ‘‘any two positive tests’’ of the remaining four tests produces almost as good a result (likelihood ratio ¼ 4.0). Because the thigh thrust and distraction tests have the highest individual sensitivity and speciﬁcity, respectively (see Table 3), performance of these tests ﬁrst seems reasonable. If both tests provoke familiar pain, no further testing is indicated. If one test is positive, the compression test is applied and if positive, a painful SIJ is likely and no further testing is required. If compression is not painful the sacral thrust test is applied. If this is painful, SIJ pathology is likely, whereas if it is not painful, SIJ pain is unlikely. Not only does this rule avoid subjecting patients to unnecessary tests, but also would in most cases permit a diagnosis even if one or more tests were not completed. Fig. 7 presents a diagnostic algorithm for this reasoning process.

ARTICLE IN PRESS M. Laslett et al. / Manual Therapy 10 (2005) 207–218

215

Table 5 Two by two contingency tables for results of composites of SIJ tests out of distraction, thigh thrust, compression and sacral thrust versus diagnostic injection results Composite of SIJ provocation tests

Positive SIJ injection

Negative SIJ injection

Totals

1 or more positive tests (+) Zero positive tests () Totals

16 0 16

17 15 32

32 15 48

2 or more positive tests (+) Less than 2 tests () Totals

14 2 16

7 25 32

16 27 48

3 or more positive tests (+) Less than 3 positive tests () Totals

10 6 16

5 27 32

15 8 48

4 positive tests (+) Less than 4 positive tests () Totals

4 1 15

5 27 32

9 38 47*

*

One patient without a distraction test but positive on the other three. Bold numerals indicate the actual data in the 2 2 tables.

Table 6 Sensitivity, speciﬁcity, positive and negative predictive values and likelihood ratios for two positive tests of distraction, thigh thrust, compression and sacral thrust Statistic

Estimate

95% conﬁdence interval

Sensitivity Speciﬁcity PPV NPV +LR LR

0.88 0.78 0.67 0.93 4.00 0.16

0.64, 0.61, 0.45, 0.77, 2.13, 0.04,

0.97 0.89 0.83 0.98 8.08 0.47

Notes: PPV ¼ positive predictive value, NPV ¼ negative predictive value. +LR ¼ likelihood ratio for positive test, LR ¼ likelihood ratio for negative test.

When severe pain occurs with all body movements (e.g. acute disc prolapse, fractures, etc.), pain is provoked by any test including the provocation SIJ tests. In these circumstances interpretation of the SIJ tests is inappropriate. In our opinion, where another source of pain is known to be a major source of pain, the interpretation of the SIJ tests as evidence of a symptomatic SIJ should be avoided or entertained only with scepticism. No single study can satisfy all criteria recommended by advisory groups (Deyo et al., 1994) and this study is no exception. One threat to external validity within this study is that the patients in this study were more chronic and disabled than those usually seen in primary care or most secondary referral environments. While generalizability of the study results must be questioned, it is our anecdotal experience that most primary care and secondary referral patient populations are less difﬁcult to examine and analyse, and these results understate

rather than overstate the diagnostic power of the provocation SIJ tests. Additionally, the effects of preceding provocation tests may confound interpretation of single test results. Progressive increases or decreases in pain responses to the second, third or fourth tests cannot be ruled out as a confounding factor. A different study design would be required to eliminate this confounder, such as allowing a speciﬁed rest period between tests, or applying only a single test to each individual patient before the diagnostic injection. However, the latter design would not permit evaluation of groups or sequences of tests. The criterion standard for the diagnosis of painful lumbar facet joint is comparative anaesthetic or placebo controlled blocks and this is widely accepted and utilized in studies (Dreyfuss et al., 2003). However, standards used in recent studies of SIJ pain diagnosis are diverse. The International Association for the Study of Pain (IASP) has proposed criteria for making the diagnosis of symptomatic SIJ and are: (1) pain is present in the region of the SIJ, (2) stressing the SIJ by clinical tests that are selective for the joint reproduces the patient’s pain, (3) selectively inﬁltrating the putatively symptomatic joint with local anaesthetic completely relieves the patient of pain (Merskey and Bogduk, 1994). In recent diagnostic studies of SIJ pain there are variations on a general theme. Fortin et al. (1994a) used patterns of pain distribution, provocation of pain during SIJ injection and a single anaesthetic block. Schwarzer et al. (1995) used a single injection in patients with pain ‘centred’ below L5/S1 and a 75% reduction in pain following injection of local anaesthetic. Dreyfuss et al. (1996) used a single injection of local anesthetic and cortico-steroid, noted pain provocation and required more than 90% reduction in the ‘main pain’ as distinct from a change in

ARTICLE IN PRESS M. Laslett et al. / Manual Therapy 10 (2005) 207–218

216

Patient with buttock pain with or without LBP

Distraction and Thigh Thrust tests applied

Is familiar pain provoked by both yes no

Compression test applied

SIJ pain ruled out

SIJ pain unlikely

Are 2 tests positive so far

yes

Diagnosis of symptomatic SIJ

no

yes

no Compression test provoke familiar pain?

Are all SIJ tests negative

yes

no

yes

Sacral Thrust test applied

Sacral Thrust test provoke familiar pain?

no

yes

Are 2 tests positive so far

no

Fig. 7. Diagnostic algorithm for SIJ pain using provocation SIJ tests: distraction, thigh thrust, compression and sacral thrust.

VAS assessment of pain generally. Maigne et al. (1996) used comparative double blocks in patients selected by pain drawing as likely to have SIJ pain and at least 75% reduction on a general pain VAS. Slipman et al. (1998) used an 80% reduction on a general pain VAS following single anaesthetic injection in consecutive LBP patients. In an earlier presentation of a subset of patients from the current study, we utilized double comparative blocks and 80% or more reduction in a verbal analogue scale of pain intensity and provocation of pain during SIJ injection as the criterion standard (Laslett et al., 2003). In the current analysis, a single diagnostic injection under ﬂuoroscopic control and contrast enhancement that provoked familiar pain was used and resulted in 80% or more relief of pain as measured by a verbal analogue scale of pain intensity. Where familiar pain was provoked during injection, corticosteroid was injected in addition to local anaesthetic and the patient scheduled for a conﬁrmatory, comparative block. It is noted that in a recent publication (Bogduk and McGuirk, 2002, p. 174), double comparative blocks

are recommended for conﬁrmation of the diagnosis. The data collection for the current paper was between 1996 and 1998, at the time when mixtures of standards were common. Future criterion standard validity studies should use the standard recommended by Bogduk and McGuirk without inclusion of corticosteroid in the initial screening injection. Although false positive rates for SIJ injections have not been previously reported, a rate of 7.7% may be calculated from data presented from one study (Schwarzer et al., 1995) and 20.5% from another (Maigne et al., 1996). In this current analysis, the 16 patients reporting a positive response to a single anaesthetic injection and 12 proceeded on to receive a second injection. All of these patients reported a positive anaesthetic response, conﬁrming the diagnosis of SIJ pathology with a false positive rate of zero. Of the four initial responders who did not receive a conﬁrmatory block, three derived such pain relief from the initial block that a conﬁrmatory block was inappropriate. It is assumed that ablation of pain following the initial block was a consequence of the

ARTICLE IN PRESS M. Laslett et al. / Manual Therapy 10 (2005) 207–218

introduction of corticosteroid during the initial procedure. One patient did not return for the scheduled conﬁrmatory block for unknown reasons. In a worst-case scenario using the comparative conﬁrmatory blocks as a criterion standard, we can propose that all four cases not returning for a conﬁrmatory block would have returned a negative response to that procedure and the initial block deemed false positive. Estimations (with 95% conﬁdence intervals) for sensitivity, speciﬁcity, positive/negative predictive values would be 83.3 (55.2, 95.3), 69.4 (53.1, 82.0), 47.6 (28.3, 67.7), 92.6 (76.6, 97.9) percent, respectively, and positive/negative likelihood ratios would be 2.72 (1.57, 4.74) and 0.24 (0.66, 0.87), respectively. The estimations from this scenario still exceed what can be expected by random chance at the lower 95% conﬁdence limit. However, in this scenario the false positive rate (95% conﬁdence intervals) would have been 30.6% (15.1, 45.6). Although diagnostic injection is the only available criterion standard against which clinical tests can reasonably be evaluated for validity, it is acknowledged that false negative and false positive responses to injection are possible. Where there is a defect in the articular capsule, leakage of anaesthetic into adjacent areas may occur (Fortin et al., 1994a; Schwarzer et al., 1995), and pain relief may be a reﬂection of an anaesthetic affect of these structures rather than the SIJ structures. This possibility and the unknown effect of psychosocial inﬂuences on pain responses to invasive diagnostic procedures may contribute to the false positive and negative rates. No attempt to estimate these inﬂuences was attempted during this study. In addition, intra-articular injection of anaesthetic has the potential to ablate SIJ pain when originating within the joint cavity, but is unlikely to have an anaesthetic effect on SIJ structures external to the joint (Grieve, 1988). (Maigne et al., 1996; Laslett et al., 2003) Where SIJ structures external to the joint cavity are actual pain generators, an intra-articular injection of local anaesthetic into and conﬁned to the joint space will produce a false negative diagnostic result, whereas the clinical examination may possibly correctly identify the periarticular and unanaesthetized SIJ structures as pain generators. The patients entered into this study were not consecutive. The physiotherapists performing the clinical examination were not residents in New Orleans where the diagnostic injections were being carried out and could visit only intermittently over a 19-month period. Consequently, no estimate of prevalence should be inferred from the data presented in this report. Additionally, calculation of predictive values or false positive rates in a sample, at least partially selected for possible SIJ involvement, are not be generalizable to other patient populations.

217

The results of this study are in contrast to the results of earlier similar studies (Schwarzer et al., 1995; Dreyfuss et al., 1996; Maigne et al., 1996; Slipman et al., 1998), and the conclusion from a meta-analysis of studies of clinical tests for painful SIJs (van der Wurff et al., 2000). However, there is support for the use of pain provocation tests in SIJ diagnosis (Laslett et al., 2003) and these tests are preferred over palpation tests for mobility or position (Freburger and Riddle, 2001). It is difﬁcult to account for the differences between our results and the results from other studies. However, some of the explanation may lie in differences in application of the examination technique. There is evidence that physiotherapists apply different degrees of force when utilizing SIJ provocation tests (Levin et al., 1998, 2001) and this may be one of several factors inﬂuencing results.

5. Conclusion Provocation SIJ tests have signiﬁcant diagnostic utility. Six provocation tests were selected on the basis of previously demonstrated acceptable inter-examiner reliability. Two of four positive tests (distraction, compression, thigh thrust or sacral thrust) or three or more of the full set of six tests are the best predictors of a positive intra-articular SIJ block. When all six SIJ provocation tests are negative, painful SIJ pathology may be ruled out.

Acknowledgements Thanks to Duncan Reid, Wayne Hing, and the Auckland University of Technology Multimedia Unit for assistance with photographs. Travel and Louisiana licensing costs for Mrs. Young were funded by The McKenzie Institute International.

References Adams MA, Bogduk N, Dolan P. Biomechanics of low back pain. London: Churchill-Livingstone; 2002. Altman DG, Machin D, Bryant TN, Gardner MJ. Statistics with conﬁdence. 2nd ed. Bristol: British Medical Journal; 2000. Barnsley L, Lord S, Bogduk N. Comparative local anaesthetic blocks in the diagnosis of cervical zygapophysial joint pain. Pain 1993:99–106. Beattie PF, Meyers SP, Stratford P, Millard RW, Hollenberg GM. Associations between patient report of symptoms and anatomic impairment visible on magnetic resonance imaging. Spine 2000; 25(7):819–28. Bogduk N. The anatomical basis for spinal pain syndromes. Journal of Manipulative and Physiological Therapeutics 1995;18(9):603–5. Bogduk N, McGuirk B. Medical management of acute and chronic low back pain, vol. 13. Amsterdam: Elsevier Science BV; 2002.

ARTICLE IN PRESS 218

M. Laslett et al. / Manual Therapy 10 (2005) 207–218

Bryant TN. Conﬁdence interval analysis for windows. (2.0.0): BMJ Books, 2000. Cyriax, J., 6th ed. Textbook of orthopaedic medicine. Volume one: diagnosis of soft tissue lesions. London: Balliere Tindall; 1975. p. 546–54. Deville WLJM, van der Windt DAWM, Dzaferagic A, Bezemer PD, Bouter LM. The test of lasegue: systematic review of the accuracy in diagnosing herniated discs. Spine 2000;25(9):1140–7. Deyo RA, Haselkorn J, Hoffman R, Kent DL. Designing studies of diagnostic tests for low back pain or radiculopathy. Spine 1994;19(18 (Suppl)):2057S–65S. Dreyfuss PH, Michaelsen M, Pauza K, McLarty J, Bogduk N. The value of history and physical examination in diagnosing sacroiliac joint pain. Spine 1996(21):2594–602. Dreyfuss PH, Dreyer SJ, Vaccaro A. Lumbar zygapophysial (facet) joint injections. The Spine Journal 2003;3(Suppl):50–9. Fortin JD, Falco FJ. The Fortin ﬁnger test: an indicator of sacroiliac pain [see comments]. American Journal of Orthopedics 1997;26(7):477–80. Fortin JD, Aprill C, Pontieux RT, Pier J. Sacroiliac joint: pain referral maps upon applying a new injection/arthrography technique. Part II: clinical evaluation. Spine 1994;19(13):1483–9. Fortin JD, Dwyer AP, West S, Pier J. Sacroiliac joint: pain referral maps upon applying a new injection/arthrography technique. Part 1: asymptomatic volunteers. Spine 1994;19:1475–82. Freburger JK, Riddle DL. Using published evidence to guide the examination of the sacroiliac joint region. Physical Therapy 2001;81(5):1135–42. Grieve GP. Diagnosis. Physiotherapy Practice 1988;4:73–7. Jensen MP, Strom SE, Turner JA, Romano JM. Validity of the sickness impact proﬁle Roland scale as a measure of dysfunction in chronic pain patients. Pain 1992;50:157–62. Kokmeyer DJ, van der Wurff P, Aufdemkampe G, Fickenscher TCM. The reliability of multitest regimens with sacroiliac pain provocation tests. Journal of Manipulative and Physiological Therapeutics 2002;25(1):42–8. Laslett M, Williams M. The reliability of selected pain provocation tests for sacroiliac joint pathology. Spine 1994;19(11):1243–9. Laslett M, Young SB, Aprill CN, McDonald B. Diagnosing painful sacroiliac joints: a validity study of a McKenzie evaluation and sacroiliac joint provocation tests. Australian Journal of Physiotherapy 2003;49:89–97. Lawlis GF, Cuencas R, Selby D, McCoy CE. The development of the Dallas pain questionnaire. An assessment of the impact of spinal pain on behavior. Spine 1989;14(5):511–6.

Levin U, Nilsson-Wikmar L, Stenstrom CH, Lundeberg T. Reproducibility of manual pressure force on provocation of the sacroiliac joint. Physiotherapy Research International 1998;3(1): 1–14. Levin U, Nilsson-Wikmar L, Harms-Ringdahl K, Stenstrom CH. Variability of forces applied by experienced physiotherapists during provocation of the sacroiliac joint. Clinical Biomechanics 2001; 16:300–6. Maigne JY, Aivaliklis A, Pfefer F. Results of sacroiliac joint double block and value of sacroiliac pain provocation tests in 54 patients with low back pain. Spine 1996;21(16):1889–92. McCombe PF, Fairbank JCT, Cockersole BC, Pynsent PB. Reproducibility of physical signs in low back pain. Spine 1989;14(9): 908–18. McKenzie RA. The lumbar spine: mechanical diagnosis and therapy. Waikanae: Spinal Publications Ltd.; 1981. Meijne W, van Neerbos K, Aufdemkampe G, van der Wurff P. Intraexaminer and interexaminer reliability of the Gillet test. Journal of Manipulative and Physiological Therapeutics 1999; 22(1):4–9. Merskey H, Bogduk N. Classiﬁcation of chronic pain: descriptions of chronic pain syndromes and deﬁnitions of pain terms. 2nd ed. Seattle: IASP Press; 1994. Ohnmeiss DD, Vanharanta H, Ekholm J. Relationship of pain drawings to invasive tests assessing intervertebral disc pathology. European Spine Journal 1999;8(2):126–31. Potter NA, Rothstein JM. Intertester reliability for selected clinical tests of the sacroiliac joint. Physical Therapy 1985;65(11): 1671–5. Roland M, Morris R. A study of the natural history of back pain. Part I: development of a reliable and sensitive measure of disability in low-back pain. Spine 1983;8(2):141–50. Sakamoto N, Yamashita T, Takebayashi T, Sekine M, Ishii S. An electrophysiologic study of mechanoreceptors in the sacroiliac joint and adjacent tissues. Spine 2001;26:E468–71. Schwarzer AC, Aprill C, Bogduk N. The sacroiliac joint in chronic low back pain. Spine 1995;20(1):31–7. Slipman CW, Sterenfeld EB, Chou LH, Herzog R, Vresilovic E. The predictive value of provocative sacroiliac joint stress maneuvers in the diagnosis of sacroiliac joint syndrome. Archives of Physical Medicine and Rehabilitation 1998;79(3):288–92. van der Wurff P, Meyne W, Hagmeijer RHM. Clinical tests of the sacroiliac joint: a systematic methodological review. Part 2: validity. Manual Therapy 2000;5(2):89–96.

ARTICLE IN PRESS

Manual Therapy 10 (2005) 219–223 www.elsevier.com/locate/math

Technical and measurement report

Intra- and inter-rater reliability of the anterior atlantodental interval measurement from conventional lateral view ﬂexion/extension radiographs Michael D. Westawaya,, William Y. Hub, Paul W. Stratfordc, Murray E. Maitlanda, a

Faculty of Kinesiology, University of Calgary, 19 Discovery Valley Cove SW, Calgary, Alb., Canada T3H 5H3 b Faculty of Medicine, Department of Diagnostic Imaging, Foothills Medical Center, Calgary, Alb., Canada c School of Rehabilitation Science and Department of Clinical Epidemiology and Biostatistics, Hamilton, Ont., Canada Received 1 November 2003; received in revised form 16 August 2004; accepted 8 December 2004

Abstract An investigation of intra- and inter-rater reliability anterior atlantodental interval (AADI) measurements was conducted using ﬂexion/extension plain radiographs. Flexion and extension lateral radiographs of individuals investigated for atlantoaxial instability were measured for AADI on three occasions. Intra-rater intraclass correlation coefﬁcients (ICC) were calculated for both ﬂexion (0.99) and extension (0.96). Inter-rater ICCs were 0.93 and 0.84 for ﬂexion and extension, respectively. The AADI measurement proved to be reproducible with a minimal standard of error, between and within raters. r 2005 Elsevier Ltd. All rights reserved. Keywords: Atlantoaxial; Atlantodental interval; Reliability; Radiographs; Neck; Instability; Rheumatoid arthritis

1. Introduction The atlantal transverse ligament contributes to atlantoaxial congruency by directly acting as a primary restraint to anterior translation of the atlas on the axis. Atlantoaxial instability has been attributed to trauma, articular degeneration, and congenital anomalies (Coutts, 1996). Although magnetic resonance imaging is considered the current gold standard for demonstrating cord compromise due to atlantoaxial subluxation (Dvorak et al., 1989), it is time-consuming, expensive, and impractical to use in some clinical settings. Conventional plain radiographic ﬂexion/extension cervical spine views have been used in diagnostic radiology for years and continue to serve as a relatively Corresponding authors. Tel.: +1 403 280 9728; fax: +1 403 280 7168. E-mail address: [email protected] (M.D. Westaway).

1356-689X/$ - see front matter r 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2004.12.001

inexpensive screening method. Speciﬁcally, the anterior atlantodental interval ([AADI]- the distance between the atlas and the odontoid process) is used to identify instability at the atlantoaxial articulation. A number of conventional plain radiographic ﬂexion/ extension cervical spine motion studies have been done to quantify normative values for atlantoaxial anterior displacement (Hinck and Hopkins, 1960; Locke et al., 1966). Age, gender, degeneration, and certain diseases affect the atlantoaxial complex, and therefore these variables also effect published AADI normative values. In general, an AADI measurement of greater than 4 mm in ﬂexion indicates anterior instability at the atlantoaxial complex (Locke et al., 1966). A reliable measurement process is required to detect the existence and advancement of anterior atlantoaxial subluxation. Moreover, reliable AADI values are of paramount importance given that surgical decisions are based on radiological measurements. In addition,

ARTICLE IN PRESS 220

M.D. Westaway et al. / Manual Therapy 10 (2005) 219–223

manual therapists are interested in AADI normative values and progression if high velocity, low-amplitude manipulation is contemplated in a patient’s treatment. A Medline literature search revealed little information concerning the reliability of the AADI measurement. Selby et al. (1991) investigated clinical signs and symptoms in 135 children with Down’s syndrome. AADI was measured on all the children in ﬂexion, extension and neutral. Repeated measurements of the AADI were performed on 19 children on two occasions separated by 10 min. Although the authors concluded that the AADI was an unreliable predictor for atlantoaxial subluxation in this sample, no formal reliability analysis was performed. For a measure to be reliable it must provide consistent values on replicate tests and be able to differentiate among patients. Typically, the standard error of measurement (SEM) is applied to describe a measure’s consistency (Stratford and Goldsmith, 1997) and an intraclass correlation coefﬁcient (ICC) is used to represent a measure’s ability to differentiate among patients (Shrout and Fleiss, 1979). The SEM provides an estimate of the measurement error in the same units as the original measurement; whereas, the ICC provides a relative index of reliability. ICCs can take on values from 0 to 1 with higher values representing greater reliability. When a measure’s reliability is lower than desired, it is informative to examine the sources of variation that contribute to the poor reliability. Typically, reliability studies partition the variance into between and withinpatient variation. Factors contributing to the withinpatient variation include inherent variation within a patient, the method used to acquire the image, and rater variation in interpreting the ﬁlm. An alternate investigative approach would be to estimate the reliability and error variance under the best possible conditions. If the magnitude of error was deemed to be too large, steps could be taken to improve the reliability prior to advancing to more complex and expensive designs. Investigations that require multiple radiographs on the same patient would be undertaken only after acceptable rater reliability had been achieved. In keeping with this view, the purpose of this study was to investigate intra- and inter-rater reliability of the AADI in a sample of conventional lateral ﬂexion/ extension cervical spine radiographs.

2. Materials and methods 2.1. Subjects Cervical ﬂexion and extension radiographs from 15 patients who were investigated for possible atlantoaxial instability (nine males and six females; mean age—30

Table 1 Characteristics of the 15 subjects Subject

Gender

Group

Visit/reason

Age

1

Female

RA

Follow-up

38

2

Female

RA

Follow-up

37

3

Female

N

Trauma

24

4

Female

N

Trauma

28

5

Female

N

MVA

20

6

Female

N

Emergency admission

25

7

Male

RA

Follow-up

56

8

Male

RA

Follow-up

18

9

Male

N

Trauma

16

10

Male

N

Pain

40

11

Male

N

Sport injury

18

12

Male

N

MVA

37

13

Male

N

MVA

22

14

Male

N

MVA

33

15

Male

N

MVA

36

N ¼ no disease. MVA ¼ motor vehicle accident. RA ¼ rheumatoid arthritis.

years (Table 1); range 16–56 years) were obtained at random from the Foothills Medical Center Radiology Department ﬁlm library archives. The reasons for the radiographic investigations were as follows: four patients were investigated for instability associated with rheumatoid arthritis (RA); nine patients were investigated following trauma; and two patients were investigated for unusual signs and symptoms (unreported). Of the four RA subjects, one (subject 7) presented with signiﬁcant degenerative erosion to the odontoid. The other three rheumatoid arthritic subjects had no identiﬁable pannus formation, osseous anomalies, or observable degenerative changes at the atlantoaxial motion segment. 2.2. Design This retrospective study investigated radiographs of suspected craniovertebral unstable patients. The craniovertebral radiographic procedure is standardized for cervical spine instability detection as per the protocol of the Foothills Medical Center (180 cm source to ﬁlm distance). Each subject was asked to actively position the neck in full ﬂexion and then into full extension while standing. At each respective end range, a lateral radiograph was taken. To investigate intra-rater reliability, the same radiologist measured AADI on three occasions over a 9-

ARTICLE IN PRESS M.D. Westaway et al. / Manual Therapy 10 (2005) 219–223

221

week period. The radiologist reviewed the ﬁlms in random order and a total of 90 measurements were performed (45 ﬂexion and 45 extension). The second and third readings were performed at 3-week intervals and the radiologist was blind with respect to previous results. The radiologist performing the assessments had 7 years experience and routinely performed AADI measurements; however no special preparation was carried out prior to this study. To examine inter-rater reliability, a second radiologist interpreted the AADI on the same set of ﬁlms on three separate occasions over a 3-week duration. This radiologist also had 7 years experience and did not have any special training previous to the study. Both radiologists agreed to a speciﬁc AADI measurement approach. Fourteen patients’ ﬁlms were measured using the same technique. Speciﬁcally, the anterior arch of the atlas was identiﬁed. The superior-most and inferiormost points were identiﬁed along the sagittal plane (Fig. 1: point A vertical line). A point was made on the posterior cortical border of the atlas equidistant between the inferior and superior border (Fig. 1: B vertical line).

Fig. 2. Conventional lateral radiograph in Fig. 1. Point C is determined as the equidistant point along the posterior border of the anterior atlantal arch cortex whereas point D is the point along the line AB on the anterior cortical border of the odontoid.

A similar approach was used on the posterior arch of the atlas. The posterior arch was identiﬁed and the inferiormost and superior-most points were taken in the sagittal plane. A point was determined equidistant from the anterior cortex of the posterior arch of the atlas between to the two previously identiﬁed cranial and caudal points. From these two respective anterior and posterior mid-atlantal arch points a line was drawn horizontally to join them (Fig. 2). The AADI was measured from the anterior cortex of the odontoid to the posterior cortex of the anterior arch of the atlas (Fig. 2: line CD). Atlantodental intervals were measured with a standard ruler calibrated in millimeters. The radiologist estimated the measure to 0.5 mm. This technique was modiﬁed for one patient’s ﬁlms because of an osseous edge detection problem.

2.3. Analysis and sample size justification Fig. 1. Conventional lateral radiograph of a subject in ﬂexion. A and B points are determined as equidistant between the superior and inferior borders of the anterior and posterior arches of the atlas, respectively.

A Shrout and Fleiss (1979) type 2, 1 ICC and lower 1sided 95% conﬁdence interval of the ICC were applied to assess intra- and inter-rater reliability of ﬂexion and

ARTICLE IN PRESS 222

M.D. Westaway et al. / Manual Therapy 10 (2005) 219–223

extension measurements. The Shrout and Fleiss type 2, 1 ICC provides the theoretical reliability for a single measurement; also, it partitions the within subject variance into two components: systematic difference between replicate measurements and residual error. The SEM and upper 1-sided 95% conﬁdence interval of the SEM (Stratford and Goldsmith, 1997) were used to quantify the consistency of the replicate measurements in millimeters. Sample size was based on three assumptions: each ﬁlm would be read three times, the point estimate of the ICC would be 0.95, and the desired limit of the lower 1-sided conﬁdence interval equaled 0.05. We used the estimation method of Walter et al. (1998) and set the z-value associated with a Type II error to zero. This produced a sample size of 15 ﬁlms of ﬂexion and extension.

3. Results The mean ﬂexion and extension measurements were 4.0 mm (SD ¼ 3:3) and 1.8 mm (SD ¼ 1:1), respectively. Intra-rater reliability Type 2,1 ICCs for ﬂexion and extension were 0.99 (lower 1-sided 95% CI ¼ 0:97) and 0.96 (lower 1-sided 95% CI ¼ 0:90), respectively. The SEMs for ﬂexion and extension were 0.38 mm (upper 1sided 95% CI ¼ 0:49 mm) and 0.22 mm (upper 1-sided 95% CI ¼ 0:28 mm), respectively. The four rheumatoid arthritic subjects had an AADI range on ﬂexion of 8.0–13.0 mm whereas the other 11 subjects presented with a range of 1.0–4.0 mm. Extension AADI measurements for the rheumatoid arthritic subjects ranged from 1.0 to 5.0 mm and from 1.0 to 3.0 mm for the remainder of the subject radiographs. Inter-rater reliability Type 2, 1 ICCs for ﬂexion was 0.93 (lower 1-sided 95% CI ¼ 0:99) and 0.84 lower 1-sided 95% CI ¼ 0:96 for extension.

4. Discussion To our knowledge this is the ﬁrst study to report reliability coefﬁcients and quantify measurement error for AADI measurements. Anterior subluxation is the most frequent abnormality at the atlantoaxial complex, occurring in approximately one-fourth to one-third of patients with rheumatoid arthritis (Boden, 1994). The anterior atlantodental interval has been used as an objective indicator of anterior atlantoaxial subluxation. Atlantoaxial subluxation is manifested in the presence of rheumatoid arthritis, by pannus formation, ligamentous distention, synovitis and bone resorption (Kuhr et al., 1996). Clinical symptoms range from subtle neck pain to neurological compromise and myelopathic dysfunction. However, Boden (1994) states that patients who have

radiographic evidence of atlantoaxial instability involvement do not necessarily have impending neurological signs. Joint instability can manifest from ligament laxity due to synovial and osseous articular erosion combined. Mulherin (2000) has noted that inﬂammation and osseous erosion may represent two distinct processes. In the inﬂamed joint, the processes are related, but even when articular inﬂammation is negligible, articular erosion may continue because it is thought to be an independent process. Progression of atlantoaxial instability may be a continuous subtle manifestation of rheumatoid arthritis. Braunstein et al. (1984), note that a correlation could not be made between the progress of radiographic subluxation and the development of spinal cord compression. Although computed tomography has been shown to have a higher correlation with neurological status than the conventional AADI measurement (Braunstein et al., 1984), best-practice methods from an economic standpoint, support the use of lateral radiographs. Reliability of AADI measurement is important for clinical decision-making with respect to further interventions (CT, MR, surgery, mobilization/manipulation). As such, our study investigated the reliability of quantifying AADI. The method in this study for AADI measurement was modiﬁed from the method employed in the study by Locke et al. (1966). Their anterior atlantodental distance was measured from the posterior inferior portion of the anterior arch of the atlas to the adjacent anterior border of the dens. This method is difﬁcult to use in a population that presents with odontoid erosion and therefore, cannot be used universally. Our technique of obtaining the equidistant superior/inferior point of the posterior and anterior arches proved to be reproducible. The AADI is a very small measurement to quantify in a majority of subjects. The error resulting from the use of crude techniques may take on statistical signiﬁcance. The standard error of measurement is noted to be 0.38 and 0.22 mm for ﬂexion and extension, respectively. When measuring small distances at the AADI, the amount of error is signiﬁcant in normal subjects for ﬂexion whereas, in unstable subjects the error is not as relevant due to a larger AADI. Clinically, the error seems negligible and is an indication of the quality of the radiographs and the ability to identify osseous edge detection. The intra-class correlation coefﬁcient gives an indication of the reproducibility of the measures from the same subject. Our results show an extension AADI measurement ICC of 0.96 and ﬂexion ADDI measurement ICC of 0.99, thus representing a large betweenperson variability (AADI extension range: 1.0–5.0 mm, ﬂexion AADI range: 1.0–13.0 mm) and small withinperson variability. Within the context of this study, the intra-class correlation coefﬁcient provides a relative index for the

ARTICLE IN PRESS M.D. Westaway et al. / Manual Therapy 10 (2005) 219–223

radiologist to differentiate among patients in a consistent manner. Excellent intra-class correlation coefﬁcients were noted for both ﬂexion and extension in this study. The SEM provides an estimate of the measurement error in the same units as the original measurement, in this case millimeters. Both radiologists were able to accurately differentiate unstable and stable atlantoaxial complexes based on the AADI measurement. Therefore, the utility of monitoring (by the same practitioner or by another clinician), AADI progression due to repetitive trauma or systemic disease with our standardized measurement technique is supported with minimal error and excellent reliability coefﬁcients. Inter-rater ICC for extension was comparably less (0.84). This was indicative of a small AADI range and the chance for greater error in measuring. Clinically however, monitoring ﬂexion AADI range is more valuable than extension excursion as the magnitude of cord compression, due to osseous migration, is appreciated. We believe the results of the current study are generalizable to clinical settings because the radiologists did not have any previous measurement practice or cues to enhance performance. In addition, the subjects examined (random sampling) were typical of a generalized manual therapy population. On the whole, the same technique and strategy was used with all the radiographs, however, where there was an edge detection issue, a modiﬁed technique was used. This modiﬁcation proved to be reproducible for the subject in question (subject 14). The AADI has traditionally been used as an indicator of atlantoaxial instability. Boden et al. (1993) uses the posterior atlantodental interval (PADI) approach, measuring from the posterior wall of the dens to the anterior aspect of the C1 lamina. This measurement was compared and evaluated to that of the AADI measurement. Although the PADI approach is presented as a superior measurement interval, Boden et al. (1993) used this approach as a predictor for paralysis onset in the rheumatoid arthritic population but the reliability of repeated measures was not discussed. Boden et al. (1993) presents strong evidence to support the utility of using the PADI approach to accurately determine positive and negative predictive values. To the best of the authors’ knowledge, this study represents the ﬁrst study to support the reliability of the AADI using repeated-measures methodology. This is

223

important to accurately obtain normative values but to monitor possible pathological progression at the atlantoaxial level. Further research should investigate predictive utility of the measurement in other populations that are subject to atlantoaxial instability (i.e., Down’s syndrome). Although this study provides evidence for high intra- and inter-rater reliability, further research studies might investigate variability in radiographic techniques and measurement approaches. Our study supports the use of the AADI as a reliable measurement at the atlantoaxial complex to monitor progressive anterior displacement.

References Boden S. Rheumatoid arthritis of the cervical spine: surgical decision making based on predictors of paralysis and recovery. Spine 1994;19:2275–80. Boden SD, Dodge LD, Bohlman HH, Rechtine GR. Rheumatoid arthritis of the cervical spine: a long-term analysis with predictors of paralysis and recovery. J Bone Joint Surg (Am) 1993;75:1282–97. Braunstein EM, Weissman BN, Seltzer SE, Sosman JL, Wang A-M, Zamani A. Computed tomography and conventional radiographs of the craniovertebral region in rheumatoid arthritis. Arth Rheum 1984;17:26–31. Coutts MB. Atlanto-epistropheal subluxations. Arch Surg 1996;29:297–311. Dvorak J, Grob D, Baumgartner H, Gschwend N, Grauer W, Larsson S. Functional evaluation of the spinal cord by magnetic resonance imaging in patients with rheumatoid arthritis and instability of upper cervical spine. Spine 1989;14:1046–57. Hinck VC, Hopkins CE. Measurement of the atlanto-dental interval in the adult. AJR 1960;84:945–51. Kuhr M, Hohmann D, Schramm M, Martus P. Radiographic evaluation of the upper cervical spine in rheumatoid arthritis: a retrospective analysis. Eur Spine J 1996;5:107–11. Locke GR, Gardener JI, Van Epps EF. Atlas-dens interval (ADI) in children: a survey based on 200 normal cervical spines. AJR 1966;97:135–40. Mulherin DM. Mechanisms of inﬂammation in rheumatoid arthritis. J Irish Coll Phys Surg 2000;29(1):160–72. Selby KA, Newton RW, Gupta S, Hunt L. Clinical predicators and radiological reliability in atlantoaxial subluxation in Down’s syndrome. Arch Dis Child 1991;66:876–8. Shrout PE, Fleiss JL. Intraclass correlations: uses in assessing rater reliability. Psych Bull 1979;86:420–8. Stratford PW, Goldsmith CH. Use of the standard error as a reliability index of interest: an applied example using elbow ﬂexor strength data. Phys Ther 1997;77:745–50. Walter SD, Eliasziw M, Donner A. Sample size and optimal designs for reliability studies. Statist Med 1998;17:101–5.

ARTICLE IN PRESS

Manual Therapy 10 (2005) 224–231 www.elsevier.com/locate/math

Case report

The use of manipulation in a patient with an ankle sprain injury not responding to conventional management: a case report$ J.M. Whitmana,b,, J.D. Childsc, V. Walkerd a

Affiliate Faculty, Regis University, Denver, CO, USA US Army-Baylor University Postprofessional Doctoral Program in Orthopaedic and Manual Physical Therapy, USA c Department of Physical Therapy, Wilford Hall Medical Center, Lackland Air Force Base, San Antonio, TX, USA d West Texas Rehab Center, Abilene TX, USA

b

Received 12 January 2004; received in revised form 13 September 2004; accepted 14 October 2004

1. Introduction Ankle sprains are common among physically active individuals, (Almeida et al., 1999) with a reported incidence of seven injuries per 1000 persons over a 1year period. (Holmer et al., 1994). The primary environments in which these injuries occurred were during sports (45%), play (20%), and work (16%) activities, with inversion ankle sprains accounting for over 60% of the sprains. (Holmer et al., 1994). In a study of 547 patients with ankle sprains, Fallat et al. (1998) found that the anterior taloﬁbular ligament (ATFL) was most frequently injured, followed by the calcaneoﬁbular ligament (CFL) and posterior taloﬁbular ligament (PTFL). A combination of injury to the ATFL and the CFL accounted for 34.2% of the ankle sprains, and involvement of all three ligaments was found in 31.3% of the injuries (Fallat et al., 1998). Inversion ankle sprains are typically classiﬁed as Grades I, II, or III based on a pathoanatomical model

$

Previous Presentation: This case was presented as a Sports Section Research Platform Presentation at the 2002 Combined Section Meeting of the American Physical Therapy Association in Boston, MA. This study was exempt from review by the Wilford Hall Medixcal Center Institutional Review Board (IRB) and the University of Pittsburgh IRB based on the study being a case report. Corresponding author. Regis University, Rueckert-Hartman School for Health Professionals, Mail Code G-9, 3333 Regis, Blvd, Denver, CO 80221-1099, USA. Tel.: +1 303 458 4340; fax: +1 303 964 5474. E-mail address: [email protected] (J.M. Whitman). 1356-689X/$ - see front matter r 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2004.10.003

that consists of a combination of factors detected during the physical examination. These factors include the location of tenderness, the presence of oedema/ecchymosis, reduced weight-bearing ability, ligament damage, reaction to ligamentous stability testing, and the presence of instability (Gerber et al., 1998). Grade I sprains have been reported to account for 71.3% of injuries, with Grade II and III sprains accounting for 9.5% and 2.9% of the injuries, respectively (Fallat et al., 1998). Conventional management of Grade I ankle sprains incorporates the RICE principles (Rest, Ice, Compression, and Elevation) combined with early motion and full weight bearing (Wolfe et al., 2001). Its success in improving mobility, pain, and disability has been well documented in the literature (Linde et al., 1971; Dettori et al., 1994; Eiff et al., 1994; Dettori and Basmania, 1994; Karlsson et al., 1996). Further, this approach has been shown to lead to greater improvements in motion and decreased pain and swelling than a program that includes immobilization (Dettori et al., 1994). The generally accepted prognosis is that a Grade I ankle sprain treated with conventional management will resolve within 7–14 days (Safran et al., 1999). However, there appears to be a subgroup of patients who continue to experience pain and functional limitations substantially longer than 2 weeks, (Dettori and Basmania, 1994; Gerber et al., 1998), with some patients remaining symptomatic even 1 year after injury (Dettori and Basmania, 1994). Perhaps one reason that some individuals continue to experience prolonged pain and

ARTICLE IN PRESS J.M. Whitman et al. / Manual Therapy 10 (2005) 224–231

functional limitations even after completing a traditional rehabilitation program is that the conventional management approach does not adequately address the potential for underlying hypomobility in joints that are susceptible to injury during an inversion ankle sprain. Joints that may become injured and contribute to the pain, limited motion, and functional limitations associated with an inversion ankle sprain include the proximal and distal tibioﬁbular, talocrural, and the subtalar joints. The talocrural joint is primarily responsible for the motions of dorsiﬂexion and plantar ﬂexion, and limited dorsiﬂexion is a common impairment in individuals with an inversion ankle sprain (Denegar et al., 2002). It is possible that an individual with a Grade I ankle sprain may exhibit decreased passive accessory motion of this joint which may not be addressed by conventional management. Passive accessory motion is deﬁned as movements that a patient cannot perform himself but which can be performed on the patient by someone else (Maitland, 1991). For example, gliding the talus in an anterior to posterior direction on a ﬁxed distal tibia and ﬁbula would be considered an accessory motion that is required for normal ankle physiologic dorsiﬂexion. Restricted ankle accessory motions could contribute to a slower improvement in pain and function than that typically observed in individuals who sustain a Grade I ankle sprain. The subtalar joint, which has also been implicated in ankle sprain injuries, is primarily responsible for inversion and eversion and contributes to the tri-planar motions of supination and pronation. The subtalar joint is important for functional movement of the talus, as a restriction in this joint can restrict ankle motion, thus possibly contributing to the recalcitrant nature of some inversion ankle sprains (Beirne et al., 1984). It seems reasonable to suggest that manipulation/ mobilization techniques for joints that exhibit limited passive accessory motion may be helpful in the management of ankle sprains that do no respond to conventional management. The Guide to Physical Therapist Practice (American Physical Therapy Association (APTA), 2001) deﬁnes manipulation/mobilization 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.’’ Unfortunately, there is little evidence on the efﬁcacy of these types of interventions for patients with ankle sprains not responding to conventional management. Thus, the purpose of this case report is to describe the use of manipulation/ mobilization for a patient after an inversion ankle sprain who did not demonstrate any improvements in pain or function after 3 weeks of conventional management.

225

2. Methods 2.1. History The patient was a 27-year old volleyball player who had suffered from an ankle sprain three weeks prior to her ﬁrst visit to physical therapy. The patient clearly recalled and described an inversion mechanism of injury that occurred while returning to the ground after jumping to hit a volleyball. She had administered selftreatment with rest, ice, compression with self-ankle taping, and elevation. This individual also reported that she had been consistently doing strengthening exercises with resistive tubing (dorsiﬂexion, plantarﬂexion, inversion, and eversion) per instruction by a therapist after a previous ankle sprain injury. The patient noted no change in symptoms over the 3 weeks of self-treatment, although she had forced herself to stop using the crutches approximately 1 week prior to her visit to the physiotherapist. The patient reported having a history of 6–7 inversion ankle sprains of the involved ankle over the last 10–15 years. For previous injuries, symptoms typically resolved in 1 week, occasionally in up to 2 weeks, with self-treatment of rest, ice, compression, and elevation. This patient decided to seek medical care because this injury was not responding to self-treatment using conventional management. Although very active prior to the injury, to include playing volleyball 2–3 days per week and running 6–10 miles weekly, she was currently completely unable to participate in exercise or sports. The patient’s current symptoms included a constant ache to the medial calcaneal region that varied based on activity and an intermittent, burning pain extending along the medial leg up to approximately 10 cm below the medial tibial plateau (Fig. 1). On a numeric pain rating scale (Downie et al., 1978; Jensen et al., 1994) the patient reported a range of pain from 5 to 9 out of 10 over the last 24 h (Table 1). Interestingly, the patient’s current symptoms were not characteristic of those from previous injuries. Previous episodes involved only symptoms localized to the lateral aspect of the ankle, without any pain in the leg. The patient reported increased pain with running, squatting, going up and down steps, and prolonged weight-bearing. Non-steroidal anti-inﬂammatory medications and non-weightbearing positions temporarily eased her symptoms and there were no other reported lower extremity symptoms or low back pain (LBP). Her baseline scores for several self-report measures of function can be seen in Table 1. For the Foot and Ankle Ability Index (FAAI), higher numbers represent greater functional ability (Pugia et al., 2001). The Patient Speciﬁc Functional Scale (PSFS) was used to help quantify the patient’s speciﬁc functional limitations (Stratford et al., 1995; Chatman et al., 1997). In this

ARTICLE IN PRESS J.M. Whitman et al. / Manual Therapy 10 (2005) 224–231

226

scale, patients select a score for 3–5 speciﬁc activities that they are having difﬁculty with as a result of their problem. The range of available scores is 0–10, with 0 representing an inability to perform the activity and 10 representing an ability to perform activity at same level as before the injury or problem. The patient identiﬁed difﬁculty with negotiating stairs, squatting, prolonged standing, and running. Her average score for the PSFS was 5.5 and her score on the FAAI was 68.3%. The patient’s primary goal was to quickly return to highlevel physical activity, including running without pain. 2.2. Physical examination Based on a visual observation of the patient’s gait, the patient was judged to exhibit a slightly antalgic gait, with pain primarily occurring during the late stance phase of gait when maximal talocrural dorsiﬂexion range of motion (ROM) is required. Active dorsiﬂexion ROM on the involved lower extremity, both with the knee ﬂexed and the knee fully extended, was limited to 51 and was painless with overpressure. Active ankle

ROM on the uninvolved lower extremity was normal. ROM measurements were performed with a universal goniometer, both in sitting with 901 knee ﬂexion (as described by Norkin and White, 2003), as well as in supine with full knee extension. The patient’s strength was essentially normal and pain free. Mild laxity was present with the inversion talar tilt and anterior drawer tests. No swelling or ecchymosis was present. Speciﬁc pain scores were obtained during walking, squatting, and with a step-up at baseline (Table 2). Based on the patient’s self-report of limited oedema and ability to fully bear weight soon after the initial injury, the patient was judged to have a Grade I ankle sprain that was not responding to conventional management. The presence of slight laxity with the talar tilt and anterior drawer tests was judged to be a sequela of previous ankle sprain injuries. Based on our clinical experience and the suggestion of others (Greenman 1996), patients with ankle sprains not responding to conventional management and those with a history of recurrent ankle sprains frequently demonstrate decreased passive accessory motion of the proximal and distal tibioﬁbular joint, talocrural joint, and the subtalar joint. As a result, the authors of this manuscript routinely examine these joints in the management of all ankle sprain injuries. Passive accessory motion testing revealed decreased mobility at the proximal and distal tibio-ﬁbular joints and the talocrural and subtalar joints relative to the opposite lower extremity. All passive accessory motion testing was performed as described by Maitland (1991). Radiographs of the tibia, ﬁbula, and foot and ankle were negative for fracture or any other abnormalities, and the dorsiﬂexion/ external rotation and ‘‘squeeze tests’’ to rule out a syndesmosis injury were negative (Alonso et al., 1998). 2.3. Treatment

Fig. 1. Patient’s pain diagram.

Based on the patient’s failure to respond with selftreatment utilizing conventional management and the presence of decreased passive accessory motion in several joints of the leg and ankle, the decision was made to utilize manipulation/mobilization techniques that targeted the underlying joint hypomobility identiﬁed in the examination. The techniques that were used

Table 1 Self-report measures of pain and function Measurement

Baseline

Four-day follow-up

Six week follow-up

Average NPRS value for past 24 h Patient speciﬁc functional scale Foot and ankle ability index score Running activity

7/10 5.5 68.30% None

1/10 10 96.30% Two miles (one time) without pain

0/10 10 95.60% Two miles, 4–6 times weekly without pain

NPRS ¼ Numeric Pain Rating Scale (0 ¼ no pain; 10 ¼ worst pain imaginable).

ARTICLE IN PRESS J.M. Whitman et al. / Manual Therapy 10 (2005) 224–231

227

Table 2 Impairment and physical performance measurements Measurement

Baseline

Immediately after initial treatment (ﬁrst visit)

Four-day follow-up

Six-week follow-up

Ankle active ROM Plantarﬂexion Dorsiﬂexion Inversion Eversion Total ankle ROM NPRS with gait NPRS with squat NPRS with step-up

541 51 401 151 1141 2/10 4/10 3/10

601 131 421 151 1301 1/10 2/10 0/10

Not assessed

Not assessed

0/10 0/10 0/10

0/10 0/10 0/10

NPRS ¼ Numeric Pain Rating Scale (0 ¼ no pain; 10 ¼ worst pain imaginable).

are outlined in Table 3 with pictures that illustrate the direction of movement. The proximal tibio-ﬁbular joint manipulation and the rearfoot distraction manipulation were performed one time each. The talocrural joint lateral glide mobilizations, subtalar joint eversion mobilizations, and the talocrural joint anterior to posterior joint mobilizations were each performed for approximately 3–4 bouts of 30 oscillations. Immediate improvements were noted after the manipulation/mobilization interventions. The patient demonstrated increased dorsiﬂexion ROM and experienced an immediate decrease in pain during gait, negotiating stairs, and squatting (Table 2). Additionally, when retested, passive accessory joint motion appeared to be equal to the opposite ankle and foot except for some remaining limitation in mobility in the rearfoot with lateral glides.

visit and the patient was instructed in proprioception and agility training exercises. In a telephone follow-up call 11 days after the initial treatment, the patient reported a return to full participation in volleyball and running without limitation or pain (Tables 1 and 2). 2.6. Longer-term follow-up All improvements in pain and function persisted 6 weeks after treatment, with a return to running 2 miles 4–6 days per week without pain. Her scores on the PSFS and the FAAI remained stable (Table 1). Based on the patient having achieved her goals and the absence of any impairments or functional limitations, the therapist reviewed the patient’s exercise program with her and discharged her from physical therapy.

2.4. Home exercise program

3. Discussion

To reinforce the manipulation/mobilization techniques, the patient was taught to self-mobilize her ankle into dorsiﬂexion and eversion. A weight bearing on/off self-mobilization technique was used to increase dorsiﬂexion ROM, and a seated self-mobilization technique was used to increase eversion ROM (Table 3).

Most patients who sustain a Grade I ankle sprain improve rapidly with conventional management utilizing an RICE approach that emphasizes early motion and full weight bearing. However, there appears to be a subgroup of patients who continue to have symptoms even at 1 year post-injury (Dettori and Basmania, 1994). It seems reasonable to suspect that some of these individuals may have decreased passive accessory joint motion that is not addressed by conventional management and may beneﬁt from interventions that utilize manipulation/mobilization techniques. There is little published evidence on the efﬁcacy of manipulation/mobilization for patients with any diagnoses involving the ankle or foot. A recent literature search revealed a total of ﬁve randomized controlled trials (Wilson, 1991; Dettori and Basmania, 1994; Green et al., 2001; Pellow and Brantingham, 2001; Coetzer et al., 2001) and a limited number of case–control studies, case series, or case reports (Marshall and Hamilton, 1992; Nield et al., 1993; Mooney and Maffey-Ward,

2.5. Short-term follow-up Four days after treatment, the patient reported resolution of pain with squatting, standing, and negotiating stairs and demonstrated no pain and normal mobility with gait, squatting, and performing a step-up during the physical exam (Table 2). The patient’s score on the PSFS improved to a 10 and both subscales of the FAAI improved substantially (Table 1). Additionally, the patient returned to running up to 2 miles without pain. Based on the presence of normal passive accessory motion in the follow-up examination, no further manipulation/mobilization was performed during this

ARTICLE IN PRESS 228

J.M. Whitman et al. / Manual Therapy 10 (2005) 224–231

Table 3 Description of mobilization/manipulation techniques

Reprinted with kind permission from Wainner R, Flynn T, Whitman J. Spinal and Extremity Manipulation: The Basic Skill Set for Physical

Therapists [book on CD-ROM]. San Antonio, TX; 2001. Copyright 2001, Manipulations Inc.

1994; O’Brien and Vicenzino, 1998; Menetrey and Fritschy 1999; Dananberg et al., 2000). The populations in these studies included normal subjects, (Nield et al.,

1993) individuals with acute (Dettori and Basmania, 1994; O’Brien and Vicenzino, 1998; Green et al., 2001; Coetzer et al., 2001) and chronic ankle sprains (Pellow

ARTICLE IN PRESS J.M. Whitman et al. / Manual Therapy 10 (2005) 224–231

and Brantingham, 2001) status post cast immobilization secondary to fracture (Wilson, 1991) and with various foot and ankle diagnoses such as ankle equinus (Dananberg et al., 2000) cuboid subluxation (Marshall and Hamilton, 1992; Mooney and Maffey-Ward, 1994) and subtalar joint subluxation (Menetrey and Fritschy, 1999). Only one study was identiﬁed with a patient population and treatment regimen similar to ours (Pellow and Brantingham, 2001). Chronicity for this study was deﬁned as the persistence of pain for more than 5 days after the initial injury. Patients in the experimental group received an ‘‘ankle mortise separation technique’’, similar to the rearfoot distraction technique that was used in this patient. The control group received a placebo treatment. Patients in the manipulation group demonstrated a signiﬁcant reduction in pain and increased function compared to the control group both immediately after treatment and at a 1-month followup. Although there are limitations in the study’s methodology, the results seem to support the use of manipulation in patients with persistent symptoms after an ankle sprain injury. In our experience, many clinicians avoid manipulation in acute and subacute injuries of the periphery because of a belief that tissue damage has occurred, and the notion that manipulation will contribute to further tissue damage. In other areas, such as the lumbopelvic region, the literature generally supports the use of manipulation in the management of acute injuries (Koes et al., 2001). Perhaps the pathoanatomical model that is currently utilized to determine the severity of ankle sprains (Grade I vs. Grade II vs. Grade III) biases clinicians to inappropriately assume that manipulation/ mobilization may be harmful, when in fact some individuals with recalcitrant ankle sprains may exhibit decreased passive accessory joint motion that, if adequately addressed, will lead to dramatic improvements in pain and function. Its interesting to note that a pathoanatomical model (Waddell, 1996) based on a ‘‘tissue damage’’ model has been largely unsuccessful in explaining pain and disability in LBP. Because of the difﬁculty in sub-grouping patients with LBP based on this model, attempts have been made to subgroup, or classify, patients based on ﬁndings from the history and physical examination (Flynn et al., 2002). Perhaps the treatment of ankle sprains would beneﬁt if clinicians and researchers explored an alternate treatment-based classiﬁcation scheme that is based on an individual patient’s response to treatment rather than on a pathoanatomical model that often fails to explain the pain and functional limitations associated with recalcitrant ankle sprains. Developing effective classiﬁcation schemes or clinical prediction rules that assist clinicians in selecting appropriate interventions based on a patient’s historical and physical examination ﬁndings should improve clinical

229

decision-making and patient outcomes. Thus, if a researcher wants to assess the efﬁcacy of manipulation/mobilization, the identiﬁcation of those patients who actually have decreased passive accessory motion of the ankle joints may be crucial. Although this may seem obvious, most studies that have assessed the efﬁcacy of manipulation/mobilization in patients with an ankle sprain did not assess passive accessory joint motion, which is the primary impairment believed to be targeted by manipulation/mobilization techniques. Without the ability to match patients to speciﬁc treatments, clinicians are left without evidence for their decision-making in selecting treatments for a particular patient. Classiﬁcation methods will also enhance the power of clinical research by permitting researchers to study more homogenous groups of patients. Because this was a single case report, one cannot conclude that the patient’s improvement in pain and function was a result of the manipulation/mobilization. However, given the recalcitrant nature of her injury, the patient’s rapid response to manipulation/mobilization suggests that this intervention may have been effective for this patient. Despite the limited number of clinical trials that assess the efﬁcacy of manipulation/mobilization in the management of ankle sprain injuries, this form of intervention seems to have some beneﬁt for patients with inversion ankle sprains. We believe it may have the most beneﬁt for patients who are not responding to conventional management, and who demonstrate limitations in passive accessory motion. However, this hypothesis has not been investigated at this time. Based on our experience with this patient and others with chronic foot and ankle disorders who have responded positively to manipulation/mobilization, it would be helpful to identify those patients who will respond to conventional management versus those would beneﬁt from the addition of manipulation/ mobilization. Perhaps this group of patients could even be identiﬁed immediately after injury, which would provide clinicians with a powerful tool to guide treatment decisions and facilitate a more rapid improvement in pain and function in individuals who would otherwise continue to have symptoms for a prolonged period of time. Eventually, it would be useful to develop a treatment-based classiﬁcation system for all foot and ankle disorders. Such a system would provide clinicians a treatment-based framework to guide the decisionmaking process rather than relying primarily on a pathoanatomical model.

4. Conclusion This case demonstrates the use of manipulation/ mobilization to manage a patient who had pain that was unresponsive to 3 weeks of conventional manage-

ARTICLE IN PRESS 230

J.M. Whitman et al. / Manual Therapy 10 (2005) 224–231

ment for her inversion ankle sprain. Supplementing conventional management strategies with manipulation/ mobilization techniques may improve treatment effectiveness by decreasing pain and improving function in shorter time periods. Although a causative relationship cannot be drawn from a case report, it is our hypothesis that utilization of manipulation/mobilization to address impairments in joint mobility in the ankle and foot may restore normal joint motion and allow for a quicker return to sporting activities. While it is not the authors’ opinion that all patients with inversion sprains need this treatment approach, perhaps there may be a subgroup of patients for whom this intervention strategy would be most effective. Future research is needed to determine the optimal role of manipulation/mobilization in the rehabilitation of patients after inversion ankle sprains.

Disclaimer The opinions or assertions contained herein are the private views of the authors and are not to be construed as ofﬁcial or as reﬂecting the views of the US Air Force or Department of Defense.

References Almeida SA, Williams KM, Shaffer RA, Brodine SK. Epidemiological patterns of musculoskeletal injuries and physical training. Medicine & Science in Sports & Exercise 1999;31(8):1176–82. Alonso A, Khoury L, Adams R. Clinical tests for ankle syndesmosis injury: reliability and prediction of return to function. Journal of Orthopaedic and Sports Physical Therapy 1998;27(4):276–84. American Physical Therapy Association (APTA). Guide to physical therapist practice. Physical therapy, Issue No. 81. 2nd ed. 2001. p. 9–744. Beirne DR, Burckhardt JG, Peters VJ. Subtalar joint subluxation. Journal of the American Podiatry Association 1984;74(11): 529–32. Chatman AB, Hyams SP, Neel JM, Binkley JM, Stratford PW, Schomberg A, Stabler M. The Patient-Speciﬁc Functional Scale: measurement properties in patients with knee dysfunction. Physical Therapy 1997;77(8):820–9. Coetzer D, Brantingham J, Nook B. The relative effectiveness of Piroxicam compared to manipulation in the treatment of acute grades 1 and 2 ankle sprains. Journal of the Neuromusculoskeletal System 2001;9(1):1–12. Dananberg HJ, Shearstone J, Guillano M. Manipulation method for the treatment of ankle equines. Journal of the American Podiatry Association 2000;90(8):385–9. Denegar CR, Hertel J, Fonseca J. The effect of lateral ankle sprain on dorsiﬂexion range of motion, posterior talar glide, and joint laxity. Journal of Orthopaedic & Sports Physical Therapy 2002;32(4):166–73. Dettori JR, Basmania CJ. Early ankle mobilization, Part II: a one-year follow-up of acute, lateral ankle sprains (a randomized clinical trial). Military Medicine 1994;159(1):20–4. Dettori JR, Pearson BD, Basmania CJ, Lednar WM. Early ankle mobilization, Part I: the immediate effect on acute, lateral ankle

sprains (a randomized clinical trial). Military Medicine 1994;159(1):15–20. Downie WW, Leatham PA, Rhind VM, Wright V, Branco JA, Anderson JA. Studies with pain rating scales. Annals of the Rheumatic Diseases 1978;37(4):378–81. Eiff MP, Smith AT, Smith GE. Early mobilization versus immobilization in the treatment of lateral ankle sprains. American Journal of Sports Medicine 1994;22(1):83–8. Fallat L, Grimm DJ, Saracco JA. Sprained ankle syndrome: prevalence and analysis of 639 acute injuries. Journal of Foot Ankle Surgery 1998;37(4):280–5. Flynn T, Fritz J, Whitman J, Wainner R, Magel J, Butler B, Rendeiro D, Garber M, Allison S. A clinical prediction rule for classifying patients with low back pain who demonstrate short term improvement with spinal manipulation. Spine 2002;27(24): 2835–43. Gerber JP, Williams GN, Scoville CR, Arciero RA, Taylor DC. Persistent disability associated with ankle sprains: a prospective examination of an athletic population. Foot & Ankle International 1998;19(10):653–60. Green T, Refshauge K, Crosbie J, Adams R. A randomized controlled trial of a passive accessory joint mobilization on acute ankle inversion sprains. Physical Therapy 2001;81(4):984–94. Greenman PE. Principles of manual medicine, 2nd ed. Philadelphia: Lippincott Williams and Wilkins; 1996. Holmer P, Sondergaard L, Konradsen L, Nielsen PT, Jorgensen LN. Epidemiology of sprains in the lateral ankle and foot. Foot & Ankle International 1994;15(2):72–4. Jensen MP, Turner JA, Romano JM. What is the maximum number of levels needed in pain intensity measurement? Pain 1994;58(3):387–92. Karlsson J, Eriksson BI, Sward L. Early functional treatment for acute ligament injuries of the ankle joint. Scandinavian Journal of Medicine and Science in Sports 1996;6(6):341–5. 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(22):2504–13. Linde F, Hvass I, Juergensen U, Madsen F. Early mobilizing treatment of ankle sprains. A clinical trial comparing three types of treatment. Scandinavian Journal of Sports Sciences 1986;8(2):71–4. Maitland GD. Peripheral manipulation, 3rd ed. Oxford: ButterworthHeinemann; 1991. Marshall P, Hamilton WG. Cuboid subluxation in ballet dancers. American Journal of Sports Medicine 1992;20(2):169–75. Menetrey J, Fritschy D. Subtalar subluxation in ballet dancers. American Journal of Sports Medicine 1999;27(2):143–9. Mooney M, Maffey-Ward L. Cuboid plantar and dorsal subluxations: assessment and treatment. Journal of Orthopaedic & Sports Physical Therapy 1994;20(4):220–6. Nield S, Davis K, Latimer J, Maher C, Adams R. The effect of manipulation on range of movement at the ankle joint. Scandinavian Journal of Rehabilitation Medicine 1993;25(4):161–6. Norkin C, White D. Measurements of Joint Motion: a guide to goniometry, 3rd ed. Philadelphia: FA Davis; 2003. O’Brien T, Vicenzino B. A study of the effects of Mulligan’s mobilization with movement treatment of lateral ankle pain using a case study design. Manual Therapy 1998;3(2):78–84. Pellow JE, Brantingham JW. The efﬁcacy of adjusting the ankle in the treatment of subacute and chronic grade I and grade II ankle inversion sprains. Journal of Manipulative and Physiological Therapeutics 2001;24(1):17–24. Pugia ML, Middel CJ, Seward SW, Pollock JL, Hall RC, Lowe L, Mahony L, Henderson NE. Comparison of acute swelling and function in subjects with lateral ankle injury. Journal of Orthopaedic & Sports Physical Therapy 2001;31(7):384–8.

ARTICLE IN PRESS J.M. Whitman et al. / Manual Therapy 10 (2005) 224–231 Safran MR, Benedetti RS, Bartolozzi AR, Mandelbaum BR. Lateral ankle sprains: a comprehensive review: part 1: etiology, pathoanatomy, histopathogenesis, and diagnosis. Medicine & Science in Sports & Exercise 1999;31(Suppl. 7):S429–37. Stratford P, Gill C, Westaway M, Binkley J. Assessing disability and change on individual patients: a report of a patient speciﬁc measure. Physiotherapy Canada 1995;47:258–63.

231

Waddell G. Low back pain: a twentieth century health care enigma. Spine 1996;21(24):2820–5. Wilson FM. Manual therapy versus traditional exercises in mobilisation of the ankle post-ankle fracture: a pilot study. New Zealand Journal of Physiotherapy 1991;19(3):11–6, Dec. (7 ref). Wolfe MW, Uhl TL, Mattacola CG, McCluskey LC. Management of ankle sprains. American Family Physician 2001;63(1):93–104.

ARTICLE IN PRESS

Manual Therapy 10 (2005) 232–233 www.elsevier.com/locate/math

Letter to the Editor Clinical anatomy serving manual therapy, by Mercer SR, Rivett DA Manual Therapy 9 (2) (2004) 59 In orthodox medicine, when it comes to uncovering what actually ails patients and why (diagnosis) anatomy is a necessary beginning. Generally however, it is only that. It is not also the middle and end. This is equally true of ‘clinical’ (applied) anatomy (Mercer and Rivett, 2004 Manual Therapy), no matter how idiosyncratically interpreted. The simplistic SAB (structural–anatomical–biomechanical) approach whereby patients are ‘assessed’ largely in terms of articulated skeletons or unfeeling cadavers is no longer sufﬁcient, or acceptable in enlightened manual therapy circles. Mercer and Rivett’s editorial appears to be an attempt to put something of a new spin on the outmoded SAB approach to clinical reasoning and decision making. For instance, the fact that the facet joints, or outer laminae of the lumbar intervertebral discs, are innervated is hardly revolutionary. Among other things, this simply suggests that there is little unique physiologically regarding the cause and mechanisms of back pain. That is, at least initially the pain is mediated by inﬂammatory chemicals, however produced, with the potential to be provoked or aggravated by mechanical (and other) stimuli. Of itself, or even when coupled with biomechanics, such routine applied anatomy tells us nothing about how manual therapy might or might not ‘work’ with our patients. It is gratifying to note that Mercer and Rivett deﬁne manual therapy as was originally meant. Namely, ‘‘y the application by hand of forces intended to move joints and surrounding tissues’’ (p.59). Hence, interventions for back pain which employ re-education of ‘wasted’ or tardy trunk muscles to actively ‘stabilise’ (sic) or control discrete segments of the lumbar spine are conceptually unrelated to such passive procedures. Not that the SAB rationale for this approach is itself entirely without uncertainty. For instance, it is unclear how and why with the resumption of everyday activities back pain is able to subside at all in the presence of such a continuous pathognomonic anatomical ‘defect’ (Hides et al., 1994, 1996,cf. Ka¨ser et al., 2001). It also seems somewhat paradoxical that there is not an automatic relationship between resolution of the clinical variables of importance—pain and disability—and change (or 1356-689X/$ - see front matter r 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2005.02.004

otherwise) of muscle bulk measured at long term followup, (Daneels, 2001; Daneels et al., 2001; Hides et al., 2001). If ‘control’ (central nervous system) is the problem, ‘wasting’ (peripheral anatomy) may effectively become an artefact. The seminal evidence for muscle ‘wasting’ indicates that the primary problem is not one of trunk muscle anatomy, but pain (Hides et al., 1994). As is the case with delayed activation of abdominal muscles, the trigger for extensor muscle ‘wasting’ (in such naı¨ ve patients) is obviously nociception, and the mediator is the nervous system (Hodges and Moseley, 2001). Spontaneously arising or mechanically provoked ‘symptoms and signs’ are not the product of applied/’clinical’ anatomy or biomechanics. They are the result of chemically mediated neural activity and an increase of sensitivity in the peripheral and/or central nervous systems. The anatomical (and physiological) changes of clinical signiﬁcance include those which transpire acutely, and may persist chronically, in pain pathways in (particularly) the central nervous system (Willis, 2002, Zusman, 2004). As Daykin and Richardson (2004) reveal, being locked-in to SAB-based ‘assessment’ with failure to recognise the actual (central) nervous system source of sensory and motor responses, can have several detrimental consequences. Understandably, this is particularly so with relatively inexperienced clinicians having to deal with more ‘difﬁcult’ cases, chronic pain, and ‘psychological overlay’. These clinicians were left with feelings of low self-efﬁcacy and poor outcome expectancies. Together, these are attributed to insufﬁcient skills and knowledge needed to treat patients in order to obtain the ‘results they had anticipated’ (Daykin and Richardson, 2004). Consequent feelings of disheartenment and frustration contribute to clinicians increased impatience, neglect to offer patients appropriate explanations (deemed critical nowadays), and a tendency to be less sympathetic. Indication that the above are a direct result of what Daykin and Richardson (2004) term clinicians ‘biomedical [effectively SAB] world view’ comes from noting their beliefs regarding the cause and meaning of patients’ pain, treatment selection, nature of any proffered explanations and reasons given for outcome expectations. Further evidence of the rigidity of

ARTICLE IN PRESS Letter to the Editor / Manual Therapy 10 (2005) 232–233

clinicians SAB orientation is the choice of ‘biomedical’ treatments in the face of overt psychological factors. The uncertainly and confusion—indeed potential harm—this can cause is suggested by a totally dichotomous approach to management. That is, when confronted with (possible) failure clinicians either ‘wrote patients off’ and returned them to the pain clinic ASAP, or were driven to persist with patently inappropriate treatment for weeks on end by the ‘‘y feeling one should be able to do something’’ (Daykin and Richardson, 2004, p.787) (italics mine). In other words, the clinician is losty. It goes without saying that of course passive movements need to be expertly selected and administered. The same is certainly the case with respect to reestablishing motor ‘control’ with the prescription of therapeutic active movement, posture re-education and gait training. Naturally, all of the above require an in depth knowledge of somatic anatomy and biomechanics. However, it is time to move beyond applying such knowledge almost exclusively for purposes of deciding ‘what to do’ with little regard for understanding why (insight into ‘why’ also helps inform ‘why not’). Practitioners knowledge base needs to be broader than applied anatomy and biomechanics if insight into (how and) why is to be included in the clinical reasoning and decision making process. It was optimistically assumed that replacing the SAB approach with a biopsychosocial model—for which there is overwhelming evidence (eg Bardin, 2002a, b)— would render sad situations such as described by Daykin and Richardson (2004) a thing of the past. Emphasis on combined physiological and psychological inﬂuences on (central) pain mechanisms is an invaluable aid to comprehending, and perhaps even predicting in advance, why different patients may and may not respond to physical treatments. Increased ability of even naive clinicians to make such judgements—and feel reasonably good about them—is what is needed. Not further endorsement of idiosyncratically interpreted applied anatomy (and biomechanics), however contemporary or ‘clinical’.

233

References Bardin LD. Physiotherapy and low back pain—Part II: outcomes research utilising the biopsychosocial model: biological outcomes. South African Journal of Physiotherapy 2002a;58(4):19–26. Bardin LD. Physiotherapy and low back pain—Part III: outcomes research utilising the biopsychosocial model: psychosocial outcomes. South African Journal of Physiotherapy 2002b;59(2):16–24. Daneels L. Evaluation and rehabilitation of functional spinal stability. PhD thesis, Department of Rehabilitation Science and Physiotherapy, Ghent University, 2001. p.119–36 [Chapter 7]. Daneels LA, Vanderstraeten DC, Witvwrou J, et al. Effects of three different training modalities on the cross sectional area of lumbar multiﬁdus muscle in patients with chronic low back pain. British Journal of Sports Medicine 2001(35):186–91. Daykin AR, Richardson B. Physiotherapists’ pain beliefs and their inﬂuence on the management of patients with chronic low back pain. Spine 2004;29(7):781–95. Hides JA, et al. Evidence of lumbar multiﬁdus muscle wasting ipsilateral to symptoms in patients with acute/subacute low back pain. Spine 1994;19(2):165–72. Hides JA, Richardson CA, Jull GA. Multiﬁdus muscle recovery is not automatic after resolution of acute, ﬁrst episode low back pain. Spine 1996;21(23):2763–9. Hides JA, Jull GA, Richardson CA. Long-term effects of speciﬁc stabilizing exercises for ﬁrst-episode low back pain. Spine 2001;11:E243–8. Hodges PW, Moseley GL. Pain and motor control of the lumbopelvic region: effect and possible mechanisms. Journal of Electromyography and Kinesiology 2001;13:361–70. Ka¨ser L, Mannion AF, Rhyner A, et al. Active therapy for chronic low back pain Part 2. Spine 2001;26(8):909–19. Mercer SB, Rivett DA. Clinical anatomy serving manual therapy. Manual Therapy 2004;9(2):59. Willis WD. Long-term potentiation in spinothalamic tract neurones. Brain Research Reviews 2002;40:202–14. Zusman M. Mechanisms of musculoskeletal physiotherapy. Physical Therapy Reviews 2004;9:39–49.

Max Zusman Curtin University of Technology School of Physiotherapy, Selby Street, P.O. Box 1987 Perth 6845, Bentley, Western Australia E-mail address: [email protected]

ARTICLE IN PRESS

Manual Therapy 10 (2005) 234 www.elsevier.com/locate/math

Letter to the Editor Response to Letter to the Editor: Clinical anatomy serving manual therapy The correspondent raises a valid point that not all reported pain is necessarily related to musculoskeletal pathology and that treatment of such pain on the assumption of such pathology is unlikely to be satisfactory for either the patient or the practitioner. We are well aware of the multifaceted nature of the pain experience (Cornwall et al., 2000; Deyo et al., 2004; Jones and Rivett, 2004a; Prkachin et al., 2001) and we did not suggest in our editorial (Mercer and Rivett, 2004) that all assessment and treatment methodologies should be solely directed towards a structural–anatomical–biomechanical approach. Nor did we suggest that clinicians should direct their attention rigidly to any such approach in manual therapy (Rivett, 1999) and limit their clinical reasoning accordingly. Indeed, pathobiological mechanisms, including pain mechanisms, and patients’ perspectives on their pain experience, including psychosocial factors, are acknowledged in the contemporary clinical reasoning literature as two categories of clinical judgment (hypothesis categories) that assist the manual therapist in understanding the patient as a person and their problem(s) (Jones and Rivett, 2004b). However, structures and tissues associated with the patient’s complaint also constitute a clinical reasoning hypothesis category. The manual therapist requires a knowledge base encompassing each of these categories and more. Even a ‘‘biopsychosocial’’ model includes a biological component—and this component requires justiﬁcation. That is, if treatment or assessment procedures are being promulgated at least partially on the basis of a biological explanation for their proposed effect then this purported effect needs to be examined for plausibility or even possibility. It is relatively easy to provide a plausible ‘story’ about the mechanism by which a particular manual intervention might achieve its effect, but as we pointed out it is difﬁcult for clinical practitioners, no matter how well they understand anatomy and biomechanics, to evaluate such explanations rigorously, particularly while dealing with the multifactorial nature of their patients’ complaints. This, we suggested, is the role of the clinical anatomist working in collaboration with the manual therapist. DOI of original article: 10.1016/j.math.2005.02.004 1356-689X/$ - see front matter r 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2005.03.003

Because manual therapy is presented to therapists and to the public as having a scientiﬁc basis it is essential that the foundations, whether they be biological, psychological or social, of clinical practice be properly established. Although it is always a clinician’s primary goal to alleviate a patient’s complaints, practices should not be adopted without investigation as to the underlying reason(s) (whatever it might be) for their effectiveness. If they are adopted without such investigation then the manual therapy community should not expect society to place it in a more privileged position than other groups of practitioners who might also provide frequent successful outcomes for their patients. We do not propose a special or exclusive role for the basic sciences, most particularly anatomy and biomechanics, in clinical practice. It is part of a four-fold foundation that also includes the behavioural sciences, (reliable, valid and efﬁcacious) clinical practice, and the development of practice standards. Importantly, the basic sciences (including anatomy and biomechanics) should be considered in such a way that manual therapy practice is properly founded in science, not in ‘‘in-depth’’ knowledge, conjecture or hearsay. References Cornwall J, Mercer SR, Harris AJ. Pain of cortical origin— implications for treatment. New Zealand Journal of Physiotherapy 2000;28:29–32. Deyo KS, Prkachin KM, Mercer SR. Development of sensitivity to facial expression of pain. Pain 2004;107:16–21. Jones MA, Rivett DA. Introduction to clinical reasoning. In: Jones MA, Rivett DA, editors. Clinical reasoning for manual therapists. Edinburgh: Butterworth-Heinemann; 2004a. p. 3–24. Jones MA, Rivett DA, editors. Clinical reasoning for manual therapists. Edinburgh: Butterworth-Heinemann; 2004b. Mercer S, Rivett DA. Clinical anatomy serving manual therapy. Manual Therapy 2004;9:59. Prkachin KM, Solomon P, Hwang T, Mercer SR. Does experience inﬂuence judgements of pain behaviour? Evidence from relatives of pain patients and therapists. Pain Research and Management 2001;6:105–12. Rivett DA. Manual therapy cults. Manual Therapy 1999;4:125–6.

Susan R. Mercer School of Biomedical Sciences, University of Queensland St Lucia, Australia Darren A. Rivett Discipline of Physiotherapy, University of Newcastle Callaghan, Australia

ARTICLE IN PRESS

Manual Therapy 10 (2005) 235 www.elsevier.com/locate/math

Book review David R. Essig-Beatty, Manipulation at Home Exercises Based on Osteopathic Structural Examination, West Virginia School of Osteopathic Medicine ($36), available from WVSOM Bookstore: http://www.wvsom.edu/clinicalsciences/opp/Faculty/ManipulationAtHome.htm. Manipulation at Home is a comprehensive text addressing the use of exercise at home to augment the impact of manipulative treatment on a patient. The author has aimed to bring together his diagnostic skills and exercises to accomplish this effect. The text is written for both practitioners and patients. It is divided into seven sections; the initial chapter describes how this book is different to other exercise books in that it aims to combine positions of ease for relieving pain, myofascial stretches for muscle tension and mobilizations for restricted movement. The author goes on describing his understanding and rationale for the use of these techniques citing a comprehensive selection of osteopathic and chiropractic research studies originating from the USA. A further ﬁve chapters cover problems in the lower back, head and neck, thoracic region, shoulder joint and upper extremity, hip joint and lower extremity respectively. A variety of clear photographs showing positions of ease, stretching and joint mobilizations are

doi:10.1016/j.math.2004.10.001

interspersed throughout the text. In each chapter clear advice is also included about indications and contraindications to the use of these techniques for the guidance of both practitioner and patient. The ﬁnal chapter focuses on the limitations of this and any other exercise book in terms of compliance with an exercise programme. The greatest part of the book is composed of appendices; these show clear pictures of all the recommended exercises. The ﬁnal appendix shows the sets of exercises required to reinforce the effect of manipulative treatment. The author explains he has included all the exercises and programmes in the appendices to allow easy reproduction for suitable patients. This is a useful, very readable text for both patients with little knowledge of exercise and practitioners looking for alternative exercises to those they are already familiar with.

C. Fawkes National Council for Osteopathic Research Clinical Research Centre for Health Professions University of Brighton, Aldro Building, 49, Darley Road Eastbourne, East Sussex, BN20 7UR, UK

ARTICLE IN PRESS

Manual Therapy 10 (2005) 236 www.elsevier.com/locate/math

MACP—Manipulation Association of Chartered Physiotherapists UK announcement 1. Effective management of Lumbar Spine Dysfunction 2. Effective management of Cervical Spine Dysfunction About the courses: These 4 day (L Sp) & 3 day courses (C Sp) are practically based and designed for those physiotherapists wishing to advance their treatment approaches in the management of low back and cervical spine pain. The initial 2 days focus on assessment and has a strong emphasis on clinical reasoning and evaluating evidence within the bio–psycho—social framework. The following days are spread apart so that the participant has time to reﬂect on his/her own needs within their clinical practice. These days aim to foster new or developing ideas in manual techniques, therapeutic exercises and to consolidate previous knowledge in the management of lumbar spine conditions. Who is the course aimed at?: Those physiotherapists wishing to develop more effective and efﬁcient management of neuromusculoskeletal dysfunction of patients with spinal pain. What is required of the participant?: Throughout the days, emphasis is placed on the use of group work to explore clinical reasoning exercises, which require the participant to draw on examples from their own clinical practice and to problem solve. An emphasis is placed on the beneﬁts to learning of active involvement, group work, discussion and debate, using interactive lectures, practical classes, case scenarios/group work & written tasks. Course tutors: MACP members and experienced lecturers Details of venues or information about these courses see website: www.macp-online.co.uk MACP Administrator: [email protected] For further information regarding running this course in your area contact: John Hammond (L Sp)—[email protected] Linda Exelby (C Sp)—[email protected]

1356-689X/$ - see front matter doi:10.1016/j.math.2005.04.001

Manual Therapy (2005) 10(3), 237

Diary of events

Instructions for abstracts available at http://www.sbpr.info Closing date for abstract submission is: 31st JULY 2005 Submit abstracts to: SBPRWARWICK2005@BOA. AC.UK

21–26 August 2005, Sydney, Australia 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

Instructions for abstracts and details of registration may be obtained from: Mrs Hazel Choules Society for Back Pain Research British Orthopaedic Association 35-43 Lincoln’s Inn Fields, London WC2A 3PN Tel: +44(0)20 7405 6507. Fax: +44(0)20 7831 2676 Email: [email protected] Or visit our website at http://www.sbpr.info Thursday, 24th November–Saturday, 26th November 2005

23–25 September 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]

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 Elsevier, The Boulevard, Langford Lane, Kidlington, Oxford OX5 1GB, UK Tel: +44 (0) 1865 843297 Fax: +44(0) 1865 843958 E-mail: [email protected]

31 March–2 April 2006 6th International Conference on Advances in Osteopathic Research 31st March to 2nd April 2006 FIRST CALL FOR PAPERS contact: www.bcom.ac.uk/research/icaor6

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.

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]

10–11 November 2005, Warwick

Evidence-based manual therapy congress Further information: www.medicongress.com

The Society For Back Pain Research Meeting . Study Design Workshop . Back Pain and the Intervertebral Disc Abstracts may be submitted on any aspect of research into back pain. The Back Care Medal (formerly National Back Pain Association Medal) and the President’s Medal (I300) will be awarded to the best two papers of the meeting. Accepted abstracts will be published in the Proceedings of the Journal of Bone and Joint Surgery. Student Prize for best paper submitted by PhD student.

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.

237